The surgeon's experience is crucial

Here is a quote from Dr. Steiner's letter to the American J. of Oncology, 1996 (vol 17, no X):

The results of microsurgery by inexperienced and inexpert surgeons are much worse than those of published series... Because of the frequent unfavorable outcome regarding the quality of life, a large fraction of patients who went through microsurgery for extirpation of vestibular schwannomas [ANs] are profoundly dissatisfied... After I provide [patients] with information on all available treatment alternatives, I try to convince them to have miscrosurgery only if they can afford to be operated on by the best hands.

As one can see, the surgeon's experience is very important to getting a good result...

There are published papers by surgeons that clearly show that there is a real learning curve for this type of surgery (two separate papers in 1996). They report that their first 50 - 100 patients, in retrospect, had a much lower chance of what we would call success, but instead would have a much higher chance of facial paralysis, total hearing loss, and other complications. Their statistics improve after treating 50 - 100 patients. Furthermore, after gaining the necessary experience, a surgeon needs to continue performing AN surgeries in order to maintain their expert skill level... 

When comparing the results you can expect from your local surgeon with those you read about in surgical literature, here is what the same letter by Steiner says:

The results of microsurgery by inexperienced and inexpert surgeons are much worse than those of published series.

The bottom line is to insist on being referred to doctors with extensive experience with Acoustic Neuromas. If your surgeon has not done at least 100 ANs, your surgeon is still "practicing AN surgery".  The "best hands" perform at least 50 AN surgeries a year (once a week), and you can use this as a "litmus test" if you are looking to minimize your odds of surgical complications.

But watch out: if a surgeon has done 100 Retrosigmoid approaches and only 10 Middle Fossa approaches, you don't want them practicing Middle Fossa on you!  Another thing to watch for are surgeons who say they have done 50 ANs, and upon further questioning, you find out that in 45 of those cases they were in the operating room as a resident or assistant,  not doing any of the real tough work

Related Literature Section

1. American Journal of Otology 1996 Jul;17(4):643-647

The operative learning curve and its effect on facial nerve outcome in vestibular schwannoma surgery. Moffat DA, Hardy DG, Grey PL, Baguley DM, Department of Otoneurological and Skull Base Surgery, Addenbrooke's Hospital, Cambridge, United Kingdom.

Abstract: The successful removal of vestibular schwannomas requires a team approach by skillful and appropriately trained surgeons. It is generally perceived that the results of surgery, especially facial nerve outcome, will improve as the surgical team acquires more experience. This study of 300 patients undergoing surgical removal of vestibular schwannomas confirms that there was a significant learning curve for facial nerve outcome. In the first 50 cases, 52% had satisfactory outcomes (House grades I-III), whereas in the last 50 cases 92% had satisfactory outcomes....

2. Laryngoscope 1996 Nov;106(11):1406-1411

The learning curve for acoustic tumor surgery.  Buchman CA, Chen DA, Flannagan P, Wilberger JE, Maroon JC, Department of Otolaryngology, University of Pittsburgh School of Medicine, USA.

Abstract: Although operative experience is considered to be critically important in the surgical management of acoustic tumors, little objective evidence substantiates this claim. The present study was undertaken to determine whether a learning curve exists for acoustic tumor surgery. The first 96 acoustic tumor patients managed surgically by a new neurotologic team were retrospectively reviewed. A significant improvement (P<.0003; F=6.32) in the ability to achieve good (grade II or better) postoperative facial nerve function was identified. Improving trends for complete resection rate and hearing preservation were documented, and the incidence of cerebrospinal fluid (CSF) leaks declined...

Last Edited: Wednesday, October 30, 2002