Management Of Skull Base Pathology Research Articles

Transnasal endoscopic skull base surgery: analysis of complications in the first 120 procedures

The endonasal endoscopic approach (EEA) has potential advantages over traditional open approaches. However, complications such as cerebrospinal fluid (CFS) leak, visual disturbances, and postoperative meningitis have been described. The aim was to present the experience accumulated in 120 cases of skull base EEA performed by the same surgical team and describe and analyze the main postoperative complications according to the complexity of the cases. Retrospective study on our database of patients undergoing skull base EEA for various pathologies between July 2011 and March 2022. 120 skull base EEA surgeries were analyzed. 57.14% were performed on women. The median age was 44 years. 26.66% were reinterventions. The most frequent pathology was pituitary adenoma (49.17%) followed by CSF leak (8.33%). The most used EEA was the transelar 65.83%. 26 complications were recorded, with no differences according to complexity. There were 13 cases of diabetes insipidus (DI) and 8 of CSF leak. This was more frequent in patients with intraoperative CSF leak. The median hospital stay was 5.5 days. Skull base EEA has become increasingly common for the surgical management of skull base pathology, with a low frequency of immediate postoperative complications and low mortality. The improvement of the technique and the improvement in postoperative care are associated with a shorter hospital stay.

Complications of Skull Base Surgery.

Approaches to surgical management of skull base pathology and reconstruction of skull base defects have evolved over the past several decades. The goal, however, remains the same-to effectively address the pathology with minimal complications. In this article, the authors try to explore multiple complications of skull base surgery, discussing their incidence, natural course, and prevention. This will prove beneficial in optimal management of patients with a myriad of skull base disorders.

Teamwork in skull base surgery: An avenue for improvement in patient care

Background:During the past several decades, numerous centers have acquired significant expertise in the treatment of skull base pathologies. Favorable outcomes are not only due to meticulous surgical planning and execution, but they are also related to the collaborative efforts of multiple disciplines. We review the impact of teamwork on patient care, elaborate on the key processes for successful teamwork, and discuss its challenges.Methods:Pubmed and Medline databases were searched for publications from 1970 to 2012 using the following keywords: “teamwork”, “multidisciplinary”, “interdisciplinary”, “surgery”, “skull base”, “neurosurgery”, “tumor”, and “outcome”.Results:Current literature testifies to the complexity of establishing and maintaining teamwork. To date, few reports on the impact of teamwork in the management of skull base pathologies have been published. This lack of literature is somewhat surprising given that most patients with skull base pathology receive care from multiple specialists. Common factors for success include a cohesive and well-integrated team structure with well-defined procedural organization. Although a multidisciplinary work force has clear advantages for improving today's quality of care and propelling research efforts for tomorrow's cure, teamwork is not intuitive and requires training, guidance, and executive support.Conclusions:Teamwork is recommended to improve quality over the full cycle of care and consequently patient outcomes. Increased recognition of the value of an integrated team approach for skull base pathologies will hopefully encourage centers, physicians, allied health caregivers, and scientists devoted to treating these patients and advancing the field of knowledge to invest the time, effort, and resources to optimize and organize their collective expertise.

Surgical anatomy and physiology for the skull base surgeon

Endoscopic management of skull base pathology requires a interdisciplinary surgical approach. A comprehensive knowledge of the extracranial and intracranial anatomy is critical to achieve successful outcomes and decrease complications. Surgeons must familiarize themselves with anatomy of the ethmoid region, lateral nasal wall, sphenoid sinus, cavernous region, sellar/suprasellar region, clivus, and pterygopalatine/infratemporal fossa before embarking on these approaches.

Closure of large skull base defects after endoscopic transnasal craniotomy

The authors describe the utility of and outcomes after endoscopic transnasal craniotomy and skull reconstruction in the management of skull base pathologies. The authors conducted a observational study of patients undergoing totally endoscopic, transnasal, transdural surgery. The patients included in the study underwent treatment over a 12-month period at 2 tertiary medical centers. The pathological entity, region of the ventral skull base resected, and size of the dural defect were recorded. Approach-related complications were documented, as well as CSF leaks, infections, bleeding-related complications, and any minor complications. Thirty consecutive patients were assessed during the study period. The patients had a mean age of 45.5 +/- 20.2 years and a mean follow-up period of 182.4 +/- 97.5 days. The dural defects reconstructed were as large as 5.5 cm (mean 2.49 +/- 1.36 cm). One patient (3.3%) had a CSF leak that was managed endoscopically. Two patients had epistaxis that required further care, but there were no complications related to intracranial infections or bleeding. Some minor sinonasal complications occurred. Skull base endoscopic reconstructive techniques have significantly advanced in the past decade. The use of pedicled mucosal flaps in the reconstruction of large dural defects resulting from an endoscopic transnasal craniotomy permits a robust repair. The CSF leak rate in this study is comparable to that achieved in open approaches. The ability to manage the skull base defects successfully with this approach greatly increases the utility of transnasal endoscopic surgery.

PR22 SKULL BASE RECONSTRUCTION WITH FREE FLAPS

Introduction & Aims Microsurgical reconstruction in skull base surgery is not universally practiced. Current evidence suggests improved outcomes allowing more aggressive management of skull base pathology. We present our experience of free flaps in skull base reconstruction.Material & Methods 17 patients (10 male, 7 female, aged 30–72 years) required microsurgical reconstruction of skull base defects from 2004–2006. The anterior cranial fossa was involved in 10/17. Indications for surgery included malignancy (12/17) and benign neoplasia (3/17).Results 18 free flaps included 10 rectus abdominis, 5 radial forearm and 5 latissimus dorsi. Complications included one complete flap loss, one anastomotic revision, one CSF leak, one case of meningitis and one subdural empyema. There were no deaths.Conclusions We recommend free flap reconstruction for significant skull base defects involving both skull and dura. Important factors determining outcome include adequate pedicle length, flap thickness, use of fascia and controlled lumbar drainage.