Endoscopic Management Of Lesions Of The Third Ventricle
Assem M. Abdel Latif;
Abstract
Each particular surgical enterprise has inherent risks and pitfalls – certain key or hazardous steps or maneuvers in its methodology. This has been the concern of neurosurgeons since very old times i.e. do no harm. But the concern of avoiding the complications and trying to improve the outcome as possible has been a recently growing trend.
Now neurosurgeons are confronted by performing invasive procedures and operations on “normal” patients. Concurrently, new non-invasive therapeutic options (e.g. radiotherapy and Gamma knife) are now available for treatment of patients with brain tumors.
These challenges have let neurosurgeons look for and try developing new non-invasive techniques to minimize iatrogenic injury and patient discomfort.
Endoscopes were actually introduced for use in other surgical fields. Although both Dandy and Mixter reported the very early ventriculoscopic procedures, yet the initial interest in neuroendoscopy was hampered by the drawbacks and difficulties of the related instruments.
With refinements in endoscope design and advances in digital imaging, these limitations have now been addressed and endoscopes have become an essential tool in minimally invasive neurosurgery. Neurosurgeons have been engaged in the development of endoscopic applications as alternatives to traditional open procedures, performing endoscopic management for hydrocephalus, arachnoid cysts, craniosynostosis, spine tumors, and skull base approaches for pituitary tumors.
Endoscopes allow access to deep lesions along a long surgical corridor, with visualization of structures around the ‘surgical corners’ minimizing the need for retracting normal brain tissue. Intraventricular tumors represent a major neurosurgical challenge. Endoscopic surgery for intraventricular brain tumors is a logical application of endoscopic technology, also the location of intraventricular tumors being within a CSF containing interface affords excellent light and image transmission, a requisite for endoscopic surgery.
This study was conducted with the aim of investigating the role of endoscopy in the operative management of tumors of the 3rd ventricle, in hope to come out with realistic, valid and applicable recommendations that will help improve patient care and management in the field of intraventricular tumors.
Conducted in 2 different tertiary-care facilities, the study started in 14-2-2012 recruiting 29 patients, all with third ventricle tumors/lesions, through 30-6-2015. Thirty endoscopic surgeries were done for 58.6% cystic tumors, 20.7% solid tumors and 17.2% tumors with mixed solid and cystic components. Mean tumor size was 26.3 mm with a median of 20mm. Preoperative hydrocephalus was present in 75.9% of the cases. Solid and flexible scopes were used in 76.7% and 23.3% respectively achieving total excision in 53.3% of the cases (2 of which were solid tumors), biopsy in 16.7% and cyst decompression in the remaining patients. The surgical objective was achieved in 90% of the cases with 63.3% of the cases receiving concomitant CSF diversion besides direct tumor management to control the presenting hydrocephalus.
The intervention proved safe with 13.8% incidence of memory deficits that were mostly transient, no wound complications, infection or failure of CSF diversion. One patient (3.4%) had transient postoperative seizures and there was a 10.4% incidence of recurrent symptoms that were also managed endoscopically.
The endoscopic approach also proved effective through a considerable rate of control of the presenting manifestations (75% complete and 8% partial resolution) with statistically significant reduction of the preoperative hydrocephalus as evidenced by the FOR value difference. Craniotomy was avoided in 93% of the patients and the obtained biopsy was sufficient for diagnosis in 96% of the cases.
Even in the challenging cases of posterior third ventricular lesions, the surgical target was achieved in 92% of the cases. Added to the tumor location, the absence of hydrocephalus or marginal ventriculomegaly required the use of the flexible endoscopic systems and despite the technical concerns, the surgical target was achieved in 100% of the cases.
Now neurosurgeons are confronted by performing invasive procedures and operations on “normal” patients. Concurrently, new non-invasive therapeutic options (e.g. radiotherapy and Gamma knife) are now available for treatment of patients with brain tumors.
These challenges have let neurosurgeons look for and try developing new non-invasive techniques to minimize iatrogenic injury and patient discomfort.
Endoscopes were actually introduced for use in other surgical fields. Although both Dandy and Mixter reported the very early ventriculoscopic procedures, yet the initial interest in neuroendoscopy was hampered by the drawbacks and difficulties of the related instruments.
With refinements in endoscope design and advances in digital imaging, these limitations have now been addressed and endoscopes have become an essential tool in minimally invasive neurosurgery. Neurosurgeons have been engaged in the development of endoscopic applications as alternatives to traditional open procedures, performing endoscopic management for hydrocephalus, arachnoid cysts, craniosynostosis, spine tumors, and skull base approaches for pituitary tumors.
Endoscopes allow access to deep lesions along a long surgical corridor, with visualization of structures around the ‘surgical corners’ minimizing the need for retracting normal brain tissue. Intraventricular tumors represent a major neurosurgical challenge. Endoscopic surgery for intraventricular brain tumors is a logical application of endoscopic technology, also the location of intraventricular tumors being within a CSF containing interface affords excellent light and image transmission, a requisite for endoscopic surgery.
This study was conducted with the aim of investigating the role of endoscopy in the operative management of tumors of the 3rd ventricle, in hope to come out with realistic, valid and applicable recommendations that will help improve patient care and management in the field of intraventricular tumors.
Conducted in 2 different tertiary-care facilities, the study started in 14-2-2012 recruiting 29 patients, all with third ventricle tumors/lesions, through 30-6-2015. Thirty endoscopic surgeries were done for 58.6% cystic tumors, 20.7% solid tumors and 17.2% tumors with mixed solid and cystic components. Mean tumor size was 26.3 mm with a median of 20mm. Preoperative hydrocephalus was present in 75.9% of the cases. Solid and flexible scopes were used in 76.7% and 23.3% respectively achieving total excision in 53.3% of the cases (2 of which were solid tumors), biopsy in 16.7% and cyst decompression in the remaining patients. The surgical objective was achieved in 90% of the cases with 63.3% of the cases receiving concomitant CSF diversion besides direct tumor management to control the presenting hydrocephalus.
The intervention proved safe with 13.8% incidence of memory deficits that were mostly transient, no wound complications, infection or failure of CSF diversion. One patient (3.4%) had transient postoperative seizures and there was a 10.4% incidence of recurrent symptoms that were also managed endoscopically.
The endoscopic approach also proved effective through a considerable rate of control of the presenting manifestations (75% complete and 8% partial resolution) with statistically significant reduction of the preoperative hydrocephalus as evidenced by the FOR value difference. Craniotomy was avoided in 93% of the patients and the obtained biopsy was sufficient for diagnosis in 96% of the cases.
Even in the challenging cases of posterior third ventricular lesions, the surgical target was achieved in 92% of the cases. Added to the tumor location, the absence of hydrocephalus or marginal ventriculomegaly required the use of the flexible endoscopic systems and despite the technical concerns, the surgical target was achieved in 100% of the cases.
Other data
| Title | Endoscopic Management Of Lesions Of The Third Ventricle | Other Titles | التعامل مع آفات و أورام البطين الثالث باستخدام المنظار الجراحي | Authors | Assem M. Abdel Latif | Issue Date | 2015 |
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