Endoscopy-assisted early correction of single-suture metopic craniosynostosis: a 19-year experience

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>The objective of this study was to present the authors’ 19-year experience treating metopic craniosynostosis by using an endoscopy-assisted technique and postoperative cranial orthotic therapy. The authors also aimed to provide a comprehensive, comparative statistical analysis of minimally invasive surgery (MIS) versus open surgery in reports previously published in the literature (through 2014) regarding only patients with metopic synostosis.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>A total of 141 patients with single-suture metopic nonsyndromic craniosynostosis sutures were treated between 1998 and 2017 by endoscopically resecting the synostosed bone followed by postoperative custom cranial orthosis use. All data used in the case series were collected prospectively and stored in a secure database. A comprehensive literature review was performed that included all previous case series reporting common surgical performance measures. A statistical comparison of traditional open methods versus MIS techniques was performed with regard to age, length of hospital stay (LOS), surgical time, estimated blood loss (EBL), and transfusion rate.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>The mean age at the time of surgery in the current series was 4.1 months. The mean EBL was 33 ml (range 5–250 ml). One patient underwent an intraoperative blood transfusion and 5 underwent postoperative blood transfusion for a total transfusion rate of 4.3%. The mean operating time was 56 minutes. Ninety-eight percent of patients were discharged on the 1st postoperative day. The median size of the removed synostosed bone was 0.6 cm × 10 cm. The primary goal of achieving correction of the forehead deformity was obtained in 94% of the patients. One hundred eight patients presented with hypotelorism (76.6%). Those with a minimum 1-year follow-up achieved 99% correction (n = 97). Six patients younger than 1 year had not achieved correction at the time of follow-up (6%). There were no intra- or postoperative deaths. One patient had a temporary contact dermatitis to the helmet materials and 2 patients developed pseudomeningoceles, which were successfully treated with a lumbar drain and/or spinal tap. No patient required nor underwent a second surgical procedure. Regarding the previously published literature through 2014, the reported EBL in patients who underwent MIS versus traditional open methods was 54.7 ml versus 224 ml, respectively. The reported average age for patients undergoing MIS versus traditional open methods was 3.8 months versus 11.5 months. The average LOS for patients undergoing MIS versus traditional open methods was 1.7 days versus 3.7 days. The average reported surgical time for those undergoing MIS versus traditional open methods was 66.7 minutes versus 223.7 minutes. The transfusion rate for patients undergoing MIS versus traditional open methods was 22% versus 77%. All of the above differences demonstrated statistical significance.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>The authors’ team has safely and effectively performed 141 metopic craniosynostosis corrections over the past 19 years, with excellent outcomes. Literature review comparing metrics such as LOS, EBL, operating time, and transfusion rate demonstrates a statistically significant improvement in all commonly reported measurements. MIS techniques are safe and effective and should be offered to parents and patients as an option at craniofacial centers treating this condition.</jats:p></jats:sec>

Endoscopic Versus Open Cranial Reconstruction Surgery for Anterior Craniosynostosis: Experience from South-East Asia

“…The surgical intention is to offer a one stage comprehensive correction, but it is associated with significant blood loss, risk of dural tears, long surgery duration and need for specialized intensive care support. 4,9,10,12,14 The endoscopic craniosynostosis surgery was first pioneered by Jimenez and Barone, as an extension of a strip craniectomy, 6,7 combining it with an external orthotics helmet. The brain acts as an internal distractor driving skull expansion in this technique.…”

“…[7][8][9][10] Minimally invasive techniques are gaining popularity due to their short incisions, reduced morbidity, quick recovery and relative safety. [7][8][9][10] In developing countries, internet penetration is increasing, along with increased acceptance of new technologies. Parents are using FACE 1 (2) the internet to research latest technical advances and are keen to seek treatment early.…”

Recent advances in trigonocephaly

“…The first description of endoscopically assisted surgery for craniosynostosis dates back to 1998 when Jimenez and Barone performed strip craniectomy on 4 patients with scaphocephaly, with good outcome [27]. The primary principle for endoscopy-assisted techniques was to perform surgery at an early age (preferably around 3 months) in order to take advantage of the very rapid brain growth during the 1 st year of life [28]. Operations in children older than 9 months were reserved for patients with mild deformity.…”

“…The reason was a high reoperation rate (25%) because of inadequate correction of the deformity, and not the suture A major limitation of MIS is the need for helmet. Jimenez et al [28] also insisted on the use of a custom-made postoperative cranial orthosis 23 hours per day to obtain good results.…”

“…Another limitation of the technique is how to manage the bleeding from bridging veins that extend from the sagittal sinus and dura to the stenosed suture and frontal lobe [28]. Bipolar coagulation with the endoscope may not be sufficient, and maneuvers (table lowered and…”