Waterjet dissection of brain metastases .pdf
Nom original: Waterjet dissection of brain metastases.pdf
Titre: Waterjet resection of brain metastases-first clinical results with 10 patients
Auteur: Oertel, J, et al
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EJSO 2003; 29: 407±414
Waterjet resection of brain metastases ±
first clinical results with 10 patients
J. Oertel, M. R. Gaab and J. Piek
Department of Neurosurgery, Ernst Moritz Arndt University, Greifswald, Germany
The waterjet technique enables precise tissue dissection without thermal damage and with preservation of vessels in
general surgery. In neurosurgery, these qualities could help to avoid damage of intact brain parenchyma in tumour
resections. The present study reports our first results with this technique in brain metastases.
Ten patients with intracranial metastases underwent surgery with the aid of the waterjet. Resection was performed
in combination with conventional neurosurgical methods. The follow-up consisted of neurological examination and
Intraoperatively, the device was easy to handle. No complications due to the device were observed. Vessels were
preserved at pressures below 20 bars. Six of the tumours consisted of soft tissue which was poorly demarcated from
the surrounding brain. In these tumours, the waterjet was very helpful. It enabled tumour debulking by aspiration
and ± more important ± precise separation of tumour and brain parenchyma. The remaining four cases were rather
hard and well demarcated metastases. In these only separation of the tumour from the surrounding brain was achieved.
In conclusion, the waterjet can be applied in surgery of brain metastases without complications. The device appears
particularly suitable for soft, poorly demarcated metastases. Further clinical studies with this device are required.
# 2003 Elsevier Science Ltd. All rights reserved.
Key words: waterjet dissection; brain metastasis; surgical technique; brain dissection.
Within the last decade, the indication for surgery of
solitary brain metastasis has been widened,1±4 and today,
the role of surgery in these cases is generally accepted.
While resection of firm clearly demarcated brain
metastases can mostly be performed with complete
excision of the tumour, resection of softer less clearly
demarcated metastases remains rather challenging. In
the latter cases, often postsurgical CT or MRI scans
demonstrate tumour remnants, and postsurgical radiotherapy is mostly applied.5,6
On the search to improve the operative results in
soft, badly demarcated brain metastases, our group
started to apply the waterjet dissection instrument in
surgery of brain metastases in August 1998. This
instrument represents a new technique for parenchymal
organ surgery. It has been industrially applied for
dissection under various conditions since many years.7
In this technique, basically water is pushed through a
Correspondence to: Joachim Oertel, MD, Department of Neurosurgery,
Ernst Moritz Arndt University, F.-Sauerbruchstrasse 8, 17487
Greifswald, Germany. Tel/Fax: #49-3834-866163/-866164; E-mail:
small nozzle under high water pressures. Its unique
advantage is that it enables separation of tissues with
different resistance to waterjet dissection. Papachristou
and Barters were the first who started to use this
instrument in surgical procedures.8 They demonstrated
a precise dissection of liver parenchyma under preservation of bile ducts and blood vessels with distinct water
pressures.8 The combination of this dissection technique
with subsequent bipolar vessel coagulation resulted in a
reduction of blood loss in liver resections in dogs and
humans.8 Meanwhile, these observations have been
confirmed by other researchers.9,10 Today, this technique is generally accepted in liver surgery.11±13 Indications for this instrument in other surgical fields are
currently under investigation.14±16 In neurosurgery,
Terzis and coworkers reported a precise dissection of
the brain parenchyma with preservation of vessels larger
than 20 mm in cadaveric porcine brains.17 Probably
because of rather high variations in the dissection depths
per pressure level, no further studies followed by this
In 1997, our group started to investigate the
dissection characteristics of a newly developed waterjet
dissection instrument approved for clinical application
by the regulatory authorities in Germany and more
2003 Elsevier Science Ltd. All rights reserved.
J. OERTEL ET AL.
recently also in the USA. With this instrument, a very
precise and reliable dissection of the brain parenchyma
under preservation of blood vessels in the porcine
cadaver brain has been shown.18,19 A linear relationship
of pressure increase and dissection depth was demonstrated.18 Clinically, the instrument has been applied in
various neurosurgical pathologies, i.e. gliomas of all
WHO grades, meningiomas, epilepsy surgery, and
various others.20 With respect to its peculiar qualities,
we also used the instrument in ten cases of brain
metastases. The present study reports our experience
and results with the waterjet device in these ten
neurosurgical procedures with a special focus on
potential advantages of this device compared with
MATERIAL AND METHODS
Ten patients (four males and six females; mean age: 57
years, range 21±70 years) underwent surgery with the
aid of the waterjet between August 1998 and April 2002.
Two men and one woman suffered from lung, three
women from breast cancer. One patient each had a
metastasis from a rhabdomyosarcoma, a melanoma,
and a renal cell carcinoma. In one patient, no primary
carcinoma of its intracranial metastasis was found
Description of the instrument
In the first two cases, the first generation of the waterjet
instrument (MuÈritz 1000) was used. Since September
1999, its successor, the Helix Hydro-Jet (Fig. 1; Erbe
Elektromedizin GmbH, TuÈbingen, Germany) has been
used in the remaining eight cases. The waterjet
instrument consists of a saline cartridge, a medium
converter, and a handpiece-applicator. It is also
equipped with a suction device. The medium converter
with electronically controlled hydraulics generates a
water jet of pressures between 1 and 150 bars. The jet is
conducted to the pencil-like handpiece consisting of a
narrow nozzle of 120 mm diameter and a surrounding
suction device through various tubes. A water jet
rotating like a drill at the surface is emitted. Sterile
isotonic saline solution is used as separating medium.
Pressure and suction are manually preset. During
surgery, both can be adjusted within the preset range
by a foot pedal. The waterjet system has been approved
by the regulatory authorities in Germany and the United
States of America for surgical use in humans.
Surgical procedure and follow up
All operations were performed by one of the authors.
A frameless neuronavigation system (Zeiss SMN; Zeiss,
Figure 1 The waterjet instrument `Helix Hydro-Jet'
connected to the handpiece-applicator via various tubes.
Oberkochen, Germany) was used for intraoperative
guidance in eight cases. Resection was performed using
waterjet dissection in combination with conventional
neurosurgical methods. The intensity and quality of
waterjet application, handling aspects and usefulness of
the device were documented directly after each
procedure. Intraoperative blood loss and tendency
toward oedema formation were monitored. Also
waterjet pressures used and complications observed
were noted. Special attention was paid to the vessel
preservation and the ability of the instrument to
separate the tumour from the surrounding brain
parenchyma as well as its ability to aspirate the tumour
mass. Follow-up included clinical examination and postoperative MRI studies and ranged from 3 to 24 months.
General handling aspects in
The waterjet was easy to use in all procedures. All
dissections were performed with a non-fragmented
beam and permanent suction. The emitted jet allowed
very precise and reliable tissue dissection with perfect
guidance by the handpiece-applicator. The waterjet device
was applied in two different procedures: (i) tumour
Patient material, waterjet application characteristics and outcome
Poor, not helpful
Poor, not helpful
Poor, not helpful
recurrence at 3-ms FU
recurrence after 1-yr
recurrence at 3-ms FU
recurrence at 6-ms FU
recurrence at 3-ms FU
Rapid recurrence and progression;
subcutaneous spreading, still alive
at 3-ms FU
Died 6 weeks after
WATERJET RESECTION OF BRAIN METASTASES
Died from MI with
recurrence at 8-ms FU
recurrence at 3-ms FU
aspiration and (ii) separation of the metastasis from the
For tumour aspiration and resection, the nozzle was
put in direct contact with the tissue but without
application of any mechanical force to it. The dissection
depth was microscopically controlled, and the waterjet
pressure was accordingly adjusted that a dissection
depth of about 5 mm resulted. After dissection, the
loose tissue pieces were washed out by the water and
sucked away. Preserved blood vessels were subsequently
coagulated with the bipolar forceps, and cut with
To separate the tumour from the adjacent brain, the
handpiece was put at a distance of 2±3 mm from the
tissue. The beam was directed at the tumour±
parenchyma border, and a plane between the metastasis
and the brain parenchyma was formed. Preserved
J. OERTEL ET AL.
vessels subsequently coagulated and cut with conventional methods.
Clinical results in brain metastases
All ten patients suffered from a solitary intracranial
metastasis of their primary carcinoma (Table 1). Five
tumours were located in the frontal lobe, and one
tumour each in the parietal and temporal lobe. In all
cases, the device was applied for tumour aspiration as
well as tumour separation from the healthy brain.
Interestingly, very variable results were observed depending on the characteristics of the metastases in both
Tumour separation from the adjacent parenchyma
was achieved with pressures between 4 and 12 bars in all
cases. In metastases firmer than the surrounding intact
Figure 2 Vessel preservation (arrowhead) at the brain-tumour border with consecutive coagulation and cutting (a,b). Vessel
preservation in tumour aspiration (c; arrowhead indicates the preserved vessel, arrows point to the dissection `cut'). Vessel
preservation and precise parenchymal dissection in the porcine cadaver brain (d; arrowheads indicate the various dissection `cuts',
arrows point to preserved pial vessels).
WATERJET RESECTION OF BRAIN METASTASES
brain parenchyma, the jet was slightly directed towards
the tumour; from there it was reflected to the braintumour border and dissected the lesion from the brain.
With this technique, a plane between the metastasis and
the brain was developed. In metastases softer than the
brain parenchyma, also the jet was directed slightly
towards the tumour, and also a plane at the braintumour border was formed. However, separation of the
lesion from the brain was then rather achieved by
dissection with subsequent aspiration of the loosened
tumour fragments than by dissection alone as in firmer
lesions. For this resection, slightly lower waterjet
pressures were required. With those techniques, all
metastases could be accurately separated from the
brain. In all cases, vessels at the brain-tumour border
were preserved with the applied pressures (Fig. 2a, b).
Tumour aspiration could also be obtained in all
metastases independently of their firmness and vascularization. In six metastases, the tumour was softer than
normal brain parenchyma. In these cases, aspiration of
the lesion was easily performed with pressures between
4 and 10 bars, and even in highly vascularized tumours,
vessels were preserved (Fig. 2c). In the firmer lesions,
maximum pressures up to 25 bars were used. However,
only very small amounts of the lesions were aspirated
and many tumour vessels were dissected at pressures of
20 bars and above. Thus, further tumour debulking was
performed with conventional methods in these cases.
Post surgery, all patients were admitted to the
intensive care unit for one night and were transferred
to the neurosurgical ward on the next day. At this stage,
no deterioration of the preoperative neurological
symptoms was observed in any case. Early postsurgical
CT or MRI scans were performed which demonstrated
complete surgical excision of the tumour in all cases. At
present, six patients remained free of brain metastasis at
their last follow up (range 3±8 months; Fig. 3a, b). One
patient (SE) was reoperated for a local recurrence of
her tumour after 1 year. She has been free of tumour
recurrence since then (2-year follow up). In another
patient (LH), a pulmonary embolism occurred at day six
after surgery. The patient survived the embolism but he
suffered from a rapid recurrence of its brain metastasis
from a small cell lung carcinoma. This patient was only
selected for surgery because the primary pathological
diagnosis was squamous cell carcinoma. He died from
myocardial infarction having a large infratentorial metastasis four months later.
Potential complications and risks of
No complications clearly due to the waterjet application
were observed. However, two of the patients presented
with clinical worsening of any kind which could be
considered to be related to the surgical procedure. One
patient (MG) suffered from brain abscess formation at
Figure 3 Pre- (a) and postsurgical MRI (b; 8 months FU) of a
patient with a right frontal breast cancer metastasis.
three weeks after surgery and died of pneumonia after
six weeks. Additionally, a rapid tumour recurrence and
growth with even subcutaneous spreading was observed
in a second patient (MA; Fig. 4a±c). Presently, this
patient with a malignant melanoma is still alive but she is
in the end stage of her disease.
J. OERTEL ET AL.
Figure 4 Preoperative (a), early postoperative (b; 2 months FU) and 3-months postoperative MRI (c) of the patient with the
rapid recurrent and spreading malignant melanoma metastasis.
Since 1982 with the first report of a clinical application of
the device,8 the waterjet instrument has become an
additional surgical tool in liver surgery, and reports of its
use have been frequent.9±13 The advantages of the
instrument compared with ultrasonic aspiration and the
finger fracture technique include a reduction of blood
loss and operation time.9,10 Liver resections in children,11 in patients with cirrhosis,13 and even laparoscopic procedures12 have been reported as possible
indications of this device. The high precision of waterjet
dissection under preservation of blood vessels
and without thermal damage to the surrounding
WATERJET RESECTION OF BRAIN METASTASES
parenchymal structures is a peculiar advantage of this
In neurosurgery, with its still high perioperative risk
for tumour patients due to operative trauma and postsurgical oedema,21 the waterjet device could represent
an enrichment of the neurosurgical armamentarium. It
could lead to a reduction of intraoperative blood loss
and postoperative oedema due to accurate tissue
dissection, vessel preservation, and minimum trauma
to the adjacent brain tissue. Particularly in indications,
where precise tissue dissection such as the separation of
tumour and normal brain is the goal, the instrument
might be helpful in accurate tumour excision without
harming the adjacent brain.
The present study reports the clinical results with this
device in ten patients with intracranial metastatic cancer.
The results show that tumour and adjacent brain can
precisely be separated by the waterjet; tumour debulking can also to be achieved to a variable degree. Very
low pressures are needed for these procedures, and
blood vessels including tumour supplying arteries and
veins are left intact. The procedure is very accurate
and safe. No complications clearly due to the application
of the device were observed. Therefore based on the
results of the present study, the waterjet appears to be
suitable for separation of metastases from the brain and
for resection of tumours which are not firmer than the
surrounding intact parenchyma. But to become a useful
addition to the neurosurgical armamentarium, peculiar
advantages of the waterjet device compared with
conventional techniques have to be demonstrated.
In brain metastasis surgery, tumour debulking by
aspiration does not required precise tissue dissection or
even vessel preservation. It can easily, accurately and
securely be obtained with conventional methods including ultrasonic aspiration techniques. Also the separation
of firm, clearly demarcated brain metastases from the
brain parenchyma is easily and accurately achieved with
conventional methods. Thus at present, we do not see
an indication for the application of the instrument under
In contrast, the waterjet device appears to be
particularly helpful in the separation of soft, poorly
demarcated brain metastases from the surrounding
brain parenchyma. This separation remains rather
challenging with conventional methods, often a plane
between tumour and adjacent parenchyma is difficult to
establish, and tumour remnants causing early recurrences are left in situ. Based on the present results in six
such tumours, the waterjet enables precise and accurate
tumour separation from the brain leaving the adjacent
Summarizing the results of the present study, the
authors are convinced that the instrument will find its
place in the neurosurgical armamentarium for certain
indications including surgery of soft brain metastases.
However, further studies with this device are required.
Evidence has to be given that the instrument allows a
more accurate tumour separation than conventional
Additionally, potential disadvantages of the instrument
such as higher risks of infection or tumour spreading due
to the almost permanent water rinsing have to be
investigated and excluded. In the present study, brain
abscess formation was observed in one patient.
However, no sign for intracranial infection was observed
in the other patients. Also the authors have not
observed any other infections in another 79 procedures
with the instrument. Thus, at present, current results do
not point to a high risk of infection caused by application
of the device.
Rapid tumour recurrence and spreading was found in
one other patient in the presented series. But malignant
melanoma is known for its potential of rapid recurrence
and tumour spreading. No early recurrence or spreading
was observed in the other cases. Thus, the results do
not give evidence of an increased risk for tumour
recurrence or spreading.
Further studies with this device are required to
support our results and to define indications and
contraindications for as well as potential disadvantages
of its application in brain metastases and in other
conditions, such as endoscopic neurosurgery22 and
intracerebral hematoma evacuation.23
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Accepted for publication 12 December 2002