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Endoscopic Endonasal Approach in the Management of Rathke's Cleft Cysts.

Solari D, Cavallo LM, Somma T, Chiaramonte C, Esposito F, Del Basso De Caro M, Cappabianca P - PLoS ONE (2015)

Bottom Line: A standard transsphenoidal approach was used in 19 cases, while the extended variation of the approach in 10 cases (5 purely suprasellar and 5 intra-suprasellar RCC).We reported a 56.2% of recovery from headache, 38.5% of complete recovery and 53.8% of improvement from visual field defect and an overall 46.7% of improvement of the endocrine functions.Postoperative permanent DI rate was 10.3%, overall post-operative CSF leak rate 6.9%; recurrence/regrowth occurred in 4 patients (4/29, 13.8%), but only one required a second surgery.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy.

ABSTRACT

Objective: Rathke's cleft cysts (RCCs) are quite uncommon sellar lesions that can extend or even arise in the suprasellar area. The purpose of this study is to evaluate the effectiveness of both standard and extended endoscopic endonasal approaches in the management of different located RCCs.

Methods: We retrospectively analyzed a series of 29 patients (9 males, 20 females) complaining of a RCC, who underwent a standard or an extended endoscopic transsphenoidal approach at the Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, of the Università degli Studi di Napoli "Federico II". Data regarding patients' demographics, clinical evaluation, cyst characteristics, surgical treatments, complications and outcomes were extracted from our electronic database (Filemaker Pro 11, File Maker Inc., Santa Clara, California, USA).

Results: A standard transsphenoidal approach was used in 19 cases, while the extended variation of the approach in 10 cases (5 purely suprasellar and 5 intra-suprasellar RCC). Cysts contents was fully drained in all the 29 cases, whilst a gross total removal, that accounts on the complete cyst wall removal, was achieved in an overall 55,1% of patients (16/29), specifically 36,8% (7/19) that received standard approach and 90% (9/10) of those that underwent to extended approach. We reported a 56.2% of recovery from headache, 38.5% of complete recovery and 53.8% of improvement from visual field defect and an overall 46.7% of improvement of the endocrine functions. Postoperative permanent DI rate was 10.3%, overall post-operative CSF leak rate 6.9%; recurrence/regrowth occurred in 4 patients (4/29, 13.8%), but only one required a second surgery.

Conclusion: The endoscopic transsphenoidal approach for the removal of a symptomatic RCC offers several advantages in terms of visualization of the surgical field during both the exposure and removal of the lesion. The "extended" variation of the endoscopic approach provides a direct access to the supradiaphragmatic space, allowing adequate view and room for the safe removal of selected supradiaphragmatic RCCs, regardless of the sellar size (even a not enlarged sella), and provides a higher likelihood of preserving normal pituitary tissue and functions.

No MeSH data available.


Related in: MedlinePlus

MRI scan after gadolinium showing an intra and suprasellar Rathke’s Cleft Cyst before and after the surgical removal via a standard endoscopic endonasal approach (case showed in the Fig 1).(A-B) Sagittal and a coronal T1-weighted scans of the lesion before being removed. The colloid has a hypointense signal and the cyst wall has post contrast enhancement. These features do not define typical aspect of RCC, whose differential diagnosis with sellar arachnoid cysts could be often challenging. (C) Axial T2-weighted scan of the lesion showing the colloid with a hyperintense signal. (D-E) Sagittal and a coronal T1-weighted scans and (F) axial T2-weightedscan at the three months postoperative MRI showing the cyst removal. It is possible to identify the decompression of the optic chiasm and the pituitary stalk.
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pone.0139609.g002: MRI scan after gadolinium showing an intra and suprasellar Rathke’s Cleft Cyst before and after the surgical removal via a standard endoscopic endonasal approach (case showed in the Fig 1).(A-B) Sagittal and a coronal T1-weighted scans of the lesion before being removed. The colloid has a hypointense signal and the cyst wall has post contrast enhancement. These features do not define typical aspect of RCC, whose differential diagnosis with sellar arachnoid cysts could be often challenging. (C) Axial T2-weighted scan of the lesion showing the colloid with a hyperintense signal. (D-E) Sagittal and a coronal T1-weighted scans and (F) axial T2-weightedscan at the three months postoperative MRI showing the cyst removal. It is possible to identify the decompression of the optic chiasm and the pituitary stalk.

Mentions: The nasal and sphenoidal steps of the procedure are performed following the same principles of the standard pituitary approach for pituitary adenomas: binarial 3–4 hands technique is usually adopted; as for standard pituitary surgery, no middle turbinate is routinely removed in both nostrils, they are simply lateralized with an elevator and are pull back at the end of the procedure. In purely intrasellar RCC sellar floor is extensively removed down to the clival recess to grant a proper maneuverability of the surgical instruments inside the sella. In case of an enlarged sella, it can be useful to preserve a good extradural plane undermining bony edges, in order to allow an effective extradural closure of the sellar floor in case of intra-op CSF leak. Dura is opened as per accessing the cyst, thus avoiding normal pituitary gland injury: this could be particularly relevant in those cases of intra or intra-suprasellar RCC, where usually the adenohypophysis is pushed anteriorly by the cyst (originated from the pars intermedia of the pituitary gland). Though, the cyst is entered and emptied and any floating part of the cyst wall is taken out and, as the residual cavity is wide enough, the endoscope is inserted (Figs 1 and 2). Eventually, the so-called “diving technique” is realized by continuous irrigation through the irrigation sheath [39]. This permits the removal of any colloid remnant tightly adherent to the cyst wall and, eventually, the detachment of any wall fragments off the adenohypophysis and/or the diafragma sellae. In case of cyst wall tightly adherent to the pituitary tissue, dissection maneuvers are limited to avoid any postoperative impairment of the pituitary function. At the end of the procedure no sellar closure is performed, unless an intra-operative CSF leak occurred [38].


Endoscopic Endonasal Approach in the Management of Rathke's Cleft Cysts.

Solari D, Cavallo LM, Somma T, Chiaramonte C, Esposito F, Del Basso De Caro M, Cappabianca P - PLoS ONE (2015)

MRI scan after gadolinium showing an intra and suprasellar Rathke’s Cleft Cyst before and after the surgical removal via a standard endoscopic endonasal approach (case showed in the Fig 1).(A-B) Sagittal and a coronal T1-weighted scans of the lesion before being removed. The colloid has a hypointense signal and the cyst wall has post contrast enhancement. These features do not define typical aspect of RCC, whose differential diagnosis with sellar arachnoid cysts could be often challenging. (C) Axial T2-weighted scan of the lesion showing the colloid with a hyperintense signal. (D-E) Sagittal and a coronal T1-weighted scans and (F) axial T2-weightedscan at the three months postoperative MRI showing the cyst removal. It is possible to identify the decompression of the optic chiasm and the pituitary stalk.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4608689&req=5

pone.0139609.g002: MRI scan after gadolinium showing an intra and suprasellar Rathke’s Cleft Cyst before and after the surgical removal via a standard endoscopic endonasal approach (case showed in the Fig 1).(A-B) Sagittal and a coronal T1-weighted scans of the lesion before being removed. The colloid has a hypointense signal and the cyst wall has post contrast enhancement. These features do not define typical aspect of RCC, whose differential diagnosis with sellar arachnoid cysts could be often challenging. (C) Axial T2-weighted scan of the lesion showing the colloid with a hyperintense signal. (D-E) Sagittal and a coronal T1-weighted scans and (F) axial T2-weightedscan at the three months postoperative MRI showing the cyst removal. It is possible to identify the decompression of the optic chiasm and the pituitary stalk.
Mentions: The nasal and sphenoidal steps of the procedure are performed following the same principles of the standard pituitary approach for pituitary adenomas: binarial 3–4 hands technique is usually adopted; as for standard pituitary surgery, no middle turbinate is routinely removed in both nostrils, they are simply lateralized with an elevator and are pull back at the end of the procedure. In purely intrasellar RCC sellar floor is extensively removed down to the clival recess to grant a proper maneuverability of the surgical instruments inside the sella. In case of an enlarged sella, it can be useful to preserve a good extradural plane undermining bony edges, in order to allow an effective extradural closure of the sellar floor in case of intra-op CSF leak. Dura is opened as per accessing the cyst, thus avoiding normal pituitary gland injury: this could be particularly relevant in those cases of intra or intra-suprasellar RCC, where usually the adenohypophysis is pushed anteriorly by the cyst (originated from the pars intermedia of the pituitary gland). Though, the cyst is entered and emptied and any floating part of the cyst wall is taken out and, as the residual cavity is wide enough, the endoscope is inserted (Figs 1 and 2). Eventually, the so-called “diving technique” is realized by continuous irrigation through the irrigation sheath [39]. This permits the removal of any colloid remnant tightly adherent to the cyst wall and, eventually, the detachment of any wall fragments off the adenohypophysis and/or the diafragma sellae. In case of cyst wall tightly adherent to the pituitary tissue, dissection maneuvers are limited to avoid any postoperative impairment of the pituitary function. At the end of the procedure no sellar closure is performed, unless an intra-operative CSF leak occurred [38].

Bottom Line: A standard transsphenoidal approach was used in 19 cases, while the extended variation of the approach in 10 cases (5 purely suprasellar and 5 intra-suprasellar RCC).We reported a 56.2% of recovery from headache, 38.5% of complete recovery and 53.8% of improvement from visual field defect and an overall 46.7% of improvement of the endocrine functions.Postoperative permanent DI rate was 10.3%, overall post-operative CSF leak rate 6.9%; recurrence/regrowth occurred in 4 patients (4/29, 13.8%), but only one required a second surgery.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy.

ABSTRACT

Objective: Rathke's cleft cysts (RCCs) are quite uncommon sellar lesions that can extend or even arise in the suprasellar area. The purpose of this study is to evaluate the effectiveness of both standard and extended endoscopic endonasal approaches in the management of different located RCCs.

Methods: We retrospectively analyzed a series of 29 patients (9 males, 20 females) complaining of a RCC, who underwent a standard or an extended endoscopic transsphenoidal approach at the Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, of the Università degli Studi di Napoli "Federico II". Data regarding patients' demographics, clinical evaluation, cyst characteristics, surgical treatments, complications and outcomes were extracted from our electronic database (Filemaker Pro 11, File Maker Inc., Santa Clara, California, USA).

Results: A standard transsphenoidal approach was used in 19 cases, while the extended variation of the approach in 10 cases (5 purely suprasellar and 5 intra-suprasellar RCC). Cysts contents was fully drained in all the 29 cases, whilst a gross total removal, that accounts on the complete cyst wall removal, was achieved in an overall 55,1% of patients (16/29), specifically 36,8% (7/19) that received standard approach and 90% (9/10) of those that underwent to extended approach. We reported a 56.2% of recovery from headache, 38.5% of complete recovery and 53.8% of improvement from visual field defect and an overall 46.7% of improvement of the endocrine functions. Postoperative permanent DI rate was 10.3%, overall post-operative CSF leak rate 6.9%; recurrence/regrowth occurred in 4 patients (4/29, 13.8%), but only one required a second surgery.

Conclusion: The endoscopic transsphenoidal approach for the removal of a symptomatic RCC offers several advantages in terms of visualization of the surgical field during both the exposure and removal of the lesion. The "extended" variation of the endoscopic approach provides a direct access to the supradiaphragmatic space, allowing adequate view and room for the safe removal of selected supradiaphragmatic RCCs, regardless of the sellar size (even a not enlarged sella), and provides a higher likelihood of preserving normal pituitary tissue and functions.

No MeSH data available.


Related in: MedlinePlus