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Endoscopic treatment of third ventricular colloid cysts: a review including ten personal cases

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Abstract

The surgical treatment of colloid cysts has been traditionally difficult with high rate of postoperative complications. The variety of surgical options reflects the technical difficulty in removing these benign lesions with low morbidity. Microsurgical removal has for years been considered the “gold standard” of treatment, with the use of either a transcortical–transventricular or a transcallosal approach. Neuroendoscopic management is emerging as a safe, effective alternative to microsurgery. The present review discusses the role of endoscopy in the surgical treatment of third ventricular colloid cysts focusing on some factors, which might influence the outcome. The results have been presented from the literature and supplemented by the results of treating ten personal cases of third ventricular colloid cysts who were operated endoscopically in the Neurosurgical Department, Cairo University. This study aims at evaluating the endoscopic approach as a surgical line of treatment in the management of third ventricular colloid cysts and to see if it has already become superior over microsurgery.

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Authors and Affiliations

  1. Faculty of Medicine, Cairo University, 81 Nasr Road, Nasr City, Cairo, Egypt

    Nasser M. F. El-Ghandour

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  1. Nasser M. F. El-Ghandour
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Correspondence to Nasser M. F. El-Ghandour.

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Dieter Hellwig, Hannover, Germany

Colloid cysts are a rare entity with an incidence of around 2% of all intracranial tumors. The different surgical approaches in treatment of this pathology range from shunting the concomitant hydrocephalus to free hand or stereotactic aspiration of the cysts contents. Microsurgical resection using either the transcallosal or the transcortical–transventricular approach was the operative state of the art over years. In the last decade, however, neuroendoscopy increasingly have been used for treatment of colloid cysts. In this paper, Dr. El-Ghandour gives an excellent overview about the indications, operative technique, results, and side effects using this technique. Although his own collective includes only ten patients, he reviews the actual literature comprehensively and describes the advantages of neuroendoscopic resection over the microsurgical approach. The transventricular endoscopic technique seems to be effective and reliable in the treatment of colloid cysts also in the long-term follow-up (1).

There is a little drawback in this paper that the author has not performed a large metaanalysis of the sampled results from other studies. However, El-Ghandour comes to the same conclusion, which we have stated in 2003 (2): Continued improvement of neuroendoscopic techniques and instruments together with good long-term results in endoscopically treated patients with colloid cysts have established this method as an alternative to microsurgery and might even set a new standard for treatment.

1. Tirakotai W, Hellwig D, Bertalanffy H et al. (2007) The role of neuroendoscopy in the management of solid or solid-cystic intra- and periventricular tumors. Childs Nerv Syst 23(6): 653–658

2. Hellwig D, Bauer BL, Schulte DM et al. (2003) Neuroendoscopic treatment for colloid cysts of the third ventricle: the experience of a decade. Neurosurgery 52:525–533

Henry W. S. Schroeder, Greifswald, Germany

The author presents his experience with the endoscopic evacuation and resection of ten colloid cysts and provides a review of the literature. All cysts were completely evacuated. In eight patients, a near-total cyst wall resection was achieved. In two patients harboring a posteriorly located cyst, a subtotal resection of the wall was performed. There were no intraoperative complications and no permanent deficits. One patient complained of transient short-term memory loss. Within the mean follow-up period of 24 months, no recurrence was observed.

This is just another report on the feasibility of endoscopic resection of colloid cysts. It shows that the endoscopic approach is safe; however, the radicality is less compared with microsurgery as stated in most published articles. The reported high complication rate of microsurgery is drawn from older studies. Recent microsurgical series have less complication. In the last decade, several papers dealing with the same topic were published. Unfortunately, this report provides no new information. It is well known that larger cyst membrane remnants lead to recurrences. However, what is with very small membrane residuals left behind? Do these residuals cause recurrence too? What we want to know is: What is the amount of residual cyst membrane which can be left behind without causing cyst recurrence? Is there a need to remove the cyst completely? Only long-term studies will answer this basic question. A follow-up period of 2 years is far too short!!! The author states that the attempt to remove the cyst completely “is not only unnecessary but also potentially dangerous”. I do not agree! In my last five consecutive endoscopic colloid cyst resection, a safe and total cyst resection was performed.

We have to compare “endoscopic” results with microsurgical series regarding complications as well as recurrences. In my opinion, a complete cyst removal should be the goal of an endoscopic approach. If this cannot be achieved (except for very tiny cyst membrane remnants), one should not hesitate to switch to microsurgical techniques via a small craniotomy following the endoscope track.

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El-Ghandour, N.M.F. Endoscopic treatment of third ventricular colloid cysts: a review including ten personal cases. Neurosurg Rev 32, 395–402 (2009). https://doi.org/10.1007/s10143-009-0208-2

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