Emerging technology in intracranial neuroendoscopy: application of the NICO Myriad

Specialised Surgical Instruments for Endoscopic and Endoscope-Assisted Neurosurgery: A Systematic Review of Safety, Efficacy and Usability

While there have been great strides in endoscopic and endoscope-assisted neurosurgical approaches, particularly in the treatment of deep-sited brain and skull base tumours, the greatest technical barrier to their adoption has been the availability of suitable surgical instruments. This systematic review seeks to identify specialised instruments for these approaches and evaluate their safety, efficacy and usability. Conducted in accordance with the PRISMA guidelines, Medline, Embase, CENTRAL, SCOPUS and Web of Science were searched. Original research studies that reported the use of specialised mechanical instruments that manipulate tissue in human patients, cadavers or surgical models were included. The results identified 50 specialised instruments over 62 studies. Objective measures of safety were reported in 32 out of 62 studies, and 20 reported objective measures of efficacy. Instruments were broadly safe and effective with one instrument malfunction noted. Measures of usability were reported in 15 studies, with seven reporting on ergonomics and eight on the instruments learning curve. Instruments with reports on usability were generally considered to be ergonomic, though learning curve was often considered a disadvantage. Comparisons to standard instruments were made in eight studies and were generally favourable. While there are many specialised instruments for endoscopic and endoscope-assisted neurosurgery available, the evidence for their safety, efficacy and usability is limited with non-standardised reporting and few comparative studies to standard instruments. Future innovation should be tailored to unmet clinical needs, and evaluation guided by structured development processes.

Methodological assessment of the reduction of dissemination risk and quantification of debris dispersion during dissection with a surgical aspirator

Objective

We developed an actuator-driven pulsed water jet (ADPJ) device to achieve maximal lesion dissection with minimal risk of normal structural damage. Despite the unique dissection characteristics, there is a risk of dissemination of tissue dispersion; however, there is no established method to quantify the dispersion. Hence, this study aimed to assess the factors associated with dispersion and propose a simple experimental method using spectrophotometry to evaluate the degree of dispersion in a wet field.

Results

Methylene blue-stained brain phantom gelatin was immersed in a chamber with distilled water solution and dissected with an ADPJ. The dispersed gelatin solution was stirred and warmed to dissolve. The absorbance of the solution was measured spectrophotometrically. First, a reference standard curve was constructed to confirm the relationship between the absorbance and the amount of the dispersed gelatin. A clear proportional correlation was observed, which indicated that absorbance measurements can help evaluate the amount of dispersion. Using this method, we revealed that a high dissection force, insufficient suction, and inappropriate long distance between the nozzle tip and the target were associated with increased dispersion. This method might constitute a versatile and reliable approach to evaluate dispersion and aid in the development of surgical devices.

Establishing a standardized method for the effective intraoperative collection and biological preservation of brain tumor tissue samples using a novel tissue preservation system: A pilot study

Glioblastoma (GB) is an aggressive tumor exhibiting extensive inter- and intratumoral heterogeneity. Several possible reasons contribute to the historical inability to develop effective therapeutic strategies for treatment of GB. One such challenge is the inability to consistently procure high quality biologically preserved specimens for use in molecular research and patient derived xenograft (PDX) model development. Currently, no scientifically derived standardized method exists for intraoperative tissue collection specifically designed with the fragility of ribonucleic acid (RNA) in mind. In this investigation, we set out to characterize matched specimens from six GB patients comparing the traditional handling and collection processes of intraoperative tissue used in most neurosurgical operating rooms (ORs) versus an automated resection, collection, and biological preservation system (APS) which captures, preserves, and biologically maintains tissue in a prescribed and controlled microenvironment. Matched specimens were processed in parallel at various time points and temperatures, evaluating viability, RNA and protein concentrations, and isolation of GB cell lines. We found that APS-derived GB slices stored in an APS modified medium remained viable and maintained high quality RNA and protein concentration for up to 24 hours. Our results demonstrated that primary GB cell cultures derived in this manner had improved growth over widely used collection and preservation methods. By implementing an automated intraoperative system, we also eliminated inconsistencies in methodology of tissue collection, handling and biological preservation, establishing a repeatable and standardized practice that does not require additional staff or a lab technician to manage.

Endoscopic and Endoscopically-Assisted Resection of Intraventricular Lesions Using a Neuroendoscopic Ultrasonic Aspirator

The development of minimally invasive neuroendoscopy has advanced in recent years. The introduction of the neuroendoscopic ultrasonic aspirator (NUA) broadened the treatment spectrum of neuroendoscopy. We aim to describe our experience with the use of NUA for the resection of intraventricular lesions. Here, we present consecutive retrospective case series of adult and pediatric patients undergoing resection of an intraventricular lesion with a NUA (Endoscopic Neurosurgical Pen, Söring GmbH, Quickborn, Germany) between January 2019 and April 2020. Eight patients between the age of 0.5 and 73 years underwent surgery using NUA and were included in this study. In four patients, an endoscopic assisted (EA) resection of the lesion was undertaken, while in four patients, the lesion was removed using purely endoscopic (PE) resection. In all cases, gross/near total resection was achieved. The average blood loss was 142.5 ± 90.4 mL (range 50–300 mL). Transient morbidity was seen in four patients (50%), while permanent morbidity or mortality did not occur. The NUA seems to be a safe and valuable tool for the minimally invasive resection of intraventricular lesions in selected cases. The type, size, consistency, and vascularization of the lesion limit at times the purely endoscopic use of the NUA.

Onscreen-guided resection of extra-axial and intra-axial forebrain masses through registration of a variable-suction tissue resection device with a neuronavigation system

OBJECTIVES

To describe a novel surgical technique in which neuronavigation is used to guide a tissue resection device during excision of forebrain masses in locations difficult to visualize optically.

STUDY DESIGN

Short case series.

ANIMALS

Six dogs and one cat with forebrain masses (five neoplastic, two nonneoplastic) undergoing excision with a novel tissue resection device and veterinary neuronavigation system.

METHODS

The animals and resection instrument were coregistered to the neuronavigation system. Surgery was guided by real-time onscreen visualization of the resection instrument position relative to the preoperative MR images. Surgical outcome was evaluated by calculating residual tumor volume according to postoperative MRI.

RESULTS

The technique was technically simple and led to the collection of diagnostic tissue samples in all cases. Postoperative MRI was available in six cases, two with gross-total resection, three with near-total resection, and one with subtotal resection.

CONCLUSION

Neuronavigation-guided resection of intra-axial and extra-axial brain masses with the resection device resulted in gross-total or near-total resection in five of six animals with tumors otherwise difficult to visualize. Risk of brain shift limited absolute reliance on navigation images.

CLINICAL SIGNIFICANCE

Real-time neuronavigation assistance is a feasible method for guidance and successful resection of brain masses that are poorly visualized because of intra-axial or deep location, tumor appearance, or hemorrhage.

Skull Base Neuroendoscopic Training Model Using a Fibrous Injectable Tumor Polymer and the Nico Myriad

The Myriad is an innovative, high precision tool for tumor resection, designed to work within narrow endoscopic corridors. Due to its application in technically demanding situations, the learning curve associated with its use might be extremely challenging and time-consuming.The authors describe the application of an already validated training model, the skull base injectable tumor model (ITM), to allow trainees to practice with the use of the Myriad during endoscopic skull base procedures.A formalin embalmed cadaveric head was used for technical assessment. Stratathane resin ST-504 derived polymer was injected to mimic skull base tumors and Myriad was used for tumor resection during different endoscopic procedures.An endoscopic endonasal transsphenoidal, a trans-planum trans-tuberculum, and a trans-clival approach have been performed after ITM injection. The Myriad was used for tumor debulking and blunt manipulation, qualitatively evaluating the technical challenges in performing the surgical dissection.Injectable tumor model demonstrates to be a valuable educational tool to train surgeons in the use of Myriad, potentially speeding up the learning curve in the acquirement of necessary technical skills in manipulating the instrument, even in case of demanding surgical situation.

The Unusual Presentation of a Myxoma Within the Sphenoid Sinus: Case Report and Review of the Literature

BACKGROUND

We describe a rare case of a sphenoid sinus myxoma that was resected via an endoscopic endonasal skull base approach. We review the literature regarding these rare tumors of the paranasal sinuses.

CASE DESCRIPTION

A 72-year-old woman was diagnosed with an incidental sphenoid sinus tumor and left sphenoid wing meningioma during a workup for left-sided proptosis and diplopia. Biopsies of the sphenoid wing and sphenoid sinus tumors were obtained. After undergoing surgical resection of the meningioma, the patient then underwent definitive resection of the sphenoid sinus myxoma via endoscopic endonasal skull base approach. Postoperative imaging demonstrated a gross total resection. The patient suffered postoperative thromboembolic complications due to underlying hypercoagulable state but made a complete recovery and returned to her neurologic baseline. There has been no evidence of recurrent myxoma in the sphenoid sinus 24 months after surgery.

DISCUSSION

Myxomas are benign tumors derived from primitive mesenchyme. Myxomas very rarely present in the paranasal or skull base location. Complete surgical resection is the primary treatment for these tumors. The endoscopic endonasal approach is an effective technique for resecting various benign and more aggressive extradural skull base tumors.

CONCLUSIONS

Myxomas of the sphenoid sinus are rare. The endoscopic endonasal skull base approach is an effective and minimal access technique for resection of this rare tumor of the sphenoid sinus.

Frontal burr hole approach for neuroendoscopic resection of craniopharyngioma with the NICO Myriad device: report of two cases

OBJECTIVE

Craniopharyngiomas are challenging tumors to resect due to their deep location and proximity to vital structures. The perceived benefit of gross total resection may be tempered by the possibility of permanent disability. Minimally invasive techniques may reduce surgical morbidity while still allowing effective resection. The authors describe their initial experience with a neuroendoscopic transcortical, transventricular approach to two craniopharyngiomas. The surgeries were performed through a right frontal burr hole using the NICO Myriad, a side-cutting, aspiration device that fits through the working channel of a standard neuroendoscope.

METHODS

The imaging and medical records of two children (a 5-year-old male and a 9-year-old female) undergoing endoscopic resection of a craniopharyngioma with this technique were reviewed. Outcomes, results, and complications were noted.

RESULTS

A gross total resection was achieved in both patients. The operative time was 180 and 143 min, respectively. The estimated blood loss was 20 and 50 cm³, respectively. Both patients required a cerebrospinal fluid shunt. There were no surgical complications.

CONCLUSIONS

The NICO Myriad is an effective tool that allows a safe minimally invasive endoscopic resection of craniopharyngiomas in patients with amenable anatomy. Surgeons with experience in neuroendoscopy may be able to achieve a gross total resection of these challenging tumors through a minimally invasive burr hole approach.

Surgical Morbidity and Mortality Associated With Transoral Approach to the Cervical Spine

STUDY DESIGN

A retrospective cohort analysis of prospectively collected data.

OBJECTIVE

The aim of this study was to analyze morbidity and mortality in adult patients undergoing transoral approach using a large national database.

SUMMARY OF BACKGROUND DATA

The transoral approach to the anterior skull base and atlanto-axial cervical spine provides a direct corridor to the lower clivus, C1, C2, and occasionally C3. Due to the rarity of this approach and the unfamiliar anatomy, there is potential for significant morbidity and mortality.

METHODS

Adult patients undergoing transoral approach to the cervical spine from 2008 to 2012 were identified by the Current Procedural Terminology (CPT) code 22548 in the ACS NSQIP database. Cases with missing preoperative information were excluded. Univariate and multivariate analyses were performed to assess associated morbidity and mortality.

RESULTS

One hundred twenty-six patients underwent cervical spine and clival surgery via the transoral approach. There were a total of 27 (21.4%) postoperative complications with three (2.4%) mortalities. On multivariate analysis, there was an increased risk of complications with operative time >4 hours [odds ratio (OR) 7.8, 95% confidence interval (95% CI) 1.8-33.1, P = 0.0054] and total length of stay >5 days (OR 7.5, 95% CI 2.4-23.4, P = 0.0006).

CONCLUSION

The transoral approach carries significant risks of morbidity and mortality. Maintaining operative time <4 hours and LOS <5 days may decrease morbidity and mortality.

LEVEL OF EVIDENCE

4.

Initial Experience with High-Definition Camera-On-a-Chip Flexible Endoscopy for Intraventricular Neurosurgery

OBJECTIVE

The usefulness of existing neuroendoscopes has been limited by either decreased range of motion or suboptimal image resolution. The flexible high-definition chip-camera endoscope has emerged as a potential solution to the shortcomings of available instruments by combining superior flexibility and image quality in order to better operate within spatially constrained intraventricular operations.

CASE DESCRIPTION

Here we describe a 36-year-old woman who presented with hydrocephalus caused by an obstructive mass arising from the tectum. A high-definition camera-on-a-chip flexible neuroendoscope was used to sample the tectal mass after a traditional neuroendoscope was used to perform a third ventriculostomy.

CONCLUSIONS

As demonstrated by this initial experience, the use of high-definition camera-on-a-chip flexible endoscopy may provide enhanced intraoperative visualization and application for intraventricular neurosurgery.

The Use of an Aspirating/Resecting Device to Reduce Stoma Closure Following Endoscopic Third Ventriculostomy for Aqueductal Stenosis

BACKGROUND

Endoscopic third ventriculostomy (ETV) is commonly used to treat obstructive hydrocephalus. Closure of the stoma can be associated with symptom recurrence and need for further surgical intervention.

OBJECTIVE

To describe the use of a side-cutting aspiration device for treatment of aqueductal stenosis in patients undergoing ETV.

METHODS

A retrospective review of 30 consecutive adults with aqueductal stenosis treated with ETV using an adjunct side-cutting aspiration device between 2011 and 2013 was performed. Patients included in the study ranged from 35 to 64 years of age. ETV success was determined by the absence of stoma closure (aqueductal and cisternal flow assessed by high-resolution, gradient-echo magnetic resonance imaging), post-ETV symptom recurrence, and need for subsequent surgical intervention.

RESULTS

Patients treated by using a side-cutting aspirator had no observed stoma closure (0%) and a 10% (n = 3) rate of post-ETV symptom recurrence. Three patients (10%) demonstrated a need for surgical revision following initial ETV with the side-cutting aspirator.

CONCLUSION

Adult patients with obstructive hydrocephalus secondary to aqueductal stenosis exhibited a low rate of stoma closure with the use of a side-cutting aspiration device, and a rate of complications comparable to the known literature. Likewise, patients treated with a side-cutting aspirator may have lower symptom recurrence post-ETV and require fewer revisions in comparison with the known literature. As such, a side-cutting aspirator may be considered as a useful adjunct to traditional ETV for the treatment of obstructive hydrocephalus secondary to aqueductal stenosis.

Purely endoscopic resection of a choroid plexus papilloma of the third ventricle: case report

The authors report an illustrative case of a purely endoscopic surgical approach to successfully remove a solid choroid plexus papilloma of the third ventricle in an infant. A 10-week-old male infant first presented with transient episodes of forced downward gaze, divergent macrocephaly, a tense anterior fontanel, diastasis of the cranial sutures, and papilledema. Brain MRI revealed a small, multilobulated contrast-enhancing mass situated within the posterior third ventricle, with resultant obstructive hydrocephalus. A purely endoscopic removal of the tumor was performed through a single right frontal bur hole. Intraoperatively, a unique vascular tributary was recognized coming from the tela choroidea and was controlled with coagulation and sharp dissection. Postoperative MRI confirmed complete tumor removal, and the tumor was classified as a choroid plexus papilloma. There has been no evidence of tumor recurrence over 42 months of follow-up. With this case report the authors intended to show that endoscopic surgery can be an additional tool to consider when planning a choroid plexus tumor approach. It seems to be of particular interest in selected cases in which there are concerns about the patient's total blood volume, as in infants with potential hemorrhagic tumors and when it is possible to preoperatively identify a single vascular pedicle that can be approached early in the surgery.

Endoscopic endonasal trans-sphenoid management of craniopharyngiomas

Introduction:

Craniopharyngiomas treatment has been challenging because of their anatomical location. The endoscopic endonasal (EE) trans-sphenoidal approach is indicated in sellar, supra sellar, selected intraventricular lesions in adults and children. We are reporting our initial experience of 44 patients managed by EE approach.

Materials and Methods:

This is a retrospective study of 44 craniopharyngiomas. The goal of surgery was gross-total resection in all cases. All patients underwent pre- and post-operative comprehensive ophthalmological and endocrinological evaluation. Lumbar drain at the start of the operation was used in all cases with tumor larger than 3 cm maximum diameter. Binostril technique vascularized nasoseptal flap and multilayer closure of the dural defect were used. Wide sphenoidotomy, posterior ethmoidectomy, tuberculum selle, and planum removal were performed in all cases. Perioperative antibiotic prophylaxis was used for 72 h.

Results:

There were 44 patients of age ranging from 8 to 65 (mean: 42) years. Diameter of the tumor varied from 3.1 cm to 6.6 cm (average: 4.3 cm). Visual and pituitary dysfunctions were observed in 44 and 33, respectively, before surgery. Vision improvement, gross-total removal, cerebrospinal fluid (CSF) leak and recurrence were observed in 34, 26, four and six patients, respectively. Average follow-up was 19 months.

Conclusion:

Endoscopic endonasal trans-sphenoidal approach for craniopharyngioma is safe and effective alternative to transcranial approach in selected patients. Although this technique is associated with effective tumor removal and improved visual outcome, CSF leak, and endocrine dysfunctions remain a major challenge.

Endoscopic excision of a lateral ventricular epidermoid-A case report of a novel technique

INTRODUCTION

Epidermoids of the lateral ventricle are relatively rare tumours. As these tumours are soft and relatively avascular, they appear to be ideally suited for endoscopic surgical excision. At present the instruments available are specifically designed for endoscopic intra ventricular surgeries, limitations being inability to rapidly debulk the tumour and achieve adequate haemostasis. We present a case of lateral ventricular epidermoid that was excised endoscopically using a system originally designed for endoscopic disc surgery.

PRESENTATION OF CASE

We describe a female patient who presented with recurrent headache and occasional episodes of vomiting since 6 years. Preoperative diagnosis of lateral intra ventricular epidermoid was made with the help of an Magnetic resonance imaging (MRI) of the brain. Intraoperatively, an incision was made over the right Kocher's point and a 2.5cm dural opening was made following a small craniotomy and the Destaudeau endoscope was introduced. A 30° scope and gentle manipulation were used to view the ventricular cavity and ensure near total excision of the tumour. Here we record this novel technique.

DISCUSSION

Lateral intra-ventricular tumours are usually approached through a trans-cortical or intra hemispheric approach, under microscope. The use of endoscopes have been largely restricted because of non-availability and relative difficulty in controlling troublesome bleeding, incase of vascular tumours.

CONCLUSION

A multi portal endoscope that allows use of routine pituitary instruments would enable the surgeon to achieve haemostasis effectively and, in our opinion, should be a viable alternative to microscope for excision of intra ventricular tumours.

Neuroendoscopic resection of intraventricular tumors: a systematic outcomes analysis

Introduction. Though traditional microsurgical techniques are the gold standard for intraventricular tumor resection, the morbidity and invasiveness of microsurgical approaches to the ventricular system have galvanized interest in neuroendoscopic resection. We present a systematic review of the literature to provide a better understanding of the virtues and limitations of endoscopic tumor resection. Materials and Methods. 40 articles describing 668 endoscopic tumor resections were selected from the Pubmed database and reviewed. Results. Complete or near-complete resection was achieved in 75.0% of the patients. 9.9% of resected tumors recurred during the follow-up period, and procedure-related complications occurred in 20.8% of the procedures. Tumor size ≤ 2cm (P = 0.00146), the presence of a cystic tumor component (P < 0.0001), and the use of navigation or stereotactic tools during the procedure (P = 0.0003) were each independently associated with a greater likelihood of complete or near-complete tumor resection. Additionally, the complication rate was significantly higher for noncystic masses than for cystic ones (P < 0.0001). Discussion. Neuroendoscopic outcomes for intraventricular tumor resection are significantly better when performed on small, cystic tumors and when neural navigation or stereotaxy is used. Conclusion. Neuroendoscopic resection appears to be a safe and reliable treatment option for patients with intraventricular tumors of a particular morphology.

Neuroendoscopic Resection of Intraventricular Tumors and Cysts through a Working Channel with a Variable Aspiration Tissue Resector: A Feasibility and Safety Study

Pure neuroendoscopic resection of intraventricular lesions through a burr hole is limited by the instrumentation that can be used with a working channel endoscope. We describe a safety and feasibility study of a variable aspiration tissue resector, for the resection of a variety of intraventricular lesions. Our initial experience using the variable aspiration tissue resector involved 16 patients with a variety of intraventricular tumors or cysts. Nine patients (56%) presented with obstructive hydrocephalus. Patient ages ranged from 20 to 88 years (mean 44.2). All patients were operated on through a frontal burr hole, using a working channel endoscope. A total of 4 tumors were resected in a gross total fashion and the remaining intraventricular lesions were subtotally resected. Fifteen of 16 patients had relief of their preoperative symptoms. The 9 patients who presented with obstructive hydrocephalus had restoration of cerebrospinal fluid flow though one required a ventriculoperitoneal shunt. Three patients required repeat endoscopic resections. Use of a variable aspiration tissue resector provides the ability to resect a variety of intraventricular lesions in a safe, controlled manner through a working channel endoscope. Larger intraventricular tumors continue to pose a challenge for complete removal of intraventricular lesions.

Side-cutting aspiration device for endoscopic and microscopic tumor removal

The authors present a unique side-cutting instrument (NICO Myriad, Indianapolis, IN) with variable aspiration designed specifically for tumor resection. The study included retrospective review of data collected from 10/2009 to 01/2011. We detail the use of the Myriad in 31 patients with the following pathologies: meningioma (n=16), chordoma (n = 3), schwannoma (n = 3), pituitary adenoma (n = 2), metastasis (n = 3), hemangioblastoma (n = 1), craniopharyngioma (n = 1), and nasopharyngeal tumors (n = 2). Surgical approaches included expanded endonasal approach (n = 19), endoscopic brain port (n = 3), supraorbital "eyebrow" craniotomy (n = 3), retrosigmoid suboccipital craniotomy (n = 3), pterional craniotomy (n = 1), extreme far lateral (n = 1), and laminectomy (n = 1). Successful tumor resection was achieved in 30 cases. Instrument failure was noted in only one extremely fibrous meningioma. The design of this instrument facilitated maneuvering through narrow corridors while providing direct visualization of the suction aperture during tumor resection. These features allowed for tumor removal without injury to adjacent neurovascular structures. The side-cutting aspiration device allows safe and effective tumor removal. Its low profile, variable aspiration, and lack of thermal heat energy are particularly useful in tumor resection through narrow corridors, such as endonasal, port, and keyhole approaches. The multifunctional nature of the instrument (suction, scissors, and dissectors) minimizes multiple exchanges, facilitating tumor resection through these minimal access corridors.

Initial experience with endoscopic side cutting aspiration system in pure neuroendoscopic excision of large intraventricular tumors

OBJECTIVE

Conventionally, neuroendoscopic excision of intraventricular tumors has been difficult and time consuming because of lack of an effective decompression system that can be used through the working channel of the endoscope.

METHODS

The authors report their initial experience in purely endoscopic excision of large intraventricular tumors with the minimally invasive NICO Myriad system. The NICO Myriad is a side cutting soft tissue aspiration system that uses an inner reciprocating cannula and an outer stationary sheath with a side port. During decompression, applied suction approximates the tumor into the lumen of the outer sheath, with the inner cannula excising the tissue by oscillation of the cutting edge. The tumor is then removed by aspiration through the inner sheath.

RESULTS

Three patients with large intraventricular tumors were operated by a purely endoscopic approach using a GAAB rigid endoscope and the NICO Myriad system. Of these, two had intraventricular craniopharyngiomas and one had a lateral ventricular subependymoma. The tumor size varied between 1.9 and 4.5 cm in the largest diameter. A relatively firm and solid tumor was encountered in two and a multicystic tumor with thick adherent walls in one. The tumor could be subtotally removed in one and near totally in two. There were no long-term complications.

CONCLUSION

The NICO Myriad is a highly effective tumor decompression system that can be effectively used in a purely endoscopic approach to intraventricular lesions.

Endoscopic endonasal trans-sphenoid surgery of pituitary adenoma

Endoscopic endonasal trans-sphenoid surgery (EETS) is increasingly used for pituitary lesions. Pre-operative CT and MRI scans and peroperative endoscopic visualization can provide useful anatomical information. EETS is indicated in sellar, suprasellar, intraventricular, retro-infundibular, and invasive tumors. Recurrent and residual lesions, pituitary apoplexy and empty sella syndrome can be managed by EETS. Modern neuronavigation techniques, ultrasonic aspirators, ultrasonic bone curette can add to the safety. The binostril approach provides a wider working area. High definition camera is much superior to three-chip camera. Most of the recent reports favor EETS in terms of safety, quality of life and tumor resection, hospital stay, better endocrinological, and visual outcome as compared to the microscopic technique. Nasal symptoms, blood loss, operating time are less in EETS. Various naso-septal flaps and other techniques of CSF leak repair could help reduce complications. Complications can be further reduced after achieving the learning curve, good understanding of limitations with proper patient selection. Use of neuronavigation, proper post-operative care of endocrine function, establishing pituitary center of excellence and more focused residency and endoscopic fellowship training could improve results. The faster and safe transition from microscopic to EETS can be done by the team concept of neurosurgeon/otolaryngologist, attending hands on cadaveric dissection, practice on models, and observation of live surgeries. Conversion to a microscopic or endoscopic-assisted approach may be required in selected patients. Multi-modality treatment could be required in giant and invasive tumors. EETS appears to be a better surgical option in most pituitary adenoma.

Use of the NICO Myriad device for tumor and cyst removals in a developing country

PURPOSE

To describe the use of the NICO Myriad, a new side-cutting aspiration device for the resection of tumors, in a developing country.

METHODS

The 11-, 13-, and 15-ga handpieces were used to resect tumors exposed via craniotomies, and the 19-ga handpiece was used down the side channel of a Storz Oi endoscope to resect tumors exposed endoscopically.

RESULTS

The Myriad was used to resect 23 tumors, including spinal cord tumors, posterior fossa tumors and pineal tumors, and the cysts associated with two craniopharyngiomas. No complications were associated with the Myriad. Handpieces that were re-sterilized in Steranios after the initial use could each be used two to four times thereafter.

CONCLUSIONS

The Myriad is the first effective tumor removal device that can be introduced down the side channel of most endoscopes, greatly expanding the spectrum of tumors that can be treated endoscopically. Its minimal diameter allows better visibility in small, deep sites such as the pineal region than is usually available when ultrasonic aspirators are used. The cost of the device, and particularly the handpieces, will limit their utility in developing countries until re-usable handpieces are developed.