Expanded Endoscopic Endonasal Approach for Suprasellar and Anterior Skull Base Tumors

Objective: Recent advances in minimally invasive surgery have allowed the use of expanded transsphenoidal approaches in the treatment of complex and bulky lesions located beyond the sella, but their indications and limitations remain controversial. We review our experience with the expanded endoscopic endonasal approach combined with reconstructive techniques through pedicled flaps, in a series of patients with suprasellar and anterior cranial base lesions.

Methods: From March 2009 to January 2012, six consecutive patients were operated on by an expanded endoscopic endonasal approach. Three patients had meningiomas, two arising from the tuberculum sellae, and the other from the anterior clinoid. Two patients had retrochiasmatic craniopharyngiomas; and one patient had a sphenoethmoidal neuroendocrine carcinoma with suprasellar and cavernous sinus invasion. This review focuses on the surgical approaches; the reconstructive technique; and the results, complications, and limitations observed.

Results: Gross total tumor removal was possible in the three meningiomas (50%), and subtotal removal was done in the other cases. The visual symptoms improved in three and remained stable in one of the four patients with preoperative campimetric deficits. Among the three patients with preoperative endocrinological disturbances, one improved, one worsened, and one remained stable, with transient diabetes insipidus in two patients and permanent in one. Cerebrospinal fluid leak was the main complication, occurring in five patients (83%), four of whom (66%) had associated meningitis.

Conclusions: The expanded endoscopic endonasal approach is a safe alternative in the treatment of selective lesions of the midline anterior cranial base. Nevertheless, the reconstruction of the induced defects can be challenging to avoid complications and some limitations can carry less resectability.