Artikel
Transsphenoidal microsurgery in children – pearls and pitfalls
Der transsphenoidale mikrochirurgische Zugang im Kindesalter
Suche in Medline nach
Autoren
Veröffentlicht: | 8. Mai 2019 |
---|
Gliederung
Text
Objective: When encountering a rare sellar pathology in childhood, transsphenoidal microsurgery is a therapeutic option. We describe our experience with this approach and analyze relevant anatomy in children to highlight pearls and pitfalls.
Methods: The institutional database of the last 10 years was retrospectively reviewed for transsphenoidal microsurgery performed in patients aged 18 years or younger. Size of the sphenoid sinus was measured on multiplanar reconstructions of MRI scans and approximate volume was calculated with the formula AxBxC/2. The intercarotid distance was measured on axial MRI planes between corresponding points of the medial borders of the carotid sulcus at the level of maximum sellar diameter.
Results: 10 transsphenoidal microsurgical operations were performed in 2 girls and 6 boys with a mean age of 14 years (range 9-18 years). Histology was pituitary adenoma (N=4), craniopharyngioma (N=2), sarcoma (N=1) and Rathke cleft cyst (N=1). Gross total resections were achieved in all pituitary adenomas, although one recurrence required repeated transsphenoidal surgery. Tumor capsule was left in situ in craniopharyngioma cases, resulting in one cystic recurrence requiring transcranial microsurgery. Sarcoma was biopsied and treated with chemotherapy. Rathke cleft cyst was fenestrated twice. No permanent morbidity and no mortality occurred. Transient diabetes insipidus was observed in 2 patients. Despite 2 cases of intraoperative CSF leakage treated with surgical repair and subsequent lumbar drainage, no persistent CSF leaks occured.
A presellar (i.e. no extension bellow the sella) sphenoid sinus was found in all children being operated before the age of 13 years (N=4). In older children, only sellar (i.e. extension anterior and below the sella) configurations of the sphenoid sinus were seen, reflecting progressive age-related pneumatisation. Mean sphenoid sinus volume in the younger group was 2.5ml, increasing to 10.1ml in the older group. Intercarotid distance was 16.0mm (12mm in non-craniopharyngioma cases versus 22mm in craniopharyngioma cases) and 17.4mm, respectively. Sphenoid sinus septum was median with sella floor insertion (N=4) or bilateral with carotid canal insertion (N=4).
Conclusion: Transsphenoidal microsurgery is safe and effective in children. Sphenoid sinus has a smaller volume and presellar configuration in the first decade of life. Intercarotid distance increases with age and appears to be increased in children with craniopharyngioma.