1
|
Desai R, Kapur Z, Hammond B, Dombaxe CP, Chavez-Herrera VR, Tabaee A, Anand VK, Kacker A, Schwartz TH. Safety and efficacy of hydroset cranioplasty as an adjunct to gasket-seal and nasoseptal flap closure of the skull base. A case-controlled study. Acta Neurochir (Wien) 2024; 166:256. [PMID: 38850489 DOI: 10.1007/s00701-024-06134-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/20/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Cerebrospinal fluid leak after endoscopic skull base surgery remains a significant complication. Several investigators have suggested Hydroset cranioplasty to reduce leak rates. We investigated our early experience with Hydroset and compared the rate of nasal complications and CSF leak rates with case-controlled historic controls. METHODS We queried a prospective database of patients undergoing first time endoscopic, endonasal resection of suprasellar meningiomas and craniopharyngiomas from 2015 to 2023. We compared cases closed with a gasket seal, Hydroset, and a nasoseptal flap with those closed with only a gasket seal and nasoseptal flap. Demographics, technical considerations and postoperative outcomes (SNOT-22) were compared. RESULTS Seventy patients met inclusion criteria, twenty patients in the Hydroset group (meningioma n = 12; craniopharyngioma n = 8) and 50 control patients (meningioma n = 25; craniopharyngioma n = 25). CSF diversion was used in fewer Hydroset patients (75%, 15/20) compared with control group (94%, 47/50; p = 0.02). CSF leak was less frequent in the Hydroset than the control group (5% versus 12%, p = 0.38). One Hydroset patient required delayed nasal debridement. SNOT-22 responses demonstrated no significant difference in sinonasal complaints between groups (Hydroset average SNOT-22 score 22.45, control average SNOT-22 score 25.90; p = 0.58). CONCLUSIONS We demonstrate that hydroxyapatite reconstruction leads to improved CSF leak control above that provided by the gasket-seal and nasoseptal flap, without significant associated morbidity as long as the cement is fully covered with vascularized tissue.
Collapse
Affiliation(s)
- Rupen Desai
- Department of Neurological Surgery, Weill Cornell Medicine, NewYork Presbyterian Hospital, New York, NY, USA
| | - Zoe Kapur
- Department of Neurological Surgery, Weill Cornell Medicine, NewYork Presbyterian Hospital, New York, NY, USA
| | - Benjamin Hammond
- Department of Neurological Surgery, Weill Cornell Medicine, NewYork Presbyterian Hospital, New York, NY, USA
| | - Cátia P Dombaxe
- Department of Neurological Surgery, Weill Cornell Medicine, NewYork Presbyterian Hospital, New York, NY, USA
| | | | - Abtin Tabaee
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | - Vijay K Anand
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | - Ashutosh Kacker
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Weill Cornell Medicine, NewYork Presbyterian Hospital, New York, NY, USA.
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA.
| |
Collapse
|
2
|
Jurlina M, Mamic M, Pupic-Bakrac J, Matoc L, Jednacak H, Luksic I, Zizic M. Free temporalis muscle fascia graft in dural reconstruction following surgical resection of intermediate and malignant skull base tumors: A 10-year experience from a single center. Head Neck 2024; 46:1380-1389. [PMID: 38587969 DOI: 10.1002/hed.27768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 02/04/2024] [Accepted: 03/29/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Data from patients with post-ablative dural defects reconstructed using a free temporalis muscle fascia graft (FTFG) after resection of anterior or central skull base tumors were retrospectively analyzed. METHODS The primary predictor and outcome variables were the reconstructive methods for dural repair and postoperative cerebrospinal fluid (CSF) leakage rate, respectively. RESULTS Eighty patients were included, and 94 postoperative dural reconstructions were performed using FTFG. The postoperative CSF leakage rate was 3.19%. The postoperative CSF leakage rates did not significantly differ between open and endonasal endoscopic surgeries (1.92% vs. 4.88%; p > 0.05). In cases completed using the endonasal endoscopic approach, the postoperative CSF leakage rate was significantly associated with the intraoperative CSF leak flow (p < 0.05). CONCLUSIONS Post-ablative dural defect reconstruction using FTFG resulted in low postoperative CSF leakage and complication rates comparable to those of free fascia lata graft from available literature.
Collapse
Affiliation(s)
- Martin Jurlina
- Department of Maxillofacial Surgery, Dubrava University Hospital, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Matija Mamic
- Department of Maxillofacial Surgery, Dubrava University Hospital, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Jure Pupic-Bakrac
- Department of Otorhinolaryngology and Maxillofacial Surgery, General Hospital Zadar, Zadar, Croatia
| | - Lovro Matoc
- Department of Otorhinolaryngology - Head and Neck Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Hrvoje Jednacak
- Department of Neurosurgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Ivica Luksic
- Department of Maxillofacial Surgery, Dubrava University Hospital, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Marica Zizic
- Department of Otorhinolaryngology - Head and Neck Surgery, University Hospital Sveti Duh, Zagreb, Croatia
| |
Collapse
|
3
|
Tan Y, Li J, Liu Y, Du J. Comparative analysis of transnasal endoscopic reconstruction techniques for managing cerebrospinal fluid rhinorrhea in skull base defects. J Clin Neurosci 2024; 125:38-42. [PMID: 38744121 DOI: 10.1016/j.jocn.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 04/23/2024] [Accepted: 05/08/2024] [Indexed: 05/16/2024]
Abstract
The nasal skull base is located into the deep position of nasal cavity and closely related to important nerves and vessels. The complete removal of tumors in this area poses a complex surgical challenge.In order to investigate the clinical efficacy of utilizing free middle turbinate mucosa (FMT), fascia lata, and pedicled nasal septum flap (known as the Hadad-Bassagasteguy flap, HBF) for the treatment of cerebrospinal fluid (CSF) rhinorrhea, a retrospective analysis was conducted on clinical data from 65 patients who underwent skull base reconstruction following endoscopic resection of nasal-skull base tumors. The selection of the repair material was based on the size and location of the defect. For defects less than 1.5 cm (n = 24), FMT was chosen, while for defects greater than or equal to 1.5 cm (n = 16), HBF was preferred. In cases where HBF was not available or not suitable (specifically, when the defect was located on the posterior wall of the frontal sinus), fascia lata was selected (n = 25). The repair outcomes of all 65 patients were summarized, and subsequently, a comparison was made between the use of fascia lata and HBF. The overall success rate for one-time repairs was 93.8 %. Specifically, the success rates for repairs using FMT, fascia lata, and HBF were 91.7 %, 96.0 %, and 93.8 %, respectively. Throughout the follow-up period, there were 2 cases of postoperative CSF leakage out of 24 patients who underwent FMT reconstruction, 1 case out of 25 patients who underwent fascia lata reconstruction, and 1 case out of 16 patients who underwent HBF reconstruction. The occurrence of postoperative complications, such as intracranial infection, lung infection, and epistaxis, was observed in both the fascia lata group and the HBF group. However, there were no statistically significant differences between the two groups. The transnasal endoscopic reconstruction of skull base defect using HBF, fascia lata, and FMT demonstrated satisfactory repair effects in managing CSF rhinorrhea. Generally, FMT has been found to be a dependable repair material for small defects measuring less than 1.5 cm, while in the case of larger defects equal to or exceeding 1.5 cm, both HBF and fascia lata can be utilized with comparable repair outcomes. The selection of fascia lata becomes a viable option when HBF is unavailable or not suitable.
Collapse
Affiliation(s)
- Yishuai Tan
- Department of Otolaryngology Head and Neck Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Chengdu 610041, China; West China School of Pharmacy, Sichuan University, No. 17, South Renmin Road, Chengdu 610041, China
| | - Jun Li
- Department of Otolaryngology Head and Neck Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Chengdu 610041, China; Affiliate Hospital of Sichuan Nursing Vocational Collage, The Third People's Hospital of Sichuan Province, Chengdu 610199, China
| | - Yafeng Liu
- Department of Otolaryngology Head and Neck Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Chengdu 610041, China
| | - Jintao Du
- Department of Otolaryngology Head and Neck Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Chengdu 610041, China.
| |
Collapse
|
4
|
Sumislawski P, Piotrowska M, Regelsberger J, Flitsch J, Rotermund R. Sphenoid Sinus Mucosal Flap after Transsphenoidal Surgery-A Systematic Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:282. [PMID: 38399569 PMCID: PMC10890001 DOI: 10.3390/medicina60020282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/24/2024] [Accepted: 01/24/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: Skull base reconstruction is a crucial step during transsphenoidal surgery. Sphenoid mucosa is a mucosal membrane located in the sphenoid sinus. Preservation and lateral shifting of sphenoid mucosa as sphenoid mucosal flap (SMF) during the transsphenoidal exposure of the sella may be important for later closure. This is the first systematic review to evaluate the utility of sphenoid mucosal flap for sellar reconstruction after transsphenoidal surgery. Materials and Methods: A systematic literature search was performed in January 2023: Cochrane, EMBASE, PubMed, Scopus, and Web of Science. The following keywords and their combinations were used: "sphenoid mucosa", "sphenoid sinus mucosa", "sphenoid mucosal flap", "sphenoid sinus mucosal flap". From a total number of 749 records, 10 articles involving 1671 patients were included in our systematic review. Results: Sphenoid sinus mucosa used to be applied for sellar reconstruction as either a vascularized pedicled flap or as a free flap. Three different types of mucosal flaps, an intersinus septal flap, a superiorly based flap and an inferiorly based flap, were described in the literature. Total SMF covering compared to partial or no SMF covering in sellar floor reconstruction resulted in fewer postoperative CSF leaks (p = 0.008) and a shorter duration of the postoperative lumbar drain (p = 0.003), if applied. Total or partial SMF resulted in fewer local complications (p = 0.012), such as fat graft necrosis, bone graft necrosis, sinusitis or fungal infection, in contrast to no SMF implementation. Conclusions: SMF seems to be an effective technique for skull base reconstruction after transsphenoidal surgery, as it can reduce the usage of avascular grafts such as fat along with the incidence of local complications, such as fat graft necrosis, bone graft necrosis, sinusitis and fungal infection, or it may improve the sinonasal quality of life by maintaining favorable wound healing through vascular flap and promote the normalization of the sphenoid sinus posterior wall. Further clinical studies evaluating sphenoid mucosal flap preservation and application in combination with other techniques, particularly for higher-grade CSF leaks, are required.
Collapse
Affiliation(s)
- Piotr Sumislawski
- Department of Neurosurgery, Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany;
| | - Martyna Piotrowska
- Faculty of Medicine and Dentistry, Pomeranian Medical University, Al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland;
| | - Jan Regelsberger
- Department of Neurosurgery, Diako Krankenhaus Flensburg, 24939 Flensburg, Germany;
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany;
| | - Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany;
| |
Collapse
|
5
|
Finlay JB, Issa K, Ackall F, Zomorodi A, Codd P, Jang DW, Goldstein BJ, Abi Hachem R. Safety and Feasibility of Steroid-Eluting Stent as a Bolster in Endoscopic Anterior Skull Base Reconstruction. Ann Otol Rhinol Laryngol 2024; 133:43-49. [PMID: 37334915 DOI: 10.1177/00034894231181178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND With a rising incidence of cerebrospinal fluid (CSF) leaks, endoscopic endonasal CSF leak repair is increasingly performed. Current approaches utilize a variety of materials including free mucosal grafts and vascularized flaps, but post-op leaks continue to be reported. Steroid-eluting bioabsorbable stents (SES) are used during functional endoscopic sinus surgery for chronic rhinosinusitis to reduce inflammation and scarring while maintaining patency of sinus ostia. OBJECTIVE The aim of this study is to assess the feasibility of SES as a graft/flap bolster for endoscopic endonasal CSF leak repair. METHODS This is a retrospective review of patients undergoing endoscopic endonasal CSF leak repair with SES placed as part of the bolster technique at a tertiary care center between January 2019 and May 2022. Age, sex, BMI, comorbid idiopathic intracranial hypertension, pathology, location of CSF leak, intraoperative CSF leak flow, reconstruction type, and presence of post-op CSF leak were recorded. RESULTS Twelve patients (mean age 52, median BMI 30.9, 58% female) had SES placement as part of the bolster technique. The most common pathology was meningoencephalocele (75%). Reconstruction was performed with either a free mucosal graft (6), or a flap (6). No post-op CSF leaks occurred at a reconstruction site with a stent, and no known complications were reported. All sinusotomies were patent at the last follow-up visit. CONCLUSIONS SES placement as an adjunct to graft and/or flap bolster appears to be safe and feasible during anterior skull base reconstruction and CSF leak repair providing longer term structural support and preserving sinus drainage patency.
Collapse
Affiliation(s)
- John B Finlay
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC, USA
- Medical Scientist Training Program, Duke University School of Medicine, Durham, NC, USA
| | - Khalil Issa
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Feras Ackall
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Ali Zomorodi
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
- Duke Skull Base Center, Duke University School of Medicine, Durham, NC, USA
| | - Patrick Codd
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
- Duke Skull Base Center, Duke University School of Medicine, Durham, NC, USA
| | - David W Jang
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
- Duke Skull Base Center, Duke University School of Medicine, Durham, NC, USA
| | - Bradley J Goldstein
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Neurobiology, Duke University School of Medicine, Durham, NC, USA
| | - Ralph Abi Hachem
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
- Duke Skull Base Center, Duke University School of Medicine, Durham, NC, USA
| |
Collapse
|
6
|
Robbins KT, Ronen O, Saba NF, Strojan P, Vander Poorten V, Mäkitie A, López F, Rodrigo JP, Homma A, Hanna E, Ferlito A. Progress and emerging strategies to preserve function in the treatment of sinonasal cancer. Head Neck 2023; 45:2955-2966. [PMID: 37740399 DOI: 10.1002/hed.27510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/27/2023] [Accepted: 08/27/2023] [Indexed: 09/24/2023] Open
Abstract
The sinonasal structures and their adjacent organs host several functions including vision, olfaction, nasal respiration and filtration, secretory immunity, facial expression, articulation, and oral deglutition. We reviewed the current evidence supporting functional preservation in sinonasal cancer treatment. Primary surgery with or without adjuvant modalities continues to be the standard of care for sinonasal cancer. Unfortunately, functional compromise remains a dominant negative feature of this approach. More recently, through advances in therapeutic techniques and improved understanding of the relevant tumor biology, treatments aimed at preserving function and cosmesis are emerging. The evidence for such progress involving minimal access surgery, surgical reconstruction for rehabilitation, new techniques in radiation therapy, inclusion of systemic and locally enhanced chemotherapy, and therapeutic agents based on molecular targets are highlighted. This multi-prong approach bodes well for future patients with sinonasal cancer to undergo successful treatment that includes maximal preservation of associated functions.
Collapse
Affiliation(s)
- Kevin T Robbins
- Department of Otolaryngology - Head and Neck Surgery, School of Medicine, Southern Illinois University, Springfield, Illinois, USA
| | - Ohad Ronen
- Department of Otolaryngology - Head and Neck Surgery, Galilee Medical Center, Affiliated with Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Nabil F Saba
- Department of Hematology and Medical Oncology, The Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Primoz Strojan
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
| | - Vincent Vander Poorten
- Otorhinolaryngology - Head and Neck Surgery and Leuven Cancer Institute, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, Section of Head and Neck Oncology, KU Leuven, Leuven, Belgium
| | - Antti Mäkitie
- Department of Otorhinolaryngology - Head and Neck Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Fernando López
- Department of Otolaryngology, Hospital Universitario Central de Asturias, University of Oviedo, ISPA, IUOPA, CIBERONC, Oviedo, Spain
| | - Juan P Rodrigo
- Department of Otolaryngology, Hospital Universitario Central de Asturias, University of Oviedo, ISPA, IUOPA, CIBERONC, Oviedo, Spain
| | - Akihiro Homma
- Department of Otolaryngology - Head and Neck Surgery, Faculty of Medicine, Graduate School of Medicine, Hokkaido University, Hokkaido, Japan
| | - Ehab Hanna
- Department of Head & Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Alfio Ferlito
- International Head and Neck Scientific Group, Padua, Italy
| |
Collapse
|
7
|
Hannan CJ, Kewlani B, Browne S, Javadpour M. Multi-layered repair of high-flow CSF fistulae following endoscopic skull base surgery without nasal packing or lumbar drains: technical refinements to optimise outcome. Acta Neurochir (Wien) 2023; 165:2299-2307. [PMID: 37074392 PMCID: PMC10409672 DOI: 10.1007/s00701-023-05581-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/05/2023] [Indexed: 04/20/2023]
Abstract
AIMS Post-operative CSF leak remains a significant problem following endoscopic skull base surgery, particularly when there is a high-flow intra-operative CSF leak. Most skull base repair techniques are accompanied by the insertion of a lumbar drain and/or the use of nasal packing which have significant shortcomings. Our aim was to review the results of a large series of endoscopic skull base cases where a high-flow intra-operative CSF leak rate was encountered and repaired to assess if modifications in technique could reduce the post-operative CSF leak rate. METHODS A retrospective review of a prospectively maintained database of skull base cases performed by a single surgeon over a 10-year period was performed. Data regarding patient demographics, underlying pathology, skull base repair techniques and post-operative complications were analysed. RESULTS One hundred forty-two cases with high-flow intra-operative CSF leak were included in the study. The most common pathologies were craniopharyngiomas (55/142, 39%), pituitary adenomas (34/142, 24%) and meningiomas (24/142, 17%). The CSF leak rate was 7/36 (19%) when a non-standardised skull base repair technique was used. However, with the adoption of a standardised, multi-layer repair technique, the post-operative CSF leak rate decreased significantly (4/106, 4% vs. 7/36, 19%, p = 0.006). This improvement in the rate of post-operative CSF leak was achieved without nasal packing or lumbar drains. CONCLUSION With iterative modifications to a multi-layered closure technique for high-flow intra-operative CSF leaks, it is possible to obtain a very low rate of post-operative CSF leak, without lumbar drains or nasal packing.
Collapse
Affiliation(s)
| | - Bharti Kewlani
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Steven Browne
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.
- Royal College of Surgeons in Ireland, Dublin, Ireland.
- School of Medicine, Trinity College Dublin, Dublin, Ireland.
| |
Collapse
|
8
|
CSF rhinorrhoea after endonasal intervention to the skull base (CRANIAL): A multicentre prospective observational study. Front Oncol 2023; 12:1049627. [PMID: 36688936 PMCID: PMC9846732 DOI: 10.3389/fonc.2022.1049627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 10/24/2022] [Indexed: 01/09/2023] Open
Abstract
Objective Despite progress in endonasal skull-base neurosurgery, cerebrospinal fluid (CSF) rhinorrhoea remains common and significant. The CRANIAL study sought to determine 1) the scope of skull-base repair methods used, and 2) corresponding rates of postoperative CSF rhinorrhoea in the endonasal transsphenoidal approach (TSA) and the expanded endonasal approach (EEA) for skull-base tumors. Methods A prospective observational cohort study of 30 centres performing endonasal skull-base neurosurgery in the UK and Ireland (representing 91% of adult units). Patients were identified for 6 months and followed up for 6 months. Data collection and analysis was guided by our published protocol and pilot studies. Descriptive statistics, univariate and multivariable logistic regression models were used for analysis. Results A total of 866 patients were included - 726 TSA (84%) and 140 EEA (16%). There was significant heterogeneity in repair protocols across centres. In TSA cases, nasal packing (519/726, 72%), tissue glues (474/726, 65%) and hemostatic agents (439/726, 61%) were the most common skull base repair techniques. Comparatively, pedicled flaps (90/140, 64%), CSF diversion (38/140, 27%), buttresses (17/140, 12%) and gasket sealing (11/140, 9%) were more commonly used in EEA cases. CSF rhinorrhoea (biochemically confirmed or requiring re-operation) occurred in 3.9% of TSA (28/726) and 7.1% of EEA (10/140) cases. A significant number of patients with CSF rhinorrhoea (15/38, 39%) occurred when no intraoperative CSF leak was reported. On multivariate analysis, there may be marginal benefits with using tissue glues in TSA (OR: 0.2, CI: 0.1-0.7, p<0.01), but no other technique reached significance. There was evidence that certain characteristics make CSF rhinorrhoea more likely - such as previous endonasal surgery and the presence of intraoperative CSF leak. Conclusions There is a wide range of skull base repair techniques used across centres. Overall, CSF rhinorrhoea rates across the UK and Ireland are lower than generally reported in the literature. A large proportion of postoperative leaks occurred in the context of occult intraoperative CSF leaks, and decisions for universal sellar repairs should consider the risks and cost-effectiveness of repair strategies. Future work could include longer-term, higher-volume studies, such as a registry; and high-quality interventional studies.
Collapse
|
9
|
Baussart B, Venier A, Jouinot A, Reuter G, Gaillard S. Closure strategy for endoscopic pituitary surgery: Experience from 3015 patients. Front Oncol 2023; 12:1067312. [PMID: 36686774 PMCID: PMC9846073 DOI: 10.3389/fonc.2022.1067312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/05/2022] [Indexed: 01/05/2023] Open
Abstract
Introduction Effective strategies are required to ensure optimal management of the crucial closure step in endoscopic pituitary surgery. Many surgical techniques have been reported but no significant consensus has been defined. Methods Between January 2006 and March 2022, 3015 adult patients with pituitary adenomas were operated on by a single expert neurosurgical team, using a mononostril endoscopic endonasal approach. Based of preoperative risk factors of and operative findings, a detailed closure strategy was used. Body mass index >40, sellar floor lysis, number of surgeries>2, large skull base destruction, prior radiotherapy were considered as preoperative risk factors for closure failure. All patients treated with an expanded endonasal approach were excluded. Results Patients were mostly women (F/M ratio: 1.4) with a median age of 50 (range: 18 -89). Intraoperative CSF leak requiring specific surgical management was observed in 319/3015 (10.6%) of patients. If intraoperative leak occurred, patients with predictive risk factors were managed using a Foley balloon catheter in case of sellar floor lysis or BMI>40 and a multilayer repair strategy with a vascularized nasoseptal flap in other cases. Postoperative CSF leak occurred in 29/3015 (1%) of patients, while meningitis occurred in 24/3015 (0.8%) of patients. In patients with intraoperative leak, closure management failed in 11/319 (3.4%) of cases. Conclusion Based on our significant 16-year experience, our surgical management is reliable and easy to follow. With a planned and stepwise strategy, the closure step can be optimized and tailored to each patient with a very low failure rate.
Collapse
Affiliation(s)
- Bertrand Baussart
- Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France,Université Paris Cité, Institut Cochin, CNRS, INSERM, Paris, France,*Correspondence: Bertrand Baussart, ;
| | - Alice Venier
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Anne Jouinot
- Université Paris Cité, Institut Cochin, CNRS, INSERM, Paris, France
| | - Gilles Reuter
- Department of Neurosurgery, Centre Hospitalier Universitaire (CHU) de Liège, Bat B35, Domaine Universitaire du Sart-Tilman, Liège, Belgium
| | - Stephan Gaillard
- Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| |
Collapse
|
10
|
Machine learning driven prediction of cerebrospinal fluid rhinorrhoea following endonasal skull base surgery: A multicentre prospective observational study. Front Oncol 2023; 13:1046519. [PMID: 37035179 PMCID: PMC10076706 DOI: 10.3389/fonc.2023.1046519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/27/2023] [Indexed: 04/11/2023] Open
Abstract
Background Cerebrospinal fluid rhinorrhoea (CSFR) is a common complication following endonasal skull base surgery, a technique that is fundamental to the treatment of pituitary adenomas and many other skull base tumours. The CRANIAL study explored CSFR incidence and related risk factors, particularly skull base repair techniques, via a multicentre prospective observational study. We sought to use machine learning to leverage this complex multicentre dataset for CSFR prediction and risk factor analysis. Methods A dataset of 865 cases - 725 transsphenoidal approach (TSA) and 140 expanded endonasal approach (EEA) - with cerebrospinal fluid rhinorrhoea as the primary outcome, was used. Relevant variables were extracted from the data, and prediction variables were divided into two categories, preoperative risk factors; and repair techniques, with 6 and 11 variables respectively. Three types of machine learning models were developed in order to predict CSFR: logistic regression (LR); decision tree (DT); and neural network (NN). Models were validated using 5-fold cross-validation, compared via their area under the curve (AUC) evaluation metric, and key prediction variables were identified using their Shapley additive explanations (SHAP) score. Results CSFR rates were 3.9% (28/725) for the transsphenoidal approach and 7.1% (10/140) for the expanded endonasal approach. NNs outperformed LR and DT for CSFR prediction, with a mean AUC of 0.80 (0.70-0.90) for TSA and 0.78 (0.60-0.96) for EEA, when all risk factor and intraoperative repair data were integrated into the model. The presence of intraoperative CSF leak was the most prominent risk factor for CSFR. Elevated BMI and revision surgery were also associated with CSFR for the transsphenoidal approach. CSF diversion and gasket sealing appear to be strong predictors of the absence of CSFR for both approaches. Conclusion Neural networks are effective at predicting CSFR and uncovering key CSFR predictors in patients following endonasal skull base surgery, outperforming traditional statistical methods. These models will be improved further with larger and more granular datasets, improved NN architecture, and external validation. In the future, such predictive models could be used to assist surgical decision-making and support more individualised patient counselling.
Collapse
|
11
|
Shaftel KA, Przybylowski CJ, Little AS. Endoscopic Endonasal Transsphenoidal Approach to Repair Cerebrospinal Fluid Rhinorrhea After an Anterior Clinoidectomy for Aneurysm Clipping: Series of 4 Cases. Oper Neurosurg (Hagerstown) 2023; 24:17-22. [PMID: 36227187 DOI: 10.1227/ons.0000000000000430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 07/16/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Cerebrospinal fluid (CSF) rhinorrhea through a pneumatized optic strut is a known potential complication after an anterior clinoidectomy that is used to microsurgically clip a proximal internal carotid artery aneurysm. The original craniotomy site can be reopened to repair the skull base defect, but this technique has disadvantages. OBJECTIVE To avoid a repeat craniotomy and address the limitations of a transcranial approach, a straightforward alternative was used for skull base repair-the binostril endoscopic endonasal transsphenoidal approach. METHODS This retrospective case series describes the use of endoscopic transsphenoidal repair and outcomes for patients with CSF leaks after anterior clinoidectomy for aneurysm repair between January 1, 2015, and December 31, 2019. RESULTS Four adult patients (3 women and 1 man) with a mean age of 59.5 years were reviewed. Skull base repair occurred on average 24 days (range, 4-75 days) after the index operation. After demucosalization of the parasellar sphenoid sinus, the fistula in the pneumatized optic strut was reconstructed with a free nasal mucosal graft with or without an autologous muscle graft. None of the patients developed a recurrent CSF leak at a mean follow-up of 12.5 months (range, 8-22 months), and none experienced complications. CONCLUSION The endoscopic endonasal transsphenoidal approach was safe and effective for skull base repair in 4 patients with CSF rhinorrhea after an anterior clinoidectomy for aneurysm clipping.
Collapse
Affiliation(s)
- Kelly A Shaftel
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | | | | |
Collapse
|
12
|
Fujino A, Tanaka Y, Abe D, Ariizumi Y, Inaji M, Maehara T. A New Technique for the Endoscopic Reconstruction of Skull Base Defects Using Multiple-balloon Catheters. Neurol Med Chir (Tokyo) 2022; 62:483-487. [PMID: 36070960 DOI: 10.2176/jns-nmc.2022-0146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Cerebrospinal fluid (CSF) leakage is a major complication following endoscopic endonasal skull base surgery. Various skull base reconstruction methods are available, and the use of a vascularized nasoseptal flap (NSF) in skull base reconstruction has greatly contributed to a decrease in the CSF leak rate. A balloon catheter such as a sinus balloon or a Foley catheter is often used to support an NSF; however, in cases wherein nasal and/or paranasal structures supporting the balloon are lacking following the surgery, the NSF is not properly fixed and postoperative CSF leak may occur. Here we introduce a new technique of using multiple-balloon catheters to fix an NSF in such cases and provide the results of our analysis of the new technique's efficacy. Eight patients who underwent endonasal endoscopic surgery for the following cases were included: olfactory neuroblastoma (n = 6), recurrent craniofacial meningioma (n = 1), and recurrent chordoma (n = 1). After tumor resection, multilayered reconstruction with vascularized NSF was performed. Given that the Foley catheter was not stable to fix the flap in each case, we used an additional nasal catheter to support the Foley catheter. No complications such as postoperative CSF leak and necrosis of the vascularized flap were observed. These results suggest that the multiple-balloon catheter technique is a useful method for fixing the NSF to the skull base even when nasal cavity structures are missing due to surgical removal.
Collapse
Affiliation(s)
- Asuka Fujino
- Department of Neurosurgery, Tokyo Medical and Dental University
| | - Yoji Tanaka
- Department of Neurosurgery, Tokyo Medical and Dental University
| | - Daisu Abe
- Department of Neurosurgery, Tokyo Medical and Dental University
| | - Yosuke Ariizumi
- Department of Head and Neck Surgery, Tokyo Medical and Dental University
| | - Motoki Inaji
- Department of Neurosurgery, Tokyo Medical and Dental University
| | | |
Collapse
|
13
|
Qadeer N, Mehrara BJ, Cohen M, Tabar V, Shahzad F. Endoscopic Endonasal Repair of Recurrent Cerebrospinal Fluid Leak With Adipofascial Anterolateral Thigh Free Flap: Case Report and Review of Literature. EPLASTY 2022; 22:e32. [PMID: 36000006 PMCID: PMC9361343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Background. Cerebrospinal fluid leaks are the most common complication of endoscopic endonasal skull base tumor resection. The workhorse nasoseptal flap or other vascularized intranasal flaps may not be a viable option in patients who have previously undergone surgery or local radiation; in these cases, pericranial flaps may also be unavailable. Free flap reconstruction in patients undergoing endoscopic resection is challenging because of limited exposure. The transmaxillary approach has recently been reported for free flap reconstruction of these defects. This report describes a patient with a pituitary tumor who underwent craniotomy and resection of a pituitary mass via an endoscopic endonasal approach. Postoperatively, the patient developed a high flow cerebrospinal fluid leak that did not resolve with lumbar drain and attempts at endoscopic revision of nasoseptal flap. An adipofascial anterolateral thigh free flap was harvested, based on the descending branch of the lateral circumflex femoral vessels. An upper gingivobuccal sulcus incision was used to access the maxilla. Openings were created in the anterior and medial maxillary sinus to create a passage to the sphenoid sinus. The flap was inset into the defect via this transmaxillary channel. The pedicle was tunneled subcutaneously through the cheek to recipient facial vessels. The procedure resulted in complete resolution of cerebrospinal fluid rhinorrhea and pneumocephalus. Imaging at 18 months showed the flap in good position. This report describes the technique in detail along with a review of the current literature.
Collapse
Affiliation(s)
| | - Babak J Mehrara
- Plastic and Reconstructive Surgery Service, Memorial Sloan-Kettering Cancer, New York, NY
| | - Marc Cohen
- Head and Neck Surgery Service, Memorial Sloan-Kettering Cancer, New York, NY
| | - Viviane Tabar
- Department of Neurosurgery, Memorial Sloan-Kettering Cancer, New York, NY
| | - Farooq Shahzad
- Plastic and Reconstructive Surgery Service, Memorial Sloan-Kettering Cancer, New York, NY
| |
Collapse
|
14
|
Complications in Endoscopic Pituitary Surgery. Otolaryngol Clin North Am 2022; 55:431-448. [DOI: 10.1016/j.otc.2021.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
15
|
Hannan CJ, Nolan D, Corr P, Amoo M, Murray D, Looby S, Javadpour M. Sinonasal outcomes associated with the use of BioGlue® in endoscopic transsphenoidal pituitary surgery. Neurosurg Rev 2022; 45:2249-2256. [PMID: 35083593 DOI: 10.1007/s10143-021-01723-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 12/03/2021] [Accepted: 12/19/2021] [Indexed: 11/30/2022]
Abstract
Concerns have been raised in the neurosurgical literature regarding the use of BioGlue®, a tissue sealant initially developed for cardiothoracic surgery, due to reports of an increased incidence of infection, wound breakdown, and CSF fistulae. The aim of this study was to determine if the use of BioGlue® in skull base repair impacts on the sinonasal outcomes and the incidence of post-operative infection following endoscopic pituitary surgery. SNOT-22 questionnaires were completed pre-operatively, and at 6, 12, and 24 weeks post-operatively by 50 patients. Pre- and post-operative MRI scans were reviewed and assessed for evidence of post-operative sinusitis. Patient records were consulted to ascertain the incidence of post-operative infection. Repeated measures ANOVA and Wilcoxon signed rank test were used for data analysis. Statistical analysis revealed a significant difference in the mean SNOT-22 scores across the four time intervals (F(1.605, 78.642) = 9.180, p = 0.001). This difference was powered by a deterioration at 6 weeks that recovered completely by 12 weeks. The mean SNOT-22 score in the study cohort at 24 weeks was 16.84/110 (range 0-57, ± 2.04) which was lower than the mean pre-operative score and is consistent with mild rhinosinusitis. There were no cases of post-operative meningitis and 1/50 (2%) case of post-operative sinusitis in this cohort. The use of BioGlue® in endoscopic endonasal pituitary surgery does not appear to lead to significant sinonasal morbidity. Previous concerns about the use of BioGlue® in transcranial procedures may not apply to extradural application of this tissue sealant in endoscopic transnasal surgery.
Collapse
Affiliation(s)
- Cathal John Hannan
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester, England
| | - Deirdre Nolan
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Paula Corr
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Michael Amoo
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Daniel Murray
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Seamus Looby
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland. .,Royal College of Surgeons in Ireland, Dublin, Ireland. .,Department of Academic Neurology, Trinity College Dublin, Dublin, Ireland.
| |
Collapse
|
16
|
Lubomirsky B, Jenner ZB, Jude MB, Shahlaie K, Assadsangabi R, Ivanovic V. Sellar, suprasellar, and parasellar masses: Imaging features and neurosurgical approaches. Neuroradiol J 2021; 35:269-283. [PMID: 34856828 DOI: 10.1177/19714009211055195] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The sellar, suprasellar, and parasellar space contain a vast array of pathologies, including neoplastic, congenital, vascular, inflammatory, and infectious etiologies. Symptoms, if present, include a combination of headache, eye pain, ophthalmoplegia, visual field deficits, cranial neuropathy, and endocrine manifestations. A special focus is paid to key features on CT and MRI that can help in differentiating different pathologies. While most lesions ultimately require histopathologic evaluation, expert knowledge of skull base anatomy in combination with awareness of key imaging features can be useful in limiting the differential diagnosis and guiding management. Surgical techniques, including endoscopic endonasal and transcranial neurosurgical approaches are described in detail.
Collapse
Affiliation(s)
- Bryan Lubomirsky
- Department of Radiology, Section of Neuroradiology, 21772University of California Davis Medical Center, Sacramento, CA, USA
| | - Zachary B Jenner
- Department of Radiology, Diagnostic and Interventional Radiology Residency, 21772University of California Davis Medical Center, Sacramento, CA, USA
| | - Morgan B Jude
- School of Medicine, 21772University of California Davis Medical Center, Sacramento, CA, USA
| | - Kiarash Shahlaie
- Department of Neurological Surgery, 21772University of California Davis Medical Center, Sacramento, CA, USA
| | - Reza Assadsangabi
- Department of Radiology, Section of Neuroradiology, 21772University of California Davis Medical Center, Sacramento, CA, USA
| | - Vladimir Ivanovic
- Department of Radiology, Section of Neuroradiology, 21772University of California Davis Medical Center, Sacramento, CA, USA
| |
Collapse
|
17
|
Khan DZ, Ali AMS, Koh CH, Dorward NL, Grieve J, Layard Horsfall H, Muirhead W, Santarius T, Van Furth WR, Zamanipoor Najafabadi AH, Marcus HJ. Skull base repair following endonasal pituitary and skull base tumour resection: a systematic review. Pituitary 2021; 24:698-713. [PMID: 33973152 PMCID: PMC8416859 DOI: 10.1007/s11102-021-01145-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE Postoperative cerebrospinal fluid rhinorrhoea (CSFR) remains a frequent complication of endonasal approaches to pituitary and skull base tumours. Watertight skull base reconstruction is important in preventing CSFR. We sought to systematically review the current literature of available skull base repair techniques. METHODS Pubmed and Embase databases were searched for studies (2000-2020) that (a) reported on the endonasal resection of pituitary and skull base tumours, (b) focussed on skull base repair techniques and/or postoperative CSFR risk factors, and (c) included CSFR data. Roles, advantages and disadvantages of each repair method were detailed. Random-effects meta-analyses were performed where possible. RESULTS 193 studies were included. Repair methods were categorised based on function and anatomical level. There was absolute heterogeneity in repair methods used, with no independent studies sharing the same repair protocol. Techniques most commonly used for low CSFR risk cases were fat grafts, fascia lata grafts and synthetic grafts. For cases with higher CSFR risk, multilayer regimes were utilized with vascularized flaps, gasket sealing and lumbar drains. Lumbar drain use for high CSFR risk cases was supported by a randomised study (Oxford CEBM: Grade B recommendation), but otherwise there was limited high-level evidence. Pooled CSFR incidence by approach was 3.7% (CI 3-4.5%) for transsphenoidal, 9% (CI 7.2-11.3%) for expanded endonasal, and 5.3% (CI 3.4-7%) for studies describing both. Further meaningful meta-analyses of repair methods were not performed due to significant repair protocol heterogeneity. CONCLUSIONS Modern reconstructive protocols are heterogeneous and there is limited evidence to suggest the optimal repair technique after pituitary and skull base tumour resection. Further studies are needed to guide practice.
Collapse
Affiliation(s)
- Danyal Z Khan
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Ahmad M S Ali
- Department of Neurosurgery, The Walton Centre, Liverpool, UK
| | - Chan Hee Koh
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Neil L Dorward
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Joan Grieve
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Hugo Layard Horsfall
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - William Muirhead
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Thomas Santarius
- Division of Neurosurgery, University of Cambridge and Cambridge University Hospitals, Cambridge, UK
| | - Wouter R Van Furth
- Department of Neurosurgery, University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Amir H Zamanipoor Najafabadi
- Department of Neurosurgery, University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Hani J Marcus
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK.
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK.
| |
Collapse
|
18
|
Surgical Management of Sinonasal Cancers: A Comprehensive Review. Cancers (Basel) 2021; 13:cancers13163995. [PMID: 34439150 PMCID: PMC8393312 DOI: 10.3390/cancers13163995] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/03/2021] [Accepted: 08/05/2021] [Indexed: 12/21/2022] Open
Abstract
Surgery plays an important role in the treatment of sinonasal cancer. Many surgical approaches have been described, including open, endoscopic, or combined approaches. The choice is based on several criteria: general criteria related to the oncological results and morbidity of each technique, specific criteria related to the tumor (tumor extensions, tumor pathology), the patient, or the surgeon himself. The aims of this review are (i) to provide a complete overview of the surgical techniques available for the management of sinonasal malignant tumors, with a special focus on recent developments in the field of transnasal endoscopic surgery; (ii) to summarize the criteria that lead to the choice of one technique over another. In particular, the oncological outcomes, the morbidity of the different techniques, and the specificities of each histologic subtype will be discussed based on a comprehensive literature review.
Collapse
|
19
|
Javadpour M, Amoo M, Crimmins D, Caird J, Daly P, Pears J, Owens C, Capra M, Cody D. Endoscopic extended transsphenoidal surgery for newly diagnosed paediatric craniopharyngiomas. Childs Nerv Syst 2021; 37:1547-1561. [PMID: 33665678 DOI: 10.1007/s00381-021-05108-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 03/01/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE Endoscopic extended transsphenoidal surgery (EETSS) has gained popularity for treatment of craniopharyngiomas. The aim of this study is to assess the outcome of endoscopic extended transsphenoidal surgery (EETSS) for newly diagnosed paediatric craniopharyngiomas. METHODS Patient details were obtained from a prospective database of all endoscopic transnasal operations performed by a single surgeon. Outcomes including visual function, pituitary function, body mass index (BMI), postoperative neurological deficit, extent of resection and recurrence on follow-up were obtained. Obesity was defined as BMI percentile of equal to or greater than 95%. RESULTS Between January 2011 and January 2020, 15 of 16 children (5-18 years old) with newly diagnosed craniopharyngiomas underwent EETSS. Four patients had a conchal-type sphenoid sinus. Gross total resection (GTR) was achieved in 4 patients and near total resection (NTR) in 5 patients. The remaining 6 had subtotal resection (STR). Postoperative radiotherapy was used in 6 patients (4 with STR, 2 with NTR). There were no postoperative deaths, strokes or CSF leaks. Normalisation of visual fields (VF) occurred in 9/13 patients with preoperative VF defects. One patient developed a new visual field defect. During a median follow-up period of 74 (8-104) months, 2 patients have required further surgery for tumour progression following initial STR, where a tumour remnant was left in situ to preserve the pituitary stalk. 6/11 patients developed new anterior pituitary dysfunction as a result of surgery and 9/12 developed new diabetes insipidus (DI). At the time of last follow-up, 14/15 children had anterior panhypopituitarism, 13/15 had DI and 1 patient developed new onset obesity. Two patients, who were obese preoperatively, were no longer obese at last follow-up. CONCLUSIONS EETSS can be performed as the first option in the majority of children with newly diagnosed craniopharyngioma, despite factors such as small nose, non-pneumatised sphenoid sinus, small sella or purely suprasellar tumour location. Preservation of the pituitary stalk at the expense of leaving residual tumour may not be in the best interests of the patient.
Collapse
Affiliation(s)
- Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.
- Trinity College Dublin, Dublin, Ireland.
- Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Michael Amoo
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Darach Crimmins
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - John Caird
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Patricia Daly
- Trinity College Dublin, Dublin, Ireland
- St Luke's Radiation Oncology Network, Dublin, Ireland
| | - Jane Pears
- Departments of Paediatric Oncology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Cormac Owens
- Departments of Paediatric Oncology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Michael Capra
- Departments of Paediatric Oncology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Declan Cody
- Departments of Paediatric Endocrinology, Children's Health Ireland at Crumlin, Dublin, Ireland
| |
Collapse
|
20
|
CSF Rhinorrhoea After Endonasal Intervention to the Skull Base (CRANIAL) - Part 1: Multicenter Pilot Study. World Neurosurg 2021; 149:e1077-e1089. [PMID: 33444844 PMCID: PMC8105646 DOI: 10.1016/j.wneu.2020.12.171] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 01/29/2023]
Abstract
Background CRANIAL (CSF Rhinorrhoea After Endonasal Intervention to the Skull Base) is a prospective multicenter observational study seeking to determine 1) the scope of skull base repair methods used and 2) corresponding rates of postoperative cerebrospinal fluid (CSF) rhinorrhea in the endonasal transsphenoidal approach (TSA) and the expanded endonasal approach (EEA) for skull base tumors. We sought to pilot the project, assessing the feasibility and acceptability by gathering preliminary data. Methods A prospective observational cohort study was piloted at 12 tertiary neurosurgical units in the United Kingdom. Feedback regarding project positives and challenges were qualitatively analyzed. Results A total of 187 cases were included: 159 TSA (85%) and 28 EEA (15%). The most common diseases included pituitary adenomas (n = 142/187), craniopharyngiomas (n = 13/187). and skull base meningiomas (n = 4/187). The most common skull base repair techniques used were tissue glues (n = 132/187, most commonly Tisseel), grafts (n = 94/187, most commonly fat autograft or Spongostan) and vascularized flaps (n = 51/187, most commonly nasoseptal). These repairs were most frequently supported by nasal packs (n = 125/187) and lumbar drains (n = 20/187). Biochemically confirmed CSF rhinorrhea occurred in 6/159 patients undergoing TSA (3.8%) and 2/28 patients undergoing EEA (7.1%). Four patients undergoing TSA (2.5%) and 2 patients undergoing EEA (7.1%) required operative management for CSF rhinorrhea (CSF diversion or direct repair). Qualitative feedback was largely positive (themes included user-friendly and efficient data collection and strong support from senior team members), demonstrating acceptability. Conclusions Our pilot experience highlights the acceptability and feasibility of CRANIAL. There is a precedent for multicenter dissemination of this project, to establish a benchmark of contemporary practice in skull base neurosurgery, particularly with respect to patients undergoing EEA.
Collapse
|