An Amazing story – Brain surgery

 By OLIVER FRANKLIN-WALLIS – Wired Magazine -11 Nov ’17

The remarkable story of the world’s first brain surgery… on a bear

“Pizzi has operated on thousands of wild animals, in the wildest conditions. What he’s learned has lessons for innovation – and the planet.”

In 2012, the conservation charity Free The Bears approached Romain Pizzi with an unusual patient. One of the most innovative wildlife surgeons in Europe and perhaps the world, Pizzi is short, with a goatee, dark receding hair and muscular forearms which, when held out ready for surgery, give him the look of an otter on hind legs. A specialist in laparoscopic, or keyhole, surgery – commonplace in humans, but until recently rare in veterinary medicine – he has operated on giraffes and tarantulas, penguins and baboons, giant tortoises and at least one shark, and maintains a reputation for taking on cases others won’t. If you’re in possession of a tiger with gallstones, or a suspiciously sickly beaver, you call Pizzi. As Matt Hunt, CEO of Free The Bears, told me recently,”We have other vets who are incredibly talented. But Romain is one of a kind.”

The patient in question was a three-year-old Asiatic black bear called Champa. Known as moon bears for the white, crescent-shaped markings on their chests, Asiatic black bears are threatened across Asia, where their bile, paws and bones are used as ingredients in traditional medicine. Bears in bile farms are crammed into tiny cages with catheters surgically inserted into their gall bladders to drain the fluid. Countless bears die from infection and open wounds. As a result, moon bears are classified as vulnerable by the IUCN Red List of Threatened Species, indicating a population decline of 30 per cent or more in the last ten years.

Free The Bears, established in 1993, runs sanctuaries for rescued bile bears – moon bears and also sun and sloth bears, which are similarly at risk – in Laos, Vietnam and Cambodia. In 2010, the charity had gifted two rescued sun bears to Edinburgh Zoo, where Pizzi works part-time as a veterinary surgeon. In return, the charity received financial support – and Pizzi. He travelled to Vietnam, working to train local vets, and performed the world’s first laparoscopic gall-bladder removals on rescued bears.

Champa was not your average bear. Rescued as a cub and brought to Free The Bears’ sanctuary in Laos, the bear had a deformed, domed skull and impaired vision. While other bears would socialise, Champa would mope around her enclosure, head down, seemingly in agony. Pizzi suspected she had hydrocephalus, a rare condition in which excess cerebrospinal fluid builds up in the skull, causing brain damage.

“Anywhere else in the world, the recommendation would have been to euthanise her,” says Hunt. But Laos, which has a Buddhist tradition and strict conservation laws shaped in part as a response to the bear bile trade, forbids euthanasia even in cases when it might reduce suffering. So Hunt asked Pizzi for a solution.

“”We have other vets who are incredibly talented. But Romain is one of a kind.”

Veterinary surgeons operate under unique constraints. There’s scale: it’s hard to fit an elephant in an MRI machine. There’s temperament: you don’t want a tiger to wake up on the operating table. And of course there are financial pressures. A cutting-edge surgery on a domestic cat or dog, such as those practiced by Noel Fitzpatrick of TV’s The Supervet, can cost the owner tens of thousands of pounds. By contrast, wildlife charities – even ones working with endangered species – can have annual budgets less than that. What’s more, surgeries are often performed in the field, at sanctuaries and wildlife reserves with few of your average zoo luxuries like sterile theatres and reliable electricity.

“There’s no money in Laos,” Pizzi told me recently. “There’s no MRI scanner in the whole country. They don’t even do the operation on humans; if they can find the money, they’ll take them to Thailand.” No vet had ever attempted to perform brain surgery on a bear before. In Champa’s case, even confirming the diagnosis proved impossible. The nearest human hospital refused to admit a bear for an X-ray.”We started talking with Romain about the possibility of surgery,” Hunt says. “Then we barely heard from him for six months.”

Undeterred, Pizzi contacted the National Museum Of Scotland, which keeps an archive of mammal skeletons for scientific study, and borrowed the skull of a young female moon bear. He X-rayed the skull, then used photogrammetry, in which photographs are stitched together over a 3D model, to create a digital replica. Next, he poured a layer of latex into the brain cavity. When it set, he removed it, and filled that with Plaster of Paris, creating a mould of the space where the bear’s brain would be. “Then I just took photogrammetry again, used some modelling software and put one inside the other. And then I have a model,” Pizzi said, as if it was obvious. He showed me the digital model: “You can see where you’d normally do the surgery for the human is here, but with a bear there’s this big gap because they’ve got a hollow olfactory sinus in the front of their head. This means we have to go in the back way.”

Without an MRI, visualising Champa’s brain in advance was impossible. So Pizzi worked out a way to use an ultrasound probe of the kind used to check unborn babies. “When we drill the little hole for the surgery, you can put the ultrasound gel on the scanner, and you can get that little window,” he says. “Which is not what humans would bother to do, because you’ve got access to an MRI scanner. So you find a different way.” Pizzi sourced the brains of a hydrocephalous red fox and a European otter, suspended in formalin, and consulted with other neurosurgeons.

Pizzi turned to Jonathan Cracknell, a veterinary anaesthetist and regular collaborator – “I’m his gas man,” Cracknell says – to assist. Pizzi and Donna Brown, head veterinary nurse at Edinburgh Zoo, set about sourcing supplies for the six-hour operation. Then, in February 2013, having prepared as much as possible, they packed up their equipment and boarded a plane to Laos.

Romain Pizzi always had an affinity for small and fragile things. Growing up in Port Elizabeth, South Africa, he wanted to be a paediatrician. (“I think that’s a pretty meaningful job,” he says.) Then, when he was a teenage student at Pretoria Boys High School – alumni include Elon Musk – he came across a dove that had fallen from its nest. “I nursed it back to health and then released it,” he says. “It would visit for weeks afterwards.”

He enrolled in the University of Pretoria Veterinary College, and after graduating came to the UK to undertake a Masters at London Zoo. He was stunned how far veterinary-surgery techniques were behind human medicine. He quickly developed an interest in laparoscopy, in which surgical tools are passed into the body through a small tube; the surgeon operates with the use of a camera and light source. “I think there were two of us who started doing it in the UK around the same time,” says Pizzi. Today, he lectures veterinary students on the technique. “He has an incredible thirst for knowledge and an eye for detail, and is always looking to apply or pioneer new techniques in our field,” says Nic Masters, head of veterinary services at London Zoo.

“The challenges of my patients are that with less money, the results have to be – I wouldn’t say better than human surgery, but they have to be really robust,” he says. A smart animal such as a bear will pull out its stitches if it can reach them. Set an ape’s broken arm and it’ll hang from it immediately. Each species presents its own set of unique challenges. “You wouldn’t think about going swimming for weeks if you’d had surgery,” he says. “If we do surgery on beavers, they go back in the water the same or the next day.”

he National Wildlife Rescue Centre in Fishcross is about an hour’s drive north of Edinburgh. In June 2017, I visited Pizzi at work in the facility, which is run by the Scottish Society for the Prevention of Cruelty to Animals (SSPCA). Pizzi splits his time between running the veterinary service here, working at Edinburgh Zoo and travelling for surgeries. Since he joined in 2010, the centre has grown into one of the largest wildlife rehabilitation hubs in the UK.

Every day, members of the public call the SSPCA to report injured wildlife, caused by accident, by each other, but mostly by us. Drivers are dispatched to collect them, and late in the afternoon, the vans roll up to the centre and unload their casualties.

Domestic vets might see hundreds of cats and dogs, but little in the way of diversity. Zoo vets get species variety, but little turnover; not counting invertebrates, the Royal Zoological Society Of Scotland counts around 730 animals on its books. The Rescue Centre treated 9,300 animals in 2016. This year, Pizzi expects that number to surpass 10,000.

A series of low brick buildings and enclosures, the Centre is divided into four sections: Small Mammals; Large Mammals; Seals and Waterfowl; and Birds. The corridors are thick with rasping shrieks and caws. The odour is sharp, acrid, like something you might produce by emptying a pet shop on to a compost heap. Whiteboards in each section list the species currently being held and which need Pizzi’s attention. Today, Birds alone lists woodpeckers; crossbills; jackdaw; crows; robin; thrush; blue tits and great tits; goldfinch; chaffinch; bullfinch; osprey; lapwings; oystercatchers; kestrel; a pheasant; and several varieties of owl.

That caseload has helped Pizzi develop new approaches. When he started working at the Centre and his wife Yolanda – a veterinary cardiologist at Edinburgh University – was away, Pizzi would stay late at night, practising on cadavers, familiarising himself with anatomies, developing new techniques.

“His case load is unusual,” says Claudia Hartley, a veterinary ophthalmologist at the University of Bristol Veterinary School. “Before you take a case, you see who else has done this, on any species, anywhere in the world. Often the literature isn’t massive for an individual species – for endangered species, especially.”

In Small Mammals, Pizzi diagnoses a hedgehog the way you might check a ripe avocado: deliberately, with his fingertips. He cups it in two hands, an old towel draped over its spines, feeling the animal’s abdomen, searching for tenderness. “You can feel the thickness of their intestine,” he says. “If the tissue is swollen, you can feel it. If it’s not just a bit of poo – it doesn’t compress – it’s a section of the intestine that is swollen.”

Pizzi explains how surgeons in China operated on a giant panda with a sore abdomen. “They took the gall bladder out – but it died three days later. For humans, an acute sore abdomen is going to be the gall bladder. But pandas get intestinal problems, not gall bladder problems.”
He can do this, he explains, “Because I’ve felt maybe 10,000 hedgehogs.” He’s seen every affliction: bacteria, broken bones; even a rare case of balloon syndrome, in which a damaged glottis caused a hedgehog to inflate to the size of a beach ball.

“He shows off his endoscopy rig that he has pieced together. “I get a lot on eBay,” he says

His South African lilt is soft, but around patients gets even softer. Wild animals are stressed by human presence, so over time, he has developed ways to reduce this stress. He moves gracefully, telegraphing intent like a dancer leading their partner. He neither hesitates nor hurries. He never holds an animal for longer than necessary. (“To them, being held is like being in the jaws of a predator,” he says.)

It saddens him that the endangered species, the Planet Earth species – lions, rhino, bears – get all the attention, when there are those threatened here in the UK. “I never want to just be doing these big [operations] the media likes,” he says. “I probably make more of a difference here.”

The hedgehog has an infection, so Pizzi prescribes Betamox, an antibiotic, and an anti-fungal for ringworm, which will be administered by veterinary nurses. There’s plenty more to do: a rabbit with a suspected spinal fracture which needs an X-ray, and an exploratory laparoscopy on a beaver called Justin. (“It took me a week to figure out why,” he says. “Justin. Justin Beaver.”)

The SPCC’s budgets don’t stretch very far. But over time, Pizzi has accumulated the equipment he needs. He shows off his endoscopy rig that he has pieced together and topped with a Samsung TV screen and an Archos MP4 player, which serves to record operations or act as a backup display. “I get a lot on eBay,” he smiles proudly. When American hospitals have their assets sold, veterinary surgeons are one of the few beneficiaries.

His desk is littered with GoPro cameras – used for teaching – and a Philips electric razor, to remove fur. There’s a portable X-ray and an ultrasound. “There are very cheap veterinary ones now,” Pizzi says – an unlikely side effect of China’s one-child policy. “People used to tell [the government] they were for veterinary use – for cattle – but used them for selective-sex abortion, so that really drove the market.”

Along one wall are shelves containing sutures, scrubs, gauze, what Pizzi calls “hospital skip-diving”. “All of this is expired NHS stuff – they have expiry dates for humans, but they’re still sterile and usable for animals,” he explains. “Not only that, but the NHS would have to pay to have it incinerated.” Instead, he talks to the hospitals and the materials end up here.

He demonstrates his favourite toy: a FreeHand surgical robot for holding additional implements, which Pizzi can control using a head-mounted sensor. “When I’m travelling I may be working with people whose English is quite poor, so this works quite well.”

His collection, he says, is the result of “being frustrated at not being able to do things well”. But it’s also reflective of the wider field: there is little in the way of a veterinary surgical market, instead surgeons adapt and repurpose tools from human medicine (paediatric implements suit smaller mammals and birds, which require particularly delicate work). Pizzi holds four patents – one is a surgical implement of his own design – and he sits on the advisory board of one device manufacturer, which benefits from his unique perspective.

Elephants are so mammoth that performing an autopsy on one can take 30 people a full day. “An elephant in captivity can’t walk enough, so they sometimes develop arthritis,” says Pizzi. Their legs contain numerous bones which can overlap in an X-ray. Pizzi came across a technique for making simple 3D images that you can view using cinema-type glasses. “We would take an X-ray of an elephant’s leg, move the plate slightly, and take a second.” He can stitch the images together using free software – voilà – 3D X-rays. He tested the technique with veterinary students and found it improved the accuracy of diagnosis; the findings will be presented at an academic conference later this year.

“I like ideas,” he says. “There’s always got to be an easier, simpler, better way to do things. And instead of sometimes going to such a massive expense, sometimes a cheaper way.” For example, before endoscopic surgery the implements must be warmed to body temperature, to avoid the glass components misting up inside the patient. “If you’re the NHS you buy a machine for several thousand pounds to do that for you. Which I found quite ludicrous.” Pizzi’s solution: hand warmers.

No sterilisation equipment? Paraformaldehyde tablets inside a hardware-shop rubble bag work just as well. Photogrammetry can also be done relatively cheaply with a smartphone and laptop software, and the 3D file embedded in a PDF to send overseas for second opinions.

“People think you’re a kook,” he says. “There’s that saying: All progress relies on the unreasonable man.”

Champa’s surgery started poorly. Keyhole surgery requires the use of an insufflator, which uses carbon dioxide to inflate the body cavity enough for the surgical implements to move and see. The problem: when Pizzi and Cracknell arrived in the rescue centre in Laos, they couldn’t find a carbon dioxide cylinder compatible with the machine.

The centre itself lies in a forested national park about 32 kilometres south of the city of Luang Prabang, with few amenities. The answer finally came from an unlikely source. “There was one bar that does draft beer. Once a week they had a keg come up from Luang Prapang,” he says. “They said, OK, we’ll have no draft beer for the next five days.” They donated their CO², which Pizzi managed to connect with some gas piping and hose clamps.

Anaesthesia proved tricky. “She went down on the sedative and stopped breathing,” says Hunt. (“I missed on the first try,” says Cracknell; it was quickly readministered.) The room was cramped and humid, and made hotter by the presence of a BBC documentary unit, which had come to film the procedure. Sweat dripped on to the floor tiles. As Pizzi prepared to drill into the skull – using a Dremel woodworking tool – the room held their breath.

It was indeed hydrocephalus. The 3D model and ultrasound worked; Pizzi was able to fit a ventricul-operitoneal shunt, a tube which sits in the brain cavity and funnels excess fluid down into the abdomen, where it is absorbed by the body.

However, when Pizzi started to fit the tube, a minor disaster struck: the sanctuary’s electricity supply – already stretched by the film crew’s studio lights – blew. “The electrics arced and fused,” says Cracknell. The insufflator was fried.

But Pizzi prepares for these kinds of scenarios. “There’s so many things that can go wrong or break, I try to build in a redundancy for all the main equipment,” he says. He produced his favourite piece of frugal innovation: an inflatable mattress pump. “You run that into the abdomen in short bursts, and it will puff up with air,” says Pizzi. “It’s not filtered, so it’s not ideal, but it’s OK. And if you suddenly have a big bleed, then you run the pump in reverse with a cola bottle for a water trap and use it as suction.”

“He comes up with these amazing things,” says Cracknell. “There are some surgeries where, halfway through, you might think, ‘I’ve bitten off more than I can chew.’ With Romain, I’ve never had one go wrong.”

The surgery took six hours. The next morning, he and Hunt went to Champa’s den, where she was starting to rouse. “For many years she’d been in pain, she’d been blind, she never looked up,” says Hunt. “And we called her, and she looked up and fixed us with her eyes. It was quite amazing.”

Rockhopper penguins kept in captivity are fond of eating anything visitors might choose to drop into their enclosures. The array of items Pizzi has had to surgically remove from their stomachs in the past have included socks, coins, a broken broom handled a pair of batteries.

Tim Flach

Not every animal can be saved. If it can’t be treated, Pizzi will wrap it in a towel – it’s darker in there, calmer – and inject the animal with an overdose of the sedative pentobarbital. “It goes to sleep without being stressed by us being around,” he says, administering a dose to an injured gull. “Seagulls are amazing birds; they can sleep in the air and stay aloft for days. If they were endangered, people would be fascinated.” He places the corpse in a box to be taken to an animal crematorium for disposal.

When he does treat endangered species, there’s always a greater awareness of what its death means. Pizzi has operated on the Socorro dove, a beautiful brown bird native to the Revillagigedo Islands off the west coast of Mexico, now extinct in the wild. And he keeps a photograph of himself with the last known Partula Faba, or Captain Cook’s bean snail, named because it was first discovered on Cook’s expedition in 1791. It died at Edinburgh Zoo in 2016, and its species with it.

When there’s an unusual case, Pizzi will perform the autopsy himself, to try and learn from it. As evening approaches, I watch him cut open Grey Worm, a harbour seal. (This month, seals are Game of Thrones characters.) “She’s been in six months, never been well. We almost put her down twice,” he says. Pizzi had previously operated to remove plastic from her stomach; a common and growing complaint with sea life. Her body is brown, wrinkled and skinny.

Autopsies are teachable procedures, so the veterinary nurses at the centre have gathered around to watch. “She doesn’t have very big lymph nodes, which she might if there was an infection,” he says. There’s a sawing sound and a crack as he opens the sternum. “There’s the heart, the lungs, the diaphragm.”

When Pizzi opens Grey Worm’s stomach, there’s an audible intake of breath. One of the nurses says, “Oh my god.” The seal’s stomach is full, nearly bursting, with bright green plastic. “Bugger,” he sighs, visibly saddened. “This is why.” The plastic is from the non-slip mats that line the seals’ enclosures. With a stomach full of this, Grey Worm had starved.

“Bugger,” Pizzi says again. “It’s my fault.” He should have spotted that the plastic was from the centre during the first operation. But it has treated hundreds of seals, and never had a case like this. (The National Wildlife Centre has since removed the plastic mats.)

For the rest of the day, Pizzi is distant. “He’s very self-critical,” says Colin Seddon, manager of the National Wildlife Rescue Centre. “He always wants to do better.”

“It’s my failures I remember the most,” says Pizzi. “If it doesn’t hurt when things don’t work – things that you could have fixed – and animals die,” he continues, “then you shouldn’t be doing this.”

Pizzi’s caseload has helped him develop new approaches. “I like ideas,” he says. “There’s always got to be an easier, simpler, better way of doing things.”

Later this year, Pizzi will fly back to Laos to operate on Champa again. It’s been four years, but her health has deteriorated. Shunts can become blocked, and the pressure in the brain builds up. He’ll operate, check, and replace if needed.

But maybe that’s not the answer. Maybe it would be better if Champa died. She has improved of late, but remains brain damaged. Released to the wild, she would die. “Things are developing in Laos,” he says. “So we’re not far off being able to put her down if she does deteriorate.”

That’s the question veterinarians have to deal with. How much suffering is enough? If an animal is being kept alive even when they’re suffering, who are we keeping it alive for?

Then again, aren’t all animals we keep alive for our benefit, rather than theirs? If we wanted to save the planet’s wildlife we’d be preserving their habitats, not burning down their forests, polluting their environments and hunting them into extinction. “Conservation – it’s such a meaningless word,” Pizzi says later over dinner in Edinburgh. “Keeping animals and breeding them in captivity, in some people’s minds that’s conservation, because you’re not taking them from the wild. I don’t think that’s genuine. When people come in [to the zoo], they’re not going to save the orang-utans. They just want a good day out.”

As more wildlife is driven to extinction, the pressure on veterinary surgeons to intervene will only grow. “We’re in for a couple of decades where we watch the loss of biodiversity on a massive scale,” says Hunt. “There almost isn’t a wild out there any more.”

When it’s the last rhino or tiger, no expense will be spared. There will be publicity, campaigns, documentaries, T-shirts. But by then it’ll be too late.

“”When people come in [to the zoo], they’re not going to save the orang-utans. They just want a good day out.”

Simon Girling, head of veterinary services at the Royal Zoological Society of Scotland, which runs Edinburgh Zoo, disagrees. “I don’t feel that because an animal was endangered we would act any differently,” he says. Still, several vets I spoke to agreed that the pressure to intervene was greater with endangered species and those that attract visitors.

“In the most threatened species it can be the case where every individual is vitally important to that species’ survival. This is when people may push the boundaries of welfare.” says Martin Whiting, a lecturer in veterinary ethics and law at the Royal Veterinary College, London.

“In veterinary medicine people say, ‘unnecessary suffering’,” says Pizzi. “Which means that there is some suffering we’re OK with.” We hate to see zoo animals suffer, but care little about the cattle slaughtered for agriculture. (Pizzi is a vegetarian.) We fret about mass extinction, but not enough to change our habits.

Therein lies the tragedy at Pizzi’s work: he can develop new ways to save the wildlife, but even if he saves 10,000 animals this year, it’s just a drop in the rapidly acidifying ocean. How much suffering is enough?

He thinks about that a lot. But then he also thinks about the case of a white-tailed sea eagle he treated a few years ago. It had a broken wing and one leg. “It’s easier to kill the bird, and maybe it’s the right thing,” Pizzi says. The bone was protruding through the skin. But the bird had spirit; even then, it tried to fly. “Do I go in and chop a bunch of the dead bone out? How much is too much intervention?” He ended up setting the bones and released it after three months with a tracking implant. Its flight always looked a bit off; to this day he wonders if he should have done more. But the eagle lived, and it flew – until it died, four years later, of natural causes.”

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