Expanded Endoscopic Endonasal Approach (EEEA) for Clival Chordomas

Objective: To evaluate the role of expanded endoscopic endonasal approach in removal of clival chordomas. Patients & Methods: Nine patients with clival chordomas were operated upon in Cairo University hospital from September 2015 to September 2018 using the EEEA a recurrent case and seven new cases were involved in these study and ten operations were done. All patients had preoperative neurological and radiological examination. The study was focusing on the approach, efficacy of tumor removal, reconstruction of the base and complications related to this approach. Results: Nine patients were operated in this study in which ten operations were done. It included six males (66.6%) and three females (33.3%) with age ranging from 4 years to 63 years with average age 40.7 years. Headache and diplopia were the most common symptoms found in six patients (66.6%). Brainstem affection was found in two patients (22.2%). Lower cranial nerves affection was found in two patients (22.2%). One case developed CSF leakage postoperatively (11.1%). Two patients underwent tracheostomy. We achieve total removal in four patients (44.4%), near total removal in one patient (11.1%) and subtotal tumor resection in four patients (44.4%). Conclusion: EEEA for clival chordomas is safe and effective approach regarding the results of the incidence of complications, and the percentage of tumor resection.

Clinical application of reserved gastric tube in neuroendoscopic endonasal surgery for pituitary tumor

BACKGROUND The neuroendoscopic approach has the advantages of a clear operative field,convenient tumor removal,and less damage,and is the development direction of modern neurosurgery.At present,transnasal surgery for sphenoidal pituitary tumor is widely used.But it has been found in clinical practice that some patients with this type of surgery may experience post-operative nausea and vomiting and other discomforts.AIM To explore the effect of reserved gastric tube application in the neuroendoscopic endonasal resection of pituitary tumors.METHODS A total of 60 patients who underwent pituitary adenoma resection via the endoscopic endonasal approach were selected and randomly divided into the experimental and control groups,with 30 in each group.Experimental group:After anesthesia,a gastric tube was placed through the mouth under direct vision using a visual laryngoscope,and the fluid accumulated in the oropharynx was suctioned intermittently with low negative pressure throughout the whole process after nasal disinfection,during the operation,and when the patient recovered from anesthesia.Control group:Given the routine intraoperative care,no gastric tube was left.The number of cases of nausea/vomiting/aspiration within 24 h post-operation was counted and compared between the two groups;the scores of pharyngalgia after waking up,6 h post-operation,and 24 h postoperation.The frequency of postoperative cerebrospinal fluid leakage and intracranial infection were compared.The hospitalization days of the two groups were statistically compared.RESULTS The times of postoperative nausea and vomiting in the experimental group were lower than that in the control group,and the difference in the incidence of nausea was statistically significant(P<0.05).After the patient woke up,the scores of sore throat 6 h after the operation and 24 h after operation were lower than those in the control group,and the difference was statistically significant(P<0.05).The number of cases of postoperative cerebrospinal fluid leakage and intracranial infection was higher than that of the control group,but there was no statistically significant difference from the control group(P>0.05).The hospitalization days of the experimental group was lower than that of the control group,and the difference was statistically significant(P<0.05).CONCLUSION Reserving a gastric tube in the endoscopic endonasal resection of pituitary tumors,combined with intraoperative and postoperative gastrointestinal decompression,can effectively reduce the incidence of nausea,reduce the number of vomiting and aspiration in patients,and reduce the complications of sore throat The incidence rate shortened the hospitalization days of the patients.

Application of endoscopic endonasal approach in skull base surgeries: summary of 1886 cases in a single center for 10 consecutive years

Background:Endonasal endoscopic skull base surgery has undergone rapid technological developments and is now widely performed,but its strengths and weaknesses deserve further investigation and deliberation.This study was performed to investigate the surgical indications,complications,and technical advantages and disadvantages of endonasal endoscopic skull base surgery.Methods:The clinical data of 1886 endoscopic endonasal skull base surgeries performed in our ward at Beijing Tiantan Hospital from June 2006 to June 2016 were retrospectively analyzed.Results:One thousand ninety-three(73.4%,1490)pituitary adenomas,54(24.9%,217)chordomas,28(80.0%,35)craniopharyngiomas,and 15(83.3%,18)meningiomas underwent total resection.Two patients died postoperatively,both having pituitary adenomas.Other postoperative complications included olfactory disorders(n=226,11.9%),postoperative cerebrospinal fluid leakage(n=78,4.1%),hypopituitarism(n=74,3.9%),diabetes insipidus(n=64,3.4%),intracranial infection(n=36,1.9%),epistaxis(n=24,1.3%),vascular injury(n=8,0.4%),optic nerve injury(n=8,0.4%),and oculomotor movement impairment(n=4,0.2%).In total,1517(80.4%)patients were followed up for 6 to 126 months(average,42.5 months)postoperatively.A total of 196(13.2%)pituitary adenomas and 13(37.1%)craniopharyngiomas recurred but no meningiomas recurred.Chordomas recurred in 97(44.7%)patients,in whom 5-year survival rate was 65%.Conclusion:Endoscopic surgery is an innovative surgical technique and the first choice for most midline extradural lesions such as chordomas,and an excellent choice for pituitary adenomas.It probably will be a good technique for many kinds of craniopharyngiomas and a common technique for most of skull base meningiomas,so the surgical indications of these cases should be chosen carefully to make good use of its respective advantages.

Combined Transcranial and Endoscopic Endonasal Approach for Resecting a Giant Intracranial and Extracranial Communicating Meningioma:A Case Report

Objective Although intracranial and extracranial communicating meningiomas are uncommon in clinical settings,they pose a considerable challenge for surgeons.Thus,one-stage surgery should be more comprehensively explained as it is not frequently reported as a first-line treatment.Case report A 27-year-old man with a massive intracranial and extracranial communicating meningioma was admitted with nasal congestion and mild numbness on the left side of his face.A combined transcranial and endoscopic endonasal approach was performed in a single day aided by preoperative tumor embolization.The tumor was nearly completely removed without any serious complications.Follow-up revealed the disappearance of diplopia,with the patient having a normal life.Furthermore,no tumor progression was noted.Conclusion The combined transcranial and endoscopic endonasal approach is feasible for removing certain massive intracranial and extracranial communicating tumors.Hybrid techniques,such as embolization,microscopic,and endoscopic manipulation,are indispensable tools for treating such cases.

“In situ bone flap” combined with vascular pedicled mucous flap to reconstruction of skull base defect

BACKGROUND At present,neuroendoscopy technology has made rapid development,and great progress has been made in the operation of lesions in the saddle area of the skull base.However,the complications of cerebrospinal fluid and intracranial infection after the operation are still important and life-threatening complications,which may lead to poor prognosis.AIM To investigate the method of in situ bone flap combined with nasal septum mucosal flap for reconstruction of enlarged skull base defect by endonasal sphenoidal approach and to discuss its application effect.METHODS Clinical data of 24 patients undergoing transnasal sphenoidal endoscopic approach in the Department of Neurosurgery,Affiliated 2 Hospital of Nantong University from January 2019 to December 2022 were retrospectively analyzed.All patients underwent multi-layer reconstruction of skull base using in situ bone flap combined with nasal septum mucosa flap.The incidence of intraoperative and postoperative cerebrospinal fluid leakage and intracranial infection were analyzed,and the application effect and technical key points of in situ bone flap combined with nasal septum mucosa flap for skull base bone reconstruction were analyzed.RESULTS There were 5 cases of high flow cerebrospinal fluid(CSF)leakage and 7 cases of low flow CSF leakage.Postoperative cerebrospinal fluid leakage occurred in 2 patients(8.3%)and intracranial infection in 2 patients(8.3%),which were cured after strict bed rest,continuous drainage of lumbar cistern combined with antibiotic treatment,and no secondary surgical repair was required.The patients were followed up for 8 to 36 months after the operation,and no delayed cerebrospinal fluid leakage or intracranial infection occurred during the follow-up.Computed tomography reconstruction of skull base showed satisfactory reconstruction after surgery.CONCLUSION The use of in situ bone flap combined with vascular pedicled mucous flap to reconstruction of skull base defect after endonasal sphenoidal approach under neuroendoscopy has a lower incidence of cerebrospinal fluid leakage and lower complications,which has certain advantages and is worthy of clinical promotion.

Endoscopic expand transnasal approach to the suprasellar region ： anatomical study and clinical considerations

Backgroud The expanded endonasal approach （EEA） is used sparingly by surgeons for resection of lesions in the ventrocranial base. Herein, we examined the anatomy of the ventrocranial base by endoscopy and comment on the use of EEA in clinical practice. Methods Twenty artery-injected adult cadaveric heads were studied under surgical conditions using the endoscopic EEA. The extent of the surgical exposure, the endoscopic anatomic view and the maneuverability of surgical instruments about the suprasellar region were studied by the endoscopic EEA. Results The EEA by endoscope can reach the suprasellar region. In this approach, the optocarotid recess, supra and infra-optic chiasm interspace, the ophthalmic artery and others were important anatomical landmarks for identification of the suprasellar region. Conclusions The endoscopic EEA can be used to remove many types of lesions in the ventrocranial base. The microanatomy observed using the endoscope provides important anatomical information on the suprasellar region for neurosurgeons.

Surgical approaches to the petrous apex

The petrous apex is a difficult to reach surgical area due to its deep position in the skull base and many vital surrounding structures.Petrous apex pathology ranges from extradural cholesterol granulomas,cholesteatomas,asymmetric pneumatization,and osteomyelitis to intradural meningiomas and schwannomas.Certain lesions,such as cholesterol granulomas,can be managed with drainage while neoplastic lesions must be completely resected.Surgical options use open,endoscopic,and combined techniques and are categorized into anterior,lateral,and posterior approaches.The choice of approach is determined by the nature of the pathology and location relative to vital structures and extension into surrounding structures and requires thorough preoperative evaluation and discussion of surgical goals with the patient.The purpose of this state-of-the-art review is to discuss the most commonly used surgical approaches to the petrous apex,and the anatomy on which these approaches are based.