This quarter’s international section offers a real treat. We had the fabulous opportunity to interview Matteo Zoli, MD. I have known Dr. Zoli for several years; as residents, we had the opportunity to publish a series on endoscopic meningiomas. Since this time, it has been a true pleasure to see Dr. Zoli train and become an up-and-coming world expert on pituitary surgery and expanded endoscopic endonasal surgery. Dr. Zoli hails from the great country of Italy. Masters of meticulous and beautiful surgery have come from Italy, such as Dr. Sanna with lateral skull base, Drs. Cappabianca and Luigi, as well as Dr. Zoli’s mentors, Drs. Frank and Pasquini. In Italy, surgery is not surgery; it is treated much like Michelangelo’s ceiling in the Sistine chapel, it is art. Dr. Zoli has also spent time in the U.S. with Dr. Prevadello at The Ohio State University. He has a unique perspective, and we thank him for sharing it with us.
Jamie J. Van Gompel (JV): Matteo, please describe for us your practice.
Matteo Zoli (MZ): I practice in the neurosurgery department of IRCCS Istituto delle Scienze Neurologiche di Bologna (IRCCS Institute of Neurological Sciences of Bologna) in the northern Italy. Founded in the 1950s by Prof. Mario Milletti and by some general surgeons from the Ospedale Maggiore (Maggiore Hospital), which was destroyed during World War II, our neurosurgery department is one of the oldest in Italy. In 1961, it moved to the Ospedale Bellaria (Bellaria Hospital) where it still exists today. Over time, thanks to the great contribution of many eminent neurosurgeons, such as Prof. Mario Milletti, Prof. Fabio Columella and Prof. Giulio Gaist, among others, it has become a neurosurgical center of national importance.
Currently, in our department we have 44 regular neurosurgical beds for adults, eight for pediatric patients and four dedicated operating rooms available per day. We work in very close collaboration with all the other relevant units of our hospital, whose excellence is acknowledged nationally, such as the Neuro-ICU, where 12 intensive-care beds and four intermediate-care beds are mostly dedicated to neurosurgery needs; the neuroradiology department, where one CT scan, one angiographic suite and two MRI machines (one 3T and one 1.5T) are available every day; and the neurology department, where specific and uncommon skills in neuroscience are collected. A team of 18 neurosurgeons and four residents, directed by Dr. Carmelo Sturiale, are the backbone of the neurosurgery department. We perform an average of 1,800 surgical procedures per year, covering all areas of neurosurgical activities, including functional, pediatric, vascular, trauma, pituitary, open and endoscopic skull base, endoscopic endoventricular and spine surgery. A team, composed of senior and junior surgeons, is dedicated to each subspecialty.
In the last eight years, after my graduation at the Medical School of Bologna, I have worked mainly as resident in the Center of Pituitary and Endoscopic Skull Base Surgery, which was directed by Giorgio Frank, MD, until 2013 and now by Diego Mazzatenta, MD. This center, founded in 1998, was one of the first in the world to have introduced the endoscopic endonasal technique in pituitary and skull base surgery. It is composed of a multidisciplinary team that includes an ENT surgeon, Dr. Ernesto Pasquini; a neuroendocrinologist, Dr. Marco Faustini-Fustini; a neuroradiologist, Dr. Antonella Bacci; and a pathologist, Dr. Gianluca Marucci. Our common interest is to consistently improve patient care and to give our contribution to the scientific knowledge in this field. In particular, we mostly perform pituitary surgery, but our activity has extended to the main skull base pathologies, such as chordomas, menigiomas and CSF leaks, among others.
JV: What attracted you to a neurosurgical practice?
MZ: In 2004, I was a medical student, and thanks to one professor of anatomy, Prof. Gianni Mazzotti, I had the opportunity to spend a summer at New York University (NYU), attending a gross anatomy course. At that time, we had no opportunities to perform cadaveric dissection in Bologna, and discovering the anatomy of the brain was a really exciting experience for me. This chance triggered my passion for this topic so I decided to follow this interest with an internship in neurosurgery, collaborating with the department of human anatomy at the University of Bologna. I realized both my dreams when I was accepted for a neurosurgery residency program in Bologna in 2008 and when a modern and fully-equipped dissection room, available for teaching and research purposes, was opened in 2014 by the University of Bologna.
JV: Despite your largely subspecialized practice, please describe what you believe is the typical practice of neurosurgery in your country.
MZ: Italy is a country with many neurosurgery departments, and the practice differs from one to another. The greatest peculiarity in my town’s hospital is that we don’t treat spine traumas, for which there’s an orthopedic team available at the trauma center of a dedicated hospital. We are consultants for this trauma center as concerns head and brain lesions. In my hospital, we treat all elective, urgent/emergent non-traumatic, brain, degenerative and tumoral spine cases both in adults and children. All facilities, including ICU, angiography suite, CT scan and MRI machines, are available 24/7. Noteworthy is that we offer good skills in multiple treatments, such as neuroradiological endovascular and surgical treatment of brain aneurysms or transcranial and endoscopic approaches for skull base pathologies. This allows us to give to each patient the most effective and tailored treatment within a real patient-based therapeutic model.
JV: What is a typical day in practice for you?
MZ: Different from other health-care systems, in Italy all neurosurgeons working in the same hospital collaborate as a team, sharing patients, knowledge, experience and choosing collegially the treatment strategy in a morning meeting under the supervision of the department director. Each morning, we collectively discuss every single case; we plan surgeries for the following days and confirm surgical indications. In a multidisciplinary weekly conference, we discuss the most challenging cases of the week. As a center for pituitary and endoscopic surgery, we are used to involving also the non-neurosurgical part of the team, which we mentioned above, in the decision-making process, discussing each single pre- or post-operative step together. After the morning meeting, one or more residents and some members of the staff not involved in the surgical activity of the day take care of the patients in the neurosurgery department, and every morning, one of us visits patients in the outpatient clinic. When I am not busy with the daily clinical and surgical activities, I usually spend some hours in our laboratory of endoscopic skull base anatomy to improve my surgical skills and develop our multidisciplinary research projects, including multiple topics related to skull base anatomy that are relevant for both ENTs and neurosurgeons.
JV: Describe how you believe your practice differs from neurosurgery in the Americas.
MZ: The most relevant aspect in which the Italian system differs from the American one consists in sharing all medical decisions with each single team member and with all the colleagues under the responsibility of the department director. In this way, the responsibility is shared, and we can guarantee double-checks on the decisions, especially with the help of senior and more experienced surgeons. No surgeon has the feeling of being left “alone,” facing complications or difficult medical situations. Indeed, each surgeon has a more experienced colleague as mentor or guide who can help him or her to avoid possible dramatic mistakes in every step of their career. However, at the same time, this makes the decision-making process more hierarchic and rigid. A distinctive trait of the Center of Pituitary and Skull Base Surgery is that we share our experience not only with the other neurosurgeons, but also with other specialists, such as the ENT or the endocrinologist. This allows us to provide a real multidisciplinary answer to the patients’ needs.
JV: Describe the biggest issue you see challenging your practice.
MZ: The biggest issue in my practice is the high level of medicolegal risk that we have in Italy, where a high number of surgeons are sued by patients. The main consequence of this unfriendly environment is that a senior and more experienced surgeon is very often preferred for more complex cases, limiting the access to the OR to the junior surgeons and to the residents, especially for the more challenging surgeries.
JV: That issue must be uniform across the world and seems to be the same in the States. Medicolegal risk lingers in all. Describe the biggest issue you see challenging neurosurgery in your country.
MZ: I think that, beyond the high medicolegal risk that I mentioned before, the biggest issue challenging neurosurgery in Italy is represented by the mismatch between the greater number of neurosurgeons than the number of neurosurgical procedures. This is an issue both for training, increasing the number of not properly qualified specialists, and for trained neurosurgeons, increasing the competitiveness between different centers and also within the single center. A further issue, derived by this high level of competitiveness, is the fragmentation of health-care services offering treatment for rare pathologies, such as pituitary and skull base disorders, so that multiple small centers deal with a small volume of patients per year. This has led to a global reduction of the quality of treatments, which should be counteracted by instituting local or national centers of excellence for each specific disease, to which all patients affected by the same pathology should be referred.
JV: What is the biggest opportunity for neurosurgery in your country, moving forward?
MZ: In my country, and in particular, in my hospital, we have already achieved an organizational system and patient management standards at the same level as other European countries or the U.S. Our equipment and technology are optimal, and we already pursue the continuous modernization of surgical techniques and have made a point of keeping our scientific knowledge up-to-date. Currently, our most important goal is to maintain these high standards. I think that one of the greatest contributions that Italy can make to the rest of the world concerns the evaluation and critical analysis of each single innovative treatment. Indeed, in my country, the treatment proposed to the patient is not related to any economic or insurance considerations, and every surgeon is free to adopt the treatment that he or she believes can be the best for the patient. This lack of any external conditioning factors and the substantial stability of the population (Italians do not move across the country with a rate comparable to that of U.S., but are used to staying in their hometown all their lives and sometimes for multiple generations) can give us rare and precious scientific elements to evaluate each surgical treatment in the long term.
JV: Please share with us a unique aspect of neurosurgery in Italy that may not be practiced in the Americas.
MZ: As I said, we have no economic or insurance-related pressure in our daily practice, and our remuneration is not connected to the volume of activity. This allows us to tailor the treatment for each patient, trying to give the best option to everyone without pressure. A peculiarity in our department is the extremely high number of brain surgeries compared with spine surgeries. Indeed, brain surgery represents about 70 percent of our global surgical activity, attracting patients from other cities and regions of the country.
JV: You have a particular interest in endoscopic skull base surgery. How do you feel your practice differs from U.S. practices?
MZ: In our Center of Pituitary and Endoscopic Skull Base Surgery, multidisciplinarity represents a core value of our activity. We do not have a reimbursement system such as the American one, and it is much easier to share the surgical experience with other colleagues. Neurosurgeons and ENT surgeons are used to performing surgery together, which allows us to grow as a team, sharing each procedure and its difficulties within the group. Over time, we have seen that this has led to a common point of view, a common surgical plan and a common treatment strategy agreed by each member of the team, from the ENT to the endocrinologist, avoiding conflicting personal interests and creating a cooperative environment for teaching and sharing knowledge.
JV: What challenges do you see in endoscopic skull base surgery in the future?
MZ: Since its introduction, the endoscopic technique has represented the treatment of choice for a selected number of pathologies, such as pituitary adenomas, craniopharyngiomas, CSF leaks, chordomas, meningiomas, etc. The main features of this technique are its good tolerability and the good outcomes in patients, coupled with its safety. In the future, the efficacy and in particular, the safety of this technique should continue to increase. We believe that this is possible, passing from the initial phase of enthusiasm to a more realistic phase of critical analysis with the aim of identifying the proper indications of this type of surgery and its limits. We are convinced that the reason that induced many surgeons to convert to endoscopy, namely the attempt of achieving the highest level of patient tolerability, will guide us in this phase. A further challenge for this branch of surgery is represented by training. Indeed, the endoscopic endonasal technique requires a long training, which, we think, should be started during the residency program. Conversely, the majority of training programs do not include endoscopic endonasal surgery, which reduces its spread.
JV: Thank you so much for your time and insight into your practice and perspectives. It will be a pleasure to continue to see you ascend as a skull base master.
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