New procedure could reduce brain surgery risks

Neurosurgeon Ben Warf is trying to change fifty years of surgical practice one patient at a time.

He opens a small hole in the brain of Naphtalie Bazile, a 10-month-old Haitian girl, and is about to use his novel technique to relieve her massively swollen head, caused by water on the brain - or hydrocephalus.

The standard treatment - installing a shunt, a drainage tube running from the brain under the skin to the abdomen - is fraught with malfunctions and infections.

Warf believes he has found a better way: after guiding a thin, flexible surgical instrument into her brain, he seals up tissue that produces some of the excess fluid. He also cuts a hole in one of the chambers holding the liquid inside the brain, freeing trapped cerebrospinal fluid to be reabsorbed normally into the bloodstream.

The 50-year-old surgeon hopes the procedure at Thomas Jefferson University Hospital will save more than one patient.

He wants to convince his colleagues across the country that his treatment - which he developed over six years in Uganda to fill a critical need there - should replace failure-prone shunts as the first-line approach for hydrocephalus in most cases.

In East Africa and other areas where emergency brain surgery isn't readily available, shunt failures are deadly, the Harvard-trained doctor explains.

Even in the United States a shunt malfunction can be catastrophic. It is not uncommon for some children with the devices to undergo dozens of surgeries to fix problems, most often blockages.

"Shunt dependence puts the patient in a very precarious situation," Warf says.

One recent morning, Warf performed emergency surgery at 3 a.m. on a patient whose shunt had failed. Without the operation, he says, the child would have died.

"I have parents who are afraid to go to Disney World because they worry about a shunt failure," Warf says. "Every time the kid has a headache they are worried about a failure. Every time she has a fever, they are worried about a shunt infection."

Beyond the psychological toll, each repeated operation carries the risk of infection and other complications.

And there's a financial toll. Each shunt surgery costs about $30,000.

That's about the same amount that Warf's procedure costs, but if it works, his patients should never need another operation.

Overall, $1 billion a year is spent inserting, fixing and reinserting shunts in this country, according to a recent article in the Journal of Neurosurgery: Pediatrics.

Nationwide, about 4,000 infants a year are newly diagnosed with hydrocephalus and treated with shunts.

Unlike many of the patients Warf cared for in Uganda whose condition was often caused by infection, about half of the U.S. cases were premature babies who developed the condition after brain hemorrhages. Most of the others have congenital problems, such as spina bifida, that can cause hydrocephalus.

In 2000, compelled by his religious beliefs and a desire to use his surgical skills to help sick children in Africa, Warf moved to Uganda with his wife and six kids.

He went to help build and run a pediatric neurosurgical hospital for CURE International, a Christian nonprofit group.

Warf saw large numbers of Ugandan children with hydrocephalus. But he was wary of using shunts in patients with little access to emergency care.

So he searched for an alternative.

What he found were two older approaches: choroid plexus cauterization (sealing the fluid-making tissue), and ventriculostomy (making a small hole in the bottom of the third ventricle, the liquid-filled space in the center of the brain) so it can be absorbed normally.

When he combined the two procedures, Warf said he was able to treat hydrocephalus in more than 70 percent of his patients without resorting to a shunt.

He performed the operation on more than 1,200 children in Uganda.

Then, after training a Ugandan surgeon to perform the procedure, Warf returned to the United States in June 2006. He joined the staff at the Alfred I. duPont Hospital for Children in Wilmington and Thomas Jefferson University.

From those posts, he hopes to spread the word about his approach.

So far he has performed the procedure on 32 American children and six Haitians, including Naphtalie.

Naphtalie's operation takes 42 minutes to finish, about as long as it would take to insert a shunt. After the anesthesia wears off, Warf checks on the infant in the neonatal intensive care unit, but he knows it will take several months to determine if the operation succeeded.

And he knows it will take much longer - many more patients, and lots of scientific evidence - to get his colleagues to accept his approach.

"There is a lot of work to do to develop credible clinical evidence that what he is doing will yield outcomes that are equivalent to the standard treatment," says Joseph H. Piatt, chief of neurosurgery at St. Christopher's Hospital for Children. "We are rooting for him but glad we are not him."

First, he needs to show that other surgeons can safely perform the procedure and demonstrate that it will succeed here on children whose hydrocephalus is often caused by different problems than are common in Uganda.

The biggest challenge - and one that Warf readily accepts - is to demonstrate that the children who undergo his procedure will develop mentally and physically as well or better than those who get shunts.

That could take years, although Warf says early results following the development of patients in East Africa are promising.

"It will require a lot of very rigorous scientific study," said Joseph R. Madsen a neurosurgeon at Children's Hospital Boston and associate professor of neurosurgery at Harvard Medical School.

"My guess is that it will almost certainly be the best treatment for somebody," Madsen says, "but I don't know if that is one in 100 or 60 in 100 babies."

In early July, Warf determined that Naphtalie's surgery had succeeded.

And on July 12, the little girl was able to return to her parents in Haiti.

Naphtalie will always have an abnormally large head and some developmental impairment because she went untreated for so long, Warf says. "But the prognosis for her hydrocephalus is excellent, and that gives her a chance for a more normal life."