Three-Dimensional Endoscopic Endonasal Approach and Outcomes in Sellar Lesions: A Single-Center Experience of 104 Cases

Endoscopic thyroidectomy via chest-collarbone approach versus conventional open thyroidectomy: a retrospective comparative study

OBJECTIVE(S)

Endoscopic thyroidectomy, such as axillary, areola and transoral approaches, offer the advantage of a good cosmetic outcome, but it requires a wider dissection field compared to open thyroidectomy. Recently, chest-collarbone approach thyroidectomy has been widely developed in China because of its shorter anatomical route compared to other endoscopic approaches. This study retrospectively evaluated endoscopic thyroidectomy via chest-collarbone approach in patients with thyroid nodules to determine its feasibility.

METHODS

A total of 46 patients with thyroid disease who underwent endoscopic thyroidectomy between January 2022 and December 2022 were enrolled in the study and randomly matched to patients with thyroid disease who underwent open thyroidectomy at the same time based on nodule size and pathology. Postoperative bleeding, hoarseness situation, hospital stay, postoperative drainage volume, laryngeal nerve palsy, hypoparathyroidism and wound infection were assessed in both groups.

RESULTS

Forty-four patients underwent endoscopic thyroidectomy successfully and two patients changed to open thyroidectomy. The amount of postoperative drainage for the endoscopic thyroidectomy group was 102.78 ± 28.04 mL, and which was 71.91 ± 19.20 for open thyroidectomy group (p < 0.001). The postoperative hospital stay for the endoscopic thyroidectomy group was 8.78 ± 2.57 days, and which was 7.22 ± 1.13 for open thyroidectomy group (p < 0.001). There was no significant difference in postoperative bleeding, hoarseness situation, and wound infection between the two groups. Laryngeal nerve palsy, supraclavicular nerve injury and hypoparathyroidism were not observed in any patient during this study.

CONCLUSION

Chest-collarbone endoscopic thyroid surgery is acceptable. This treatment improves in a good cosmetic outcome in patients with thyroid disease. To assess patients with preoperative nodule size and nature of the case is the impact of the success rate, which is particularly important.

Utility of copeptin in predicting non-pathological postoperative polyuria in patients affected by acromegaly undergoing pituitary neurosurgery

PURPOSE

Copeptin efficiently predicts post-neurosurgical central diabetes insipidus (CDI) in patients with hypothalamic-pituitary lesions, but its role in characterizing changes in diuresis in individuals with acromegaly undergoing neurosurgery remains unexplored. Our study aimed to assess changes in postoperative fluid balance in acromegaly patients and correlate them with both copeptin and growth hormone (GH) levels.

METHODS

This was a secondary analysis of a prospective study involving 15 acromegaly patients undergoing endoscopic endonasal resection at our University Hospital. Fluid balance was assessed daily, and copeptin and GH levels were evaluated preoperatively (T0), and serially on the morning of the first (T2) and second (T3) postoperative day, with an additional measurement of copeptin one hour post-extubation (T1). Patients with pre-existing or post-neurosurgical CDI were excluded from the analysis.

RESULTS

Most patients (11/15) exhibited a negative fluid balance on the second postoperative day, with 4 developing polyuria. Postoperative GH levels did not differ significantly between polyuric and non-polyuric patients, but GH measured at T2 correlated significantly with negative total balance (r = -0.519, p = 0.048). Copeptin levels at T1 were significantly higher in those who developed polyuria (p = 0.013), and a copeptin value > 39.9 pmol/L at T1 showed excellent ability (Sensitivity 100%, Specificity 90.9%, p < 0.001) in predicting postoperative polyuria. Additionally, polyuric patients exhibited a higher T1 / T3 copeptin ratio (p = 0.013) and a negative fluid balance was associated with the remission of acromegaly at 12 months (p = 0.046).

CONCLUSION

The early assessment of copeptin, in addition to facilitating the rapid identification of individuals at increased risk of developing CDI, could also allow the recognition of subjects with a tendency towards non-pathological polyuria in the postoperative setting, at least in individuals affected by acromegaly.

Two- and three-dimensional endoscopic endonasal surgery of large and giant pituitary adenomas-outcome analysis of a series of 62 patients from a single pituitary center

To analyze the perioperative course and clinical outcome of patients with large (lPA) and giant (gPA) pituitary adenoma who underwent endoscopic endonasal transsphenoidal surgery (EETS) using either two-dimensional (2D-E) or three-dimensional (3D-E) endoscopic systems. Single-center retrospective study of consecutive patients with lPA and gPA who underwent EETS between November 2008 and January 2023. LPA were defined as ≥ 3 cm and < 4 cm in diameter in at least one dimension and a volume of ≥ 10ccm; gPA were defined as larger than 4 cm in diameter and with a greater volume than 10ccm. Patient data (age, sex, endocrinological and ophthalmological status) and tumor data (histology, tumor volume, size, shape, cavernous sinus invasion according to the Knosp classification) were analyzed. 62 patients underwent EETS. 43 patients were treated for lPA (69.4%) and 19 patients for gPA (30.6%). 46 patients (74.2%) underwent surgical resection using 3D-E and 16 patients 2D endoscopy (25.8%). Statistical results are referred to the comparison between 3D-E and 2D-E. Patients' age ranged from 23-88 years (median 57), 16 patients were female (25.8%), 46 male (74.2%). Complete tumor resection was possible in 43.5% (27/62), partial resection in 56.5% (35/62). Resection rates did not differ between 3D-E (27 patients [43.5%]) and 2D-E (7 patients [43.8%], (p = 0.985). Visual acuity improved in 30 of 46 patients with preoperative deficit (65.2%). In the 3D-E group 21 of 32 patients (65.7%) improved, compared to 9 of 14 patients in the 2D-E group (64.3%). Improvement of visual field was achieved in 31 of 50 patients (62.0%; 22 of 37 patients in the 3D-E group [59.4%] and 9 of 13 patients in the 2D-E group [69.2%]). CSF leak was the most frequent complication and occurred in 9 patients (14.5%, [8 patients 17.4% 3D-E]) without statistical significance. Other surgical complications like postoperative bleeding, infection (meningitis) and deterioration of visual acuity and field were detected without statistical difference. New pituitary anterior lobe dysfunction was observed in 30 of 62 patients (48.4%, 8 patients [50.0%] in the 2D-E group and 22 patients [47.8%] in the 3D-E group). A transient deficit of posterior lobe was detected in 22.6% (14/62). No patient died within 30 days of surgery. Although 3D-E may improve surgical dexterity, in this series of lPA and gPA it was not associated with higher resection rates compared to 2D-E. However, 3D-E visualization during resection of large and giant PA is safe and feasible and patient's clinical outcome is not different compared to 2D-E.

Current Role of Endoscopic Endonasal Approach for Craniopharyngiomas: A 10-Year Systematic Review and Meta-Analysis Comparison with the Open Transcranial Approach

In recent years, the endoscopic endonasal approach (EEA) for craniopharyngiomas has proven to be a safe option for extensive tumor resection, with minimal or no manipulation of the optic nerves and excellent visualization of the superior hypophyseal branches when compared to the Transcranial Approach (TCA). However, there is an ongoing debate regarding the criteria for selecting different approaches. To explore the current results of EEA and discuss its role in the management of craniopharyngiomas, we performed MEDLINE, Embase, and LILACS searches from 2012 to 2022. Baseline characteristics, the extent of resection, and clinical outcomes were evaluated. Statistical analysis was performed through an X² and Fisher exact test, and a comparison between quantitative variables through a Kruskal-Wallis and verified with post hoc Bonferroni. The tumor volume was similar in both groups (EEA 11.92 cm³, -TCA 13.23 cm³). The mean follow-up in months was 39.9 for EEA and 43.94 for TCA, p = 0.76). The EEA group presented a higher visual improvement rate (41.96% vs. 25% for TCA, p < 0.0001, OR 7.7). Permanent DI was less frequent with EEA (29.20% vs. 67.40% for TCA, p < 0.0001, OR 0.2). CSF Leaks occurred more frequently with EEA (9.94% vs. 0.70% for TCA, p < 0.0001, OR 15.8). Recurrence rates were lower in the EEA group (EEA 15.50% vs. for TCA 21.20%, p = 0.04, OR 0.7). Our results demonstrate that, in selected cases, EEA for resection of craniopharyngiomas is associated with better results regarding visual preservation and extent of tumor resection. Postoperative CSF leak rates associated with EEA have improved compared to the historical series. The decision-making process should consider each person's characteristics; however, it is noticeable that recent data regarding EEA justify its widespread application as a first-line approach in centers of excellence for skull base surgery.

The learning curve of endoscopic endonasal transsphenoidal surgery for pituitary adenomas with different surgical complexity

Objective

To investigate the learning curve under different surgical complexity in endoscopic transsphenoidal approach for pituitary adenoma.

Methods

273 patients undergoing endoscopic transsphenoidal surgery for pituitary adenoma were collected retrospectively and divided into three groups chronologically (early, middle, and late periods). Surgical complexity was differentiated based on Knosp classification (Knsop grade 0-2 vs. Knosp grade 3-4), tumor maximum diameter (MD) (macroadenomas vs. giant adenomas), and history of previous surgery for pituitary adenoma (first operation vs. reoperation). Then the temporal trends in operative time, surgical outcomes, and postoperative complications were evaluated from early to late.

Results

The median operative time decrease from 169 to 147 min across the three periods (P = 0.001). A significant decrease in operative time was seen in the simple groups [Knosp grade 0-2 adenoma (169 to 137 min, P < 0.001), macroadenoma (166 to 140 min, P < 0.001), and first operation (170.5 to 134 min, P < 0.001)] but not in their complex counterparts (P > 0.05). The GTR rate increased from 51.6% to 69.2% (P = 0.04). The surgical period was an independent factor for GTR in the simple groups [Knosp grade 0-2 adenoma: OR 2.076 (95%CI 1.118-3.858, P = 0.021); macroadenoma: OR = 2.090 (95%CI 1.287-3.393, P = 0.003); first operation: OR = 1.809 (95%CI 1.104-2.966, P = 0.019)] but not in the complex groups. The biochemical cure rate increased over periods without statistical significance (from 37.5% to 56.3%, P = 0.181). Although intraoperative CSF leakage rose (from 20.9% to 35.2%) and postoperative CSF leakage reduced (from 12.1% to 5.5%), there was no statistically significant trend across the three time periods (P > 0.05).

Conclusion

This study showed that complex operations might have a prolonged learning curve. Differentiating surgical difficulty and using multivariate combined analysis may be more helpful in clinical practice.

Does High-Definition 3-Dimensional Imaging Improve Orientation During Endoscopic Transsphenoidal Surgery? A Prospective Trial

BACKGROUND

Endoscopy has evolved as the standard visualization tool for endonasal transsphenoidal resection of sellar lesions. The most widely used 2-dimensional (2D) endoscopes harbor the problem of limited depth perception. Therefore, 3-dimensional (3D) endoscopes have been developed to enable depth perception through a stereoscopic view.

OBJECTIVE

To evaluate the impact of high-definition (HD) 2D vs 3D HD endoscopes on spatial orientation within the sphenoid sinus.

METHODS

In this prospective single-center study, 21 patients have been investigated (2021-2022). Eleven standardized anatomic landmarks, which were preoperatively defined on neuronavigation imaging, were intraoperatively targeted with a navigation probe using either 2D HD or 3D HD endoscopes for visualization.

RESULTS

Overall, 3D HD endoscopes provided a statistically significant higher accuracy of identification of sphenoid sinus landmarks (median deviation: 5.2 mm vs 4.2 mm, P < .001). In detail: tuberculum sellae (3.0 mm vs 4.3 mm, P = .047), most anterior point of sella (3.3 mm vs 4.8 mm, P = .049), and clivus indentation (3.8 mm vs 5.3 mm, P = .035). Anatomic variations such as a complex sphenoid sinus configuration had no influence on identifying sphenoid sinus landmarks.

CONCLUSION

According to our data, stereoscopic 3D HD endoscopy enhances intraoperative orientation by improved depth perception within the sphenoid sinus. This may add to the safety of endoscopic skull base procedures, especially in extended approaches and cases with distorted anatomy.

The use of three-dimensional endoscope in transnasal skull base surgery: A single-center experience from China

Objective

The development of skull base surgery in the past decade has been influenced by advances in visualization techniques; recently, due to such improvements, 3D endoscopes have been widely used. Herein, we address its effect for transnasal endoscopic skull base surgery.

Methods

A total of 63 patients who under endoscopic endonasal surgery (EES) with 3-D endoscope were retrospectively reviewed, including pituitary adenomas, craniopharyngiomas, meningiomas, Rathke’s cleft cysts, and chordomas. According to different lesions, transsellar approach (24 cases), transsphenoidal–transtuberculum approach (14 cases), transclival approach (6 cases), and transpterygoid approach (19 cases) were selected.

Results

Total removal of tumors was achieved in 56 patients (88.9%) and subtotal removal in 7 cases (11.1%). Complications included diabetes insipidus in seven patients (11.1%), cerebrospinal fluid (CSF) leakage in two patients (3.2%), major vascular injury occurred in one patient (1.6%), cranial nerve injury in nine patients (14.3%), and meningitis in two patients (3.2%). There was no mortality in the series. All patients recovered and were back to normal daily life, and no tumor recurrence or delayed CSF leakage was detected during the follow-up (2–13 months, mean 7.59 months).

Conclusions

Via 3D EES, it improved depth perception and preserved important neurovascular tissue when tumors were removed, which is important for improving the operative prognosis.

3D Virtual Modeling for Morphological Characterization of Pituitary Tumors: Preliminary Results on Its Predictive Role in Tumor Resection Rate

Among potential factors affecting the surgical resection in pituitary tumors, the role of tumor three-dimensional (3D) features is still unexplored. The aim of this study is to introduce the use of 3D virtual modeling for geometrical and morphological characterization of pituitary tumors and to evaluate its role as a predictor of total tumor removal. A total of 75 patients operated for a pituitary tumor have been retrospectively reviewed. Starting from patient imaging, a 3D tumor model was reconstructed, and 3D characterization based on tumor volume (Vol), area, sphericity (Spher), and convexity (Conv) was provided. The extent of tumor removal was then evaluated at post-operative imaging. Mean values were obtained for Vol (9117 ± 8423 mm3), area (2352 ± 1571 mm2), Spher (0.86 ± 0.08), and Conv (0.88 ± 0.08). Total tumor removal was achieved in 57 (75%) cases. The standard prognostic Knosp grade, Vol, and Conv were found to be independent factors, significantly predicting the extent of tumor removal. Total tumor resection correlated with lower Knosp grades (p = 0.032) and smaller Vol (p = 0.015). Conversely, tumors with a more irregular shape (low Conv) have an increased chance of incomplete tumor removal (p = 0.022). 3D geometrical and morphological features represent significant independent prognostic factors for pituitary tumor resection, and they should be considered in pre-operative planning to allow a more accurate decision-making process.

2D versus 3D Endoscopy: Head-to-Head Comparison in a Simulated Model of Endoscopic Endonasal Dural Suturing

Objective Endonasal dural suturing (EDS) has been reported to decrease the incidence of cerebrospinal fluid fistula. This technique requires handling of single-shaft instrumentation in the narrow endonasal corridor. It has been proposed that three-dimensional (3D) endoscopes were associated with improved depth perception. In this study, we sought to perform a comparison of two-dimensional (2D) versus 3D endoscopy by assessing surgical proficiency in a simulated model of EDS.

Materials and Methods Twenty-six participants subdivided into groups based on previous endoscopic experience were asked to pass barbed sutures through preset targets with either 2D (Storz Hopkins II) or 3D (Storz TIPCAM) endoscopes on 3D-printed simulation model. Surgical precision and procedural time were measured. All participants completed a Likert scale questionnaire.

Results Novice, intermediate, and expert groups took 11.0, 8.7, and 5.7 minutes with 2D endoscopy and 10.9, 9.0, and 7.6 minutes with 3D endoscopy, respectively. The average deviation for novice, intermediate, and expert groups (mm) was 5.5, 4.4, and 4.3 with 2D and 6.6, 4.6, and 3.0 with 3D, respectively. No significant difference in procedural time or accuracy was found in 2D versus 3D endoscopy. 2D endoscopic visualization was preferred by the majority of expert/intermediate participants, while 3D endoscopic visualization by the novice group.

Conclusion In this pilot study, there was no statistical difference in procedural time or accuracy when utilizing 2D versus 3D endoscopes. While it is possible that widespread familiarity with 2D endoscopic equipment has biased this study, preliminary analysis suggests that 3D endoscopy offers no definitive advantage over 2D endoscopy in this simulated model of EDS.

Pituitary metastases from neuroendocrine neoplasms: case report and narrative review

PURPOSE

Pituitary metastases (PM) are uncommon findings and are mainly derived from breast and lung cancers. No extensive review of PM from neuroendocrine neoplasms (NENs) is on record. Here we describe a clinical case of PM from pancreatic NEN and review the clinical features of PM from NENs reported in the literature.

METHODS

A case of PM from a pancreatic NEN followed at our institution is described. We also reviewed the 43 cases of PM from NENs reported in the literature.

RESULTS

A 59-year old female patient, previously submitted to duodeno-cephalo-pancreasectomy for a well-differentiated pancreatic NEN, with known hepatic metastases, underwent a ⁶⁸ Ga-DOTATOC PET/CT that revealed an uptake in the pituitary gland. A subsequent MRI displayed a pituitary lesion, with suprasellar extension. After a hormonal and genetic diagnostic workup that excluded the diagnosis of MEN 1, the worsening of headache and visual impairment and the growth of the lesion lead to its surgical removal. A pituitary localization of the pancreatic NEN was identified. Regarding the published cases of PM from NENs, the most common tumour type was small cell lung cancer (SCLC), accounting for nearly half of the cases, followed by bronchial and pancreatic well differentiated NENs. The most frequent symptom was a variable degree of visual impairment, while headache was reported in half of the cases. Partial or total anterior hypopituitarism was present in approximately three quarters of the cases, while diabetes insipidus was less common. The most frequent treatment for PM was surgical resection, followed by radiotherapy and chemotherapy. The clinical outcome was in line with previous reports of PM from solid tumours, with a median survival of 14 months. Surgery of PM was associated with prolonged survival.

CONCLUSIONS

PM from NENs have clinical features similar to metastases derived from other solid tumours, albeit the involvement of the anterior pituitary seems more frequent; a thorough pituitary hormonal evaluation is mandatory, after focused radiological studies, particularly if a surgical approach is considered. The optimal management of PM remains disputed and seems mainly driven by the aggressiveness of the primary tumour and the presence of symptoms. In well-differentiated NENs, particularly in the case of symptomatic PM, surgical removal may be a reasonable approach.

Comparative Evaluation of 3-Dimensional High Definition and 2-Dimensional 4-K Ultra-High Definition Endoscopy Systems in Endonasal Skull Base Surgery

BACKGROUND

The differences between 3-dimensional (3D) high definition (HD) and 2-dimensional (2D) 4-K ultra-HD (4K) endoscopy and their respective advantages remain unclear.

OBJECTIVE

To evaluate the utility of these endoscopy systems in endonasal skull base surgery.

METHODS

Consecutive series of endoscopic endonasal surgeries performed after introduction of 3D/HD and 2D/4K systems (July 2017) were retrospectively evaluated. Sporadic cases treated with either system, or a conventional 2D standard definition (SD) system, during the rental period from March 2016 were also included. Objective comparisons between the systems were made for newly diagnosed Knosp grade 0 to 3 pituitary adenomas. Surgical procedures were divided into nasal, sphenoidal, and intradural phases, and the surgical procedural time was compared for each phase. The time required for and accuracy of suturing the sellar floor dura was also evaluated.

RESULTS

A total of 74 cases were treated with 3D/HD and/or 2D/4K, and 12 cases with 2D/SD. 3D/HD was advantageous in the nasal phase because of its intuitive depth perception. 2D/4K was advantageous in the intradural phase because of its superior image quality. Surgical time of the nasal phase with 3D/HD, and that of the intradural phase with 2D/4K, were significantly shorter than that with 2D/SD. The time required for and accuracy of sellar floor dural suturing showed a trend toward improving in the order of 2D/SD, 2D/4K, and 3D/HD.

CONCLUSION

3D/HD and 2D/4K endoscopy systems have different advantages, which are useful in distinct surgical phases. Understanding the characteristics of endoscopy systems is important for selecting the most appropriate system for distinct surgical situations.

Creative and Innovative Methods and Techniques for the Challenges in the Management of Adult Craniopharyngioma

Craniopharyngioma remains a major challenge in daily clinical practice. The pathobiology of the tumor is still elusive, and there are no consensus or treatment guidelines on the optimal management strategy for this relatively rare tumor. However, recent technical and scientific advances, including genomic and radiomic profiling, innovation in surgical approaches, more precise radiotherapy protocols, targeted therapy, and restoration of lost functions all have the potential to significantly improve the outcome of patients with craniopharyngioma in the near future. Although many of these innovative tools in the new armamentarium of the clinician are still in their infancy, they could reduce craniopharyngioma-related morbidity and mortality and improve the patients' quality of life. In this article, we discuss these creative and innovative approaches that may offer solutions to the obstacles faced in treating craniopharyngioma and future possibilities in improving the care of these patients.

Skull base reconstruction: A question of flow? A critical analysis of 521 endoscopic endonasal surgeries

INTRODUCTION

Post-operative CSF leak still represents the main drawback of Endoscopic Endonasal Approach (EEA), and different reconstructive strategies have been proposed in order to decrease its rate.

OBJECTIVE

To critically analyze the effectiveness of different adopted reconstruction strategies in patients that underwent EEA.

MATERIALS AND METHODS

Adult patients with skull base tumor surgically treated with EEA were retrospectively analyzed. Data recorded for each case concerned patient demographics, type of surgical approach, histotype, anatomical site of surgical approach, intra-operative CSF leak grade (no leak (INL), low flow (ILFL), high flow (IHFL)), reconstructive adopted strategy, Lumbar Drain positioning, post-operative CSF leak rate and intra/post-operative complications.

RESULTS

A total number of 521 patients (January 2012-December 2019) was included. Intra-operative CSF leak grade showed to be associated with post-operative CSF leak rate. In particular, the risk to observe a post-operative CSF leak was higher when IHFL was encountered (25,5%; Exp(B) 16.25). In particular, vascularized multilayered reconstruction and fat use showed to be effective in lowering post-operative CSF leaks in IHFL (p 0.02). No differences were found considering INL and ILFL groups. Yearly post-operative CSF leak rate analysis showed a significative decreasing trend.

CONCLUSION

Intra-operative CSF leak grade strongly affected post-operative CSF leak rate. Multilayer reconstruction with fat and naso-septal flap could reduce the rate of CSF leak in high risk patients. Reconstructive strategies should be tailored according also to the type and the anatomical site of the approach.

Second-Day Morning Cortisol Levels after Transsphenoidal Surgery Are Accurate Predictors of Secondary Adrenal Insufficiency with Diagnostic Cut-Offs Similar to Those in Non-Stressed Conditions

INTRODUCTION

Multiple studies tried to identify cortisol cut-offs after pituitary surgery that could accurately assess hypothalamic-pituitary-adrenal (HPA) axis function; however, there is no consensus nowadays. This study aimed to evaluate the accuracy of morning cortisol after transsphenoidal surgery in predicting long-term secondary adrenal insufficiency.

METHODS

In our tertiary center, we prospectively determined first- and second-day cortisol after transsphenoidal surgery in 92 patients without preoperative adrenal -insufficiency and not treated with glucocorticoids perioperatively. Definitive diagnosis of secondary adrenal insufficiency was obtained with re-evaluation 3 months after trans-sphenoidal surgery and clinical follow-up of at least 1 year.

RESULTS

Ten patients (10.8%) developed long-term postoperative secondary adrenal insufficiency. The ROC curves demonstrated that first-day cortisol had a moderate diagnostic accuracy, while a second-day cortisol ≤9.3 µg/dL (257 nmol/L) showed the best performance in predicting adrenal insufficiency (sensitivity [Se] 88.9%, specificity [Sp] 86.9%, AUC 0.921). Moreover, a second-day cortisol ≤3.2 µg/dL (89 nmol/L) was able to diagnose adrenal insufficiency in 100% of cases (Se 22.2%, Sp 100%) and >14 µg/dL (386 nmol/L) was able to exclude ACTH deficiency (Se 100%, Sp 57.4%).

CONCLUSIONS

Adrenal function can be carefully studied on the second day after pituitary surgery, using cut-off values that international guidelines suggested for non-stressed conditions. In fact, second-day cortisol levels ≤3.2 μg/dL (89 nmol/L) and >14 μg/dL (386 nmol/L) are diagnostic of secondary adrenal insufficiency and normal function, respectively. We also suggest performing a definitive re-evaluation with an HPA axis stimulation test when second-day cortisol values are between 3.3 and 14 μg/dL (90-386 nmol/L).

Three-Dimensional versus 2-Dimensional Endoscopic Third Ventriculostomy: Surgical Results of a Preliminary Comparative Study

BACKGROUND

Three-dimensional (3-D) endoscopes have been widely used for a large variety of approaches in neurosurgical practice. However, in the last decade, 3-D scopes were barely used for ventricular surgery. In this study, we illustrated our preliminary experience with a 3-D endoscope for third ventriculostomy using new dedicated endoscopic equipment.

METHODS

Over a 12-month period, a high-definition 3-D endoscopic third ventriculostomy (ETV) was performed in 14 patients with obstructive hydrocephalus. Patients were followed prospectively and compared retrospectively with a matched group of 16 similar patients who underwent ETV with a standard 2-dimensional (2-D) endoscope. Surgical outcome and intra- and postoperative course were retrospectively reviewed.

RESULTS

3-D ETV provided excellent surgical results, and no significant difference was shown in terms of outcome, complication, and length of hospitalization between the 2 groups. Moreover, operative time (minutes) was significantly shorter in the 3-D group than the 2-D ETV group (19.9 ± 4.8 vs. 22.9 ± 1.4, respectively; P < 0.05), and the use of the 3-D endoscope provided subjective improvements of depth perception, hand-eye coordination, and surgeon comfort.

CONCLUSIONS

Our preliminary study clearly demonstrated the effectiveness of 3-D ETV and provided a significant reduction of operative time. Depth information from the 3-D scope appears to facilitate rapid and stable ETV maneuvers, representing a critical development that may become a valuable tool for neuroendoscopy.

3-D endoscopy in surgery of pituitary adenomas, prospective evaluation of patient gain using basic outcome parameters

The present prospective cohort study evaluates the effect of three-dimensional (3-D) endoscopy on outcome in transphenoidal endoscopic surgery of pituitary adenomas compared to conventional two-dimensional (2-D) endoscopy. Prospective data was collected from patients undergoing endoscopic surgery for pituitary adenomas before and after the introduction of 3-D endoscopy. Patients, grouped by having 2-D or 3-D endoscopic surgery, were compared in regard to procedure time, intraoperative blood loss, complications, hospital stay, grade of resection and quality of life (QoL). Twenty-six patients having surgery with 2-D endoscopy were compared with 29 patients having surgery with 3-D endoscope. Only primary procedures were included. There were no significant differences in baseline characteristics between the two groups. No statistically significant differences in outcome were noted with 3-D endoscopy. Procedure time, complication rate, hospital stay, rate of gross total resection and post-operative QoL were unaffected by surgical technique though there were non-significant increases in new pituitary insufficiency with 3-D endoscopy and diabetes insipidus with 2-D endoscopy. This prospective cohort study fails to show obvious outcome advantages with 3-D endoscopy in pituitary surgery using basic parameters including post-operative QoL. To our knowledge this is the first prospective study published on the matter, thus corroborating results from previous retrospective studies with similar results on 3-D neuroendoscopy and 3-D endoscopy in general. The main advantage of increased depth perception is more likely found in more complex extended transphenoidal skull base procedure.

Surgical management of pituitary adenomas: does age matter?

PURPOSE

Along with increased life expectancy and improvements in the diagnostic tools and techniques, the number of elderly patients with symptomatic pituitary tumors being evaluated for surgery is increasing. To date, contrasting results of the safety and effectiveness of transsphenoidal surgery in patients over 65 years old were published in the medical literature. An investigation concerning the extension of resection, post operative complications and, recovery rate from endocrinological and visual symptoms in elderly patients who underwent transsphenoidal surgery for pituitary adenoma was conducted.

METHODS

A retrospective review, which included a series of 81 patients 65 years old or older who underwent endoscopic endonasal surgery for pituitary adenomas was analyzed. Pre operative and post operative data were collected and patients were then compared among four age groups: 65-69 years old, 70-74 years old, 75-79 years old and 80 years and over. The results were then compared with the findings from the medical literature review.

RESULTS

The statistical analysis failed to highlight any difference in terms of clinical presentation or complications among the four age groups, however there seems to be a slightly higher risk of post operative hypopituitarism in patients over 74 years old.

CONCLUSION

The results of the study seem to confirm that transsphenoidal surgery for PA is safe and effective among patients that are 65 and over. Moreover, a partial resection is preferred over a gross total one in order to reduce the surgical risk.

Common tools for pituitary adenomas research: cell lines and primary cells

PURPOSE

Pituitary tumor is the common primary brain tumor in humans. For further studying the pathogenesis and new therapeutic targets of pituitary adenoma, cell lines and primary cells are necessary tools. Different from primary cells that have short survival time and hormone secretion maintenance time, cell lines would be endowed with immortal characteristics under the help of gene modification. This review is to explore whether these cell lines still have similar pathophysiological changes in pituitary adenoma cells and methods to prolong the lifespan of pituitary adenoma primary cells.

RESULTS

In the cell lines summarized in the review, HP75, PDFS, HPA and GX were derived from human pituitary adenomas. It was found that the cell lines commonly used in articles published between January 2014 and July 2019 were GH3, AtT20, MMQ, GH4C1, HP75 and TtT/GF. Besides, it was glad that many methods had been used to prolong the lifespan and maintain characteristics of pituitary adenoma primary cells.

CONCLUSION

The paper reviews most of pituitary adenoma cell lines that have been successfully established since 1968 and the relevant situation of primary culture of pituitary adenoma cells. Obviously, it requires us to make more efforts to obtain human pituitary adenoma cell lines and prolong the lifespan of pituitary adenoma primary cells with maintaining their morphology and ability to secret hormones.

The effect of three-dimensional visualisation on performance in endoscopic sinus surgery: A clinical training study using surgical navigation for movement analysis in a randomised crossover design

OBJECTIVES

Endoscopic imaging techniques and endoscopic endonasal surgery (EES) expertise have evolved rapidly. Only few studies have assessed the effect of three-dimensional (3D) endoscopy on endoscopic sinus surgery (ESS). The present study aimed to objectively and subjectively assess the additional value of 3D high-definition (HD) endoscopy in ESS.

DESIGN

A randomized crossover study of endoscopic surgery performance, using five ESS tasks of varying complexity, performed on Thiel embalmed human specimens.

SETTING

Simulated surgical environment.

PARTICIPANTS

Thirty participants, inexperienced in ESS.

MAIN OUTCOME MEASURES

Performance was assessed using video imaging, surgical navigation and questionnaires. Main outcome measures were as follows: efficiency (defined by time to task completion), distance covered inside the nose, average velocity towards target, accuracy (measured by error rate), and subjective assessment of endoscope characteristics.

RESULTS

During ESS tasks, both efficiency and accuracy did not differ significantly between 2D HD and 3D HD endoscopy. Subjectively, imaging characteristics of the 3D HD endoscope were rated significantly better.

CONCLUSIONS

ESS performance of inexperienced participants was not significantly improved by the use of 3D HD endoscopy during ESS tasks, although imaging characteristics of the 3D HD endoscope were rated significantly better. Surgical field characteristics and surgical techniques are likely to influence any additional value of 3D HD endoscopy.

Low-Grade Chondrosarcoma In The Sellar Area: Case Report And Literature Review

Low-grade chondrosarcoma (LGC) is a very rare intracranial tumor, particularly in the sellar area. Herein, we describe an unusual case of LGC occurring in the sellar area. A 52-year-old man presented with diminution of vision for more than 3 months, but did not exhibit headaches reported in previous cases. MRI showed that the maximum size of the tumor was 7 cm on the left side of the saddle. We characterized the specific pathological characteristics. Histologically, the tumor had polypoid areas and a lobulated growth pattern under low-power examination. At high magnification, the tumor consisted of small cells with hyperchromatic nuclei in the cartilage matrix, with an alternating loose hypocellular zone and rich myxoid area. In our case, LGC needed to be distinguished from chordoma. Immunohistochemically, the tumor cells showed diffuse positivity for S-100 and vimentin, IDH1 was weakly cytoplasm positive. The Ki-67 labeling index was less than 5%. Additionally, AE1/3, EMA, and CK19 were negative, which could be used to exclude chordoma. This case report expands the literature on LGC and will help clinicians and pathologists better understand this entity.

3D video-assisted trans-oral removal of deep hilo-parenchymal sub-mandibular stones

The aim of this paper is to describe the intra-operative findings and surgical results of the first application of 3D high-definition (HD) endoscopic support to the trans-oral surgical treatment of five patients with deep hilo-parenchymal sub-mandibular stones who underwent clinical and ultrasonographic (US) follow-up examinations at one month after the procedure. Five patients undergoing 2D-HD video-assisted transoral surgery for the same condition were used as controls. The results were classified as successful (US - demonstrated complete clearance) or unsuccessful (US - demonstrated total or partial persistence). Visual analogue scales (VAS) were used post-surgically to evaluate the sharpness and brightness of the 2D and 3D images on the screen and stereoscopic depth perception (SDP) of the 3D-HD endoscope. Successful stone removal and significant subjective improvement (lack of obstructive symptoms) was obtained in all but one of the patients in the 3D group, in whom the one-month US evaluation revealed a residual 3 mm asymptomatic hilo-parenchymal stone that was successfully treated by sialendoscopy-assisted intra-corporeal laser lithotripsy. Wharton’s duct and the lingual nerve were identified and preserved in all cases. The mean 3D-HD VAS results were brightness 7 (range 6-8), sharpness 7.8 (range 7-9) and SDP 8.2 (range 8-9); the mean 2D-HD results were brightness 7.8 (range 7-9) and sharpness 7 (range 7-8). Our findings confirm the safety and efficacy of conservative transoral surgical treatment of hilo-parenchymal sub-mandibular stones. From a surgeon’s perspective, 3D-HD guided exploration of the oral floor seems to provide a better view of Wharton’s duct and the lingual nerve, especially near the sub-mandibular parenchyma. The 3D-HD video-assisted transoral removal of deep hilo-parenchymal sub-mandibular stones can therefore be considered a useful new means of preserving the function of an obstructed salivary gland.

Utilization of the Nasoseptal Flap for Repair of Cerebrospinal Fluid Leak after Endoscopic Endonasal Approach for Resection of Pituitary Tumors

Background

One of the most frequent complications after endoscopic endonasal approach (EEA) for resection of pituitary tumors is cerebrospinal fluid (CSF) leaks. With the introduction of the pedicled nasoseptal flap, the reconstruction of the skull base has improved significantly resulting in a decrease in the occurrence of persistent CSF leaks. We present our experience utilizing the pedicled nasoseptal flap technique after EEA for reconstruction of the skull base in cases where CSF leak was detected.

Methods

Data for patients undergoing EEA for pituitary tumors was retrospectively reviewed. These included demographic, clinical, operative, radiographic, and pathological information. Incidence of post-operative complications and CSF leaks were recorded. Descriptive statistical analysis was performed.

Results

Between 2008 and 2015, 67 patients and 69 hospital admissions with pituitary tumors underwent a nasoseptal flap to reconstruct a skull base defect at Johns Hopkins Hospital. The mean age at surgery was 54.5±14.2 years. Fifty-two percent of patients were male. Forty-six percent of patients were white, 33% African-American, and 12% belonged to other racial groups. There was an intraoperative CSF leak in 39% of patients. Seventy percent of patients with an intraoperative CSF leak had a nasoseptal flap reconstruction of the skull base. There were zero postoperative CSF leaks.

Conclusion

With the introduction of the pedicled nasoseptal flap for reconstruction of the skull base after EEA for resection of pituitary adenomas, the incidence of postoperative CSF leaks has decreased significantly. In this retrospective analysis, we demonstrate the effectiveness of the use of nasoseptal flap in repairing CSF leak after EEA.

The Endoscopic Endonasal Approach to Craniovertebral Junction Pathologies: Surgical Skills and Anatomical Study

INTRODUCTION

Surgical anterior decompression is the treatment of choice for symptomatic irreducible ventral craniovertebral junction (CVJ) compression. Along with the classic transoral approach, the endoscopic endonasal approach has evolved and is gaining growing success.

MATERIALS AND METHODS

In this work we discuss the surgical technique, give a complete step-by-step description of dissection of the craniovertebral junction and report a specific case of endoscopic endonasal odontoidectomy with use of a high-definition (HD) three-dimensional (3D) endoscope.

DISCUSSION

The extended endonasal approach exploits an anatomical corridor to the odontoid process, involving only a small incision in the nasopharynx and sparing palate integrity. The most important limitation of the technique is 2D visualization, which hinders correct recognition of anatomical structures.

CONCLUSION

The endoscopic endonasal route to the odontoid process has proven to be a feasible, safe and well-tolerated procedure. Anatomical study is very important for better understanding of the 3D anatomy of the CVJ and relation of critical neurovascular structures to specific bony and muscular landmarks.

Nasal Functions in Three-Dimensional Endoscopic Skull Base Surgery

OBJECTIVES

Endoscopic transnasal transsphenoidal surgery has become the standard procedure for the majority of skull base diseases, including sellar, parasellar, and clival pathologies. The aim of this study was the objective evaluation of nasal airflow resistances and olfactory function in 3-dimensional (3D) endoscopic transnasal transsphenoidal surgery.

METHODS

One hundred patients who underwent 3D transnasal endoscopic surgery for sellar, parasellar, and clival diseases were enrolled. Active anterior rhinomanometry and Sniffin' Sticks tests were performed before endoscopic surgery and at 3 and 6 months postoperatively.

RESULTS

No significant difference about nasal airflow resistance and olfactory function was observed between preoperative and postoperative subjective and objective scores. In the group of patients with sellar and parasellar diseases, a worst nasal respiratory function was seen when crusting was present, and a worst olfactory function was observed in patients with synechiae. Nasal functions returned to previous levels when crusting or synechiae solved. No statistically significant correlation was observed between the evaluated nasal functions and the reconstruction with flaps.

CONCLUSIONS

The 3D endoscopic transnasal transsphenoidal surgery represents a more and more important tool in skull base surgery. It does not determine nasal respiratory and olfactory alterations after the treatment, without an increase in nasal complaints that could worsen quality of life.

The experience with transsphenoidal surgery and its importance to outcomes

PURPOSE

Surgical experience is considered paramount for excellent outcome of transsphenoidal surgery (TSS). However, objective data demonstrating the surgical success in relation to the experience of pituitary surgery units or individual experience of pituitary surgeons is sparse.

METHODS

Based on literature data, we have investigated the influence of experience with TSS for pituitary adenomas on endocrinological remission rates and on operative complications. The surgical experience was assessed by calculating the number of transsphenoidal operations per year.

RESULTS

For TSS of microprolactinomas, mean remission rates were 77% in centers with < 2 operations per year for microprolactinomas, 82% with 2-4 operations, 84% with 4-6 operations, and 91% with > 6 operations. A yearly experience with more than 10 initial operations for Cushing's disease (CD) warrants a remission rate exceeding 70%. Remission rates in CD exceeding 86% have only been reported for single surgeon series. Extraordinarily high complication rates were found in some series with < 25 yearly total operations for pituitary adenomas. Major vascular complications were less than 2% and revision rates for rhinorrhea usually < 2.5% in centers performing > 25 transsphenoidal operations per year.

CONCLUSIONS

We conclude that a center with experience of > 25 transsphenoidal operations for pituitary adenomas per year provides a high likelihood of safe TSS. Surgery for CD requires a particularly high level of practice to guarantee excellent remission rates. The endocrinologist has the unique opportunity to audit the surgical success by hormone measurement and to refer patients to neurosurgeons with proven excellence.

Endoscopic Endonasal Surgery for Removal of Pituitary Adenomas: A Surgical Case Series of Treatment Results Using Different 2- and 3-Dimensional Visualization Systems

BACKGROUND

Endoscopic endonasal transsphenoidal surgery (EETS) is a common treatment for patients with pituitary adenomas (PAs). A disadvantage of endoscopic surgery has been the lack of stereoscopic vision and depth perception. Recent developments offer high-definition 3-dimensional (3D-HD) visualization with a higher resolution and better image quality compared with 3D standard endoscopy (3D-SD). In this study, we compared treatment results of surgically treated patients with PAs using 3 different visualization systems: 2-dimensional (2D)-HD, 3D-SD, and 3D-HD.

METHODS

Data from patients with primary PAs that were surgically treated between December 2008 and December 2017 were analyzed. Preoperative and postoperative tumor size and location, perioperative complications, and ophthalmologic, endocrine, and clinical outcomes were compared.

RESULTS

A total of 170 patients underwent endoscopic resection of a primary PA (54 patients with 2D-HD, 75 with 3D-SD, and 41 with 3D-HD). Preoperatively, no statistical differences were found for tumor size, extension, and endocrine and ophthalmologic status. Tumor resection was not statistically different among the 3 groups. Complete resection was performed in 33 patients (80%) in the 3D-HD group, 54 patients (72%) in the 3D-SD group, and 39 patients (72%) in the 2D-HD group. The number of complications was not different across the groups (P = 0.436). Ophthalmologic outcomes did not differ based on EETS technique. The rate of new pituitary insufficiency was slightly lower in the 3D-HD group compared with 2D-HD and 3D-SD groups (4.8%, 16.6%, and 12%, respectively; P = 0.290).

CONCLUSIONS

Although the resection rate was higher in the 3D-HD group, and subjective advantages of the 3D-HD endoscopes were noted, there were no significant differences in terms of gross total resection or new hormonal deficits among the 3 groups.

Endoscopic endonasal transsphenoidal surgery using the iArmS operation support robot: initial experience in 43 patients

Objective The intelligent arm-support system, iArmS, which follows the surgeon's arm and automatically fixes it at an adequate position, was developed as an operation support robot. iArmS was designed to support the surgeon's forearm to prevent hand trembling and to alleviate fatigue during surgery with a microscope. In this study, the authors report on application of this robotic device to endoscopic endonasal transsphenoidal surgery (ETSS) and evaluate their initial experiences. Methods The study population consisted of 43 patients: 29 with pituitary adenoma, 3 with meningioma, 3 with Rathke's cleft cyst, 2 with craniopharyngioma, 2 with chordoma, and 4 with other conditions. All patients underwent surgery via the endonasal transsphenoidal approach using a rigid endoscope. During the nasal and sphenoid phases, iArmS was used to support the surgeon's nondominant arm, which held the endoscope. The details of the iArmS and clinical results were collected. Results iArmS followed the surgeon's arm movement automatically. It reduced the surgeon's fatigue and stabilized the surgeon's hand during ETSS. Shaking of the video image decreased due to the steadying of the surgeon's scope-holding hand with iArmS. There were no complications related to use of the device. Conclusions The intelligent armrest, iArmS, seems to be safe and effective during ETSS. iArmS is helpful for improving the precision and safety not only for microscopic neurosurgery, but also for ETSS. Ongoing advances in robotics ensure the continued evolution of neurosurgery.

Endoscopic Endonasal Transsphenoidal Approach From the Surgeon Point of View

OBJECTIVE

In February 2009, the authors' center formed a team of neurosurgeons, otolaryngologists, endocrinologists, and radiologists to perform pituitary surgery using the endoscopic endonasal transsphenoidal approach (EETSA). This paper reviews the authors' experience with the technique, pathological outcomes, hormone profiles, and postoperative complications.

METHODS

Between February 2009 and December 2015, 535 patients underwent the EETSA with 2-nostrils/4-hands surgery. All of the patients had preoperative neurophthalmological and endocrinological assessments and neuroimaging. Patients were followed for at least 6 months with otolaryngological evaluations.

RESULTS

The most common pathology treated was pituitary adenomas, with 390 (72.9%) patients. Of these, 287 (73.6%) were nonfunctioning adenomas. As the surgical method, the conventional 2-nostrils/4-hands technique was performed in 77 patients (14.4%), a right conventional nasoseptal flap and left modified nasoseptal rescue flap technique was used in 135 patients (25.2%), and bilateral modified nasoseptal rescue flaps were used in 323 patients (60.4%). Postoperative complications occurred in 46 patients (8.6%). The most common complications were vascular injury or hematoma (10 patients, 1.9%), and the most common postoperative sinonasal complaints were hyposmia or anosmia. Olfactory function was significantly decreased according to the Connecticut Chemosensory Clinical Research Center test (P <0.001) and Cross-Cultural Smell Identification Test scores (P <0.001) evaluated 6 months postoperatively.

CONCLUSIONS

Skull-base tumor surgery via an EETSA with a team approach was performed for various extended tumors. It is important to consider postoperative sinonasal dysfunction, such as hyposmia or anosmia, and to have this followed by an otolaryngologist.

Outcome of endoscopic vs microsurgical transsphenoidal resection for Cushing's disease

INTRODUCTION

It is unclear whether the proportions of remission and the recurrence rates differ between endoscopic transsphenoidal surgery (TS) and microscopic TS in Cushing's disease (CD); thus, we conducted a systematic review and meta-analysis to evaluate studies of endoscopic TS and microscopic TS.

METHODS

We conducted a comprehensive search of PubMed to identify relevant studies. Remission and recurrence were used as outcome measures following surgical treatment of CD.

RESULTS

A total of 24 cohort studies involving 1670 adult patients were included in the comparison. Among these studies, 702 patients across 9 studies underwent endoscopic TS, and 968 patients across 15 studies underwent microscopic TS. Similar baseline characteristics were observed in both groups. There was no significant difference in remission between the two groups: 79.7% (95% CI: 73.1-85.0%) in the endoscopic group and 76.9% (95% CI: 71.3-81.6%) in the microscopic group (P = 0.485). It appears that patients who underwent endoscopic surgery experience recurrence less often than patients who underwent microscopic surgery, with recurrence proportions of 11.0% and 15.9%, respectively (P = 0.134). However, if follow-up time is taken into account, both groups had a recurrence rate of approximately 4% per person per year (95% CI: 3.1-5.4% and 3.6-5.1%, P = 0.651).

CONCLUSIONS

We found that remission proportion and recurrence rate were the same in patients who underwent endoscopic TS as in patients who underwent microscopic TS. The definition of diagnosis, remission and recurrence should always be considered in the studies assessing therapeutic efficacy in CD.

Transoral robotic surgery for sellar tumors: first clinical study

OBJECTIVE

The aim of this study was to confirm the feasibility of an innovative transoral robotic surgery (TORS), using the da Vinci Surgical System, for patients with sellar tumors. This technique was designed to offer a new minimally invasive approach, without soft-palate splitting, that avoids the rhinological side effects of classic endonasal approaches.

METHODS

The authors performed a prospective study of TORS in patients with symptomatic sellar tumors. Specific anatomical features were required for inclusion in the study and were determined on the basis of preoperative open-mouth CT scans of the brain. The main outcome measure was sellar accessibility using the robot. Resection quality, mean operative time, postoperative changes in patients' vision, side effects, and complications were additionally reported.

RESULTS

Between February and May 2016, 4 patients (all female, mean age 49.5 years) underwent TORS for resection of sellar tumors as participants in this study. All patients presented with symptomatic visual deficits confirmed as bitemporal hemianopsia. All tumors had a suprasellar portion and a cystic part. In all 4 cases, the operation was performed via TORS, without the need for a second surgery. Sella turcica accessibility was satisfactory in all cases. In 3 cases, tumor resection was complete. The mean operative time was 2 hours 43 minutes. Three patients had a significant visual improvement at Day 1. No rhinological side effects or complications in patients occurred. No pathological examination was performed regarding the fluid component of the tumors. There was 1 postoperative delayed CSF leak and 1 case of transient diabetes insipidus. Side effects specific to TORS included minor sore throat, transient hypernasal speech, and 1 case of delayed otitis media. The mean length of hospital stay and mean follow up were 8.25 days and 82 days, respectively.

CONCLUSIONS

To our knowledge, this is the first report of the surgical treatment of sellar tumors by means of a minimally invasive TORS. This approach using the da Vinci Surgical System seems feasible and constitutes an innovative neurosurgical technique that may avoid the adverse side effects and technical disadvantages of the classic transsphenoidal route. Moreover, TORS allows an inferosuperior approach to the sella turcica, which is a key point, as the tumor is approached in the direction of its growth.

Two-Dimensional High Definition Versus Three-Dimensional Endoscopy in Endonasal Skull Base Surgery: A Comparative Preclinical Study

BACKGROUND AND OBJECTIVE

Three-dimensional (3D) endoscopy has been recently introduced in endonasal skull base surgery. Only a relatively limited number of studies have compared it to 2-dimensional, high definition technology. The objective was to compare, in a preclinical setting for endonasal endoscopic surgery, the surgical maneuverability of 2-dimensional, high definition and 3D endoscopy.

METHODS

A group of 68 volunteers, novice and experienced surgeons, were asked to perform 2 tasks, namely simulating grasping and dissection surgical maneuvers, in a model of the nasal cavities. Time to complete the tasks was recorded. A questionnaire to investigate subjective feelings during tasks was filled by each participant. In 25 subjects, the surgeons' movements were continuously tracked by a magnetic-based neuronavigator coupled with dedicated software (ApproachViewer, part of GTx-UHN) and the recorded trajectories were analyzed by comparing jitter, sum of square differences, and funnel index.

RESULTS

Total execution time was significantly lower with 3D technology (P < 0.05) in beginners and experts. Questionnaires showed that beginners preferred 3D endoscopy more frequently than experts. A minority (14%) of beginners experienced discomfort with 3D endoscopy. Analysis of jitter showed a trend toward increased effectiveness of surgical maneuvers with 3D endoscopy. Sum of square differences and funnel index analyses documented better values with 3D endoscopy in experts.

CONCLUSIONS

In a preclinical setting for endonasal skull base surgery, 3D technology appears to confer an advantage in terms of time of execution and precision of surgical maneuvers.

First intraoperative experience with three-dimensional (3D) high-definition (HD) nasal endoscopy for lacrimal surgeries

The aim of this study is to report our preliminary experiences with regard to safety and feasibility of three-dimensional (3D) endoscopic lacrimal surgeries with a recently launched latest generation 3D endoscope. A 4-mm rigid three-dimensional (3D) endoscope (TIPCAM 1S 3D ORL^R, Karl Storz, Tuttlingen, Germany) was used. Fifteen patients who underwent various endoscopic lacrimal procedures by a single surgeon (MJA) were included. The procedures included probing with nasolacrimal intubation, cruciate marsupialization of intranasal cysts for congenital dacryoceles, powered endoscopic dacryocystorhinostomy, post-operative stent removal with ostium granuloma excision. The implementation, visualization, optical performance, ease of tissue handling and complications were noted. Ten surgical observers filled a questionnaire to rate their experiences. Enhanced depth perception was found to be very beneficial intraoperatively. Greater anatomical delineation facilitated improved hand-eye coordination and dexterity. Intraoperative assessment and handling of tissues and surgical manoeuvring were precise and did not require the additional spatial cues that the surgeon derives from a two-dimensional image. These benefits were more appreciated in the complex cases. The setup was easy on previous endoscopic platforms and did not consume any additional time. All the surgical procedures were completed successfully without any complications. The surgical observers unanimously noted enhanced anatomical understanding and surgical learning as compared to the routine 2D planes. Operating in 3D planes enhances depth perception, dexterity and precision. Although initial results are promising, further randomized studies with head-on comparisons between 3D and 2D would help formulate specific guidelines.

The use of a three-dimensional endoscope for different skull base tumors: results of a preliminary extended endonasal surgical series

BACKGROUND

The evolution of skull base surgery over the past decade has been influenced by advancement in visualization technology. Recently, as a result of such improvements, three-dimensional (3-D) scopes have been widely used during endoscopic endonasal approaches. In the present study, we describe the use of 3-D stereoscopic endoscope for the treatment of a variety of skull base lesions.

METHODS

From January 2010 to June 2015, a 3-D endoscopic endonasal approach (4 and 4.9 mm, 0°, and 30° rigid endoscopes) was performed in 70 patients with the following lesions: 42 large extrasellar pituitary macroadenomas, seven tuberculum sellae meningiomas, seven clivus chordomas, five craniopharyngiomas, three fibrous dysplasia of the clivus, three sinonasal malignancies, one orbital lymphangioma, one trigeminal neurinoma, one primary suprasellar lymphoma.

RESULTS

Total tumor removal was obtained in 50 patients (71.4 %) while in 14 (20 %), subtotal removal was possible in six (8.6 %) only partial removal was achieved. Overall complications included diabetes insipidus in eight patients (11.4 %), hypopituitarism in seven patients (10 %), CSF leak in five patients (7.1 %), cranial nerve injury in two patients (2.8 %), panhypopituitarism in two patients (2.8 %), meningitis in one (1.4 %) and one postoperative central retinal artery occlusion (1.4 %). There was no mortality in the series. The mean follow-up time was 39 months (range, 6-72 months).

CONCLUSIONS

In our experience, the 3-D endoscope represents a critical development in visualization, thus enabling improved hand-eye coordination and depth perception, which are mandatory for the management of complex intradural neurovascular structures during tumor removal surgery.