THIRTY YEARS IN SKULL BASE SURGERY

The skull base generally refers to the anterior, middle and posterior cranial fossa and structures on the outside side of these skull areas. The cranial roof and skull base are separated by a line connecting the external occipital protuberance, parietal notch and supraorbital ridge[1].The skull base supports the brain above, is connected to

Simulation training in endoscopic skull base surgery: A scoping review

Objective:Proficiency in endoscopic endonasal skull base surgery requires both substantial baseline training and progressive lifelong learning.Endoscopic simulation models continue to evolve in an effort to optimize trainee education and preoperative preparation and improve surgical outcomes.The current scoping review systematically reviews all available literature and synthesizes the current paradigms of simulation models for endoscopic skull base surgery training and skill enhancement.Methods:In accordance with Preferred Reporting Items for Systemic Review and Meta-Analyses guidelines,we systematically searched PubMed,Embase,CINAHL,and Cochrane databases.Studies were categorized according to the type of simulation models investigated.Results:We identified 238 unique references,with 55 studies ultimately meeting inclusion criteria.Of these,19 studies described cadaveric dissection models,17 discussed three-dimensional(3D)printed models,14 examined virtual surgical planning and augmented reality-based models,and five 5 articles described task trainers.Conclusions:There are a wide variety of simulation models for endoscopic skull base surgery,including high-fidelity cadaveric,virtual reality,and 3D-printed models.These models are an asset for trainee development and preoperative surgical preparation.

Safety of restarting continuous positive airway pressure (CPAP) therapy following endoscopic endonasal skull base surgery

Objectives:Patients with obstructive sleep apnea(OSA)are at increased risk of perioperative and postoperative morbidity.The use of continuous positive airway pressure(CPAP)in the perioperative period may be of potential benefit.However,among patients who have undergone endonasal skull base surgery,many surgeons avoid prompt re-initiation of CPAP therapy due to the theoretical increased risk of epistaxis,excessive dryness,pneumocephalus,repair migration,intracranial introduction of bacteria,and cerebrospinal fluid(CSF)leak.The objective of this article is to review the most up-to-date literature regarding when it is safe to resume CPAP usage in the patient undergoing endonasal skull base surgery.Data Sources and Methods:This review combines the most recent literature as queried through PubMed regarding the safety of CPAP resumption following endonasal skull base surgery.Results:Recent surveys of skull base surgeons demonstrate little consensus regarding the post-operative management of OSA.Recent cadaveric studies suggest that approximately 85%of delivered CPAP pressures are transmitted to the sphenoid sinus.Further,at frequently prescribed CPAP pressure settings,common sellar reconstruction techniques maintain their integrity while preventing very little transmission of pressure into the sella.In small retrospective case series,patients with OSA who received CPAP immediately following transsphenoidal pituitary surgery had similar rates of surgical complications as OSA patients who did not receive CPAP in the immediate post-operative period.Concerns of reinitiating CPAP too early,such as the development of pneumocephalus,rarely develop.Conclusions:There remains a paucity of objective data regarding when it is safe to resume CPAP following endonasal skull base surgery.Recent cadaveric studies and small retrospective case series suggest that it may be safe to resume CPAP earlier than is often practiced following endonasal skull base surgery.

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.

The translabyrinthine approach in residency training.“Step by step”surgical anatomy from the dissection laboratory to the operative room

Surgical anatomy training in a dedicated research laboratory and attendance to focused“hands-on”dissection courses are of high educational importance in order to acquire and maintain surgical expertise in skull base surgery,both for young and more experienced surgeons.Nevertheless,transitioning surgical skills and anatomic knowledge from the laboratory to the operative room it is not free of challenges,especially during skull base approaches where the three-dimensional surgical orientation can be quite complex.We present a“step-by-step”and“side-by-side”surgical anatomy report on a translabyrinthine approach that was practiced in the laboratory then performed in the operative room by the surgical team,and we compare surgical anatomy exposures while discussing intraoperative techniques,nuances and challenges,both in the laboratory and the operative room.

Pediatric sinonasal and skull base lesions

Pediatric skull base lesions are complex and challenging disorders.Safe and comprehensive management of this diverse group of disorders requires the expertise of an experienced multidisciplinary skull base team.Adult endoscopic skull base surgery has evolved due to technologic and surgical advancements,multidisciplinary team approaches,and continued innovation.Similar principles continue to advance the care delivered to the pediatric population.The approach and management of these lesions varies considerably based on tumor anatomy,pathology,and surgical goals.An understanding of the nuances of skull base reconstruction unique to the pediatric population is critical for successful outcomes.

Carotid artery injury in endoscopic endonasal surgery: Risk factors, prevention, and management

Objective:Endoscopic approaches for sinus and skull base surgery are increasing in popularity.The objective of this narrative review is to characterize risk factors for internal carotid artery injury in endoscopic endonasal surgery(EES),highlight preventative measures,and illustrate key management principles.Data Sources:Comprehensive literature review.Methods:Relevant literature was reviewed using PubMed/MEDLINE.Results:Carotid artery injury in EES is rare,with most studies reporting an incidence below 0.1%.Anatomic aberrancies,wide dissection margins,as well as specific provider and hospital factors,may increase the risk of injury.Multidisciplinary teams,comprehensive preoperative imaging,patient risk assessment,and formal training in vascular emergencies may reduce the risk.Management protocols should emphasize proper visualization of the injury site,fluid replacement,rapid packing,angiography,and endovascular techniques to achieve hemostasis.Conclusions:While EES is a relatively safe procedure,carotid artery injury is a devastating complication that warrants full consideration in surgical planning.Important preventative measures include identifying patients with notable risk factors and obtaining preoperative imaging.Multidisciplinary teams and management protocols are ultimately necessary to reduce morbidity and mortality.

Integration of an enhanced recovery after surgery program for patients undergoing pituitary surgery

Evidence-based enhanced recovery after surgery(ERAS)programs aim to improve patient outcomes and shorten hospital stays.The objective of this study is to describe the development,implementation,and evolution of an ERAS protocol to optimize the perioperative management for patients undergoing endoscopic skull base surgery for pituitary tumors.A systematic review of the literature was performed,best practices were discussed with stakeholders,and institutional guidelines were established and implemented.Key performance indicators(KPI)were measured and patient-reported outcome surveys were collected.The ERAS protocol was introduced successfully at our institution.We describe the process of initiation of the program and the perioperative management of our patients.We demonstrated the feasibility of integration of ERAS protocols for pituitary tumors with multidisciplinary engagement,with a particular emphasis on the use of data informatics and metrics to monitor outcomes.We expect that this approach will translate to improved quality of care for these often-complex patients.

Perioperative management of endoscopic transsphenoidal pituitary surgery

The contemporary embrace of endoscopic technology in the approach to the anterior skull base has altered the perioperative landscape for patients requiring pituitary surgery.Utility of a multi-disciplinary unit in management decisions facilitates the delivery of optimal care.Evolution of technology and surgical expertise in pituitary surgery mandates ongoing review of all components of the care central to these patients.The many areas of potential variability in the pre,intra and post-operative timeline of pituitary surgery are readily identifiable.Core undertakings and contemporary controversies in the peri-operative management of patients undergoing endoscopic transsphenoidal pituitary surgery are assessed against the available literature with a view to providing guidance for the best evidence-based practice.

Craniofacial resection of advanced oral and maxillofacial malignant tumors

Objective To evaluate the clinical outcome of craniofacial resection for advanced malignant tumors in oral and maxillofacial regions.Methods Forty-six patients who underwent craniofacial resection for malignancies involving the anterior and middle cranial fossa over a 20-year period between June 1978 and December 1997 at our department were evaluated. Twenty patients received radiation therapy and an adjuvant therapy after the operation. Eleven patients received chemotherapy of various types as an adjuvant therapy.Results The 3- and 5-year survival rates were 48.8% (20/41) and 35.1% (13/37), respectively, while the 10-year survival rate was 20% (4/20).Conclusions Our results revealed good prospects of using craniofacial resection on patients with advanced malignancies in the oral and maxillofacial regions.

Endoscopic endonasal approach to the craniovertebral junction

The surgical approach to lesions of the ventral craniovertebral junction(CVJ)has evolved significantly in the last several years with the advent of endoscopic skull base surgery.Differing pathologies of the CVJ can result in irreducible compression of the cervicomedullary region.The endoscopic endonasal approach lends itself well to this region due to the ventral location,and while there is a steep learning curve,is a safe and effective way to perform decompression of the cervicomedullary region.Herein,we discuss the anatomy of the CVJ,preoperative evaluation and surgical considerations,our surgical approach,complications,and outcomes.

Exclusively endoscopic surgical resection of esthesioneuroblastoma: A systematic review

Background:Historically sinonasal malignancies were always addressed via open craniofacial surgery for an oncologic resection.Increasingly esthesioneuroblastomas are excised using an exclusively endoscopic approach,however,the rarity of this disease limits the availability of long-term and large scale outcomes data.Objective:The primary objective is to evaluate the treatment modalities used and the overall survival of patients with esthesioneuroblastoma managed with exclusively endoscopic surgery.Methods:In accordance with PRISMA guidelines,PubMed was queried to identify studies describing outcomes associated with endoscopic management of esthesioneuroblastomas.Results:Forty-four out of 2462 articles met inclusion criteria,totaling 399 patients with esthesioneuroblastoma treated with an exclusively endoscopic approach.Seventy-two patients(18.0%)received adjuvant chemotherapy and 331 patients(83.0%)received postoperative radiation therapy.The average age was 50.6 years old(range 6-83).Of the 399 patients,57(16.6%)were Kadish stage A,121(35.2%)were Kadish stage B,145(42.2%)were Kadish stage C,and 21(6.1%)were Kadish stage D.Pooled analysis demonstrated that 66.0%of patients had Hyams histologic GradeⅠorⅡ,while 34.0%of patients had GradeⅢorⅣdisease.Negative surgical margins were achieved in 86.9%of patients,and recurrence was identified in 10.3%of patients.Of those with 5-year follow-up,reported overall survival was 91.1%.Conclusion:Exclusively endoscopic surgery for esthesioneuroblastoma is performed for a wide range of disease stages and grades,and the majority of these patients are also treated with adjuvant chemotherapy or radiation therapy.Reported overall recurrence rate is 10.3%and 5-year survival is 91.1%.

Endoscopic endonasal approaches to the craniovertebral junction:The Otolaryngologist’s perspective

Objective:To review indications and techniques for the endoscopic endonasal approach to the craniovertebral junction(CVJ),analyze postoperative outcomes,and discuss important technical considerations.Methods:A retrospective analysis was performed on all patients undergoing endonasal endoscopic approaches to the CVJ from May 2007 to June 2017.Demographic information,presenting symptoms,imaging results,treatment course,postoperative functional status,and followup were recorded.Results:There was a total of 30 patients in this series,with a mean follow-up of 11.7 months.The average age was 33.6 years(range,5e75 years),with 18 females and 12 males.The majority of patients(n Z 22,73.3%)had Chiari malformation type 1 with basilar invagination and symptomatic cervicomedullary compression as the indication for surgery.Intraoperative cerebrospinal fluid leak(CSF)was noted in 3 cases of odontoid resection and a single case of skull base resection.There were no postoperative CSF leaks.Overall,81%of patients resumed regular diet by post-operative day 2(range,0e8 days).Severe postoperative dysphagia occurred in two cases with one requiring gastrostomy tube placement and another utilizing total parenteral nutrition for support prior to eventual gastrostomy.On average,patients were extubated by postoperative day 0.93(range 0e3 days),with 85%extubated by postoperative day 1.A tracheotomy was required in one patient.Conclusion:The endonasal endoscopic approach is a valuable technique for access to the CVJ with minimal disruption of respiratory and alimentary function.