Light at the End of the Tunnel: The Learning Curve Associated with Endoscopic Transsphenoidal Skull Base Surgery

Smith, Stuart; Eralil, George; Woon, Kelvin; Sama, Anshul; Dow, Graham; Robertson, Iain

doi:10.1055/s-0029-1238214

Cited by 48 publications

(50 citation statements)

References 24 publications

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“…Prior studies evaluating the learning curve in endoscopic endonasal pituitary surgery have yielded mixed results. Sonnenburg et al evaluated their results with pi- 30 Another study demonstrated significant improvement in visual outcome and operating time after 50 endoscopic endonasal pituitary cases. 18 It would seem self-evident that there would be a learning curve in expanded endonasal cranial base procedures in which the depth of surgical field is increased and the lesions are more intimately associated with critical neurovascular structures.…”

Section: Learning Curve In Craniopharyngioma Surgerymentioning

confidence: 99%

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The learning curve in endoscopic endonasal resection of craniopharyngiomas

Kshettry

Do²,

Elshazly

et al. 2016

FOC

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OBJECTIVE There is a paucity of literature regarding the learning curve associated with performing endoscopic endonasal cranial base surgery. The purpose of this study was to determine to what extent a learning curve might exist for endoscopic endonasal resection in cases of craniopharyngiomas. METHODS A retrospective review was performed for all endoscopic endonasal craniopharyngioma resections performed at Thomas Jefferson University from 2005 to 2015. To assess for a learning curve effect, patients were divided into an early cohort (2005–2009, n = 20) and a late cohort (2010–2015, n = 23). Preoperative demographics, clinical presentation, imaging characteristics, extent of resection, complications, tumor control, and visual and endocrine outcomes were obtained. Categorical variables and continuous variables were compared using a 2-sided Fisher's exact test and t-test, respectively. RESULTS Only the index operation performed at the authors' institution was included. There were no statistically significant differences between early and late cohorts in terms of patient age, sex, presenting symptoms, history of surgical or radiation treatment, tumor size or consistency, hypothalamic involvement, or histological subtype. The rate of gross-total resection (GTR) increased over time from 20% to 65% (p = 0.005), and the rate of subtotal resection decreased over time from 40% to 13% (p = 0.078). Major neurological complications, including new hydrocephalus, meningitis, carotid artery injury, or stroke, occurred in 6 patients (15%) (8 complications) in the early cohort compared with only 1 (4%) in the late cohort (p = 0.037). CSF leak decreased from 40% to 4% (p = 0.007). Discharge to home increased from 64% to 95% (p = 0.024). Visual improvement was high in both cohorts (88% [early cohort] and 81% [late cohort]). Rate of postoperative panhypopituitarism and permanent diabetes insipidus both increased from 50% to 91% (p = 0.005) and 32% to 78% (p = 0.004), which correlated with a significant increase in intentional stalk sacrifice in the late cohort (from 0% to 70%, p < 0.001). CONCLUSIONS High rates of near- or total resection and visual improvement can be achieved using an endoscopic endonasal approach for craniopharyngiomas. However, the authors did find evidence for a learning curve. After 20 cases, they found a significant decrease in major neurological complications and significant increases in the rates of GTR rate and discharge to home. Although there was a large decrease in the rate of postoperative CSF leak over time, this was largely attributable to the inclusion of very early cases prior to the routine use of vascularized nasoseptal flaps. There was a significant increase in new panhypopituitarism and diabetes insipidus, which is attributable to increase rates of intentional stalk sacrifice.

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Section: Learning Curve In Craniopharyngioma Surgerymentioning

confidence: 99%

“…In fact, very little published documentation exists regarding the learning curve associated with endonasal cranial base cases in general. 17,18,24,30,33 The purpose of the present study was to determine if, and to what extent, a learning curve exists for the endoscopic transnasal resection of craniopharyngiomas.…”

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confidence: 99%

The learning curve in endoscopic endonasal resection of craniopharyngiomas

Kshettry

Do²,

Elshazly

et al. 2016

FOC

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“…19,26 Although the benefits of the endoscopic technique for properly selected patients are clear, neurosurgeons have been slow to adopt it because of the steep operator's learning curve. 20,34,40 To that end, we present this technical descriptive report and detailed illustrations of the technical nuances recommended for endonasal endoscopic resection of craniopharyngiomas.…”

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Endoscopic extended transsphenoidal resection of craniopharyngiomas: nuances of neurosurgical technique

Conger¹,

M.S.

Lucas

et al. 2014

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Endoscopic approaches to the midline ventral skull base have been extensively developed and refined for resection of cranial base tumors over the past several years. As these techniques have improved, both the degree of resection and complication rates have proven comparable to those for transcranial approaches, while visual outcomes may be better via endoscopic endonasal surgery and hospital stays and recovery times are often shorter. Yet for all of the progress made, the steep learning curve associated with these techniques has hampered more widespread implementation and adoption. The authors address this obstacle by coupling a thorough description of the technical nuances for endoscopic endonasal craniopharyngioma resection with detailed illustrations of the important steps in the operation. Traditionally, transsphendoidal approaches to craniopharyngiomas have been restricted to lesions mostly confined to the sella. However, recently, endoscopic endonasal resections are more frequently employed for extrasellar and purely third ventricle craniopharyngiomas, whose typical retrochiasmatic location makes them ideal candidates for endoscopic transnasal surgery. The endonasal endoscopic approach offers many advantages, including direct access to the long axis of the tumor, early tumor debulking with minimal manipulation of the optic apparatus, more precise visualization of tumor planes, particularly along the undersurface of the chiasm and the roof of the third ventricle, and a minimal-access corridor that obviates the need for brain retraction. Although much emphasis has been placed on technical tenets of exposure and “how to get there,” this article focuses on nuances of tumor resection “when you are there.” Three operative videos illustrate our discussion of technical tenets.

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“…13,20,25 To flatten the learning curve and clarify some of the technical nuances involved in successful removal of tuberculum sellae meningiomas, we present a purely technical descriptive study and provide elaborate illustrations prepared through 3D graphic models. The purpose of this report is to familiarize the novice endonasal surgeon with a 6-step process for removing these meningiomas.…”

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confidence: 99%

“…7 As demonstrated by the higher complication rates reported for those early in their endoscopic neurosurgical careers, the learning curve can be steep, particularly for neurosurgeons not well trained in endonasal endoscopy. 13,20,25 To flatten the learning curve and clarify some of the technical nuances involved in successful removal of tuberculum sellae meningiomas, we present a purely technical descriptive study and provide elaborate illustrations prepared through 3D graphic models. The purpose of this report is to familiarize the novice endonasal surgeon with a 6-step process for removing these meningiomas.…”

mentioning

confidence: 99%

Endoscopic extended transsphenoidal resection of tuberculum sellae meningiomas: nuances of neurosurgical technique

Kulwin

Schwartz

Cohen-Gadol

2013

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Over the past decade, advances in endoscopic microsurgical techniques have resulted in an increasingly aggressive endonasal approach to tumors of the midline skull base. Meningiomas of the tuberculum sellae are often closely associated with cerebrovascular structures, and their removal has traditionally required a transcranial approach. An endonasal approach offers many advantages, including early tumor devascularization and tumor debulking (without manipulation of the optic apparatus), direct access to the medial optic canal, and a minimal-access corridor. Although recent articles have focused on techniques for reaching and approaching the area of the pathology (how to get there), the authors of this report discuss the technical nuances of endoscopic microsurgery when the operator is already “there.” They describe their 6-step technique for endoscopic skull base bone removal, tumor dissection/resection, and closure. They also augment their description with elaborate illustrations.

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Light at the End of the Tunnel: The Learning Curve Associated with Endoscopic Transsphenoidal Skull Base Surgery

Cited by 48 publications

References 24 publications

The learning curve in endoscopic endonasal resection of craniopharyngiomas

The learning curve in endoscopic endonasal resection of craniopharyngiomas

Endoscopic extended transsphenoidal resection of craniopharyngiomas: nuances of neurosurgical technique

Endoscopic extended transsphenoidal resection of tuberculum sellae meningiomas: nuances of neurosurgical technique

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