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Purpose: The petroclival region represents the "Achille's heel" for the neurosurgeons. Many ventral endoscopic routes to this region, mainly performed as isolated, have been described. The aim of the present study is to verify the feasibility of a modular, combined, multiportal approach to the petroclival region to overcome the limits of a single approach, in terms of exposure and working areas, brain retraction and manipulation of neurovascular structures., Methods: Four cadaver heads (8 sides) underwent endoscopic endonasal transclival, transorbital superior eyelid and contralateral sublabial transmaxillary-Caldwell-Luc approaches, to the petroclival region. CT scans were obtained before and after each approach to rigorously separate the contribution of each osteotomy and subsequentially to build a comprehensive 3D model of the progressively enlarged working area after each step., Results: The addition of the contralateral transmaxillary and transorbital corridors to the extended endoscopic endonasal transclival in a combined multiportal approach provides complementary paramedian trajectories to overcome the natural barrier represented by the parasellar and paraclival segments of the internal carotid artery, resulting in significantly greater area of exposure than a pure endonasal midline route (8,77 cm 2 and 11,14 cm 2 vs 4,68 cm 2 and 5,83cm 2 , extradural and intradural, respectively)., Conclusion: The use of different endoscopic "head-on" trajectories can be combined in a wider multiportal extended approach to improve the ventral route to the most inaccessible petroclival regions. Finally, by combining these approaches and reiterating the importance of multiportal strategy, we quantitatively demonstrate the possibility to reach "far away" paramedian petroclival targets while preserving the neurovascular structures., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Background: Combined endonasal and transorbital multiportal surgery has been recently described for selected skull base pathologies. Nevertheless, a detailed anatomic description and a quantitative comprehensive anatomic study of the skull base areas where these 2 endoscopic routes converge, a so-called connection areas, are missing in the scientific literature., Objective: To identify all the skull base areas and anatomic structures where endonasal and transorbital endoscopic avenues could be connected and combined., Methods: Five cadaveric specimens (10 sides) were used for dissection. Qualitative description and quantitative analysis of each connection areas were performed., Results: At the anterior cranial fossa, the connection area was found at the level of the sphenoid planum; in the middle cranial fossa, it was at the Mullan triangle; finally, in the posterior cranial fossa, the connection area was just behind the medial portion of the petrous apex. The average extradural working areas through the transorbital approach were 4.93, 12.93, and 1.93 cm 2 and from the endonasal corridor were 7.75, 10.45, and 7.48 cm 2 at the level of anterior, middle, and posterior cranial fossae, respectively., Conclusion: The combined endonasal and transorbital endoscopic approach is an innovative entity of skull base neurosurgery. From the anatomic point of view, our study demonstrated the feasibility of this combined approach to access the entire skull base, by both corridors, identifying a working connection area in each cranial fossa. These data could be extremely useful during the surgical planning to predict which portion of a lesion could be removed through each route and to optimize patients' care., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

Endoscopic ultrasonography (EUT) enables not only the visualization of the portal system and of the esophageal varices, as obtained by transabdominal ultrasonography and fiberoptic endoscopy, but also the visualization of intramural and periesophageal collateral veins. Fifteen cirrhotic patients were examined by EUT without complications. When present, esophageal or gastric varices were always detected. In all cases enlarged extrinsic periesophageal veins were visualized, and in 14 of 15 their caliber was correlated with the size of esophageal varices. In three patients examined after sclerotherapy the submucosal veins had disappeared, but extrinsic collateral vessels were patent. EUT will probably become a fundamental technique in the study of portal hypertension and esophageal varices, before and after therapy.