Cylinder tumor surgery in pediatric low-grade gliomas.

BACKGROUND: Periventricular pediatric low-grade gliomas (pLGG) present a surgical challenge due to their deep-seated location, accessibility, and relationship with the subcortical network connections. Minimally invasive parafascicular approaches with tubular brain retractors (port brain surgery) have emerged, in recent years, as an alternative to conventional microsurgical and endoscopic approaches for removal of periventricular tumors. OBJECTIVES: To describe the minimally invasive approach with tubular brain retractors for periventricular pLGG, its technique, applications, safety, and efficacy. METHODS: In this article, we describe the port brain surgery techniques for periventricular pLGG as performed in different centers, with different commercialized tubular retractor systems. Illustrative cases followed by a literature review are analyzed, with a detailed description of different approaches or techniques, comparing their advantages and disadvantages with contemporary microsurgical and endoscopic approaches. CONCLUSIONS: The port brain surgery with micro-exoscopic vision and endoscopic assistance, for the treatment of deep-seated lesions such as periventricular pLGG, is an alternative for achieving a functionally safe-gross total or subtotal-tumor resection, obtaining adequate tissue for pathological examination. This technique could offer a new dimension for a less-invasive, safe, and effective access to deep-seated tumors, offering the possibility to lower morbidity in experienced hands.

A Purely Endoscopic and Simultaneous Transsphenoidal and Transcranial Keyhole Approach for Giant Pituitary Adenoma Resection: A Technical Case Report.

A combined transsphenoidal-transcranial approach for the resection of pituitary adenomas has previously been reported. While this approach is useful for specific types of pituitary adenomas, it is an invasive technique. To reduce the invasiveness of this approach, we adopted the keyhole concept for pituitary adenoma resection. A 23-year-old man presented at a local hospital with a 6-month history of bilateral hemianopia. Magnetic resonance imaging revealed a large pituitary adenoma extending from the sella turcica toward the right frontal lobe. Endoscopic transsphenoidal surgery was planned at a local hospital; however, the operation was abandoned at the start of the resection because of the firm and fibrous nature of the tumor. The patient was subsequently referred to our hospital for additional surgery. The tumor was removed purely endoscopically via a transsphenoidal and transcranial route. Keyhole craniotomy, 3 cm in diameter, was performed, and a tubular retractor was used to achieve a wider surgical corridor; this enabled better visualization and dissection from the surrounding brain and provided enough room for the use of surgical instruments under endoscopic view. The tumor was successfully removed without complication. This is the first case report to describe the resection of a giant pituitary adenoma using a purely endoscopic and simultaneous transsphenoidal and transcranial keyhole approach.

A novel method for managing water and electrolyte balance after transsphenoidal surgery: preliminary study of moderate water intake restriction.

Hyponatremia is a common and potentially serious complication of transsphenoidal surgery (TSS). Since September 2009, we have implemented moderate water intake restriction (< 2500 mL/day) after TSS in an attempt to prevent this complication. The aim of this study was to investigate the efficacy of a combination of moderate restriction of water intake plus antidiuretic hormone (arginine vasopressin [AVP]) replacement therapy in patients with diabetes insipidus (DI) for reducing the incidence of delayed hyponatremia after TSS. Patients treated from September 2005 to August 2009 were allowed to drink water freely after surgery (the control group), while patients treated from September 2009 to June 2012 were restricted to less than 2500 mL water per day (the water restriction group). To reduce the occurrence of hypernatremia, AVP replacement therapy was provided immediately after the development of DI. We retrospectively analyzed the incidence of hyponatremia, DI, and hypernatremia in patients following TSS. Hyponatremia incidence was significantly lower in the water restriction group (P = 0.017); however, there were no significant differences in DI incidence and hypernatremia incidence between the 2 groups. Under DI control with AVP replacement therapy, the water restriction group showed no significant difference in the daily self-rated thirst level for the patients with and without DI. Moderate water intake restriction in addition to AVP replacement therapy significantly decreases the incidence of hyponatremia without patient discomfort (extreme thirst) and other complications. However, further studies are required to determine the most effective amount of water and the optimal duration of postoperative water restriction.