endoscopic

Craniopharyngioma endoscopic endonasal approach

Craniopharyngioma endoscopic endonasal approach

Latest Craniopharyngioma endoscopic endonasal approach PubMed-related Articles

Indications

Craniopharyngioma endoscopic endonasal approach Indications.

Systematic reviews

The endoscopic endonasal approach (EEA) for craniopharyngiomas has proven to be a safe option for extensive tumor resection, with minimal or no manipulation of the optic nerves and excellent visualization of the superior hypophyseal artery branches when compared to the Transcranial Approach (TCA). However, there is an ongoing debate regarding the criteria for selecting different approaches. To explore the current results of EEA and discuss its role in the management of craniopharyngiomas, Figueredo et al. performed MEDLINE, Embase, and LILACS searches from 2012 to 2022. Baseline characteristics, the extent of resection, and clinical outcomes were evaluated. Statistical analysis was performed through an X2 and Fisher exact test, and a comparison between quantitative variables through a Kruskal-Wallis and verified with post hoc Bonferroni. The tumor volume was similar in both groups (EEA 11.92 cm3, -TCA 13.23 cm3). The mean follow-up in months was 39.9 for EEA and 43.94 for TCA, p = 0.76). The EEA group presented a higher visual improvement rate (41.96% vs. 25% for TCA, p < 0.0001, OR 7.7). Permanent DI was less frequent with EEA (29.20% vs. 67.40% for TCA, p < 0.0001, OR 0.2). CSF Leaks occurred more frequently with EEA (9.94% vs. 0.70% for TCA, p < 0.0001, OR 15.8). Recurrence rates were lower in the EEA group (EEA 15.50% vs. for TCA 21.20%, p = 0.04, OR 0.7). The results demonstrate that, in selected cases, EEA for resection of craniopharyngiomas is associated with better results regarding visual preservation and extent of tumor resection. Postoperative cerebrospinal fluid fistula rates associated with EEA have improved compared to the historical series. The decision-making process should consider each person’s characteristics; however, it is noticeable that recent data regarding EEA justify its widespread application as a first-line approach in centers of excellence for skull base surgery 1).

Qiao et al., conducted a systematic review and meta-analysis. They conducted a comprehensive search of PubMed to identify relevant studies. Pituitary, hypothalamus functions and recurrence were used as outcome measures. A total of 39 cohort studies involving 3079 adult patients were included in the comparison. Among these studies, 752 patients across 17 studies underwent endoscopic transsphenoidal resection, and 2327 patients across 23 studies underwent transcranial resection. More patients in the endoscopic group (75.7%) had visual symptoms and endocrine symptoms (60.2%) than did patients in the transcranial group (67.0%, p = 0.038 and 42.0%, p = 0.016). There was no significant difference in hypopituitarism and pan-hypopituitarism after surgery between the two groups: 72.2% and 43.7% of the patients in endoscopic group compared to 80.7% and 48.3% in the transcranial group (p = 0.140 and p = 0.713). We observed same proportions of transient and permanent diabetes insipidus in both groups. Similar recurrence was observed in both groups (p = 0.131). Pooled analysis showed that neither weight gain (p = 0.406) nor memory impairment (p = 0.995) differed between the two groups. Meta-regression analysis revealed that gross total resection contributed to the heterogeneity of recurrence proportion (p < 0.001). They observed similar proportions of endocrine outcomes and recurrence in both endoscopic and transcranial groups. More recurrences were observed in studies with lower proportions of gross total resection 2).

Komotar et al performed a systematic review of the available published reports after endoscope-assisted endonasal approaches and compared their results with transsphenoidal purely microscope-based or transcranial microscope-based techniques.

The endoscopic endonasal approach is a safe and effective alternative for the treatment of certain craniopharyngiomas. Larger lesions with more lateral extension may be more suitable for an open approach, and further follow-up is needed to assess the long-term efficacy of this minimal access approach 3)

Nowadays, an endoscopic endonasal approach (EEA) provides an “easier” way for CPs resection allowing a direct route to the tumor with direct visualization of the surrounding structures, diminishing inadvertent injuries, and providing a better outcome for the patient 4).

Historically, aggressive surgical resection was the treatment goal to minimize the risk of tumor recurrence via open transcranial midline, anterolateral, and lateral approaches, but could lead to clinical sequela of visual, endocrine, and hypothalamic dysfunction. However, recent advances in the endoscopic endonasal approach over the last decade have mostly supplanted transcranial surgery as the optimal surgical approach for these tumors. With viable options for adjuvant radiation therapy, targeted medical treatment, and alternative minimally invasive surgical approaches, the management paradigm for craniopharyngiomas has shifted from aggressive open resection to more minimally invasive but maximally safe resection, emphasizing quality of life issues, particularly in regards to visual, endocrine, and hypothalamic function. 5).

Craniopharyngioma surgery has evolved over the last two decades. Traditional transcranial microsurgical approaches were the only option until the advent of the endoscopic endonasal approach 6).

The endoscopic endonasal approach for craniopharyngiomas is increasingly used as an alternative to microsurgical transsphenoidal or transcranial approaches. It is a step forward in treatment, providing improved resection rates and better visual outcome. Especially in retrochiasmatic tumors, this approach provides better lesion access and reduces the degree of manipulations of the optic apparatus. The panoramic view offered by endoscopy and the use of angulated optics allows the removal of lesions extending far into the third ventricle avoiding microsurgical brain splitting. Intensive training is required to perform this surgery 7).

The highest priority of current surgical craniopharyngioma treatment is to maximize tumor removal without compromising the patients’ long-term functional outcome. Surgical damage to the hypothalamus may be avoided or at least ameliorated with a precise knowledge regarding the type of adherence for each case.

Endoscopic endonasal approach, has been shown to achieve higher rates of hypothalamic preservation regardless of the degree of involvement by tumor 8) 9).

Extended endoscopic transsphenoidal approach have gained interest. Surgeons have advocated for both approaches, and at present there is no consensus whether one approach is superior to the other.

With the widespread use of endoscopes in endonasal surgery, the endoscopic transtuberculum transplanum approach have been proposed as an alternative surgical route for removal of different types of suprasellar tumors, including solid craniopharyngiomas in patients with normal pituitary function and small sella.

As part of a minimally disruptive treatment paradigm, the extended endoscopic transsphenoidal approach has the potential to improve rates of resection, improve postoperative visual recovery, and minimize surgical morbidity 10).

Corridors

The endoscopic endonasal approach has become a valid surgical technique for the management of craniopharyngiomas. It provides an excellent corridor to infra- and supradiaphragmatic midline craniopharyngiomas, including the management of lesions extending into the third ventricle chamber. Even though indications for this approach are rigorously lesion based, the data confirm its effectiveness in a large patient series 11).

The endoscopic endonasal approach offers advantages in the management of craniopharyngiomas that historically have been approached via the transsphenoidal approach (i.e., purely intrasellar or intra-suprasellar infradiaphragmatic, preferably cystic lesions in patients with panhypopituitarism).

Use of the extended endoscopic endonasal approach overcomes the limits of the transsphenoidal route to the sella enabling the management of different purely suprasellar and retrosellar cystic/solid craniopharyngiomas, regardless of the sellar size or pituitary function 12).

They provide acceptable results comparable to those for traditional craniotomies. Endoscopic endonasal surgery is not limited to adults and actually shows higher resection rates in the pediatric population 13).

Infrachiasmatic corridor

Infrachiasmatic corridor

Complications

Craniopharyngioma endoscopic endonasal approach complications.

Case series

see Craniopharyngioma endoscopic endonasal approach case series.

References

1)

Figueredo LF, Martínez AL, Suarez-Meade P, Marenco-Hillembrand L, Salazar AF, Pabon D, Guzmán J, Murguiondo-Perez R, Hallak H, Godo A, Sandoval-Garcia C, Ordoñez-Rubiano EG, Donaldson A, Chaichana KL, Peris-Celda M, Bendok BR, Samson SL, Quinones-Hinojosa A, Almeida JP. Current Role of Endoscopic Endonasal Approach for Craniopharyngiomas: A 10-Year Systematic Review and Meta-Analysis Comparison with the Open Transcranial Approach. Brain Sci. 2023 May 23;13(6):842. doi: 10.3390/brainsci13060842. PMID: 37371322.
2)

Qiao N. Endocrine outcomes of endoscopic versus transcranial resection of craniopharyngiomas: A system review and meta-analysis. Clin Neurol Neurosurg. 2018 Apr 7;169:107-115. doi: 10.1016/j.clineuro.2018.04.009. [Epub ahead of print] Review. PubMed PMID: 29655011.
3)

Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH. Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of craniopharyngiomas. World Neurosurg. 2012 Feb;77(2):329-41. doi: 10.1016/j.wneu.2011.07.011. Epub 2011 Nov 1. Review. PubMed PMID: 22501020.
4)

Aragón-Arreola JF, Marian-Magaña R, Villalobos-Diaz R, López-Valencia G, Jimenez-Molina TM, Moncada-Habib JT, Sangrador-Deitos MV, Gómez-Amador JL. Endoscopic Endonasal Approach in Craniopharyngiomas: Representative Cases and Technical Nuances for the Young Neurosurgeon. Brain Sci. 2023 Apr 28;13(5):735. doi: 10.3390/brainsci13050735. PMID: 37239207; PMCID: PMC10216292.
5)

Hong CS, Omay SB. The Role of Surgical Approaches in the Multi-Modal Management of Adult Craniopharyngiomas. Curr Oncol. 2022 Feb 24;29(3):1408-1421. doi: 10.3390/curroncol29030118. PMID: 35323318; PMCID: PMC8947636.
6)

Fong RP, Babu CS, Schwartz TH. Endoscopic endonasal approach for craniopharyngiomas. J Neurosurg Sci. 2021 Apr;65(2):133-139. doi: 10.23736/S0390-5616.21.05097-9. PMID: 33890754.
7)

Baldauf J, Hosemann W, Schroeder HW. Endoscopic Endonasal Approach for Craniopharyngiomas. Neurosurg Clin N Am. 2015 Jul;26(3):363-75. doi: 10.1016/j.nec.2015.03.013. Epub 2015 May 26. PMID: 26141356.
8)

Tan TSE, Patel L, Gopal-Kothandapani JS, Ehtisham S, Ikazoboh EC, Hayward R, et al: The neuroendocrine sequelae of paediatric craniopharyngioma: a 40-year meta-data analysis of 185 cases from three UK centres. Eur J Endocrinol 176:359–369, 2017
9)

Yokoi H, Kodama S, Kogashiwa Y, Matsumoto Y, Ohkura Y, Nakagawa T, et al: An endoscopic endonasal approach for early-stage olfactory neuroblastoma: an evaluation of 2 cases with minireview of literature. Case Rep Otolaryngol 2015:541026, 2015
10)

Zacharia BE, Amine M, Anand V, Schwartz TH. Endoscopic Endonasal Management of Craniopharyngioma. Otolaryngol Clin North Am. 2016 Feb;49(1):201-12. doi: 10.1016/j.otc.2015.09.013. Review. PubMed PMID: 26614838.
11)

Cavallo LM, Frank G, Cappabianca P, Solari D, Mazzatenta D, Villa A, Zoli M, D’Enza AI, Esposito F, Pasquini E. The endoscopic endonasal approach for the management of craniopharyngiomas: a series of 103 patients. J Neurosurg. 2014 May 2. [Epub ahead of print] PubMed PMID: 24785324.
12)

Cavallo LM, Solari D, Esposito F, Villa A, Minniti G, Cappabianca P. The Role of the Endoscopic Endonasal Route in the Management of Craniopharyngiomas. World Neurosurg. 2014 Dec;82(6S):S32-S40. doi: 10.1016/j.wneu.2014.07.023. Review. PubMed PMID: 25496633.
13)

Koutourousiou M, Gardner PA, Fernandez-Miranda JC, Tyler-Kabara EC, Wang EW, Snyderman CH. Endoscopic endonasal surgery for craniopharyngiomas: surgical outcome in 64 patients. J Neurosurg. 2013 Nov;119(5):1194-207. doi: 10.3171/2013.6.JNS122259. Epub 2013 Aug 2. PubMed PMID: 23909243.

Percutaneous Transforaminal Endoscopic Lumbar Discectomy

Percutaneous Transforaminal Endoscopic Lumbar Discectomy

Transforaminal lumbar endoscopic discectomy (TLED) is a minimally invasive surgery for removing lumbar disc herniations. This technique was initially reserved for herniations in the foraminal or extraforaminal region.

It seems to be a promising technique to effectively treat LDH. The reported complication rate of PTED is low, as is the percentage of patients requiring additional surgery due to recurrent LDH. Due to its steep learning curve, however, PTED should be further investigated before widespread implementation. Open microdiscectomy remains the current standard therapy for the surgical decompression of LDH. High-quality randomized controlled trials are needed to generate Class I evidence on the efficacy and cost-effectiveness of PTED 1).

History

A technique for percutaneous nonvisualized indirect spinal canal decompression—percutaneous nucleotomy— through a posterolateral approach was described by Parviz Kambin in 1973 2) and Hijikata et al. in 1975. 3).

Kambin described using a Craig cannula and Hijikata a 2.6-mm cannula. The technical challenge of achieving sufficient removal of nucleus pulposus material through a needle was addressed by Kambin and coworkers in 1986 and 1987 with the introduction of working cannulas possessing diameters up to 5 mm and flexible forceps 4) 5).

The next step in the advancement of the percutaneous discectomy technique was the addition of the endoscope. The first endoscopic views of a herniated nucleus pulposus were published by Kambin et al. in 1988 6) and the first reported introduction of a modified arthroscope into the intervertebral disc space was reported by Forst and Hausman in 1983 7)

Schreiber et al. 8) and Suezawa et al. 9) published their bilateral approach for a percutaneous nucleotomy under endoscopic control and described injecting indigo carmine into the disc space to stain the abnormal nucleus pulposus and anular fissures.

Percutaneous endoscopic discectomy certainly must receive a great portion of the credit for advancing endoscopic spine surgery, but it also must likely take responsibility for endoscopic spine surgery’s slow rate of acceptance as a feasible technique by most orthopedic and neurosurgical spine specialists. The surgical goal of percutaneous endoscopic discectomy is to indirectly decompress the neural elements by selectively removing the nucleus pulposus from the posterior one-third of the disc space. From its origin, the technique showed promising results: Kambin and Gellman reported a 72% success rate in 136 patients with their percutaneous technique in 1983, but it has been difficult to quantify the impact of such results because they were not matched with nonoperative controls 10)

It has several advantages over open lumbar discectomy, including less paravertebral muscle injury, preservation of bony structure, and rapid recovery, and has gained popularity for removal of herniated disc (HD) material over the past few years since Kambin 11) introduced the percutaneous posterolateral approach in 1983.

Even sequestered disc material – regardless of its size and level – that slipped into the spinal channel can be removed with the minimal invasive method.

Large, uncontained, lumbar disc herniations can be sufficiently removed with remarkable long-term outcome. Although the neurological outcome is the same, the morbidity is significantly less than open discectomy. Maximum benefit can be gained if we adhere to strict selection criteria. The optimum indication is single- or multi-level radiculopathy secondary to a single-level, large, uncontained, lumbar disc herniation 12).

Indications

Proper surgical indications and good working channel position are important for successful PELD. PELD techniques should be specifically designed to remove the disc fragments in various types of disc herniation 13).

Advantages

Immediate pain relief in 95% of the cases – study info needed

Direct access to herniated disc/sequester

The disc-annulus and the ligament remain intact

No general anesthesia, only a sparing local anesthetic necessary

Outpatient treatment

Shorter rehabilitation -study info needed

Faster return to profession and everyday life – study info needed

Small incision (only one stitch) = hardly any scarring.

For adjacent segment degeneration (ASD) and recurrent lumbar disc herniation, PELD had more advantages over open lumbar surgery in terms of reduced blood loss, shorter hospital stay, operating time, fewer complications, and less postoperative discomfort 14).

Technique

It can be performed under local anesthesia and requires only an 8-mm skin incision.

PTED performed under local anesthesia and conscious sedation is safe and effective to treat sciatica and yields high satisfaction rates from surgeons, anesthesiologists, and patients 15)

Reoperations

Reoperation rates of PELD have been reported from 2.3% to 15% 16) 17) 18) 19) 20).

According to a nationwide cohort study, there is no significant difference in the reoperation rates between open discectomy (13.7%) and endoscopic discectomy (12.4%) 21).

Age

PELD may not be an applicable option for all ages.

Kim et al. selected 15,817 patients who underwent open discectomy (n = 12,816) or PELD (n = 3,001) in 2003 from Korean Health Insurance Review & Assessment Service (HIRA) database. All patients in the cohort were followed until December 31, 2008, and the minimum follow-up period was 5 years. A time to event survival analysis was performed. Primary end-point was any type of second lumbar spine surgery during the follow-up period. Minimum P-value approach and two-fold cross validation approach were utilized to determine an age cut-off point.

The optimal age cut-off point was determined as 57 years. PELD for elder patients (≥ 57 years) had a higher reoperation risk during postoperative 3.4 years (Hazard ratio [HR] at 1 yr, 1.75; 2 yr, 1.57; 3 yr, 1.41). However, re-operation risk was not higher after PELD for patients of < 57 years from 1.9 years than open diskectomy (HR at 2 yr, 0.86; 3 yr, 0.78; 4 yr, 0.70; 5 yr, 0.63).

In the present study, they showed that an age cut-off point of PELD for optimal reoperation rate may be 57 years with national-wide population based data. Reoperation rate seems to be not higher for patients younger than 57 years after PELD than open diskectomy, but applying PELD for elder patients need careful consideration 22).

Case series

Percutaneous Transforaminal Endoscopic Lumbar Discectomy Case series.

Case reports

Full-endoscopic Transforaminal lumbar endoscopic discectomy is based on a puncture technique using a guide needle to reach the target area of the foramen via a percutaneous posterolateral/lateral approach. It may correlate with specific approach-related complications, as exiting nerve root injury.

Panagiotopoulos et al., report the first case of pseudoaneurysm of the lumbar segmental artery secondary to a transforaminal full-endoscopic surgery in the treatment of a lumbar disc herniation. A 39-year-old man underwent left L4-L5 full-endoscopic transforaminal lumbar discectomy for a herniated disc. Three hours after surgery, he experienced acute progressive abdominal pain. An abdomen CT scan showed contrast extravasation in the left paraspinal compartment at L4 vertebral body level. The selective left lumbar angiogram revealed a pseudoaneurysm of a side branch of the left lumbar segmental artery, which was treated by endovascular coiling. The patient made a rapid postoperative recovery without further complications and was discharged 4 days later. This report identifies a rare complication of transforaminal full-endoscopic surgery in the treatment of a herniated lumbar disc. This is the first case of pseudoaneurysm formation of the lumbar artery following a full-endoscopic transforaminal lumbar discectomy 23).

1)

Gadjradj PS, van Tulder MW, Dirven CM, Peul WC, Sanjay Harhangi B. Clinical outcomes after percutaneous transforaminal endoscopic discectomy for lumbar disc herniation: a prospective case series. Neurosurg Focus. 2016 Feb;40(2):E3. doi: 10.3171/2015.10.FOCUS15484. PubMed PMID: 26828884.
2)

Kambin P: Arthroscopic Microdiscectomy: Minimal Intervention Spinal Surgery Baltimore, MD, Urban & Schwarzenberg, 1990
3)

Hijikata S, Yamagishi M, Nakayma T: Percutaneous discectomy: a new treatment method for lumbar disc herniation. J Todenhosp 5:5–13, 1975
4)

Kambin P, Brager MD: Percutaneous posterolateral discectomy. Anatomy and mechanism. Clin Orthop Relat Res 223145–154, 1987
5)

Kambin P, Sampson S: Posterolateral percutaneous suction-excision of herniated lumbar intervertebral discs. Report of interim results. Clin Orthop Relat Res 20737–43, 1986
6)

Kambin P, Nixon JE, Chait A, Schaffer JL: Annular protrusion: pathophysiology and roentgenographic appearance. Spine (Phila Pa 1976) 13:671–675, 1988
7)

Forst R, Hausmann B: Nucleoscopy—a new examination technique. Arch Orthop Trauma Surg 101:219–221, 1983
8)

Schreiber A, Suezawa Y, Leu H: Does percutaneous nucleotomy with discoscopy replace conventional discectomy? Eight years of experience and results in treatment of herniated lumbar disc. Clin Orthop Relat Res 23835–42, 1989
9)

Suezawa Y, Jacob HA: Percutaneous nucleotomy. An alternative to spinal surgery. Arch Orthop Trauma Surg 105:287–295, 1986
10)

Kambin P, Gellman H: Percutaneous lateral discectomy of the lumbar spine: a preliminary report. Clin Orthop Relat Res 174127–132, 1983
11)

Kambin P, Gellman H. Percutaneous lateral discectomy of the lumbar spine: a preliminary report. Clin Orthop. 1983;174:127–132.
12)

Hussein M, Abdeldayem A, Mattar MM. Surgical technique and effectiveness of microendoscopic discectomy for large uncontained lumbar disc herniations: a prospective, randomized, controlled study with 8 years of follow-up. Eur Spine J. 2014 Sep;23(9):1992-9. doi: 10.1007/s00586-014-3296-9. Epub 2014 Apr 16. PubMed PMID: 24736930.
13)

Choi KC, Lee JH, Kim JS, Sabal LA, Lee S, Kim H, Lee SH. Unsuccessful percutaneous endoscopic lumbar discectomy: a single-center experience of 10 228 cases. Neurosurgery. 2015 Apr;76(4):372-81. doi: 10.1227/NEU.0000000000000628. PubMed PMID: 25599214.
14)

Chen HC, Lee CH, Wei L, Lui TN, Lin TJ. Comparison of Percutaneous Endoscopic Lumbar Discectomy and Open Lumbar Surgery for Adjacent Segment Degeneration and Recurrent Disc Herniation. Neurol Res Int. 2015;2015:791943. Epub 2015 Mar 10. PubMed PMID: 25861474.
15)

Gadjradj PS, Arjun Sharma JRJ, Harhangi BS. Quality of conscious sedation using dexmedetomidine during full-endoscopic transforaminal discectomy for sciatica: a prospective case series. Acta Neurochir (Wien). 2022 Jan 31. doi: 10.1007/s00701-021-05100-x. Epub ahead of print. PMID: 35098351.
16)

Ahn Y, Lee SH, Park WM, Lee HY, Shin SW, Kang HY. Percutaneous endoscopic lumbar discectomy for recurrent disc herniation: surgical technique, outcome, and prognostic factors of 43 consecutive cases. Spine (Phila Pa 1976). 2004;29(16):E326–E332.
17)

Hoogland T, van den Brekel-Dijkstra K, Schubert M, Miklitz B. Endoscopic transforaminal discectomy for recurrent lumbar disc herniation: a prospective, cohort evaluation of 262 consecutive cases. Spine (Phila Pa 1976). 2008;33(9):973–978.
18)

Kambin P. Arthroscopic microdiscectomy. Arthroscopy. 1992;8(3):287–295.
19)

Ruetten S, Komp M, Godolias G. An extreme lateral access for the surgery of lumbar disc herniations inside the spinal canal using the full-endoscopic uniportal transforaminal approach-technique and prospective results of 463 patients. Spine (Phila Pa 1976). 2005;30(22):2570–2578.
20)

Mayer HM, Brock M. Percutaneous endoscopic discectomy: surgical technique and preliminary results compared to microsurgical discectomy. J Neurosurg. 1993;78(2):216–225.
21)

Kim CH, Chung CK, Park CS, Choi B, Kim MJ, Park BJ. Reoperation rate after surgery for lumbar herniated intervertebral disc disease: nationwide cohort study. Spine (Phila Pa 1976). 2013;38(7):581–590.
22)

Kim CH, Chung CK, Choi Y, Shin S, Kim MJ, Lee J, Park BJ. The selection of open or percutaneous endoscopic lumbar diskectomy according to an age cut-off point: national-wide cohort study. Spine (Phila Pa 1976). 2015 Jul 17. [Epub ahead of print] PubMed PMID: 26192722.
23)

Panagiotopoulos K, Gazzeri R, Bruni A, Agrillo U. Pseudoaneurysm of a segmental lumbar artery following a full-endoscopic transforaminal lumbar discectomy: a rare approach-related complication. Acta Neurochir (Wien). 2019 Mar 16. doi: 10.1007/s00701-019-03876-7. [Epub ahead of print] PubMed PMID: 30879131.

Endoscopic third ventriculostomy and choroid plexus cauterization

Endoscopic third ventriculostomy and choroid plexus cauterization

Endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) offers an alternative to shunt.

While ventriculoperitoneal shunt (VPS) insertion is the standard treatment for myelomeningocele-associated hydrocephalus (MAH), it can be complicated by shunt infection and shunt malfunction. As such, endoscopic third ventriculostomy (ETV), with or without choroid plexus coagulation (CPC), has been proposed as an alternative.

ETV+CPC was associated with a higher success rate than ETV alone for MAH in a meta-analysis of published studies. ETV, with or without CPC, was technically feasible and safe for this patient population 1).

In the twenty-first century, choroid plexus cauterization (CPC) in combination with endoscopic third ventriculostomy (ETV) has emerged as an effective treatment for some infants with hydrocephalus, leading to the favourable condition of ‘shunt independence‘.

Coulter et al. provide a narrative technical review considering the indications, procedural aspects, morbidity and its avoidance, postoperative care and follow-up. The CP has been the target of hydrocephalus treatment for more than a century. Early eminent neurosurgeons including Dandy, Putnam and Scarff performed CPC achieving generally poor results, and so the procedure fell out of favour. In recent years, the addition of CPC to ETV was one of the reasons greater ETV success rates were observed in Africa, compared to developed nations, and its popularity worldwide has since increased. Initial results indicate that when ETV/CPC is performed successfully, shunt independence is more likely than when ETV is undertaken alone. CPC is commonly performed using a flexible endoscope via septostomy and aims to maximally cauterize the CP. Success is more likely in infants aged >1 month, those with hydrocephalus secondary to myelomeningocele and aqueductal obstruction and those with >90% cauterized CP. Failure is more likely in those with post-haemorrhagic hydrocephalus of prematurity (PHHP), particularly those <1 month of corrected age and those with prepontine scarring. High-quality evidence comparing the efficacy of ETV/CPC with shunting is emerging, with data from ongoing and future trials offering additional promise to enhance our understanding of the true utility of ETV/CPC 2).

In the quest to identify the optimal means of cerebrospinal fluid diversion free of shunt dependency, endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) has been proposed as a promising procedure in select children. Supplementing traditional ETV with obliteration of the choroid plexus has been shown to decrease the likelihood of ultimate shunt dependency by roughly 20%. Originally devised to treat hydrocephalus in infants in sub-Saharan Africa, ETV/CPC has gained eager attention and cautious support in the developed world 3).

Diagnosing treatment failure is dependent on infantile hydrocephalus metrics, including head circumference, fontanel quality, and ventricle size.

Systematic review

Systematic review was performed using four electronic databases and bibliographies of relevant articles, with no language or date restrictions. Cohort studies of participants undergoing ETV/CPC that reported outcome were included using MOOSE guidelines. The outcome was time to repeat CSF diversion or death. Forest plots were created for pooled mean and its 95 % CI of outcome and morbidity.

Of 78 citations, 11 retrospective reviews (with 524 total participants) were eligible. Efficacy was achieved in 63 % participants at follow-up periods between 6 months and 8 years. Adverse events and mortality was reported in 3.7 and 0.4 % of participants, respectively. Publication bias was detected with respect to efficacy and morbidity of the procedure. A large discrepancy in success was identified between ETV/CPC in six studies from sub-Saharan Africa (71 %), compared to three studies from North America (49 %).

The reported success of ETV/CPC for infantile hydrocephalus is higher in sub-Saharan Africa than developed nations. Large long-term prospective multi-center observational studies addressing patient-important outcomes are required to further evaluate the efficacy and safety of this re-emerging procedure 4).

Case series

2016

It is not clear to what degree these metrics should be expected to change after ETV/CPC. Using these clinical metrics, Dewan et al., present and analyze the decision making in cases of ETV/CPC failure.

Infantile hydrocephalus metrics, including bulging fontanel, head circumference z-score, and frontal and occipital horn ratio (FOHR), were compared between ETV/CPC failures and successes. Treatment outcome predictive values of metrics individually and in combination were calculated.

Forty-four patients (57% males, median age 1.2 months) underwent ETV/CPC for hydrocephalus; of these patients, 25 (57%) experienced failure at a median time of 51 days postoperatively. Patients experiencing failure were younger than those experiencing successful treatment (0.8 vs 3.9 months, p = 0.01). During outpatient follow-up, bulging anterior fontanel, progressive macrocephaly, and enlarging ventricles each demonstrated a positive predictive value (PPV) of no less than 71%, but a bulging anterior fontanel remained the most predictive indicator of ETV/CPC failure, with a PPV of 100%, negative predictive value of 73%, and sensitivity of 72%. The highest PPVs and specificities existed when the clinical metrics were present in combination, although sensitivities decreased expectedly. Only 48% of failures were diagnosed on the basis all 3 hydrocephalus metrics, while only 37% of successes were negative for all 3 metrics. In the remaining 57% of patients, a diagnosis of success or failure was made in the presence of discordant data.

Successful ETV/CPC for infantile hydrocephalus was evaluated in relation to fontanel status, head growth, and change in ventricular size. In most patients, a designation of failure or success was made in the setting of discordant data 5).

2014

A study retrospectively reviewed medical records of 27 premature infants with intraventricular hemorrhage (IVH) and hydrocephalus treated with ETV and CPC from 2008 to 2011. All patients were evaluated using MRI before the procedure to verify the anatomical feasibility of ETV/CPC. Endoscopic treatment included third ventriculostomy, septostomy, and bilateral CPC. After ETV/CPC, all patients underwent follow-up for a period of 6-40 months (mean 16.2 months). The procedure was considered a failure if the patient subsequently required a shunt. The following factors were analyzed to determine a relationship to patient outcomes: gestational age at birth, corrected age and weight at surgery, timing of surgery after birth, grade of IVH, the status of the prepontine cistern and cerebral aqueduct on MRI, need for a ventricular access device prior to the endoscopic procedure, and scarring of the prepontine cistern noted at surgery.

Seventeen (63%) of 27 patients required a shunt after ETV/CPC, and 10 patients did not require further CSF diversion. Several factors studied were associated with a higher rate of ETV/CPC failure: Grade IV hemorrhage, weight 3 kg or less and age younger than 3 months at the time of surgery, need for reservoir placement, and presence of a normal cerebral aqueduct. Two factors were found to be statistically significant: the patient’s corrected gestational age of less than 0 weeks at surgery and a narrow prepontine cistern on MRI. The majority (83%) of ETV/CPC failures occurred in the first 3 months after the procedure. None of the patients had a complication directly related to the procedure.

Endoscopic third ventriculostomy/CPC is a safe initial procedure for hydrocephalus in premature infants with IVH and hydrocephalus, obviating the need for a shunt in selected patients. Even though the success rate is low (37%), the lower rate of complications in comparison with shunt treatment may justify this procedure in the initial management of hydrocephalus. As several of the studied factors have shown influence on the outcome, patient selection based on these observations might increase the success rate 6).

2005

A total of 710 children underwent ventriculoscopy as candidates for ETV as the primary treatment for hydrocephalus. The ETV was accomplished in 550 children: 266 underwent a combined ETV-CPC procedure and 284 underwent ETV alone. The mean and median ages were 14 and 5 months, respectively, and 443 patients (81%) were younger than 1 year of age. The hydrocephalus was postinfectious (PIH) in 320 patients (58%), nonpostinfectious (NPIH) in 152 (28%), posthemorrhagic in five (1%), and associated with myelomeningocele in 73 (13%). The mean follow up was 19 months for ETV and 9.2 months for ETV-CPC. Overall, the success rate of ETV-CPC (66%) was superior to that of ETV alone (47%) among infants younger than 1 year of age (p < 0.0001). The ETV-CPC combined procedure was superior in patients with a myelomeningocele (76% compared with 35% success, p = 0.0045) and those with NPIH (70% compared with 38% success, p = 0.0025). Although the difference was not significant for PIH (62% compared with 52% success, p = 0.1607), a benefit was not ruled out (power = 0.3). For patients at least 1 year of age, there was no difference between the two procedures (80% success for each, p = 1.0000). The overall surgical mortality rate was 1.3%, and the infection rate was less than 1%.

The ETV-CPC was more successful than ETV alone in infants younger than 1 year of age. In developing countries in which a dependence on shunts is dangerous, ETV-CPC may be the best option for treating hydrocephalus in infants, particularly for those with NPIH and myelomeningocele 7).

1)

Omar AT, Espiritu AI, Spears J. Endoscopic third ventriculostomy with or without choroid plexus coagulation for myelomeningocele-associated hydrocephalus: systematic review and meta-analysis. J Neurosurg Pediatr. 2022 Jan 21:1-9. doi: 10.3171/2021.11.PEDS21505. Epub ahead of print. PMID: 35061994.
2)

Coulter IC, Dewan MC, Tailor J, Ibrahim GM, Kulkarni AV. Endoscopic third ventriculostomy and choroid plexus cauterization (ETV/CPC) for hydrocephalus of infancy: a technical review. Childs Nerv Syst. 2021 May 15. doi: 10.1007/s00381-021-05209-5. Epub ahead of print. PMID: 33991213.
3)

Dewan MC, Naftel RP. The Global Rise of Endoscopic Third Ventriculostomy with Choroid Plexus Cauterization in Pediatric Hydrocephalus. Pediatr Neurosurg. 2016 Dec 22. doi: 10.1159/000452809. [Epub ahead of print] PubMed PMID: 28002814.
4)

Weil AG, Westwick H, Wang S, Alotaibi NM, Elkaim L, Ibrahim GM, Wang AC, Ariani RT, Crevier L, Myers B, Fallah A. Efficacy and safety of endoscopic third ventriculostomy and choroid plexus cauterization for infantile hydrocephalus: a systematic review and meta-analysis. Childs Nerv Syst. 2016 Nov;32(11):2119-2131. PubMed PMID: 27613635.
5)

Dewan MC, Lim J, Morgan CD, Gannon SR, Shannon CN, Wellons JC 3rd, Naftel RP. Endoscopic third ventriculostomy with choroid plexus cauterization outcome: distinguishing success from failure. J Neurosurg Pediatr. 2016 Dec;25(6):655-662. PubMed PMID: 27564786.
6)

Chamiraju P, Bhatia S, Sandberg DI, Ragheb J. Endoscopic third ventriculostomy and choroid plexus cauterization in posthemorrhagic hydrocephalus of prematurity. J Neurosurg Pediatr. 2014 Apr;13(4):433-9. doi: 10.3171/2013.12.PEDS13219. PubMed PMID: 24527862.
7)

Warf BC. Comparison of endoscopic third ventriculostomy alone and combined with choroid plexus cauterization in infants younger than 1 year of age: a prospective study in 550 African children. J Neurosurg. 2005 Dec;103(6 Suppl):475-81. PubMed PMID: 16383244.

Endoscopic transsphenoidal approach

Endoscopic transsphenoidal approach

The endoscopic transsphenoidal approach shown to be as effective as, if not more than, the traditional transseptal microscopic transsphenoidal surgery 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11).

Endoscopic transsphenoidal surgery is associated with higher gross tumor removal and lower incidence of septal perforation in patients with pituitary adenoma. Future large-scale prospective randomized controlled trials are needed to verify these findings 12)

The interest in endoscopic endonasal transsphenoidal surgery for the treatment of sellar and perisellar lesions is growing as a consequence of the results achieved in the past years and of the interest by patients, endocrinologists, and neurosurgeons. Furthermore, the special ability of the endoscope to offer a wider and detailed view of anatomic structures is a major advantage that increases the attention of neurosurgeons who seek less invasive procedures and better results. Most neurosurgeons performing transsphenoidal surgery, however, are not used to endoscopy, and changing from microsurgical to endoscopic technique can be difficult and even discouraging, often because of difficulties in the initial phase of the procedure.

With the purpose of helping minimize some of the difficulties, Cavallo et al., described useful tips and tricks that mainly concern familiarization with the endoscopic equipment, details of the transsphenoidal anatomy, and endoscopic skills. They stressed the steps and details that they judge most important.

They believed that by following these recommendations neurosurgeons can overcome, or even avoid, the difficulties frequently encountered transsphenoidal surgery, allowing them to safely and efficiently perform endonasal transsphenoidal endoscopic procedures 13).

Anatomical Variations

Castle-Kirszbaum et al. described the skeletal, vascular and neural anatomical variations that could be encountered from the nasal phase, through the sphenoid phase, to the sellar phase of the operative exposure. A preoperative checklist is also provided 14)

Complications

see Transsphenoidal approach complications

Outcome

A study assessed the long-term impact of endoscopic skull base surgery on olfaction, sinonasal symptoms, mucociliary clearance time (MCT), and quality of life (QoL). Patients with pituitary adenomas underwent TTEA (n = 38), while patients with other benign parasellar tumours who underwent an EEA with vascularised septal flap reconstruction (n = 17) were enrolled in this prospective study between 2009 and 2012. Sinonasal symptoms (Visual Analogue Scale), subjective olfactometry (Barcelona Smell Test-24, BAST-24), MCT (saccharin test), and QoL (short form SF-36, rhinosinusitis outcome measure/RSOM) were evaluated before, and 12 months after, surgery. At baseline, sinonasal symptoms, MCT, BAST-24, and QoL were similar between groups. Twelve months after surgery, both TTEA and EEA groups experienced smell impairment compared to baseline. Moreover, EEA (but not TTEA) patients reported increased posterior nasal discharge and longer MCTs compared to baseline. No significant changes in olfactometry or QoL were detected in either group 12 months after surgery. Over the long-term, expanded skull base surgery, using EEA, produced more sinonasal symptoms (including loss of smell) and longer MCTs than pituitary surgery (TTEA). EEA showed no long-term impact on smell test or QoL 15).

Case series

Endoscopic transsphenoidal approach case series.

Instruments

Endoscopic transsphenoidal approach Instruments.

In-Hospital Costs

All endoscopic transphenoidal pituitary surgeries performed from January 1, 2015, to October 24, 2017, with complete data were evaluated in a retrospective single-institution study. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables during each hospital stay. Multivariate linear regression was performed using Stata software.

The analysis included 190 patients and average length of stay was 4.71 days. Average total in-hospital cost was $28,624 (95% confidence interval $25,094-$32,155) with average total direct cost of $19,444 ($17,136-$21,752) and total indirect cost of $9181 ($7592-$10,409). On multivariate regression, post-operative cerebrospinal fluid (CSF) leak was associated with a significant increase in all cost variables, including a total cost increase of $40,981 ($15,474-$66,489, P = .002). Current smoking status was associated with an increased total cost of $20,189 ($6,638-$33,740, P = .004). Self-reported Caucasian ethnicity was associated with a significant decrease in total cost of $6646 (-$12,760 to -$532, P = .033). Post-operative DI was associated with increased costs across all variables that were not statistically significant.

Post-operative CSF leak, current smoking status, and non-Caucasian ethnicity were associated with significantly increased costs. Understanding of cost drivers of endoscopic transphenoidal pituitary surgery is critical for future cost control and value creation initiatives 16).

1)

The endoscopic versus the traditional approach in pituitary surgery. Frank G, Pasquini E, Farneti G, Mazzatenta D, Sciarretta V, Grasso V, Faustini Fustini M. Neuroendocrinology. 2006;83:240–248.
2)

Pure endoscopic endonasal approach for pituitary adenomas: early surgical results in 200 patients and comparison with previous microsurgical series. Dehdashti AR, Ganna A, Karabatsou K, Gentili F. Neurosurgery. 2008;62:1006–1015.
3)

Microscopic versus endoscopic transnasal pituitary surgery. Schaberg MR, Anand VK, Schwartz TH, Cobb W. Curr Opin Otolaryngol Head Neck Surg. 2010;18:8–14.
4)

Endoscopic versus microscopic trans-sphenoidal pituitary surgery: a systematic review and meta-analysis. Goudakos JK, Markou KD, Georgalas C. Clin Otolaryngol. 2011;36:212–220.
5)

Meta-analysis of endoscopic versus sublabial pituitary surgery. DeKlotz TR, Chia SH, Lu W, Makambi KH, Aulisi E, Deeb Z. Laryngoscope. 2012;122:511–518.
6)

Evaluation of trans-sphenoidal surgery in pituitary GH-secreting micro- and macroadenomas: a comparison between microsurgical and endoscopic approach. Lenzi J, Lapadula G, D’Amico T, et al. https://www.minervamedica.it/en/journals/neurosurgical-sciences/article.php?cod=R38Y2015N01A0011. J Neurosurg Sci. 2015;59:11–18.
7)

Endoscopic versus microscopic transsphenoidal surgery in the treatment of pituitary tumors: systematic review and meta-analysis of randomized and non-randomized controlled trials. Bastos RV, Silva CM, Tagliarini JV, Zanini MA, Romero FR, Boguszewski CL, Nunes VD. Arch Endocrinol Metab. 2016;60:411–419.
8)

Endoscopic versus microscopic approach in pituitary surgery. Gao Y, Zheng H, Xu S, Zheng Y, Wang Y, Jiang J, Zhong C. J Craniofac Surg. 2016;27:157–159.
9)

Resection of pituitary tumors: endoscopic versus microscopic. Singh H, Essayed WI, Cohen-Gadol A, Zada G, Schwartz TH. J Neurooncol. 2016;130:309–317.
10)

Endoscopic endonasal versus microsurgical transsphenoidal approach for growth hormone-secreting pituitary adenomas-systematic review and meta-analysis. Phan K, Xu J, Reddy R, Kalakoti P, Nanda A, Fairhall J. http://www.sciencedirect.com/science/article/pii/S1878875016310178. World Neurosurg. 2017;97:398–406.
11) , 12)

Endoscopic versus microscopic transsphenoidal surgery in the treatment of pituitary adenoma: A Systematic review and meta-analysis. Li A, Liu W, Cao P, Zheng Y, Bu Z, Zhou T. http://www.sciencedirect.com/science/article/pii/S1878875017300323. World Neurosurg. 2017;101:236–246.
13)

Cavallo LM, Dal Fabbro M, Jalalod’din H, Messina A, Esposito I, Esposito F, de Divitiis E, Cappabianca P. Endoscopic endonasal transsphenoidal surgery. Before scrubbing in: tips and tricks. Surg Neurol. 2007 Apr;67(4):342-7. Review. PubMed PMID: 17350397.
14)

Castle-Kirszbaum M, Uren B, Goldschlager T. Anatomical Variation for the Endoscopic Endonasal Transsphenoidal Approach. World Neurosurg. 2021 Oct 2:S1878-8750(21)01456-X. doi: 10.1016/j.wneu.2021.09.103. Epub ahead of print. PMID: 34610448.
15)

Rioja E, Bernal-Sprekelsen M, Enriquez K, Enseñat J, Valero R, de Notaris M, Mullol J, Alobid I. Long-term outcomes of endoscopic endonasal approach for skull base surgery: a prospective study. Eur Arch Otorhinolaryngol. 2015 Dec 19. [Epub ahead of print] PubMed PMID: 26688432.
16)

Parasher AK, Lerner DK, Glicksman JT, et al. Drivers of In-Hospital Costs Following Endoscopic Transphenoidal Pituitary Surgery [published online ahead of print, 2020 Aug 24]. Laryngoscope. 2020;10.1002/lary.29041. doi:10.1002/lary.29041

Cerebrospinal fluid leak after endoscopic skull base surgery

Cerebrospinal fluid leak after endoscopic skull base surgery

Although rates of postoperative morbidity and mortality have become relatively low in patients undergoing transnasal transsphenoidal surgery (TSS) for pituitary adenoma, cerebrospinal fluid fistulas remain a major driver of postoperative morbidity. Persistent CSF fistulas harbor the potential for headache and meningitis.

Staartjes et al., trained and internally validated a robust deep neural network-based prediction model that identifies patients at high risk for intraoperative CSF. Machine learning algorithms may predict outcomes and adverse events that were previously nearly unpredictable, thus enabling safer and improved patient care and better patient counseling 1).

The objective of a study of Umamaheswaran et al., was to assess the incidence of CSF leak following pituitary surgery and the methods of effective skull base repair. This retrospective observational study conducted in a tertiary care hospital after obtaining due clearance from the Institutional ethics committee. The charts of patients who underwent endonasal pituitary surgery between 2013 and 2018 were studied and details noted. Patients undergoing revision surgery or with history of preoperative radiotherapy were excluded from the study. 52 patients were included in the study. Based on the type of CSF leak, the patients were grouped into four. 19 patients (36.5%) had an intraoperative CSF leak. 3 patients developed a postoperative CSF leak. Based on the histopathology, 4 patients had ACTH secreting tumor. 8 patients had growth hormone secreting tumor, 22 had gonadotropin secreting tumor, 9 patients had a non-functioning tumour and 9 patients had prolactinoma. The type of skull base repair performed in these patients were grouped into 4.18 patients underwent type I repair, 21 patients underwent type II repair, 8 patients underwent type III repair and 5 patients underwent type IV repair. They observed that the pedicled nasoseptal flap is particularly advantageous over other repair techniques, especially in low pressure leaks. The strategy for skull base repair should be tailored to suit each patient to minimise the occurrence of morbidity and the duration of hospital stay 2).

Cerebrospinal fluid leakage is always the primary complication during the endoscopic endonasal skull base surgery.

Dural suturing technique may supply a rescue method. However, suturing and knotting in such a deep and narrow space are difficult. Training in the model can improve skills and setting a stepwise curriculum can increase trainers’ interest and confidence.

Xie et al. constructed an easy model using silicone and acrylic as sphenoid sinus and using the egg-shell membrane as skull base dura. The training is divided into three steps: Step 1: extracorporeal knot-tying suture on the silicone of sphenoid sinus, Step 2: intra-nasal knot-tying suture on the same silicone, and Step 3: intra-nasal egg-shell membrane knot-tying suture. Fifteen experienced microneurosurgical neurosurgeons (Group A) and ten inexperienced PGY residents (Group B) were recruited to perform the tasks. Performance measures were time, suturing and knotting errors, and needle and thread manipulations. The third step was assessed through the injection of full water into the other side of the egg to verify the watertight suture. The results were compared between two groups.

Group A finishes the first and second tasks in significantly less time (total time, 125.1 ± 10.8 vs 195.8 ± 15.9 min) and fewer error points (2.4 ± 1.3 vs 5.3 ± 1.0) than group B. There are five trainers in group A who passed the third step, this number in group B was only one.

This low cost and stepwise training model improved the suture and knot skills for skull base repair during endoscopic endonasal surgery. Experienced microneurosurgical neurosurgeons perform this technique more competent 3).

In-Hospital Costs

All endoscopic transsphenoidal approach for pituitary surgeries performed from January 1, 2015, to October 24, 2017, with complete data were evaluated in a retrospective single-institution study. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables during each hospital stay. Multivariate linear regression was performed using Stata software.

The analysis included 190 patients and average length of stay was 4.71 days. Average total in-hospital cost was $28,624 (95% confidence interval $25,094-$32,155) with average total direct cost of $19,444 ($17,136-$21,752) and total indirect cost of $9181 ($7592-$10,409). On multivariate regression, post-operative cerebrospinal fluid (CSF) leak was associated with a significant increase in all cost variables, including a total cost increase of $40,981 ($15,474-$66,489, P = .002). Current smoking status was associated with an increased total cost of $20,189 ($6,638-$33,740, P = .004). Self-reported Caucasian ethnicity was associated with a significant decrease in total cost of $6646 (-$12,760 to -$532, P = .033). Post-operative DI was associated with increased costs across all variables that were not statistically significant.

Post-operative CSF leak, current smoking status, and non-Caucasian ethnicity were associated with significantly increased costs. Understanding of cost drivers of endoscopic transphenoidal pituitary surgery is critical for future cost control and value creation initiatives 4).

Case series

see Cerebrospinal fluid leak after endoscopic skull base surgery case series.

References

1)

Staartjes VE, Zattra CM, Akeret K, Maldaner N, Muscas G, Bas van Niftrik CH, Fierstra J, Regli L, Serra C. Neural network-based identification of patients at high risk for intraoperative cerebrospinal fluid leaks in endoscopic pituitary surgery. J Neurosurg. 2019 Jun 21:1-7. doi: 10.3171/2019.4.JNS19477. [Epub ahead of print] PubMed PMID: 31226693.
2)

Umamaheswaran P, Krishnaswamy V, Krishnamurthy G, Mohanty S. Outcomes of Surgical Repair of Skull Base Defects Following Endonasal Pituitary Surgery: A Retrospective Observational Study. Indian J Otolaryngol Head Neck Surg. 2019 Mar;71(1):66-70. doi: 10.1007/s12070-018-1511-4. Epub 2018 Oct 15. PubMed PMID: 30906716; PubMed Central PMCID: PMC6401034.
3)

Xie T, Zhang X, Gu Y, Sun C, Liu T. A low cost and stepwise training model for skull base repair using a suturing and knotting technique during endoscopic endonasal surgery. Eur Arch Otorhinolaryngol. 2018 Jun 1. doi: 10.1007/s00405-018-5024-2. [Epub ahead of print] PubMed PMID: 29858924.
4)

Parasher AK, Lerner DK, Glicksman JT, et al. Drivers of In-Hospital Costs Following Endoscopic Transphenoidal Pituitary Surgery [published online ahead of print, 2020 Aug 24]. Laryngoscope. 2020;10.1002/lary.29041. doi:10.1002/lary.29041

May 2, Webinar Topic: Endoscopic Ant Fossa Meningioma Excision/ Intraventricular Tumor Management

IFNE/ WFNS Endoscopy Weekend Update 3
Topic: Endoscopic Ant Fossa Meningioma Excision/ Intraventricular Tumor Management

Time: May 2, 2020
08:00 AM (Ohio GMT -4)
02:00 PM (Italy GMT +2)
12:00 PM (GMT +0)
05:00 PM (Pakistan Time GMT +5)

Join Zoom Meeting
https://zoom.us/j/93802030387
Meeting ID: 938 0203 0387

Endoscopic Third Ventriculostomy for Obstructive Hydrocephalus

Endoscopic Third Ventriculostomy for Obstructive Hydrocephalus

Treatment options include endoscopic approaches, which should be individualized to the child. The long-term outcome for children that have received treatment for hydrocephalus varies. Advances in the brain imaging, technology, and understanding of the pathophysiology should ultimately lead to improved treatment of the disorder. 1).

Age and etiology play a crucial role in the success of endoscopic third ventriculostomy (ETV) as a treatment of obstructive hydrocephalus. The outcome is worse in infants, and controversies still exist whether ETV is superior to shunt placement.

El Damaty et al. retrospectively analyzed 70 patients below 2 years from 4 different centers treated with ETV and assessed success.

Children < 2 years who received an ETV within 1994-2018 were included. Patients were classified according to age and etiology; < 3, 4-12, and 13-24 months, etiologically; aqueductal stenosis, posthemorrhagic hydrocephalus (PHH), tumor-related, fourth ventricle outlet obstruction, with Chiari type 2 malformation and following cerebrospinal fluid infection. They investigated statistically the predictors for ETV success through computing Kaplan-Meier estimates using the patient’s follow-up time and time to ETV failure.

They collected 70 patients. ETV success rate was 41.4%. The highest rate was in tumor-related hydrocephalus and fourth ventricle outlet obstruction (62.5%, 60%) and the lowest rate was in Chiari-type II and following infection (16.7%, 0%). The below 3 months age group showed a relatively lower success rate (33.3%) in comparison to older groups which showed similar results (46.4%, 46.6%). Statistically, a previous VP shunt was a predictor for failure (p-value < 0.05).

Factors suggesting a high possibility of failure were age < 3 months and etiology such as Chiari type 2 malformation or following cerebrospinal fluid infection. Altered CSF dynamics in patients with posthemorrhagic hydrocephalus and under-developed arachnoid villi may play a role in ETV failure. They do not recommend ETV as first-line in children < 3 months of age or in case of Chiari II or following infection 2).

Hydrocephalus/Myelomeningocele

A role for endoscopic third ventriculostomy (ETV) in myelomeningocele (MM) has provoked much debate, principally due to anatomical variants described, which may complicate the procedure.

Perez da Rosa et al. present 7 cases of children with MM and hydrocephalus undergoing a total of 10 ETV procedures. All patients demonstrated clinical improvement (in acute/subacute cases) or stabilization (in chronic cases). Three patients requiring a second ETV have shown clinical stability and renewed radiological evidence of functioning ventriculostomies in follow-up since reintervention. ETV can be used, albeit cautiously, in selected cases of hydrocephalus associated with MM. However, the frequency with which anatomical variation is encountered and the difficulty of the assessment of success make the procedure more challenging than usual 3).

Idiopathic normal pressure hydrocephalus

The only randomized trial of endoscopic third ventriculostomy (ETV) for idiopathic normal pressure hydrocephalus (iNPH) compares it to an intervention which is not a standard practice (VP shunting using a non-programmable valve). The evidence from this study is inconclusive and of very low quality. Clinicians should be aware of the limitations of the evidence. There is a need for more robust research on this topic to be able to determine the effectiveness of ETV in patients with iNPH 4).

Endoscopic third ventriculostomy (ETV) provides a physiological restoration of cerebrospinal fluid and a shunt-free option for pediatric hydrocephalus. Continuous developments in techniques and instruments have improved ETV as the first-line treatment.

Endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) offers an alternative to shunt treatment for infantile hydrocephalus.

More patients undergo ETV with a better outcome, identifying a new era of hydrocephalus treatment. Deeper understanding of ETV will improve a better shunt-free survival for pediatric hydrocephalus patients 5).

Hydrocephalus from thalamic hemorrhage

ETV is a safe and effective technique for the management of hydrocephalus resulting from an extraventricular obstruction in ETV is a safe and effective technique for the management of hydrocephalus resulting from an extraventricular obstruction in thalamic hemorrhage. It can avoid the need for permanent shunting in this patient population. Larger studies should be conducted to validate and further analyze this intervention.

It can avoid the need for permanent shunting in this patient population. Larger studies should be conducted to validate and further analyze this intervention 6).

References

1)

Kahle KT, Kulkarni AV, Limbrick DD Jr, Warf BC. Hydrocephalus in children. Lancet. 2015 Aug 6. pii: S0140-6736(15)60694-8. doi: 10.1016/S0140-6736(15)60694-8. [Epub ahead of print] Review. PubMed PMID: 26256071.
2)

El Damaty A, Marx S, Cohrs G, Vollmer M, Eltanahy A, El Refaee E, Baldauf J, Fleck S, Baechli H, Zohdi A, Synowitz M, Unterberg A, Schroeder HWS. ETV in infancy and childhood below 2 years of age for treatment of hydrocephalus. Childs Nerv Syst. 2020 Mar 28. doi: 10.1007/s00381-020-04585-8. [Epub ahead of print] PubMed PMID: 32222800.
3)

Perez da Rosa S, Millward CP, Chiappa V, Martinez de Leon M, Ibáñez Botella G, Ros López B. Endoscopic Third Ventriculostomy in Children with Myelomeningocele: A Case Series. Pediatr Neurosurg. 2015 May 27. [Epub ahead of print] PubMed PMID: 26021675.
4)

Tudor KI, Tudor M, McCleery J, Car J. Endoscopic third ventriculostomy (ETV) for idiopathic normal pressure hydrocephalus (iNPH). Cochrane Database Syst Rev. 2015 Jul 29;7:CD010033. doi: 10.1002/14651858.CD010033.pub2. Review. PubMed PMID: 26222251.
5)

Feng Z, Li Q, Gu J, Shen W. Update on Endoscopic Third Ventriculostomy in Children. Pediatr Neurosurg. 2018 Aug 15:1-4. doi: 10.1159/000491638. [Epub ahead of print] Review. PubMed PMID: 30110690.
6)

Zeineddine HA, Dono A, Kitagawa R, Savitz SI, Choi HA, Chang TR, Ballester LY, Esquenazi Y. Endoscopic Third Ventriculostomy for Hydrocephalus Secondary to Extraventricular Obstruction in Thalamic Hemorrhage: A Case Series. Oper Neurosurg (Hagerstown). 2020 May 4. pii: opaa094. doi: 10.1093/ons/opaa094. [Epub ahead of print] PubMed PMID: 32365205.

Precautions for endoscopic transnasal skull base surgery during the COVID-19 pandemic

PRECAUTIONS FOR ENDOSCOPIC TRANSNASAL SKULL BASE SURGERY DURING THE COVID-19 PANDEMIC

Key Words: COVID-19, coronavirus, transmission, endoscopic surgery, extended endoscopic skull base surgery, personal protective equipment (PPE), Powered Air Purifying Respirators (PAPR)

Zara M. Patel, MD; Juan Fernandez-Miranda, MD; Peter H. Hwang, MD; Jayakar V. Nayak, MD, PhD; Robert Dodd, MD, PhD; Hamed Sajjadi, MD; Robert K. Jackler, MD

Stanford University School of Medicine
Departments of Otolaryngology-Head & Neck Surgery and Neurosurgery

On March 12, 2020 the World Health Organization (WHO) officially announced the COVID-19 outbreak a pandemic, where to date there have been over 381,000 cases resulting in over 16,500

1

The compilation of information below is anecdotal, based primarily on personal communication with international colleagues reporting their individual experiences, and more data is needed before strict policies are set. There is no scientific evidence in this report. However, based on the preliminary observations summarized below and the fast course of events, it would be prudent to exercise an abundance of caution as more data accumulates. Our goal with this preliminary, rapid article is to alert surgeons of the need to temporarily alter their practices to avoid repeating the unfortunate experience of the early period of the epidemic.

Personal communication with colleagues deployed in Wuhan, China to combat the COVID-19 outbreak, have warned us about the potential risks of endonasal endoscopic surgery in COVID – 19 symptomatic patients. From their reports, a patient with mild flu-like symptoms underwent transphenoidal pituitary surgery in early January 2020, before the severity of this pandemic was well established. Multiple members (>14 by report) of the patient care team, both within and outside of the operating room, became infected from what became recognized as human-to-

2

deaths worldwide.
information that we can gain from our international colleagues who have already experienced this, or are currently going through it, should be utilized to protect our patients, our hospital teams and ourselves.

The COVID-19 pandemic is accelerating within the United States, and any

human transmission of COVID-19.
second case of intraoperative transmission of COVID-19 occurred later on January 2020, at the peak of the pandemic in Wuhan province. A young patient with a known pituitary adenoma developed fever and acute vision changes and was diagnosed with pituitary apoplexy and suspected viral pneumonia based on imaging studies. The surgical team was aware of the potential risks of infection, but given the acuity of symptoms proceeded with transphenoidal surgery using personal protective equipment (PPE). The neurosurgeon and two OR nurses employed N95 masks and the anesthesiologist reportedly used a “home-made” positive pressure helmet. The operation was completed successfully without incident and the surgical team was quarantined after surgery. Within 3-4 days, all of them developed fever and respiratory

Testing for COVID-19 prior to that time was scarce. A

symptoms compatible with pneumonia, except the anesthesiologist. Fortunately, all recovered with no sequelae. The patient, however, required prolonged intubation, but finally recovered.

A significant number of doctors who became infected and even died in Wuhan, China were anesthesiologists/critical care doctors, ophthalmologists, and otolaryngologists, possibly due to

3

From our colleagues in Iran, Dr. Ebrahim Razmpa, Professor of Otolaryngology at Tehran University Medical Sciences, Dr. Saee Atighechi, Associate Professor of Otolaryngology at Yazd University School of Medicine, and Dr. Mohammed Hossein Baradanfar, Professor and Chairman of Otolaryngology Yazd University School of Medicine, we have additionally heard that at least 20 otolaryngologists in Iran are currently hospitalized with COVID-19, with 20 more in isolation at home. They are testing only people who have been admitted to the hospital,

so those twenty at home are not confirmed, but have classic symptoms. A previously healthy 60 year old facial plastic surgeon died from COVID-19 three days ago. A young, otherwise healthy otolaryngology chief resident had a short prodrome, rapidly decompensated and died from what was found to be acute myocarditis and cardiac arrest. It was recently confirmed from these colleagues that he did also test positive for COVID-19.

The British Association of Otorhinolaryngology has now also stated two of its consultants are on

8

Our colleague Dr. Puya Deghani-Mobaraki, in Italy, also reports otolaryngologists being affected adversely, but his information is about the possible loss of smell and taste that this virus brings. They are not only seeing it in their patients, but they have noticed it within their own ranks, in otherwise healthy asymptomatic doctors, at rates far above what could be considered normal. This observation has also been reported in the media regarding patients, as an under-reported

9,10

quarantine or to come in and be tested, depending on individual evaluation.

Based on this information, and until we know more, we are performing only urgent/emergent surgery at Stanford University at this time. Due to this apparent high risk with endoscopic transnasal surgery on COVID-19 symptomatic patients, in spite of current limitations in testing capacity, our institution has approved testing for COVID-19 in pre-operative patients needing this type of procedure urgently or emergently. This is true even for asymptomatic patients (ie. no cough and/or fever), although the true risk in this cohort of patients is still unknown. If the test is negative and the patient is asymptomatic, we may proceed using normal levels of protective gear; however, the rate of false negative tests is still to be determined, and until this is known , the use of additional levels of PPE, such as N95 and face shields can be considered. If the test is

the high viral shedding from the nasal and oropharyngeal cavity.
high risk of infection when taking care of COVID-19 patients without PPE. High risk procedures include intubation and procedures involving the upper respiratory tract and gastrointestinal tract with risk for aerosolization, such as endoscopy, bronchoscopy, and laryngoscopy.

7
Hospital “Hippocrates” are quarantined, as a doctor at the Otolaryngology Clinic reportedly

ventilators and being treated for COVID-19.

In Athens, 21 staff members of the Athens General

tested positive for COVID-19.

aspect of this disease process.
France in association with COVID-19 that the government has issued an official statement instructing citizens with this symptom to contact their physicians, who may advise self-

11

In fact, this symptom has been seen now so commonly in

Healthcare providers are at

positive, we defer surgery if at all possible until the infection is cleared, verified by repeat testing. When endonasal surgery cannot be postponed in a COVID-19 positive patient, based on guidelines now being used in China, we have recommended to our institutional officials that we utilize full PAPR (an enclosed powered system with HEPA filter), acknowledging that they have challenging decisions surrounding allocation of limited resources that are urgently needed by our

12

The question of whether two separate negative tests are needed before surgery, or if one is sufficient, is under active discussion. The test that we are using, developed at Stanford, is an in- house assay that uses a real time RT-PCR for SARS-CoV-2. This first screens for the presence of virus envelope protein, and if positive then evaluates for the presence of the RNA-dependent RNA polymerase gene for confirmation (Developed by Benjamin Pinsky MD, Stanford University). Positive results from this test have been demonstrated to be very sensitive and very specific and have been given early approval by the FDA. The Chinese CDC test uses different gene targets and primers and thus may, or may not, have a different accuracy profile. Conservation of precious testing and PPE resources is another reason to limit these operations to the bare minimum at this time. We also recommend use of as minimal an OR team as necessary and that no trainees or observers be allowed in the room both for reasons of safety and to preserve PPE.

In the clinic setting, we have similarly restricted visits to only urgent/emergent patients and have ceased the use of spray anesthetic/decongestants, opting instead for nasal pledgets as needed, but preferably avoiding endoscopy whenever possible. We are using N95 masks, face shields and gowns for all outpatient nasal endoscopies.

Please keep in mind that from the time of this submission, the situation may have evolved, and our policies may have changed. We hope that more hard data becomes available soon upon which to base these important decisions. We follow with tempered optimism the evolution of this pandemic in China, where at this point no new local cases have been reported for several days now, with gradual return to normal surgical activities, including endoscopic endonasal surgery.

We thank our international colleagues who have given us this important information, and we extend wishes of safety and health to all our otolaryngology, neurosurgery, and critical care/anesthesia colleagues at this challenging time.

John’s Hopkins Coronovirus Center. https://coronavirus.jhu.edu/map.html Accessed March 21, 2020

2China Newsweek. View.inews.qq.com/a/20200125A07TT200?uid=&devid=BDFE70CD-5BF1-4702-91B7- 329F20A6E839&qimei=bdfe70cd-5bf1-4702-91b7-329f20a6e839

3https://www.bloomberg.com/news/articles/2020-03-17/europe-s-doctors-getting-sick-like-in-wuhan-chinese- doctors-say?fbclid=IwAR2ds9OWRxQuMHAuy5Gb7ltqUGMZNSojVNtFmq3zzcSLb_bO9aGYr7URxaI

critical care teams taking care COVID-19 patients.
should be considered whenever possible. Because endonasal surgery creates clouds of droplets and aerosols which may permeate the operating environment, anyone in the operating theater requires the same protection when operating on known COVID-19 positives.

Alternatively, a transcranial approach

3van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med. 2020 Mar 17. doi: 10.1056/NEJMc2004973. [Epub ahead of print]

55Zou L, Ruan F, Huang M, et al. SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients. N Engl J Med. 2020 Mar 19;382(12):1177-1179. doi: 10.1056/NEJMc2001737. Epub 2020 Feb 19.

6121
6Xu K , Lai XQ , Liu Z . Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2020 Feb 2;55(0):E001. doi:

10.3760/cma.j.issn.1673-0860.2020.0001. [Epub ahead of print] [Suggestions for prevention of 2019 novel coronavirus infection in otolaryngology head and neck surgery medical staff].
[Article in Chinese (translated via Google translator); Abstract available in Chinese from the publisher]

7 https://news.sky.com/story/coronavirus-experts-say-new-symptoms-could-be-loss-taste-or-smell-11961439 8 8https://www.euractiv.com/section/politics/news/cracks-appear-in-nordic-response-to-covid-19-crisis/

9 9https://en.radiofarda.com/a/loss-of-sense-of-smell-among-iranians-coinciding-with-coronavirus- epidemic/30478044.html

10 https://www.forbes.com/sites/judystone/2020/03/20/theres-an-unexpected-loss-of-smell-and-taste-in-coronavirus- patients/#48e2a8c85101

11https://www.sortiraparis.com/news/coronavirus/articles/210162-coronavirus-update-on-the-situation-in-paris-and- ile-de-france-controls-reinforc/lang/en

12 Lian, Tingbo (Editor). Handbook of COVID-19 Prevention and Treatment. The First Affiliated Hospital. Zhejiang University School of Medicine. Compiled according to Clinical Experience.

2nd Erlangen Interdisciplinary Course for Microscopic and Endoscopic Surgery of the Anterior and Lateral Skull Base

2nd Erlangen Interdisciplinary Course for Microscopic and Endoscopic Surgery of the Anterior and Lateral Skull Base

Program

International course designed for residents in ENT and Neurosurgery as well as more advanced surgeons looking for recent developments in their field of expertise

Topics:

-> Anterior skull base: Endoscopic/open transfacial approaches to the anterior skull base; Endoscopic/open surgery of the orbita; Cavernous sinus surgery; Pituitary surgery
-> Lateral skull base: Mastoidectomy; Petrosectomy; Translabyrinthine/retrosigmoid/middle fossa approach;
-> Management of complications; Skull base reconstruction, Oncologic therapy concepts

Course Organisation:

Hals-Nasen-Ohren-Klinik,
Kopf- und Halschirurgie
Director: Prof. Dr. med. Heinrich Iro

Neurochirurgische Klinik
Director: Prof. Dr. med. Michael Buchfelder

Institut für Funktionelle und Klinische Anatomie
Associate Director: Prof. Dr. Lars Bräuer