El Beltagy Mohamed A, Atteya Mostafa M E
1Neurosurgery Department, Children's Cancer Hospital Egypt (CCHE-57357), Cairo; and.
2Neurosurgery Department, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt.
Neurosurg Focus. 2021 Jan;50(1):E7. doi: 10.3171/2020.10.FOCUS20620.
Microsurgical and endoscopic techniques are vastly utilized in brain tumor surgery. Combining both techniques in the same procedure has different forms and applications. The aim of this work was to discuss the usefulness and describe the technical benefits of endoscope-assisted microsurgery (EAMS) in treating pediatric brain tumors in various anatomical locations.
The medical records of 106 children who had undergone EAMS for brain tumors at Children's Cancer Hospital Egypt (CCHE-57357) between January 2009 and January 2017 were reviewed. The patients' ages ranged from 1 to 16 years (mean age 7.5 years). Technical variations, difficulties, complications, strategies, and extent of resection were addressed according to anatomical location.
In general, EAMS enabled closer inspection of tumor extension and surrounding vital structures, especially in the hidden corners not appreciable by the microscope alone, such as tumors in the internal auditory canal and cerebellopontine angle contents in 14 cases, all of which were totally excised, and the undersurface of the optic apparatus in 65 craniopharyngiomas. Total excision was achievable in 51 of the 65 craniopharyngiomas; residual tumor was intentionally left behind under endoscopic guidance in the remaining 14 patients to ensure better hypothalamic function. Vision improved in 15 of 16 patients who initially presented with visual defects. Only 4 patients had new-onset postoperative endocrinopathies. For intraventricular tumors, EAMS allowed earlier recognition of tumor pedicle and, hence, earlier control of the blood supply of the tumor and safer total excision of 12 lateral ventricle, 6 pineal and third ventricle, and 9 fourth ventricle tumors. The tandem use of the endoscope and microscope enabled safer tumor dissections that were performed with more confidence in situations in which pure microscopic excision was either not achievable or less safe. Technical strategies, pitfalls, difficulties, and precautions were categorized and described per tumor location.
EAMS of pediatric brain tumors is a promising, user-friendly tool that complements microsurgery in the management of these complex lesions. The benefits of 2D endoscopy are added to the benefits of stereoscopic perception. EAMS is especially helpful during the removal of different complex pediatric brain tumors. Simultaneous or tandem endoscopic and microscopic approaches may have the potential for better functional outcomes through better visualization and preservation of vital structures in corners that are hidden from the microscope.
显微外科和内镜技术在脑肿瘤手术中得到广泛应用。在同一手术中结合这两种技术有不同的形式和应用。本研究的目的是探讨内镜辅助显微手术（EAMS）在治疗不同解剖部位儿童脑肿瘤中的实用性，并描述其技术优势。
回顾了2009年1月至2017年1月期间在埃及儿童癌症医院（CCHE - 57357）接受EAMS治疗脑肿瘤的106例儿童的病历。患者年龄在1至16岁之间（平均年龄7.5岁）。根据解剖部位探讨了技术变化、困难、并发症、策略及切除范围。
总体而言，EAMS能够更仔细地检查肿瘤的延伸情况及周围重要结构，特别是在仅靠显微镜难以察觉的隐蔽角落，如14例内耳道肿瘤和桥小脑角内容物肿瘤，所有这些肿瘤均被完全切除，以及65例颅咽管瘤视器下表面情况。65例颅咽管瘤中有51例实现了全切；其余14例患者在内镜引导下有意残留部分肿瘤以确保更好的下丘脑功能。最初有视力缺陷的16例患者中有15例视力得到改善。仅4例患者出现新发术后内分泌疾病。对于脑室内肿瘤，EAMS能够更早识别肿瘤蒂，从而更早控制肿瘤血供，并更安全地全切12例侧脑室肿瘤、6例松果体区和第三脑室肿瘤以及9例第四脑室肿瘤。在内镜和显微镜联合使用的情况下，在单纯显微切除无法实现或安全性较低的情况下，能够更安全地进行肿瘤分离，且操作更有信心。针对每个肿瘤部位对技术策略、陷阱、困难及注意事项进行了分类和描述。
儿童脑肿瘤的EAMS是一种有前景、便于使用的工具，在这些复杂病变的管理中对显微手术起到补充作用。二维内镜的优势与立体视觉的优势相结合。EAMS在切除不同复杂儿童脑肿瘤时特别有用。同时或联合使用内镜和显微镜方法，通过更好地可视化和保护显微镜难以观察到的角落中的重要结构，可能具有实现更好功能预后的潜力。
