The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors.
OBJECTIVE
The extended transsphenoidal approach, which requires a bone and dural opening through the tuberculum sellae and posterior planum sphenoidale, is increasingly used for the treatment of nonadenomatous suprasellar tumors. The authors present their experiences in using the direct endonasal approach in patients with nonadenomatous suprasellar tumors.


METHODS
Surgery was performed with the aid of an operating microscope and angled endoscopes were used to assess the completeness of resection. Bone and dural defects were repaired using abdominal fat, collagen sponge, titanium mesh, and, in most cases, lumbar drainage of cerebrospinal fluid (CSF). Twenty-six procedures for tumor removal were performed in 24 patients (ages 9-79 years), including two repeated operations for residual tumor. Gross-total removal could be accomplished in only 46% of patients, with near-gross-total removal or better in 74% of 23 patients (five of eight with craniopharyngiomas, six of seven with meningiomas, five of six with Rathke cleft cysts, and one of two with a dermoid or epidermoid cyst); a patient with a lymphoma only underwent biopsy. Of 13 patients with tumor-related visual loss, 85% improved postoperatively. The complications that occurred included five patients (21%) with postoperative CSF leaks, one patient (4%) with bacterial meningitis; five patients (21%) with new endocrinopathy; and two patients (8%) who needed to undergo repeated operations to downsize suprasellar fat grafts. The only permanent neurological deficit was anosmia in one patient; there were no intracranial vascular injuries.


CONCLUSIONS
The direct endonasal skull-base approach provides an effective minimally invasive means for resecting or debulking nonadenomatous suprasellar tumors that have traditionally been approached through a sublabial or transcranial route. Procedures in the supraglandular space can be performed effectively with excellent visualization of the optic apparatus while preserving pituitary function in most cases. The major challenge remains developing consistently effective techniques to prevent postoperative CSF leaks.
Dusick
Joshua R
JR
Divisions of Neurosurgery and Endocrinology, University of California at Los Angeles School of Medicine, USA.
Esposito
Felice
F
Kelly
Daniel F
DF
Cohan
Pejman
P
DeSalles
Antonio
A
Becker
Donald P
DP
Martin
Neil A
NA
D000293:Adolescent; D000328:Adult; D000368:Aged; D001927:Brain Diseases / Q000601:surgery; D001932:Brain Neoplasms / Q000601:surgery*; D020863:Central Nervous System Cysts / Q000601:surgery; D002648:Child; D003397:Craniopharyngioma / Q000601:surgery; D004814:Epidermal Cyst / Q000601:surgery; D006801:Humans; D008577:Meningeal Neoplasms / Q000601:surgery; D008579:Meningioma / Q000601:surgery; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D019635:Neurosurgical Procedures / Q000379:methods*; D010911:Pituitary Neoplasms / Q000601:surgery; D011183:Postoperative Complications; D013100:Sphenoid Bone; D016896:Treatment Outcome