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  • Author or Editor: Luigi M. Cavallo x
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Paolo Cappabianca, Luigi Maria Cavallo, AnnaMaria Colao and Enrico de Divitiis

Object. To assess postoperative complications related to the surgical procedure, a retrospective analysis was conducted in a series of 146 consecutively treated patients who underwent an endoscopic endonasal transsphenoidal approach to the sellar region for resection of pituitary adenomas between January 1997 and July 2001.

Methods. Complications were divided into groups (nasofacial, sphenoid sinus, sella turcica, supra or parasellar, and endocrine complications) according to the anatomical structures and the systems involved. Overall, a decreased incidence of complications has been observed, compared with large historical series of the traditional microsurgical transsphenoidal approach, likely because of the overview inside the anatomy facilitated by the endoscope, and the decreased surgical trauma.

Conclusions. Transsphenoidal surgery, either microscopic or endoscopic, is a safe procedure in experienced hands, but serious complications still occur and must be reduced as much as possible. Additional improvement can be expected with greater experience and new technical developments. A coordinated team effort with other dedicated colleagues from different specialties is advised.

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Luigi M. Cavallo, Andrea Messina, Paul Gardner, Felice Esposito, Amin B. Kassam, Paolo Cappabianca, Enrico de Divitiis and Manfred Tschabitscher

Object

The pterygopalatine fossa is an area located deep in the skull base. The microsurgical transmaxillary–transantral route is usually chosen to remove lesions in this region. The increasing use of the endoscope in sinonasal functional surgery has more recently led to the advent of the endoscope for the treatment of tumors located in the pterygopalatine fossa as well.

Methods

An anatomical dissection of three fresh cadaveric heads (six pterygopalatine fossas) and three dried skull base specimens was performed to evaluate the feasibility of the approach and to illustrate the surgical landmarks that are useful for operations in this complex region.

The endoscopic endonasal approach allows a wide exposure of the pterygopalatine fossa. Furthermore, with the same access (that is, through the nostril) it is possible to expose regions contiguous with the pterygopalatine fossa, either to visualize more surgical landmarks or to accomplish a better lesion removal.

Conclusions

In this anatomical study the endoscopic endonasal approach to the pterygopalatine fossa has been found to be a safe approach for the removal of lesions in this region. The approach could be proposed as an alternative to the standard microsurgical transmaxillary–transantral route.

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Paolo Cappabianca, Luigi M. Cavallo, Felice Esposito and Enrico De Divitiis

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Luigi M. Cavallo, Andrea Messina, Paolo Cappabianca, Felice Esposito, Enrico de Divitiis, Paul Gardner and Manfred Tschabitscher

Object

The midline skull base is an anatomical area that extends from the anterior limit of the cranial fossa down to the anterior border of the foramen magnum. Resection of lesions involving this area requires a variety of innovative skull base approaches. These include anterior, anterolateral, and posterolateral routes, performed either alone or in combination, and resection via these routes often requires extensive neurovascular manipulation. The goals in this study were to define the application of the endoscopic endonasal approach and to become more familiar with the views and skills associated with the technique by using cadaveric specimens.

Methods

To assess the feasibility of the endonasal route for the surgical management of lesions in the midline skull base, five fresh cadaver heads injected with colored latex were dissected using a modified endoscopic endonasal approach.

Full access to the skull base and the cisternal space around it is possible with this route. From the crista galli to the spinomedullary junction, with incision of the dura mater, a complete visualization of the carotid and vertebrobasilar arterial systems and of all 12 of the cranial nerves is obtainable.

Conclusions

The major potential advantage of the endoscopic endonasal approach to the skull base is that it provides a direct anatomical route to the lesion without traversing any major neurovascular structures, obviating brain retraction. Many tumors grow in a medial-to-lateral direction, displacing structures laterally as they expand, creating natural corridors for their resection via an anteromedial approach.

Potential disadvantages of this procedure include the relatively restricted working space and the danger of an inadequate dural repair with cerebrospinal fluid (CSF) leakage and potential for meningitis resulting. These approaches often require a large opening of the dura mater over the tuberculum sellae and posterior planum sphenoidale, or retroclival space. In addition, they typically involve large intraoperative CSF leaks, which necessitate precise and effective dural closure.

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Salvatore Di Maio, Luigi M. Cavallo, Felice Esposito, Vita Stagno, Olga Valeria Corriero and Paolo Cappabianca

Object

Whereas most pituitary adenomas are removable via the transsphenoidal approach, certain cases, such as dumbbell-shaped or suprasellar adenomas and recurrent and/or fibrous tumors, remain difficult to treat. The authors present their experience with the extended endoscopic endonasal approach to the suprasellar area in managing this subset of tumors, which are classically treated through a transcranial route.

Methods

From June 1997 to December 2008, 615 patients underwent endoscopic endonasal transsphenoidal surgery for pituitary adenomas in the Department of Neurosurgery of the Università degli Studi di Napoli Federico II. Of this group, 20 patients with pituitary adenomas needed an extended endoscopic endonasal transtuberculum/transplanum approach for tumor removal. Two surgical corridors were used during the transsphenoidal approach: 1) the conventional endosellar extraarachnoidal corridor and 2) a suprasellar transarachnoidal corridor.

Results

The extent of resection was gross total in 12 (60%) of the 20 patients, near total in 4 (20%), subtotal in 3 (15%), and partial in 1 (5%). Postoperative CSF leakage occurred in 1 patient. One patient experienced worsening of temporal hemianopsia.

Conclusions

The authors' initial results with the extended endoscopic approach to the suprasellar area for selected pituitary adenomas are promising and may justify a widening of the current classical indications for transsphenoidal surgery.

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Enrico de Divitiis, Felice Esposito, Paolo Cappabianca, Luigi M. Cavallo, Oreste de Divitiis and Isabella Esposito

Object

The extended transnasal approach, a recent surgical advancements for the ventral skull base, allows excellent midline access to and visibility of the anterior cranial fossa, which was previously thought to be approachable only via a transcranial route. The extended transnasal approach allows early decompression of the optic canals, obviates the need for brain retraction, and reduces neurovascular manipulation.

Methods

Between 2004 and 2007, 11 consecutive patients underwent transnasal resection of anterior cranial fossa meningiomas—4 olfactory groove (OGM) and 7 tuberculum sellae (TSM) meningiomas. Age at surgery, sex, symptoms, and imaging studies were reviewed. Tumor size and tumor extension were estimated, and the anteroposterior, vertical, and horizontal diameters were measred on MR images. Medical records, surgical complications, and outcomes of the patients were collected.

Results

A gross-total removal of the lesion was achieved in 10 patients (91%), and in 1 patient with a TSM only a near-total (> 90%) resection was possible. Four patients with preoperative visual function defect had a complete recovery, whereas 3 patients experienced a transient worsening of vision, fully recovered within few days. In 3 patients (2 with TSMs and 1 with an OGM), a postoperative CSF leak occurred, requiring a endoscopic surgery for skull base defect repair. Another patient (a case involving a TSM) developed transient diabetes insipidus. The operative time ranged from 6 to 10 hours in the OGM group and from 4.5 to 9 hours in the TSM group. The mean duration of the hospital stay was 13.5 and 10 days in the OGM and TSM groups, respectively. Six patients (3 with OGMs and 3 with TSMs) required a blood transfusion. Surgery-related death occurred in 1 patient with TSM, in whom the tumor was successfully removed.

Conclusions

The technique offers a minimally invasive route to the midline anterior skull base, allowing the surgeon to avoid using brain retraction and reducing manipulation of the large vessels and optic apparatus; hastens postoperative recovery; and improves patient compliance. Further assessment and refinement are required, particularly because of the potential risk of CSF leakage. Other studies and longer follow-up periods are necessary to ascertain the benefits of the technique.

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Luigi M. Cavallo, Daniel M. Prevedello, Domenico Solari, Paul A. Gardner, Felice Esposito, Carl H. Snyderman, Ricardo L. Carrau, Amin B. Kassam and Paolo Cappabianca

Object

The management of recurrent or residual craniopharyngiomas remains controversial. Although possible, revision surgery is more challenging than primary surgery, and more often results in incomplete resection and an increased risk of death and complications. The extended (also called expanded) endoscopic endonasal transsphenoidal approach through the planum sphenoidale has been proposed over the past decade as an alternative surgical route for removal of various suprasellar tumors including craniopharyngiomas. In this study, the authors describe the feasibility and advantages of this technique in recurrent or symptomatic residual craniopharyngiomas.

Methods

Between January 2004 and June 2008, 22 patients underwent surgery via the extended endoscopic transsphenoidal approach for the treatment of recurrent or residual symptomatic craniopharyngiomas at either the University of Pittsburgh or the Universita degli Studi di Napoli. The lesions included 12 purely suprasellar craniopharyngiomas, 9 with both intra- and suprasellar extensions, and 1 arising from a remnant in the Meckel cave. To better evaluate the features of the extended endonasal approach for recurrent or residual craniopharyngiomas, each patient was assigned to 1 of 3 subgroups depending on the original surgical treatment: transcranial pterional route (13 patients), transphenoidal approach (3 patients; 2 microsurgically and 1 with the standard endoscopic technique), or extended endonasal endoscopic approach (6 patients).

Results

Total removal was achieved in 9 patients (40.9%), and in 8 patients (36.4%) near-total removal (defined as > 95% removal) was possible. Subtotal removal (> 70%) was attained in 4 patients (18.2%), and tumor removal was partial (< 50%) in only 1 case (4.5%). There were no deaths or major complications, including behavior changes. Postoperative CSF leaks developed in 2 patients in the transcranial subgroup, and 1 in the transsphenoidal subgroup (overall rate 13.6%), requiring early successful endoscopic revision surgery for the cranial base defect.

Conclusions

Most of the advantages of the endoscopic endonasal technique were noted during tumor dissection from the inferior aspect of the chiasm, the infundibulum, the third ventricle, and/or the retro- and parasellar areas. These benefits were best appreciated in patients who had originally undergone transcranial surgery, since in such cases the authors' endoscopic endonasal approach was a virgin route. However, the extended endoscopic endonasal technique can also be safely used in patients who originally underwent transsphenoidal surgery. The endoscopic endonasal technique should be considered as a therapeutic option in selected cases of recurrent or symptomatic residual craniopharyngiomas.

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Domenico Solari, Francesco Magro, Paolo Cappabianca, Luigi M. Cavallo, Amir Samii, Felice Esposito, Vincenzo Paternò, Enrico de Divitiis and Madjid Samii

Object

The pterygopalatine fossa is an area that lies deep within the skull base. The recent extensive use of the endoscopic endonasal approach has provided neurosurgeons with a method to reach various areas of the skull base through a less invasive approach than traditional transcranial or transfacial approaches. This study aims to provide neurosurgeons with new data concerning direct endoscopic measurements and precise anatomical topography features of the pterygopalatine fossa.

Methods

An anatomical dissection of six fixed cadaver heads (12 pterygopalatine fossae) was performed to analyze spatial relationships and distances between the most important neurovascular structures in this region, and to estimate the size of the endoscopic surgical field for operations in this area. The endoscopic endonasal approach offers direct access to the pterygopalatine fossa through its anteromedial walls.

Conclusions

Using an endoscopic endonasal approach makes it possible to identify all of the anatomical landmarks of the pterygopalatine fossa and almost all of the contiguous skull base areas.

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Gabriel Zada, Luigi M. Cavallo, Felice Esposito, Julio Cesar Fernandez-Jimenez, Anastasia Tasiou, Michelangelo De Angelis, Tullio Cafiero, Paolo Cappabianca and Edward R. Laws Jr.

Object

In addition to difficulties with anesthetic and medical management, transsphenoidal operations in patients with longstanding acromegaly are associated with inherent intraoperative challenges because of anatomical variations that occur frequently in these patients. The object of this study was to review the overall safety profile and anatomical/technical challenges associated with transsphenoidal surgery in patients with acromegaly.

Methods

The authors performed a retrospective analysis of 169 patients who underwent endoscopic transsphenoidal operations for growth hormone–secreting adenomas to assess the incidence of surgical complications. A review of frequently occurring anatomical challenges and operative strategies employed during each phase of the operation to address these particular issues was performed.

Results

Of 169 cases reviewed, there was no perioperative mortality. Internal carotid artery injury occurred in 1 patient (0.6%) with complex sinus anatomy, who remained neurologically intact following endovascular unilateral carotid artery occlusion. Other complications included: significant postoperative epistaxis (5 patients [3%]), transient diabetes insipidus (5 patients [3%]), delayed symptomatic hyponatremia (4 patients [2%]), CSF leak (2 patients [1%]), and pancreatitis (1 patient [0.6%]). Preoperative considerations in patients with acromegaly should include a cardiopulmonary evaluation and planning regarding intubation and other aspects of the anesthetic technique. During the nasal phase of the transsphenoidal operation, primary challenges include maintaining adequate visualization and hemostasis, which is frequently compromised by redundant, edematous nasal mucosa and bony hypertrophy of the septum and the nasal turbinates. During the sphenoid phase, adequate bony removal, optimization of working space, and correlation of imaging studies to intraoperative anatomy are major priorities. The sellar phase is frequently challenged by increased sellar floor thickness, distinct patterns of tumor extension and bony invasion, and anatomical variations in the caliber and course of the internal carotid artery. Specific operative techniques for addressing each of these intraoperative challenges are discussed.

Conclusions

Transsphenoidal surgery in patients with longstanding acromegaly frequently poses greater challenges than operations for other types of sellar lesions, yet these challenges may be safely and effectively overcome with the anticipation of specific issues and implementation of various intraoperative techniques.