June 30, 2014 07:15 PM

The 6 Pillar Approach is to brain surgery what GPS is to modern-day travel: miles ahead.

The 6 Pillar Approach is to brain surgery what GPS is to modern-day travel: miles ahead. By Walter Pierce

Tuesday, July 1, 2014

Dr. Alan Appley  

If you're 30 or older you probably remember the pre-GPS family road trip: Plan the journey, pull out the road map that never folded back up just right, gas up and go. Always an imprecise adventure.

Brain surgery used to be like that. It's not anymore.

"It was called exploratory craniotomy," Dr. Alan Appley, a neurosurgeon at Lafayette General Medical Center, recalls with a chuckle what brain surgery was like before imaging systems like CT scans and MRI were in wide use. "You really didn't know. You had a good idea of what [the patient] had - a tumor on the right side near the back [for example] - but that's about it. You had to make a huge opening."

Appley was the first surgeon in Acadiana to employ a suite of technologies referred to as the "6 Pillar Approach." Most of the technologies are not particularly new, but using them in concert is, and the result is better patient outcomes: less brain trauma, quicker recovery time, financial savings.

The so-called pillars in the approach Appley is pioneering in Lafayette are imaging/trajectory planning (mapping the brain), navigation (like using GPS to chart a path to the lesion or tumor), access/cannulation (getting there), optics (having a clean windshield and new wipers), resection (removal of soft tissue) and regenerative medicine (healing).

Some of the pillars include new technologies patented by the NICO Corporation. They cost LGMC about $300,000.

Big picture: Combining the pillars is like that old family road trip, except it allows the surgeons to chart a precise course to their destination. No more pulling over to see "The World's Largest Yarn Ball." The approach lessens the risk of trauma to the patient - trauma that can manifest itself as speech or motor impairment or memory loss.

"There are a lot of things that are fairly easy to get to; they're close to the surface and it's no mystery how to get there," says Appley. "But for deeper lesions we've found that not necessarily the shortest way is the best way. The best way is to go parallel or at least tangential to the fiber tracks. You know, white matter isn't just like a big Jell-O bowl."

The brain, Appley explains, is like a complex systems of canals or roads, and although taking a circuitous route to get to a lesion and remove it may mean more figurative mileage on the wagon, it greatly diminishes the risk of brain trauma and, consequently, increases the odds for favorable outcomes for the patient.

"It's really two main things," Appley adds. "One is the imaging and using those tracks to find your way in. The other is using this minimally invasive cylindrical tubular dialator that pushes away the tissue.

"You can slide this tube really very minimally traumatically down through the tissue, if you plan it correctly, parallel to these fiber tracks and down to the lesion."

It really is like using GPS to get to the destination, but unlike those family road trips, it's about seeking the smoothest route not the shortest.

"Each of these little steps, none of them is tremendously revolutionary, but putting them all together, especially using the fiber tracks and the tubular dialator, are definitely the big advantage," Appley says.

Appley's first patient was Mary Ardoin, a developmentally-disabled Lafayette woman who was suffering up to eight seizures per day. Lafayette neurologist Dr. Diana Fernandez recommended Ardoin see Appley about the new 6 Pillar approach to solving what had become a debilitating situation.

"Everything took longer for her because of her seizures," recalls Jeanine Guilbeau, Ardoin's caregiver. Ardoin's seizures could last a few seconds or up to four hours. Guilbeau says Ardoin has only had four seizures since her surgery last October. "It is truly amazing," she adds.

Appley says LGMC jumped at the opportunity to bring in the 6 Pillar technology despite the cost.

"With this [technology], they have shown that not only can patients do tremendously well very quickly, but it can save everybody a whole lot of money - saves patients a lot of money, saves the hospital a tremendous amount of money because they're getting them out of the [intensive care unit] a lot quicker if they don't have to have a breathing machine or be intubated; they get out of rehab quicker as opposed to being in ICU for two weeks on a ventilator and on to a nursing home or something like that," Appley explains. "That's why the hospital was so quick to adopt this technology when I presented it to them. We have a new technology and patients are not only going to do better, which is the first goal, but it's also going to save money."

That's a far cry from those old stubborn road maps.

"I'm kind of spoiled," says Appley, who began his post-residency career in 1989. "When I started training, MRI was just starting. The people who are five, 10 years older than me, they saw that huge transition between nothing and then CT scans and then MRI.

"...Each of these things that come along - doing awake surgery, doing brain mapping, stimulation, now fiber track mapping, doing the functional MRIs, the computer guidance - each of those has been an incremental improvement. Patients often go home the next day or two days later."