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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

Intraoperative images showing a suprasellar Ratkhe’s Cleft Cyst removed via an extended endoscopic endonasalapproach.(A) colloid suctioning after dural opening and exposure of the cyst’s wall (B)Imagine showing the cyst’s wall covering the neurovascular structures of the suprasellar area. (C) cyst wall removal with a forceps and aspirator. (D) after cyst wall removal it is possible to identify: A1 and A2; optic chiasm with optic nerves; pituitary stalk and gland. Co: colloid; CW: cystwall; D: dura mater; Ch: optic chiasm; Ps: pituitary stalk; Pg: pituitary gland; A1: A1 segment of the anterior cerebral artery; A2: A2 segment of the anterior cerebral artery.
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pone.0139609.g003: Intraoperative images showing a suprasellar Ratkhe’s Cleft Cyst removed via an extended endoscopic endonasalapproach.(A) colloid suctioning after dural opening and exposure of the cyst’s wall (B)Imagine showing the cyst’s wall covering the neurovascular structures of the suprasellar area. (C) cyst wall removal with a forceps and aspirator. (D) after cyst wall removal it is possible to identify: A1 and A2; optic chiasm with optic nerves; pituitary stalk and gland. Co: colloid; CW: cystwall; D: dura mater; Ch: optic chiasm; Ps: pituitary stalk; Pg: pituitary gland; A1: A1 segment of the anterior cerebral artery; A2: A2 segment of the anterior cerebral artery.

Mentions: In purely suprasellar RCC the sellar cavity is usually not enlarged and an endoscopic endonasal transtuberculum/transplanum approach is required to access the suprasellar area. As described elsewhere [28–32, 40], the approach is realized through both nostrils with a middle turbinectomy on one side, resection of the posterior portion of the nasal septum and a wider anterior sphenoidotomy. Owing that RCCs content is manly fluid, large bone opening over the planum sphenoidale is usually not required and extensive drilling at the level of the medial opto-carotid recess or over the planum sphenoidale is not mandatory [41]. The RCC is clearly identified after the dural opening with the pituitary stalk, often dislocated on one side. While the anterior part of the cyst wall is surrounded by the arachnoid of the suprasellar cistern, the remaining part of the cyst wall can be attached to the pituitary stalk, the superior hypophyseal arteries and/or the optic chiasm(Figs 3 and 4). In these cases it is of utmost importance to avoid tractions in order to prevent injuries to these structures. Bimanual dissection is performed according to the rules of microsurgery: one surgeon works bimanually to dissect and remove the cyst wall, while a second surgeon drives dynamically the endoscope.


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)

Intraoperative images showing a suprasellar Ratkhe’s Cleft Cyst removed via an extended endoscopic endonasalapproach.(A) colloid suctioning after dural opening and exposure of the cyst’s wall (B)Imagine showing the cyst’s wall covering the neurovascular structures of the suprasellar area. (C) cyst wall removal with a forceps and aspirator. (D) after cyst wall removal it is possible to identify: A1 and A2; optic chiasm with optic nerves; pituitary stalk and gland. Co: colloid; CW: cystwall; D: dura mater; Ch: optic chiasm; Ps: pituitary stalk; Pg: pituitary gland; A1: A1 segment of the anterior cerebral artery; A2: A2 segment of the anterior cerebral artery.
© Copyright Policy
Related In: Results  -  Collection

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

pone.0139609.g003: Intraoperative images showing a suprasellar Ratkhe’s Cleft Cyst removed via an extended endoscopic endonasalapproach.(A) colloid suctioning after dural opening and exposure of the cyst’s wall (B)Imagine showing the cyst’s wall covering the neurovascular structures of the suprasellar area. (C) cyst wall removal with a forceps and aspirator. (D) after cyst wall removal it is possible to identify: A1 and A2; optic chiasm with optic nerves; pituitary stalk and gland. Co: colloid; CW: cystwall; D: dura mater; Ch: optic chiasm; Ps: pituitary stalk; Pg: pituitary gland; A1: A1 segment of the anterior cerebral artery; A2: A2 segment of the anterior cerebral artery.
Mentions: In purely suprasellar RCC the sellar cavity is usually not enlarged and an endoscopic endonasal transtuberculum/transplanum approach is required to access the suprasellar area. As described elsewhere [28–32, 40], the approach is realized through both nostrils with a middle turbinectomy on one side, resection of the posterior portion of the nasal septum and a wider anterior sphenoidotomy. Owing that RCCs content is manly fluid, large bone opening over the planum sphenoidale is usually not required and extensive drilling at the level of the medial opto-carotid recess or over the planum sphenoidale is not mandatory [41]. The RCC is clearly identified after the dural opening with the pituitary stalk, often dislocated on one side. While the anterior part of the cyst wall is surrounded by the arachnoid of the suprasellar cistern, the remaining part of the cyst wall can be attached to the pituitary stalk, the superior hypophyseal arteries and/or the optic chiasm(Figs 3 and 4). In these cases it is of utmost importance to avoid tractions in order to prevent injuries to these structures. Bimanual dissection is performed according to the rules of microsurgery: one surgeon works bimanually to dissect and remove the cyst wall, while a second surgeon drives dynamically the endoscope.

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