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Suprasellar Approaches: New Techniques and Old Tricks for Cerebrospinal Fluid Leaks
Perspectives Commentary on: The Transplanum Transtuberculum Approaches for Suprasellar and Sellar-Suprasellar Lesions: Avoidance of Cerebrospinal Fluid Leak and Lessons Learned by Mascarenhas et al. World Neurosurg 2014 http://dx.doi.org/10.1016/j.wneu.2013.02.032
Mauro Loyo-Varela, M.D. Chairman, Department of Neurosurgery Hospital Regional Veracruz Department of Neurosurgery American British Cowdray Medical Center
Suprasellar Approaches: New Techniques and Old Tricks for Cerebrospinal Fluid Leaks Mauro Loyo-Varela1 and Salvador Manrique-Guzman2
M
ascarenhas et al. elegantly summarize their surgical experience with a total of 122 patients, done in a two-stage report, the first part a total of 63 patients were included and the second had 59 patients. The patients underwent to a transsphenoidal transplanum sphenoidale approach for sellar and suprasellar region tumors. The article focused on complication incidence and proves that the learning curve is an important factor for success for this complex approach. Results from the first group showed four patients with cerebrospinal fluid (CSF) leak, the rest of the patients did not experience any other complication. Mascarenhas et al. describe the development a packing technique using fascia, contained by a plaque of porous polyethylene (Medpore [Stryker Corporation, Kalamazoo, Michigan, USA]), covered by a nasoseptal pedicle flap, and finally all covered with fibrin sealant. Using this novel packing technique, they report 0 incidence of CSF leak. The tumors treated by the approach included pituitary adenomas (51.6%), craneopharingioma (20.6%), and meningiomas (15.9%). The main symptom was visual disturbances in 73% of the cohort. Patient selection has an extra credit from my point of view, proving that the learning curve has a direct influence in patient outcome using this novel approach.
The transsphenoidal approach was described more than a century ago for the treatment of sellar region tumors. This approach has evolved over time along with technology (microscope) reaching its current gold standard for these tumors. Limitation for this approach has been extension beyond the midline. The transcranial approach still helpful to treat this kind of tumor. Our team was
Key words - Craniopharyngioma - Endonasal transsphenoidal approach - Meningioma - Planum sphenoidale - Rathke cleft cyst - Skull base - Tuberculum sellae
Abbreviations and Acronyms CSF: Cerebrospinal fluid
WORLD NEUROSURGERY 00 (0): ---, MONTH 2014
a pioneer in the transcranial and transsphenoidal combined approaches. After we published our experience, other groups of investigators also tried this technique. Currently, this approach is limited for unique and complex cases, recalling the mobility of the extensive brain retraction. The extended transsphenoidal approaches with enhanced access to the skull base to treat parasellar and clival tumors was described by Liu et al. (1). They proposed to modify the retractor position and asymmetric retracts so that different parts of the skull base could be visualized and bony resection could be extended superiorly, inferiorly, and laterally. With this modification, the extended transsphenoidal approach offers a wide window for the resection of the tumor located beyond the conventional sella and suprasellar cistern limits. The suprasellar tumor can be reached by extending anteriorly after the removal of the bone. The cavernous sinus will be located laterally. During the past two decades endonasal endoscopic approaches have gained enormous terrain, treating tumors located in the skull base. Confidence and ability gain by neurosurgeons and with better visual definition of the surgical field makes it an effective and safe surgical tool. Development of new angled loops allows the treatment of tumors near or within the nasal cavities. Brain retraction can be excluded using endoscopy for skull base lesions and enhances ventral exposure compared with the traditional transcranial route. Tumors near the internal carotid artery and the optic nerve can be treated as first-line choice by the transcranial route.
From the 1Department of Neurosurgery, Hospital Regional Veracruz, Veracruz; and the Department of Neurosurgery, American British Cowdray Medical Center, Mexico City; and 2Department of Neurosurgery, Centro Medico ABC, Mexico City, Mexico To whom correspondence should be addressed: Mauro Loyo-Varela, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2014). http://dx.doi.org/10.1016/j.wneu.2013.03.065
www.WORLDNEUROSURGERY.org
1
PERSPECTIVES
The intraoperative navigation system along with the endoscope, guided by the highest definition radiologic study, has allowed for more lesions to be treated using this approach. Neurosurgical centers around the world have been publishing their own experience using endonasal endoscopic approaches for the surgical treatment of lesions located in the cavernous sinus, clivus, and planum-sphenoidale. The major optic difference between the microscopic and endoscopic approach for skull base tumors, is that with the microscope, the surgeon perceived the depth, with the endoscopic approach optic allows only a two-dimensional view but it allows for a more dynamic interaction between the optics and the surgeon. Currently, most surgeons use active movement to sense the depth, but that ability is learned after a learning curve.
REFERENCES 1. Liu JK, Weiss MH, Couldwell WT: Surgical approaches to pituitary tumors. Neurosurg Clin N Am 14:93-107, 2003.
2
www.SCIENCEDIRECT.com
At present we use microscopic- and endoscopic-assisted approaches and neuronavigation systems when skull base tumors will be resected, mainly to avoid vascular complications. Using the microscope during closure of the work helps to improve the perspective of patching. Because complications of CFS leak are serious central nervous system infections, more than one technique has been proposed to avoid this difficulty. In these 122 cases, Mascarenhas et al. did not experience CFS leaks. Three factors influenced this result—the surgeon’s experience in skull base tumors, nasoseptal flap, and fibrin sealant over the defect. We found no evidence that Mascarenhas et al. used a patch over the defect as most surgeons do in this kind of surgical approach.
Citation: World Neurosurg. (2014). http://dx.doi.org/10.1016/j.wneu.2013.03.065
1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved.
Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2013.03.065
Mauro Loyo-Varela, M.D. Chairman, Department of Neurosurgery Hospital Regional Veracruz Department of Neurosurgery American British Cowdray Medical Center
Suprasellar Approaches: New Techniques and Old Tricks for Cerebrospinal Fluid Leaks Mauro Loyo-Varela1 and Salvador Manrique-Guzman2
M
ascarenhas et al. elegantly summarize their surgical experience with a total of 122 patients, done in a two-stage report, the first part a total of 63 patients were included and the second had 59 patients. The patients underwent to a transsphenoidal transplanum sphenoidale approach for sellar and suprasellar region tumors. The article focused on complication incidence and proves that the learning curve is an important factor for success for this complex approach. Results from the first group showed four patients with cerebrospinal fluid (CSF) leak, the rest of the patients did not experience any other complication. Mascarenhas et al. describe the development a packing technique using fascia, contained by a plaque of porous polyethylene (Medpore [Stryker Corporation, Kalamazoo, Michigan, USA]), covered by a nasoseptal pedicle flap, and finally all covered with fibrin sealant. Using this novel packing technique, they report 0 incidence of CSF leak. The tumors treated by the approach included pituitary adenomas (51.6%), craneopharingioma (20.6%), and meningiomas (15.9%). The main symptom was visual disturbances in 73% of the cohort. Patient selection has an extra credit from my point of view, proving that the learning curve has a direct influence in patient outcome using this novel approach.
The transsphenoidal approach was described more than a century ago for the treatment of sellar region tumors. This approach has evolved over time along with technology (microscope) reaching its current gold standard for these tumors. Limitation for this approach has been extension beyond the midline. The transcranial approach still helpful to treat this kind of tumor. Our team was
Key words - Craniopharyngioma - Endonasal transsphenoidal approach - Meningioma - Planum sphenoidale - Rathke cleft cyst - Skull base - Tuberculum sellae
Abbreviations and Acronyms CSF: Cerebrospinal fluid
WORLD NEUROSURGERY 00 (0): ---, MONTH 2014
a pioneer in the transcranial and transsphenoidal combined approaches. After we published our experience, other groups of investigators also tried this technique. Currently, this approach is limited for unique and complex cases, recalling the mobility of the extensive brain retraction. The extended transsphenoidal approaches with enhanced access to the skull base to treat parasellar and clival tumors was described by Liu et al. (1). They proposed to modify the retractor position and asymmetric retracts so that different parts of the skull base could be visualized and bony resection could be extended superiorly, inferiorly, and laterally. With this modification, the extended transsphenoidal approach offers a wide window for the resection of the tumor located beyond the conventional sella and suprasellar cistern limits. The suprasellar tumor can be reached by extending anteriorly after the removal of the bone. The cavernous sinus will be located laterally. During the past two decades endonasal endoscopic approaches have gained enormous terrain, treating tumors located in the skull base. Confidence and ability gain by neurosurgeons and with better visual definition of the surgical field makes it an effective and safe surgical tool. Development of new angled loops allows the treatment of tumors near or within the nasal cavities. Brain retraction can be excluded using endoscopy for skull base lesions and enhances ventral exposure compared with the traditional transcranial route. Tumors near the internal carotid artery and the optic nerve can be treated as first-line choice by the transcranial route.
From the 1Department of Neurosurgery, Hospital Regional Veracruz, Veracruz; and the Department of Neurosurgery, American British Cowdray Medical Center, Mexico City; and 2Department of Neurosurgery, Centro Medico ABC, Mexico City, Mexico To whom correspondence should be addressed: Mauro Loyo-Varela, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2014). http://dx.doi.org/10.1016/j.wneu.2013.03.065
www.WORLDNEUROSURGERY.org
1
PERSPECTIVES
The intraoperative navigation system along with the endoscope, guided by the highest definition radiologic study, has allowed for more lesions to be treated using this approach. Neurosurgical centers around the world have been publishing their own experience using endonasal endoscopic approaches for the surgical treatment of lesions located in the cavernous sinus, clivus, and planum-sphenoidale. The major optic difference between the microscopic and endoscopic approach for skull base tumors, is that with the microscope, the surgeon perceived the depth, with the endoscopic approach optic allows only a two-dimensional view but it allows for a more dynamic interaction between the optics and the surgeon. Currently, most surgeons use active movement to sense the depth, but that ability is learned after a learning curve.
REFERENCES 1. Liu JK, Weiss MH, Couldwell WT: Surgical approaches to pituitary tumors. Neurosurg Clin N Am 14:93-107, 2003.
2
www.SCIENCEDIRECT.com
At present we use microscopic- and endoscopic-assisted approaches and neuronavigation systems when skull base tumors will be resected, mainly to avoid vascular complications. Using the microscope during closure of the work helps to improve the perspective of patching. Because complications of CFS leak are serious central nervous system infections, more than one technique has been proposed to avoid this difficulty. In these 122 cases, Mascarenhas et al. did not experience CFS leaks. Three factors influenced this result—the surgeon’s experience in skull base tumors, nasoseptal flap, and fibrin sealant over the defect. We found no evidence that Mascarenhas et al. used a patch over the defect as most surgeons do in this kind of surgical approach.
Citation: World Neurosurg. (2014). http://dx.doi.org/10.1016/j.wneu.2013.03.065
1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved.
Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2013.03.065