Endoscopic, Endonasal Resection of Craniopharyngiomas

Abstract BACKGROUND The endoscopic, endonasal, extended transsphenoidal approach is a minimal-access technique for managing craniopharyngiomas. Outcome measures such as return to employment and body mass index (BMI) have not been reported and are necessary for comparison with open transcranial approaches. Most prior reports of the endoscopic, endonasal approach have reported unacceptably high cerebrospinal fluid (CSF) leak rates. OBJECTIVE To assess the outcome of endoscopic, endonasal surgery in a consecutive series of craniopharyngiomas with special attention to extent of resection, CSF leak, return to employment, and BMI. METHODS Twenty-six surgeries were performed on 24 patients at Weill Cornell Medical College-New York Presbyterian Hospital. Five patients had recurrent lesions. Gross-total resection (GTR) was attempted in 21 surgeries. Indications for intended subtotal resection were advanced age, medical comorbidities, preservation of pituitary function, and hypothalamic invasion. RESULTS Mean tumor diameter was 2.9 cm. GTR (18 surgeries) or near-total (>95%) resection (2 surgeries) was achieved in 95% when GTR was the goal. Seven patients received postoperative radiation therapy. Mean follow-up was 35 months with no recurrences in GTR cases and stable disease in all patients at last follow-up. Vision improved in 77%. Diabetes insipidus and panhypopituitarism developed in 42% and 38%, respectively. A more than 9% increase in BMI occurred in 39%; 69% returned to their preoperative profession/schooling. The postoperative CSF leak rate was 3.8%. CONCLUSION Minimal-access, endoscopic, endonasal surgery for craniopharyngioma can achieve high rates of GTR with low rates of CSF leak. Return to employment and obesity rates are comparable to microscope-assisted transcranial and transsphenoidal reports.

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Surgical Outcomes of Endoscopic Endonasal Surgery in 29 Patients with Craniopharyngioma

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1713108 ◽

2020 ◽

Author(s):

Arad Iranmehr ◽

Mostafa Esmaeilnia ◽

Khashayar Afshari ◽

Seyed Mousa Sadrehosseini ◽

Azin Tabari ◽

...

Keyword(s):

Tumor Resection ◽

Visual Outcome ◽

Extent Of Resection ◽

Csf Leak ◽

Endoscopic Endonasal Surgery ◽

Endonasal Surgery ◽

Endoscopic Endonasal ◽

Pituitary Dysfunction ◽

Before And After

Abstract Background Recently the endoscopic endonasal surgery (EES) has been introduced as a modality for the treatment of patients with craniopharyngiomas. In this study, we describe our initial experience in treatment of 29 patients with craniopharyngiomas using this approach. Methods Twenty-nine consecutive patients with craniopharyngiomas who had undergone EES in a 5-year period were studied retrospectively. Patients underwent preoperative and postoperative endocrinologic and ophthalmologic evaluations. Radiologic characteristics of tumors and extent of resection were determined. The recurrence and complications were evaluated. Results Pituitary and visual dysfunction were observed preoperatively in 89.7 and 86% of patients, respectively. After EES, visual outcome either showed an improvement or else remained unchanged in 92.3% of the cases; however, pituitary function remained unchanged and even got worsened in 34.6% of the cases. Prevalence of diabetes insipidus before and after surgery was 58.6 and 69.2%. The rate of gross total resection was 62%. Moreover, 86.2% of the tumors were almost totally resected (more than 95% of the tumor size resected). After surgery, cerebrospinal fluid (CSF) leak and meningitis occurred in four (13.8%) and two (6.9%) patients, respectively. Perioperative mortality was seen in two of the cases (6.9%). The mean follow-up was 25 months and tumor recurrence was discovered in four patients (15.3%). Conclusion The EES with the goal of maximal and safe tumor resection could be used for the treatment of most craniopharyngiomas. Although the rates of visual improvement and gross tumor resection are high, CSF leak, pituitary dysfunction, and meningitis are serious concerns.

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Endoscopic endonasal surgery for epidermoid and dermoid cysts: a 10-year experience

Journal of Neurosurgery ◽

10.3171/2017.7.jns162783 ◽

2019 ◽

Vol 130 (2) ◽

pp. 368-378 ◽

Cited By ~ 2

Author(s):

Francisco Vaz-Guimaraes ◽

Maria Koutourousiou ◽

John R. de Almeida ◽

Elizabeth C. Tyler-Kabara ◽

Juan C. Fernandez-Miranda ◽

...

Keyword(s):

Cranial Base ◽

Csf Leak ◽

Subtotal Resection ◽

Total Removal ◽

Endoscopic Endonasal Surgery ◽

Endonasal Surgery ◽

Total Resection ◽

Endoscopic Endonasal ◽

Intracranial Infection ◽

Incomplete Removal

OBJECTIVEEpidermoid and dermoid cysts may be found along the cranial base and are commonly resected via open transcranial approaches. The use of endoscopic endonasal approaches for resection of these tumors has been rarely reported.METHODSThe authors retrospectively reviewed the medical records of 21 patients who underwent endoscopic endonasal surgery for epidermoid and dermoid cyst resection at the University of Pittsburgh Medical Center between January 2005 and June 2014. Surgical outcomes and variables that might affect the extent of resection and complications were analyzed.RESULTSTotal resection (total removal of cyst contents and capsule) was achieved in 8 patients (38.1%), near-total resection (total removal of cyst contents, incomplete removal of cyst capsule) in 9 patients (42.9%), and subtotal resection (incomplete removal of cyst contents and capsule) in 4 patients (19%). Larger cyst volume (≥ 3 cm3) and intradural location (15 cysts) were significantly associated with nontotal resection (p = 0.008 and 0.0005, respectively). In the whole series, surgical complications were seen in 6 patients (28.6%). No complications were observed in patients with extradural cysts. Among the 15 patients with intradural cysts, the most common surgical complication was postoperative CSF leak (5 patients, 33.3%), followed by postoperative intracranial infection (4 patients, 26.7%). Larger cysts and postoperative CSF leak were associated with intracranial infection (p = 0.012 and 0.028, respectively). Subtotal resection was marginally associated with intracranial infection when compared with total resection (p = 0.091). All patients with neurological symptoms improved postoperatively with the exception of 1 patient with unchanged abducens nerve palsy.CONCLUSIONSEndoscopic endonasal approaches may be effectively used for resection of epidermoid and dermoid cysts in carefully selected cases. These approaches are recommended for cases in which a total or near-total resection is possible in addition to a multilayer cranial base reconstruction with vascularized tissue to minimize the risk of intracranial infection.

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Endoscopic endonasal surgery for giant pituitary adenomas: advantages and limitations

Journal of Neurosurgery ◽

10.3171/2012.11.jns121190 ◽

2013 ◽

Vol 118 (3) ◽

pp. 621-631 ◽

Cited By ~ 82

Author(s):

Maria Koutourousiou ◽

Paul A. Gardner ◽

Juan C. Fernandez-Miranda ◽

Alessandro Paluzzi ◽

Eric W. Wang ◽

...

Keyword(s):

Surgical Outcome ◽

Pituitary Adenomas ◽

Maximum Diameter ◽

Csf Leak ◽

Pituitary Insufficiency ◽

Endoscopic Endonasal Surgery ◽

Endonasal Surgery ◽

Endoscopic Endonasal ◽

Giant Pituitary Adenomas

Object Giant pituitary adenomas (> 4 cm in maximum diameter) represent a significant surgical challenge. Endoscopic endonasal surgery (EES) has recently been introduced as a treatment option for these tumors. The authors present the results of EES for giant adenomas and analyze the advantages and limitations of this technique. Methods The authors retrospectively reviewed the medical files and imaging studies of 54 patients with giant pituitary adenomas who underwent EES and studied the factors affecting surgical outcome. Results Preoperative visual impairment was present in 45 patients (83%) and partial or complete pituitary deficiency in 28 cases (52%), and 7 patients (13%) presented with apoplexy. Near-total resection (> 90%) was achieved in 36 patients (66.7%). Vision was improved or normalized in 36 cases (80%) and worsened in 2 cases due to apoplexy of residual tumor. Significant factors that limited the degree of resection were a multilobular configuration of the adenoma (p = 0.002) and extension to the middle fossa (p = 0.045). Cavernous sinus invasion, tumor size, and intraventricular or posterior fossa extension did not influence the surgical outcome. Complications included apoplexy of residual adenoma (3.7%), permanent diabetes insipidus (9.6%), new pituitary insufficiency (16.7%), and CSF leak (16.7%, which was reduced to 7.4% in recent years). Fourteen patients underwent radiation therapy after EES for residual mass or, in a later stage, for recurrence, and 10 with functional pituitary adenomas received medical treatment. During a mean follow-up of 37.9 months (range 1–114 months), 7 patients were reoperated on for tumor recurrence. Three patients were lost to follow-up. Conclusions Endoscopic endonasal surgery provides effective initial management of giant pituitary adenomas with favorable results compared with traditional microscopic transsphenoidal and transcranial approaches.

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A propensity-adjusted comparison of endoscopic endonasal surgery versus transcranial microsurgery for pediatric craniopharyngioma: a single-center study

Journal of Neurosurgery Pediatrics ◽

10.3171/2021.10.peds21392 ◽

2021 ◽

pp. 1-10

Keyword(s):

Perioperative Complications ◽

Single Center ◽

Endoscopic Endonasal Surgery ◽

Endonasal Surgery ◽

Endoscopic Endonasal ◽

Adjusted Analysis ◽

Significant Difference ◽

Csf Leakage ◽

Hypothalamic Function

OBJECTIVE When comparing endoscopic endonasal surgery (EES) and transcranial microsurgery (TCM) for adult and mixed-age population craniopharyngiomas, EES has become an alternative to TCM. To date, studies comparing EES and TCM for pediatric craniopharyngiomas are sparse. In this study, the authors aimed to compare postoperative complications and surgical outcomes between EES and TCM for pediatric craniopharyngiomas. METHODS The data of pediatric patients with craniopharyngiomas who underwent surgery between February 2009 and June 2021 at a single center were retrospectively reviewed. All included cases were divided into EES and TCM groups according to the treatment modality received. The baseline characteristics of patients were compared between the groups, as well as surgical results, perioperative complications, and long-term outcomes. To control for confounding factors, propensity-adjusted analysis was performed. RESULTS Overall, 51 pediatric craniopharyngioma surgeries were identified in 49 patients, among which 35 were treated with EES and 16 were treated with TCM. The proportion of gross-total resection (GTR) was similar between the groups (94.3% for EES vs 75% for TCM, p = 0.130). TCM was associated with a lower rate of hypogonadism (33.3% vs 64.7%, p = 0.042) and a higher rate of growth hormone deficiency (73.3% vs 26.5%, p = 0.002), permanent diabetes insipidus (DI) (60.0% vs 29.4%, p = 0.043), and panhypopituitarism (80.0% vs 47.1%, p = 0.032) at the last follow-up. CSF leakage only occurred in the EES group, with no significant difference observed between the groups (p > 0.99). TCM significantly increased the risk of worsened visual outcomes (25.0% vs 0.0%, p = 0.012). However, TCM was associated with a significantly longer median duration of follow-up (66.0 vs 40.5 months, p = 0.007) and a significantly lower rate of preoperative hypogonadism (18.8% vs 60.0%, p = 0.006). The propensity-adjusted analysis revealed no difference in the rate of recurrence, hypogonadism, or permanent DI. Additionally, EES was associated with a lower median gain in BMI (1.5 kg/m2 vs 7.5 kg/m2, p = 0.046) and better hypothalamic function (58.3% vs 8.3%, p = 0.027) at the last follow-up. CONCLUSIONS Compared with TCM, EES was associated with a superior visual outcome, better endocrinological and hypothalamic function, and less BMI gain, but comparable rates of GTR, recurrence, and perioperative complications. These findings have indicated that EES is a safe and effective surgical modality and can be a viable alternative to TCM for pediatric midline craniopharyngiomas.

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Extended Endoscopic Approach for Resection of Craniopharyngiomas

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0037-1620244 ◽

2018 ◽

Vol 79 (S 02) ◽

pp. S201-S202 ◽

Cited By ~ 1

Author(s):

João Almeida ◽

Suganth Suppiah ◽

Claire Karekezi ◽

Miguel Marigil-Sanchez ◽

Jay Wong ◽

...

Keyword(s):

Surgical Technique ◽

Endoscopic Resection ◽

Cystic Lesion ◽

Endoscopic Approach ◽

Csf Leak ◽

Cystic Lesions ◽

Endoscopic Endonasal Surgery ◽

Endonasal Surgery ◽

Endoscopic Endonasal ◽

Extended Endoscopic Approach

Objectives Extended endoscopic approaches are useful for resection of selected craniopharyngiomas. Midline, extraventricular, and predominantly cystic lesions are good candidates for endoscopic resection. In this video, we demonstrate the endoscopic endonasal resection of a large suprasellar craniopharyngioma and discuss the nuances of the surgical technique. Design/Setting Surgical video of an extended endoscopic approach for resection of a suprasellar craniopharyngioma. Results We report the case of a 56-year-old woman who presented with bitemporal hemianopsia and visual acuity deterioration secondary to a large suprasellar solid–cystic lesion. The patient underwent an extended endoscopic transtuberculum approach for resection of the lesion, which was diagnosed as a papillary craniopharyngioma. This video discusses the anatomy and surgical technique applied for endoscopic resection of such lesions. Conclusion Endoscopic endonasal surgery is a useful technique for management of craniopharyngiomas. It is associated with good clinical outcomes in selected cases. Complications, such as postoperative CSF leak, may occur and should be carefully managed.The link to the video can be found at: https://youtu.be/EneOCiQE7yo.

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Stepwise Algorithm for Skull Base Reconstruction in Endoscopic Endonasal Surgery: From the Simple to the Complex

Neurosurgery ◽

10.1093/neuros/nyz310_430 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Maria Belen Vega ◽

Philippe Lavigne ◽

Vanessa Hernandez-Hernandez ◽

Aldo Eguiluz-Menendez ◽

Eric Wang ◽

...

Keyword(s):

Skull Base ◽

Posterior Fossa ◽

Free Flaps ◽

Fat Graft ◽

Csf Leak ◽

Endoscopic Endonasal Surgery ◽

Endonasal Surgery ◽

Endoscopic Endonasal ◽

Skull Base Reconstruction ◽

Skull Base Defects

Abstract INTRODUCTION The most frequent complication of endoscopic endonasal surgery (EES) is postoperative cerebrospinal fluid (CSF) leak. This study was designed to develop a step-wise algorithm for EES reconstruction across the spectrum of skull base defects: from free mucosal graft for uncomplicated pituitary adenomas to free flaps in complex cases with recurrent leaks. METHODS All patients with skull base pathologies who underwent EES between January 2017 and December 2018 were included and retrospectively analyzed. Tumor location, reconstruction method and postoperative CSF leak were reviewed and a step-wise algorithm based on size and location of defect was developed. RESULTS Location of skull base defects was categorized as follows: anterior fossa, suprasellar, sellar and posterior fossa. For all nonsellar sites, we performed a multilayer (collagen matrix + /- fascia lata + /− fat graft + vascularized flap) reconstruction. The nasoseptal flap (NSF) was the first choice for vascularized reconstruction when available. For all sellar lesions we employed a free mucosal graft unless a high-flow CSF leak was present, in which case a single-layer reconstruction with NSF was performed. When the NSF was not available, alternative local (lateral nasal wall flap) and regional (extracranial pericranial flap) pedicled flaps were successful choices. When patients failed multiple attempts at repair, regional or microvascular free flaps were options. Lumbar spinal drainage was employed for large anterior and posterior fossa defects and during secondary repair of postoperative CSF leaks. Of 347 patients, 4.6% had a postoperative CSF leak. Of 158 patients with an intraoperative leak (45.5%), 10.1% developed a postoperative CSF leak: 7.8% for sellar/suprasellar defects and 13% for anterior/posterior fossa defects. CONCLUSION This algorithm provides a standardized, stepwise approach to the reconstruction of all skull base defects after EES based on location.

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Endoscopic endonasal skull base surgery in the pediatric population

Journal of Neurosurgery Pediatrics ◽

10.3171/2012.10.peds12160 ◽

2013 ◽

Vol 11 (3) ◽

pp. 227-241 ◽

Cited By ~ 65

Author(s):

Srinivas Chivukula ◽

Maria Koutourousiou ◽

Carl H. Snyderman ◽

Juan C. Fernandez-Miranda ◽

Paul A. Gardner ◽

...

Keyword(s):

Skull Base ◽

Pituitary Adenomas ◽

Skull Base Surgery ◽

Pediatric Population ◽

Skull Base Tumors ◽

Endoscopic Endonasal Surgery ◽

Endonasal Surgery ◽

Endoscopic Endonasal ◽

The Mean

Object The use of endoscopic endonasal surgery (EES) for skull base pathologies in the pediatric population presents unique challenges and has not been well described. The authors reviewed their experience with endoscopic endonasal approaches in pediatric skull base surgery to assess surgical outcomes and complications in the context of presenting patient demographics and pathologies. Methods A retrospective review of 133 pediatric patients who underwent EES at our institution from July 1999 to May 2011 was performed. Results A total of 171 EESs were performed for skull base tumors in 112 patients and bony lesions in 21. Eighty-five patients (63.9%) were male, and the mean age at the time of surgery was 12.7 years (range 2.3–18.0 years). Skull base tumors included angiofibromas (n = 24), craniopharyngiomas (n = 16), Rathke cleft cysts (n = 12), pituitary adenomas (n = 11), chordomas/chondrosarcomas (n = 10), dermoid/epidermoid tumors (n = 9), and 30 other pathologies. In total, 19 tumors were malignant (17.0%). Among patients with follow-up data, gross-total resection was achieved in 16 cases of angiofibromas (76.2%), 9 of craniopharyngiomas (56.2%), 8 of Rathke cleft cysts (72.7%), 7 of pituitary adenomas (70%), 5 of chordomas/chondrosarcomas (50%), 6 of dermoid/epidermoid tumors (85.7%), and 9 cases of other pathologies (31%). Fourteen patients received adjuvant radiotherapy, and 5 received chemotherapy. Sixteen patients (15.4%) showed tumor recurrence and underwent reoperation. Bony abnormalities included skull base defects (n = 12), basilar invagination (n = 4), optic nerve compression (n = 3) and trauma (n = 2); preexisting neurological dysfunction resolved in 12 patients (57.1%), improved in 7 (33.3%), and remained unchanged in 2 (9.5%). Overall, complications included CSF leak in 14 cases (10.5%), meningitis in 5 (3.8%), transient diabetes insipidus in 8 patients (6.0%), and permanent diabetes insipidus in 12 (9.0%). Five patients (3.8%) had transient and 3 (2.3%) had permanent cranial nerve palsies. The mean follow-up time was 22.7 months (range 1–122 months); 5 patients were lost to follow-up. Conclusions Endoscopic endonasal surgery has proved to be a safe and feasible approach for the management of a variety of pediatric skull base pathologies. When appropriately indicated, EES may achieve optimal outcomes in the pediatric population.

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Endoscopic endonasal surgery for olfactory groove meningiomas: outcomes and limitations in 50 patients

Neurosurgical FOCUS ◽

10.3171/2014.7.focus14330 ◽

2014 ◽

Vol 37 (4) ◽

pp. E8 ◽

Cited By ~ 64

Author(s):

Maria Koutourousiou ◽

Juan C. Fernandez-Miranda ◽

Eric W. Wang ◽

Carl H. Snyderman ◽

Paul A. Gardner ◽

...

Keyword(s):

Mental Status ◽

Tumor Size ◽

Tumor Diameter ◽

Endoscopic Endonasal Surgery ◽

Endonasal Surgery ◽

Endoscopic Endonasal ◽

Primary Tumors ◽

Olfactory Groove ◽

Presenting Symptoms ◽

Csf Leakage

Object Recently, endoscopic endonasal surgery (EES) has been introduced in the management of skull base tumors, with constantly improving outcomes and increasing indications. The authors retrospectively reviewed the effectiveness of EES in the management of olfactory groove meningiomas. Methods Between February 2003 and December 2012, 50 patients (64% female) with olfactory groove meningiomas underwent EES at the University of Pittsburgh Medical Center. The authors present the results of EES and analyze the resection rates, clinical outcome, complications, and limitations of this approach. Results Forty-four patients presented with primary tumors, whereas six were previously treated elsewhere. The patients’ mean age was 57.1 years (range 27–88 years). Clinical presentation included altered mental status (36%), visual loss (30%), headache (24%), and seizures (20%). The mean maximum tumor diameter was 41.6 mm (range 18–80 mm). All patients underwent EES, which was performed in stages in 18 giant tumors. Complete tumor resection (Simpson Grade I) was achieved in 66.7% of the 45 patients in whom it was the goal, and 13 (28.9%) had near-total resection (> 95% of the tumor). Tumor size, calcification, and absence of cortical cuff from vasculature were significant factors that influenced the degree of resection (p = 0.002, p = 0.024, and p = 0.028, respectively). Tumor residual was usually at the most lateral and anterior tumor margins. Following EES, mental status was improved or normalized in 77.8% of the cases, vision was improved or restored in 86.7 %, and headaches resolved in 83.3 %. There was no postoperative deterioration of presenting symptoms. Complications were increased in tumors > 40 mm and included CSF leakage (30%), which was significantly associated with lobular tumor configuration (p = 0.048); pulmonary embolism/deep vein thrombosis, more commonly in elderly patients (20%); sinus infections (10%); and delayed abscess months or years after EES (6%). One patient had an intraoperative vascular injury resulting in transient hemiparesis (2%). There were no perioperative deaths. During a mean follow-up period of 32 months (median 22 months, range 1–115 months), 1 patient underwent repeat EES for tumor regrowth. Conclusions Endoscopic endonasal surgery has shown good clinical outcomes regardless of patient age, previous treatment, or tumor characteristics. Tumor size > 40 mm, calcification, and absence of cortical vascular cuff limit GTR with EES; in addition, large tumors are associated with increased postoperative complications. Significant lateral and anterior dural involvement may represent indications for using traditional craniotomies for the management of these tumors. Postoperative CSF leakage remains a problem that necessitates innovations in EES reconstruction techniques.

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Endoscopic endonasal resection of midline cranial base tumors

JBNC - JORNAL BRASILEIRO DE NEUROCIRURGIA ◽

10.22290/jbnc.v19i2.1521 ◽

2018 ◽

Vol 19 (2) ◽

pp. 7-17

Author(s):

Enrico De Divitiis ◽

Felice Esposito ◽

Paolo Cappabianca ◽

Luigi M. Cavallo ◽

Oreste De Divitiis ◽

...

Keyword(s):

Skull Base ◽

Cranial Base ◽

Transsphenoidal Approach ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Visual Deficits ◽

Extended Transsphenoidal Approach ◽

Anterior Cranial Base ◽

Subtotal Removal

Objective: The advent of the endoscope in transsphenoidalsurgery has permitted to expand the indications of such approach also for the treatment of on tumors located in supra, para, retro and infrasellar regions, enabling the neurosurgeon to work under direct visual control in a minimally invasive way. Since 2004 we have started to use the extended endonasal transsphenoidal approach for a variety of lesions involving the midline skull base and, in particular, the suprasellar area, the cavernous sinus and the retroclival prepontine region. Methods: Over a 36-month period, sixty-four procedures have been performed. The series consisted of 29 males and 35 females, aged from 24 to 80 years (median 49.8 years). The mean follow-up was of 18 months (ranging from 3 to 36 months). Among the patients with midline lesions, who were 90.6 % of the total, seven patients had a pituitary adenoma, sixteen patients were affected by a craniopharyngioma, six patients had a suprasellar Rathke’s cleft cyst, seven subjects had a tuberculum sellae meningioma, four had an olfactorygroove meningioma, and six a clival tumor. Other lesions ofthe midline skull base were, 1 chiasmatic astrocytoma, 1 neuroendocrine tumor, 4 post-traumatic cerebro-spinal fluid rhinorrhea, and one optic nerve glioma. Three other patients had anterior cranial base meningoencephaloceles. Results: Overall, gross total removal of the lesion was achieved in 30/49 tumoral lesions (61.2%); subtotal removal was achieved in 12/49 cases (24.5%). The three cases of meningoencephaloceles were all successfully treated. Among the patients with preoperative visual deficits, most of them fully recovered or improved and only two worsened in one eye. Major complications consisted in 2 deaths (one not directly related with the surgical procedure), 6 postoperative CSF leak (one complicated with bacterial meningitis), one ICA injury, and 6 cases of permanent diabetes insipidus.Conclusion: The extended transsphenoidal approach tothe supra and parasellar lesions seems Endoscopy; Transsphenoidal surgery; Extended approach; Parasellar; Tumors; Anterior skull base. A promising minimally invasivetechnique for the removal of lesions affecting these areas,once thought to be suitable only of the transcranial routes.Concerning the lesion removal and the recurrence rate compared with the transcranial routes, it is too early to pose a definitive word, since the follow-up is still too short.

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Graded Reconstruction Strategy Using a Multi-Layer Technique without Lumbar Drainage After Endoscopic Endonasal Surgery

10.21203/rs.3.rs-749900/v1 ◽

2021 ◽

Author(s):

Chang-Min Ha ◽

Sang Duk Hong ◽

Jung Won Choi ◽

Ho Jun Seol ◽

Do-Hyun Nam ◽

...

Keyword(s):

High Flow ◽

Csf Leak ◽

Endoscopic Endonasal Surgery ◽

Endonasal Surgery ◽

Endoscopic Endonasal ◽

Layer Technique ◽

Grade Ii ◽

Reconstruction Strategy ◽

Acellular Dermal ◽

Grade Iii

Abstract Introduction Sellar reconstruction following endoscopic endonasal surgery (EES) requires modification based on the degree of cerebrospinal fluid (CSF) leak. For high-flow (grade II or III) intraoperative CSF leak, lumbar drainage (LD), in addition to the multi-layer closing technique, is generally recommended. However, LD has complications occasionally, including post-puncture headache, over-drainage symptoms, and increased length of stay (LOS). We retrospectively evaluated the outcome of our graded reconstruction strategy using a multi-layer technique with a novel material, without LD, after EES.Methods Ninety-seven patients who underwent EES with grade II or III intraoperative CSF leak between June 2020 and March 2021 were retrospectively reviewed. For grade II CSF leak, fibrin sealant and a nasoseptal flap (NSF) were placed; for grade III CSF leak, a multi-layer technique was utilized in combination with collagen matrix, an acellular dermal graft, injectable hydroxyapatite (HXA), and an NSF. Postoperatively, routine LD was not performed.Results This study included 48 (49.5%) grade II and 49 (50.5%) grade III CSF leaks. Upon follow-up period (mean, 8.7 months), no patient showed postoperative CSF leak in either group. The postoperative LOS was not significantly different between the grade II (6.68 [range, 3–14] days) and grade III CSF leak groups (7.38 [range, 4–15] days) (p>0.05). No HXA-associated complications occurred.ConclusionsA graded surgical repair strategy after EES could avoid postoperative CSF leak. Combined use of injectable HXA and acellular dermal grafts for high-flow CSF leak can limit LD requirement, without significant risks.

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