Elsevier

World Neurosurgery

Volume 82, Issue 6, December 2014, Pages 1187-1197
World Neurosurgery

Peer-Review Report
Endoscopic Versus Microsurgical Resection of Colloid Cysts: A Systematic Review and Meta-Analysis of 1278 Patients

https://doi.org/10.1016/j.wneu.2014.06.024Get rights and content

Objective

Colloid cysts of the third ventricle have been successfully treated with transcranial microsurgical approaches. However, the endoscopic approach has recently been advocated as a lesser invasive technique. We conducted a systematic review and meta-analysis of published studies to compare the outcomes between the two approaches.

Methods

A PubMED search of contemporary literature (1990–2014) was performed to identify surgical series of open and endoscopic treatment of colloid cysts. Relevant articles were identified and data were extracted concerning surgical treatment, extent of resection, and outcomes.

Results

A meta-analysis was performed for recurrence rates based on treatment strategy. A total of 583 patients were included in the microsurgical group, and 695 patients in the endoscopic group. The microsurgical approach was found to have a significantly higher gross total resection rate (96.8% vs. 58.2%; P < 0.0001), lower recurrence rate (1.48% vs. 3.91%; P = 0.0003), and lower reoperation rate (0.38% vs. 3.0%; P = 0.0006) compared with the endoscopic group. There was no significant difference in mortality rate (1.4% vs. 0.6%) or shunt dependency (6.2% vs. 3.9%) between the two groups. The overall morbidity rate was lower in the endoscopic group (10.5%) than in the microsurgery group (16.3%). Within the microsurgery group, the transcallosal approach had a lower overall morbidity rate (14.4%) than the transcortical approach (24.5%).

Conclusions

Microsurgical resection of colloid cysts is associated with a higher rate of complete resection, lower rate of recurrence, and fewer reoperations than with endoscopic removal. However, the rate of morbidity is higher with microsurgery than with endoscopy.

Introduction

Colloid cysts of the third ventricle are benign tumors that are thought to have a neuroectodermal origin 53, 57. These cysts arise from the roof of the third ventricle in close proximity to the interventricular foramen of Monro, typically obstructing the flow of cerebrospinal fluid (CSF) leading to hydrocephalus or in extreme cases sudden death 1, 10, 16, 53, 59. Colloid cysts are noted to have a thin collagen wall lined with a single layer of cuboidal epithelium that is ciliated and/or nonciliated 1, 26, 53, 57. Cyst contents are typically characterized by a mucinous suspension ranging in dark green to brown color, occasionally being solid (26). The incidence of colloid cyst ranges from 0.5% to 2.0% of all intracranial tumors 29, 31, 53, 57. Surgical resection is often chosen for large symptomatic colloid cysts, whereas small asymptomatic lesions can be managed by close observation with serial magnetic resonance imaging (MRI) 45, 46, 59. Currently, surgical interventions include CSF shunting, cyst aspiration, microsurgical resection, and more recently, endoscopic resection 19, 34, 41, 53.

Simple decompression of the cyst contents without complete removal of the cyst wall often results in recurrence, previously reported by Mathiesen et al. 41, 42, at a rate of 80% (27). Therefore, radical removal of the cyst wall and intracystic contents is necessary to minimize recurrence 27, 41. Traditionally, transcortical or transcallosal microsurgical approaches with a craniotomy have been the mainstay for surgical treatment of colloid cysts. This approach provides excellent access to the third ventricle and foramen of Monro, and allows for bimanual microdissection of the cyst wall from the critical structures such as the fornix, choroid plexus, and internal cerebral vein 6, 25, 49. However, one disadvantage may be the risk of postoperative morbidities associated with a craniotomy 21, 53. Recently, there has been increased interest in endoscopic approaches for colloid cyst resection because some investigators believe that it is a less invasive technique than traditional microsurgical approaches, which may potentially minimize postoperative complications and perioperative morbidity 1, 7, 9, 11, 14, 23, 24, 30, 41, 52, 59. One major criticism of the standard single-burr hole endoscopic approach is the inability to perform bimanual microdissection of the cyst wall from the critical structures as this technique relies on cyst wall aspiration followed by coagulation of the residual cyst wall remnants (28). The presence of residual cyst wall increases the risk of future recurrence 7, 11, 20, 23, 48, 59. Microsurgical series have typically reported higher rates of complete resection, whereas endoscopic series have reported shorter hospital stays and decreased complication rates 21, 32, 49, 50, 59.

Currently, there is no consensus on which surgical intervention is the most effective. In the present study, we analyzed the differences in endoscopic and microsurgical management of colloid cysts of the third ventricle by performing a systematic review and meta-analysis on the current literature, focusing on the extent of resection, morbidities, recurrence rates, and shunt dependency.

Section snippets

Literature Search Strategy

A systematic review of published literature on cases of colloid cysts was performed. The PubMed database was searched from 1990 to 2014 for “Colloid Cysts” and “Colloid AND cyst AND resection.” Article titles were scanned to identify studies that included colloid cyst treatment data. Abstracts were then reviewed, followed by close inspection of acquired full-text articles. Finally, the bibliographies of the retrieved articles were examined for additional studies missed from the original PubMed

Results

Searching the PubMed database using the key words and manual bibliography search identified 773 studies (Figure 1). Exclusion criteria included studies published before 1990 (292), non-English language (150), nonsurgical (106), not third ventricular colloid cyst (64), non-human subject (35), insufficient data (23), could not locate (18), type of surgical technique (15), insufficient outcome or follow-up data (14), unextractable data (10), and different diagnosis (6). After using the previously

Discussion

In the present systematic review and meta-analysis, 1278 patients who underwent surgical treatment for colloid cyst of the third ventricle were grouped into either microsurgical or endoscopic resection. It was found that the microsurgical group had a significantly greater extent of resection, lower rates of recurrence, and lower rates of reoperation than the endoscopic group. Both groups had similar rates of mortality and shunt dependency. The overall complication rate was lower in the

Conclusion

In the present study, the microsurgical removal of colloid cysts appears to result in a significantly higher rate of complete radical resection, decreased rate of recurrence, and fewer reoperations than with endoscopic removal. This may be related to the advantage of performing 2-handed microdissection of the cyst wall from critical adherent structures to achieve true GTR. The rate of mortality and shunt dependency is similar between both groups. The overall morbidity rate is lower in the

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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