RESUMEN
Wound liquorrhea is a serious and dangerous complication developing after neurosurgical interventions. The highest risk group includes patients operated on using approaches to the skull base. In pediatric neurosurgery, approaches to the posterior cranial fossa are some of the most common ones, with wound liquorrhea amounting to 33%. Studies devoted to the wound liquorrhea problem have been performed in heterogeneous patient groups, which complicates evaluation of the results and reduces their practical value. MATERIAL AND METHODS: The analysis included pediatric patients operated on by a single surgeon for posterior cranial fossa (PCF) tumors in the period from 2009 to 2016. There were 472 patients. Criteria for inclusion in the study were as follows: age under 18 years; predominant tumor location in the fourth ventricle; primary surgery. According to the inclusion criteria, the study involved 211 patients. A search for the key words 'liquorrhea', 'pooling', 'meningocele', 'pseudomeningocele', and 'meningitis' was performed through electronic medical records of the involved patients. We analyzed the data on the total bed-day and the number of days spent in the critical care unit. Surgery protocols were the source of the following information: the presence of an external ventricular drain or ventriculoperitoneal shunt before tumor resection; information on DM closure; information on additional sealing of dura sutures. In addition, the patients were divided into two groups, the main difference between which was the use of additional sealing of dura sutures (Tachocomb, fibrin-thrombin glues, and their combination) to minimize the risk of wound liquorrhea. RESULTS: A total of 211 patients were included in the study. Postoperative wound liquorrhea occurred in 6 (2.8%) patients; another 5 (2.4%) patients had significant pseudomeningocele. Most children spent no more than 1 day in the critical care unit - totally 176 (83.4%) patients; the other 35 (16.6%) children spent more than 1 day in the critical care unit. A group of patients without sealing of dura sutures consisted of 144 (68.2%) patients. Liquorrhea occurred in 4 (2.8%) cases; in 3 (2.1%) cases, there was symptomatic pseudomeningocele without liquorrhea. In a group of patients with the use of suture sealing (Tachocomb, fibrin-thrombin glue in various combinations - 67 (31.8%) patients), there was liquorrhea in 2 (3%) cases and pseudomeningocele without liquorrhea in 2 (3%) cases. On the basis of PSM algorithm application, 2 groups of 67 patients each were formed: the group with sealing (A) and the group without sealing (B) of the DM. Of the 67 cases of sealing, Tachocomb was used in 64 (95.5%) patients, and fibrin-thrombin glue was applied in 53 (59.1%) patients. Differences between the groups in the rate of liquorrhea (2 (3.0%) patients in group A and 4 (6.0%) patients in group B) and pseudomenigocele (3 (4.5%) patients in group A and 5 (7.5%) patients in group B) were statistically insignificant (p=0.68 and p=0.58, respectively). CONCLUSION: Wound liquorrhea has remained a topical issue in surgery for posterior cranial fossa tumors and, if develops, doubles the postoperative bed-day. Our strategy of perioperative management of patients proved its efficacy in reducing the rate of postoperative liquorrhea up to 2.8%. A low percentage of liquorrhea did not allow unambiguous evaluation of the effect of additional sealing of dura sutures (Tachocomb and fibrin-thrombin glue).
Asunto(s)
Neoplasias Encefálicas , Rinorrea de Líquido Cefalorraquídeo , Cuarto Ventrículo , Procedimientos Neuroquirúrgicos , Neoplasias Encefálicas/cirugía , Niño , Fosa Craneal Posterior , Duramadre , Cuarto Ventrículo/cirugía , Humanos , Procedimientos Neuroquirúrgicos/efectos adversos , Complicaciones Posoperatorias , Estudios RetrospectivosRESUMEN
Treatment of primary malignant neuroepithelial tumors of the posterior cranial fossa (PCF) in childhood includes surgical resection, radiation therapy (RT), and chemotherapy (CT). The radicalness of surgery is one of the most important prognostic factors of survival. Despite the significant advances in treatment, many of these tumors recur. Today, oncologists are increasingly recommending repeated surgery for recurrent malignant neuroepithelial tumors of the PCF to achieve gross total resection (GTR). Patients undergo this surgery after RT and palliative CT, which may increase surgical risks. OBJECTIVE: The study objective was to assess the resection extent of recurrent malignant neuroepithelial tumors of the PCF in children as well as the risk and structure of postoperative complications. MATERIAL AND METHODS: The prospective study included 50 patients under the age of 18 who underwent surgery for recurrent malignant neuroepithelial tumors of the PCF at the Neurosurgical Institute (NSI) in the period between 2002 and June 2015. Anaplastic ependymomas were present in 37 patients, and medulloblastomas were detected in 13 patients. A total of 58 repeated surgeries were performed. RESULTS: GTR was achieved in 53 (91.4%) cases, near total resection (NTR) was achieved in 2 (3.4%) cases, and subtotal resection (STR) was achieved in 3 (5.2%) cases. The mean bed-day after surgery was 12 (4-47) days, and the mean critical care stay was 3.2 (0-23) days. Seven patients required tracheostomy; meningitis developed in 3 patients; liquorrhea occurred in 2 cases. Ventriculoperitoneal shunting was used in 8 (13.8%) cases. One (1.7%) patient died in the early postoperative period. CONCLUSION: Our results demonstrate that resection of recurrent malignant neuroepithelial tumors in children can be performed with high radicalness (90%) and acceptable risks.
Asunto(s)
Neoplasias Cerebelosas , Ependimoma , Neoplasias de la Base del Cráneo , Neoplasias Cerebelosas/cirugía , Niño , Fosa Craneal Posterior , Ependimoma/cirugía , Humanos , Recurrencia Local de Neoplasia , Estudios Prospectivos , Estudios Retrospectivos , Neoplasias de la Base del Cráneo/cirugía , Resultado del TratamientoRESUMEN
One of the main manifestations of posterior cranial fossa (PCF) tumors is the development of hydrocephalus (HC) symptoms that in most cases are the reason for examination and diagnosis [1, 2]. According to the literature, the rate of shunt surgery after removal of PCF tumors in the children's population is 18-40% [3-9]. Hydrocephalus remaining after removal of PCF tumor and requiring further treatment is called persistent hydrocephalus. The above figures are based on the treatment outcomes in children, which were obtained as early as in the 1990s. Given these facts, we conducted a modern study to assess the risk of persistence/development of persistent hydrocephalus in children after removal of posterior cranial fossa tumors and to explore factors affecting this risk. MATERIAL AND METHODS: We performed a retrospective analysis of the treatment outcomes in 155 children operated on at the Burdenko Neurosurgical Institute between 2012 and 2014. All children were operated on by a single surgeon. Factors, such as the patient age, histological pattern of tumor, and primary/repeated surgery, were analyzed. RESULTS: A total of 13 (8.4%) patients needed shunt surgery. An analysis demonstrated no need for shunt surgery in children with piloid astrocytomas. In children with medulloblastoma, the need for a permanent shunt occurred in 5 (9.1%) cases; all these children were older than 3 years. A group of anaplastic ependymoma included 23 children; of these, 13 children were older than 3 years, and 10 children were under the age of 3 years. Five (21.7%) patients required shunt surgery. Shunting was needed in 3 children from group 4. In one case, a child younger than 3 years of age who was operated on for a dermoid cyst of the PCF, and in 2 children older than 3 years of age who were operated on for ganglioastroscytoma and atypical teratoid-rhabdoid tumor (ATRT). CONCLUSION: At present, the risk of persistent hydrocephalus in children after removal of PCF tumors is lower than that reported in the literature. In our study, it was 8.4%. The age of children under 3 years and repeated operations do not statistically significantly increase the risk of persistent hydrocephalus. Only tumor histology is statistically significant: the highest risk of the need for implantation of VPS was found in the group with anaplastic ependymomas, and the minimal risk was in the group of piloid astrocytomas.
Asunto(s)
Neoplasias Encefálicas/cirugía , Fosa Craneal Posterior , Glioma/cirugía , Hidrocefalia/prevención & control , Complicaciones Posoperatorias/prevención & control , Derivación Ventriculoperitoneal , Neoplasias Encefálicas/complicaciones , Niño , Glioma/complicaciones , Humanos , Hidrocefalia/etiología , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Posterior cranial fossa tumors are the most common neuro-oncological pathology of childhood. More than half of them are located along the midline, occupying the cerebellar vermis and 4th ventricle cavity. Historically, most of these tumors were operated on with the patient in sitting position. This tendency has significantly changed in the last 30 years. For example, 95% of all operations in Japan are now performed with the patient in lying position; for the US and Europe, these figures are 80 and 60%, respectively. This global tendency of switching to the lying position is mainly associated with a high risk of venous air embolism in the sitting position. In the period between 1999 and 2013, the first author used only the sitting position for resection of PCF tumors. During this period, he performed 606 operations. In patients with large/giant tumors (usually, these were piloid astrocytomas with cysts), the surgeon often faced the problem of excessive retraction of the cerebellum and rupture of the bridging veins, sometimes outside the surgical approach area. This situation led either to massive blood loss or to venous air embolism. MATERIAL AND METHODS: Therefore, beginning at 2013, we started to selectively use the prone position in cases of hemispheric piloid astrocytomas of the cerebellum. This initial experience allowed us to assess the surgical features of the procedure and use the experience in more complex interventions. Since the middle of 2016, given the tendency of using key-hole approaches, we have increasingly used the prone position in surgery of PCF tumors, sometimes removing tumors even through the burr hole. Since the end of 2016, we have routinely used the prone position for various tumors of the 4th ventricle. Between November 2016 and September 2017, the first author performed 113 surgeries for PCF tumors in children; of these, only 4 operations were performed in the sitting position. Thus, in less than a year, the prone position has become the main one in surgery for all PCF tumors in our practice. In this article, we would like to share our practical suggestions both about using the prone position and about its advantages and disadvantages that should be considered by a doctor who does not have experience of PCF surgery with the patient in prone position.
Asunto(s)
Neoplasias Encefálicas , Fosa Craneal Posterior , Cerebelo , Niño , Humanos , Posicionamiento del Paciente , Postura , Posición PronaRESUMEN
The article describes in detail a large modern clinical series of patients operated on for spinal cord epidermoid cysts. AIM: the study aim was to comprehensively investigate the epidemiological and clinical peculiarities of spinal cord epidermoid cysts and evaluate immediate and long-term results of their surgical treatment. MATERIAL AND METHODS: We describe and analyze surgical outcomes of 20 patients with spinal cord epidermoid cysts. This sample was selected from 554 patients with intramedullary tumors and 365 patients with spinal dysraphism (aged from 2 months to 72 years) who were operated on by the first author in 2002-2017. RESULTS: Our findings confirm a high efficacy and low risk of surgical treatment of patients diagnosed with spinal epidermoid cysts. Severe complications of disease progression serve as indications for 'preventive' surgery even in asymptomatic cases. Complete resection of the tumor capsule without deterioration of the functional surgical result is the main goal of surgical treatment. Incomplete resection is associated with a high risk of recurrence. The most thorough follow-up with annual MRI examination is necessary for the first 6 years after surgery.