Joaquim Enseñat

Impairment of Olfaction and Mucociliary Clearance After Expanded Endonasal Approach Using Vascularized Septal Flap Reconstruction for Skull Base Tumors

BACKGROUND Endoscopic skull base surgery is now the preferred treatment option to remove skull base tumors. OBJECTIVE To evaluate the patients sense of smell and mucociliary clearance time (MCT) after skull base surgery. METHODS Patients with pituitary adenoma underwent a transnasal transsphenoidal endoscopic approach (TTEA group, n = 36), whereas patients with other benign parasellar tumors underwent an expanded endonasal approach (EEA group, n = 14) with a vascularized septal flap. Assessment of symptoms (Visual Analogue Scale), olfactometry (Barcelona Smell Test, BAST-24), and MCT (saccharin test) were performed before and 3 months after surgery. RESULTS Before surgery, patients reported poorer BAST-24 scores on detection, identification, and forced choice than the healthy population, but both study groups had similar sinonasal symptoms, BAST-24, and MCT scores. After surgery, no changes in symptom scores (Visual Analogue Scale) were observed except for the loss of smell (26.7 ± 30.5 mm, P < .05) and posterior nasal discharge (29.7 ± 30.3 mm, P < .05) compared with baseline (5.2 ± 11.3, 19.1 ± 25.3, respectively). EEA patients reported higher loss of smell and posterior nasal discharge compared with TTEA. TTEA and EEA groups had similar scores on postoperative BAST-24. After surgery, however, patients showed prolonged saccharin test (15.6 ± 10.8 min, P < .05) compared with baseline (8.4 ± 4.4 min). In addition, EEA patients reported longer MCT than TTEA patients. CONCLUSION EEA but not TTEA has a short-term (3 months) negative impact on patients olfaction and mucociliary clearance. Patients should be informed about smell loss as a consequence of skull base surgery to prevent legal claims. Likewise, further research and some modifications on reconstruction flaps are encouraged to avoid damaging the olfactory neuroepithelium.

Expanded endonasal approach using vascularized septal flap reconstruction for skull base tumors has a negative impact on sinonasal symptoms and quality of life.

Background Endoscopic transsphenoidal surgery is currently the optimal treatment for skull base tumors. This study was designed to assess patients sinonasal symptoms and quality of life (QoL) after resection of pituitary adenoma or skull base tumors using vascularized septal flap (VSF) reconstruction. Methods Patients with pituitary adenoma underwent the transnasal transsphenoidal endoscopic approach (TTEA; n = 38), and patients with other benign parasellar tumors underwent the expanded endonasal approach (EEA; n = 17) with VSF. Assessment of sinonasal symptoms and QoL by the 36-item Short-Form (SF-36) and the 31-item Rhinosinusitis Outcome Measure (RSOM-31) were performed before and 3 months after surgery. Results At baseline, the total seven-sinonasal symptom score (T7SSS) was similar between both groups. After surgery, T7SSS significantly increased in EEA but not in TTEA patients. EEA patients reported more smell loss (40.1 ± 26.2; p < 0.05) and posterior nasal discharge (49.3 ± 30.1; p < 0.05) than TTEA patients (21.6 ± 30.9 and 22.5 ± 27.5, respectively). At baseline, both groups had poorer SF-36 compared with the general population. TTEA patients had poorer QoL (on general health, vitality, and mental health) than EEA patients. After surgery, TTEA patients showed impaired physical role and bodily pain compared with baseline, and EEA patients showed impaired physical role and mental health. At baseline, RSOM scores were similar in TTEA and EEA groups. After surgery, EEA but not TTEA patients reported poorer nasal and general symptoms. Conclusion The EEA with VSF produces more sinonasal symptoms than pituitary surgery, surgery for skull base and pituitary tumors has negative impact on QoL, and functioning tumors have no further negative effect on sinonasal symptoms and QoL.

The use of a three-dimensional novel computer-based model for analysis of the endonasal endoscopic approach to the midline skull base.

OBJECTIVES To apply a three-dimensional geometric model to various endoscopic endonasal approaches to analyze the bony anatomy of this area, quantify preoperatively bone removal, and optimize surgical planning. METHODS Investigators dissected 18 human cadaveric heads at the Laboratory of Surgical NeuroAnatomy (LSNA) of the University of Barcelona (Spain). Before and after each dissection, a computed tomography (CT) scan was performed to create a three-dimensional geometric model of the approach performed in the dissection room. The model protocol was designed as follows: (i) a preliminary exploration of each specimen using the preoperative CT scan, (ii) creation of a computer-generated three-dimensional virtual model of the approach, (iii) cadaveric anatomic dissection, and (iv) development of a CT-based model of the approach as a result of the superimposition of predissection and postdissection digital imaging and communications in medicine (DICOM) images of specimens. RESULTS This method employing preliminary virtual exploration of each specimen, the creation of a three-dimensional virtual model of the approach, and the overlapping of the predissection and postdissection three-dimensional models was useful to define the exact boundaries of the endoscopic endonasal craniectomy. CONCLUSIONS Aside from laboratory anatomic dissection itself, this model is very effective in providing a depiction of bony landmarks and visual feedback of the amount of bone removed, improving the design of the craniectomy in the endoscopic endonasal midline skull base approach.

The oculomotor nerve: microanatomical and endoscopic study.

OBJECTIVEThis study was performed to assess the anatomy of the oculomotor nerve and to describe its course from the brainstem to the orbit. A new anatomically and surgically oriented classification of the nerve has been provided to illustrate its topographic and neurovascular relationships. METHODSFifty-nine human cadaveric heads (118 specimens) were used for the anatomical dissection. Forty-four of these were embalmed in a 10% formalin solution for 3 weeks, and 15 were fresh frozen injected with colored latex. The nerve was exposed along its pathway via frontotemporal, frontotemporo-orbitozygomatic, and subtemporal transtentorial approaches. These approaches were performed to expose each segment of the nerve. An endoscopic endonasal transsphenoidal approach was performed on 9 heads to visualize and compare the neurovascular relationships of the same areas from an inferomedial perspective. Measurements of each segment of the nerve were taken in all specimens during the dissecting process. RESULTSThe nerve was divided into 5 segments: cisternal, petroclinoid, cavernous, fissural, and orbital. The simultaneous use of a microscopic transcranial and an endoscopic endonasal route allows a better understanding of the spatial relationship of the nerve. CONCLUSIONThe knowledge of the dural, bony, and neurovascular relationships of the oculomotor nerve may help to prevent common complications during both microsurgical and endoscopic approaches to the cavernous sinus, interpeduncular, middle cranial fossa, and orbital regions. We discuss the possible significance of the observed anatomical data and propose classification of the different segments of the nerve.

Management of anterior skull base defect depending on its size and location.

Introduction. We present our experience in the reconstruction of these leaks depending on their size and location. Material and Methods. Fifty-four patients who underwent advanced skull base surgery (large defects, >20 mm) and 62 patients with CSF leaks of different origin (small, 2–10 mm, and midsize, 11–20 mm, defects) were included in the retrospective study. Large defects were reconstructed with a nasoseptal pedicled flap positioned on fat and fascia lata. In small and midsized leaks. Fascia lata in an underlay position was used for its reconstruction covered with mucoperiosteum of either the middle or the inferior turbinate. Results. The most frequent etiology for small and midsized defects was spontaneous (48.4%), followed by trauma (24.2%), iatrogenic (5%). The success rate after the first surgical reconstruction was 91% and 98% in large skull base defects and small/midsized, respectively. Rescue surgery achieved 100%. Conclusions. Endoscopic surgery for any type of skull base defect is the gold standard. The size of the defects does not seem to play a significant role in the success rate. Fascia lata and mucoperiosteum of the turbinate allow a two-layer reconstruction of small and midsized defects. For larger skull base defects, a combination of fat, fascia lata, and nasoseptal pedicled flaps provides a successful reconstruction.

Anatomic skull base education using advanced neuroimaging techniques.

OBJECTIVE The goal of the present article was to describe our dissection training system applied to a variety of endoscopic endonasal approaches. It allows one to perform a 3D virtual dissection of the desired approach and to analyze and quantify critical surgical measurements. METHODS All the human cadaveric heads were dissected at the Laboratory of Surgical Neuro-Anatomy (LSNA) of the University of Barcelona (Spain). The model surgical training protocol was designed as follows: 1) virtual dissection of the selected approach using our dissection training 3D model; 2) preliminary exploration of each specimen using a second 3D model based on a preoperative computed tomographic scan; 3) cadaveric anatomic dissection with the aid of a neuronavigation system; and 4) quantification and analysis of the collected data. RESULTS The virtual dissection of the selected approach, preliminary exploration of each specimen, a real laboratory dissection experience, and finally, the analysis of data retrieved during the dissection step was a complete method for training manual dexterity and hand-eye coordination and to improve the general knowledge of surgical approaches. CONCLUSIONS The present model results are found to be effective, providing a valuable representation of the surgical anatomy as well as a 3D visual feedback, thus improving study, design, and execution in a variety of approaches. Such a system can also be developed as a preoperative planning tool that will allow the neurosurgeon to practice and manipulate 3D representations of the critical anatomic landmarks involved in the endoscopic endonasal approaches to the skull base.

Cirugía endoscópica endonasal en tumores de hipófisis. Resultados en una serie de 121 casos operados en un mismo centro y por un mismo neurocirujano

INTRODUCTION Pituitary adenomas account for approximately 15% of intracranial benign tumors. The neurosurgical results achieved since the endoscopic endonasal transsphenoidal (EET) approach was introduced in our center in 2005 are reported here. PATIENTS AND METHODS A retrospective analysis of 121 patients with sellar lesions (58% females, age 55.7 ± 16 years, range 18-82) who underwent EET surgery from February 2005 to January 2012 and were followed up for a mean time of 4.58 years (range 1.08-8.58). RESULTS Six Rathke cleft cysts (3 intra-suprasellar, 1 intrasellar, 2 suprasellar); 114 pituitary adenomas (16 microadenomas, 98 macroadenomas), and 1 case of normal MRI were included. Baseline findings included hormonal changes in 59 patients (48,7%) and visual field changes in 38 patients (31%); in 7 patients (5.8%), clinical presentation was pituitary apoplexy. Complete resection was achieved in 77 patients (63.6%), subtotal resection in 29 (23.9%), and partial resection in 15 (12.3%). In patients with Grade 3 and 4 cavernous sinus invasion, resection was subtotal in 30% (12/39) and complete in 46% (18/39). Hormonal remission was achieved in 16 patients with Cushing disease (84%), 18 patients with prolactinoma (78.2%), and 18 patients with acromegaly (85,7%). There were 12 cases (9%) of cerebrospinal fluid leak, 4 cases of diabetes insipidus, and 3 cases with transient SIADH/hyponatremia. Seven patients developed panhypopituitarism. Postoperative mortality rate was 2.4%. One hundred and three patients (85.3%) were discharged from the hospital less than 48 hours after surgery. CONCLUSION Our results are similar to those reported by renowned pituitary units. Results achieved using an endoscopic approach in pituitary neurosurgery are better than those of microneurosurgery for cavernous sinus invasion.

A three-dimensional computer-based perspective of the skull base.

OBJECTIVE To describe our designed protocol for the reconstruction of three-dimensional (3D) models applied to various endoscopic endonasal approaches that allows performing a 3D virtual dissection of the desired approach and analyzing and quantifying critical surgical landmarks. METHODS All human cadaveric heads were dissected at the Laboratory of Surgical Neuroanatomy of the University of Barcelona. The dissection anatomic protocol was designed as follows: 1) virtual surgery simulation systems, 2) navigated cadaver dissection, and 3) postdissection analysis and quantification of data. RESULTS The virtual dissection of the selected approach, the preliminary exploration of each specimen, the real dissection laboratory experience, and the analysis of data retrieved during the dissection step provide a complete method to improve general knowledge of the main endoscopic endonasal approaches to the skull base, at the same time allowing the development of new surgical techniques. CONCLUSIONS The methodology for surgical training in the anatomic laboratory described in this article has proven to be very effective, producing a depiction of anatomic landmarks as well as 3D visual feedback that improves the study, design, and execution in various neurosurgical approaches. The Dextroscope as a virtual surgery simulation system can be used as a preoperative planning tool that can allow the neurosurgeon to perceive, practice reasoning, and manipulate 3D representations using the transsphenoidal perspective acquiring specifically visual information for endoscopic endonasal approaches to the skull base. The Dextroscope also can be used as an advanced tool for analytic purposes to perform different types of measurements between surgical landmarks before, during, and after dissection.

Endoscopic endonasal surgery for skull base tumours: technique and preliminary results in a consecutive case series report.

BACKGROUND The introduction of the endoscope in transsphenoidal surgery has allowed access to lesions located in complex regions of the skull base under direct visual control. With the application of this technique, our group started treating pituitary tumours and from 2009 onwards began treating skull base lesions through extended endoscopic endonasal approaches. The AIM OF THE PRESENT STUDY is to report our experience with extended endoscopic approaches. Indications, results, limitations and complications of this new technique are also discussed. MATERIAL AND METHODS From January 2007 to January 2012, the endonasal approach was used in 40 patients with different cancerous lesions. RESULTS Total tumour removal, as assessed by postoperative magnetic resonance imaging, occurred in 30/ 40 patients (75%), but in 10 patients only partial removal was possible. Major complications, including cerebrospinal fluid leak, were observed in 5/40 patients (8%). One patient died 3 months after surgery due to a severe systemic sepsis. CONCLUSION The extended endoscopic endonasal approach could be used as a minimally invasive and innovative technique for the removal of selected skull base lesions.

Extended Endoscopic Endonasal Approaches for Cerebral Aneurysms: Anatomical, Virtual Reality and Morphometric Study

Introduction. The purpose of the present contribution is to perform a detailed anatomic and virtual reality three-dimensional stereoscopic study in order to test the effectiveness of the extended endoscopic endonasal approaches for selected anterior and posterior circulation aneurysms. Methods. The study was divided in two main steps: (1) simulation step, using a dedicated Virtual Reality System (Dextroscope, Volume Interactions); (2) dissection step, in which the feasibility to reach specific vascular territory via the nose was verified in the anatomical laboratory. Results. Good visualization and proximal and distal vascular control of the main midline anterior and posterior circulation territory were achieved during the simulation step as well as in the dissection step (anterior communicating complex, internal carotid, ophthalmic, superior hypophyseal, posterior cerebral and posterior communicating, basilar, superior cerebellar, anterior inferior cerebellar, vertebral, and posterior inferior cerebellar arteries). Conclusion. The present contribution is intended as strictly anatomic study in which we highlighted some specific anterior and posterior circulation aneurysms that can be reached via the nose. For clinical applications of these approaches, some relevant complications, mainly related to the endonasal route, such as proximal and distal vascular control, major arterial bleeding, postoperative cerebrospinal fluid leak, and olfactory disturbances must be considered.