Expert comments

Comments on this technology were invited from clinical experts working in the field and relevant patient organisations. The comments received are individual opinions and do not represent NICE's view.

All 4 experts were familiar with the ViewSite Brain Access System (VBAS) tubular retractors and 3 had used the technology before.

Level of innovation

All experts felt that the technology is relatively established and no longer new, although it is not widely used across the NHS. One expert felt that the technology has the potential to replace standard care for deep brain lesions. Another expert said it could become an alternative first choice, depending on the specific nature of the lesion and its accessibility. The remaining 2 experts said that it would be used in addition to other technologies and minimally invasive approaches for deep brain lesions. Two of the experts noted that other tubular retractors like VBAS are available. Another noted VBAS's unique tapered design, transparent material and availability in a range of diameters and depths. The remaining expert said that the fully endoscopic approach is a competing procedure available to the NHS and felt that this was preferable for deep and difficult to access lesions. The fully endoscopic approach is a minimally invasive brain surgery done using endoscopic instruments through a working channel, under complete endoscopic visualisation. The expert noted that the working channel of endoscopes is smaller than most tubular retractors so has potential to cause less brain injury.

Potential patient impact

Potential patient benefits noted by the experts include reduced brain injury from retraction, earlier recovery, and reduced complications. The experts also noted that use of the technology may allow improved accessibility and visualisation of deep lesions during surgery in a minimally invasive way.

Potential system impact

Three of the experts felt the technology could lead to improved clinical outcomes which would benefit the system. These included shorter procedure times, shorter hospital stays, improved recovery time, avoiding procedure-related complications, improved extent of resection and improved clinical outcomes. One expert did not think the benefit to the healthcare system would be statistically significant compared with the current clinical pathway. Two experts noted that use of the technology involves an initial cost increase for the disposable retractor but felt that its use is likely to save costs overall when considering the impact on areas such as procedure time, clinical outcomes, recovery, and length of hospital stay. One expert was not sure about the cost impact of the technology.

Three experts said that no changes to current facilities would be needed to adopt the technology. Two experts said that training would be needed to ensure safe and efficient use of the technology, while 2 said that initial familiarisation with the system would be enough.

General comments

Two experts noted that the use of VBAS in the NHS has been increasing in recent years. Another said that they expect rapid uptake once it is widely available and known. Another noted that it is readily available in the UK and was aware of multiple centres around the world using it. Three experts were not aware of any issues that would prevent its adoption. One expert said that the only potential barrier to adoption would be hesitation around adopting new technology.

Three experts felt that no further evidence would be needed to adopt the technology. Another noted that randomised controlled trials (RCT) evidence can be difficult to collect because the choice of brain retractors and surgical approach is surgeon specific. The expert noted that although RCT evidence is not impossible, data from retrospective case series may be more appropriate for this type of technology.

All experts noted that the technology would not be used in every hospital but in neurosurgical units only. One of the experts said that it would likely be available in large neurosurgical units that have large numbers of people needing surgery for brain tumours (between 10 and 20 units). Another said that all neurosurgical units in the UK should be able to use it.