4
2013 Pietro Paoletti Conference: Endoscopic Transsphenoidal Surgery—An Educational Perspective Paolo Cappabianca I considered this commitment, assigned to me for 2013, a prestigious form of recognition, and I have tried to give this distinguished auditorium the sense of the work that has been evolving throughout my years of neurosurgery. Since the late 1970s, surgery via a transsphenoidal approach had been used in our medical school to treat pituitary ade- nomas. As a result of transsphenoidal surgery, we have been able ascend to a new level, which has been our center of gravity and our model for renovation and improvement. We created a team committed to meticulous hard work, with each member in his or her own field and with his or her own techniques striving to turn projects into reality. This is a team of people who refuse to remain where they are, with respect for and always in favor of better outcomes for patients. This attitude has permitted the development of an efficient system of care and has made Naples a center of excellence for pituitary and skull base surgery. We all are equal but different, and everyone has his own story I t was a great joy for me to speak on November 29, 2013, in Pavia, in the room dedicated to a great anatomist, Antonio Scarpa, who began the academic tradition of the anatomic school of Pavia. Scarpa gave an historic talk on October 31, 1785, the day this room was inaugurated. I thank the organizers, specifically Lorenzo Magrassi, Chief of the Division of Neurosurgery of the University of Pavia, and Rodolfo Paoletti, President of the Giovanni Lorenzini Medical Science Foundation, for inviting me to honor the memory of an exceptional man, Pietro Paoletti (1934e1991)—excellent surgeon, dedicated researcher, and critical thinker. Paoletti was Professor and Chairman of Neurosurgery at the Uni- versity of Pavia and made important contributions during his life both in neurosurgery and in pharmacologic research related to central nervous system tumors. Since 1992, the Giovanni Lorenzini Medical Science Foundation has organized a yearly conference in memory of Paoletti. The first invited speaker was Anders Bjorklund, histologist at the University of Lund. Subsequent honored speakers included Cesare Fieschi, outstanding Italian neurologist; Mitchel Berger, neurosurgeon at the University of California in San Francisco and past president of the American Association of Neurological Sur- geons (AANS); Graham Teasdale, famous for the Glasgow Coma Scale; Nicolas de Tribolet, present editor-in-chief of Acta Neuro- chirurgica; Davide Schiffer, leading Italian neuropathologist; Albert Rhoton, the father of modern microsurgical neuroanatomy; Gio- vanni Broggi, past president of the Italian Society of Neurosurgery, and Giacomo Rizzolatti, known for the concept of mirror neurons. These individuals are just some of the renowned speakers who have shared the privilege to give this lecture. I considered this commitment, assigned to me for 2013, a pres- tigious form of recognition, and I have tried to give this distin- guished auditorium the sense of the work that has been evolving throughout my years of neurosurgery. Apart from a few months spent in New York and in London while I was medical student, I had only 2 extramural experiences at the beginning of my career: the first one in Sweden, at the Department of Neurosurgery of the Karolinska Sjukhuset in Stockholm with Olof Backlund, and the second in Austria, at the Institute of Anatomy of the University of Vienna with Manfred Tschabitscher. Otherwise, all my training occurred in Naples, the city where I was born, where an historic past and a wonderful sense of nature are intensely combined with a “tricky” daily way of life. Since the late 1970s, surgery via a transsphenoidal approach had been used in our medical school for the treatment of pituitary ad- enomas. However, the Sixth European Workshop on Pituitary Key words - Education - Endoscopic skull base surgery - Philosophy - Pituitary surgery - Transsphenoidal surgery Abbreviations and Acronyms AANS: American Association of Neurological Surgeons Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy To whom correspondence should be addressed: Paolo Cappabianca, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2014) 81, 3/4:483-486. http://dx.doi.org/10.1016/j.wneu.2014.01.003 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved. WORLD NEUROSURGERY 81 [3/4]: 483-486, MARCH/APRIL 2014 www.WORLDNEUROSURGERY.org 483 Education & Training

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Page 1: Education & Training...Steve Jobs, “Stay hungry, stay foolish,” perfectly fits our emo-tions (1). I did not discover or invent anything, but on the old continent and in my very

Education & Training

2013 Pietro Paoletti Conference: Endoscopic Transsphenoidal Surgery—An

Educational Perspective

Paolo Cappabianca

I considered this commitment, assigned to me for 2013, aprestigious form of recognition, and I have tried to give thisdistinguished auditorium the sense of the work that hasbeen evolving throughout my years of neurosurgery. Sincethe late 1970s, surgery via a transsphenoidal approach hadbeen used in our medical school to treat pituitary ade-nomas. As a result of transsphenoidal surgery, we havebeen able ascend to a new level, which has been ourcenter of gravity and our model for renovation andimprovement. We created a team committed to meticuloushard work, with each member in his or her own field andwith his or her own techniques striving to turn projects intoreality. This is a team of people who refuse to remainwhere they are, with respect for and always in favor ofbetter outcomes for patients. This attitude has permittedthe development of an efficient system of care and hasmade Naples a center of excellence for pituitary and skullbase surgery.

We all are equal but different,

Key-

-

-

-

-

AbbAA

WO

and everyone has his own story

t was a great joy for me to speak on November 29, 2013,in Pavia, in the room dedicated to a great anatomist,

I Antonio Scarpa, who began the academic tradition of the

anatomic school of Pavia. Scarpa gave an historic talk onOctober 31, 1785, the day this room was inaugurated. I thankthe organizers, specifically Lorenzo Magrassi, Chief of theDivision of Neurosurgery of the University of Pavia, andRodolfo Paoletti, President of the Giovanni Lorenzini MedicalScience Foundation, for inviting me to honor the memory of

wordsEducationEndoscopic skull base surgeryPhilosophyPituitary surgeryTranssphenoidal surgery

reviations and AcronymsNS: American Association of Neurological Surgeons

RLD NEUROSURGERY 81 [3/4]: 483-486, MARCH/APRIL 2014

an exceptional man, Pietro Paoletti (1934e1991)—excellentsurgeon, dedicated researcher, and critical thinker.

Paoletti was Professor and Chairman of Neurosurgery at the Uni-

versity ofPavia andmade important contributionsduringhis lifebothin neurosurgery and in pharmacologic research related to central

nervoussystemtumors.Since1992, theGiovanniLorenziniMedicalScienceFoundationhasorganizeda yearly conference inmemoryof

Paoletti. The first invited speaker was Anders Bjorklund, histologist

at the University of Lund. Subsequent honored speakers includedCesare Fieschi, outstanding Italian neurologist; Mitchel Berger,

neurosurgeon at the University of California in San Francisco andpast president of the American Association of Neurological Sur-

geons (AANS); Graham Teasdale, famous for the Glasgow ComaScale; Nicolas de Tribolet, present editor-in-chief of Acta Neuro-

chirurgica; Davide Schiffer, leading Italian neuropathologist; AlbertRhoton, the father of modern microsurgical neuroanatomy; Gio-

vanni Broggi, past president of the Italian Society of Neurosurgery,and Giacomo Rizzolatti, known for the concept of mirror neurons.

These individuals are justsomeof the renownedspeakerswhohaveshared the privilege to give this lecture.

I considered this commitment, assigned to me for 2013, a pres-

tigious form of recognition, and I have tried to give this distin-guished auditorium the sense of the work that has been evolving

throughout my years of neurosurgery. Apart from a few monthsspent in New York and in London while I was medical student,

I had only 2 extramural experiences at the beginning of my career:the first one in Sweden, at the Department of Neurosurgery of the

Karolinska Sjukhuset in Stockholm with Olof Backlund, and thesecond in Austria, at the Institute of Anatomy of the University of

Vienna with Manfred Tschabitscher. Otherwise, all my trainingoccurred in Naples, the city where I was born, where an historic

past and a wonderful sense of nature are intensely combined with

a “tricky” daily way of life.

Since the late 1970s, surgery via a transsphenoidal approach hadbeen used in our medical school for the treatment of pituitary ad-

enomas. However, the Sixth European Workshop on Pituitary

Department of Neurosciences and Reproductive and OdontostomatologicalSciences, Università degli Studi di Napoli Federico II, Naples, Italy

To whom correspondence should be addressed: Paolo Cappabianca, M.D.[E-mail: [email protected]]

Citation: World Neurosurg. (2014) 81, 3/4:483-486.http://dx.doi.org/10.1016/j.wneu.2014.01.003

Journal homepage: www.WORLDNEUROSURGERY.org

Available online: www.sciencedirect.com

1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved.

www.WORLDNEUROSURGERY.org 483

Page 2: Education & Training...Steve Jobs, “Stay hungry, stay foolish,” perfectly fits our emo-tions (1). I did not discover or invent anything, but on the old continent and in my very

Figure 1. Synchrony and harmony of 4 oars.

EDUCATION & TRAINING

Adenomas in Berlin in 1996 gave me the insight that would ulti-

mately guidemyentire career.A videotapepresentedbyHaeDongJho, a Korean physician working in the United States, showing the

endoscopic endonasal procedure for the removal of pituitary ade-nomas triggered the spark of future developments in this area.

I began to work diligently with this perspective in anatomic labo-ratory training and with superb tutelage in rhinology by Paolo

Castelnuovo, a new friend and generous teacher. At the beginningof 1997, we started using the purely endoscopic technique in

Naples, with this novel methodology for sellar region surgeryaccessed via an endonasal pathway (3).

As a result of transsphenoidal surgery, we have been able ascendto a new level, which has been our center of gravity and our model

for renovation and improvement. Transsphenoidal surgery hastraditionally gone through different historical phases and several

different approaches—sublabial, transnasal, microscopic, andfinally endoscopic (12). We entered this workflow, adopting new

instruments, the endoscope first and designing some additionalspecialized instruments (4), and employing different materials (6),

but above all we adopted a team strategy, creating a neuroendo-crine unit with Annamaria Colao, with whom we have shared

respect, friendship, and relevant studies on both functioning (8-10)and nonfunctioning (5) pituitary adenomas. Furthermore, the

pituitary gland, which is of extraordinary importance as theorchestra conductor of the endocrine system and the entire body,

is a common platform for educational advancement driven byparticipants from different disciplines, including endocrinologists,

radiologists, ophthalmologists, anesthesiologists, neurosurgeons,otorhinolaryngologists, pathologists, and radiation oncologist.

We created a team committed to meticulous hard work, with each

member in his or her own field and with his or her own techniquesstriving to turn projects into reality. This is a team of people who

refuse to remain where they are, seeking to push the limits, withrespect for and always in favor of better outcomes for patients. As

for gliomas, where significant advancement has not yet been

reached, for adenomas and other neoplasms of the skull base, therelief of symptoms occurs in parallel with continuous advancement

in research and understanding of biology. Creating and maintainingthe harmony of the group has not always been easy (7), but the aim

of improving and simplifying even the most complex proceduresthroughaspirit of service, reliability, anddisciplinehaspermitted the

development of an efficient system of care and has made Naples acenter of excellence for pituitary and skull base surgery (15).

Whether or not we leave our footprint, the motto reinterpreted by

Steve Jobs, “Stay hungry, stay foolish,” perfectly fits our emo-tions (1). I did not discover or invent anything, but on the old

continent and in my very traditional country, I expressed adifferent concept of leadership, focusing on a team made up of

givers, individuals who prefer to contribute more than theyreceive, rather than takers, individuals who put their interest first,

to provide a better life for people at work and for peoplesuffering—a better life for you, a better life for me. This evolution

has the characteristics of a Socratic Academy, receptive to theinfluence of many cultures, open to foreigners as well as com-

patriots, where everyone has the chance to develop his or herown inclinations, resulting in a joint methodologic flow. Again

adopting the Socratic method, we shared with close and distantfriends and colleagues the extraordinary experience of teaching

from learning (i.e., lifelong learning).

484 www.SCIENCEDIRECT.com WORLD NEU

I consider myself lucky for the individuals I have met in life,

especially for 3 magnificent teachers of various subjects: in highschool, the teacher of philosophy, Vera Lombardi, who provided

great inspiration for systematic thought; at University, GaetanoSalvatore, pathologist, scientist, and inventive and enthusiastic

designer with great foresight; and, last but not least, in themiddle of my career, Ed Laws, American neurosurgeon of Italian

extraction, who transported me back to a stage of life where youlook at the future as a whole, as a great dream that can be

realized, changing the world day by day, leaving no stonesunturned. Ed taught me neurosurgery (13, 14) and interactions

with other disciplines; he turned my attention to modern societyand to the patient’s point of view. From him I learned how to get

up again after a fall, how to develop constant receptiveness tonew initiatives with sheer curiosity and not for self-interest,

without distraction from our own pleasures and passions, butrather sharing and enjoying these in everyday life.

I was privileged for the atmosphere of my family, of ancient and

sturdy origins. My parents loved each other; my mother spread a

tender austere serenity, while my father imposed moral firm-ness. I have also been lucky in my own family, rich of a lovely

wife, 3 healthy children, and some dogs as true family members.I have been lucky for the lessons of sport, especially rowing,

which after years of sacrifices and fatigue, strengthens the bodyand the mind with steadiness, the harmony with fellow adven-

turers, and the education of never giving up (Figure 1) (2).

I have been lucky, once again, to encounter in my homeland trueneurosurgical talents such as Francesco Castellano, student of the

Swedish neurosurgeon Herbert Olivecrona, who was the first toremove a brain tumor in Naples in the 1950s. He represented for

me an example of impetuous enthusiasm and extraordinaryrefinement; as did Faust D’Andrea, who introduced the neuro-

surgery of southern Italy into the National Academy; as did PaoloConforti,who, thanks to his foresight, elevated the nameofNaples

into the neurosurgical world and left his precious legacy to hisdisciple, Francesco Tomasello. I cannot forget to mention, and

I have not forgotten, the prosperous season that I experiencedwith Enrico de Divitiis, who for decades was my daily reference

and introduced me to transsphenoidal surgery. He allowed me totravel around the world looking for new winds, while he, at home,

was securing improvements and looking after the daily needs that,

left unchecked, do not allow a project to become reality. At ouruniversity, in Naples, former capital of the Kingdom of the Two

Sicilies, city of a rich past but of an uncertain future, we were ableto install in 2005 the first fully integrated operating room in a public

ROSURGERY, http://dx.doi.org/10.1016/j.wneu.2014.01.003

Page 3: Education & Training...Steve Jobs, “Stay hungry, stay foolish,” perfectly fits our emo-tions (1). I did not discover or invent anything, but on the old continent and in my very

Figure 2. Statue of Plato (Athens 427 BCe347 BC),founder of the “Academy,” in Athens, known as the firstinstitution of higher learning.

Figure 3. Pituitary gland and stalk resembling hibiscus flower and its pistil.

EDUCATION & TRAINING

institution in Europe, following my experience of a visiting pro-fessorship in Los Angeles, California, in 2002. Los Angeles is

where the most eclectic and brilliant mind among contemporaryneurosurgeons, Michael Apuzzo, lives and works.

From travels from East to West, each time, I learned, and I evenrediscovered myself. I would not have otherwise been able to

recall the summer nights in early childhood and the trunk of thehuge eucalyptus in the garden outside my room that we 3 kids

stretching all together could not even embrace, its honey-milkbark, the oblong leaves, the bluebells, the balsamic smell, and

the harsh roots, if I had not gone “down under” to Australia.Traveling around the world, I could appreciate the slight differ-

ences that characterize each individual, between the variousspecies of animals and plants, the assortment of landscapes

and seasons always in constant motion in the cycle of life. InAsia, I looked at the most ancient cultures and religions, the

“harmony of the Zen garden,” the deep respect for nature andthe precise care for details, the perfect integration of 2 worlds,

vegetable and mineral, both combed as we comb our hair, asthe wind combs the leaves of a tree. In Africa, I saw the most

beautiful skies in the world, the desert, the beauty of the darknights as Paolo Rumiz tells (16), the origin of the world. In

America, I found amazing dynamism and equality, whereeveryone can experience a great career, regardless of where he

or she comes from. Last, in my Europe, I see a continent weary,despite the taste for tradition and memories that still survive. In

my “voyage” through neurosurgery, I visited many areas of thebrain, many countries, and many institutions and houses

without necessarily bringing any truth; I have just been a trav-eler. In this journey, I tried to respect the words of Thucydides

in his “Peloponnesian War”: freedom and courage, the courage

WORLD NEUROSURGERY 81 [3/4]: 483-486, MARCH/APRIL 2014

to look for the truth, the courage not to hide behind shadows

and pretenses.

My coworkers and I all shared the desire for knowledge, theneed to embark on a journey with curiosity, and the importance

of research as a means to improve the status quo and to aspire tohigher goals. We are a team of surgeons who believe that culture

comes first and is allied with the promotion of health educationand the growth of research. Education is first (17); I learned this

when my parents enrolled me in high school for classic studies.The “classic studies” represented for me the foundations of my

medical career. I believe that today, more than ever, physiciansare required to extend their knowledge beyond the walls of

medicine because technologic innovation requires the decisivecontribution of people of broad culture, able to derive insights

from different fields. The cross-fertilization between apparentlydifferent fields, within medical boundaries or from other areas,

such as sport, music, art, and literature, create added value andnever subtract. Philosophy and science have always been indis-

soluble, exemplified in Anglo-Saxon countries, where the title of

Ph.D. was commonly assigned at the end of a doctorate inchemistry or biology (Figure 2). Poetry and science, to me, are

simply 2 different ways to understand nature (11) and its struc-ture, which I have admired in the pituitary stalk as well as in the

pistil of a hibiscus (Figure 3). The anatomy of the world offersphotographic poetry for our eyes, for people who have the

empathy and desire for knowledge.

Today, the educational perspective has reversed in teaching, andmy heritage is reflected frommy disciples as in amirror. I have the

privilege to look at the world through the eyes of my students,especially those that I have raised; I share their successes in life

and their triumphs and disappointments at work, their journeys,and their researches. I observe the life of their newborn, like a

father would do with his sons and daughters.

I believe that each of us will have left a trace on this world, more or

less enduring. The lessons of Paoletti, which I listened to everyyear at the National Congress of the Italian Society of Neurosur-

gery, concerninghis studiesonbrain tumors andhis attempt to finda “Lazarus effect,” still appear bright in contrast to this difficult

time of Italian biomedical research. I am honored, beyond mymerits, to share todaywith you thememory of awitness to a great

message of commitment and culture. Thanks Professor Paoletti,once again, and thanks to the keepers of his heritage.

www.WORLDNEUROSURGERY.org 485

Page 4: Education & Training...Steve Jobs, “Stay hungry, stay foolish,” perfectly fits our emo-tions (1). I did not discover or invent anything, but on the old continent and in my very

EDUCATION & TRAINING

REFERENCESvacuo—use of fibrinneurosurgical “dead

1. Whole earth epilog, in: Brand S, ed: Whole EarthCatalog. San Francisco: Portola Institute; 1974:324.

2. Cappabianca P: Sublime synchronicity: rowing, itsstory, and the forging of mind and body inneurosurgery. Neurosurgery 54:1278-1281, 2004.

3. Cappabianca P, Alfieri A, de Divitiis E: Endo-scopic endonasal transsphenoidal approach to thesella: towards functional endoscopic pituitarysurgery (FEPS). Minim Invasive Neurosurg 41:66-73, 1998.

4. Cappabianca P, Alfieri A, Thermes S,Buonamassa S, de Divitiis E: Instruments forendoscopic endonasal transsphenoidal surgery.Neurosurgery 45:392-395, 1999 [discussion 395-396].

5. Cappabianca P, Esposito F, Cavallo LM, Colao A:Endocrinologically silent tumors, in: Quinones-Hinojosa A, ed: Schmideck & Sweet OperativeNeurosurgical Techniques: Indications, Methods,and Results. 6th ed. Philadelphia: Saunders; 2012:246-256.

6. Cappabianca P, Esposito F, Magro F, Cavallo LM,Solari D, Stella L, de Divitiis O: Natura abhorret a

486 www.SCIENCEDIRECT.com

glue as a filler and sealant inspaces.” Technical note. Acta

Neurochir (Wien) 152:897-904, 2010.

7. Cappabianca P, Magro F. Leadership. Surg Neurol68:354-355, 2007.

8. Colao A, Attanasio R, Pivonello R, Cappabianca P,Cavallo LM, Lasio G, Lodrini A, Lombardi G,Cozzi R: Partial surgical removal of GH-secretingpituitary tumors enhances the response to so-matostatin analogues in acromegaly. J ClinEndocrinol Metab 91:85-92, 2006.

9. Colao A, Di Sarno A, Cappabianca P, DiSomma C, Pivonello R, Lombardi G: Withdrawalof long-term cabergoline therapy for tumoral andnontumoral hyperprolactinemia. N Engl J Med349:2023-2033, 2003.

10. Colao A, Ferone D, Cappabianca P, del Basso DeCaro ML, Marzullo P, Monticelli A, Alfieri A,Merola B, Cali A, de Divitiis E, Lombardi G: Effectof octreotide pretreatment on surgical outcome inacromegaly. J Clin Endocrinol Metab 82:3308-3314,1997.

11. De Luca E, Sassone Corsi P: Ti sembra il caso?Schermaglia tra un narratore e un biologo. Milan:Feltrinelli; 2013.

WORLD NEUROSURGERY, http://

12. Doglietto F, Prevedello DM, Jane JA Jr, Han J,Laws ER Jr: Brief history of endoscopic trans-sphenoidal surgery—from Philipp Bozzini to theFirst World Congress of Endoscopic Skull BaseSurgery. Neurosurg Focus 19:E3, 2005.

13. Kaye AH, Laws ER, eds. Brain Tumors. Philadel-phia: Saunders; 2011.

14. Laws ER, Lanzino G, eds. Transsphenoidal Sur-gery. Philadelphia: Saunders; 2010.

15. McLaughlin N, Laws ER, Oyesiku NM,Katznelson L, Kelly DF: Pituitary centers ofexcellence. Neurosurgery 71:916-924, 2012 [dis-cussion 924-916].

16. Rumiz P: Il bene Ostinato. Milan: Feltrinelli; 2011.

17. Yousafzai M: United Nations speech, July 12, 2013.

Citation: World Neurosurg. (2014) 81, 3/4:483-486.http://dx.doi.org/10.1016/j.wneu.2014.01.003

Journal homepage: www.WORLDNEUROSURGERY.org

Available online: www.sciencedirect.com

1878-8750/$ - see front matter ª 2014 Elsevier Inc.All rights reserved.

dx.doi.org/10.1016/j.wneu.2014.01.003