Real Voices interview: Conor Mallucci
Paediatric neurosurgeon at Alder Hey Children’s Hospital, Liverpool
What you do?
I am a consultant paediatric [children’s] neurosurgeon at Alder Hey. I was appointed when I was 31 and I’m now 46, so I’ve been doing it for 14 years. My main interest is paediatric brain tumours, and that’s what I do 90 per cent of the time. I also do other types of brain surgery, including surgery for hydrocephalus [a build-up of fluid on the brain, which can cause it to be damaged] and minimally invasive surgery. Each day is different. It’s a mixture of dealing with emergencies and clinics, seeing patients and operating.
How do you use MRI?
All kids with brain tumours need magnetic resonance imaging (MRI) scans at some point before their operation. It’s standard practice. When you take out a paediatric brain tumour, you’ve only got the surgeon’s word for it that it’s been removed. You need to confirm that with a post-operative [after the operation] MRI scan. This would be done the next day, and if there is some residual tumour, you’d then have to discuss whether to take the child back to theatre within the next couple of weeks to remove that residual tumour. The vast majority of brain tumours do better, and the patient’s chances of survival are much improved, if you remove them completely.
How is intraoperative MRI different?
Intraoperative [during the operation] MRI brings the scanner into theatre. When we think we’ve completed a resection [removal], we keep the head open and move the patient into the scanner, which is next to theatre, through a special transport system. While the head is still open, we do an intraoperative MRI scan. Then we discuss the results, and if we are happy with the scan we go back and close the patient. If we’re not happy, we do more surgery. In the past couple of years, we’ve done more surgery in 30 per cent of cases.
What are the advantages?
It means that we can be sure that we’ve done exactly what we wanted to do – that we’ve resected the whole tumour – at the time of the first surgery without having to wait until the next day for the post-operative scan. That’s particularly important for kids because there’s good evidence that complete resection improves survival in the majority of tumours. Using intraoperative MRI reduces the chance of having to bring the child back for repeated surgery over the next couple of weeks. We used to have a 12 per cent return-to-theatre rate within six months for further surgery. That rate is now zero per cent. In addition, kids need to be anaesthetised for scans, so if you’re doing a scan the next day they have to go all the way back to theatre and be put back to sleep. It’s more trauma for the family. Doing the scan at the time of surgery means we no longer have to do that.
Does this type of MRI have other uses?
It’s predominately used for brain tumours, but it does have other functions. Kids between six months and six years of age need a general anaesthetic to lie still for a scan, so we tend to use the scanner for patients in that age group. We also use it for epilepsy surgery. When we have to resect an abnormality on the brain that’s causing epilepsy, we use the intraoperative MRI to verify that the operation has been successful.
What are the disadvantages?
The problem with intraoperative MRI scanners is that they’re extremely expensive, and paediatric brain tumours are rare. This scanner has benefited a small group of children every year. The parents know that they have benefited, we know we’ve benefited the patients, and we know we’ve improved their survival outlook – but how do you measure that in terms of cost-effectiveness? It’s an expensive luxury, which is paramount to the parent of a child with a brain tumour but not necessarily to the NHS. However, I think in 20 or 30 years’ time, everybody will have an intraoperative MRI. We happened to be the first because we raised the money. I’d prefer to lead rather than follow – I’ve always been keen on innovation. Neurosurgery is driven by technology and its interaction with radiology and advance imaging is so intimate that if you want to do something innovative in neurosurgery you really have to link in with modern imaging techniques and get them into theatre.
Have you had to learn new skills?
You operate in a slightly different way. If you’re going to have to go into a big magnet halfway through the operation, then you have to learn some new skills. We work much more closely with the radiologists and the imaging team. It’s benefited both specialties. We understand much more how we all work. I’ve learnt about imaging and advanced imaging, and as imaging develops we have new techniques such as functional imaging. We pull all that into our surgical planning, and hopefully it brings greater safety, fewer deficits and less harm. It’s a complicated equation that involves computer planning, imaging, physicists, radiologists and neurosurgeons. The final result of that interaction is intraoperative MRI.
How would you sum up your job in a single sentence?
It has to be the best job in the world and the most privileged job in the world.