Benefits of endoscope-assisted microsurgery in the management of pediatric brain tumors

OBJECTIVE 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.