Endoscopic Endonasal Surgery (EES) for Craniopharyngiomas: Experience of the Neurosurgery Institute Dr. Alfonso Asenjo, Chile

Introduction: Conventionally, the transsphenoidal approach (TE) has been considered as an effective surgical method for craniopharyngiomas that originated and developed in the sella turcica. However, recently, extended TE surgery with endoscopy has subsequently expanded its range of indication, which allows its use in suprasellar craniopharyngiomas. The purpose of this paper is to show our experience in endonasal endoscopic surgery for craniopharyngiomas.

Methods: Data were obtained from patients diagnosed with craniopharyngioma and who underwent endoscopic endonasal surgery (EES) at the Dr. Alfonso Asenjo Institute of Neurosurgery, Santiago-Chile, between November 2011 and May 2019, to analyze them retrospectively. The diagnosis of craniopharyngioma was histologically confirmed. We consider pre and postoperative evaluations for neurophthalmology, endocrinology, and skull base repair in operative protocol.

Results: We included 16 patients, average age 32.2 (6–69) years, 50% male and 50% female. They were classified into two groups; Primary surgery and reintervention (transcranial or transsphenoidal). The 47.3% (9/16) received primary surgery; 11.1% presented panhypopituitarism prior to surgery and 33.3% presented it in the postoperative period. 66.6% had visual field disturbance prior to surgery, of which four improved after surgery and two remained with the same postoperative deficit. Of the eight patients in the reintervention group, there were two with more than one EES, and the rest previously underwent transcranial surgery. Of these, 62.5% had panhypopituitarism, and after surgery 75%. Also, 87.5% had altered visual field, two with postoperative deterioration. Of the 20 surgeries, 17 used nasoseptal flap with vascular pedicle and bone in situ to repair the skull base defect, the rest; one was repaired with a titanium plate-abdominal subcutaneous fat-Duraseal; one with Surgicel-abdominal subcutaneous fat; one with abdominal subcutaneous fat-Bone-Beriplast. Three of the patients presented CSF leak after surgery. All of them were repaired with the nasoseptal flap, previously in de EES. As for other complications, six had diabetes insipidus, three transiently. One of our patients evolved with CNS infection associated with acute hydrocephalus that required external ventricular drainage. Another of our patients presented CSF fistula, which required reoperation, then evolved with meningitis, multisystem failure, and died.

Conclusion: The surgical approach is challenging in craniopharyngioma. The use of the endoscopic endonasal technique provides great exposure for the neurosurgeon. The injury of the endocrine and visual function should be considered. The septal flap with vascular pedicle and bone in situ, for the reconstruction of the skull base defect, was used in the majority of our surgeries with an acceptable number of CSF leakage.