- Department of Neurosurgery, Faculty of Life Sciences Research, Kumamoto University Graduate School, Kumamoto, Japan
- Department of Pharmacology and Molecular Therapeutics, Faculty of Life Sciences Research, Kumamoto University Graduate School, Kumamoto, Japan
Department of Neurosurgery, Faculty of Life Sciences Research, Kumamoto University Graduate School, Kumamoto, Japan
DOI:10.4103/2152-7806.130901Copyright: © 2014 Yano S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Yano S, Hide T, Shinojima N, Hasegawa Y, Kawano T, Kuratsu J. Endoscopic endonasal skull base approach for parasellar lesions: Initial experiences, results, efficacy, and complications. Surg Neurol Int 16-Apr-2014;5:51
How to cite this URL: Yano S, Hide T, Shinojima N, Hasegawa Y, Kawano T, Kuratsu J. Endoscopic endonasal skull base approach for parasellar lesions: Initial experiences, results, efficacy, and complications. Surg Neurol Int 16-Apr-2014;5:51. Available from: http://sni.wpengine.com/surgicalint_articles/endoscopic-endonasal-skull-base-approach-for-parasellar-lesions-initial-experiences-results-efficacy-and-complications/
Background:Endoscopic surgery is suitable for the transsphenoidal approach; it is minimally invasive and provides a well-lit operative field. The endoscopic skull base approach through the large opening of the sphenoid sinus through both nostrils has extended the surgical indication for various skull base lesions. In this study, we describe the efficacy and complications associated with the endoscopic skull base approach for extra- or intradural parasellar lesions based on our experiences.
Methods:Seventy-four cases were treated by an endoscopic skull base approach. The indications for these procedures included 55 anterior extended approaches, 10 clival approaches, and 9 cavernous approaches. The operations were performed through both the nostrils using a rigid endoscope. After tumor removal, the skull base was reconstructed by a multilayered method using a polyglactin acid (PGA) sheet.
Results:Gross total resection was achieved in 82% of pituitary adenomas, 68.8% of meningiomas, and 60% of craniopharyngiomas in anterior extended approach and in 83.3% of chordomas in clival approach, but only in 50% of the tumors in cavernous approach. Tumor consistency, adhesion, and/or extension were significant limitations. Visual function improvements were achieved in 37 of 41 (90.2%) cases. Cerebrospinal fluid (CSF) leakage (9.5%), infections (5.4%), neural injuries (4.1%), and vascular injuries (2.7%) were the major complications.
Conclusions:Our experiences show that the endoscopic skull base approach is a safe and effective procedure for various parasellar lesions. Selection of patients who are unlikely to develop complications seems to be an important factor for procedure efficacy and good outcome.
Keywords: Endonasal, endoscopic surgery, skull base, transsphenoidal approach
Endoscopic transsphenoidal surgery (ETSS) allows for safe and sufficient resection of sellar lesion tumors. Recently, the standard endoscopic transsphenoidal approach has been modified in various ways to develop extended endonasal approaches.[
We began using the endoscopic endonasal transsphenoidal surgery with a bilateral nostril approach in 2001. In 2004, when we had performed the surgery for 84 sellar lesions,[
We used the endoscopic endonasal skull base approach for 74 cases in Kumamoto University and related hospitals between June 2004 and December 2012. Twenty-seven patients with pituitary adenomas were subjected in this study. Of them, 19 tumors extended to planum sphenoidale beyond the tuberculum sellae, 4 tumors extended into the retrochiasmatic space with a dumbbell shape, and 4 tumors extended to cavernous sinus. In four tumors extended to cavernous sinus, two cases were nonfunctioning pituitary adenomas and two were growth hormone (GH)-secreting adenoma that extended beyond the outside line of the internal carotid artery (ICA). All of these tumors required the subarachnoid dissection or cavernous dissection for removal. Other types of pituitary adenomas that were operated in parallel at the same time and did not require the opening of extrasellar bone were excluded from this study. Twelve cases of meningiomas were located on the tuberculum sellae, four were intraorbital or extended over the anterior clinoid process, two were in the cavernous sinus, and one was intradural meningioma attached to the clivus. Craniopharyngiomas (10 cases) and Rathke's cleft cysts (3 cases) were located in the suprasellar retrochiasmatic space. Two cases of astrocytomas originating from the optic chiasm and two dermoid cysts occurred at each location of the planum sphenoidale and cavernous sinus. Chordomas were located in the clivus in six patients and mainly intracavernous in one patient. Ecchordosis physaliphora and plasmacytoma originating from the clival and pyramidal bone, fibrous dysplasia of the sphenoid bone, and adenoid cystic carcinoma in the cavernous sinus were also treated respectively. Visual field defect and decreased visual acuity were observed in 40 of the 55 patients with parachiasmatic lesion and 1 patient with fibrous dysplasia. Diplopia due to occulomotor or abducens nerve palsy was observed in 8 of the 10 patients with clival lesion tumors, 4 of the 9 patients with cavernous lesion tumors, and 1 patient with clinoidal meningioma. Hormonal deficit was observed in 4 of the 55 patients with the tumors adjacent to the pituitary gland (1 with pituitary adenoma, 2 with craniopharyngioma, and 1 with Rathke's cleft cyst) and in 2 of the 9 patients with cavernous sinus tumors; both these patients had GH-secreting adenomas extending to the cavernous sinus. Seven patients did not present with any clinical symptoms, but their tumor showed growth during the follow-up period.
Our previously reported standard endoscopic endonasal transsphenoidal approach through both the nostrils[
After confirmation of bilateral sphenoid ostia, we prepared a wide flap of unilateral septal mucosa to reconstruct the skull base. The mucosal flap was reflected to the inferior meatus and covered with gauze soaked in saline during tumor resection. The contralateral septal mucosa was dissected 7-9 mm in the length around the sphenoid ostium. The posterior part of the bony septum was partially removed, and both enlarged ostea were connected. The bony septum was used to reinforce the skull base after tumor removal. The contralateral septal mucosa was preserved. The sellar floor, tuberculum sellae, planum sphenoidale, or cavernous protuberance was opened depending on the degree of tumor extension [
Intraoperative view of each approach. (a) Opening the planum sphenoidale. (b) The anterior extended approach. The tumor (T) was removed. Optic chiasm (Chi) and anterior cerebral arteries were visualized. (c) The clival approach after removing a chordoma. The dura of clivus (C) and bilateral carotid prominences (*) were visualized. (d) The cavernous approach after removing a pituitary adenoma. The right cavernous sinus was opened, and the ICA was visualized. OCR, optico-carotid recess; Op, optic nerve prominence; Ts, tuberculum sellae; Ser, sellar floor
The skull base repair was performed by a multiple repair method. An abdominal fat graft was positioned inside the residual cavity, and the remaining dural edge was attached to the fat and covered by the polyglactin acid (PGA) sheet.[
Intraoperative photograph of skull base reconstruction. (a) After removing the tumor, a wide opening of the skull base dura was observed. (b) Abdominal fat was inserted into the cavity and attached to surrounding dura. (c) The defect was covered with a PGA sheet. (d) The skull base was reinforced with bony septum to prevent from protrusion of the fat due to intracranial pressure and pulsation. (e) A large mucosal flap was used to cover the skull base. (f) A sinus Balloon catheter™ was inserted to confirm mucosal flap attachment to the skull base
The extent of surgical removal, which was evaluated on the basis of postoperative magnetic resonance images (MRIs) obtained in the immediate postoperative period and 3 months later, was classified as total (no residual tumor), subtotal (presence of residual part but removed more than 95%), and partial (removed less than 95%). On postoperative day 3 and after 1 month, the patients underwent endoscopic exploration of the nasal cavities by otolaryngologists to determine cranial base reconstruction effectiveness. Statistical analysis was performed with Welch's t tests and Fisher's exact tests.
The median follow-up period was 23.1 months for the anterior extended approach and 12.6 months for the cavernous approach. The extent of surgical removal was evaluated from postoperative MRI scans obtained 3 months later.
Degree of tumor removal for each type of approach is summarized in
Representative pre- and postoperative MRI of the cases treated with the anterior extended approach. (a, b) A case of tuberculum sellae meningioma. Preoperative MRI revealed a 25-mm meningioma (a). Postoperative MRI shows total removal (b). (c, d) A case of craniopharyngioma. Preoperative MRI showed a cystic mass located in a suprasellar lesion (c). Postoperative MRI revealed total removal (d). (e, f) A case of pituitary adenoma. Preoperative MRI showed a pituitary adenoma located in the sellar to frontal skull base (e). Postoperative MRI demonstrated total removal (f)
Representative pre- and postoperative MRI of the cases treated with the clival or cavernous approach. (a, b): A case of chordoma. Preoperative Gd-enhanced MRI showed a chordoma located in the sphenoid sinus with destruction of the clivus (a). Postoperative MRI confirmed gross total removal (b). (c and d) A case of pituitary adenoma. Preoperative MRI showed the tumor located in an intrasellar lesion that extended into the cavernous sinus (c). Postoperative MRI revealed a small remnant below the ICA (d)
We analyzed the factors influencing removal rate in three types of tumors treated by anterior extended approach [
Representative pre- and postoperative MRI of cases with partial removal. (a, b) A case of pituitary adenoma with extension to the retrochiasmatic space (a), which remained in the retrochiasmatic space (b). (c, d) A case of tuberculum meningioma located in the tuberculum sellae that extended over the anterior clinoid process (c). Postoperative MRI showed that the tumor remained around the clinoid process (d). The outline of the tumor surrounded by a dotted line. (e, f) A case of suprasellar craniopharyngioma with multiple cysts (e), which remained in the suprasellar lesion (f)
Preoperative visual deficits were observed in 41 of the 55 (74.5%) cases treated by anterior extended approach and 1 case of fibrous dysplasia that filled in the sphenoid sinus. Among them, 37 patients (90.2%) experienced improved postoperative visual function, whereas the remaining 4 patients (2 with optic gliomas, 1 with meningioma extending into the optic canal, and 1 with recurrent pituitary adenoma that developed intratumoral hemorrhage in the remnant tumor) did not show any improvement. Preoperative diplopia manifested in 12 cases; of these 8 cases of clival lesions showed complete recovery postoperatively, and 3 cases of cavernous lesion and 1 case of atypical meningioma extending into the superior orbital fissure showed no improvement after surgery. Five patients experienced headache that remitted postoperatively [
The complication rate for each approach is shown in
Surgical approach and indication
The endoscope provides a bright and spacious surgical field, and the surgeon can easily confirm structural details by increasing magnification. Proponents of this method contend that despite the loss of stereoscopic vision, the field of view is better than that achieved with a microscope because the light source and lens are closer to the lesion.[
The anterior extended transsphenoidal approach expands operative exposure beyond the sellar floor by removal of the tuberculum sellae and planum sphenoidale. This approach can be easily modified from the standard endoscopic approach though both the nostrils as we reported previously.[
Perfect resection was not achieved for tumors extending into the cavernous sinus.[
Clival chordoma seems to be a good indication for the endoscopic transsphenoidal approach. Komotor et al.[
Kassam et al.[
Postoperative CSF leakage was the most common complication; previous reports have described rates of 20 - 30% for craniopharyngioma surgery[
Postoperative infection is a concern for intradural skull base surgery because of large amount of intraoperative CSF leakage. Although the incidence rates of meningitis after resection of pituitary adenomas extending to suprasellar lesions were reported from 0.7% to 1%,[
The incidence of intraoperative neural injury reported was 2.2-33%,[
Vascular injury is the most dangerous complications. Although the overall incidence rate is low (1.1-2%),[
In this series, there were no instances of ICA injury because we did not perform aggressive extractions for paramedian lesions. Kassam et al.[
This study summarizes our initial experiences using the endoscopic skull base approach for midline lesions. Although there was obvious learning curve in these procedures, symptom improvement was high, and the complication rate was low; moreover, it seemed to be minimally invasive compared with conventional skull base surgery, especially for anterior skull base and clival lesions. The factors that reduced the successful resection rate in this series were consistency, extension, and adhesion of the tumor. It is important for the operators to expect these factors by preoperative imaging as much as possible and to keep in mind that they may be risk factors, which will be helpful to avoid complications such as CSF leakage, infection, and vascular injury. Ultimately, the surgical approach should be chosen with the ultimate goal of improving patient symptoms and minimizing risk.
1. Cappabianca P, Cavallo LM, Colao A, de Divitiis E. Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg. 2002. 97: 293-8
2. Cappabianca P, Cavallo LM, Esposito F, De Divitiis O, Messina A, De Divitiis E. Extended endoscopic endonasal approach to the midline skull base: The evolving role of transsphenoidal surgery. Adv Tech Stand Neurosurg. 2008. 33: 151-199
3. Cavallo LM, de Divitiis O, Aydin S, Messina A, Esposito F, Iaconetta G. Extended endoscopic endonasal transsphenoidal approach to the suprasellar area: Anatomic considerations--part 1. Neurosurgery. 2007. 61: 24-33
4. Cavallo LM, Messina A, Esposito F, de Divitiis O, Dal Fabbro M, de Divitiis E. Skull base reconstruction in the extended endoscopic transsphenoidal approach for suprasellar lesions. J Neurosurg. 2007. 107: 713-20
5. Cavallo LM, Prevedello DM, Solari D, Gardner PA, Esposito F, Snyderman CH. Extended endoscopic endonasal transsphenoidal approach for residual or recurrent craniopharyngiomas. J Neurosurg. 2009. 111: 578-89
6. Ceylan S, Koc K, Anik I. Endoscopic endonasal transsphenoidal approach for pituitary adenomas invading the cavernous sinus. J Neurosurg. 2010. 112: 99-107
7. Ceylan S, Koc K, Anik I. Extended endoscopic approaches for midline skull-base lesions. Neurosurg Rev. 2009. 32: 309-19
8. de Divitiis E, Cappabianca P, Cavallo LM. Endoscopic transsphenoidal approach: Adaptability of the procedure to different sellar lesions. Neurosurgery. 2002. 51: 699-705
9. de Divitiis E, Cappabianca P, Cavallo LM, Esposito F, de Divitiis O, Messina A. Extended endoscopic transsphenoidal approach for extrasellar craniopharyngiomas. Neurosurgery. 2007. 61: S219-27
10. de Divitiis E, Cavallo LM, Esposito F, Stella L, Messina A. Extended endoscopic transsphenoidal approach for tuberculum sellae meningiomas. Neurosurgery. 2007. 61: S229-37
11. de Divitiis E, Esposito F, Cappabianca P, Cavallo LM, de Divitiis O. Tuberculum sellae meningiomas: High route or low route? A series of 51 consecutive cases. Neurosurgery. 2008. 62: 556-63
12. Dehdashti AR, Ganna A, Karabatsou K, Gentili F. Pure endoscopic endonasal approach for pituitary adenomas: Early surgical results in 200 patients and comparison with previous microsurgical series. Neurosurgery. 2008. 62: 1006-15
13. Fatemi N, Dusick JR, de Paiva Neto MA, Kelly DF. The endonasal microscopic approach for pituitary adenomas and other parasellar tumors: A 10-year experience. Neurosurgery. 2008. 63: S244-56
14. Feiz-Erfan I, Han PP, Spetzler RF, Horn EM, Klopfenstein JD, Porter RW. The radical transbasal approach for resection of anterior and midline skull base lesions. J Neurosurg. 2005. 103: 485-90
15. Frank G, Pasquini E, Doglietto F, Mazzatenta D, Sciarretta V, Farneti G. The endoscopic extended transsphenoidal approach for craniopharyngiomas. Neurosurgery. 2006. 59: ONS75-83
16. Frank G, Sciarretta V, Calbucci F, Farneti G, Mazzatenta D, Pasquini E. The endoscopic transnasal transsphenoidal approach for the treatment of cranial base chordomas and chondrosarcomas. Neurosurgery. 2006. 59: ONS50-57
17. Gardner PA, Kassam AB, Snyderman CH, Carrau RL, Mintz AH, Grahovac S. Outcomes following endoscopic, expanded endonasal resection of suprasellar craniopharyngiomas: A case series. J Neurosurg. 2008. 109: 6-16
18. Holzmann D, Reisch R, Krayenbuhl N, Hug E, Bernays RL. The transnasal transclival approach for clivus chordoma. Minim Invasive Neurosurg. 2010. 53: 211-7
19. Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded endonasal approach: The rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus. 2005. 19: E3-
20. Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded endonasal approach: The rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum. Neurosurg Focus. 2005. 19: E4-
21. Kassam AB, Prevedello DM, Carrau RL, Snyderman CH, Thomas A, Gardner P. Endoscopic endonasal skull base surgery: Analysis of complications in the authors’ initial 800 patients. J Neurosurg. 2011. 114: 1544-68
22. Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH. The endoscope-assisted ventral approach compared with open microscope-assisted surgery for clival chordomas. World Neurosurg. 2011. 76: 318-27
23. Laufer I, Anand VK, Schwartz TH. Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. J Neurosurg. 2007. 106: 400-6
24. Ogawa Y, Nakagawa A, Takayama K, Tominaga T. Pulsed laser-induced liquid jet for skull base tumor removal with vascular preservation through the transsphenoidal approach: A clinical investigation. Acta Neurochir (Wien). 2011. 153: 823-30
25. Rutka JT. Endonasal resection of craniopharyngiomas. J Neurosurg. 2008. 109: 1-
26. Sen C, Triana A. Cranial chordomas: Results of radical excision. Neurosurg Focus. 2001. 10: E3-
27. Taniguchi M, Kohmura E. Endoscopic endonasal removal of laterally extended clival chordoma using side-viewing scopes. Acta Neurochir (Wien). 2012. 154: 627-32
28. Wang Q, Lan Q, Lu XJ. Extended endoscopic endonasal transsphenoidal approach to the suprasellar region: Anatomic study and clinical considerations. J Clin Neurosci. 2010. 17: 342-6
29. Wang Q, Lu XJ, Li B, Ji WY, Chen KL. Extended endoscopic endonasal transsphenoidal removal of tuberculum sellae meningiomas: A preliminary report. J Clin Neurosci. 2009. 16: 889-93
30. Yamamoto T, Yano S, Hide T, Kuratsu J. A case of ecchordosis physaliphora presenting with an abducens nerve palsy: A rare symptomatic case managed with endoscopic endonasal transsphenoidal surgery. Surg Neurol Int. 2013. 4: 13-
31. Yano S, Kawano T, Kudo M, Makino K, Nakamura H, Kai Y. Endoscopic endonasal transsphenoidal approach through the bilateral nostrils for pituitary adenomas. Neurol Med Chir (Tokyo). 2009. 49: 1-7
32. Yano S, Tsuiki H, Kudo M, Kai Y, Morioka M, Takeshima H. Sellar repair with resorbable polyglactin acid sheet and fibrin glue in endoscopic endonasal transsphenoidal surgery. Surg Neurol. 2007. 67: 59-64