| IntroductionMicrosurgical transcranial approach for resection of the tumor was thought as a golden standard of treating craniopharyngioma until the advent of endoscopy. Endoscopic technique offers a new option for resection of craniopharyngioma, compared with traditional macroscopic surgery, endoscopic approach has many advantages such as panoramic visualization, more close surgical target, minimal invasion, however, this approach was rare reported in China. In this study, we reported our experience of managing craniopharyngioma via endoscopic approach, and evaluated safety and efficiency of endoscopic endonasal transsphenoidal approach for resection of craniopharyngioma.Materials and MethodsWe performed a retrospective review of operative cases over a 5-year period (from July 2009 to June 2014), in which 98 patients with craniopharyngioma underwent a EETA to remove a craniopharyngioma were identified and compared with a series of 95 patients who underwent macroscopic procedure during the same period. Medical charts of the patients were reviewed to collected demographic information, such as age, sex, clinical symptoms, tumor size, the extent of tumor resection, hospitalization, clinical outcome and complications. All patients have been evaluated preoperatively such as imaging features of the tumor, adjusting serum electrolytes level, and hormone replacement.Endoscopic groupAll patients underwent pure EETA for resection of the tumor (standard or extended approach).Under general anesthesia with orotracheal intubation, the patient was placed in the supine position with slight rotation of the head toward the right shoulder to allow for easy surgical access. We routinely performed by four-hands-and-two-surgeons. Typically, the right lateral thigh was prepared for harvest of the fascia lata, fat or muscle to repair the skull base as needed. The nasal mucous membranes were decongested with injection of 1% lidocaine with epinephrine (1:100,000 dilution). For large tumor, we usually harvested vascularized pedicled nasoseptal flap (PNSF) by Hadad’s method. If expected flap was large, the first incision was taken more laterally along the floor of the nose to increase the width of the flap. The second incision is made from inferior aspect of the sphenoid opening and advanced superiorly. The third incision was made between the previous 2 incisions.The procedure was performed with a 0 degree endoscope,4 mm in diameter and 18 cm in length. The endoscope was routinely inserted into the right nostril. The middle turbinates were lateralized to increase the surgical corridor, and the endoscope was then directed upwards approximately 1.5 cm above the posterior nasal apertures to access the sphenoid ostium, a key anatomical landmark. A wide sphenoidotomy, and posterior septectomy were performed to expose the sellar turcica, carotid protuberances, bilateral optic canals, tuberculum sellae, and planum sphenoidale. In which, opticocarotid recesses (OCRs) are key landmarks in endoscopic skull base surgery. Dura of sellar floor usually with high tension when sellar floor was opened via high-speed microdrill. During the extended approach, ethmoidectomy is necessary, it is important to recognize an Onodi cell, which is a posterior ethmoid cell that is postioned superolateral to the sphenoid sinus.We routinely cut dura of the floor by means of method introduce by Weiss et al. A cruciate incision over the sellar dura was made by a size 15 blade, and a second horizontal incision is made in the dura of the planum sphenoidale. The intercavernous sinus is coagulated with bipolar device. Then cut the dura between the previous 2 incisions by microsissors, and the dura was opened. Upon opening the dura, preinfundibular tumors are immediately visible, it is important to try to identify the stalk and the superior hypophyseal arteries, care should be taken to preserve the previous structures during the resection of the tumor. The capsule is then incised, allowing drainage of cystic tumors or internal debulking of solid tumors using a ring curette. Once the tumor has been debulked, the surgeon may sharply dissect its capsule while meticulously preserving the perforators supplying the chiasm.The surgical cavity was filled with Gelfoam(?). If an intraoperative CSF leak was suspected or confirmed, a reconstruction of the skull base was implied using the following technique:an autologous fat or fascia lata graft was placed within the dural defect as an inlay graft, a synthetic dural graft was used as an overlay graft, and a small amount of muscle pulp was placed in between the inlayer and overlayer to enhance graft adherence. Fibrin glue was applied over the synthetic dura, the sphenoid sinus was filled with Gelfoam(?), and the nasal cavity was packed with pledgets. A vascularized pedicled nasoseptal flap (PNSF) was used as previously described if CSF was confirmed during the surgery. All of the patients received intraoperative prophylaxis of a third-generation cephalosporin.Postoperatively, a third-generation cephalosporin was continued for approximately 7 days. Urine volume as well as fluid intake and output were routinely monitored. All of the functioning adenoma patients were endocrinologically evaluated to observe hormone function after surgery. Hormone replacement therapy was applied in cases with insufficient postoperative hormones levels. MRI imaging was routinely performed 1-3 days postoperatively and at 3 months to evaluate the extent of tumor resection (total resection, no evidence of residual tumor; subtotal resection, residual tumor<20%; partial resection, residual tumor<50%; and insufficient resection, residual tumor>50%). Nasal packing was generally removed endoscopically 1-3 days after surgery. Patients were instructed to rest with their head elevated approximately 15°and to avoid any activity that might raise their intracranial pressure such as straining or nose blowing. Patients who had evidence of postoperative CSF leakage were managed with lumbar drainage and bedrest for 1 week. Especially for the elderly patients, either active or passive movements of the lower limbs were performed to prevent venous thromboembolism, and chest physiotherapy and pulmonary hygiene were performed to avoid pulmonary complications. In cases with postoperative DI, hypophysin was injected subcutaneously to control symptoms for the first 3 days. If that treatment was insufficient, Minirin was administrated daily, as we do not typically use controlled-release vasopressin tannate because of the inconvenience to be used by the patient, and difficulty with controlling effect. During the follow-up period, a routine MR scan was used as a primary method of monitoring. Based on the imaging, discovering the regrowth of residual tumor more than 20% in volume was defined as a recurrence of the tumor.Microscopic groupVarious transcranial surgical approaches were applied such as transbasal subfrontal, frontalbasal interhemispheric, pterional, petrosal and so on, we omitted the detailed procedures due to limited length of the article. The postoperative management and follow-up are same to those of endoscopic group.ResultsEndoscopic group:55 (56.1%) of the cases were males and 43 were females. The patients’ages in the endoscopic group ranged from 14 to 81 years (mean 47.5 years). Mean follow-up is 38 months (from 7 month to 60 months).Most frequent complaint is vision loss (55,56.1%), followed by headache (52,53.1%), then diabetes insipidus (16,16.3%), there were 7 (7.1%) cases of irregular menstruation and dullness respectively,5.1%of the cases presented with short stature, dysplasia and fatigue, other symptoms such as alerted mental status, decreased libido and epilepsy varied from 1 to 3 (1.0%-3.1%). For preoperative evaluation,30 patients presented hypopituitarism, including hypocotisolism(19,19.4%), hypothyroidism (66.1%), and both (55.1%).There were 7 (7.1%) patients presenting higher prolactin level. About type of the tumor,5 (5.1%) of the patients were defined as type I (prefundibular),65 (66.3%) of the patients were identified as type II (transfundibular), and 28 (28.6%) case were type III (interventricular).Total resection was achieved in 35 (35.7%) patients, subtotal resection in 31 (31.6%) patients, and partial resection in 23 (23.5%) patients, with 9 (9.2%) of the patients experiencing an insufficient resection or biopsy. For 55 patients who presented preoperative vision loss,9 (9.2%) obtained recovery of vision,43 (78.2%) cases got improved vision,3 (5.5%) cases have no change of vision, there was no case developed decreased vision.3 (8.1%) of 37 patients who presented hypopituitarism preoperatively obtained a normal hormone level after surgery,10 (27.0%) cases improved hormone level,24 (64.9%) cases have no change of hormone symptom. There were 19 (19.4%) cases occurred post-surgical transient DI, in which,9 (9.2%) cases developed permonent DI. All of 16 cases who presented DI have no change after surgery. There were 5 patients occurred post-surgical CSF leakage. New hypopituiarism occurred in 15 (15.3%) patients, intercranial infection were 2 (2.0%), there was 1 case developed intercranial hemorrhage, re-operation was needed. There is no case of death, brain edema and artery injury. During the following-up of mean 38 months,25 (25.5%) cases occurred recurrence. For QOL evaluation,11 (54.1%) patients obtained Excellent and Good,26 (26.5%) patients leaded a life without extra care,3 (3.1%) patients died.Transcranial group:There were 95 patients entered into this group, including 56 (58.9%) males and 39 (41.1%) females. The patients’ages ranged from 3 to 75 years (mean 44.5 years). Mean follow-up is 41 months (from 6 month to 62 months). Most common symptom is vision loss (53,55.8%), the second frequent presentation is headache (49,51.6%), followed by polydipsia and polyuria (17,17.9%), then irregular menstruation 11 (11.6%), there were 8 (8.4%) and 7 (7.4%) of the cases presented with short stature, dysplasia and fatigue respectively, other symptoms such as alerted mental status, decreased libido and epilepsy varied from 1 to 3 cases. For preoperative evaluation, there were 20 (21.1%) patients presented hypocotisolism, (7,7.4%) occurred hypothyroidism and both of presentations were 3 (3.2%). There were 11 (11.6%) patients presenting higher prolactin level. About type of the tumor,4 (4.2%) of the patients were defined as type I (prefundibular),58 (61.1%) of the patients were identified as type II (transfundibular), and 33 (34.7%) case were type III (interventricular).Total resection was achieved in 39 (41.1%) patients, subtotal resection in 29 (30.5%) patients, and partial resection in 20 (21.1%) patients, with 7 (7.3%) of the patients experiencing an insufficient resection or biopsy. There were 53 patients presented preoperative vision loss, in which,7 (13.2%) obtained normal vision after surgery, 36 (67.9%) cases got improved vision,8 (15.1%) cases have no change of vision, there was 2 (3.8%) case developed decreased vision, both presented single eye blind. Additional 7 (7.3%) patients presented normal vision preoperatively developed decreased visual acuity or field. All of 41 patients who presented hypopituitarism preoperatively,4 (9.8%) obtained a normal hormone level after surgery,9 (22.0%) cases improved hormone level,28 (68.2%) cases have no change of hormone symptom. There were 31 (32.6%) cases occurred post-surgical transient DI, in which, 23 (24.2%) cases developed permonent DI. All patients who presented DI have no change after surgery. There were no patient occurred post-surgical CSF leakage. New hypopituiarism occurred in 34 (35.8%) patients, intercranial hematoma were 8 (8.4%), brain edema were 3 (3.2%), there was 6 (6.3%) patients experienced re-exploration for removal of the intercranial hematoma. There were 9 (9.5%) patients occurred intercranial infection,7 (7.4%) patients incurred wound problems, and also 7 (7.4%) patients incurred hypothalamus injury. There is 2 (2.1%) case of death after surgery due to severe complications. During the following-up of mean 38 months,23 (24.7%) of 93 followed-up patients occurred recurrence,88 (94.6%) patients were live in 5 years after surgery. For QOL evaluation,46 (49.5%) patients obtained Excellent and Good,25 (26.9%) patients leaded a life without extra care,5 (5.4%) patients died during the period of following-up.ConclusionsNeuroendoscopy is navel neurosurgical technique with many advantages, such as panoramic visualization and excellent lighting, more close surgical target, minimal invasion without retraction of the brain, minimally injury of neurovasscular structures on skull base, no scar of head and face. Endoscopic endonasal transsphenoidal approach for resection of craniopharyngioma has specific advantages as follows,1. EETA for resection of craniopharyngioma is a minimally invasive, safe and effective technique;2. EETA for resection of craniopharyngioma can get the same or better rate of resection with more minimally invasion;3. EETA for resection of craniopharyngioma has lower rates of surgical complications and mortality related the approach;4. EETA for resection of craniopharyngioma has no scar left on the head and no cosmetological problems;5. EETA for resection of craniopharyngioma can be used in elderly patients with serious basic diseases.We believe that neuroendoscopy will be applied in wider fields of neurosurgery with development of endoscopic techniques and instruments. |
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