1
|
Douglas JE, Adappa ND, Choby G, Levine CG, Rabinowitz MR, Sindwani R, Wang EW, Woodworth BA, Kuan EC. American Rhinologic Society expert practice statement part 2: Postoperative precautions and management principles following endoscopic skull base surgery. Int Forum Allergy Rhinol 2024. [PMID: 38995330 DOI: 10.1002/alr.23406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 06/13/2024] [Accepted: 06/25/2024] [Indexed: 07/13/2024]
Abstract
The goal of this American Rhinologic Society expert practice statement (EPS) is to summarize the best available evidence regarding postoperative precautions for patients following endoscopic skull base surgery for intradural pathology. These topics include the administration of postoperative nasal hygiene; patient mobilization and activity level; the resumption of continuous positive airway pressure in patients with obstructive sleep apnea; and the timing and capacity with which a patient may be subjected to barotrauma, such as air travel postoperatively. This EPS was developed following the recommended methodology and approval process as previously outlined. Given the diverse practices and limited agreement on the accepted principles regarding postoperative precautions for patients following skull base surgery, this EPS seeks to summarize the existing literature and provide clinically relevant guidance to bring clarity to these differing practice patterns. Following a modified Delphi approach, four statements were developed, all of which reached consensus. Because of the paucity of literature on these topics, these statements represent a summation of the limited literature and the experts' opinions. These statements and the accompanying evidence are summarized below, along with an assessment of future needs.
Collapse
Affiliation(s)
- Jennifer E Douglas
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Nithin D Adappa
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Garret Choby
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Corinna G Levine
- Department of Otolaryngology-Head & Neck Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Mindy R Rabinowitz
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Health System, Philadelphia, Pennsylvania, USA
| | - Raj Sindwani
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Bradford A Woodworth
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Edward C Kuan
- Departments of Otolaryngology-Head & Neck Surgery and Neurological Surgery, University of California, Irvine, California, USA
| |
Collapse
|
2
|
Wei W, Yan B, Zhang Q, Qi Y, Ren Q, Wang L, Liu J, Yang X, Wang Z. Endoscopic Endonasal Reconstruction of Intraoperative Cerebrospinal Fluid Leak in Different Skull Base Regions: Outcomes, Meningitis, and Risk Factors. World Neurosurg 2024:S1878-8750(24)01133-1. [PMID: 38964462 DOI: 10.1016/j.wneu.2024.06.158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 06/27/2024] [Accepted: 06/28/2024] [Indexed: 07/06/2024]
Abstract
OBJECTIVES Various nonvascularized or vascularized techniques have been adopted in endoscopic endonasal surgery (EES) for repairing intraoperative cerebrospinal fluid (CSF) leaks after tumor resection. Vascularized nasoseptal flaps, free nasoseptal grafts, free turbinate grafts, and fascia lata and mashed muscle are frequently used. Outcomes of those grafts applied in the defects of different regions need to be clarified. METHODS The data from a series of 162 patients with skull base tumor who underwent EES that had intraoperative CSF leak between Jan 2012 and Jan 2021 were retrospectively analyzed. The regions included anterior skull base, sellar region, clivus and infratemporal fossa. Repair failure rate (RFR), meningitis rate, and associated risk factors were assessed. RESULTS In total, 172 reconstructions were performed in 162 patients for the 4 sites of the skull base. There were 7 cases (4.3%) that had postoperative CSF leaks, which required second repair. The RFR for anterior skull base, sellar region, clivus, and infratemporal fossawas 2.6%, 2.2%, 16.7%, and 0%, respectively. The clivus defect was an independent risk factor for repair failure (P < 0.01). The postoperative meningitis rate was 5.6%. Repair failure was an independent risk factor for meningitis (P < 0.01). CONCLUSIONS Vascularized nasoseptal flap, free nasoseptal graft, free turbinate graft, and fascia lata and mashed muscle are reliable autologous materials for repairing the dural defects in different regions during EES. Clivus reconstruction remains a great challenge, which had a higher RFR and meningitis rate. Repair failure is significantly associated with postoperative meningitis.
Collapse
Affiliation(s)
- Wei Wei
- Departments of Otorhinolaryngology-Head and Neck Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Bo Yan
- Departments of Otorhinolaryngology-Head and Neck Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qiuhang Zhang
- Departments of Otorhinolaryngology-Head and Neck Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Qi
- Departments of Otorhinolaryngology-Head and Neck Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qinzhan Ren
- Departments of Otorhinolaryngology-Head and Neck Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Li Wang
- Departments of Otorhinolaryngology-Head and Neck Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Junqi Liu
- Departments of Otorhinolaryngology-Head and Neck Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaotong Yang
- Departments of Otorhinolaryngology-Head and Neck Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhenlin Wang
- Departments of Otorhinolaryngology-Head and Neck Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
3
|
Torales J, Di Somma A, Alobid I, Lopez M, Hoyos J, Ferres A, Morillas R, Reyes L, Roldan P, Valero R, Enseñat J. Endonasal versus supraorbital approach for anterior skull base meningiomas: Results and quality of life assessment from a single-surgeon cohort. NEUROCIRUGIA (ENGLISH EDITION) 2024; 35:177-185. [PMID: 38185276 DOI: 10.1016/j.neucie.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/28/2023] [Accepted: 12/07/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVE In this prospective non-randomized study we reported our experience related to planum sphenoidale (PS) and tuberculum sellae (TS) meningiomas in a similar cohort of patients operated via the endonasal or the supraorbital route. A comprehensive quality of life analysis has been performed. METHODS Being comparable in general features, between November 2017 to January 2020, a total of 20 patients with anterior skull base meningioma were included. Hence, 10 patients were treated using the supraorbital keyhole procedure (SO) while 10 patients received an endoscopic endonasal approach (EEA). Both surgical techniques were analyzed and compared. Quality of life has been analyzed with the SF-36 questionnaire. RESULTS Twenty patients were identified who underwent either EEA (n=10) or SO (n=10). The average extent of resection achieved was not significantly different between the 2 groups. Post-operatively, the EEA group demonstrated a longer hospital stay and bed days compared with SO patients as well as a longer surgical time. There was a significant rate of more CSF leakage after EEA then after SO (20% vs 0%, p=0,0491). The follow-up period resulted shorter in the SO group, with a slight increased recurrence rate. Overall, no differences in visual outcome were detected. There were no differences in terms of quality of life between the two groups in all the explored items. CONCLUSIONS In this single-center single-surgeon study of similarly sized and located PS and TS meningiomas, EEA showed longer hospital stays with higher degree of CSF leak compared with the SO group. Supraorbital craniotomy via eyebrow incision reported a comparable quality of life results, even if with a slightly higher percentage of recurrence and less follow-up.
Collapse
Affiliation(s)
- Jorge Torales
- Departments of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Alberto Di Somma
- Departments of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain.
| | - Isam Alobid
- Departments of ENT Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | - Jhon Hoyos
- Departments of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Abel Ferres
- Departments of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Ruben Morillas
- Departments of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Luis Reyes
- Departments of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Pedro Roldan
- Departments of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Ricard Valero
- Departments of Anesthesiology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Departments of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain
| |
Collapse
|
4
|
Baussart B, Hudelist B, Reina V, Villa C, Bertherat J, Assié G, Gaillard S. Diaphragm reconstruction using a TachoSil patch as alternative to intrasellar packing for small focal diaphragm defects in pituitary surgery: a cohort study. Acta Neurochir (Wien) 2024; 166:258. [PMID: 38853198 DOI: 10.1007/s00701-024-06152-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/31/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND During pituitary surgery, CSF leaks are often treated by intrasellar packing, using muscle or fat grafts. However, this strategy may interfere with the interpretation of postoperative MRI and may impact the quality of resection in cases of second surgery, due to the existence of additional fibrous tissue. We present an alternative technique, using a diaphragm reconstruction with a heterologous sponge combining fibrinogen and thrombin (TachoSil), applied in selected patients with low-flow CSF leaks. This study investigates the surgical outcome of patients treated with this strategy. METHODS From a cohort of 2231 patients treated from June 2011 to June 2023 by endoscopic endonasal approach for pituitary surgery, the surgical technique of diaphragm repair with TachoSil patch performed in 55 patients (2.6%) was detailed, and the rate of closure failure was analyzed at 6 months postoperatively. No intrasellar packing was used and sellar floor reconstruction was performed whenever possible. The rate of postoperative CSF leak was compared with that reported in three previous publications that also used the TachoSil patch technique. RESULTS Patients were mostly women (F/M ratio: 1.2) with a median age of 53.6 years. Surgery was indicated for non-functioning adenomas, Cushing's disease, acromegaly, and Rathke's cleft cysts in 38/55 (69.1%), 6/55 (10.9%), 5/55 (9.1%) and 6/55 (10.9%) patients respectively. The rate of postoperative CSF leak was 1.8% (n = 1/55), which was not significantly different from that reported in the three cohorts from the literature (2.8%, p > 0.05). No postoperative meningitis was recorded. CONCLUSIONS In highly selected patients with low-flow CSF leaks related to small focal diaphragm defects, diaphragm reconstruction using a TachoSil patch can be a safe and valuable alternative to intrasellar packing.
Collapse
Affiliation(s)
- Bertrand Baussart
- Department of Neurosurgery, Assistance Publique-Hôpitaux de Paris, La Pitié-Salpêtrière University Hospital, Assistance Publique Hôpitaux de Paris, 47-83 Boulevard de L'Hôpital, 75013, Paris, France.
- Université Paris Cité, CNRS, INSERM, Institut Cochin, 75014, Paris, France.
| | - Benoit Hudelist
- Department of Neurosurgery, Assistance Publique-Hôpitaux de Paris, La Pitié-Salpêtrière University Hospital, Assistance Publique Hôpitaux de Paris, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Vincent Reina
- Department of Neurosurgery, Assistance Publique-Hôpitaux de Paris, La Pitié-Salpêtrière University Hospital, Assistance Publique Hôpitaux de Paris, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Chiara Villa
- Department of Neuropathology, Assistance Publique-Hôpitaux de Paris, La Pitié-Salpêtrière University Hospital, Paris, France
| | - Jérôme Bertherat
- Université Paris Cité, CNRS, INSERM, Institut Cochin, 75014, Paris, France
- Department of Endocrinology, Center for Rare Adrenal Diseases, Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Guillaume Assié
- Université Paris Cité, CNRS, INSERM, Institut Cochin, 75014, Paris, France
- Department of Endocrinology, Center for Rare Adrenal Diseases, Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Stephan Gaillard
- Department of Neurosurgery, Assistance Publique-Hôpitaux de Paris, La Pitié-Salpêtrière University Hospital, Assistance Publique Hôpitaux de Paris, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| |
Collapse
|
5
|
Zhao J, Wang S, Zhao X, Cui H, Zou C. Risk factors of cerebrospinal fluid leakage after neuroendoscopic transsphenoidal pituitary adenoma resection: a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2024; 14:1263308. [PMID: 38260170 PMCID: PMC10800519 DOI: 10.3389/fendo.2023.1263308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 11/23/2023] [Indexed: 01/24/2024] Open
Abstract
Introduction Cerebro spinal fluid (CSF) leakage is common and might lead to severe postoperative complications after endoscopic transsphenoidal pituitary adenoma resection. However, the risk factors of postoperative CSF leakage are still controversial. This article presents a systematic review to explore the explicit risk factors of CSF leakage after endoscopic transsphenoidal pituitary adenomere section. Methods PRISMA and AMSTAR guidelines were followed to assess the methodological quality of the systematic review. PubMed, Medline, Embase, Web of Science, Cochrane, Clinical Trails, CNKI, CBM, Wan Fang, and VIP databases were searched for all studies on postoperative CSF leak risk factors. The quality of the included studies was assessed by the Newcastle-Ottawa scale. Review Manager 5.4 software was used to calculate the pooled effect size of potential factors with statistical significance. Results A total of 6775 patients with pituitary adenoma across 18 articles were included, containing 482 cases of postoperative CSF leakage (accounting for 7.11%). All of the articles had a quality score > 5, indicating good quality. Meta-analysis showed that an increased risk of CSF leak was found for higher levels of BMI (MD=1.91, 95% CI (0.86,2.96), bigger tumor size [OR=4.93, 95% CI (1.41,17.26)], greater tumor invasion (OR=3.01, 95% CI (1.71, 5.31), the harder texture of tumor [OR=2.65, 95% CI (1.95,3.62)], intraoperative cerebrospinal fluid leakage [OR=5.61, 95% CI (3.53,8.90)], multiple operations [OR=2.27, 95% CI (1.60,3.23)]. Conclusion BMI, multiple operations, tumor size, tumor invasion, hard texture, and intraoperative cerebrospinal fluid leakage are the risk factors of postoperative CSF leakage. Clinical doctors should pay attention to these risk factors, and conduct strict skull base reconstruction and careful postoperative management.
Collapse
Affiliation(s)
| | | | | | | | - Cunyi Zou
- Department of Neurosurgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| |
Collapse
|
6
|
Liu J, Li R, Zhao J, Zhao Y, Wang Y, Yang D, Yu Y. Application of a Novel Versatile Mini Posterior Nasoseptal Graft in Endoscopic Transsphenoidal Pituitary Adenoma Surgery. J Craniofac Surg 2023; 34:2488-2491. [PMID: 37522424 PMCID: PMC10597421 DOI: 10.1097/scs.0000000000009573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 05/24/2023] [Indexed: 08/01/2023] Open
Abstract
BACKGROUND Skull base reconstruction is a key technique in patients undergoing endoscopic transnasal skull base surgery. Although a pedicled nasoseptal flap (PNSF) is often used to repair large skull base defects with high-flow cerebrospinal fluid leakage, bone exposure of the donor site of the PNSF can result in long-term crusting. OBJECTIVE To design a novel and versatile mini posterior nasoseptal graft for the reconstruction of defects in the sellar floor or PNSF or pedicled nasoseptal rescue flap (PNSRF) donor site in patients undergoing pituitary adenoma surgery. METHODS Patients who underwent pituitary adenoma removal through an endoscopic endonasal approach and repair of a sellar defect or PNSF/PNSRF donor site using the mini posterior nasoseptal graft technique from January 2019 to January 2020 were retrospectively evaluated. Pituitary adenomas were removed using a binostril 4-hand technique through a transnasal transsphenoidal transsellar approach or an expanded transsellar approach. RESULTS Mini posterior nasoseptal grafts were successfully used in 70 patients who underwent pituitary adenoma removal through an endoscopic transsphenoidal sellar approach. Mini posterior nasoseptal grafts repaired sellar defects in 40 patients and donor site defects of the contralateral PNSF/PNSRF in 30 patients. None of these patients experienced cerebrospinal fluid leakage or major complications. CONCLUSIONS A mini posterior nasoseptal graft is a safe and effective technique for repairing sellar defects after endoscopic transnasal pituitary adenoma surgery. This technique can also be used to repair defects in PNSF/PNSRF donor sites.
Collapse
Affiliation(s)
- Jianfeng Liu
- Department of Otolaryngology-Head and Neck Surgery, China-Japan Friendship Hospital
| | - Rui Li
- Department of Neurosurgery, China-Japan Friendship Hospital, Beijing, China
| | - Jianhui Zhao
- Department of Otolaryngology-Head and Neck Surgery, China-Japan Friendship Hospital
| | - Yu Zhao
- Department of Otolaryngology-Head and Neck Surgery, China-Japan Friendship Hospital
| | - Yibei Wang
- Department of Otolaryngology-Head and Neck Surgery, China-Japan Friendship Hospital
| | - Dazhang Yang
- Department of Otolaryngology-Head and Neck Surgery, China-Japan Friendship Hospital
| | - Yanbing Yu
- Department of Neurosurgery, China-Japan Friendship Hospital, Beijing, China
| |
Collapse
|
7
|
Cavallo LM, Solari D, d'Avella E, Colangelo M, Cappabianca P. Endoscopic Endonasal Approach for Tuberculum Sellae Meningioma: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 25:e273. [PMID: 37846141 DOI: 10.1227/ons.0000000000000746] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 03/14/2023] [Indexed: 10/18/2023] Open
Abstract
INDICATIONS CORRIDOR AND LIMITS OF EXPOSURE Ideal indications for tuberculum sellae meningiomas (TSM) removal through endoscopic endonasal approach (EEA) are midline tumors (<3.5 cm), possibly with no optic canal invasion and no vessels encasement. The EEA is favored by a wide tuberculm sellae (TS) angle and a deep sella at the sphenoid sinus (SS). 1 Adequate removal of paranasal structures provides a wider surgical corridor ensuring exposure at the suprasellar area and safe instruments manuevrability. 2. ANATOMIC ESSENTIALS NEED FOR PREOPERATIVE PLANNING AND ASSESSMENT The endoscopic transtuberculum transplanum approach allows for wide suprasellar intradural exposure. 3 Removal of the supraoptic recess (SOR) provides further lateral extension over the planum sphenoidale (PS) and proper management of dural involvement at the optic canal. 4. ESSENTIAL STEPS OF THE PROCEDURE The patients have consented to the procedure. Bone removal starts at the upper sella and TS and is extended anteriorly over the PS and laterally, upon needs, at the SORs. On dural opening, tumor devascularization, dedressing, debulking, and dissection are run. Skull base reconstruction is performed using the 3F technique. 5. PITFALLS/AVOIDANCE OF COMPLICATIONS In those cases with vessel encasement, possibility of achieving total resection has to be balanced with risk of vascular injury. 6 Optic canal dural invasion precludes tumor total removal; however, bony decompression is maximal using the EEA. Concerning postoperative cerebrospinal fluid fistula, nowadays the rates have dropped to <2%. VARIANTS AND INDICATIONS FOR THEIR USE A wider skull base osteodural opening allows for the removal of selected meningiomas extending to the PS and cribriform plate.
Collapse
Affiliation(s)
- Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, University of Napoli "Federico II," Naples, Italy
| | | | | | | | | |
Collapse
|
8
|
Hannan CJ, Kewlani B, Browne S, Javadpour M. Multi-layered repair of high-flow CSF fistulae following endoscopic skull base surgery without nasal packing or lumbar drains: technical refinements to optimise outcome. Acta Neurochir (Wien) 2023; 165:2299-2307. [PMID: 37074392 PMCID: PMC10409672 DOI: 10.1007/s00701-023-05581-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/05/2023] [Indexed: 04/20/2023]
Abstract
AIMS Post-operative CSF leak remains a significant problem following endoscopic skull base surgery, particularly when there is a high-flow intra-operative CSF leak. Most skull base repair techniques are accompanied by the insertion of a lumbar drain and/or the use of nasal packing which have significant shortcomings. Our aim was to review the results of a large series of endoscopic skull base cases where a high-flow intra-operative CSF leak rate was encountered and repaired to assess if modifications in technique could reduce the post-operative CSF leak rate. METHODS A retrospective review of a prospectively maintained database of skull base cases performed by a single surgeon over a 10-year period was performed. Data regarding patient demographics, underlying pathology, skull base repair techniques and post-operative complications were analysed. RESULTS One hundred forty-two cases with high-flow intra-operative CSF leak were included in the study. The most common pathologies were craniopharyngiomas (55/142, 39%), pituitary adenomas (34/142, 24%) and meningiomas (24/142, 17%). The CSF leak rate was 7/36 (19%) when a non-standardised skull base repair technique was used. However, with the adoption of a standardised, multi-layer repair technique, the post-operative CSF leak rate decreased significantly (4/106, 4% vs. 7/36, 19%, p = 0.006). This improvement in the rate of post-operative CSF leak was achieved without nasal packing or lumbar drains. CONCLUSION With iterative modifications to a multi-layered closure technique for high-flow intra-operative CSF leaks, it is possible to obtain a very low rate of post-operative CSF leak, without lumbar drains or nasal packing.
Collapse
Affiliation(s)
| | - Bharti Kewlani
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Steven Browne
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.
- Royal College of Surgeons in Ireland, Dublin, Ireland.
- School of Medicine, Trinity College Dublin, Dublin, Ireland.
| |
Collapse
|
9
|
Wang X, Wang B, Cheng G, You Y, Tao C. Intradural fat graft packing is not indispensable in preventing postoperative cerebrospinal fluid leakage in endoscopic endonasal pituitary adenoma surgeries. Front Oncol 2023; 13:1222581. [PMID: 37564933 PMCID: PMC10410438 DOI: 10.3389/fonc.2023.1222581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 07/10/2023] [Indexed: 08/12/2023] Open
Abstract
Objectives Is intradural fat graft packing indispensable in preventing postoperative cerebrospinal fluid leakage in endoscopic endonasal pituitary adenoma surgeries? This study aimed to review the methods and outcomes of our graded sellar floor reconstruction strategy without fat graft packing in endoscopic endonasal pituitary adenoma surgeries. Methods From March 2018 to December 2022, 200 patients underwent endoscopic endonasal pituitary adenoma resection by a single author in our institute. We applied different graded skull base reconstruction strategies in different periods. Intradural fat graft packing was used to reconstruct the skull base in the early period, from March 2018 to June 2019, but fat graft was not used in the late period, from January 2020 to December 2022. The effect of these different graded skull base reconstruction strategies and whether intradural fat graft packing is necessary were evaluated by observing the incidence of postoperative cerebrospinal fluid leak. Results In the early period, fat graft was used to reconstruct skull base when the intraoperative cerebrospinal fluid (CSF) leakage existed. There were two patients who suffered from postoperative cerebrospinal fluid leak in this group. In the late period, fat graft was not used to reconstruct the skull base, and no patient suffered from postoperative cerebrospinal fluid leakage in this group. Conclusions Intradural fat graft packing is unnecessary in the endoscopic endonasal pituitary adenoma resection. The outcome of our graded sellar floor reconstruction strategy is satisfactory.
Collapse
Affiliation(s)
| | | | | | - Yongping You
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Chao Tao
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| |
Collapse
|
10
|
Carretta A, Zoli M, Guaraldi F, Sollini G, Rustici A, Asioli S, Faustini-Fustini M, Pasquini E, Mazzatenta D. Endoscopic Endonasal Transplanum-Transtuberculum Approach for Pituitary Adenomas/PitNET: 25 Years of Experience. Brain Sci 2023; 13:1121. [PMID: 37509051 PMCID: PMC10377303 DOI: 10.3390/brainsci13071121] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/16/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
The role of the endoscopic transplanum-transtuberculum approach (ETTA) in the treatment of pituitary adenomas/PitNETs (PAs) is sparsely analyzed in the literature, and its use is still debated in the current practice. The aim of this study was to report our experience with this approach. Our institutional registry was retrospectively reviewed, and patients who underwent ETTA for a PA from 1998 to 2022 were included. Fifty-seven cases were enrolled over a time span of 25 years, corresponding to 2.4% of our entire PA caseload. Radical resection was achieved in 57.9% of cases, with re-do surgery (p = 0.033) and vessel encasement/engulfment (p < 0.001) as predictors of partial resection. CSF leak incidence stood at 8.8%, with higher BMI (p = 0.038) as its only significant predictor. Partial or full improvement of the visual field deficits was achieved in 73.5% of cases. No surgical mortality was observed. According to our results, ETTA for the treatment of PAs is characterized by a satisfactory surgical outcome but with greater morbidity than the conventional endoscopic approach. Therefore, it should be reserved for the few selected cases otherwise unsuitable for the endoscopic trans-sphenoidal route, representing a valid alternative and an effective complementary route for the transcranial approach for these challenging PAs.
Collapse
Affiliation(s)
- Alessandro Carretta
- Department of Bio-Medical and Neuromotor Sciences (DIBINEM), University of Bologna, 40138 Bologna, Italy
| | - Matteo Zoli
- Department of Bio-Medical and Neuromotor Sciences (DIBINEM), University of Bologna, 40138 Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi-Pituitary Unit, 40139, Bologna, Italy
| | - Federica Guaraldi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi-Pituitary Unit, 40139, Bologna, Italy
| | - Giacomo Sollini
- ENT Unit, Bellaria Hospital, Azienda USL Bologna, 40139 Bologna, Italy
| | - Arianna Rustici
- Department of Bio-Medical and Neuromotor Sciences (DIBINEM), University of Bologna, 40138 Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Neuroradiology Unit, Ospedale Maggiore, 40139 Bologna, Italy
| | - Sofia Asioli
- Department of Bio-Medical and Neuromotor Sciences (DIBINEM), University of Bologna, 40138 Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy
| | - Marco Faustini-Fustini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi-Pituitary Unit, 40139, Bologna, Italy
| | - Ernesto Pasquini
- ENT Unit, Bellaria Hospital, Azienda USL Bologna, 40139 Bologna, Italy
| | - Diego Mazzatenta
- Department of Bio-Medical and Neuromotor Sciences (DIBINEM), University of Bologna, 40138 Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi-Pituitary Unit, 40139, Bologna, Italy
| |
Collapse
|
11
|
Passeri T, Champagne PO, Giammattei L, Abbritti R, Cartailler J, Calugaru V, Feuvret L, Guichard JP, Polivka M, Adle-Biassette H, Mammar H, Bresson D, Herman P, Mandonnet E, George B, Froelich S. Management strategies in clival and craniovertebral junction chordomas: a 29-year experience. J Neurosurg 2023; 138:1640-1652. [PMID: 36272118 DOI: 10.3171/2022.8.jns221621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/30/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Chordomas represent one of the most challenging subsets of skull base and craniovertebral junction (CVJ) tumors to treat. Despite extensive resection followed by proton-beam radiation therapy, the recurrence rate remains high, highlighting the importance of developing efficient treatment strategies. In this study, the authors present their experience in treating clival and CVJ chordomas over a 29-year period. METHODS The authors conducted a retrospective study of clival and CVJ chordomas that were surgically treated at their institution from 1991 to 2020. This study focuses on three aspects of the management of these tumors: the factors influencing the extent of resection (EOR), the predictors of survival, and the outcomes of the endoscopic endonasal approaches (EEAs) compared with open approaches (OAs). RESULTS A total of 265 surgical procedures were performed in 210 patients, including 123 OAs (46.4%) and 142 EEAs (53.6%). Tumors that had an intradural extension (p = 0.03), brainstem contact (p = 0.005), cavernous sinus extension (p = 0.004), major artery encasement (p = 0.01), petrous apex extension (p = 0.003), or high volume (p = 0.0003) were significantly associated with a lower EOR. The 5-year progression-free survival (PFS) and overall survival (OS) rates were 52.1% and 75.1%, respectively. Gross-total resection and Ki-67 labeling index < 6% were considered to be independent prognostic factors of longer PFS (p = 0.0005 and p = 0.003, respectively) and OS (p = 0.02 and p = 0.03, respectively). Postoperative radiation therapy correlated independently with a longer PFS (p = 0.006). Previous surgical treatment was associated with a lower EOR (p = 0.01) and a higher rate of CSF leakage after EEAs (p = 0.02) but did not have significantly lower PFS and OS compared with primary surgery. Previously radiation therapy correlated with a worse outcome, with lower PFS and OS (p = 0.001 and p = 0.007, respectively). EEAs were more frequently used in patients with upper and middle clival tumors (p = 0.002 and p < 0.0001, respectively), had a better rate of EOR (p = 0.003), and had a lower risk of de novo neurological deficit (p < 0.0001) compared with OAs. The overall rate of postoperative CSF leakage after EEAs was 14.8%. CONCLUSIONS This large study showed that gross-total resection should be attempted in a multidisciplinary skull base center before providing radiation therapy. EEAs should be considered as the gold-standard approach for upper/middle clival lesions based on the satisfactory surgical outcome, but OAs remain important tools for large complex chordomas.
Collapse
Affiliation(s)
| | | | | | | | | | - Valentin Calugaru
- 3Department of Radiation Oncology, Institut Curie-Proton Beam Therapy Center, Orsay; and
| | - Loïc Feuvret
- 3Department of Radiation Oncology, Institut Curie-Proton Beam Therapy Center, Orsay; and
- 4Department of Radiation Oncology, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, France
| | | | | | | | - Hamid Mammar
- 3Department of Radiation Oncology, Institut Curie-Proton Beam Therapy Center, Orsay; and
| | | | - Philippe Herman
- 7Otorhinolaryngology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris
| | | | | | | |
Collapse
|
12
|
Racette S, Tekumalla S, Agarwal A, Curry J, Beahm DD. Anterior Skull Base Reconstruction. Otolaryngol Clin North Am 2023:S0030-6665(23)00072-5. [PMID: 37268516 DOI: 10.1016/j.otc.2023.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Anterior skull base reconstruction requires careful preoperative planning to use the most effective technique for the expected defect. Adherence to the principles of skull base reconstruction is imperative to minimize complications and improve patient outcomes.
Collapse
Affiliation(s)
- Samuel Racette
- Department of Otolaryngology, University of Kansas Medical Center, Kansas City, KS, USA.
| | - Sruti Tekumalla
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Aarti Agarwal
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Joseph Curry
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Donald David Beahm
- Department of Otolaryngology, University of Kansas Medical Center, Kansas City, KS, USA.
| |
Collapse
|
13
|
Yang F, Bi Y, Zhou Q, Li H, Xue Y, Zhu Q, Yin J, Wang Z, Lou M. Pituitary adenoma with cavernous sinus compartment penetration and intracranial extension: surgical anatomy, approach, and outcomes. Front Oncol 2023; 13:1169224. [PMID: 37274295 PMCID: PMC10232909 DOI: 10.3389/fonc.2023.1169224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 04/27/2023] [Indexed: 06/06/2023] Open
Abstract
Objectives To understand the different characteristics and growth corridors of knosp grade 4 pituitary adenomas (Knosp4PA) with cavernous sinus (CS) compartments penetration and intracranial extension, aiming to improve the safety, effectiveness, and total resection rate of surgery. Methods A case series of 120 Knosp4PA patients with 187 invaded compartments were retrospectively reviewed. A novel surgery-relevant grading system was proposed according to the CS penetrating features. The details of approach drafting, risk prediction, and complication avoidance were analyzed and integrated through illustrated cases. Results All enrolled tumor was Knosp4PA which was derived from Knosp subgrades 3A(62.5%) and 3B(37.5%). Based on the tumor growth pathway and its relevant features, five subclassifications of intracranial extension(n=98,81.7%) were classified, which derived from the superior (Dolenc's and Oculomotor subtype, 5% and 24.2%), lateral (Parkinson's subtype,18.3%), and posterior (cerebral peduncle and Dorello's subtype, 5.8% and 1.7%) CS compartment penetration. The size of intracranial extension is assessed by Lou's scale proposed here based on preoperative MRI characteristics. Under Lou's scale, the gross total rate (GTR) decreased (82%, 53%, 22%, and 19%) with grades increased (grade 0,1,2,3, respectively), and presents significant difference between the four groups (p=0.000), as well as between single and multiple compartments involved (p=0.001). Preoperative cranial nerve deficits included the optic nerve (53%), oculomotor nerve (24.2%), and abducent nerve (4.2%), with an overall rate of visual function improvement in 68.1%. Postoperative complications of transient diabetes insipidus, cerebrospinal fluid (CSF) leakage, and cranial nerve deficits were 6.7%, 0.8%, and 0%. No new cranial nerve deficits occurred. The mortality rate was 0.8%. Conclusion The concept of "penetration" refines the extracavernous growth pattern, and the five intracranial subclassifications help to understand the potential extension corridors, enhancing adequate exposure and targeted resection of Knosp4PA. This grading system may benefit from its predictive and prognostic value, from which a higher GTR rate can be achieved.
Collapse
Affiliation(s)
- FuMing Yang
- Department of Neurosurgery, Shanghai General Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - YunKe Bi
- Department of Neurosurgery, Shanghai General Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - QiangYi Zhou
- Department of Neurosurgery, Shanghai General Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - HongChan Li
- Department of Neurosurgery, Shanghai General Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - YaJun Xue
- Department of Neurosurgery, Shanghai General Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - QingWei Zhu
- Department of Neurosurgery, Shanghai General Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Jian Yin
- Department of Neurosurgery, Shanghai General Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - ZhiYu Wang
- Department of Radiology, Shanghai General Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - MeiQing Lou
- Department of Neurosurgery, Shanghai General Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| |
Collapse
|
14
|
Godse NR, Sreenath SB, Sbeih F, Woodard TD, Kshettry VR, Recinos PF, Sindwani R. Fascia Lata: Another Workhorse for Complex Skull Base Reconstruction. Am J Rhinol Allergy 2023:19458924231170955. [PMID: 37081750 DOI: 10.1177/19458924231170955] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
BACKGROUND Multiple methods exist for skull base reconstruction of defects created by expanded endonasal approaches. While the nasoseptal flap (NSF) has been well established as the workhorse of mucosal reconstruction in complex skull base defects in multi-layered closures, a variety of options exist for the inner layer of multilayer reconstruction, including fascia lata (FL). OBJECTIVE To present our experience and outcomes in utilizing FL in multiple ways to reconstruct a wide variety of complex skull base defects. METHODS Retrospective review was performed from May 2017 to February 2022 to identify 50 consecutive patients who underwent endoscopic skull base reconstruction using FL. RESULTS FL was employed for reconstruction in 50 patients included in the study: 37 undergoing primary expanded endonasal skull base surgery and 13 revision cases. A wide range of complex pathology was treated, with meningioma and craniopharyngioma being the two most common. FL was utilized as a "button" graft (34/50, 68.0%), free graft inlay/onlay (13/50, 26.0%), and as a button graft combined with onlay (3/50, 6.0%). Expanded surgery defects addressed included tuberculum sella/sphenoid planum (36/50, 72.0%), clivus (6/50, 12.0%), and cribriform/planum (8/50, 16.0%). Successful reconstruction with fascia lata was accomplished in 46/50 cases (92%), with only 4 cases (8%) requiring revision for post-op CSF leak. Donor-site complications were rare with only 1 case (2.0%) of post-op seroma. CONCLUSION FL, usually with NSF, offers a versatile option for the reconstruction of challenging defects with excellent outcomes and minimal morbidity. FL is emerging as a workhorse for reconstruction of the inner layer of complex skull base defects.
Collapse
Affiliation(s)
- Neal R Godse
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Satyan B Sreenath
- Department of Otolaryngology-Head and Neck Surgery, Indiana University, Indianapolis, IN, USA
| | - Firas Sbeih
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Troy D Woodard
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Minimally Invasive Cranial Base and Pituitary Surgery Section, Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| | - Varun R Kshettry
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Minimally Invasive Cranial Base and Pituitary Surgery Section, Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| | - Pablo F Recinos
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Minimally Invasive Cranial Base and Pituitary Surgery Section, Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| | - Raj Sindwani
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Minimally Invasive Cranial Base and Pituitary Surgery Section, Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
15
|
Zhang C, Yang Z, Liu P. Strategy of skull base reconstruction after endoscopic transnasal pituitary adenoma resection. Front Surg 2023; 10:1130660. [PMID: 36998598 PMCID: PMC10043245 DOI: 10.3389/fsurg.2023.1130660] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/27/2023] [Indexed: 03/15/2023] Open
Abstract
ObjectiveEndoscopic endonasal surgery (EES) is commonly performed for resection of lesions of the anterior/middle cranial fossa region. Cerebrospinal fluid (CSF) leakage is a major complication. Skull base reconstruction after EES is challenging. We describe our reconstruction strategy and technique and analyze its outcomes.MethodsWe retrospectively analyzed 703 patients with pituitary adenoma who underwent EES in our center from January 2020 to August 2022. Clinical, imaging, operative, and pathologic data were recorded from the medical records and analyzed. Skull base reconstruction was performed to achieve the following three goals: seal the original leak, eliminate dead space, provide blood supply, and early ambulation. Reconstruction was tailored to individual patients based on grade of CSF leakage encountered during surgery.ResultsThe number of patients with a grade 0, 1, 2, and 3 intraoperative CSF leak was 487, 101, 86, and 29, respectively. Overall incidence of postoperative CSF leakage was 0.14% (1/703). Fascia sutured and vascularized nasoseptal flap were selected for all grade 3 CSF leaks. One patient who experienced postoperative CSF leakage developed intracranial infection and were treated with lumbar CSF drainage that failed; eventually re-exploration surgery for repair was required. Other patients did not have complications such as CSF leak and infection. 29 patients with grade 3 CSF leakage did not complain of severe nasal complications after operation. No perioperative complications related to the strategy (overpacking, infections, or hematomas) occurred. Incidence of postoperative CSF leak according to intraoperative leak grade was as follows: grade 0, zero; grade 1, zero; grade 2, 1.16% (1/86); and grade 3, zero.ConclusionThe principles of sealing the original leak, eliminating dead space, providing blood supply, and early ambulation are key in skull base reconstruction after EES. Individualization of these principles can significantly reduce the incidence of postoperative CSF leakage and intracranial infection and reduce the use of lumbar CSF drainage. Skull base suture technique is safe and effective in patients with high-flow cerebrospinal fluid leaks.
Collapse
Affiliation(s)
- Chao Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhijun Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Correspondence: Pinan Liu Zhijun Yang
| | - Pinan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Correspondence: Pinan Liu Zhijun Yang
| |
Collapse
|
16
|
Bove I, Cheok S, Ruzevick JJ, Zada G. Endoscopic Endonasal and Keyhole Surgery for Skull Base Meningiomas. Neurosurg Clin N Am 2023; 34:393-402. [DOI: 10.1016/j.nec.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
|
17
|
Villalonga JF, Burroni M, Fabozzi GL, Solari D, Campero A, Cappabianca P, Cavallo LM. Guanti bianchi technique for resection of selected pituitary adenomas. BRAIN & SPINE 2023; 3:101724. [PMID: 37383463 PMCID: PMC10293224 DOI: 10.1016/j.bas.2023.101724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/17/2023] [Accepted: 02/22/2023] [Indexed: 06/30/2023]
Abstract
Introduction Since the introduction of the endoscopic endonasal approach (EEA) to skull base, the nasal phase has been a true challenge as it represents the moment of definition of the corridor, thus defining the instruments maneuverability at tumor removal phase. The longstanding cooperation between ENT and neurosurgeons have provided the possibility of creating adequate corridor with maximal respect toward nasal structures and mucosa. This sparked the idea of entering the sella as thieves, so we named "Guanti Bianchi" technique a lesser invasive variation of the approach for the removal of selected pituitary adenoma. Research Question The purpose of this study is to present the preliminary results of "Guanti Bianchi" technique. Material and Methods Data from 17 patients undergoing "Guanti Bianchi" technique (out of 235 standard EEA) at our center, were retrospectively analysed. ASK Nasal-12, a quality-of-life instrument developed specifically to assess patient perception of nasal morbidity, was administered pre- and postoperatively. Results 10 (59%) patients were men and 7 (41%) women. The mean age was 67.7 (range 35-88). The average duration of the surgical procedure was 71.17 minutes (range 45-100). GTR was achieved in all patients, no postoperative complications were observed. Baseline ASK Nasal-12 was near normal in all patients, 3/17 (17,6%) experienced transitory very mild symptoms without any worsening at 3 and 6 months. Discussion and Conclusions This minimally invasive technique does not require turbinectomy or carving of the nasoseptal flap, it alters the nasal mucosa as little as necessary, and it is quick and easy to perform.
Collapse
Affiliation(s)
- Juan F. Villalonga
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina
- Department of Neurological Surgery, Hospital Padilla, Tucumán, Argentina
| | - Matias Burroni
- Department of Neurosurgery, Hospital Pedro de Elizalde, Buenos Aires, Argentina
| | - Gianluca L. Fabozzi
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli “Federico II”, Naples, Italy
| | - Domenico Solari
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli “Federico II”, Naples, Italy
| | - Alvaro Campero
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina
- Department of Neurological Surgery, Hospital Padilla, Tucumán, Argentina
| | - Paolo Cappabianca
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli “Federico II”, Naples, Italy
| | - Luigi M. Cavallo
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli “Federico II”, Naples, Italy
| |
Collapse
|
18
|
Corvino S, Guizzardi G, Sacco M, Corrivetti F, Bove I, Enseñat J, Colamaria A, Prats-Galino A, Solari D, Cavallo LM, Di Somma A, de Notaris M. The feasibility of three port endonasal, transorbital, and sublabial approach to the petroclival region: neurosurgical audit and multiportal anatomic quantitative investigation. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05498-6. [PMID: 36752892 DOI: 10.1007/s00701-023-05498-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/02/2023] [Indexed: 02/09/2023]
Abstract
PURPOSE The petroclival region represents the "Achille's heel" for the neurosurgeons. Many ventral endoscopic routes to this region, mainly performed as isolated, have been described. The aim of the present study is to verify the feasibility of a modular, combined, multiportal approach to the petroclival region to overcome the limits of a single approach, in terms of exposure and working areas, brain retraction and manipulation of neurovascular structures. METHODS Four cadaver heads (8 sides) underwent endoscopic endonasal transclival, transorbital superior eyelid and contralateral sublabial transmaxillary-Caldwell-Luc approaches, to the petroclival region. CT scans were obtained before and after each approach to rigorously separate the contribution of each osteotomy and subsequentially to build a comprehensive 3D model of the progressively enlarged working area after each step. RESULTS The addition of the contralateral transmaxillary and transorbital corridors to the extended endoscopic endonasal transclival in a combined multiportal approach provides complementary paramedian trajectories to overcome the natural barrier represented by the parasellar and paraclival segments of the internal carotid artery, resulting in significantly greater area of exposure than a pure endonasal midline route (8,77 cm2 and 11,14 cm2 vs 4,68 cm2 and 5,83cm2, extradural and intradural, respectively). CONCLUSION The use of different endoscopic "head-on" trajectories can be combined in a wider multiportal extended approach to improve the ventral route to the most inaccessible petroclival regions. Finally, by combining these approaches and reiterating the importance of multiportal strategy, we quantitatively demonstrate the possibility to reach "far away" paramedian petroclival targets while preserving the neurovascular structures.
Collapse
Affiliation(s)
- Sergio Corvino
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | - Giulia Guizzardi
- Laboratory of Surgical Neuroanatomy, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Matteo Sacco
- Department of Neurosurgery, "Riuniti" Hospital, Foggia, Italy
| | - Francesco Corrivetti
- Department of Neurosurgery, San Luca Hospital, Vallo Della Lucania, Salerno, Italy.,Laboratory of Neuroscience, EBRIS Foundation, European Biomedical Research Institute of Salerno, Salerno, Italy
| | - Ilaria Bove
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | - Joaquim Enseñat
- Departments of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | - Alberto Prats-Galino
- Laboratory of Surgical Neuroanatomy, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | - Alberto Di Somma
- Laboratory of Surgical Neuroanatomy, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain. .,Departments of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain.
| | - Matteo de Notaris
- Laboratory of Neuroscience, EBRIS Foundation, European Biomedical Research Institute of Salerno, Salerno, Italy.,Neurosurgery Operative Unit, Department of Neuroscience, "San Pio" Hospital, Benevento, Italy
| |
Collapse
|
19
|
Solari D, Mastantuoni C, Cavallo LM, Esposito F, Cappabianca P. Endoscopic endonasal treatment of craniopharyngiomas: current management strategies and future perspectives. J Neurosurg Sci 2023; 67:26-35. [PMID: 35301832 DOI: 10.23736/s0390-5616.21.05507-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Craniopharyngiomas are locally aggressive disembryogenetic tumors presenting mostly in childhood and late adulthood. They are often burdened by an unfavorable clinical course due to close relationships with nearby critical neurovascular structures and high risk of recurrences. The aim of our paper is to provide a systematic review of the literature regarding current strategies and future perspectives for the treatment of craniopharyngiomas, focusing on the role of endoscopic endonasal surgery. EVIDENCE ACQUISITION A comprehensive literature search of three databases (PubMed, Ovid Medline, and Ovid Embase) has been conducted to identify papers addressing the management strategies in adult and pediatric craniopharyngioma patients. EVIDENCE SYNTHESIS Twenty-two articles have been included, providing data for 560 adult and 215 pediatric patients. Mean follow-up was 40.29 months for the adult and 58.05 months for pediatric population. GTR rate was 60.97% and 82.52% in adult and pediatric patients, respectively. Adjuvant radiotherapy was delivered in 20.99% of adult and 8.25% of pediatric cases; 89% of adult patients and 94.11% of pediatric patients receiving radiotherapy had previously undergone NTR, STR or partial resection. The recurrence rate was 19.32% and 18.61% for adult and pediatric population, respectively. Recurrences occurred mostly in patients receiving incomplete resection without adjuvant radiotherapy (72.87% in adults and 51.28% in children); 86.69% and 87.12% of adult and pediatric patients reported improvement of their previous ophthalmologic deficit; 40% of the adult population and 41.86%% of pediatric patients worsened or developed endocrinological disturbances. CSF leak rate was 16.4% in adults and 13.95%% in children. CONCLUSIONS Modern policy of craniopharyngioma management is represented by the combination of a "maximum safe" allowed surgical removal plus radiotherapy. In this scenario, the endoscopic endonasal technique proved to be a valid approach for removing these lesions, providing satisfactory outcomes with lower morbidity.
Collapse
Affiliation(s)
- Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy -
| | - Ciro Mastantuoni
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Luigi M Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Felice Esposito
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Paolo Cappabianca
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| |
Collapse
|
20
|
Solari D, d'Avella E, Agresta G, Catapano D, D'Ecclesia A, Locatelli D, Massimi L, Mazzatenta D, Spena G, Tamburrini G, Zoia C, Zoli M, Cinalli G, Cappabianca P, Cavallo LM. Endoscopic endonasal approach for infradiaphragmatic craniopharyngiomas: a multicentric Italian study. J Neurosurg 2023; 138:522-532. [PMID: 35901705 DOI: 10.3171/2022.5.jns212974] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 05/20/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Infradiaphragmatic craniopharyngiomas (ICs) represent a distinct subtype, harboring a sellar-suprasellar origin and generally growing in the extra-arachnoidal space contained by the diaphragma sellae. They have been considered ideal for surgical removal through the transsphenoidal approach since the 1960s. The authors present a multicentric national study, intending to selectively analyze IC behavior and the impact of the transsphenoidal endoscopic endonasal approach (EEA) on surgical outcomes. METHODS Craniopharyngiomas that were intraoperatively recognized as infradiaphragmatic and removed with standard EEA between 2000 and 2021 at 6 Italian neurosurgical departments were included in the study. Clinical, radiological, and surgical findings and outcomes were evaluated and reviewed. RESULTS In total, 84 patients were included, with 45.23% identified as pediatric cases and 39.28% as having recurrent tumors. The most common presenting symptoms were endocrine (75%), visual (59.52%), and hypothalamic (26.19%) disorders. ICs were classified as extending below (6 intrasellar and 41 occupying the suprasellar cistern) or above (26 obliterating the anterior recesses of the third ventricle and 11 extending up to the foramina of Monro) the chiasmatic cistern. Gross-total resection (GTR) was achieved in 54 cases (64.28%). Tumor extension above the chiasmatic cistern and calcifications were associated with lower likelihood of GTR. The cumulative rate of postoperative complications was 34.53%, with CSF leak being the most common (14.28%). Endocrine, visual, and hypothalamic functions deteriorated postoperatively in 41/78 patients (52.56%), 5/84 (5.95%), and 14/84 (16.67%), respectively. Twenty-eight patients (33.33%) had recurrence during follow-up (mean 63.51 months), with a mean 5-year progression-free survival (PFS) rate of 58%. PFS was greater in patients who achieved GTR than patients with other extent of resection. CONCLUSIONS This is the largest series in the literature to describe ICs removed with standard EEA, without the need for additional bone and dural opening over the planum sphenoidale. EEA provides a direct route to ICs, the opportunity to manage lesions extending up to the third ventricle without breaching the diaphragma, and high rates of GTR and satisfactory clinical outcomes. Increased surgical complexity and morbidity should be expected in patients with extensive suprasellar extension and involvement of the surrounding vital neurovascular structures.
Collapse
Affiliation(s)
- Domenico Solari
- 1Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II," Naples, Italy
| | - Elena d'Avella
- 1Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II," Naples, Italy
| | - Gianluca Agresta
- 2Division of Neurosurgery, Università degli Studi dell'Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Domenico Catapano
- 3Division of Neurosurgery, IRCCS "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Italy
| | - Aurelio D'Ecclesia
- 4ENT Operative Unit, IRCCS "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Italy
| | - Davide Locatelli
- 2Division of Neurosurgery, Università degli Studi dell'Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Luca Massimi
- 5Section of Pediatric Neurosurgery, Institute of Neurosurgery, Catholic University Medical School, Rome, Italy
| | - Diego Mazzatenta
- 6Department of Biomedical and Neuromotor Sciences, University of Bologna, IRCCS Institute of Neurological Sciences of Bologna, "Bellaria" Hospital, Bologna, Italy
| | - Giannantonio Spena
- 7Division of Neurosurgery, Neurosurgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; and
| | - Gianpiero Tamburrini
- 5Section of Pediatric Neurosurgery, Institute of Neurosurgery, Catholic University Medical School, Rome, Italy
| | - Cesare Zoia
- 7Division of Neurosurgery, Neurosurgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; and
| | - Matteo Zoli
- 6Department of Biomedical and Neuromotor Sciences, University of Bologna, IRCCS Institute of Neurological Sciences of Bologna, "Bellaria" Hospital, Bologna, Italy
| | - Giuseppe Cinalli
- 8Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Paolo Cappabianca
- 1Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II," Naples, Italy
| | - Luigi Maria Cavallo
- 1Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II," Naples, Italy
| |
Collapse
|
21
|
Baussart B, Venier A, Jouinot A, Reuter G, Gaillard S. Closure strategy for endoscopic pituitary surgery: Experience from 3015 patients. Front Oncol 2023; 12:1067312. [PMID: 36686774 PMCID: PMC9846073 DOI: 10.3389/fonc.2022.1067312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/05/2022] [Indexed: 01/05/2023] Open
Abstract
Introduction Effective strategies are required to ensure optimal management of the crucial closure step in endoscopic pituitary surgery. Many surgical techniques have been reported but no significant consensus has been defined. Methods Between January 2006 and March 2022, 3015 adult patients with pituitary adenomas were operated on by a single expert neurosurgical team, using a mononostril endoscopic endonasal approach. Based of preoperative risk factors of and operative findings, a detailed closure strategy was used. Body mass index >40, sellar floor lysis, number of surgeries>2, large skull base destruction, prior radiotherapy were considered as preoperative risk factors for closure failure. All patients treated with an expanded endonasal approach were excluded. Results Patients were mostly women (F/M ratio: 1.4) with a median age of 50 (range: 18 -89). Intraoperative CSF leak requiring specific surgical management was observed in 319/3015 (10.6%) of patients. If intraoperative leak occurred, patients with predictive risk factors were managed using a Foley balloon catheter in case of sellar floor lysis or BMI>40 and a multilayer repair strategy with a vascularized nasoseptal flap in other cases. Postoperative CSF leak occurred in 29/3015 (1%) of patients, while meningitis occurred in 24/3015 (0.8%) of patients. In patients with intraoperative leak, closure management failed in 11/319 (3.4%) of cases. Conclusion Based on our significant 16-year experience, our surgical management is reliable and easy to follow. With a planned and stepwise strategy, the closure step can be optimized and tailored to each patient with a very low failure rate.
Collapse
Affiliation(s)
- Bertrand Baussart
- Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France,Université Paris Cité, Institut Cochin, CNRS, INSERM, Paris, France,*Correspondence: Bertrand Baussart, ;
| | - Alice Venier
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Anne Jouinot
- Université Paris Cité, Institut Cochin, CNRS, INSERM, Paris, France
| | - Gilles Reuter
- Department of Neurosurgery, Centre Hospitalier Universitaire (CHU) de Liège, Bat B35, Domaine Universitaire du Sart-Tilman, Liège, Belgium
| | - Stephan Gaillard
- Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| |
Collapse
|
22
|
Guizzardi G, Prats-Galino A, Mosteiro A, Santos C, Topczewski T, Torales J, Roldan P, Reyes L, Di Somma A, Enseñat J. Multiportal Combined Endoscopic Endonasal and Transorbital Pathways: Qualitative and Quantitative Anatomic Studies of the "Connection" Skull Base Areas. Oper Neurosurg (Hagerstown) 2023; 24:e342-e350. [PMID: 36715996 DOI: 10.1227/ons.0000000000000577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 10/07/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Combined endonasal and transorbital multiportal surgery has been recently described for selected skull base pathologies. Nevertheless, a detailed anatomic description and a quantitative comprehensive anatomic study of the skull base areas where these 2 endoscopic routes converge, a so-called connection areas, are missing in the scientific literature. OBJECTIVE To identify all the skull base areas and anatomic structures where endonasal and transorbital endoscopic avenues could be connected and combined. METHODS Five cadaveric specimens (10 sides) were used for dissection. Qualitative description and quantitative analysis of each connection areas were performed. RESULTS At the anterior cranial fossa, the connection area was found at the level of the sphenoid planum; in the middle cranial fossa, it was at the Mullan triangle; finally, in the posterior cranial fossa, the connection area was just behind the medial portion of the petrous apex. The average extradural working areas through the transorbital approach were 4.93, 12.93, and 1.93 cm 2 and from the endonasal corridor were 7.75, 10.45, and 7.48 cm 2 at the level of anterior, middle, and posterior cranial fossae, respectively. CONCLUSION The combined endonasal and transorbital endoscopic approach is an innovative entity of skull base neurosurgery. From the anatomic point of view, our study demonstrated the feasibility of this combined approach to access the entire skull base, by both corridors, identifying a working connection area in each cranial fossa. These data could be extremely useful during the surgical planning to predict which portion of a lesion could be removed through each route and to optimize patients' care.
Collapse
Affiliation(s)
- Giulia Guizzardi
- Laboratory of Surgical Neuroanatomy, Universitat de Barcelona, Spain
| | - Alberto Prats-Galino
- Laboratory of Surgical Neuroanatomy, Universitat de Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Alejandra Mosteiro
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Carlos Santos
- Department of Neurological Surgery and Spine Unit, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Thomaz Topczewski
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Jorge Torales
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Pedro Roldan
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Luis Reyes
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Alberto Di Somma
- Laboratory of Surgical Neuroanatomy, Universitat de Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| |
Collapse
|
23
|
Choi HW, Choi JW, Seol HJ, Nam DH, Lee JI, Kong DS. Impact of Postural Changes on Sinonasal Pressure After Endoscopic Endonasal Surgery. World Neurosurg 2023; 169:e110-e113. [PMID: 36283649 DOI: 10.1016/j.wneu.2022.10.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Postoperative management following endoscopic endonasal surgery (EES) is important to prevent cerebrospinal fluid leak and preserve the integrity of the nasoseptal flap. No consensus regarding an optimal posture in the postoperative period has been established. We hypothesized that sinonasal pressure (SNP) can represent intracranial pressure affecting the sellar floor in the absence of the sellar bone after surgery. This study provides evidence for the effect of postural changes and recommends optimal posture to reduce SNP following EES. METHODS The authors conducted a retrospective analysis of 50 patients who underwent reconstruction for skull base defects with nasoseptal flap after EES for resection of suprasellar tumor between March 2020 and August 2020. The Spiegelberg intracranial pressure probe was placed through the nostril over the nasoseptal flap. SNPs were measured in Fowler' (45° tilt) and supine positions, respectively, daily for the first 3 days immediately after EES. RESULTS For the first 3 days after surgery, the mean SNP in Fowler' position (24.82 mmHg; standard deviation, 12.23 mmHg) was lower than that in the supine position (28.42 mmHg; standard deviation, 12.33 mmHg) (P < 0.01). There were no significant differences in mean SNP for age, sex, tumor size, presence of hydrocephalus, and body mass index. CONCLUSIONS There was a significant correlation between Fowler' position and a decrease in SNP measurements. Placing a patient in Fowler' position after surgery can decrease the SNP. We recommend that patients should be placed in a Fowler' position as an optimal position after surgery.
Collapse
Affiliation(s)
- Hye Won Choi
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School, of Medicine, Seoul, Republic of Korea
| | - Jung Won Choi
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School, of Medicine, Seoul, Republic of Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School, of Medicine, Seoul, Republic of Korea
| | - Do-Hyun Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School, of Medicine, Seoul, Republic of Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School, of Medicine, Seoul, Republic of Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School, of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
24
|
Onorini N, Spennato P, Mirone G, Vitulli F, Solari D, Cavallo LM, Cinalli G. Surgical Approaches to the Third Ventricle: An Update. Adv Tech Stand Neurosurg 2023; 48:207-249. [PMID: 37770686 DOI: 10.1007/978-3-031-36785-4_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
The third ventricle is located in the deepest part of the brain and is delimited by both telencephalic and diencephalic structures. Its location makes every surgical procedure inside or around it quite challenging, due to the distance from the surface to the fragility of the neurovascular structures that is necessary to dissect before entering its cavity and to the narrow surgical corridors through which it is necessary to work. Its geometric localization inside the cranial cavity and the anatomical relationship with the interhemispheric fissure offers nevertheless to the surgeon an impressive variety of surgical approaches, which allow to reach every millimeter of the third ventricle lumen. Mastering properly all these approaches requires an impressive anatomical knowledge, the best available technology, and most refined technical skills, making the surgery of the third ventricle a point of excellence in the evolution of each neurosurgeon. The development of neuronavigation and neuroendoscopy has been a revolution in neurosurgery in the last 20 years and offered special advantages for the surgery of the third ventricle. In fact, the narrow corridors of approach make the precision of the neuronavigation and the enlightenment and magnification of the neuroendoscopy especially useful to reach the third ventricle cavity and working inside or around it. This chapter reviews the history of the surgery of the third ventricle and offers an update of the variety of surgical corridors identified and of the technology now available to properly work through them and inside the third ventricle cavity.
Collapse
Affiliation(s)
- Nicola Onorini
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, AORN, Naples, Italy
| | - Pietro Spennato
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, AORN, Naples, Italy
| | - Giuseppe Mirone
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, AORN, Naples, Italy
| | - Francesca Vitulli
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, AORN, Naples, Italy
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, "Federico II" University, Naples, Italy
| | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, "Federico II" University, Naples, Italy
| | - Giuseppe Cinalli
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, AORN, Naples, Italy
| |
Collapse
|
25
|
d'Avella E, Solari D, Cavallo LM. In Reply to the Letter to the Editor Regarding "The Fate of Fat Graft in Extended Endoscopic Transtuberculum-Transplanum Approaches". World Neurosurg 2023; 169:120. [PMID: 36585094 DOI: 10.1016/j.wneu.2022.10.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 10/22/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Elena d'Avella
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples, Italy
| | - Domenico Solari
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples, Italy.
| | - Luigi Maria Cavallo
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples, Italy
| |
Collapse
|
26
|
Piscopo AJ, Dougherty MC, Woodiwiss TR, Ankrah N, Hughes T, Seaman SC, Walsh JE, Graham SM, Greenlee JDW. Endoscopic Reconstruction of the Anterior Skull Base Following Tumor Resection: Application of a Novel Bioabsorbable Plate. Laryngoscope 2022; 133:1092-1098. [PMID: 36477852 DOI: 10.1002/lary.30501] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/30/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Endoscopic repair of skull base defects is required following resection of intracranial pathology via the endoscopic endonasal approach (EEA). Many closure techniques have been described, but choosing between techniques remains controversial. We report outcomes of 560 EEA procedures of skull base reconstruction performed on 508 patients over a 15-year-period. Halfway through this period, we adopted the use of a rigid, bioabsorbable extrasellar plate for reconstruction, enabling a comparison between this technique and those used previously. METHODS All patients undergoing EEA from 2005 to 2019 at our institution were retrospectively reviewed. Demographic information, surgical pathology, tumor dimensions and radiographic features, reconstructive technique, and patient-related outcomes were collected and analyzed with univariate and multivariate statistical modeling. RESULTS Five-hundred sixty procedures were performed on 508 patients. The series complication rate was 8.2%. Overall, cerebrospinal fluid (CSF) leak rate was 5.0% but varied significantly across closure techniques (p < 0.001). Critically, the CSF leak rate in the 272 cases prior to our 2013 adoption of the Resorb-X Plate (RXP) was 8.5%, whereas leak rate in the subsequent 288 cases was 1.7%. RXP was protective against CSF leak (p = 0.001), whereas gross total resection (GTR) correlated with increased leak rate (p = 0.001). Patient BMI was significantly associated with risk of leak (p = 0.047). Other variables did not impact leak risk. CONCLUSION Reconstructive technique, extent of resection, and patient BMI significantly contributed to CSF leak rate. GTR was associated with increased leak risk while the RXP was protective. The bioabsorbable RXP is an effective option for rigid skull base repair with comparatively few complications. LEVEL OF EVIDENCE 3 Laryngoscope, 133:1092-1098, 2023.
Collapse
Affiliation(s)
| | | | | | - Nii‐Kwanchie Ankrah
- Department of Radiation Oncology University of Alabama at Birmingham Birmingham Alabama USA
| | - Tyler Hughes
- Department of Neurosurgery University of Iowa Iowa City Iowa USA
| | - Scott C. Seaman
- Department of Neurosurgery University of Iowa Iowa City Iowa USA
| | - Jarrett E. Walsh
- Department of Otolaryngology University of Iowa Iowa City Iowa USA
| | - Scott M. Graham
- Department of Otolaryngology University of Iowa Iowa City Iowa USA
| | | |
Collapse
|
27
|
Laurent C, Gaillard S, Baussart B. Expanded endoscopic endonasal approach for the resection of midline craniopharyngiomas with hypothalamic involvement. Acta Neurochir (Wien) 2022; 164:3291-3296. [PMID: 36219245 DOI: 10.1007/s00701-022-05387-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 10/01/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND With relevant surrounding neurological structures and potential involvement of the hypothalamus, the surgical management of craniopharyngiomas is complex. Compared to the transcranial approach, the expanded endoscopic endonasal approach provides direct access to the supradiaphragmatic and retrochiasmatic areas without crossing nerves and arteries. METHOD Based on our substantial experience of 68 patients operated on between 2008 and 2022 by endoscopic surgery, our strategy has evolved such that all of our midline infundibular craniopharyngiomas with hypothalamic involvement are currently treated with an expanded endonasal route, except for tumours isolated to the third ventricle. Vascularized mucosal nasoseptal flaps are required for closure. Fine details of the related anatomy and surgical technique are described. CONCLUSION Expanded endoscopic endonasal approach is a safe and effective route for resection of midline suprasellar craniopharyngiomas with hypothalamic involvement in centres of expertise.
Collapse
Affiliation(s)
- Come Laurent
- Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Stephan Gaillard
- Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Bertrand Baussart
- Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.
| |
Collapse
|
28
|
Grasso G, Buscemi F. Sealing the Cranial Base Access After Endonasal Endoscopic Approach: Reabsorption Rate of Fat Graft in the "3FTechnique". World Neurosurg 2022; 167:78-80. [PMID: 36089280 DOI: 10.1016/j.wneu.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Giovanni Grasso
- Neurosurgical Unit, Surgical Neuro-oncology Section, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy.
| | - Felice Buscemi
- Neurosurgical Unit, Surgical Neuro-oncology Section, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
| |
Collapse
|
29
|
d'Avella E, Solari D, De Rosa A, Elefante A, Tortora F, Esposito F, Cavallo LM. The Fate of Fat Graft in Extended Endoscopic Transtuberculum-Transplanum Approaches. World Neurosurg 2022; 167:e590-e599. [PMID: 35995356 DOI: 10.1016/j.wneu.2022.08.059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To analyze the long-term fate of autologous fat graft in skull base reconstruction after an extended endoscopic transtuberculum-transplanum approach. METHODS Data from 98 consecutive patients undergoing a transtuberculum-transplanum approach and skull base reconstruction using the 3F technique between June 2017 and January 2022 were retrospectively analyzed. Fat graft volume was measured on postoperative day 1 computed tomography scan and early (≤15 days), 3-month, and 1-year magnetic resonance imaging scans. Fat graft volumes and resorption rate were calculated in patients with a complete radiological follow-up and correlated to demographic, pathological, and surgical features. RESULTS Fat volumes and resorption rate were calculated in 55 patients. Mean volume of fat on postoperative day 1 computed tomography scan was 3.58 ± 1.89 cm3 and on early, 3-month, and 1-year postoperative magnetic resonance imaging scans was 2.45 ± 1.57 cm3, 1.40 ± 0.76 cm3, and 0.92 ± 0.56 cm3, respectively. Resorption rate was 44% after 3 months and 67% after 1 year. Resorption rate did not significantly correlate with demographic, pathological, and surgical features. Cerebrospinal fluid leak requiring redo surgery occurred in 1 patient (1/98, 1.2%). There were 6 cases of visual worsening (6/98, 6.1%); no cases correlated to fat overpacking. No delayed complications at the donor site or at the grafting site were noted. CONCLUSIONS Autologous fat graft in skull base reconstruction is observed to shrink significantly over time, reaching 67% in 1 year. Its use is associated with excellent outcomes, making it a favored material for skull base reconstruction.
Collapse
Affiliation(s)
- Elena d'Avella
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples, Italy
| | - Domenico Solari
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples, Italy.
| | - Andrea De Rosa
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples, Italy
| | - Andrea Elefante
- Department of Advanced Biomedical Science, University of Napoli "Federico II", Naples, Italy
| | - Fabio Tortora
- Department of Advanced Biomedical Science, University of Napoli "Federico II", Naples, Italy
| | - Felice Esposito
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples, Italy
| | - Luigi Maria Cavallo
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples, Italy
| |
Collapse
|
30
|
Giant Non-Functioning Pituitary Adenomas: Treatment Considerations. Brain Sci 2022; 12:brainsci12091256. [PMID: 36138992 PMCID: PMC9497296 DOI: 10.3390/brainsci12091256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/07/2022] [Accepted: 09/13/2022] [Indexed: 11/23/2022] Open
Abstract
Giant pituitary adenomas are a subgroup of pituitary adenomas defined by a diameter greater than 4 cm, and they account for 5–14% of adenomas in surgical series. Because of their growth patterns and locations, often involving critical neurovascular structures, they represent a true surgical challenge, and gross total resection is difficult to achieve. There is no consensus on the optimal surgical strategy for giant pituitary adenomas, and, often, integrated multi-staged treatment strategies have been considered. Transcranial or transsphenoidal approaches, alone or combined, according to tumor and patient features are the two main routes. Each of these strategies has pros and cons. The conventional transcranial approach has for a long time been considered the first choice for the removal of giant pituitary adenomas. Currently, with endoscopic techniques, it is also possible to remove lesions that involve the intradural compartment and the adjacent neurovascular structures with the use of extended approaches. Our policy for the management of these lesions is to adopt the endoscopic endonasal approach as the first choice unless the tumor presents significant intracranial extension that results in it being outside the visibility and maneuverability of the endoscopic endonasal route. In these latter cases, we agree that the transcranial approach is more appropriate. However, accurate preoperative evaluation and refined treatment plans for each patient are mandatory to define a proper strategy in order to achieve the most effective long-term result.
Collapse
|
31
|
Villalonga JF, Solari D, Cuocolo R, De Lucia V, Ugga L, Gragnaniello C, Pailler JI, Cervio A, Campero A, Cavallo LM, Cappabianca P. Clinical application of the “sellar barrier’s concept” for predicting intraoperative CSF leak in endoscopic endonasal surgery for pituitary adenomas with a machine learning analysis. Front Surg 2022; 9:934721. [PMID: 36157423 PMCID: PMC9492953 DOI: 10.3389/fsurg.2022.934721] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Recently, it was defined that the sellar barrier entity could be identified as a predictor of cerebrospinal fluid (CSF) intraoperative leakage. The aim of this study is to validate the application of the sellar barrier concept for predicting intraoperative CSF leak in endoscopic endonasal surgery for pituitary adenomas with a machine learning approach. Methods We conducted a prospective cohort study, from June 2019 to September 2020: data from 155 patients with pituitary subdiaphragmatic adenoma operated through endoscopic approach at the Division of Neurosurgery, Università degli Studi di Napoli “Federico II,” were included. Preoperative magnetic resonance images (MRI) and intraoperative findings were analyzed. After processing patient data, the experiment was conducted as a novelty detection problem, splitting outliers (i.e., patients with intraoperative fistula, n = 11/155) and inliers into separate datasets, the latter further separated into training (n = 115/144) and inlier test (n = 29/144) datasets. The machine learning analysis was performed using different novelty detection algorithms [isolation forest, local outlier factor, one-class support vector machine (oSVM)], whose performance was assessed separately and as an ensemble on the inlier and outlier test sets. Results According to the type of sellar barrier, patients were classified into two groups, i.e., strong and weak barrier; a third category of mixed barrier was defined when a case was neither weak nor strong. Significant differences between the three datasets were found for Knosp classification score (p = 0.0015), MRI barrier: strong (p = 1.405 × 10−6), MRI barrier: weak (p = 4.487 × 10−8), intraoperative barrier: strong (p = 2.788 × 10−7), and intraoperative barrier: weak (p = 2.191 × 10−10). We recorded 11 cases of intraoperative leakage that occurred in the majority of patients presenting a weak sellar barrier (p = 4.487 × 10−8) at preoperative MRI. Accuracy, sensitivity, and specificity for outlier detection were 0.70, 0.64, and 0.72 for IF; 0.85, 0.45, and 1.00 for LOF; 0.83, 0.64, and 0.90 for oSVM; and 0.83, 0.55, and 0.93 for the ensemble, respectively. Conclusions There is a true correlation between the type of sellar barrier at MRI and its in vivo features as observed during endoscopic endonasal surgery. The novelty detection models highlighted differences between patients who developed an intraoperative CSF leak and those who did not.
Collapse
Affiliation(s)
- J. F. Villalonga
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina
- Correspondence: J. F. Villalonga
| | - D. Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
| | - R. Cuocolo
- Department of Advanced Biomedical Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
| | - V. De Lucia
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
| | - L. Ugga
- Department of Advanced Biomedical Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
| | - C. Gragnaniello
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
- Department of Neurological Surgery, Swedish Neuroscience Institute, Seattle, WA, United States
| | - J. I. Pailler
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina
| | - A. Cervio
- Departamento de Neurocirugía, FLENI, Buenos Aires, Argentina
| | - A. Campero
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina
| | - L. M. Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
| | - P. Cappabianca
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
| |
Collapse
|
32
|
Baiano C, Somma T, Franca RA, Di Costanzo M, Scala MR, Cretella P, Esposito F, Cavallo LM, Cappabianca P, Solari D. Evolution in endoscopic endonasal approach for the management of hypothalamic–pituitary region metastasis: A single-institution experience. Front Oncol 2022; 12:975738. [PMID: 35965539 PMCID: PMC9366217 DOI: 10.3389/fonc.2022.975738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/30/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionEndonasal endoscopic surgery has changed the treatment perspectives for different lesions of the hypothalamic–pituitary region. The metastases of the hypothalamic–pituitary region represent 0.4% of all intracranial metastatic tumors and account for only 1.8% of surgically managed pituitary lesions. The aim of tshis study is to describe a single-center institutional experience with 13 cases of hypothalamic–pituitary metastasis focused on presurgical workup, the evolution of the surgical technique, and postsurgical management according to our protocols, showing effects on progression-free and overall survival rates for this relatively uncommon location.Material and MethodsWe retrospectively reviewed the whole series of patients that received the endoscopic endonasal approach at the Division of Neurosurgery at the University of Naples “Federico II” undergoing surgery from January 1997 to December 2021. We identified 13 cases whose pathology reports revealed a metastatic lesion. Statistical analysis was performed to determine the Kaplan–Meier survival function and assess for log-rank differences in survival based on gender, surgical treatment, and postoperative therapy (p-value < 0.02*).ResultsThe pathology report disclosed lung adenocarcinoma (six cases, 46%), breast adenocarcinoma (two cases, 15.4%), clear cell renal carcinoma (one case, 7%), melanoma (one case, 7%), colorectal adenocarcinoma (one case, 7%), uterine cervix carcinoma (one case, 7%), and follicular thyroid carcinoma (one case, 7%). A standard endoscopic endonasal approach was performed in 10 patients (76.9%), while an extended endonasal procedure was performed in only three cases (23%). Biopsy was the surgical choice in five patients with infiltrative and invasive lesions and a poor performance status (38%), while in the cases where neurovascular decompression was necessary, a subtotal resection was achieved in five patients (38%) and partial resection in three patients (23%). Recovery of visual field defect was observed in six of seven patients with visual loss (85.7%), improvement of oculomotor nerve palsy occurred in four of seven patients with this defect (57.1%), while the impairment of oculomotor palsy was observed in three patients (42.9%). Visual function was stable in the other patients. The median progression-free survival and overall survival were 14 and 18 months, respectively. There were statistically significant differences in PFS and OS in patients who underwent adjuvant radiotherapy (p=0.019 is referred to OS and p=0.017 to PFS, respectively; p-value = 0.02).ConclusionsThe endoscopic endonasal approach is a viable approach for the management of hypothalamic–pituitary metastases as this surgery provides an adequate opportunity to obtain tissue sample and neurovascular decompression, both being crucial for continuing the integrated adjuvant therapy protocols.
Collapse
Affiliation(s)
- Cinzia Baiano
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
- *Correspondence: Cinzia Baiano,
| | - Teresa Somma
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Raduan Ahmed Franca
- Pathology Section, Department of Advanced Biomedical Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Marianna Di Costanzo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Maria Rosaria Scala
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Pasquale Cretella
- Pathology Section, Department of Advanced Biomedical Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Felice Esposito
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Paolo Cappabianca
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| |
Collapse
|
33
|
Zoli M, Guaraldi F, Zenesini C, Acciarri N, Sollini G, Asioli S, Faustini-Fustini M, Agati R, Cirillo L, Tonon C, Lodi R, Pasquini E, Mazzatenta D. Role of endoscopic endonasal approach for craniopharyngiomas extending into the third ventricle in adults. BRAIN & SPINE 2022; 2:100910. [PMID: 36248121 PMCID: PMC9560538 DOI: 10.1016/j.bas.2022.100910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 05/21/2022] [Accepted: 06/25/2022] [Indexed: 06/16/2023]
Abstract
•EAA is an innovative, promising, safe and effective approach for 3VCPs.•Key of success is surgeon learning curve in endoscopy and patients selection.•With correct indications, EEA gives GTR and morbidity rate similar to other routes.•Clinical, tumoral and anatomical features should be considered for EEA selection.
Collapse
Affiliation(s)
- Matteo Zoli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi - Pituitary Unit, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | - Federica Guaraldi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi - Pituitary Unit, Bologna, Italy
| | - Corrado Zenesini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Epidemiology and Statistics Unit, Bologna, Italy
| | - Nicola Acciarri
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi - Pituitary Unit, Bologna, Italy
| | - Giacomo Sollini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi - Pituitary Unit, Bologna, Italy
- Azienda USL di Bologna, ENT Department, Bellaria Hospital, Bologna, Italy
| | - Sofia Asioli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
- Azienda USL di Bologna, Anatomic Pathology Unit, Bellaria Hospital, Bologna, Italy
| | - Marco Faustini-Fustini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi - Pituitary Unit, Bologna, Italy
| | - Raffaele Agati
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neuroradiologia con Tecniche ad Elevata Complessità, Bologna, Italy
| | - Luigi Cirillo
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC di Neuroradiologia, Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neuroimmagini Funzionali e Molecolari, Bologna, Italy
| | - Caterina Tonon
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neuroimmagini Funzionali e Molecolari, Bologna, Italy
| | - Raffaele Lodi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Ernesto Pasquini
- Azienda USL di Bologna, ENT Department, Bellaria Hospital, Bologna, Italy
| | - Diego Mazzatenta
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi - Pituitary Unit, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| |
Collapse
|
34
|
Midline Skull Base Meningiomas: Transcranial and Endonasal Perspectives. Cancers (Basel) 2022; 14:cancers14122878. [PMID: 35740543 PMCID: PMC9220797 DOI: 10.3390/cancers14122878] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/25/2022] [Accepted: 06/03/2022] [Indexed: 12/07/2022] Open
Abstract
Simple Summary Skull base meningiomas have always represented a challenge for neurosurgeons. Despite their histological nature, they may be associated with unfavorable outcomes due to their deep-seated location and the surrounding neurovascular structures. Over time, several corridors have been proposed, each one carrying its own pros and cons. During the last decades, the endoscopic endonasal route has been asserted among the classic routes for a growing number of midline and paramedian lesions. Therefore, the aim of our paper is to present a comprehensive review of the indications and techniques for the management of skull base meningiomas, emphasizing the ambivalent and complementary role of the low and high routes. Abstract Skull base meningiomas have always represented a challenge for neurosurgeons. Despite their histological nature, they may be associated with unfavorable outcomes due to their deep-seated location and the surrounding neurovascular structures. The state of the art of skull base meningiomas accounts for both transcranial, or high, and endonasal, or low, routes. A comprehensive review of the pertinent literature was performed to address the surgical strategies and outcomes of skull base meningioma patients treated through a transcranial approach, an endoscopic endonasal approach (EEA), or both. Three databases (PubMed, Ovid Medline, and Ovid Embase) have been searched. The review of the literature provided 328 papers reporting the surgical, oncological, and clinical results of different approaches for the treatment of skull base meningiomas. The most suitable surgical corridors for olfactory groove, tuberculum sellae, clival and petroclival and cavernous sinus meningiomas have been analyzed. The EEA was proven to be associated with a lower extent of resection rates and better clinical outcomes compared with transcranial corridors, offering the possibility of achieving the so-called maximal safe resection.
Collapse
|
35
|
Zhou Y, Hei Y, Soto JM, Jin T, Jiang X, Feng D, Liu W, Gao D. Clinical Efficacy of the Multilayered Skull Base Reconstruction Using In Situ Bone Flap in Endoscopic Endonasal Approach for Craniopharyngioma. Skull Base Surg 2022; 83:e291-e297. [PMID: 35832974 DOI: 10.1055/s-0041-1726128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 01/29/2021] [Indexed: 10/21/2022]
Abstract
Objective The aim of the study is to summarize and analyze the efficacy of the multilayered skull base reconstruction using in situ bone flap in endoscopic endonasal approach (EEA) for craniopharyngiomas. Methods A retrospective review of 65 patients who underwent resection of their histopathology confirmed craniopharyngiomas performed at a single institution. Based on the team's understanding and mastery of skull base reconstruction techniques, patients were divided into two groups according to the methods of reconstruction in two periods. First (March 2015 through August 2016), osseous reconstruction was not adopted and served as the control group (34 cases). Second (September 2016 through July 2019), in situ bone flap repair of the skull base (complete osseous reconstruction) served as observation group (31 cases). The length of hospitalization and nasal exudation, bed rest time of hospital discharge, the incidence of cerebrospinal fluid leaks, lumbar drainage, and intracranial/pulmonary infections were collected and compared. Results Compared with the control group, patients in the observation group had obviously less lumbar drainage and CSF leakage ( p < 0.05), but had no significant difference in cases of re-operation, meningitis, and pulmonary infection. At the meantime, cases of nasal exudation, bed rest, and hospitalization of the observation group were significantly reduced ( p < 0.05) in the observation group. Conclusion The multilayered reconstruction technique (especially using in situ bone flap, combined with vascularized pedicled nasoseptal flap) is a safe and effective method in achieving watertight closure after EEEA, and can significantly reduce the incidence of cerebrospinal fluid leaks, and facilitate rehabilitation in skull base reconstruction of craniopharyngiomas.
Collapse
Affiliation(s)
- Yuefei Zhou
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yue Hei
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Jose M Soto
- Department of Neurosurgery, Baylor Scott and White Medical Center, Texas A&M University, College of Medicine, Temple, Texas, United States
| | - Tao Jin
- Department of Neurosurgery, The Center Hospital of Ankang City, Ankang, Shaanxi, China
| | - Xiaofan Jiang
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Dongxia Feng
- Department of Neurosurgery, Baylor Scott and White Medical Center, Texas A&M University, College of Medicine, Temple, Texas, United States
| | - Weiping Liu
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Dakuan Gao
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| |
Collapse
|
36
|
Cossu G, Turin-Huet V, Garvayo Navarro M, Papadakis G, Daniel RT, Dunet V, Messerer M. Radiological evolution of autograft fat used for skull base reconstruction after transsphenoidal surgery for pituitary adenomas. Pituitary 2022; 25:468-473. [PMID: 35194708 PMCID: PMC9170666 DOI: 10.1007/s11102-022-01210-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 10/26/2022]
Abstract
PURPOSE Cerebro-spinal fluid leak after transsphenoidal surgery for pituitary adenomas may be prevented by skull base reconstruction with fat autograft. However, graft changes may interfere with the interpretation of postoperative images. Our aim is to describe the radiological evolution of the fat autograft. METHODS A retrospective analysis was performed, including patients undergoing a transsphenoidal surgery for pituitary adenomas with a fat autograft for skull base reconstruction. Clinical and radiological data were collected, with assessment of fat autograft and extent of resection. Statistical analysis was performed using Kruskal-Wallis and Wilcoxon signed-rank test while Spearman's Rho was used to analyze the relationship between variables. RESULTS Seventy-two patients were included. Macroadenomas were diagnosed in 62 cases (86.1%) and in 21 cases an invasion of the cavernous sinus was described (29%). Gross total resection was achieved in 84.7% of cases. The volume of the fat graft significantly decreased between 3 months and 1 year after surgery (p = 0.01) and between 1 year and the last follow-up (mean 4.63 years, p < 0.01). Fat signal ratio significantly diminished between 3 months and 1 year in unenhanced and enhanced T1-weighted sequences (p = 0.04 and p = 0.02 respectively). Volume reduction was related to the decrease in signal ratio in unenhanced T1 sequences (p = 0.008). CONCLUSION Fat resorbs with time: almost 50% of the fat volume is lost during the first year after surgery and 60% is resorbed at 4.6 years. T1-signal, before and after gadolinium injection, also decreases during the first year, probably because of the progressive fibrosis of the graft. This information will contribute to the interpretation of postoperative images.
Collapse
Affiliation(s)
- Giulia Cossu
- Department of Neurosurgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Victoire Turin-Huet
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Marta Garvayo Navarro
- Department of Neurosurgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Georgios Papadakis
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Department of Endocrinology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Roy Thomas Daniel
- Department of Neurosurgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Vincent Dunet
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Department of Medical Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Mahmoud Messerer
- Department of Neurosurgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.
| |
Collapse
|
37
|
Alshareef M, Alroqi A, Albaharna H, Alsayed A, Alromaih S, Alrasheed AS, Ajlan A, Alsaleh S. Nasoseptal flap and rigid reconstruction in endoscopic endonasal skull base surgeries: The longitudinal experience of a single center. EAR, NOSE & THROAT JOURNAL 2022:1455613221099483. [PMID: 35603535 DOI: 10.1177/01455613221099483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Recently, endoscopic endonasal approaches (EEA) have been used for skull base defect reconstruction surgeries. The nasoseptal flap (NSF), a vascular pedicled flap, was introduced to decrease postoperative cerebrospinal fluid (CSF) leakage. PURPOSES This study aimed to outline the authors' institutional experience using NSF and rigid implants in anterior skull base defect reconstruction surgeries following EEA. DESIGN A retrospective cohort review of patients who underwent NSF reconstruction following EEA in the Otorhinolaryngology and Neurosurgery Departments at King Saud University Medical City, Riyadh, Saudi Arabia, from January 2015 to May 2021, divided into 2 time periods according to the reconstruction technique. RESULT Out of the 106 patients who underwent EEA, 77 underwent NSF reconstruction. The majority had expanded EEA (94.8%). The mean age was 40.21 ± 17.7 years, and the female gender represented 61% of the sample. More than half of the sample underwent right NSF (57.1%). Meningioma was the most common diagnosis (45.5%). The clivus was the most frequent site of lesions (23.4%). The overall rate of postoperative CSF leakage and lumbar drainage (LD) insertion was 15.6% and 51.9%, respectively. The duration of LD was a median of four days. The overall failure rate was 13%, declining from 20% in the first period to 5.4% in the second period. Rigid implants were used significantly more in the first period than in the second period (67.5% versus 16.2%, P < 0.001). Meningitis, the highest postoperative complication, was reported in 6 patients (7.8%). One patient died three weeks postoperatively after massive nasal bleeding. No significant difference was found between either side of the NFS regarding the CSF leakage and failure rate. CONCLUSION In the authors' experience, there has been an overt decline in failure rates and complications of EEA over the last three years due to increased experience among surgeons and a standardization of reconstruction techniques. Minimal reconstruction may provide satisfactory results by decreasing the use of rigid implants. An endoscopic endonasal approach with an NSF for anterior skull base defect reconstruction is considered a safe procedure with no significant difference between the sides of the flap.
Collapse
Affiliation(s)
- Mohammad Alshareef
- Department of Otolaryngology-Head and Neck Surgery, Khamis Mushait General hospital - Khamis Mushait City, Saudi Arabia
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, 191082King Saud University, Riyadh, Saudi Arabia
| | - Ahmad Alroqi
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, 191082King Saud University, Riyadh, Saudi Arabia
| | - Hussain Albaharna
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, 191082King Saud University, Riyadh, Saudi Arabia
- Department of Otolaryngology-Head and Neck Surgery, 48070Qatif Central Hospital - Qatif City, Saudi Arabia
| | - Ahmed Alsayed
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, 191082King Saud University, Riyadh, Saudi Arabia
| | - Saud Alromaih
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, 191082King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz S Alrasheed
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, 191082King Saud University, Riyadh, Saudi Arabia
| | - Abdulrazag Ajlan
- Department of Neurosurgery, 191082College of Medicine King Saud University, Riyadh, Saudi Arabia
| | - Saad Alsaleh
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, 191082King Saud University, Riyadh, Saudi Arabia
| |
Collapse
|
38
|
Experience and modification of skull base reconstruction results in lower complications rates. Acta Neurochir (Wien) 2022; 164:1127-1133. [PMID: 35039957 DOI: 10.1007/s00701-021-05082-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 11/29/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVES To investigate the efficacy of nasal septum bone flap combined with vascularized pedicle nasoseptal flap (VP-NSF) in the treatment of high-flow cerebrospinal fluid (CSF) leakage in the endonasal endoscopic skull base surgery. METHODS A total of 156 patients in group A used a multi-layer skull base reconstruction method of fat-absorbable artificial dura mater- fascia lata-VP-NSF, and were treated with drainage of the lumbar cistern after surgery, in addition, a total of 94 patients in group B used a multi-layer skull base reconstruction method of fat-absorbable artificial dura mater-nasal septal bone flap-VP-NSF, and no lumbar cistern drainage was performed after surgery. Analyzed and compared the differences of postoperative cerebrospinal fluid rhinorrhea, intracranial infection, re-repair, average bed rest time, pulmonary infection and deep venous thrombosis of lower extremities were analyzed and compared in the two groups. RESULTS In group A, 11 cases of cerebrospinal fluid rhinorrhea occurred after operation. In addition, 15 cases developed intracranial infection. During this period, there were 20 cases of pulmonary infection and 3 cases of deep venous thrombosis of lower extremities. In group B, there were 1 case of cerebrospinal fluid rhinorrhea (P < 0.05), 2 cases of intracranial infection (P < 0.05), 2 cases of pulmonary infection (P < 0.05), and 0 case of deep venous thrombosis of lower extremities (P > 0.05). CONCLUSION Nasal septum bone flap combined with VP-NSF is effective in the treatment of high-flow CSF leaks in the endonasal endoscopic skull base surgery, which can avoid postoperative lumbar cistern drainage and is worth popularizing.
Collapse
|
39
|
Mattogno PP, Caccavella VM, Giordano M, D'Alessandris QG, Chiloiro S, Tariciotti L, Olivi A, Lauretti L. Interpretable Machine Learning-Based Prediction of Intraoperative Cerebrospinal Fluid Leakage in Endoscopic Transsphenoidal Pituitary Surgery: A Pilot Study. J Neurol Surg B Skull Base 2022; 83:485-495. [PMID: 36091632 PMCID: PMC9462964 DOI: 10.1055/s-0041-1740621] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 11/12/2021] [Indexed: 01/18/2023] Open
Abstract
Purpose Transsphenoidal surgery (TSS) for pituitary adenomas can be complicated by the occurrence of intraoperative cerebrospinal fluid (CSF) leakage (IOL). IOL significantly affects the course of surgery predisposing to the development of postoperative CSF leakage, a major source of morbidity and mortality in the postoperative period. The authors trained and internally validated the Random Forest (RF) prediction model to preoperatively identify patients at high risk for IOL. A locally interpretable model-agnostic explanations (LIME) algorithm is employed to elucidate the main drivers behind each machine learning (ML) model prediction. Methods The data of 210 patients who underwent TSS were collected; first, risk factors for IOL were identified via conventional statistical methods (multivariable logistic regression). Then, the authors trained, optimized, and audited a RF prediction model. Results IOL reported in 45 patients (21.5%). The recursive feature selection algorithm identified the following variables as the most significant determinants of IOL: Knosp's grade, sellar Hardy's grade, suprasellar Hardy's grade, tumor diameter (on X, Y, and Z axes), intercarotid distance, and secreting status (nonfunctioning and growth hormone [GH] secreting). Leveraging the predictive values of these variables, the RF prediction model achieved an area under the curve (AUC) of 0.83 (95% confidence interval [CI]: 0.78; 0.86), significantly outperforming the multivariable logistic regression model (AUC = 0.63). Conclusion A RF model that reliably identifies patients at risk for IOL was successfully trained and internally validated. ML-based prediction models can predict events that were previously judged nearly unpredictable; their deployment in clinical practice may result in improved patient care and reduced postoperative morbidity and healthcare costs.
Collapse
Affiliation(s)
- Pier Paolo Mattogno
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemell iIstituto di Ricovero e Cura a Carattere Scientifico Università Cattolica del Sacro Cuore, Rome, Italy
| | - Valerio M. Caccavella
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemell iIstituto di Ricovero e Cura a Carattere Scientifico Università Cattolica del Sacro Cuore, Rome, Italy
| | - Martina Giordano
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemell iIstituto di Ricovero e Cura a Carattere Scientifico Università Cattolica del Sacro Cuore, Rome, Italy,Address for correspondence Martina Giordano, MD Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico Università Cattolica del Sacro CuoreLargo Agostino Gemelli, 8 00168 RomeItaly
| | - Quintino G. D'Alessandris
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemell iIstituto di Ricovero e Cura a Carattere Scientifico Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sabrina Chiloiro
- Department of Endocrinology, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico Università Cattolica del Sacro Cuore, Rome, Italy
| | - Leonardo Tariciotti
- Unit of Neurosurgery, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Milan, Italy,University of Milan, Milan, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemell iIstituto di Ricovero e Cura a Carattere Scientifico Università Cattolica del Sacro Cuore, Rome, Italy
| | - Liverana Lauretti
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemell iIstituto di Ricovero e Cura a Carattere Scientifico Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
40
|
Soliman AY, Ebeid K, Elfadle AA. Recurrent spontaneous CSF rhinorrhea: combined endo-nasal endoscopic repair with lumbo-peritoneal shunt insertion. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00298-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Spontaneous cerebrospinal fluid (CSF) leaks are associated with high morbidity and recurrence rates. Most cases had increased intracranial pressure (ICP) on presentation. There is still controversy regarding the use of lumbo-peritoneal shunt to prevent its recurrence.
Aim
This study was conducted to evaluate the impact of lumbo-peritoneal CSF shunt following the initial as well as recurrent repair of spontaneous CSF leaks to avoid recurrence.
Methods
A retrospective cohort study reviewed patients with recurrent spontaneous CSF leaks over a 4-year period. All patients had increased ICP and were subjected to endoscopic repair and lumbo-peritoneal shunt procedure.
Results
Eighteen patients were included in this study. Most patients were obese (BMI = 33.6 ± 1.8 kg/m2) women (88.9%), with sleep apnea syndrome (77.8%). All patients presented with headache and visual complaints. Meningitis was recorded in two patients (11.1%). The most common sites of leakage were the cribriform (66.7%), followed by both cribriform and ethmoidal (16.7%), sphenoid (11.1%), and ethmoidal (5.6%) bones. The mean defect size was 5.1 ± 1.1 mm. About one third of cases had multiple defects. Encephalocele and meningocele were encountered in 61.1% and 66.7% of cases, respectively. The mean preoperative CSF pressure was 36.5 ± 1.7 mm H2O. Lumbo-peritoneal shunt was inserted for all our patients. The failure rate of repair was 11.1%.
Conclusion
Success rate is higher in patients with spontaneous CSF leaks and CSF hypertension treated by lumbo-peritoneal shunt. Future prospective studies with larger sample sizes should confirm the efficacy and safety of this management plan.
Collapse
|
41
|
Topical hemostatic agents in neurosurgery, a comprehensive review: 15 years update. Neurosurg Rev 2021; 45:1217-1232. [PMID: 34734343 DOI: 10.1007/s10143-021-01684-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/26/2021] [Accepted: 10/25/2021] [Indexed: 12/30/2022]
Abstract
Hemostasis in neurosurgery is of utmost importance. Bleeding management is one of the crucial steps of each neurosurgical procedure. Several strategies, namely thermal, mechanical, electric, and chemical, have been advocated to face blood loss within the surgical field. Over time, countless hemostatic agents and devices have been proposed. Furthermore, the ever-growing recent technological innovation has made available several novel and interesting tools. Pursuant to their impact on surgical practice, we perceived the imperative to update our previous disclosure paper. Therefore, we reviewed the literature and analyzed technical data sheets of each product in order to provide an updated and comprehensive overview in regard to chemical properties, mechanisms of action, use, complications, tricks, and pitfalls of topical hemostatic agents.
Collapse
|
42
|
Khalafallah AM, Rakovec M, Burapachaisri K, Fung S, Kozachik SL, Valappil B, Abou-Al-Shaar H, Wang EW, Snyderman CH, Zenonos GA, Gardner PA, Baskaya MK, Dornbos D, Choby G, Kuan EC, Roxbury C, Overdevest JB, Gudis DA, Lee VS, Levy JM, Thamboo A, Schlosser RJ, Huang J, Bettegowda C, London NR, Rowan NR, Wu AW, Mukherjee D. The Suprasellar Meningioma Patient-Reported Outcome Survey: a disease-specific patient-reported outcome measure for resection of suprasellar meningioma. J Neurosurg 2021:1-9. [PMID: 34874673 DOI: 10.3171/2021.6.jns21517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 06/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Suprasellar meningioma resection via either the transcranial approach (TCA) or the endoscopic endonasal approach (EEA) is an area of controversy and active evaluation. Skull base surgeons increasingly consider patient-reported outcomes (PROs) when choosing an approach. No PRO measure currently exists to assess quality of life for suprasellar meningiomas. METHODS Adult patients undergoing suprasellar meningioma resection between 2013 and 2019 via EEA (n = 14) or TCA (n = 14) underwent semistructured interviews. Transcripts were coded using a grounded theory approach to identify themes as the basis for a PRO measure that includes all uniquely reported symptoms. To assess content validity, 32 patients and 15 surgeons used a Likert scale to rate the relevance of items on the resulting questionnaire and the general Patient-Reported Outcomes Measurement Information System-29 (PROMIS29). The mean scores were calculated for all items and compared for TCA versus EEA patient cohorts by using unpaired t-tests. Items on either questionnaire with mean scores ≥ 2.0 from patients were considered meaningful and were aggregated to form the novel Suprasellar Meningioma Patient-Reported Outcome Survey (SMPRO) instrument. RESULTS Qualitative analyses resulted in 55 candidate items. Relative to patients who underwent the EEA, those who underwent the TCA reported significantly worse future outlook before surgery (p = 0.01), tiredness from medications 2 weeks after surgery (p = 0.001), and word-finding and memory difficulties 3 months after surgery (p = 0.05 and < 0.001, respectively). The items that patients who received a TCA were most concerned about included medication-induced lethargy after surgery (2.9 ± 1.3), blurry vision before surgery (2.7 ± 1.5), and difficulty reading due to blurry vision before surgery (2.7 ± 2.7). Items that patients who received an EEA were most concerned about included blurry vision before surgery (3.5 ± 1.3), difficulty reading due to blurry vision before surgery (2.4 ± 1.3), and problems with smell postsurgery (2.9 ± 1.3). Although surgeons overall overestimated how concerned patients were about questionnaire items (p < 0.0005), the greatest discrepancies between patient and surgeon relevance scores were for blurry vision pre- and postoperatively (p < 0.001 and < 0.001, respectively) and problems with taste postoperatively (p < 0.001). Seventeen meningioma-specific items were considered meaningful, supplementing 8 significant PROMIS29 items to create the novel 25-item SMPRO. CONCLUSIONS The authors developed a disease- and approach-specific measure for suprasellar meningiomas to compare quality of life by operative approach. If demonstrated to be reliable and valid in future studies, this instrument may assist patients and providers in choosing a personalized surgical approach. ABBREVIATIONS EEA = endoscopic endonasal approach; GTR = gross-total resection; PRO = patient-reported outcome; PROMIS29 = Patient-Reported Outcomes Measurement Information System-29; QOL = quality of life; SMPRO = Suprasellar Meningioma Patient-Reported Outcome Survey; TCA = transcranial approach.
Collapse
Affiliation(s)
| | - Maureen Rakovec
- Department of Neurosurgery, Johns Hopkins University School of Medicine
| | | | - Shirley Fung
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Sharon L. Kozachik
- Medical University of South Carolina College of Nursing, Charleston, South Carolina
| | - Benita Valappil
- Department of Otolaryngology, University of Pittsburgh School of Medicine
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Eric W. Wang
- Department of Otolaryngology, University of Pittsburgh School of Medicine
| | - Carl H. Snyderman
- Department of Otolaryngology, University of Pittsburgh School of Medicine
| | - Georgios A. Zenonos
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Paul A. Gardner
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Mustafa K. Baskaya
- Department of Neurosurgery, University of Wisconsin–Madison School of Medicine and Public Health, Madison, Wisconsin
| | - David Dornbos
- Department of Neurological Surgery, Ohio State University Medical Center, Columbus, Ohio
| | - Garrett Choby
- Department of Otorhinolaryngology–Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Edward C. Kuan
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, Orange, California
| | - Christopher Roxbury
- Department of Surgery, Section of Otolaryngology–Head and Neck Surgery, University of Chicago School of Medicine, Chicago, Illinois
| | - Jonathan B. Overdevest
- Department of Otolaryngology–Head and Neck Surgery, Columbia University Irving Medical Center, New York, New York
| | - David A. Gudis
- Department of Otolaryngology–Head and Neck Surgery, University of Illinois at Chicago, Illinois
| | - Victoria S. Lee
- Department of Otolaryngology–Head and Neck Surgery, University of Illinois at Chicago, Illinois
| | - Joshua M. Levy
- Department of Otolaryngology–Head and Neck Surgery, Division of Rhinology and Anterior Skull Base, Emory University Hospital, Atlanta, Georgia
| | - Andrew Thamboo
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Rodney J, Schlosser
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine
| | - Nyall R. London
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nicholas R. Rowan
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Albert W. Wu
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine
| |
Collapse
|
43
|
Khan DZ, Ali AMS, Koh CH, Dorward NL, Grieve J, Layard Horsfall H, Muirhead W, Santarius T, Van Furth WR, Zamanipoor Najafabadi AH, Marcus HJ. Skull base repair following endonasal pituitary and skull base tumour resection: a systematic review. Pituitary 2021; 24:698-713. [PMID: 33973152 PMCID: PMC8416859 DOI: 10.1007/s11102-021-01145-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE Postoperative cerebrospinal fluid rhinorrhoea (CSFR) remains a frequent complication of endonasal approaches to pituitary and skull base tumours. Watertight skull base reconstruction is important in preventing CSFR. We sought to systematically review the current literature of available skull base repair techniques. METHODS Pubmed and Embase databases were searched for studies (2000-2020) that (a) reported on the endonasal resection of pituitary and skull base tumours, (b) focussed on skull base repair techniques and/or postoperative CSFR risk factors, and (c) included CSFR data. Roles, advantages and disadvantages of each repair method were detailed. Random-effects meta-analyses were performed where possible. RESULTS 193 studies were included. Repair methods were categorised based on function and anatomical level. There was absolute heterogeneity in repair methods used, with no independent studies sharing the same repair protocol. Techniques most commonly used for low CSFR risk cases were fat grafts, fascia lata grafts and synthetic grafts. For cases with higher CSFR risk, multilayer regimes were utilized with vascularized flaps, gasket sealing and lumbar drains. Lumbar drain use for high CSFR risk cases was supported by a randomised study (Oxford CEBM: Grade B recommendation), but otherwise there was limited high-level evidence. Pooled CSFR incidence by approach was 3.7% (CI 3-4.5%) for transsphenoidal, 9% (CI 7.2-11.3%) for expanded endonasal, and 5.3% (CI 3.4-7%) for studies describing both. Further meaningful meta-analyses of repair methods were not performed due to significant repair protocol heterogeneity. CONCLUSIONS Modern reconstructive protocols are heterogeneous and there is limited evidence to suggest the optimal repair technique after pituitary and skull base tumour resection. Further studies are needed to guide practice.
Collapse
Affiliation(s)
- Danyal Z Khan
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Ahmad M S Ali
- Department of Neurosurgery, The Walton Centre, Liverpool, UK
| | - Chan Hee Koh
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Neil L Dorward
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Joan Grieve
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Hugo Layard Horsfall
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - William Muirhead
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Thomas Santarius
- Division of Neurosurgery, University of Cambridge and Cambridge University Hospitals, Cambridge, UK
| | - Wouter R Van Furth
- Department of Neurosurgery, University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Amir H Zamanipoor Najafabadi
- Department of Neurosurgery, University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Hani J Marcus
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK.
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK.
| |
Collapse
|
44
|
Dorismond C, Santarelli GD, Thorp BD, Kimple AJ, Ebert CS, Zanation AM. Heterogeneity in Outcome Reporting in Endoscopic Endonasal Skull Base Reconstruction: A Systematic Review. J Neurol Surg B Skull Base 2021; 82:506-521. [PMID: 34513556 DOI: 10.1055/s-0040-1714108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 05/17/2020] [Indexed: 10/23/2022] Open
Abstract
Objective Presently, there are no standards for reporting outcomes of endoscopic endonasal skull base reconstruction (ESBR). This is problematic as a lack of consistent reporting makes synthesizing findings in systematic reviews and meta-analysis challenging. Thus, the aim of this study was to systematically review and describe the patterns of reporting outcomes in ESBR as a foundation for developing reporting guidelines. Study Design Present study is a systematic review. Methods Embase, PubMed, CINAHL, Cochrane Library, and Web of Science were searched for all publications with ≥25 patients and a focus on ESBR. The reporting patterns of each study's variables and outcomes were assessed. Results A total of 112 studies were included in the review. The most commonly reported demographic variables were the number of included patients ( n = 112, 100%) and types of pathologies treated ( n = 104, 92.9%). Meanwhile, the most routinely described preoperative variable was history of prior treatment ( n = 48, 42.9%). Type of reconstruction was a commonly reported intraoperative variable ( n = 110, 98.2%), though the rate of intraoperative cerebrospinal fluid (CSF) leak was noted in only 76 studies (67.9%). With regard to postoperative outcomes, postoperative CSF leak rate was routinely provided ( n = 101, 90.2%), but reporting of other surgical complications was more inconsistent. Ultimately, of the 43 variables and outcomes reviewed, a median of 12 (range: 4-22) was reported in each study. Conclusion There is significant heterogeneity in the outcomes reported in studies relating to ESBR. This highlights the need for the development of standard reporting guidelines to minimize bias and improve interstudy comparability.
Collapse
Affiliation(s)
- Christina Dorismond
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Griffin D Santarelli
- Department of Otolaryngology, Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, United States
| | - Brian D Thorp
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Adam J Kimple
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Charles S Ebert
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Adam M Zanation
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| |
Collapse
|
45
|
Shimohonji W, Morisako H, Ohata H, Valenzuela JC, Sakaeyama Y, Goto T. Osaka Sliding Knot Seals Dural Defect Simply in Extended Endoscopic Endonasal Approach. World Neurosurg 2021; 155:144-149. [PMID: 34419659 DOI: 10.1016/j.wneu.2021.08.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 11/18/2022]
Abstract
An extended endoscopic endonasal approach (EEA) has become standard for parasellar and midline skull base lesions. However, postoperative leakage of cerebrospinal fluid (CSF) can result from dural defects after lesion removal. We present a simple and effective technique, the Osaka sliding knot, to prevent CSF leakage. Between November 2018 and March 2021, a total of 41 patients underwent reconstruction of skull base defects with intraoperative high-flow CSF leaks after extended EEA by using this closure technique, of whom only 1 patient experienced postoperative CSF leakage. This technically simple and efficient method seals the dural defect to prevent CSF leakage after surgeries using an extended EEA.
Collapse
Affiliation(s)
- Wataru Shimohonji
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroki Morisako
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan.
| | - Hiroki Ohata
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | | | - Yuki Sakaeyama
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Takeo Goto
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| |
Collapse
|
46
|
Chibbaro S, Signorelli F, Milani D, Cebula H, Scibilia A, Bozzi MT, Messina R, Zaed I, Todeschi J, Ollivier I, Mallereau CH, Dannhoff G, Romano A, Cammarota F, Servadei F, Pop R, Baloglu S, Lasio GB, Luca F, Goichot B, Proust F, Ganau M. Primary Endoscopic Endonasal Management of Giant Pituitary Adenomas: Outcome and Pitfalls from a Large Prospective Multicenter Experience. Cancers (Basel) 2021; 13:cancers13143603. [PMID: 34298816 PMCID: PMC8304085 DOI: 10.3390/cancers13143603] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/22/2021] [Accepted: 07/10/2021] [Indexed: 11/30/2022] Open
Abstract
Simple Summary Giant pituitary adenomas are highly invasive tumors whose treatment is challenging. Surgery is their management mainstay. However, there is no consensus about the type of approach. Open transcranial, microscopic, and endoscopic trans-sphenoidal approaches have all been employed, alone or in combination. Extended endoscopic endonasal techniques may represent a versatile and safe one-stage approach. Our research aimed at evaluating prospectively their applicability, effectiveness, and safety in a multicenter series, to acquire further evidence toward its use in the treatment of those challenging lesions. Ninety-six patients were recruited and followed-up for 52.4 months on average. Most of them (81.2%) presented with visual deficits and >50% had various degrees of adenohypophysis insufficiency. Resection of at least 75% of initial volume was achieved in all cases, with 98.7% visual improvement, >50% endocrine deficit recovery and a permanent complication rate of 4.2%, indicating extended endoscopic endonasal approaches as a valuable treatment option. Abstract Purpose: To evaluate factors influencing clinical and radiological outcome of extended endoscopic endonasal transtuberculum/transplanum approach (EEA-TTP) for giant pituitary adenomas (GPAs). Methods: We recruited prospectively all consecutive GPAs patients undergoing EEA-TTP between 2015 and 2019 in 5 neurosurgical centers. Preoperative clinical and radiologic features, visual and hormonal outcomes, extent of resection (EoR), complications and recurrence rates were recorded and analyzed. Results: Of 1169 patients treated for pituitary adenoma, 96 (8.2%) had GPAs. Seventy-eight (81.2%) patients had visual impairment, 12 (12.5%) had headaches, 3 (3.1%) had drowsiness due to hydrocephalus, and 53 (55.2%) had anterior pituitary insufficiency. EoR was gross or near-total in 46 (47.9%) and subtotal in 50 (52.1%) patients. Incomplete resection was associated with lateral suprasellar, intraventricular and/or cavernous sinus extension and with firm/fibrous consistence. At the last follow-up, all but one patient (77, 98.7%) with visual deficits improved. Headache improved in 8 (88.9%) and anterior pituitary function recovered in 27 (50.9%) patients. Recurrence rate was 16.7%, with 32 months mean recurrence-free survival. Conclusions: EEA-TTP is a valid option for GPAs and seems to provide better outcomes, lower rate of complications and higher EoR compared to one- or multi-stage microscopic, non-extended endoscopic transsphenoidal, and transcranial resections.
Collapse
Affiliation(s)
- Salvatore Chibbaro
- Neurosurgery Unit, Hautepierre Regional Hospital, Strasbourg University, 67200 Strasbourg, France; (S.C.); (H.C.); (A.S.); (M.T.B.); (I.Z.); (J.T.); (I.O.); (C.H.M.); (G.D.); (F.C.); (R.P.); (S.B.); (F.P.); (M.G.)
| | - Francesco Signorelli
- Neurosurgery Unit, Department of Basic Medical Sciences, Neurosciences, Sense Organs, University “Aldo Moro”, 70124 Bari, Italy;
- Correspondence: ; Tel.: +39-0805592900
| | - Davide Milani
- Neurosurgery Unit, Humanitas Research Hospital, 20089 Milano, Italy; (D.M.); (F.S.); (G.B.L.)
| | - Helene Cebula
- Neurosurgery Unit, Hautepierre Regional Hospital, Strasbourg University, 67200 Strasbourg, France; (S.C.); (H.C.); (A.S.); (M.T.B.); (I.Z.); (J.T.); (I.O.); (C.H.M.); (G.D.); (F.C.); (R.P.); (S.B.); (F.P.); (M.G.)
| | - Antonino Scibilia
- Neurosurgery Unit, Hautepierre Regional Hospital, Strasbourg University, 67200 Strasbourg, France; (S.C.); (H.C.); (A.S.); (M.T.B.); (I.Z.); (J.T.); (I.O.); (C.H.M.); (G.D.); (F.C.); (R.P.); (S.B.); (F.P.); (M.G.)
| | - Maria Teresa Bozzi
- Neurosurgery Unit, Hautepierre Regional Hospital, Strasbourg University, 67200 Strasbourg, France; (S.C.); (H.C.); (A.S.); (M.T.B.); (I.Z.); (J.T.); (I.O.); (C.H.M.); (G.D.); (F.C.); (R.P.); (S.B.); (F.P.); (M.G.)
| | - Raffaella Messina
- Neurosurgery Unit, Department of Basic Medical Sciences, Neurosciences, Sense Organs, University “Aldo Moro”, 70124 Bari, Italy;
| | - Ismail Zaed
- Neurosurgery Unit, Hautepierre Regional Hospital, Strasbourg University, 67200 Strasbourg, France; (S.C.); (H.C.); (A.S.); (M.T.B.); (I.Z.); (J.T.); (I.O.); (C.H.M.); (G.D.); (F.C.); (R.P.); (S.B.); (F.P.); (M.G.)
- Neurosurgery Unit, Humanitas Research Hospital, 20089 Milano, Italy; (D.M.); (F.S.); (G.B.L.)
| | - Julien Todeschi
- Neurosurgery Unit, Hautepierre Regional Hospital, Strasbourg University, 67200 Strasbourg, France; (S.C.); (H.C.); (A.S.); (M.T.B.); (I.Z.); (J.T.); (I.O.); (C.H.M.); (G.D.); (F.C.); (R.P.); (S.B.); (F.P.); (M.G.)
| | - Irene Ollivier
- Neurosurgery Unit, Hautepierre Regional Hospital, Strasbourg University, 67200 Strasbourg, France; (S.C.); (H.C.); (A.S.); (M.T.B.); (I.Z.); (J.T.); (I.O.); (C.H.M.); (G.D.); (F.C.); (R.P.); (S.B.); (F.P.); (M.G.)
| | - Charles Henry Mallereau
- Neurosurgery Unit, Hautepierre Regional Hospital, Strasbourg University, 67200 Strasbourg, France; (S.C.); (H.C.); (A.S.); (M.T.B.); (I.Z.); (J.T.); (I.O.); (C.H.M.); (G.D.); (F.C.); (R.P.); (S.B.); (F.P.); (M.G.)
| | - Guillaume Dannhoff
- Neurosurgery Unit, Hautepierre Regional Hospital, Strasbourg University, 67200 Strasbourg, France; (S.C.); (H.C.); (A.S.); (M.T.B.); (I.Z.); (J.T.); (I.O.); (C.H.M.); (G.D.); (F.C.); (R.P.); (S.B.); (F.P.); (M.G.)
| | - Antonio Romano
- Neurosurgery Department, Parma and Reggio Emilia Hospital, University of Parma, 43126 Parma, Italy;
| | - Francesco Cammarota
- Neurosurgery Unit, Hautepierre Regional Hospital, Strasbourg University, 67200 Strasbourg, France; (S.C.); (H.C.); (A.S.); (M.T.B.); (I.Z.); (J.T.); (I.O.); (C.H.M.); (G.D.); (F.C.); (R.P.); (S.B.); (F.P.); (M.G.)
| | - Franco Servadei
- Neurosurgery Unit, Humanitas Research Hospital, 20089 Milano, Italy; (D.M.); (F.S.); (G.B.L.)
| | - Raoul Pop
- Neurosurgery Unit, Hautepierre Regional Hospital, Strasbourg University, 67200 Strasbourg, France; (S.C.); (H.C.); (A.S.); (M.T.B.); (I.Z.); (J.T.); (I.O.); (C.H.M.); (G.D.); (F.C.); (R.P.); (S.B.); (F.P.); (M.G.)
| | - Seyyid Baloglu
- Neurosurgery Unit, Hautepierre Regional Hospital, Strasbourg University, 67200 Strasbourg, France; (S.C.); (H.C.); (A.S.); (M.T.B.); (I.Z.); (J.T.); (I.O.); (C.H.M.); (G.D.); (F.C.); (R.P.); (S.B.); (F.P.); (M.G.)
| | - Giovanni Battista Lasio
- Neurosurgery Unit, Humanitas Research Hospital, 20089 Milano, Italy; (D.M.); (F.S.); (G.B.L.)
| | - Florina Luca
- Endocrinology Unit, Hautepierre Regional Hospital, Strasbourg University, 67200 Strasbourg, France; (F.L.); (B.G.)
| | - Bernard Goichot
- Endocrinology Unit, Hautepierre Regional Hospital, Strasbourg University, 67200 Strasbourg, France; (F.L.); (B.G.)
| | - Francois Proust
- Neurosurgery Unit, Hautepierre Regional Hospital, Strasbourg University, 67200 Strasbourg, France; (S.C.); (H.C.); (A.S.); (M.T.B.); (I.Z.); (J.T.); (I.O.); (C.H.M.); (G.D.); (F.C.); (R.P.); (S.B.); (F.P.); (M.G.)
| | - Mario Ganau
- Neurosurgery Unit, Hautepierre Regional Hospital, Strasbourg University, 67200 Strasbourg, France; (S.C.); (H.C.); (A.S.); (M.T.B.); (I.Z.); (J.T.); (I.O.); (C.H.M.); (G.D.); (F.C.); (R.P.); (S.B.); (F.P.); (M.G.)
- Neurosurgery Department, Oxford University Hospital, Oxford OX3 9DU, UK
| |
Collapse
|
47
|
Kondo T, Kishida Y, Watanabe T, Nagatani T, Seki Y. Combined Transcranial-endonasal Reconstructive Surgery for Cerebrospinal Fluid Leakage Resulting from Traumatic Anterior Skull Base Fractures Involving the Parasellar Region. Neurol Med Chir (Tokyo) 2021; 61:557-562. [PMID: 34078831 PMCID: PMC8443972 DOI: 10.2176/nmc.tn.2021-0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Extensive traumatic anterior skull base fractures from the frontal sinus to the parasellar region are frequently accompanied by multiple dural defects that cause persistent cerebrospinal fluid (CSF) leakage. Conventional transcranial reconstruction using a frontal periosteal flap is frequently insufficient, and parasellar dural defects are often deep, complex, and difficult to identify. In this report, we describe a combined transcranial–endonasal reconstructive technique and report our experience. Simultaneous combined transcranial and endoscopic surgery was performed in three patients with CSF leakage resulting from traumatic anterior skull base fractures. Dural defects were thoroughly identified from the transcranial and endonasal surgical fields, and covered using a multilayer sealing technique. The anterior regions of the anterior skull base were reconstructed using a free fascial flap and frontal periosteal flap; posterior and parasellar regions were reconstructed using a fat graft, vascularized nasoseptal flap, and endonasal balloon. Suturing the transcranial grafts to the parasellar dura mater was performed collaboratively by the transcranial and endonasal surgeons. In our cases, complete cessation of CSF leakage was achieved without perioperative lumbar drainage in all patients. Mean time to postoperative ambulation was 7 days (range, 3–11). No surgical complications occurred. Simultaneous transcranial and endonasal procedures were helpful to detect all sites of CSF leakage and secure reconstructive grafts. The combined transcranial and endonasal reconstructive technique achieved secure skull base reconstruction without recurrence of CSF leakage, and allowed early postoperative ambulation. This technique can be a reliable surgical option to repair CSF leakage resulting from extensive anterior skull base fractures.
Collapse
Affiliation(s)
- Tatsuma Kondo
- Department of Neurosurgery, Japanese Red Cross Nagoya Daini Hospital
| | - Yugo Kishida
- Department of Neurosurgery, Japanese Red Cross Nagoya Daini Hospital
| | | | - Tetsuya Nagatani
- Department of Neurosurgery, Japanese Red Cross Nagoya Daini Hospital
| | - Yukio Seki
- Department of Neurosurgery, Japanese Red Cross Nagoya Daini Hospital
| |
Collapse
|
48
|
di Russo P, Fava A, Giammattei L, Passeri T, Okano A, Abbritti R, Penet N, Bernat AL, Labidi M, Froelich S. The Rostral Mucosa: The Door to Open and Close for Targeted Endoscopic Endonasal Approaches to the Clivus. Oper Neurosurg (Hagerstown) 2021; 21:150-159. [PMID: 34038940 DOI: 10.1093/ons/opab141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/14/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Extended endoscopic endonasal approaches (EEAs) have progressively widened the armamentarium of skull base surgeons. In order to reduce approach-related morbidity of EEAs and closure techniques, the development of alternative strategies that minimize the resection of normal tissue and alleviate the use of naso-septal flap (NSF) is needed. We report on a novel targeted approach to the clivus, with incision and closure of the mucosa of the rostrum, as the initial and final step of the approach. OBJECTIVE To present an alternative minimally invasive approach and reconstruction technique for selected clival chordomas. METHODS Three cases of clival chordomas illustrating this technique are provided, together with an operative video. RESULTS The mucosa of the rostrum is incised and elevated from the underlying bone, as first step of surgery. Following tumor resection with angled scope and instruments, the mucosa of the sphenoid sinus (SS) is removed and the tumor cavity and SS are filled with abdominal fat. The mucosal incision of the rostrum is then sutured. A hangman knot is prepared outside the nasal cavity and tightened after the first stitch and a running suture is performed. CONCLUSION We propose, in this preliminary report, a new targeted approach and reconstruction strategy, applying to EEAs the classic concept of skin incision and closure for transcranial approaches. With further development in the instrumentations and visualization tools, this technique may become a valuable minimally invasive endonasal approach for selected lesions.
Collapse
Affiliation(s)
- Paolo di Russo
- Department of Neurosurgery, Lariboisiere Hospital, Paris, France
| | - Arianna Fava
- Department of Neurosurgery, Lariboisiere Hospital, Paris, France
| | - Lorenzo Giammattei
- Department of Neurosurgery, Lariboisiere Hospital, University of Paris, Paris, France
| | - Thibault Passeri
- Department of Neurosurgery, Lariboisiere Hospital, University of Paris, Paris, France
| | - Atsushi Okano
- Department of Neurosurgery, Lariboisiere Hospital, Paris, France
| | - Rosaria Abbritti
- Department of Neurosurgery, Lariboisiere Hospital, Paris, France
| | - Nicolas Penet
- Department of Neurosurgery, Lariboisiere Hospital, University of Paris, Paris, France
| | | | - Moujahed Labidi
- Department of Neurosurgery, Lariboisiere Hospital, Paris, France
| | - Sebastien Froelich
- Department of Neurosurgery, Lariboisiere Hospital, University of Paris, Paris, France
| |
Collapse
|
49
|
Van Gerven L, Qian Z, Starovoyt A, Jorissen M, Meulemans J, van Loon J, De Vleeschouwer S, Lambert J, Bex M, Vander Poorten V. Endoscopic, Endonasal Transsphenoidal Surgery for Tumors of the Sellar and Suprasellar Region: A Monocentric Historical Cohort Study of 369 Patients. Front Oncol 2021; 11:643550. [PMID: 34026618 PMCID: PMC8138557 DOI: 10.3389/fonc.2021.643550] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/06/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The endoscopic endonasal transsphenoidal approach (EETA) is an established technique for the resection of a large variety of benign sellar and suprasellar lesions, mostly pituitary adenomas. It has clear advantages over the microscopic approach, like a superior close-up view of the relevant anatomy and the tumor-gland interface, an enlarged working angle, as well as an increased panoramic vision inside the surgical area. We have been performing the EETA for over a decade, and this study will focus on perioperative and postoperative outcomes and complications and their association with the learning curve. MATERIAL AND METHODS All patients in our tertiary referral center (n = 369) undergoing an EETA for a lesion of the sellar and suprasellar region between January 1st 2008 and December 31st 2018 were included, and data were retrospectively retrieved from the electronic patient records. RESULTS Median follow-up after surgery was 55 months. Pituitary adenomas (n = 322) were the most frequent pathology. Headache (43.4%) and loss of vision (29.3%) were the most common presenting symptoms. Median procedure duration was significantly longer during the initial 5 years (106 versus 79 minutes; p <0.0001), but incidence of peri- and postoperative CSF leaks in the early years was not significantly higher. Knosp grade >2 was associated with perioperative CSF leak (p =0.002), and perioperative CSF leak was associated with postoperative CSF leak (p <0.001). Almost all cases of meningitis were preceded by a postoperative CSF leak. In 22.4% of patients, tumor recurrence required additional therapy. Perioperative (iatrogenic) mortality was 0.8%. The overall hospital stay decreased over time from an average of 7 to 5 days, and the case load increased yearly (p =0.015). CONCLUSION The EETA is an excellent technique with complication rates comparable to or even lower than those in large microsurgical series in the literature. EETA has a significant learning curve affecting the procedure duration. Throughout the first 10 years following the transition from the microscopic approach to the EETA in our cohort, the caseload increased and hospital stay was reduced, while no increase in peri- and postoperative complications was observed.
Collapse
Affiliation(s)
- Laura Van Gerven
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Otorhinolaryngology, KU Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and transplantation, Allergy and Clinical Immunology Research Unit, KU Leuven, Leuven, Belgium
| | - Zhen Qian
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Anastasiya Starovoyt
- Department of Neurosciences, Experimental Otorhinolaryngology, KU Leuven, Leuven, Belgium
| | - Mark Jorissen
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Jeroen Meulemans
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, Section Head and Neck Oncology, KU Leuven, Leuven, Belgium
| | - Johannes van Loon
- Neurosciences, Research Group Experimental Neurosurgery and Neuroanatomy and Leuven Brain Institute, Leuven, Belgium
| | - Steven De Vleeschouwer
- Neurosciences, Research Group Experimental Neurosurgery and Neuroanatomy and Leuven Brain Institute, Leuven, Belgium
| | - Julie Lambert
- Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Marie Bex
- Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Vincent Vander Poorten
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, Section Head and Neck Oncology, KU Leuven, Leuven, Belgium
| |
Collapse
|
50
|
Di Perna G, Penner F, Cofano F, De Marco R, Baldassarre BM, Portonero I, Garbossa D, Ceroni L, Pecorari G, Zenga F. Skull base reconstruction: A question of flow? A critical analysis of 521 endoscopic endonasal surgeries. PLoS One 2021; 16:e0245119. [PMID: 33720937 PMCID: PMC7959384 DOI: 10.1371/journal.pone.0245119] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 12/23/2020] [Indexed: 01/15/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Giuseppe Di Perna
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Federica Penner
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Fabio Cofano
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
- Spine Surgery Unit, Humanitas Gradenigo Hospital, Turin, Italy
| | - Raffaele De Marco
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Bianca Maria Baldassarre
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Irene Portonero
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Diego Garbossa
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Luca Ceroni
- Psychological Sciences and Techniques, Psychology Department, University of Turin, Turin, Italy
| | - Giancarlo Pecorari
- Department of Surgical Sciences, ENT Surgery Unit, University of Turin, Turin, Italy
| | - Francesco Zenga
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| |
Collapse
|