Fronto - temporal approach in sellar and parasellar tumors

Abstract

Abstract Introduction: The fronto-temporal approach represent the shortest distance to the ipsilateral optic nerve and carotid artery, and allow the direct verification of the optical nerves, the carotid arteries, the pituitary stalk, the tumor and its relationship with the suprasellar structures. Objective: The purpose of this study is to advocate an available cranial base technique for removing these tumors and to delineate the technique’s advantages that aid in achieving an improved extent of tumor resection and enhancing the patients’ overall outcome. Materials and methods: We present a retrospective study of a single surgeon experience on 355 consecutive cases with sellar and parasellar tumors admitted and operated by transcranial approaches in our department between January 2000 and December 2012. Results: Tumors in the sellar region represent 11, 8% of all tumors operated in our department. The most common type of tumor was pituitary adenomas, 165 of cases, followed by sellar and parasellar meningiomas, 128 of cases. Craniopharyngioma represent 12% of cases encountered in this region. All our cases underwent surgery by transcranial approach, unilateral frontotemporal in 252 of cases (71%). In pituitary adenomas total and near total resection was achieved in 100% of patients operated by transcranial approaches. For resection of craniopharyngiomas we have frequently chosen the extended fronto-temporal approach. The most common surgical related complications were: postoperative hematomas 9 of cases; wound infections, 6 of cases and CSF leakage, 12 of cases; transient visual alteration in 12 cases, transient third cranial nerve palsy in 6 of cases, transient motor deficit in 7 cases, hydrocephalus, 6 cases; transient diabetes insipidus in the large majority of pituitary adenomas and craniopharingiomas. Only 4 cases of pituitary adenomas and 6 of craniopharingiomas recurred after subtotal resection, requiring re-intervention. The mortality rate in our study was 2%. Conclusions: Our experience demonstrated that the management of the large suprasellar tumors via fronto-temporal approach remains the main route for these tumors with significant extrasellar extension, fibrous tumors, cases with unrelated pathology that might complicate a transsphenoidal approach and recurrent tumors after previous transsphenoidal surgery. In our opinion there is no need for larger osteotomies or extensive drilling of cranial base. “Instead of bone, remove the tumor; it's easier even for the patient”.