Transnasal Endoscopic Skull Base Research Articles

Side-door temporoparietal fascia flap: First experience with a novel technique for anterior skull base reconstruction.

Modern achievements in transnasal endoscopic skull base (SB) surgery have led to complex resections that render reconstruction a challenge. Temporoparietal fascia flap (TPFF) is a suitable option for SB reconstruction. The side-door TPFF technique for anterior SB reconstruction is described here for the first time in a real-life surgical setting. Patients affected by a SB malignancy who underwent cranioendoscopic resection were included. For reconstruction, a multilayer reconstruction technique including side-door TPFF transposition was employed. TPFF transposition was performed in five patients. The TPFF could be easily transposed via a side-door approach. It adequately covered the edges of the defect and supported optimal healing of the surgical site. During follow-up, vitality and integration of the TPFF were assessed endoscopically and radiologically. The TPFF side-door transposition technique is a valuable option in anterior SB reconstruction that can provide fast and effective healing, especially in patients needing adjuvant radiotherapy.

Evaluating the Efficacy of a Novel Side-Support Surgical Tray Stand for Endoscopic Transnasal Skull Base Surgery: A Prospective Study.

Objective Endoscopic transnasal skull base surgery is a valuable technique used in the surgical treatment of various skull base pathologies. In such surgeries, the reconstruction of the skull base is crucial for surgical success and minimizing complications. This study presents a new side-support surgical tray designed to improve the exposure of the lateral femoral surgical area during surgery, enhancing surgical efficiency and reducing the risk of surgical complications. The study compared this innovative tray stand with the conventional double-sided support tray stand to evaluate its impact on surgical procedures and complications. Materials and methods The study prospectively analyzed 248 endoscopic transnasal skull base surgeries requiring lateral femoral autologous tissue harvesting. One hundred fifty-eight cases were performed using the side-support surgical tray stand (experimental group), while 90 cases used the conventional double-sided support tray stand (control group). Various parameters were evaluated, including satisfaction scores of surgeons, circulating nurses, instrument nurses, and anesthetists, as well as objective outcomes such as surgical duration and the incidence of complications. Results Surgeons in the experimental group expressed higher satisfaction with the surgical field exposure and the portability of the surgical tray stand compared to the control group. Likewise, circulating nurses in the experimental group reported greater satisfaction with the installation and portability, surpassing that of the control group (p< 0.01). Although the stability of instrument nurses in the experimental group was slightly less than that of the control group, it had no discernible impact on surgical cooperation. Anaesthesiologists in the experimental group exhibited higher satisfaction regarding the convenience of intraoperative monitoring and management than their counterparts in the control group. The average duration required for intraoperative autologous tissue harvesting in the experimental group was significantly shorter than in the control group (p< 0.01). Furthermore, the incidence of postoperative wound infections and intracranial infections in the experimental group was notably lower than in the control group (would infections,p= 0.046; intracranial infection,p= 0.025). Conclusion The novel side-support surgical tray stand effectively improves surgical exposure, convenience, and safety while reducing the risk of surgical site and intracranial infections. It also shortens surgical duration and lowers complication rates, making it a suitable choice for clinical application.

Application of a Novel Versatile Mini Posterior Nasoseptal Graft in Endoscopic Transsphenoidal Pituitary Adenoma Surgery.

Skull base reconstruction is a key technique in patients undergoing endoscopic transnasal skull base surgery. Although a pedicled nasoseptal flap (PNSF) is often used to repair large skull base defects with high-flow cerebrospinal fluid leakage, bone exposure of the donor site of the PNSF can result in long-term crusting. To design a novel and versatile mini posterior nasoseptal graft for the reconstruction of defects in the sellar floor or PNSF or pedicled nasoseptal rescue flap (PNSRF) donor site in patients undergoing pituitary adenoma surgery. Patients who underwent pituitary adenoma removal through an endoscopic endonasal approach and repair of a sellar defect or PNSF/PNSRF donor site using the mini posterior nasoseptal graft technique from January 2019 to January 2020 were retrospectively evaluated. Pituitary adenomas were removed using a binostril 4-hand technique through a transnasal transsphenoidal transsellar approach or an expanded transsellar approach. Mini posterior nasoseptal grafts were successfully used in 70 patients who underwent pituitary adenoma removal through an endoscopic transsphenoidal sellar approach. Mini posterior nasoseptal grafts repaired sellar defects in 40 patients and donor site defects of the contralateral PNSF/PNSRF in 30 patients. None of these patients experienced cerebrospinal fluid leakage or major complications. A mini posterior nasoseptal graft is a safe and effective technique for repairing sellar defects after endoscopic transnasal pituitary adenoma surgery. This technique can also be used to repair defects in PNSF/PNSRF donor sites.

Skull base reconstruction strategies and techniques for endoscopic transnasal skull base surgery

颅底重建是经鼻内镜颅底手术最重要的技术环节之一，直接影响手术的成败和患者的预后。在过去10年中，得益于鼻内镜技术、手术设备与器械、内镜颅底解剖学、内镜颅底外科理念等多方面的进步，内镜颅底重建技术也得到了快速发展。本文就鼻颅底外科手术中不同类型颅底缺损的特点、修复重建原则与方法、术后管理等方面进行阐述与总结，以期加强该领域学者之间的交流和对相关理论体系的再认识。.

Evaluation of MRI and transnasal endoscopic surgery for the diagnosis of perineural tumor spread to the skull base

Introduction: Magnetic resonance imaging (MRI) provides information about tumor size and extension, infiltration of major blood vessels and nerves, early bone-marrow infiltration, and lymph node involvement. Transnasal endoscopic approaches are an integral part of the therapeutic arsenal developed to address malignant sinonasal and skull-base neoplasms. Objective: To analyze the use of magnetic resonance imaging in the diagnosis of perineural tumor spread involving the skull base region. Methods: We describe two cases of patients who presented with primary squamous cell carcinoma in the malar region and suspected perineural spread to the skull base on MRI. One frozen cadaver head, were dissected to expose the trigeminal nerve and it branches. Results: MRI showed evidence of perineural spread to the skull base, which was confirmed histopathologically after endoscopic transnasal biopsy. Conclusion: MRI plays an important role in the diagnosis of perineural spread of tumors originating in the nose and skull base. In the two cases reported herein, the diagnostic suspicion raised by MRI was confirmed by histopathological examination. Endoscopic transnasal skull base surgery proved to be an important tool for diagnostic confirmation, with low procedure-associated morbidity. The presence of perineural spread changes the staging and, consequently, the prognosis and treatment of these tumors. Thus, its active search should be encouraged to improve diagnosis and help ensure appropriate treatment. Keywords: endoscopic surgery, magnetic resonance imaging, perineural tumor, bone-marrow infiltration

The use of three-dimensional endoscope in transnasal skull base surgery: A single-center experience from China.

ObjectiveThe development of skull base surgery in the past decade has been influenced by advances in visualization techniques; recently, due to such improvements, 3D endoscopes have been widely used. Herein, we address its effect for transnasal endoscopic skull base surgery.MethodsA total of 63 patients who under endoscopic endonasal surgery (EES) with 3-D endoscope were retrospectively reviewed, including pituitary adenomas, craniopharyngiomas, meningiomas, Rathke’s cleft cysts, and chordomas. According to different lesions, transsellar approach (24 cases), transsphenoidal–transtuberculum approach (14 cases), transclival approach (6 cases), and transpterygoid approach (19 cases) were selected.ResultsTotal removal of tumors was achieved in 56 patients (88.9%) and subtotal removal in 7 cases (11.1%). Complications included diabetes insipidus in seven patients (11.1%), cerebrospinal fluid (CSF) leakage in two patients (3.2%), major vascular injury occurred in one patient (1.6%), cranial nerve injury in nine patients (14.3%), and meningitis in two patients (3.2%). There was no mortality in the series. All patients recovered and were back to normal daily life, and no tumor recurrence or delayed CSF leakage was detected during the follow-up (2–13 months, mean 7.59 months).ConclusionsVia 3D EES, it improved depth perception and preserved important neurovascular tissue when tumors were removed, which is important for improving the operative prognosis.

Predictors of improvement in quality of life at 12-month follow-up in patients undergoing anterior endoscopic skull base surgery.

BackgroundPatients with pituitary lesions experience decrements in quality of life (QoL) and treatment aims to arrest or improve QoL decline.ObjectiveTo detect associations with QoL in trans-nasal endoscopic skull base surgery patients and train supervised learning classifiers to predict QoL improvement at 12 months.MethodsA supervised learning analysis of a prospective multi-institutional dataset (451 patients) was conducted. QoL was measured using the anterior skull base surgery questionnaire (ASBS). Factors associated with QoL at baseline and at 12-month follow-up were identified using multivariate logistic regression. Multiple supervised learning models were trained to predict postoperative QoL improvement with five-fold cross-validation.ResultsASBS at 12-month follow-up was significantly higher (132.19,SD = 24.87) than preoperative ASBS (121.87,SD = 25.72,p<0.05). High preoperative scores were significantly associated with institution, diabetes and lesions at the planum sphenoidale / tuberculum sella site. Patients with diabetes were five times less likely to report high preoperative QoL. Low preoperative QoL was significantly associated with female gender, a vision-related presentation, diabetes, secreting adenoma and the cavernous sinus site. Top quartile change in postoperative QoL at 12-month follow-up was negatively associated with baseline hypercholesterolemia, acromegaly and intraoperative CSF leak. Positive associations were detected for lesions at the sphenoid sinus site and deficient preoperative endocrine function. AdaBoost, logistic regression and neural network classifiers yielded the strongest predictive performance.ConclusionIt was possible to predict postoperative positive change in QoL at 12-month follow-up using perioperative data. Further development and implementation of these models may facilitate improvements in informed consent, treatment decision-making and patient QoL.

Advances in Intraoperative Neurophysiological Monitoring Techniques in Transnasal Endoscopic Skull Base Surgery

Transnasal endoscopic skull base surgery has been increasing in volume in recent years and its indications are constantly expanding. The potential occurrence of intraoperative and postoperative neurovascular complications deserves special attention from neurosurgeons. Multimodal intraoperative neurophysiological monitoring technology allows neurosurgeons to monitor cerebral perfusion and the functional status of the associated cranial nerves in real time, thereby enabling surgeons to make prompt adjustments in surgical procedures and strategies and reduce the risks of postoperative neurological complications in patients. Based on available literature, we reviewed how appropriate monitoring strategies were optimized for different key components of transnasal endoscopic skull base procedures, intending to provide reference for clinicians.

Hybrid Robotics for Endoscopic Transnasal Skull Base Surgery: Single-Centre Case Series.

Only preclinical studies and case reports have described robotic surgery for endoscopic transnasal skull base surgery. To evaluate the role of a novel robotic endoscope holder, developed for transsphenoidal surgery. Patients were prospectively enrolled for 3 mo at the Neurosurgery Unit of Brescia. Endoscope Robot® was used to assist during the sphenoidal phase of the approach, tumor removal, and skull base reconstruction. A Likert scale questionnaire was given to all surgeons after each procedure. Patients who underwent robotic-assisted surgery were matched with nonrobotic ones for pathology and type of procedure. All surgical videos were evaluated during bimanual phases. Twenty-one patients underwent robot-assisted, endoscopic transsphenoidal surgery for different pathologies (16 pituitary adenomas, 3 chordomas, 1 craniopharyngioma, 1 pituitary exploration for Cushing disease) for a total of 23 procedures (1 patient underwent 2 endoscopic revisions of a skull base reconstruction). Subjective advantages reported by surgeons included smoothness of movement, image steadiness, and improvement of maneuvers in narrow spaces and with angled endoscopes; as the main limitation, Endoscope Robot® appeared to be relatively heavy during the initial endoscope positioning. A comparative analysis with a historical matched cohort documented similar clinical outcomes, while endoscope lens cleaning and position readjustments were significantly less frequent in robotic procedures. Although confirmation in larger studies is needed, Endoscope Robot® was a safe and effective tool, especially advantageous in lengthy interventions through deep and narrow corridors.

Design and analysis of a continuum robot for transnasal skull base surgery.

The traditional surgical instruments for transnasal endoscopic skull base surgery have poor flexibility and continuum robot has attracted extensive attention for its high dexterity and safety. A new type of micro continuum surgical robot is designed. On the basis of kinematic analysis, a superposition method is proposed to analyse the reachable configuration space of the system, and the workspace is analysed. The results obtained by superposition method can provide reference for the selection of joint parameters. At last, the static model of the system is established considering friction and coupling between two segments. The simulation results show that the workspace can meet the requirements of surgery. And the validity of the static model is verified by numerical simulation and experiment, which lays a foundation for the establishment of the driving force transmission system and precise control of the robot. The research results of this study contribute to the real-time control and movement of robot. The proposed continuum robot provides convenient conditions for the clinical application.

Three-dimensional structure of the basal lamella of the middle turbinate

The middle turbinate’s basal lamella (3BL) is a variable landmark which needs to be understood in endoscopic transnasal skull base surgery. It comprises an anterior frontal and a posterior horizontal part and appears in its simplest depiction to be “L”-shaped, when viewed laterally. In this study we analyzed its 3D morphology and variations focusing on a precise and systematic description of the anatomy. CBCTs of 25 adults, 19 cadavers and 6 skulls (total: 100 sides) were investigated with the 3DSlicer software, creating 3D models of the 3BL. We introduced a novel geometrical classification of the 3BL’s shape, based on segments. We analyzed their parameters and relationship to neighboring structures. When viewed laterally, there was no consistent “L”-shaped appearance of the 3BL, as it is frequently quoted. A classification of 9 segment types was used to describe the 3BL. The 3BLs had in average of 2.95 ± 0.70 segments (median: 3), the most frequent was the horizontal plate (23.05% of all segments), next a concave/convex plate (22.71%), then a sigma plate (22.37%). Further types were rare. We identified a horizontal plate in 68% of all lateral views whilst 32% of the 3BLs were vertical. A sigma–concave/convex–horizontal trisegmental 3BL was the most common phenotype (27%). Globally, the sigma–concave/convex pattern was present in 42%. The 3BL adhered the ethmoidal bulla in 87%. The segmenting method is eligible to describe the 3BL’s sophisticated morphology.

In Reply: Precautions for Endoscopic Transnasal Skull Base Surgery During the COVID-19 Pandemic.

In Reply: Precautions for Endoscopic Transnasal Skull Base Surgery During the COVID-19 Pandemic.

CSF Leak Post COVID-19 Swab in a Patient with Preexisting Meningiocele

A 45-year-old female with medical background significant for bronchial asthma, hypothyroidism, polycystic kidney disease and obesity presented to the emergency department in December 2020 with one week history of severe headache, unilateral rhinorrhea and metallic taste. Her symptoms started two days after she had nasopharyngeal swab as post travel screening routine. Radiological investigations revealed features of increased intracranial pressure and a suspicious skull base defect for which patient undergone endoscopic transnasal skull base repair. Intraoperative findings were positive for CSF leak from a skull base defect and an incidental finding of Meningiocle. Patient was seen after three weeks with no more CSF rhinorrhea, but was complaining of persistent mild headache, for which she was referred to neurology for further management. Conclusion: CSF leak is one of the rare, yet serious complications of nasopharyngeal swab especially in patients with previous skull base surgery, trauma, patients with pre-existing skull base defects or with elevated intracranial pressure. Meningocele found in this case report was presumed to be a predisposing factor for CSF leak post nasopharyngeal swab. Education about safe administration of nasopharyngeal swabs as well as understanding the nose anatomy is important to reduce the overall risk profile of nasopharyngeal sampling. Moreover, an alternative method of testing such as oropharyngeal specimen should be considered in populations with increased risk of CSF leak.

Olfactory Preservation in Craniofacial Resection of Tumor Invading Hemianterior Skull Base: Operative Video.

In traditional craniofacial resection of tumors invading the anterior skull base, the bilateral olfactory apparatus is resected. Recently, transnasal endoscopy has been used for olfactory preservation in resections of unilateral low-grade malignancies. However, for tumors that invade the orbita or for high-grade malignancies, the transnasal endoscopic skull base surgery has been controversial. This video demonstrates the surgical techniques of olfactory preservation during craniofacial resection of a high-grade malignancy invading the hemianterior skull base and orbita. We present the case of a 32-year-old woman with osteosarcoma in the right ethmoid sinus. The tumor invaded the ipsilateral cribriform plate, dura menta, and orbital periosteum; however, the nasal septum and crista galli were intact ( Fig. 1A, B ). Because the tumor was a high-grade malignancy and the orbita had been invaded, we performed craniofacial resection instead of endoscopic resection ( Fig. C2A ). We drilled into the right side of the crista galli, midline of the cribriform plate, and perpendicular plate of the ethmoid bone via craniotomy. As a result, we accessed the nasal cavity directly ( Fig. 2B ). To preserve the nasal septum, we detached the remaining right septal mucosa through the transfacial approach ( Fig. 2C ). Because of the high risk of cerebrospinal fluid leakage as a result of previous irradiation, we performed vascularized free flap reconstruction of the skull base instead of pericranial flap. Postoperative computed tomography revealed no evidence of tumor ( Fig. 1C, D ). The patient's sense of smell returned after 1 postoperative day, and she was discharged on the postoperative day 14. The link to the video can be found at: https://youtu.be/XzPABYwzkjs .

Anatomical localization of horizontal segment of the petrous internal carotid artery in transnasal endoscopic skull base surgery

Objective To discuss the localization of horizontal segment of petrous internal carotid artery in transnasal endoscopic skull base surgery, and to provide anatomical data for clinical surgery. Methods The horizontal segment of the petrous internal carotid artery of 5 adult cadaveric heads were exposed by endoscopic transnasal and microscopic open approaches respectively, and the relevant data and images were measured and collected. Results The medial wall of the foramen spinosum is the lateral wall of the isthmus of the eustachian tube, and the thickness of the bone is 0.5 ± 0.2 mm. The medial wall of the isthmus of the eustachian tube is the lateral wall of the posterior genu of the carotid canal and the thickness of the bone is 0.2 ± 0.1 mm. The vidian nerve originates from the anterior genu of the petrous internal carotid artery. The distance from the base of vidian nerve to the isthmus of eustachian tube is 19.2 ± 2.8 mm. Conclusion The foramen spinosum is the landmark of isthmus of the Eustachian tube. The isthmus of the Eustachian tube is the landmark of the posterior genu of the internal carotid artery. The line between the base of the vidian nerve and the isthmus of the Eustachian tube ioks the landmark of horizontal segment of the petrous internal carotid artery.

Transnasal endoscopic skull base and brain surgery: Surgical anatomy and its applications. Aldo C.StammJoaoMangussi‐GomesNew York, NY: Thieme, 2019, 690 pp., $229.99.

Transnasal endoscopic skull base and brain surgery: Surgical anatomy and its applications. Aldo C.StammJoaoMangussi‐GomesNew York, NY: Thieme, 2019, 690 pp., $229.99.

Recovery peculiarities and complications in the nasal cavity caused by skull base reconstruction with nasoseptal flap after transnasal removal of chiasmo-sellar mass lesions

Today, endoscopic endonasal approach is considered the gold standard in skull base surgery of the chiasmosellar region. Advances in transnasal endoscopic skull base surgery allow conducting more extensive interventions via wider approaches which requires more complicated plastic closure of the skull base defect. In 2006, G. Haddad et al. suggested using a vascularized nasoseptal flap to reconstruct a skull base defect. This method is generally accepted at present due to its reliability and low frequency of postoperative complications. The purpose of this article is to analyze publications on possible complications and pathological conditions of the nasal cavity when using a vascularized nasoseptal flap for skull base surgery after removal of neoplasms of the chiasmo-sellar region. The study included articles found in the Pubmed database (2006–2020) which described frequency and character of complications caused by skull base defect reconstruction by a nasoseptal flap after transnasal removal of chiasmo-sellar neoplasms. According to the literature review, the following complications are reported: cerebrospinal fluid leak, flap necrosis and infectious complications, pathological changes in the nasal cavity: prolonged crusting, synechiae, epistaxis, septum perforation, sinusitis, subatrophic changes of mucosae, nasolacrimal duct obstruction, olfactory dysfunction. The authors conclude that the nasoseptal flap is, undoubtedly, an effective material for reconstruction of dural defects by endoscopic endonasal skull base surgery, because of its good viability due to the preserved blood supply and high tightness of the plasty. However, there is a risk of complications in the nasal cavity. For these reasons, development of effective methods for prevention of nasal complications after using a vascularized flap in endoscopic endonasal surgery is an important issue today.

Quality-of-life assessment after endoscopic skull base surgeries

Introduction Endoscopic transnasal approaches have been the main treatment option for most of anterior skull base and sellar diseases. Quality-of-life (QOL) assessment after skull base surgeries are now well appreciated and measured to improve medical and surgical care for those patients. Aim To assess QOL after endoscopic transnasal skull base surgery in its six main domains. Patients and methods This study was conducted on 20 patients who had endoscopic skull base surgery for various skull base lesions. QOL was assessed by modified short form health survey questionnaire 1 and 4 weeks postoperatively. A scoring system was adopted, and cases were divided into two group according to their overall score (worse and better groups). Comparison between the two groups was conducted to determine factors that worsen QOL results after endoscopic skull base surgery. Results The overall QOL showed statistical improvement 1 month postoperatively over after 1 week. One week after operation, QOL was statistically affected by age of patient, duration of nasal pack removal, and duration of ICU admission. Postoperative pain domain is worsened by superior turbinate resection or trimming during first week. Conclusion QOL after endoscopic skull base surgeries has been associated with statistically significant improvement after 4 weeks, with significant decrease in the incidence of postoperative complications.

A novel aerosolisation mitigation device for endoscopic sinus and skull base surgery in the COVID-19 era.

PurposeTo provide a novel solution to reduce aerosol exposure in the operating room during endoscopic sinus and skull base procedures in the COVID-19 era.MethodsWe have designed a 3D printable midfacial mask that partially seals the nose, while allowing instrumentation during endoscopic transnasal surgery. The mask when connected to a vacuum system creates a constant negative pressure inside it, sucking out aerosols and gases generated during surgical procedures. Its effectiveness was tested using vapour exhalations by a human volunteer and drilling bone in a head model. The physical barrier effect was measured using fluorescein atomization in a head model.ResultsThe pressure and airflow measured remained negative inside it in all the different situations tested. The mask was capable of completely evacuating human adult exhalation, and was more effective than the hand suction instrument. However, it was as effective as hand suction instrument at preventing aerosol spread from bone drilling. The physical barrier effect achieved a 72% reduction in the splatter created from the fluorescein atomization.ConclusionsThe mask effectively prevented the spread of aerosols and reduced droplet spread during simulated transnasal endoscopic skull base surgery in laboratory conditions. This device has potential benefits in protecting surgical personnel against airborne transmission of COVID-19 and could be useful in reducing chronic exposure to the hazard of surgical smoke.Electronic supplementary materialThe online version of this article (10.1007/s00405-020-06462-1) contains supplementary material, which is available to authorized users.

In Reply: Precautions for Endoscopic Transnasal Skull Base Surgery During the COVID-19 Pandemic.

To the Editor: The COVID-19 pandemic crisis has been defying health professionals and managers at all levels. Due to the risk of health system overload, there is an unpaired need to infrastructure, human, and economic resource allocation management. At a time when global attention is focused on the pandemic, we should not overlook that people continue to face other health problems. The incidents of trauma and accidental injury tend to decrease due to social distancing, quarantine, or locking. However, other diseases, such as stroke and neoplasms, inexorably follow their natural course. The correspondence published by Patel et al1 draws attention to the potential risks of endonasal endoscopic surgery in COVID-19 diagnosed or suspected patients and the need for surgical practice provisional update. Based on personal communication, it reports, in a narrative fashion, a series of cases of health worker contamination related to the care of patients undergoing endoscopic endonasal surgery despite the best efforts to perform a safe surgery. Similar incidents occurred in several reference services around the world. The authors emphasize the need for adequate use of personal protective equipment (PPE) in cases tested positive for COVID-19—although it questions the sensitivity and specificity of such tests—and recommend limiting the number of professionals during procedures only to the essential ones. Since the pandemic breakthrough in Wuhan, China, in December 2019, thousands of health workers have been infected during the care of patients with COVID-19. The high viral load in the upper airways of infected patients poses a greater risk during endoscopic endonasal procedures, especially when high-speed drilling is needed, which increases the production of aerosols and the suspension of viral particles in the environment.2 It is very clear within the neurosurgical community that protocols should be planned to determine which neurosurgical cases must be prioritized. Such protocols should consider the urgency status and type of the procedure, the need and length of postoperative intensive care support, and the preoperative testing of patients when possible. Burke et al3 and Ramakrishna et al4 demonstrate in a pragmatic way how to implement such stratification initiatives. Moreover, given the potential shortage of intensive care unit (ICU) and ward beds, there is an opportunity to foster the ongoing phenomenon of adoption of quality improvement programs such as the Enhanced Recovery After Surgery (ERAS). The ERAS implementation initiatives have shown improved patient outcomes while reducing length of stay and costs.5 Thus, the postponement of endoscopic endonasal neurosurgical procedures seems feasible and, in the current scenario, an appropriate solution. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.