Neuroendoscopy In Tumor Surgery

Endoscopy has not had the same revolutionary impact in brain tumor surgery as it has in general and gastrointestinal surgery or in thoracic oncology. This may be because the brain does not have abundant open channels that can be readily used as navigational pathways. The use of endoscopy has been limited primarily to the ventricular system, to pituitary surgery, and to some extent to verification of resection in some sites such as the internal auditory meatus.

Intraventricular Tumors

As has been discussed elsewhere, neuroendoscopy has been suggested for a variety of uses including both biopsy and resection of tumors and cysts of the brain and ventricular system (25-28). Clearly, its most important application is for intraventricular tumors (29). Pineal region tumors can be biopsied and partially resected (30,31), and colloid cysts of the third ventricle may also be removed.

These tumors account for fewer than 5% of adult neurosurgical oncology cases, although they may be slightly more common in pediatric practice. The morbidity of endoscopy is primarily bleeding and is approx 2-3%. Its ability to biopsy tumors is great, but the capacity to remove tumors with endoscopic techniques is extremely limited. Tumors that are cystic may be removed.

Pituitary Tumors

Perhaps the most successful recent application of endoscopy has been in resecting pituitary adenomas (32-34). The endoscope in this case allows the use of a small opening at the back of the nostril and thereby avoids having to elevate a large flap. In experienced hands, it will permit very satisfactory resection of an adenoma. Usually both nostrils are used, one for visualization and the other for manipulation. In this application the major problem is bleeding, which can be significant and can obscure the surgical field, making it difficult to identify the structure being manipulated. For large, bloody adenomas, this could be a major problem. The reason for considering endoscopic surgery is that the morbidity of nose manipulation (35,36), including the need for nasal packs for more than a day, is lessened and patients may go home within a day or two of their procedure. Despite these advantages, this technique has not become the norm for most pituitary surgeons. The endoscope can, however, be very helpful in confirming that there is removal of tumor laterally and also superiorly when there may be some question of suprasellar residual tumor (37).

Other Endoscopic Applications

Some surgeons have suggested that the internal auditory meatus can be inspected with a small endoscope, for residual tumor in vestibular schwannoma surgery (38-40), or in skull base surgery potential components can be inspected, including what may be behind residual tumor.

Summary

Although neuroendoscopy has been suggested as being useful for a number of applications in tumor surgery, its use remains the preview of a few surgeons and has not been generalized for all neurosurgical applications.

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