Extended Endonasal Solo Endoscopic Approach for the Resection of Craniopharyngiomas

Background: Extended endonasal solo endoscopic approach for the non-pituitary lesions of the sellar and suprasellar regions are not new in the field of neurosurgery. Following endoscopic surgical approach of the pituitary adenoma, endoscopic neurosurgeon is eager to develop the skill for non-pituitary sellar & suprasellar lesions. Common sellar & suprasellar lesions are pituitary adenoma, craniopharyngioma, tuberculumselle meningioma and suprasellar germinoma. Objective: Traditional transsphenoidal approach gives exposure to the pituitary fossa, whereas extended approach provides exposure to the optic nerve, chiasm, acom complex and basal frontal lobe ,mammillary body, mid brain and laterally to the cavernous sinuses. Material & method: From November 2007 to March 2012, 12 cases of done by extended endonasal solo endoscopic approach among 12 cases of craniopharyngiomas. Patient’s history, clinical findings, pre-operative and post-operative visual acuity, visual field and radiological data were collected and analyzed. All patients underwent solo endoscopic extended transsphenoidal approach with or without nasoseptal flap technique for closure. Most of the patients were given lumbar drain as a treatment for CSF leak. Result: All patients were of age group of 10 to 60 years. Male were 8 (66.67%), female were 4 (33.33%) in number. Gross total removals were done in 7 cases out of 12 (58.33%) craniopharyngiomas and subtotal removal done in 5 (41.67%) cases. Visual acuity and field of vision were improved in all cases of craniopharyngiomas. One case (8.33%) of craniopharyngioma had prolong period of unconsciousness probably from hypothalamic disturbance. CSF leak developed in 2 (16.67%) cases. Patients with craniopharyngioma were required thyroxin and cortisol for replacement. Permanent diabetes insipidus developed in 5 cases (41.67%). Three patients required permanent CSF diversion via a ventriculoperitoneal shunt after documentation of postoperative HCP. There was one case of chemical meningitis, and two cases confirmed bacterial infections. Craniopharyngioma can be successfully resected via a purely endoscopic, endonasal approach. Craniopharyngioma have a higher rate of perioperative hydrocephalus and postoperative CSF leak compared with other tumor types in the same area. Conclusion: Extended transsphenoidal approach is an excellent alternative of skull base approach for the removal of most of the craniopharyngioma.The endoscopic endonasal route provides a good exposure, especially of the sub-chiasmatic and retro-chiasmatic areas, as well as of the stalk– infundibulum axis and the third ventricle chamber. It gives better visualization, improved postoperative visual outcome for less manipulation and low complication then craniotomy. However CSF leak and diabetes insipidus is common known complications which have to be manage promptly and appropriately. Bangladesh Journal of Neuroscience 2013; Vol. 29 (2) : 108-114

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Endoscopic Endonasal Transsphenoidal Approach to Pituitary Adenoma: A Multi-disciplinary Approach

Journal of Nepal Health Research Council ◽

10.3126/jnhrc.v15i2.18209 ◽

2017 ◽

Vol 15 (2) ◽

pp. 174-177 ◽

Cited By ~ 1

Author(s):

Deepak Regmi ◽

Amit Thapa ◽

Bidur KC ◽

Bikram Shakya

Keyword(s):

Pituitary Adenoma ◽

Minimally Invasive ◽

Endoscopic Approach ◽

Transsphenoidal Approach ◽

Sinus Surgery ◽

Csf Leak ◽

Technical Failure ◽

Endoscopic Endonasal ◽

Ablative Surgery ◽

Surgical Cure

Background: The excellent visualization and minimally invasive approach employed in endoscopic endonasal procedures has now revolutionized the pituitary surgery, replacing the transnasal microscopic technique worldwide. However, it involves major shift in hand-eye co-ordination from static 3 dimensional images of microscope to 2 dimensional endoscopic images hence demands training and inter-disciplinary approach. Here we present our experiences in learning and developing a safe endonasal transsphenoidal endoscopic approach to resect pituitary adenomas.Methods: This prospective study was jointly conducted in the departments of ENT and Neurologicals surgery Kathmandu Medical College, Nepal, from September 2014 to August 2016. The endoscopic approach to the sphenoid sinus was performed by an Otolaryngologist and ablative surgery by Neurosurgeon. The ease of procedure, intra operative challenges, surgical cure, post-operative cerebro spinal fluid (CSF) leaks and postoperative complaints were analyzed.Results: Sixteen consecutive patients with pituitary adenoma (macro adenoma=13, micro adenoma =3) were analyzed. There were three intraoperative CSF leak, managed successfully. Two patients developed transient diabetes insipidus and surgical cure rate was 90%. No case had to be switched over to traditional microscopic route due to technical failure. There was no mortality.Conclusions: The endoscopic endonasal transsphenoidal approach to pituitary tumors is a safe and minimally invasive procedure, which can be employed safely in any of our centers in Nepal, equipped with endoscopic sinus surgery and endoscopically trained ENT and Neurosurgeons. A multi disciplinary approach provides good access, greater tumor excision and excellent postoperative follow up.Keywords: .

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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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Outcomes following Purely Endoscopic Endonasal Resection of Pituitary adenomas

Journal of Enam Medical College ◽

10.3329/jemc.v3i1.13869 ◽

2013 ◽

Vol 3 (1) ◽

pp. 18-23

Author(s):

Shamsul Alam ◽

ATM Mosharef Hossain ◽

AN Wakil Uddin ◽

Tariqul Islam ◽

Rezaul Amin ◽

...

Keyword(s):

Pituitary Adenoma ◽

Diabetes Insipidus ◽

Pituitary Adenomas ◽

Pituitary Surgery ◽

Electrolyte Imbalance ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Microscopic Surgery ◽

Subtotal Removal

Background: The use of endoscope for the management of pituitary adenoma is not new. The better magnification and illumination provided by the endoscope gives better outcome than microscopic pituitary surgery. Objective: To find out the benefits of endoscope in relation to microscopic surgery. Materials and Methods: We performed 45 cases of pituitary adenoma surgery by endoscopic endonasal approach from July 2008 to July 2010. Results: Forty five cases underwent endoscopic transsphenoidal approach. Gross total removal was done in 35 cases and subtotal removal was done in 10 cases. Residual tumours were seen in 10 cases (22%) in postoperative follow-up MRI scan. Visual improvement was satisfactory, and hormonal improvement of functional adenoma was nice. Postoperative visual acuity and visual field were improved in 75% cases. There were 37% cases of temporary diabetes insipidus and about 4.5% cases of permanent diabetes insipidus. The average duration of follow-up was 20 months. One patient required reexploration to correct visual deterioration in the immediate postoperative period. There were 4.5% cases of CSF leak and 6.6% mortality. Mortality was due to electrolyte imbalance and improper management of infection and hydrocephalus. Conclusion: Endoscopic endonasal pituitary surgery now has become a gold standard surgery for most of the pituitary adenomas because of its better advantages in relation to microscopic surgery and less complications and less hospital stay. DOI: http://dx.doi.org/10.3329/jemc.v3i1.13869 J Enam Med Col 2013; 3(1): 18-23

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Evaluation of Pure Endoscopic Endonasal Approach in Management of Giant Pituitary Adenoma

QJM ◽

10.1093/qjmed/hcab108.008 ◽

2021 ◽

Vol 114 (Supplement_1) ◽

Author(s):

Mina M Gerges ◽

Hatem Sabry ◽

Hasan Jalalod din ◽

Mohamed Ashraf Ghobashy ◽

Theodore H Schwartz

Keyword(s):

Radiation Therapy ◽

Pituitary Adenoma ◽

Cavernous Sinus ◽

Transsphenoidal Approach ◽

Csf Leak ◽

Tumor Diameter ◽

Giant Pituitary Adenoma ◽

Postoperative Hematoma ◽

Extended Transsphenoidal Approach

Abstract Background Giant pituitary adenoma represents one of the challenging tumor for neurosurgeons. Many microsurgical approaches in the past were used for its management. Recently and with evolution of the endoscopic equipment and instruments, extended endoscopic transsphenoidal approach become one of the preferable approaches for its surgical excision. Methods We prospectively document the clinical , surgical and follow up data for all patients presented with giant pituitary adenoma to Ain-Shams university hospital and Weill Cornell Medical College, Presbyterian hospital and were surgically treated with extended transsphenoidal approach from 2015 till 2019. Results Our group study formed of 44 patients with mean age 53.03 (range 14.7-82.4) and a male predominance (59%). The main presentation was visual problems in 75% followed by partial hypopituitarism in 31.81% while headache was in 13.64%. Only 4 patients had functioning adenoma (3 prolactinoma and 1 acromegaly). Average tumor volume was 26.95 ± 17.25 cm3, while the mean maximum tumor diameter was 4.73 cm (range 4.0-8.0 cm). Radiographic invasion was found in 97.73% to suprasellar cistern, 61.36% to the cavernous sinus and in 34% to the sphenoid sinus. GTR was achieved in 45.45% with Knosp score is the only significant predictor factor for resection rate (p = 0.04). Visual improvement achieved in 75.76%. 50% (2 patient) of the patients with functioning adenoma were cured. Complications included CSF leak in 3 patients, permanent DI in 4 patients and postoperative hematoma in 2 patients. Recurrence and progression rates without upfront radiation therapy were 5.00 % and 31.81% respectively after mean follow up period 57.90 months. Conclusions Extended endoscopic approaches for achieving maximum resection with minimal morbidity for giant pituitary adenoma are very effective. Lateral tumor extension with cavernous sinus invasion represents the limiting point in achieving gross total resection. Upfront radiation therapy for patients with residual adenoma can be avoided but regular follow up should be warranted.

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Concerns of cerebrospinal fluid leak in aggressive expanded endonasal endoscopic approach for craniopharyngiomas

Journal of Neurology & Stroke ◽

10.15406/jnsk.2020.10.00430 ◽

2020 ◽

Vol 10 (4) ◽

pp. 154-156

Author(s):

Marlon Ortiz Machín ◽

Omar López Arbolay

Keyword(s):

Cerebrospinal Fluid ◽

Third Ventricle ◽

Cerebrospinal Fluid Leak ◽

Endoscopic Approach ◽

Csf Leak ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Nasoseptal Flap ◽

Endoscopic Endonasal ◽

Fluid Leak

Cerebrospinal fluid leak represents a frequent complication in Craniopharyngioma´s Endoscopic Endonasal Approach. A descriptive observational investigation was performed in 50 adult patients operated of Craniopharyngiomas by aggressive Expanded Endonasal Endoscopic Approach (EEEA) in “Hermanos Ameijeiras” Hospital since 2010 to 2019 using nasoseptal flap. The 14% of all patients develop CSF leak and 85,7 % of these cases had a great communication into third ventricle creating a cisternoventricular space. Was identified relation with tumor size, hypothalamic invasion and adhesion strength of tumour. Surgical cavity suffered hydrostatic and hydrodynamic pression than lead to CSF leak independent of multilayer reparation.

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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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Universal Sellar Anatomical Reconstruction Using the Sellar Floor Flap after Endoscopic Pituitary Adenoma Surgery

Otolaryngology ◽

10.1177/0194599818756861 ◽

2018 ◽

Vol 158 (4) ◽

pp. 774-776 ◽

Cited By ~ 2

Author(s):

Zixiang Cong ◽

Kaidong Liu ◽

Guodao Wen ◽

Liang Qiao ◽

Handong Wang ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Pituitary Adenoma ◽

Csf Leak ◽

Anatomical Reconstruction ◽

Endoscopic Endonasal ◽

Reconstructive Technique ◽

Sellar Reconstruction ◽

Sellar Floor ◽

Csf Leaks

Postoperative cerebrospinal fluid (CSF) leaks still occur in patients without intraoperative CSF leaks after endoscopic endonasal pituitary adenoma surgery. We propose a reconstructive technique, the sellar floor flap (SFF), for universal sellar anatomical reconstruction. A total of 113 patients without intraoperative CSF leaks after endoscopic endonasal pituitary adenoma surgery from July 2013 to June 2016 were reviewed: 43 underwent sellar reconstruction with the SFF (the SFF group) and 70 underwent sellar packing only (the nonreconstruction group). No case of postoperative CSF leak was reported in the SFF group, whereas 7 cases were reported in the nonreconstruction group ( P < .05). The SFF is suitable for universal reconstruction after endoscopic endonasal pituitary adenoma surgery and may decrease postoperative CSF leak.

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Predictive Factors, 30-Day Clinical Outcomes, and Costs Associated with Cerebrospinal Fluid Leak in Pituitary Adenoma Resection

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1679896 ◽

2019 ◽

Vol 81 (01) ◽

pp. 043-055 ◽

Cited By ~ 1

Author(s):

Adish Parikh ◽

Arjun Adapa ◽

Stephen E. Sullivan ◽

Erin L. McKean

Keyword(s):

Cerebrospinal Fluid ◽

Multivariate Analysis ◽

Pituitary Adenoma ◽

Demographic Data ◽

Cerebrospinal Fluid Leak ◽

Hospital Charges ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Financial Variables ◽

Clinical Complications

AbstractCerebrospinal fluid (CSF) leak is a complication of endoscopic endonasal pituitary adenoma resection. Previous studies examining complications of pituitary adenoma resection have not examined associations of an exhaustive list of clinical and financial variables with CSF leak. We designed a retrospective analysis of 334 consecutive patients that underwent endoscopic endonasal pituitary adenoma resection at a single institution over 5 years, analyzing associations between CSF leak and demographic data, operative data, comorbidities, clinical complications and outcomes, costs, charges, and payments. Of the 20 preoperative variables studied, none were positively associated with CSF leak in between-groups comparison, although multivariate analysis revealed an association with a history of radiation to the skull base (odds ratio [OR], 8.67; 95% confidence interval [CI], 0.94–57.03; p < 0.05). CSF leak was associated with a significantly higher rate of postoperative diabetes insipidus (Δ = 33.4%, p = 0.040) and increased length of stay after operation in between-groups comparison. Multivariate analysis on postoperative variables revealed significant associations between CSF leak and intracerebral hemorrhage (OR, 17.44; 95% CI, 0.65–275.3; p < 0.05) and postoperative intracranial infection (OR, 28.73; 95% CI, 2.04–438.7; p < 0.05). Also, CSF leak was associated with significantly higher costs (Δ = $15,643, p < 0.05) and hospital charges (Δ = $46,026, p < 0.05). Operating room time, room and board, and supplies and implants were the strongest cost drivers. This study highlights the difficulty of utilizing preoperative variables to predict CSF leak, the clinical complications and outcomes of leak, and the financial subcategories that drive the costs, charges, and payments associated with this complication.

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The learning curve in endoscopic endonasal resection of craniopharyngiomas

Neurosurgical FOCUS ◽

10.3171/2016.9.focus16292 ◽

2016 ◽

Vol 41 (6) ◽

pp. E9 ◽

Cited By ~ 17

Author(s):

Varun R. Kshettry ◽

Hyunwoo Do ◽

Khaled Elshazly ◽

Christopher J. Farrell ◽

Gurston Nyquist ◽

...

Keyword(s):

Learning Curve ◽

Diabetes Insipidus ◽

Neurological Complications ◽

Csf Leak ◽

Categorical Variables ◽

Total Resection ◽

Endoscopic Endonasal ◽

Visual Improvement ◽

Early Cohort ◽

Over Time

OBJECTIVE There is a paucity of literature regarding the learning curve associated with performing endoscopic endonasal cranial base surgery. The purpose of this study was to determine to what extent a learning curve might exist for endoscopic endonasal resection in cases of craniopharyngiomas. METHODS A retrospective review was performed for all endoscopic endonasal craniopharyngioma resections performed at Thomas Jefferson University from 2005 to 2015. To assess for a learning curve effect, patients were divided into an early cohort (2005–2009, n = 20) and a late cohort (2010–2015, n = 23). Preoperative demographics, clinical presentation, imaging characteristics, extent of resection, complications, tumor control, and visual and endocrine outcomes were obtained. Categorical variables and continuous variables were compared using a 2-sided Fisher's exact test and t-test, respectively. RESULTS Only the index operation performed at the authors' institution was included. There were no statistically significant differences between early and late cohorts in terms of patient age, sex, presenting symptoms, history of surgical or radiation treatment, tumor size or consistency, hypothalamic involvement, or histological subtype. The rate of gross-total resection (GTR) increased over time from 20% to 65% (p = 0.005), and the rate of subtotal resection decreased over time from 40% to 13% (p = 0.078). Major neurological complications, including new hydrocephalus, meningitis, carotid artery injury, or stroke, occurred in 6 patients (15%) (8 complications) in the early cohort compared with only 1 (4%) in the late cohort (p = 0.037). CSF leak decreased from 40% to 4% (p = 0.007). Discharge to home increased from 64% to 95% (p = 0.024). Visual improvement was high in both cohorts (88% [early cohort] and 81% [late cohort]). Rate of postoperative panhypopituitarism and permanent diabetes insipidus both increased from 50% to 91% (p = 0.005) and 32% to 78% (p = 0.004), which correlated with a significant increase in intentional stalk sacrifice in the late cohort (from 0% to 70%, p < 0.001). CONCLUSIONS High rates of near- or total resection and visual improvement can be achieved using an endoscopic endonasal approach for craniopharyngiomas. However, the authors did find evidence for a learning curve. After 20 cases, they found a significant decrease in major neurological complications and significant increases in the rates of GTR rate and discharge to home. Although there was a large decrease in the rate of postoperative CSF leak over time, this was largely attributable to the inclusion of very early cases prior to the routine use of vascularized nasoseptal flaps. There was a significant increase in new panhypopituitarism and diabetes insipidus, which is attributable to increase rates of intentional stalk sacrifice.

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Visual Improvement after Endoscopic Endonasal Transsphenoidal Excision of Pituitary Gland Tumor

Pakistan Journal Of Neurological Surgery ◽

10.36552/pjns.v23i4.385 ◽

2019 ◽

Vol 23 (4) ◽

Author(s):

ZUBAIR AHMED KHAN ◽

HABIB SULTAN ◽

MUHAMMAD WAQAS ◽

SARFRAZ KHAN ◽

TOQEER AHMED ◽

...

Keyword(s):

Visual Acuity ◽

Pituitary Gland ◽

Pituitary Surgery ◽

Transsphenoidal Approach ◽

Gland Tumor ◽

Endoscopic Endonasal ◽

Age And Gender ◽

Tumor Excision ◽

Visual Improvement ◽

And Gender

Objective: To evaluate the frequency of improved visual acuity after Endoscopic Endonasal Transsphenoidal excision of pituitary gland tumor.Study Design: Descriptive case series.Materials and Methods: In our study, Pre-operative visual acuity was noted by using the Snellen’s chart. Then patients underwent pituitary gland excision though Endoscopic Endonasal Transsphenoidal approach under general anesthesia. After surgery, patients were shifted in postsurgical wards and then will be discharged from there and were examinedfor 3 months in OPD. Snellen’s chart was used to evaluate patents for visual acuity after 3 months by an experienced ophthalmologist having at least 4 years residency experience If visual acuity increased ≥ 1 line, then improved visual acuity was labeled.Results: Improved visual acuity after pituitary gland tumor excision was seen in 59(89.39%) patients. Age and gender of patients did not show any statistically significant association for improved visual acuity.Conclusions: Results of this study showed that pituitary gland tumor excision through Endoscopic Endonasal Transsphenoidal approach is effective in terms of visual acuity improvement. Our main objectives in pituitary surgery are protection and reinstatement of vision and this surgical approach give maximum cover to vision restoration.

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