PEDIATRIC ENDOSCOPIC BRAIN SURGERY
CRANIAL ENDOSCOPIC PROCEDURES
1. ENDOSCOPIC PITUITARY SURGERY AND CRANIOPHARYNGIOMA SURGERY
Endoscopic pituitary surgery and Craniopharyngioma surgery also called as Transnasal Transphenoidal Endoscopic Pituitary Adenoma Surgery is performed through a natural nasal air pathway through the nose without any incisions unlike the conventional microscopic surgery performed with an incision made under the upper lip or inner aspect of a nostril. Endoscopic surgery does not require the use of a metallic transsphenoidal retractor that is used for conventional Microscopic Transnasal Transphenoidal Pituitary Tumour surgery. A 4-mm endoscope is placed in front of the tumor in the sphenoidal sinus and the tumor is removed with specially designed surgical tools. Postoperative nasal packing is not necessary, and postoperative discomfort is minimal. Most patients are able to go home the following day. The optical advantages of an endoscope (such as a wide-angled panoramic view, an angled view by angled lens endoscopes, and a view in the tumor removal cavity) enhance tumor removal even in complex cases of bulky tumors.
Advantages of Endoscopic Pituitary Surgery and Craniopharyngioma surgery
- This procedure does not require sublabial or nostril incisions and eliminates the need for occlusive postoperative packing used with the conventional procedures.
With this newly developed minimally invasive technique, pituitary tumors can be removed through the patient's natural nose.
- This method is minimally invasive because it directly approaches the tumor through the patient's nostril thus eliminating facial swelling, decreasing postoperative pain, and making recovery quicker.
- The procedure is innovative because it utilizes endoscopic technology to improve visualization of the pituitary gland, the tumor, and other anatomical structures.
ENDOSCOPIC MINIMALLY INVASIVE TECHNIQUE FOR TUMOR EXCISION THROUGH THE NOSE WITHOUT ANY INCISION AND A HOSPITAL STAY 24 HOURS.
2. ENDOSCOPIC MINIMALLY INVASIVE SURGERY FOR MANAGEMENT OF INTRAVENTRICULAR BRAIN TUMORS
The cerebral ventricles are chambers within the brain that contain a clear-colorless fluid called cerebrospinal fluid (CSF). CSF serves as an excellent medium for endoscopy given the clarity and space. Since many varieties of brain tumors can occur in the ventricles, biopsy is commonly recommended in order to define the best type of therapy. Conventional procedures for tumor biopsy involve either a needle biopsy using a frame attached to the skull or an open surgical procedure. Brain tumors situated in the intraventricular compartment are amenable to an endoscopic biopsy or resection.
Endoscopic Tumor Surgery
The procedure is performed through a small incision (approximately 1 inch) behind the hairline. From this site, the endoscope is inserted into the ventricular compartment of the brain and then navigated toward the tumor. The tumor is readily identified due to the difference in appearance from the surrounding tissue. Biopsy forceps are then used to sample the tumor. Because direct vision is being used, samples can be selected avoiding any small blood vessels or other important structures within the ventricle, features that cannot be done with standard "closed" needle biopsies. The endoscope is then removed and the wound is closed. The procedure is performed in approximately 30 minutes and patients can return home the following day.
Endoscopic biopsy for intraventricular brain tumors avoids many of the inherent risks associated with conventional surgical approaches. Because these tumors are typically situated deep within the brain, the ability to approach these tumors with a minimally invasive technique offers a very significant advantage to the patient.
ENDOSCOPIC MINIMALLY INVASIVE SURGERY FOR TUMOR EXCISION THROUGH A SMALL OPENING OF 2CM AND SHORT HOSPITAL STAY.
PEDIATRIC BRAIN TUMORS
Brain tumors are among the most common childhood malignancies and they vary widely in their type, location, and growth rate.
Brain tumours are the most common solid tumours in children and account for 20% of all childhood malignancies.
Brain tumours can cause a multiple symptoms depending on their location, its rate of growth, and the age of the child.
Tumours in any location can cause increased pressure within the skull causing the child to experience headaches, nausea, vomiting, and double vision. In infants, the increased pressure may cause excessive, rapid head growth. Tumours located in the back of the brain (posterior fossa) can also cause unsteadiness and difficulties with speech and swallowing. Tumours located in the top part of the brain (supratentorial) can cause seizures (involuntary convulsions with or without loss of consciousness) or weakness of the arms or legs. Tumours located near the base of the brain (suprasellar) can cause visual problems as well as hormonal imbalances that can lead to several conditions including growth disorders.
When a child develops symptoms that are suggestive of a brain tumour, the mainstay of establishing the diagnosis is through imaging of the brain. This is done by either a CT scan or MRI Scan. While these types of images will demonstrate whether an abnormal mass is present in the brain, in only a few cases will this be enough to establish what type of a mass it is. Aside from brain tumour, abnormal masses in the brain could be caused by infection, bleeding, or a long-standing congenital abnormality. In most cases, some form of surgery is required in order to remove a sample of tissue. By analyzing the tissue, one can know for sure whether the mass is a tumour and, more importantly, exactly what type of tumour it is.
The treatment of brain tumours varies greatly and is dependent by several factors including the size and location of the tumour, the age of the child, and the expected growth rate of the tumour. The main modalities of treatment are surgery, radiation therapy, and chemotherapy.
ENDOSOCPIC SURGERY DONE THROUGH NOSE OR A ENDOSCOPIC MINIMALLY INVASIVE 2CM OPENING WITH SHORT HOSPITAL STAY.
Surgery for brain tumors can be performed for different purposes, depending on the type, size and location of the tumour. The possible goals of surgery may be one of or any combination of the following:
1. To remove as much of the tumour as is safely possible. One of the great difficulties in removing brain tumours, as opposed to tumours in other locations in the body, is that extreme care must to be taken to try to prevent harm to the very delicate brain tissue. For most childhood tumours, the prognosis is generally better if the tumour can be either totally or near-totally removed. Therefore, surgery remains the mainstay of therapy for the majority of childhood tumours.
2. To remove enough of the tumour to improve the patient's symptoms. For example, if a large tumour is causing increased pressure in the skull, or weakness of the arms or legs, or seizures, then surgery on the tumour may help relieve these symptoms.
3. To provide a tissue sample of the tumour. This tissue sample is analyzed by pathologists and this will tell the surgeon what type of tumour it is and, possibly, how aggressively it might be expected to behave. This will also help decide what type of treatment is needed.
Radiation therapy involves passing high energy radiation through the body. Radiation slows rapidly growing tissue, like tumours. Radiation therapy is often used in conjunction with surgical therapy. The dose and timing of the radiation regimen depends on the type of tumour. In some cases, radiation might only be applied to the local area of the tumour, whereas in other cases, an additional radiation dose might be given to the entire brain and spinal cord to try to prevent the tumour from seeding via the spinal fluid. Because of the fear that radiation therapy may adversely effect the very young, developing brain, it is usually not performed in infants and very young children. Potential side-effects of radiation therapy include hair loss, nausea, vomiting, fatigue, and local skin irritation.
Chemotherapy involves giving very strong medications (directly into the bloodstream or occasionally as pills) that preferentially destroy tumour cells. There are numerous drugs that may be used for various types of brain tumours. Although some chemotherapy drugs can improve the survival of children with certain brain tumours, the drugs themselves can have substantial side-effects, including severe nausea, hair loss, and risk of infection.
Types of Brain Tumours
There are several different types of brain tumours that can affect children. Only some of the more common ones will be discussed here.
These tumours are located near the optic nerves and the pituitary gland, so they frequently cause visual problems and hormonal imbalances. The standard therapy for these tumours is surgery, attempting to remove as much of the tumour as is safely possible. Total removal of the tumour is very difficult and, because of its location, visual disturbances and hormonal imbalances are not uncommon after surgery. Radiation therapy is occasionally used if substantial tumour remains after surgery or if the tumour shows re-growth.
Astrocytomas are tumours that can either be low-grade or high-grade. The low-grade variety is commonly found in the back of the brain (posterior fossa) and these account for approximately 10% of all childhood brain tumours. They may, however, also be located in the top of the brain (supratentorial). Surgical removal of these tumours, especially in the posterior fossa, carries an excellent prognosis for complete cure. The overall prognosis for these tumours is very good.
High-grade astrocytomas are most commonly located in the top of the brain (supratentorial). Treatment usually consists of a combination of surgery, chemotherapy, and radiation. These are quite aggressive tumours and the prognosis is much worse than for the low-grade variety.
Ependymomas most commonly occur in the back of the brain (posterior fossa). Therapy consists of surgery, attempting to remove as much of the tumour as is safely possible, and radiation therapy.
Medulloblastoma is another common tumour of the back of the brain (posterior fossa).Treatment initially consists of surgical removal. This is usually followed by radiation therapy, which frequently involves radiation to the entire brain and spinal cord to prevent the spread of the tumour to another location. Depending on the extent of the tumour, chemotherapy may also be considered.
The brainstem is the central area of the brain, where all the nerve fibers that travel between the brain and body meet. Tumours that arise in this delicate location are usually gliomas that can either be high-grade or low-grade
High-grade brainstem gliomas are very difficult to treat. They may be diagnosed based on brain imaging alone. Surgical removal is extremely difficult and so therapy is usually confined to radiation and, sometimes, chemotherapy.
Low-grade brainstem gliomas are quite different and sometimes need no urgent therapy. They can sometimes simply be watched with repeated brain imaging. It is not uncommon for these to remain unchanged for many years.
Tumours in the brainstem are particularly prone, due to their location, to obstruct the flow of the brain's natural fluid. This causes a build-up of fluid in the brain (hydrocephalus) and increased pressure in the skull. The treatment for this can involve either placement of a silastic tube (shunt) to drain the fluid into the abdomen or the creation of a separate hole in the brain to divert the tumour obstruction (endoscopic third ventriculostomy).