Algorithm for reconstruction after endoscopic pituitary and skull base surgery

INTRODUCTION: The expanding role of endoscopic skull base surgery necessitates a thorough understanding of the indications, techniques, and limitations of the various approaches to reconstruction. The technique and outcomes of endoscopic skull base reconstruction remain incompletely described in the literature. STUDY DESIGN AND METHODS: Patients undergoing endoscopic skull base surgery underwent an algorithmic approach to reconstruction based on tumor location, defect size, and presence of intraoperative cerebrospinal fluid (CSF) leak. A prospective database was reviewed to determine the overall efficacy of reconstruction and to identify risk factors for postoperative CSF leak. RESULTS: The diagnosis in the 127 patients in this series included pituitary tumor in 70 (55%) patients, encephalocele in 16 (12.6%) patients, meningioma in 11 (8.7%) patients, craniopharyngioma in 9 (7.1%) patients, and chordoma in 6 (4.7%) patients. Successful reconstruction was initially achieved in 91.3% of patients. Eleven (8.7%) patients experienced postoperative CSF leak, 10 of which resolved with lumbar drainage alone. One (0.8%) patient required revision surgery. Correlation between postoperative CSF leak and study variables revealed a statistically significant longer duration of surgery (243 vs. 178 min, P = .008) and hospitalization (12.1 vs. 4.5 days, P < .0001) and a trend toward larger tumors (mean, 3.2 vs. 2.3 cm; P = .058) in patients experiencing postoperative CSF leak. CONCLUSION: The algorithm for reconstruction after endoscopic surgery presented in this study is associated with excellent overall efficacy. A greater understanding of risk factors for postoperative CSF leak is imperative to achieve optimal results.     

Sigmoid incision rescue nasoseptal flap technique for endoscopic endonasal skull base surgery

Conclusion The sigmoid-incision (S-I) rescue flap technique has the advantage of both reduced-invasiveness and providing a sufficient surgical corridor for endoscopic endonasal skull base surgery (EESBS). Objective Skull base reconstruction with nasoseptal flap (NSF) is critically important in managing post-operative cerebrospinal fluid (CSF) leakage after tumor removal by EESBS. The NSF needs to be elevated before sphenoidotomy and posterior septectomy to preserve the pedicle. However, most extradural surgery without CSF leakage does not require NSF and, therefore, NSF preparation is often futile. As a result, a rescue flap technique to overcome this problem has been developed, whereby a new S-I rescue flap method is used that enables wide exposure of the sphenoidal rostrum and smooth manipulation of surgical instruments to preserve the NSF pedicle. Materials and methods Starting in April 2014, 19 cases underwent EESBS with S-I rescue flap. Results All patients underwent tumor resection under an adequate operative field with smooth manipulation of surgical instruments. Two complications were experienced. One patient had CSF leak after removal of the nasal packing, but the leakage was successfully closed by conventional NSF. Another patient had epistaxis from the septal wall, but this was controlled by electrocautery.     

A standardized regimen of antibiotics prevents infectious complications in skull base surgery

Objectives/Hypothesis: Craniofacial surgery has been associated with a significant improvement in disease outcome for patients with skull base neoplasms. Despite this improved survival, complications remain considerable. One major source of complications is infectious events. The current study was designed to evaluate a prospectively designed antibiotic regimen and its impact on the incidence and severity of infectious complications. This regimen was compared with a group of historic controls in which antibiotics were administered on an ad hoc basis. The specific objectives/hypothesis were to determine 1) the incidence and severity of infection in a group of patients treated with a nonstandardized antibiotic regimen undergoing craniofacial resection, and 2) whether the use of a prospectively designed, three‐drug, broad spectrum antibiotic is associated with a reduced incidence and severity of infections. Study Design: A single‐arm, prospective antibiotic regimen consisting of ceftazidime, flagyl (metronidazole), and vancomycin (CMV) was compared with a historic control of patients treated with nonstandard antibiotic therapy (nonCMV), all of whom underwent craniofacial resection. Outcome measures focused on incidence of infection, severity of infection, and operative mortality. Methods: In July 1990, a retrospective review (1973‐1990) was performed of craniofacial resection. Beginning in July 1990, a prospective database (1990–2003) has been maintained. Demographics, prior therapy, anatomic site of origin and extent of disease, pathology, standard surgical data, and postoperative therapy were detailed. Antibiotic data were collected from chart review. Complications, focusing on infectious complications, were identified and categorized. Culture results and whether the inciting infection was sensitive or resistant to perioperative antibiotics were noted. Length of hospital stay was tabulated. Disease outcome, including incidence of postoperative mortality, was maintained for each patient. Results: A total of 211 patients underwent craniofacial resection from 1973 to 2003. Major medical comorbidities were present in 53 (25%) patients, and 96 (46%) had prior therapy. The standardized antibiotic therapy (CMV) was used in 90 patients, and the nonstandardized antibiotics (nonCMV) were used in 107 patients. Free flap reconstruction was the sole surgical factor associated with a marked reduction in complications. Infectious wound complications were 11% within the CMV group versus 29% in the nonCMV regimen (P = .002). Moreover, the severity of infections was greatly diminished in the CMV group (P = .0001). With use of a multivariate analysis, the only factor which was predictive of infectious complications was the use of CMV. Patients who received nonCMV antibiotic therapy faced a risk of infection that was 2.5 times higher than those who received CMV. Hospital stay in days and operative mortality were both adversely affected by the use of nonCMV antibiotic therapy. Conclusions: The data supports the hypothesis that the use of a three‐drug, broad spectrum antibiotic regimen in skull base surgery reduces the incidence of infectious complications and appears to reduce operative mortality. Broad spectrum coverage of Gram‐positive, Gram‐negative, and anaerobic pathogens leads to a marked reduction in infectious complications. Broad spectrum antibiotic coverage avoids many infectious complications and ultimately had a positive impact on patient outcome, quality of life, and, potentially, survival.     

虚拟现实系统在鼻内镜颅底外科中的应用前景

虚拟现实(virtual reality,VR)是目前国内外各大行业领域研究的热门,与人工智能（artificial intelligence,AI）共同引导科技前沿。目前该技术主要应用于娱乐,包括游戏、购物、家居、电影方面,在机械制造、航空航天等领域也取得广泛研究及应用。但因医学专业性较强,对于此技术的要求较其他专业更高,所以VR在医学领域的应用还有待发展。同时,随着科学技术的进步,鼻内镜颅底外科经过耳鼻咽喉科、神经外科、影像科、病理科、麻醉科等多学科的共同努力,鼻内镜手术已成为全球主流的颅内肿瘤切除术的首选术式。目前,国内外有很多学者已经开始将VR技术应用于神经外科,包括颅内、侧颅底、斜坡等区域。因此,对于正处于青少年时期的鼻内镜颅底外科来说,VR无疑是发展过程中的重要基石。     

小儿鼻颅底针形内窥镜的检查与手术

目的：探讨应用针形内窥镜对小儿鼻颅底疾病进行探查与手术的方法及疗效。方法：在外径１．９ｍｍ的进口针形内窥镜及电视同图像系统监视下,对８例小儿（７ｄ￣１２岁）鼻颅底有关疾病进行探杳与手术。结果：先天性后鼻孔闭锁３例中,１例好转,３例痊愈。外伤性脑脊液鼻漏１例,经修补痊愈先天性脑膜脑膨出２例,确诊后１例暂缓治疗。另１例行内窥镜手术痊愈。颅底神经母细胞瘤２例取材作病理检查确诊。结论：在电视图像监视下应用     

鼻内镜下可用的带血管蒂组织瓣文献综述

鼻内镜颅底外科术后隔绝颅腔与鼻腔的交通是该学科发展面对的挑战之一,近年利用带血管蒂组织瓣,经内镜手术入路修复颅底缺损获得满意疗效。颅底局部性和区域性带血管蒂组织瓣,修复范围广泛、取材方便、抗感染性强、易于成活,是修复颅底缺损的最佳选择。本文对内镜下修复颅底常用带血管蒂组织瓣进行综述。     

Morbidity in the postoperative follow-up of endoscopic anterior skull base surgery

IntroductionEndoscopic access to the sellar region by videoendoscopy shows a low rate of surgical complications, with findings that indicate risk factors for reducing morbidities during and after the postoperative period.ObjectiveTo evaluate, over a nine-year period, the acquisition of skills by the anterior skull base surgical team, according to the time of elimination of nasal crusts and/or the presence of morbidities in the postoperative follow-up of individuals treated in a tertiary public hospital.MethodsAfter confirming the diagnosis of skull base pathologies, the individuals in this study underwent endoscopic surgery according to the rostrocaudal or coronal axis. For the skull base reconstruction, the nasoseptal flap (associated or not with fascia lata with thigh fat) or free graft was used; clinical follow-up of individuals occurred for a minimum period of 12 months. To assess the impact of the surgical approach on patient clinical evolution, qualitative data related to smoking, post-nasal discharge, nasal flow, smell, taste, clinical symptoms of headache, cranial paresthesia, comorbidities and postoperative morbidities were obtained.ResultsThe most frequent diagnosis was pituitary macroadenoma (84.14%). The mean absence of crusts in this cohort was 124.45 days (confidence interval 95% = 119.50–129.39). There was a low cerebrospinal fluid fistula rate (3%). Reconstruction with the nasoseptal flap with a fat graft was an independent variable that recorded the highest mean time for the elimination of nasal crusts (=145 days, confidence interval 95% = 127.32–162.68). Allergic rhinitis and smoking were shown to be the most important and independent variables that increased the mean time to eliminate nasal crusts.ConclusionThe mean time to eliminate nasal crusts did not change over the years during which the procedures were performed, demonstrating the adequate training of the surgical team. Debridement and nasal irrigation with saline solutions should be performed more frequently and effectively in patients with allergic rhinitis, smokers and those who received the nasoseptal flap and fascia lata graft with autologous fat.     

计算机辅助导航技术在鼻窦及鼻颅底手术中的应用

目的:探讨计算机辅助导航技术在鼻窦及鼻颅底手术中的应用价值。方法:49例患者(复发性鼻窦炎、鼻息肉25例,鼻腔鼻窦肿瘤9例,脑脊液鼻漏7例,脑膜脑膨出2例,先天性后鼻孔闭锁4例,垂体瘤1例,中颅窝底异物1例)均在计算机辅助导航下行鼻内镜手术。结果:计算机辅助导航术前准备时间为5～13min,平均7min,靶点误差≤1.5mm。49例患者均顺利完成手术,无并发症出现。结论:计算机辅助导航系统有助于术者正确判断鼻窦、颅底及相邻的解剖标志,可提高手术的精确性和安全性,减少术中及术后并发症的发生。     

Reverse rotation flap for reconstruction of donor site after vascular pedicled nasoseptal flap in skull base surgery

Endonasal skull base surgery is growing exponentially as a subspecialty. In recent years, advances in endoscopic techniques and intraoperative navigation systems have allowed us to expand the indications of endoscopic skull base surgery. Major skull base centers worldwide are addressing larger and more complex lesions using endoscopic techniques. As a consequence, the skull base defects are more challenging to reconstruct. In this report, we present a novel technique to reconstruct the denuded septum remaining after the use of the vascular pedicled nasoseptal flap. Laryngoscope, 2010