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Endoscopic surgery for tumors of the pineal region via a paramedian infratentorial supracerebellar keyhole approach (PISKA)

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Abstract

The tumors of the pineal region represent a significant challenge in terms of patient selection and surgical approach. Traditional surgical options were commonly used to approach this area causing considerable surgical morbidity and mortality. We report for the first time on a series of endoscopic procedures for lesions of the pineal region performed via an infratentorial supracerebellar keyhole approach (PISKA) in the prone position using endoscope-assisted and endoscope-controlled technique. A single-institution series of 11 consecutive patients (five male and six female patients [11 total cases]; mean age 21 years, range 1–75 years) treated via the endoscope-assisted and endoscope-controlled PISKA for a pathological entity in the pineal region was retrospectively reviewed. The mean follow-up time was 24 months. The endoscopic PISKA was successfully used to approach a variety of pineal lesions, including pineocytoma (three patients), pineal cysts (four patients), germinoma, lipoma, medulloblastoma, and glioblastoma (one patient each). Gross total resection was achieved in ten cases and subtotal resection in one case. The mean preoperative tumor volumes were approximately 2 × 2 cm. Five patients developed postoperatively transient Parinaud’s syndrome. One patient underwent surgical revision for cerebrospinal fluid leak. There was no mortality. Ten patients had an uneventful postoperative course with restitutio ad integrum after a mean follow-up duration of 13.5 months. The endoscopically PISKA is a safe and effective minimally invasive approach that enables endoscopic treatment of different lesions of the pineal region with comparable results to standard microsurgical technique but less morbidity.

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Correspondence to Firas Thaher.

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Tadateru Fukami, Kazuhiko Nozaki, Shiga, Japan

The authors described a minimally invasive approach to the pineal lesion, PISKA (paramedian infratentorial supracerebellar keyhole approach) in the prone position. They treated 11 consecutive patients with lesions in the pineal region via endoscope-assisted and endoscope-controlled procedures and achieved gross total removal of the lesion in 10 out of 11 patients and major complication or mortality was not experienced. They should be congratulated by their elaborate techniques combining microsurgical and endoscopic approaches through keyhole and excellent results, but the clinical application of their approach should be considered depending on the size, nature of the lesion, and the goal of surgical procedures. The standard approaches to the pineal lesion are endoscopic transventricular approach with or without third ventriculostomy for the biopsy, microscopic occipital transtentorial approach, or infratentorial supracerebellar approach for the tumor removal (1). The lesions in their paper are less than 2.5 cm in size in seven patients and with cysts in four patients and seem to be hypovascular in most cases. Their approach may not be applied to large hypervascular lesions and solid lesions. Furthermore, only one case was treated with endoscope-controlled procedures which may indicate the limitation of their approach.

Recently, the clinical use of endoscopy has been expanded as a standard main operative tool and an assist tool for the surgical microscope and its minimal invasiveness with high effectiveness and low risks have been apparently accepted. However, recent review papers do not support the superiority of endoscopic surgery over conventional microsurgery. Sheikh et al. conducted a systematic review and meta-analysis of 1,278 cases with colloid cysts and found that gross total removal rate, recurrence rate, and reoperation rate were significantly low in endoscopic approach in the removal of colloid cyst (2). Ammirati et al. performed PubMED search for transsphenoidal surgery from 1990 to 2011 and collected 38 studies (24 endoscopic and 22 microscopic datasets) and found a significantly higher incidence of vascular complications in endoscopic surgery as compared with microscopic surgery in pituitary adenoma surgery and no significant difference in initial remission rate of hypersecretion of functioning adenoma, complete removal rate, or CFS leak between microscopic and endoscopic removal (3). Goudakos et al. conducted their systematic review of 11 relevant studies of transsphenoidal pituitary surgery including 806 patients and found similar rates of complete tumor excision and remission rates with less frequent diabetes insipidus and a shorter hospital stay in endoscopic surgery (4). Komotar et al. performed literature review about craniopharyngioma surgery and found high rates of gross total resection, improvement of visual outcome, and CSF leak in endoscopic surgery than microsurgical surgery (5).

The authors combined well endoscopic advantages such as wide view, angled view, and bright operative fields to check residual tumors and microscopic advantages such as bimanual control, stereopsis, and adequate hemostasis to remove the tumor in a safer manipulation. They used a 3–4 cm paramedian linear skin incision and a 2 × 1.5 cm craniotomy and performed the sufficient drainage of the CSF by gently retraction of the cerebellar tonsil at one side to open the cerebellomedullary cistern. However, it may be dangerous to retract the cerebellar tonsil through such a small craniotomy in order to cut arachnoid membrane of the cerebellomedullary cistern. Moreover, in the event of bleeding, the operative corridor may be obstructed and a deep operative field around quadrigeminal cistern may be severely restricted. Although PISKA itself may provide a good operative view around the dorsal midbrain, endoscopic-controlled procedures should be used by experienced surgeons who know how to avoid intra- and postoperative complications. We should combine well the advantage of endoscopic and microscopic approaches to achieve a minimally invasive and maximally effective surgery in each case.

References

(1) Waleed AA, Khurram N, Waleed S. An overview of the current surgical options for pineal region tumors. Surgical Neurology International 5:39. 2014

(2) Sheikh AB, Mendelson ZS, Liu JK. Endoscopic versus microsurgical resection of colloid cyst: a systemic review and meta-analysis of 1,278 cases. World Neurosurg 14, 2014 [Epub ahead of print]

(3) Ammirati M, Wei L, Ciric I. Short-term outcome of endoscopic versus microscopic pituitary adenoma surgery: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 84:843-849, 2013

(4) Goudakos JK, Markou KD, Georgalas C. Endoscopic versus microscopic trans-sphenoidal pituitary surgery: a systematic review and meta-analysis. Clin Otolaryngol 36:212-220, 2011

(5) Komotar RJ, Starke RM, Paper DM, Anand VK, Schwartz TH. Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of craniopharyngioma. World Neurosurg 77:329-341, 2012

Charlie Teo, Randwick, Australia

This is a small but important series of an endoscopic approach to the pineal region for varying pathologies. It is important because it illustrates the metamorphosis of complex neurosurgical operations into simple procedures simply with utilization of the latest technology and a change in one’s surgical philosophy. The senior author is a leading figure in the world of neuroendoscopy. Nevertheless, the indications, description of the surgical technique, and various pearls of wisdom included in this paper should demonstrate the clear advantage of a minimally invasive endoscopic approach that could be duplicated by any cranial neurosurgeon. Many of the complications associated with pineal region surgery are directly related to the approach rather than the actual pathology itself. Occipital lobe damage, postoperative sub-dural collections, cerebellar venous congestion, seizures, air embolism, and quadriplegia are all examples. This endoscopic-utilizing operation would preclude many of these potential complications.

There is one statement that I thought should be clarified. The authors mention that “....using such a small craniotomy there are some major limitations…”. It should be made absolutely clear that surgeons who recommend the keyhole philosophy do not use such small openings as to increase the risk to the patient. The “major” limitations that they discuss are impediments that may make it more difficult for the surgeon but do not make it riskier for the patient. If an opening is so small as to compromise safety, then that is an “inadequate” opening NOT a “keyhole” opening.

I commend the authors on this small but important series of pineal tumors removed effectively using a paramedian, suboccipital, infratentorial, supracerebellar endoscopic approach.

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Thaher, F., Kurucz, P., Fuellbier, L. et al. Endoscopic surgery for tumors of the pineal region via a paramedian infratentorial supracerebellar keyhole approach (PISKA). Neurosurg Rev 37, 677–684 (2014). https://doi.org/10.1007/s10143-014-0567-1

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