Lessons learned in the evolution of endoscopic skull base surgery

Schwartz, Theodore H.; Morgenstern, Peter; Anand, Vijay K.

doi:10.3171/2018.10.jns182154

Cited by 69 publications

(43 citation statements)

References 89 publications

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“…Numerous studies comparing EEA to transcranial surgery have demonstrated that in experienced hands, EEA can offer high rates of resection with low complications. 35 However, even after hundreds of cases, there are subtle changes in practice that indicate how the field is evolving. For example, our CSF leak rate was fairly constant and did not markedly improve over time, although our use of lumbar drains decreased.…”

Section: Evolution Of Skull Base Closurementioning

confidence: 99%

How long is the tail end of the learning curve? Results from 1000 consecutive endoscopic endonasal skull base cases following the initial 200 cases

Younus

Gerges²,

Uribe-Cardenas³

et al. 2021

Journal of Neurosurgery

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OBJECTIVEEndoscopic endonasal approaches (EEAs) to the skull base have evolved over the last 20 years to become an essential component of a comprehensive skull base practice. Many case series show a learning curve from the earliest cases, in which the authors were inexperienced or were not using advanced closure techniques. It is generally accepted that once this learning curve is achieved, a plateau is reached with little incremental improvement. Cases performed during the early steep learning curve were eliminated to examine whether the continued improvement exists over the “tail end” of the curve.METHODSA prospectively acquired database of all EEA cases performed by the senior authors at Weill Cornell Medicine/NewYork-Presbyterian Hospital was reviewed. The first 200 cases were eliminated and the next 1000 consecutive cases were examined to avoid the bias created by the early learning curve.RESULTSOf the 1000 cases, the most common pathologies included pituitary adenoma (51%), meningoencephalocele or CSF leak repair (8.6%), meningioma (8.4%), craniopharyngioma (7.3%), basilar invagination (3.1%), Rathke’s cleft cyst (2.8%), and chordoma (2.4%). Use of lumbar drains decreased from the first half to the second half of our series (p <0.05) as did the authors’ use of fat alone (p <0.005) or gasket alone (p <0.005) for dural closure, while the use of a nasoseptal flap increased (p <0.005). Although mean tumor diameter was constant (on average), gross-total resection (GTR) increased from 60% in the first half to 73% in the second half (p <0.005). GTR increased for all pathologies but most significantly for chordoma (56% vs 100%, p <0.05), craniopharyngioma (47% vs 0.71%, p <0.05) and pituitary adenoma (67% vs 75%, p <0.05). Hormonal cure for secreting adenomas also increased from 83% in the first half to 89% in the second half (p <0.05). The rate of any complication was unchanged at 6.4% in the first half and 6.2% in the latter half of cases, and vascular injury occurred in only 0.6% of cases. Postoperative CSF leak occurred in 2% of cases and was unchanged between the first and second half of the series.CONCLUSIONSThis study demonstrates that contrary to popular belief, the surgical learning curve does not plateau but can continue for several years depending on the complexity of the endpoints considered. These findings may have implications for clinical trial design, surgical education, and patient safety measures.

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Section: Evolution Of Skull Base Closurementioning

confidence: 99%

How long is the tail end of the learning curve? Results from 1000 consecutive endoscopic endonasal skull base cases following the initial 200 cases

Younus

Gerges²,

Uribe-Cardenas³

et al. 2021

Journal of Neurosurgery

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“…Therefore, the reconstruction of the skull base following extended EEA to the skull base is of paramount importance in avoiding post-operative CSF leak. Advances in skull base reconstruction, particularly the use of vascularized local flaps, have greatly reduced the incidence of this complication and have been instrumental in the expansion of these approaches for the management of skull base malignancy (25). The importance of using vascularized flaps as part of a multi-layer, rather than a monolayer closure of skull base defects to prevent post-operative CSF leak has also been highlighted in a recent study by Simal-Julián et al (26).…”

Section: Introductionmentioning

confidence: 99%

Methods of Skull Base Repair Following Endoscopic Endonasal Tumor Resection: A Review

2020

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Following the introduction of fully endoscopic techniques for the resection of pituitary tumors, there was a rapid expansion of the indications for endonasal endoscopic surgery to include extrasellar tumors of the skull base. These techniques offer significant advantages over traditional open surgical approaches to the skull base, including improved tumor resection, and better post-operative neurological outcomes. Following their introduction, however, the initial rate of post-operative CSF leak was unacceptably high. Post-operative CSF leak following skull base surgery is a major source of morbidity, and can lead to the development of life-threatening intracranial infection. The use of vascularized naso-septal flaps transformed the management of these patients, significantly reducing the rate of post-operative CSF leak and increasing the number of patients that could benefit from this less invasive treatment modality. Adequate repair of iatrogenic defects in the skull base is of crucial importance for patients with skull base tumors, as the development of a post-operative CSF leak, and the associated complications can significantly delay the administration of the adjunctive oncological therapies these patients require. In this review, we provide an overview of the latest evidence regarding skull base reconstruction following endoscopic skull base surgery, and describe the skull base repair technique in use at our institution.

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“…Lastly, skull base surgery has been modified in an attempt to make it less morbid [ 28 - 29 ]. Tailored AC aims to provide adequate exposure with less risk of neurovascular injury, allowing enough space to safely treat parasellar lesions.…”

Section: Discussionmentioning

confidence: 99%

Tailored Anterior Clinoidectomy: Beyond the Intradural and Extradural Concepts

Pacheco

Melo

Acioly

et al. 2021

Cureus

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Anterior clinoidectomy (AC) is a key microsurgical step for the safe and successful management of parasellar pathologies that involve the anterior clinoid process (ACP) and the optic canal. Traditionally, extra and intradural ACs are performed separately according to the surgeon's experience or preference. The objective is to present and discuss the tailored AC concept through illustrative cases. We conducted a retrospective record review of three patients who underwent AC as a surgical step for the treatment of parasellar pathologies that involve the ACP and optic canal. A review of the relevant literature on AC was performed in the PubMed, LILACS, and SciELO databases. In all three cases, the pterional craniotomy was the preferred approach for AC. Case 1, a 47-year-old female patient with type III anterior clinoidal meningioma, underwent a tailored intradural technique (optic canal unroofing) with total tumor resection and complete visual recovery. Case 2, a 63-year-old female patient with a complex type II anterior clinoidal meningioma with extensive hyperostosis of the ACP, underwent a hybrid AC technique with complete removal of the tumor and visual improvement. Case 3, a 62-year-old female, underwent a tailored intradural AC for clipping an incidental carotid-ophthalmic aneurysm. Tailored AC aims to provide adequate exposure with less risk of neurovascular injury, allowing enough space to safely treat parasellar lesions. The type, size, and location of the lesion, as well as the surgeon’s experience, should always be considered for surgical planning.

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Lessons learned in the evolution of endoscopic skull base surgery

Cited by 69 publications

References 89 publications

How long is the tail end of the learning curve? Results from 1000 consecutive endoscopic endonasal skull base cases following the initial 200 cases

How long is the tail end of the learning curve? Results from 1000 consecutive endoscopic endonasal skull base cases following the initial 200 cases

Methods of Skull Base Repair Following Endoscopic Endonasal Tumor Resection: A Review

Tailored Anterior Clinoidectomy: Beyond the Intradural and Extradural Concepts

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