4/16/2015

1

Endoscopic Skull Base Surgery

Vitaly Siomin, MD

Medical Director, Brain Tumor Program

Baptist Health Neurosciences

Baptist Hospital of Miami

Traditional Craniofacial Approaches

• Surgery for SBT results in a cure for many

patients.

• For many traditional open craniofacial surgery

is the mainstream with the best chance of

success.

• More recently, endoscopic approaches started

to emerge.

Traditional Craniofacial Approaches

• Nothing “minimally-invasive” about it….

Traditional Craniofacial Approaches

• Nothing “minimally-invasive” about it….

Traditional Craniofacial Approaches

• Series of reconstructive procedures

Courtesy Dr. Johnny Franco

A more elegant approach?

• Not every skull base lesion is fungating out

• Can scars be avoided?

• Can exposure be reasonably smaller, yet

adequate?

• Can anything challenge the “gold standard”

visualisation with microscope?

• Can surgical trauma be minimized and

recovery become faster?

4/16/2015

2

A more elegant approach?

Traditional approach

• Visible facial and scalp incisions

• Removal facial bones or parts of cranium

• Usually one surgeon operates at a time

Endoscopic

approach

• No incisions

• Nostrils used to

insert

instruments and

the scope

• 4-hand surgery

An approach with better

visualization?• microscope provides 3D

visualization, but less

illumination than the scope

• Endoscope provides 2D

visualization with better

illumination

• microscope gives only

direct line-of-sight

• endoscope gives around

the corner view

www.endoscopicskullbasesurgery.com

A Truly Team Approach

• It is essential that the

neurosurgeon and an ENT

surgeon are on the same

page

• operating with 4 hands, 2

separate monitors

• if tumor is growing more

to the sinuses, neurosurgeon

can simply hold the scope

www.endoscopicskullbasesurgery.com

Very good view

Pituitary Apoplexy

• 74 y.o. lady w/HA’s and decrease in vision

• Underwent TSA elsewhere and presents with worst HA ever and acute blindress

Post-op CTPre-op MRI

Pituitary Apoplexy

• Very fibrous hemorrhagic Tm

• Extending into the cavernous

sinus

4/16/2015

3

Pituitary Apoplexy

Pre-op MRI

Pituitary

macroadenoma

• 40 y.o. male with recent

h/o worsening vision on

the left and headaches,

double vision due to Rt

abducens nerve palsy

Pituitary macroadenoma

Tumor in the

cavernous sinus

Diaphragma

sellae

Pituitary macroadenoma

Olfactory Groove / Intranasal

Meningioma

• Pre-op

• 54 y.o. gentleman with olfactory groove / intranasal meningioma

• S/P bifrontal crani for resection of a 5 cm intracranial olfactory

groove meningioma 4 years ago and coiling of an incidentally found

Acom aneurysm

Olfactory Groove / Intranasal

Meningioma

4/16/2015

4

Olfactory Groove / Intranasal

Meningioma

• Pre-op

• Post-op

What’s the evidence?• Surgery on the pituitary gland is increasingly being performed through an endoscopic approach.

• still little data on safety and relative advantages over traditional microscope-based approaches.

• reports are limited by small sample size and nonrandomized study design.

• The authors performed retrospective review of their own data as well as a systematic review of

the literature.

• RESULTS:

• Nine studies (821 patients)

• rate of gross tumor removal was 78%

• Hormone resolution was achieved in 81% (95% CI 71-91%) of adrenocorticotropic hormone

secreting tumors, 84% (95% CI 76-92%) of growth hormone secreting tumors, and 82% (95% CI 70-

94%) of prolactin secreting tumors.

• complication rates were 2% (95% CI 0-4%) for CSF leak and 1% (95% CI 0-2%) for permanent

diabetes insipidus.

• 2 deaths reported in the literature that were both related to vascular injury, giving an overall

mortality rate of 0.24%.

• CONCLUSIONS:

• The results of this meta-analysis support the safety and short-term efficacy of endoscopic pituitary

surgery. Future studies with long-term follow-up are required to determine tumor control.

Tabaee A, Endoscopic pituitary surgery: a systematic review and meta-

analysis. J Neurosurg. 2009 Sep;111(3):545-54

What’s the evidence?

• 320 pts between 2000 and 2010

• newly diagnosed pituitary adenoma

• transsphenoidal microscopic technique was replaced by the endoscopic technique in June 2008.

• microscopic (n=144) and endoscopic (n=41)

• non-functional pituitary adenoma (NFPA).

• RESULTS:

• At the 3-month follow-up, hypopituitarism had improved in 7% of patients in the Microscopic group and in 9% in the Endoscopic group, and had further impaired in 13% and 9%, respectively.

• total tumor removal 45% of microscopic versus 56% of endoscopic

• Visual fields had normalized or improved in 90% versus 88% of patients, respectively (P=NS).

• CSF leak occurred in 3.5% versus 2.4% (P=NS), and DI (transient or permanent) in 7.6% versus 4.9% (P=NS)

• Larger tumor size (P<0.0005) and endoscopic technique (P=0.03) were independent predictors of increased mean operative time.

• CONCLUSIONS:

• Initial results with the endoscopic technique were statistically similar to those achieved with the microscopic technique. However there was a trend towards improved outcomes and fewer complications in the Endoscopic group.

Karppinen A Transition from microscopic to endoscopic transsphenoidal surgery for

nonfunctional pituitary adenomas. World Neurosurg. 2015 Feb 27. pii: S1878-8750

What’s the evidence?

• Refinement of endoscopic pituitary surgery requires an understanding of the impact of demographic and surgical variables on outcomes.

• METHODS:

• Multivariate logistic regression and ANOVA models were used to explore variables for association with outcomes in a consecutive series of 57 patients undergoing endoscopic pituitary surgery.

• RESULTS:

• The mean duration of surgery was 177 min and was longer in patients with larger tumor size (p=0.03) and presentation with visual symptoms (p=0.02) in univariate analyses. The median duration of hospitalization was 3 days and was longer in patients with larger tumors (p=0.0005). Gross tumor removal was achieved in 89%. Tumor size correlated with extent of tumor removal with an almost 3-fold decrease in complete tumor removal for every 1cm increase in tumor size (p=0.047). High rates of hormonal control (90%) and improvement in visual symptoms (92%) were noted.

• CONCLUSIONS:

• High rates of gross tumor removal, hormonal cure and visual field improvement were noted in this series. Markers including tumor size and visual symptoms may be used to stratify patients.

Tabaee A, Predictors of short-term outcomes following

endoscopic pituitary surgery. Clin Neurol Neurosurg. 2009

Feb;111(2):119-22.

Sino-nasal QOL• change in sinonasal-related QOL with Endoscopic Skull base Surgery (ESBS) has not been well

studied. The aim of this study was to prospectively assess QOL before and after ESBS using

validated outcome measures.

• Prospective. Each patient was asked to complete the 22-item Sinonasal Outcome Test (SNOT-22)

and the Anterior Skull Base Questionnaire (ASBQ) preoperatively, and again at 3 weeks, 6 weeks,

12 weeks, 6 months, and 1 year postoperatively.

• RESULTS:

• 85 patients, 44.7% with nonpituitary pathology.

• Mean SNOT-22 scores transiently worsened in the early postoperative period, and significantly

improved at 1 year after surgery (p < 0.01).

• GTR and use of autologous grafting materials were associated with improved SNOT-22 scores at

later time points (p < 0.05).

• Type of reconstruction, tumor pathology, and functionality did not affect QOL scores. Correlation

between SNOT-22 and ASBQ scores was good at all time points (r < -0.50). Cerebrospinal fluid

leak and other complications were uncommon.

• CONCLUSION:

• ESBS does not have a detrimental long-term effect and is associated with ultimate improvement

in sinonasal-related QOL.

• Short-term impairments of sinonasal-related QOL are predictable and self-limited.

McCoul ED, Endoscopic skull base surgery and its impact on sinonasal-related quality of life. Int

Forum Allergy Rhinol. 2012 Mar-Apr;2(2):174-81

Intra-op MRI and endoscopic TSA• The aim of this study was to report and show the technique, results, and

complications of combined endoscopic and intraoperative MRI

• Retrospective

• 10 pituitary macroadenomas using the Polestar N-10 IMRI system in a tertiary health care facility.

• RESULTS:

• IMRI images were of sufficiently high quality to indicate adequate decompression of the optic chiasm and the removal of all suprasellar tumor

• Residual tumor was found with IMRI and resected endoscopically in 3 cases.

• In 2 other cases, suspected residual tumor on IMRI was examined endoscopicallyand found to be a normal postoperative change.

• 5 patients who had preoperative progressive visual loss preoperatively improved

• No delayed cerebrospinal fluid leaks or any other complications occurred.

• CONCLUSION:

• Combining intraoperative endoscopy and IMRI is an effective surgical modality for pituitary surgery. Each technology provides complimentary information, which can assist the surgeon in safely maximizing the extent of resection.

Anand VK, Endoscopic transphenoidal pituitary surgery with real-time

intraoperative magnetic resonance imaging. Am J Rhinol. 2006 Jul-Aug;20(4):401-5

4/16/2015

5

Closure of the defect Closure of the defect

• Many options

• Autogenous fat

• Fascia lata (autogenous or lyophilized)

• Lyophilized dura

• Temporalis fascia

• Hydroxyapatite

• Allograft

• Mucosa

• Flap (vascularized or non-vascularized)

• Others (fibrin glue, dissolving packing, sealants)

Closure of the defect

• Size matters

– Avoid flaps in smaller defects → less postoperaOve pain and nasal morbidity,

• lyophilized dermal allograft

• autologous fat

– Larger defects → more Ossue

• lyophilized dermal allograft / fascia lata

• autologous fat

• flaps

Closure of the defect

• In larger defects

• vascularized pedicled nasoseptal flap (PNSF)

• Multi-layered closure

• In redo cases

– Hadad-Bassagasteguy flap (HBF): neurovascular pedicled flap of the nasal septum mucoperiosteum and mucoperichondrium based on the nasoseptal artery, a branch of the posterior septal artery

Hadad G et al A novel reconstructive technique after endoscopic

expanded endonasal approaches: vascular pedicle nasoseptal flap.

Laryngoscope. 2006 Oct;116(10):1882-6

Closure of the defect

Neurosurgery-Online.com.

oldfiles.bjorl.org

Risk of meningitis

• Review of 67 studies

• The overall risk of postoperative meningitis

following EESB surgery was 1.8% (36 of 2,005).

• For those reporting a cerebrospinal fluid (CSF)

leak, meningitis occurred in 13.0% (35 of 269).

For those not reporting a CSF leak, meningitis

occurred in 0.1% (1 of 1,736).Lai LT et al The risk of meningitis following expanded endoscopic endonasal skull

base surgery: a systematic review. J Neurol Surg B Skull Base. 2014 Feb;75(1):18-26

4/16/2015

6

Conclusions

• Endonasal Endoscopic Transphenoidal Surgery is safe and effective

• Risk of complications is comparable to or lower than in traditional microscopic cases

• Various options are available for skull base defect closure

• The risk of CSF leak is not very high

• Meningitis is very uncommon, even in patients with leak

Thank you!