Search

Introduction  The endoscopic endonasal route has demonstrated to be the approach of choice for a large majority of clival chordomas (CCs). However, its results in elderly patients are under-evaluated in the literature. The aim of this study is to assess the surgical outcome for these patients, determining the factors associated with a larger tumor resection in this population. Materials and Methods  Our institutional database of CC has been retrospectively reviewed, to identify all cases over 65 years old, operated through an endoscopic endonasal approach (EEA). Preoperative clinical and radiological features were considered, as well as surgical results, morbidity, and patients' outcome at follow-up. Results  Out of our series of 143 endoscopic surgical procedures for CC, 34 (23.8%) were in patients older than 65 and 10 in older than 75 (7.0%). Gross tumor removal was achieved in 22 cases (64.7%). Complications consisted of 2 (5.9%) postoperative cerebrospinal leaks, 1 (2.9%) meningitis, 1 (2.9%) permanent cranial nerve VI palsy, 1 (2.9%) pneumonia, and 2 (5.9%) urinary infections. In 39.1% of cases, the preoperative ophthalmoplegia improved or resolved. Twenty-seven patients (79.4%) underwent radiation therapy. At follow-up (37.7 ± 44.9 months), 13 patients (38.2%) showed a recurrence/progression and 13 (38.3%) deceased. Conclusion  EEA can be a useful approach in elderlies, balancing the large tumor removal with an acceptable morbidity rate, even if higher than that for general CC population. However, patient selection remains crucial. A multidisciplinary evaluation is important to assess not only their medical conditions, but also their social and familiar conditions., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Introduction  The endoscopic endonasal approach (EEA) might seem an "unnatural" route for intradural lesions such as meningiomas. The aim of this study is to critically revise our management of anterior skull base meningiomas to consider, in what cases it may be advantageous. Material and Methods  Each consecutive case of anterior skull base meningioma operated on through an EEA or combined endoscopic-transcranial approach at our institution, between 2003 and 2017, have been included. Tumors were classified on the basis of their location and intra or extracranial extension. Follow-up consisted of an MRI (magnetic resonance imaging) and a clinical examination 3 months after the surgery and then repeated annually. Results  Fifty-seven patients were included. The most common location was the tuberculum sellae (62%), followed by olfactory groove (14%), planum sphenoidale (12%), and frontal sinus (12%). Among these, 65% were intracranial, 7% were extracranial, and 28% both intra and extracranial. Radical removal was achieved in 44 cases (77%). Complications consisted in 10 CSF (cerebrospinal fluid) leaks (17.6%), 1 overpacking (1.7%), and 1 asymptomatic brain ischemia (1.7%). Visual acuity and campimetric deficits improved respectively in 67 and 76% of patients. Recurrence rate was of 14%. Conclusions  EEA presents many advantages in selected cases of anterior skull base meningioma. However, it is hampered by the relevant risk of CSF leak. We consider that it could be advantageous for planum/tuberculum sellae tumors. Conversely, for olfactory groove or frontal sinus meningiomas, it can be indicated for tumors with extracranial extension, while its role is still debatable for purely intracranial forms as considering our surgical results, it could be advantageous for midline planum/tuberculum sellae tumors. Conversely, it can be of first choice for olfactory groove or frontal sinus meningiomas with extracranial extension, while its role for purely intracranial forms is still debatable.

Objective:  Few studies have compared transsphenoidal endoscopic (TE) and transsphenoidal microscopic (TM) techniques for the treatment of craniopharyngiomas., Design:  We performed a systematic review of published series. The results were stratified in two time periods from 1995 to 2016., Results:  A total of 48 articles and 1,186 patients met the inclusion criteria. Overall, 60% of endoscopic cases were supradiaphragmatic, and 76% of microsurgical cases were infradiaphragmatic. Mean tumor size was 3 cm and 2.4 cm in the TE and TM series, respectively ( p  = 0.008). Total resection rate was similar (66%) between TE and TM. Considering the surgical outcome for different tumor locations, total resection rate was slightly higher in the TE for supradiaphragmatic lesions (59% versus 42.5%; p  = 0.26). Recurrence rate was higher in the endoscopic series (21.7% versus 12%). Mortality and the overall complication rates were similar ( p  = 0.84). However, hydrocephalus (7.6%) and cognitive dysfunction (15.8%) were more common in TE, and meningitis (6%) and endocrinologic complications were more common in the TM series. In the past 6 years, the rate of cerebrospinal fluid leak in TE was significantly lower (13%) and was comparable between TE and TM., Conclusion:  Both techniques appear comparable for infradiaphragmatic lesions; however, TE seems to yield better results for supradiaphragmatic tumors. In conclusion, more complex lesions with difficult locations can be effectively treated with endoscopic surgery., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: In this article, the aim of the authors is to discuss their experience with skull base reconstruction in endoscopic transsphenoidal and extended transsphenoidal surgery for pituitary tumor resection., Methods: Between January 1997 and January 2008, 665 patients underwent either transnasal transsphenoidal endoscopic or extended transsphenoidal surgery for pituitary tumors. In patients without intraoperative CSF leak, we prefer to pack the surgical cavity with absorbable material, such as collagen sponge (Gelfoam), or, in the case of thin diaphragma sellae and postoperative risk of rupture with abdominal fat. In patients with minimal CSF oozing, but without any visible diaphragma sellae defect or only a small dural defect with leak, we pack the surgical cavity with abdominal fat. In case of a leak from an anterior face of the diaphragma sellae defect we prefer to reconstruct the defect by means of mucoperiosteum taken from the resected middle turbinate. Patients with larger sellar or supradiaphragmatic defects were treated with a multilayer reconstruction., Results: 529 patients (79.5%) did not require any repair besides a packing of the surgical cavity with absorbable material such as collagen sponge, while 128 patients (19.2%) required an endoscopic skull base repair at the end of the procedure for an overt CSF leak. 8 patients (1.2%) required repair because of overt thin diaphragma sellae without a visible CSF leak but with a postoperative risk of rupture. Out of the latter two groups (n = 136) only 11 patients (8 %) developed persistent postoperative CSF leaks requiring revision multilayer reconstruction., Conclusions: More complex defects after pituitary surgery should be repaired with a multilayer technique, using autologous materials such as fat, fascia lata, bone and mucoperiosteum taken from the middle turbinate. This type of autologous material is generally reliable in more complex defects, and it appears to be easy to harvest and handle for repair.

Objective: The suitability of the endoscopic approach for the treatment of an encephalocele of the lateral wall of the sphenoid is discussed. This is a retrospective review of 4 cases diagnosed with temporosphenoidal encephalocele and having a history of CSF leak who were surgically treated using an endoscopic endonasal approach between January 2001 and June 2002 at the Department of Otolaryngology of Sant'Orsola-Malpighi University Hospital and the Department of Neurosurgery at Bellaria Hospital in Bologna., Methods: Three patients were female between 48 and 73 years of age (mean: 61 years). All patients had suffered from a CSF leak for 5 months to 18 years. None of the patients had a past medical history of head trauma. A fourth patient had undergone a previous microscopic approach for a previously misdiagnosed CSF leak wrongly ascribed to an empty sella. Three patients underwent an ethmoid-pterygo-sphenoidal endoscopic approach (EPSEA), while the patient who had undergone previous microscopic surgery, was treated using a transnasal transsphenoidal endoscopic approach., Results: The follow-up of the patients ranged from 10 to 26 months (mean: 18 months) and no case of a recurrent CSF leak was observed postoperatively., Conclusions: In our report, the endoscopic approach was a useful tool for the treatment of encephaloceles of the lateral wall of the sphenoid sinus. In skilled hands, this technique permits both the resection of the encephalocele and the subsequent reconstruction of the defect also with a low rate of morbidity.