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

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 Resection of Craniopharyngiomas

Neurosurgery ◽

10.1227/neu.0b013e31822e8ffc ◽

2011 ◽

Vol 70 (1) ◽

pp. 110-124 ◽

Cited By ~ 111

Author(s):

Lewis Z. Leng ◽

Jeffrey P. Greenfield ◽

Mark M. Souweidane ◽

Vijay K. Anand ◽

Theodore H. Schwartz

Keyword(s):

Csf Leak ◽

Subtotal Resection ◽

Consecutive Series ◽

Tumor Diameter ◽

Minimal Access ◽

Endoscopic Endonasal Surgery ◽

Endonasal Surgery ◽

Endoscopic Endonasal ◽

Extended Transsphenoidal Approach

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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Unilateral Endoscopic Endonasal Surgery for Resection of an Olfactory Schwannoma of the Anterior Cranial Base in a Patient with Hereditary Hemorrhagic Telangiectasia

World Neurosurgery ◽

10.1016/j.wneu.2016.01.050 ◽

2016 ◽

Vol 89 ◽

pp. 729.e15-729.e20 ◽

Cited By ~ 6

Author(s):

Marcelo Charles Pereira ◽

Maria Peris-Celda ◽

Jiang Qian ◽

Tyler J. Kenning ◽

Carlos D. Pinheiro-Neto

Keyword(s):

Hereditary Hemorrhagic Telangiectasia ◽

Cranial Base ◽

Endoscopic Endonasal Surgery ◽

Endonasal Surgery ◽

Endoscopic Endonasal ◽

Anterior Cranial Base

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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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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 resection of epidermoid cysts involving the ventral cranial base

Journal of Neurosurgery ◽

10.3171/2017.12.jns172575 ◽

2019 ◽

Vol 130 (5) ◽

pp. 1599-1608

Author(s):

Jonathan A. Forbes ◽

Matei Banu ◽

Kurt Lehner ◽

Malte Ottenhausen ◽

Emanuele La Corte ◽

...

Keyword(s):

Cranial Nerves ◽

Cranial Base ◽

Csf Leak ◽

Nasoseptal Flap ◽

Total Resection ◽

Endoscopic Endonasal ◽

Epidermoid Cysts ◽

Flap Coverage ◽

Csf Leakage ◽

The Impact

OBJECTIVEEpidermoid cysts (ECs) commonly extend to involve the ventral cisterns of the cranial base. When present, symptoms arise due to progressive mass effect on the brainstem and adjacent cranial nerves. Historically, a variety of open microsurgical approaches have been used for resection of ECs in this intricate region. In recent years, the endoscopic endonasal approach (EEA) has been proposed as an alternative corridor that avoids crossing the plane of the cranial nerves. To date, there is a paucity of data in the literature regarding the safety and efficacy of the EEA in the treatment of ECs of the ventral cranial base.METHODSThe authors reviewed a prospectively acquired database of EEAs for resection of ECs over 8 years at Weill Cornell, NewYork-Presbyterian Hospital. All procedures were performed by the senior authors. Standardized clinical and radiological parameters were assessed before and after surgery. Statistical tests were used to determine the impact of previous surgery and tumor volume on extent of resection and recurrence as well as the method of closure on rate of CSF leak.RESULTSBetween January 2009 and February 2017, 7 patients (4 males and 3 females; age range 16–70 years) underwent a total of 8 surgeries for EC resection utilizing the EEA. Transplanum and transclival extensions were performed in 3 and 5 patients, respectively. Methods of closure incorporated a gasket seal in 6 of 8 procedures and a nasoseptal flap in 7 of 8 procedures. Gross-total resection (GTR) was achieved in 43% of patients, and near-total resection (> 95%) was obtained in another 43%. Complications included diabetes insipidus (n = 2), postoperative CSF leak (n = 2), transient third cranial nerve palsy (n = 1), and epistaxis (n = 1). With a mean follow-up of 43.5 months, recurrence has been observed in 2 of 7 patients. In 1 case, reoperation for recurrence was required 71 months following the initial surgery. Use of the gasket-seal technique with nasoseptal flap coverage significantly correlated with the absence of postoperative CSF leakage (p = 0.018). GTR was achieved in 25% of the patients who had prior surgeries and in 50% of patients without previous resections. The mean volume of cysts in which GTR was achieved (4.3 ± 1.8 cm3) was smaller than that in which subtotal or near-total resection was achieved (12.2 ± 11 cm3, p = 0.134).CONCLUSIONSThe EEA for resection of ECs of the ventral cranial base is a safe and effective operative strategy that avoids crossing the plane of the cranial nerves. In the authors’ experience, gasket-seal closure with nasoseptal flap coverage has been associated with a decreased risk of postoperative CSF leakage.

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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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