Outcomes following endoscopic, expanded endonasal resection of suprasellar craniopharyngiomas: a case series

Abstract

Object. Craniopharyngiomas are challenging tumors that most frequently occur in the sellar or suprasellar regions. Microscopic transsphenoidal resections with various extensions and variations have been performed with good results. The addition of the endoscope as well as the further expansion of the standard and extended transsphenoidal approaches has not been well evaluated for the treatment of this pathological entity.Methods. The authors performed a retrospective review of all patients who underwent a purely endoscopic, expanded endonasal approach (EEA) for the resection of craniopharyngiomas at their institution between June 1999 and February 2006. Endocrine and ophthalmological outcomes, extent of resection, and complications were evaluated.Results. Sixteen patients underwent endoscopic EEA for the resection of craniopharyngiomas. Five patients (31%) presented with recurrent disease. Complete resection was planned in 11 of the 16 patients. Three elderly patients with vision loss underwent planned debulking, 1 patient with vision loss and a moderate-sized tumor had express wishes for debulking, and 1 patient had a separate, third ventricular nodule that was not resected. Of those in whom complete resection was planned, 91% underwent near-total (2/11) or gross-total (8/11) resection. No patient who underwent gross-total resection suffered a recurrence. The mean follow-up period was 34 months. Of the 14 patients who presented with vision loss, 93% had improvement or complete recovery and 1 patient's condition remained stable. No patient experienced visual worsening. Eighteen percent of patients (without preexisting hypopituitarism) developed panhypopituitarism and 8% developed permanent diabetes insipidus. There were no cases of new obesity. The postoperative cerebrospinal fluid leak rate was 58%. All leaks were resolved, and there were no cases of bacterial meningitis. There was 1 vascular injury (posterior cerebral artery perforator branch) resulting in the only new neurological deficit. No patient died.Conclusions. Endoscopic EEA for the resection of craniopharyngiomas provides acceptable results and holds the potential to improve outcomes. comparing these results with those previously published for other approaches, we hope to better judge both approaches in terms of their respective advantages and disadvantages.Although authors of many past studies have assessed craniopharyngioma resection via a transsphenoidal route, 2,17,23,24,29 few 7 have used a purely endoscopic technique and most are biased toward the resection of tumors with minimal supra-or parasellar extension. Our series consists of tumors located above and/or with extension superior and lateral to the sella, superior and posterior to the chiasm, and even extending into the third ventricle. MethodsAfter obtaining institutional review board approval, we reviewed the medical records and imaging studies of all patients with the histopathological diagnosis of craniopharyngioma treated via an EEA between June 1999 and February 2006. No patient was e...

Long-term quality of life after endonasal endoscopic resection of adult craniopharyngiomas

“…Endonasal endoscopic transsphenoidal resection of craniopharyngiomas, compared with open transcranial approaches, has been shown to result in comparable or even greater rates of extent of resection and GTR. 3,5,11,13,21,24,27 Moreover, rates of visual improvement may in fact be higher. 24 Nevertheless, debate regarding the relative merits of endonasal endoscopic surgery compared with open transcranial approaches continues.…”

“…22,27 An endoscopic transsphenoidal approach offers a more direct route to the tumor, avoiding brain retraction, minimizing manipulation of the optic nerves and adjacent small perforating vessels, and resulting in equally high gross-total resection (GTR) rates compared with transcranial series, as well as potentially better visual results. 3,5,11,13,21,24,27 Although there are increasing data about the oncological, neurological, and hormonal outcomes for this treatment option, there are no studies assessing postoperative QOL. In an effort to gain a better understanding of the impact of an endoscopic approach in the treatment of craniopharyngiomas, we used accepted site-specific QOL metrics to measure postoperative QOL in a series of patients with craniopharyngiomas by using their own preoperative data as an internal control in a subset of patients, as well as data from a separate group who underwent endonasal endoscopic pituitary surgery, to control for the approach and highlight disease-specific morbidity.…”

One-Piece Modified Gasket Seal Technique

“…24 Nonetheless, various case series have demonstrated exceptionally high rates of CSF leak following expanded endonasal approaches despite the incorporation of a vascularized NSF. 17,18 This underscores the importance of utilizing a sound multilayered reconstruction technique. Additionally, alternative methods for closure must be available in the event that a NSF cannot be harvested due to tumor invasion.…”

“…16 Many other studies have demonstrated a wide range of CSF leak rates following resection of these lesions, as well, ranging from 9.5 to 58% with a variety of multilayered closure methods. 2,[17][18][19][20][21] Previously, autologous free grafts including fat, muscle, fascia lata, and nasal septal bone/cartilage have served as viable options for skull base reconstruction following endoscopic endonasal surgery. Kaptain et al encountered a 2.3% postoperative CSF leak rate among 257 patients with intrasellar pathologies who were reconstructed with autologous tissues after endoscopic surgery.…”

Transsphenoidal endoscopic skull base surgery: state of the art and future perspective

“…Gardner et al [ 47 ] utilized an endonasal endoscopic approach for 16 patients with craniopharyngiomas of the suprasellar region. Of 11 patients in whom complete resection was planned, near-total resection ( > 95%) or GTR was achieved in 91% (10/11); 13/14 (93%) patients had some degree of visual improvement and no patient had visual worsening.…”