Extended Endoscopic Approach for Resection of Craniopharyngiomas.

Objectives Extended endoscopic approaches are useful for resection of selected craniopharyngiomas. Midline, extraventricular, and predominantly cystic lesions are good candidates for endoscopic resection. In this video, we demonstrate the endoscopic endonasal resection of a large suprasellar craniopharyngioma and discuss the nuances of the surgical technique. Design/Setting Surgical video of an extended endoscopic approach for resection of a suprasellar craniopharyngioma. Results We report the case of a 56-year-old woman who presented with bitemporal hemianopsia and visual acuity deterioration secondary to a large suprasellar solid-cystic lesion. The patient underwent an extended endoscopic transtuberculum approach for resection of the lesion, which was diagnosed as a papillary craniopharyngioma. This video discusses the anatomy and surgical technique applied for endoscopic resection of such lesions. Conclusion Endoscopic endonasal surgery is a useful technique for management of craniopharyngiomas. It is associated with good clinical outcomes in selected cases. Complications, such as postoperative CSF leak, may occur and should be carefully managed. The link to the video can be found at: https://youtu.be/EneOCiQE7yo .

The usefulness of routine histopathology of bilateral nasal polyps - a systematic review, meta-analysis, and cost evaluation.

BACKGROUND: Controversy regarding the usefulness of routine histopathological examination of bilateral nasal polyps removed during endoscopic sinus surgery to identify occult diagnoses still exists. There is a paucity of high-level evidence in the literature. METHODS: A systematic review and meta-analysis was conducted. Two independent reviewers were used. Pooled proportions and numbers needed to screen were calculated. A cost per life year model was generated based on varying survival benefits and compared to other Canadian screening programs to provide financial context. RESULTS: Six studies (n = 3772 patients) were included. Of the 3772 patients, 3751 had a pre-operative clinical and post-operative pathological diagnosis of inflammatory nasal polyps. Agreement proportion was 99.44 %. There were 18 unexpected benign and three unexpected malignant diagnoses identified. This translated to a proportion of 0.48 and 0.08 % respectively. Number needed to screen was 210 and 1258 respectively. Pooled proportion for expected findings using a random effect model was 0.99 (95 % CI = 0.99-1). Pooled proportion for unexpected benign findings using a random effect model was 0.00522 (95 % CI = 0.00133-0.01). Pooled proportion for unexpected malignant findings using a random effect model was 0.00107 (95 % CI = 0.000147-0.00283). The cost to pick up one unexpected benign diagnosis was $14557.2. The cost to pick up 1 unexpected malignant diagnosis was $87204.56. Cost per quality life year calculated ranged from 3211.83 to $64677.58 based on varying assumptions on the survival benefits of identifying an unexpected malignancy. CONCLUSIONS: Routine pathological examination in screening for neoplasia may be low yield, however, no compelling evidence was found to cease such practice. Surgeons should exercise individual judgment in requesting routine examination.

The utility of routine polyp histopathology after endoscopic sinus surgery.

BACKGROUND: Routine histopathological assessment is standard practice for nasal polyp specimens obtained during endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). Retrospective studies suggest that routine histopathology of nasal polyps shows few unexpected diagnoses that alter patient management. Our objective was to study the use of routine pathological analysis, and its cost to the healthcare system, in a prospective manner. METHODS: A multicenter prospective assessment was performed from data collected between 2007 and 2013. Only cases of patients undergoing ESS for bilateral CRS were included. We excluded unilateral disease cases, and cases in which diagnoses other than polyps were suspected either preoperatively or intraoperatively. We then compared the preoperative diagnosis with the final histopathology and identified the rate of unexpected pathologies. A cost analysis was performed. RESULTS: Only 4 of 866 pathological specimens were identified as having a clinically significant unexpected diagnosis. All unexpected pathologies in this series were benign. These 4 cases account for 0.46% of all specimens reviewed. This translates to a number needed to screen of 217 cases of bilateral CRS to discover 1 unexpected pathology. The associated cost for making an unexpected diagnosis was $19,192.73. CONCLUSION: Routine histopathology of nasal polyps in ESS for bilateral CRS with polyps yields few unexpected and management-altering diagnoses. It carries a significant cost to the healthcare system. In cases of bilateral CRS with no other concerning clinical features, clinicians should exercise judgment in submitting polyp specimens for pathology rather than routinely sending polyps for histopathologic analysis.