dr . juliano colonetti
TRANSCRIPT
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Dr . Juliano Colonetti
OtorrinolaringologistaFlorianópolis
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Juliano Colonetti
Florianópolis
NeuroEndo 2019
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Equipe Multidisciplinar
Neurocirurgião
Neuroendocrinologista
Neuroradiologista
Neurooftalmologista
Otorrinolaringologista
Neurologista
Anestesista
Intensivista
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1992 Jankowski et al descreveu 3 pacientes operadosadenoma de hipófise – turbinectomia média
1995 Sethi and Pillay : endonasal endoscopic transsphenoidal technique
1997 Ricardo Carrau e Hae Dong Jho : pure endoscopic approach 50 pacientes
História
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Adenoma de hipófise não funcionante : primeira linha tratamento
Doença de Cushing : primeira linha de tratamento
Acromegalia : microadenomas e macroadenomas com distúrbios visuais .
Tumores invasivos : tratamento clínico seguido de cirurgia descompressiva ( debulking )
Prolactinomas em situações especiais
FONTE : Transnasal Endoscopic Skull Base and Brain Surgery , Dr Aldo Stamm
Indicações cirúrgicas
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Aliviar efeito compressivo
Normalizar hipersecreção hormonal
Preservação/restauração da função hipofisária normal
Prevenir recorrência tumoral
Diagnóstico : obter amostras teciduais/tumorias paraestudo anatomopatológico e científico
Objetivos da Cirurgia
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Acesso Transnasal direto
Acesso Transetmoidal
Acesso Transseptal
Acesso Transplanum
Acesso Transpterigóide
Acesso Transclival
Acesso Transseptal Modificado ( Binostril ) - Dr Aldo Stamm/Dr.Leonardo
Acesso endoscópico tumoresSelares e Parasselares
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Close-up View
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Visão Angulada
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Visão Panôramica
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Vantagens
Visão mais aproximada da anatomia relevante
Visão angulada
Visão panôramica aumentada dentro da área cirúrgica
Risco de diabetes insipidus
Tempo de hospitalização
Desconforto para o paciente
Diminui tempo cirúrgico
Diminui sangramento
Complicações nasais
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Avaliação pré-operatória : RM Crânio
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Avaliação pré-operatória : TC Face
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Microadenoma
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Cirurgia Endoscópica Base de Crânio
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How I Do ItNasoseptal ‘‘Rescue’’ Flap: A Novel Modification of the
Nasoseptal Flap Technique for Pituitary Surgery
Carlos M. Rivera-Serrano, MD; Carl H. Snyderman, MD; Paul Gardner, MD;Daniel Prevedello, MD; Stephen Wheless, BS; Amin B. Kassam, MD; Ricardo L. Carrau, MD;
Laryngoscope, 121:990–993, 2011
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Pós-op microadenoma
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Macroadenoma hipofisário
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Macroadenoma hipofisário
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Ressecção endoscópica Macroadenoma hipofisário
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Rapid Rhino
RR 900 RR 750
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Pós-op retalho nasosseptal
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Pré Pós
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Pós-op retalho nasosseptal
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Pós-op tardio
Retalho Nasosseptal
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Pós-operatório tardio
RetalhoNasosseptal
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Pós-operatório
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Pós-operatório
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Transplanum/suprasellar
Transclival
Transpterigóide
Acesso Expandido
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Anatomia
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Anatomia
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Transplanum/suprasellar
Transclival
Transpterigóide
Acesso Expandido
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Acesso transseptal/transnasalmodificado
Endoscopic combined “transseptal/transnasal” approach for pituitary adenoma : Fujimoto ,Y ; Stamm ,AC , Balsalobre , L – Arquivos de Neuro-psiquiatria 2015
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The Olfactory Strip and Its Preservation in Endoscopic Pituitary Surgery Maintains Smell and Sinonasal Function
Richard J. Harvey ; Mark Winder ; Andrew Davidson ; Tim Steel Sunny NalavenkataNadine Mra ; Ali Bokhari ; Henry Barham ; Anna Knisely
Jornal of Neurological Surgery , Skull Base . June 2015
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Transplanum/suprasellar
+
Transclival
Transpterigóide
Acesso Expandido Combinado
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Transplanum/suprasellar
+
Transpterigóide
+
Transclival
Acesso Expandido Combinado
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Transplanum/suprasellar
+
Transpterigóide
+
Transclival
Acesso Expandido Combinado
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Macroadenoma Invasivo
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Macroadenoma Gigante
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RM TAC
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Macroadenoma Invasivo
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Macroadenoma
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Artéria Carótida Interna
Seio Cavernoso
Sela Túrcica
Macroadenoma hipofisário
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Macroadenoma Gigante
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A Novel Reconstructive Technique After Endoscopic Expanded Endonasal Approaches: Vascular Pedicle NasoseptalFlap
Gustavo Hadad, MD; Luis Bassagasteguy, MD; Ricardo L. Carrau, MD; Juan C. Mataza, MD; Amin Kassam, MD; Carl H. Snyderman, MD; Arlan Mintz, MD
The Laryngoscope 116 , October 2006
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“Gasket-seal”Watertight Closure in Minimal Acess Endoscopic Cranial Base Surgery
Theodore H. Schwartz,M.D. , Vijay K. Anand,M.D. , Lewis Z.L M.D. Brown S, M.D
Neurosurgery 2008 , May (62)
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Gasket Seal & Cartilagem Conchal
Juliano Colonetti
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Combined Use of a Gasket Seal Closure and a Vascularized Pedicle Nasoseptal Flap MultilayeredReconstruction Technique for High-Flow Cerebrospinal Fluid Leaks After Endonasal Endoscopic Skull Base Surgery
World Neurosurgery Volume 83, Issue 2, February 2015, Pages 181-187
Endonasal Endoscopic Skull Base SurgeryFan Hu ; Ye Gu ; Xiaobiao Zhang ; TaoXie ; YongYu ; Chongjing Sun
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Fat
Fascia Lata
Flap : Retalho Nasosseptal
Cortesia : Dr. Aldo Stamm
Triple “F”
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Retalho Nasosseptal + Gasket-seal
Juliano Colonetti
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One-Piece Modified Gasket Seal Technique Authors : Aaron Wessell , Ameet Singh , Zachary Litvack.
Journal of Neurosurgery B 2013 ; 74:305–310.
Objectives Review the effectiveness of a modified gasket seal technique utilizing a porous high-density polyethylene plate/rectus sheath fascia construct without fat grafting for primary closure of anterior defects following endoscopic skull base surgery
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Soft Gasket Seal & Retalho NS
DuraGen
Gelfoam
Retalho NS
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Acesso Endonasal TransesfenoidalTumores Selares
2009 2015
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Cirurgia Realidade Virtual 3D
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Realidade Virtual 3 D
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Treinamento em cadáveres
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Orientações : repouso fístulas ?
Tamponamento nasal
Antibiótico de largo espectro
Acetazolamida
Analgesia
Solução Salina Nasal
Cuidados pós-operatórios
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Tamponamento nasal
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Endocrinológicas : DI transitória (4-20% ) e permanente0-5%
Vasculares : hemorragia e AVC
Lesão da ACI : < 1% casuística de 250 pacientes
Fístulas Liquóricas : 5-20% pós retalho HB 0.5-5%
Neurológicas : lesão nervo óptico
Infecciosas : meningite ou abscesso
Complicações nasais e nasossinusais
Complicações
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Patologia Númeropacientes
Complicaçõestransoperatória
Complicaçõespós-operatórias
REOP
Microadenoma 21 1 fístula liquórica 1
Macroadenoma 246 30 fístulaliquórica1Perda visual
2 fístula1 meningite3 epistaxe
3
CEC / Adenocarc 28
Meningiomas/Craniofaringiomas
22
Estesioneuroblastoma 3
Cisto de Rathke 3
Fístula liquórica 125 2
Total 448 1 7 6
Casuística do Serviço
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FIM
Muito Obrigado
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Macroadenoma hipofisário
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Acesso transseptal/transnasal combinado
Endoscopic combined “transseptal/transnasal” approach for pituitary adenoma : Fujimoto ,Y ; Stamm ,AC , Balsalobre , L – Arquivos de Neuro-psiquiatria 2015
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Artéria Carótida Interna
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