{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,29]],"date-time":"2026-08-29T22:35:22Z","timestamp":1788042922957,"version":"build-2784847793"},"reference-count":68,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"6","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["FOC"],"published-print":{"date-parts":[[2016,12]]},"abstract":"\n OBJECTIVE<\/jats:title>\n There is a paucity of literature regarding the learning curve associated with performing endoscopic endonasal cranial base surgery. The purpose of this study was to determine to what extent a learning curve might exist for endoscopic endonasal resection in cases of craniopharyngiomas.<\/jats:p>\n <\/jats:sec>\n \n METHODS<\/jats:title>\n A retrospective review was performed for all endoscopic endonasal craniopharyngioma resections performed at Thomas Jefferson University from 2005 to 2015. To assess for a learning curve effect, patients were divided into an early cohort (2005\u20132009, n = 20) and a late cohort (2010\u20132015, n = 23). Preoperative demographics, clinical presentation, imaging characteristics, extent of resection, complications, tumor control, and visual and endocrine outcomes were obtained. Categorical variables and continuous variables were compared using a 2-sided Fisher's exact test and t-test, respectively.<\/jats:p>\n <\/jats:sec>\n \n RESULTS<\/jats:title>\n Only the index operation performed at the authors' institution was included. There were no statistically significant differences between early and late cohorts in terms of patient age, sex, presenting symptoms, history of surgical or radiation treatment, tumor size or consistency, hypothalamic involvement, or histological subtype. The rate of gross-total resection (GTR) increased over time from 20% to 65% (p = 0.005), and the rate of subtotal resection decreased over time from 40% to 13% (p = 0.078). Major neurological complications, including new hydrocephalus, meningitis, carotid artery injury, or stroke, occurred in 6 patients (15%) (8 complications) in the early cohort compared with only 1 (4%) in the late cohort (p = 0.037). CSF leak decreased from 40% to 4% (p = 0.007). Discharge to home increased from 64% to 95% (p = 0.024). Visual improvement was high in both cohorts (88% [early cohort] and 81% [late cohort]). Rate of postoperative panhypopituitarism and permanent diabetes insipidus both increased from 50% to 91% (p = 0.005) and 32% to 78% (p = 0.004), which correlated with a significant increase in intentional stalk sacrifice in the late cohort (from 0% to 70%, p < 0.001).<\/jats:p>\n <\/jats:sec>\n \n CONCLUSIONS<\/jats:title>\n High rates of near- or total resection and visual improvement can be achieved using an endoscopic endonasal approach for craniopharyngiomas. However, the authors did find evidence for a learning curve. After 20 cases, they found a significant decrease in major neurological complications and significant increases in the rates of GTR rate and discharge to home. Although there was a large decrease in the rate of postoperative CSF leak over time, this was largely attributable to the inclusion of very early cases prior to the routine use of vascularized nasoseptal flaps. There was a significant increase in new panhypopituitarism and diabetes insipidus, which is attributable to increase rates of intentional stalk sacrifice.<\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/2016.9.focus16292","type":"journal-article","created":{"date-parts":[[2016,12,1]],"date-time":"2016-12-01T03:37:19Z","timestamp":1480563439000},"page":"E9","source":"Crossref","is-referenced-by-count":56,"title":["The learning curve in endoscopic endonasal resection of craniopharyngiomas"],"prefix":"10.3171","volume":"41","author":[{"given":"Varun R.","family":"Kshettry","sequence":"first","affiliation":[{"name":"Departments of Neurological Surgery and"},{"name":"Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hyunwoo","family":"Do","sequence":"additional","affiliation":[{"name":"Departments of Neurological Surgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Khaled","family":"Elshazly","sequence":"additional","affiliation":[{"name":"Departments of Neurological Surgery and"},{"name":"Department of Neurological Surgery, Ain Shams University Hospital, Cairo, Egypt"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher J.","family":"Farrell","sequence":"additional","affiliation":[{"name":"Departments of Neurological Surgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gurston","family":"Nyquist","sequence":"additional","affiliation":[{"name":"Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marc","family":"Rosen","sequence":"additional","affiliation":[{"name":"Departments of Neurological Surgery and"},{"name":"Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James J.","family":"Evans","sequence":"additional","affiliation":[{"name":"Departments of Neurological Surgery and"},{"name":"Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"key":"b1-focus16292","series-title":"Pituitary","first-page":"1","article-title":"Craniopharyngioma: history","volume":"16","author":"Barkhoudarian","year":"2013"},{"issue":"4","key":"b2-focus16292","series-title":"Neurosurg Focus","first-page":"E8","article-title":"Endocrinological and ophthalmological consequences of an initial endonasal endoscopic approach for resection of craniopharyngiomas","volume":"28","author":"Campbell","year":"2010"},{"key":"b3-focus16292","series-title":"J Neurosurg","first-page":"100","article-title":"The endoscopic endonasal approach for the management of craniopharyngiomas: a series of 103 patients","volume":"121","author":"Cavallo","year":"2014"},{"key":"b4-focus16292","series-title":"Nagoya J Med Sci","first-page":"297","article-title":"Recurrent ectopic craniopharyngioma in the sylvian fissure thirty years after resection through a pterional approach: a case report and review of the literature","volume":"77","author":"Clark","year":"2015"},{"key":"b5-focus16292","series-title":"Intracranial Tumors. Notes upon a series of two thousand verified cases with surgical mortality percentages pertaining thereto","first-page":"93","article-title":"The craniopharyngiomas","author":"Cushing","year":"1932"},{"key":"b6-focus16292","series-title":"Childs Nerv Syst","first-page":"606","article-title":"A history of the treatment of craniopharyngiomas","volume":"21","author":"DiPatri","year":"2005"},{"key":"b7-focus16292","series-title":"J Neurosurg Pediatr","first-page":"30","article-title":"Efficacy and safety of radical resection of primary and recurrent craniopharyngiomas in 86 children","volume":"5","author":"Elliott","year":"2010"},{"key":"b8-focus16292","series-title":"Craniopharyngiomas: Comprehensive Diagnosis, Treatment, and Outcome","article-title":"Endoscopic resection of craniopharyngiomas","author":"Evans","year":"2014"},{"issue":"5 Suppl 2","key":"b9-focus16292","series-title":"Neurosurgery","first-page":"269","article-title":"Endonasal versus supraorbital keyhole removal of craniopharyngiomas and tuberculum sellae meningiomas","volume":"64","author":"Fatemi","year":"2009"},{"key":"b10-focus16292","series-title":"J Neurosurg","first-page":"1043","article-title":"The evolution of the endonasal approach for craniopharyngiomas","volume":"108","author":"Gardner","year":"2008"},{"key":"b11-focus16292","series-title":"J Neurosurg","first-page":"559","article-title":"Microsurgical resection of extensive craniopharyngiomas using a frontolateral approach: operative technique and outcome","volume":"120","author":"Gerganov","year":"2014"},{"key":"b12-focus16292","series-title":"J Neurosurg","first-page":"373","article-title":"Results after treatment of craniopharyngiomas: further experiences with 73 patients since 1997","volume":"116","author":"Hofmann","year":"2012"},{"key":"b13-focus16292","series-title":"Neurol Res","first-page":"796","article-title":"Effect of craniopharyngioma fluid on femoral vessels of rat","volume":"21","author":"Kamal","year":"1999"},{"key":"b14-focus16292","series-title":"J Neurosurg","first-page":"715","article-title":"Expanded endonasal approach, a fully endoscopic transnasal approach for the resection of midline suprasellar craniopharyngiomas: a new classification based on the infundibulum","volume":"108","author":"Kassam","year":"2008"},{"key":"b15-focus16292","series-title":"World Neurosurg","first-page":"329","article-title":"Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of craniopharyngiomas","volume":"77","author":"Komotar","year":"2012"},{"key":"b16-focus16292","series-title":"J Neurosurg","first-page":"1194","article-title":"Endoscopic endonasal surgery for craniopharyngiomas: surgical outcome in 64 patients","volume":"119","author":"Koutourousiou","year":"2013"},{"key":"b17-focus16292","series-title":"Neurosurgery","first-page":"614","article-title":"Endoscopic endonasal approach for resection of cranial base chordomas: outcomes and learning curve","volume":"71","author":"Koutourousiou","year":"2012"},{"key":"b18-focus16292","series-title":"Neurosurgery","first-page":"1205","article-title":"Endoscopic transsphenoidal pituitary surgery: evidence of an operative learning curve","volume":"67","author":"Leach","year":"2010"},{"key":"b19-focus16292","series-title":"Neurosurgery","first-page":"110","article-title":"Endoscopic, endonasal resection of craniopharyngiomas: analysis of outcome including extent of resection, cerebrospinal fluid leak, return to preoperative productivity, and body mass index","volume":"70","author":"Leng","year":"2012"},{"key":"b20-focus16292","series-title":"Surg Radiol Anat","first-page":"775","article-title":"Topographic variations of the optic chiasm and the pituitary stalk: a morphometric study based on midsagittal T2-weighted MR images","volume":"36","author":"Long","year":"2014"},{"key":"b21-focus16292","series-title":"Laryngoscope","first-page":"876","article-title":"Endoscopic repair of high-flow cranial base defects using a bilayer button","volume":"120","author":"Luginbuhl","year":"2010"},{"key":"b22-focus16292","series-title":"J Clin Neurosci","first-page":"348","article-title":"Subarachnoid hemorrhage and vasospasm following removal of craniopharyngioma","volume":"4","author":"Macdonald","year":"1997"},{"key":"b23-focus16292","series-title":"J Neurosurg","first-page":"1350","article-title":"Neurosurgical treatment of craniopharyngioma in adults and children: early and long-term results in a large case series","volume":"114","author":"Mortini","year":"2011"},{"issue":"6","key":"b24-focus16292","series-title":"Neurosurg Focus","first-page":"E10","article-title":"Comparison of endoscopic and microscopic removal of pituitary adenomas: single-surgeon experience and the learning 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craniopharyngioma","volume":"4","author":"Salunke","year":"2013"},{"key":"b29-focus16292","series-title":"Neurol Med Chir (Tokyo)","first-page":"666","article-title":"Symptomatic vessel narrowing caused by spontaneous rupture of craniopharyngioma cyst\u2014case report","volume":"38","author":"Shida","year":"1998"},{"key":"b30-focus16292","series-title":"Skull Base","first-page":"69","article-title":"Light at the end of the tunnel: the learning curve associated with endoscopic transsphenoidal skull base surgery","volume":"20","author":"Smith","year":"2010"},{"key":"b31-focus16292","series-title":"Laryngoscope","first-page":"699","article-title":"Acquisition of surgical skills for endonasal skull base surgery: a training program","volume":"117","author":"Snyderman","year":"2007"},{"key":"b32-focus16292","series-title":"Otolaryngol Clin North Am","first-page":"1223","article-title":"Training in neurorhinology: the impact of case volume on the learning 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Neurosurg","first-page":"100","article-title":"The endoscopic endonasal approach for the management of craniopharyngiomas: a series of 103 patients","volume":"121","author":"Cavallo","year":"2014"},{"key":"b4-focus16292","series-title":"Nagoya J Med Sci","first-page":"297","article-title":"Recurrent ectopic craniopharyngioma in the sylvian fissure thirty years after resection through a pterional approach: a case report and review of the literature","volume":"77","author":"Clark","year":"2015"},{"key":"b5-focus16292","series-title":"Intracranial Tumors. Notes upon a series of two thousand verified cases with surgical mortality percentages pertaining thereto","first-page":"93","article-title":"The craniopharyngiomas","author":"Cushing","year":"1932"},{"key":"b6-focus16292","series-title":"Childs Nerv Syst","first-page":"606","article-title":"A history of the treatment of craniopharyngiomas","volume":"21","author":"DiPatri","year":"2005"},{"key":"b7-focus16292","series-title":"J Neurosurg Pediatr","first-page":"30","article-title":"Efficacy and safety of radical resection of primary and recurrent craniopharyngiomas in 86 children","volume":"5","author":"Elliott","year":"2010"},{"key":"b8-focus16292","series-title":"Craniopharyngiomas: Comprehensive Diagnosis, Treatment, and Outcome","article-title":"Endoscopic resection of craniopharyngiomas","author":"Evans","year":"2014"},{"issue":"5 Suppl 2","key":"b9-focus16292","series-title":"Neurosurgery","first-page":"269","article-title":"Endonasal versus supraorbital keyhole removal of craniopharyngiomas and tuberculum sellae meningiomas","volume":"64","author":"Fatemi","year":"2009"},{"key":"b10-focus16292","series-title":"J Neurosurg","first-page":"1043","article-title":"The evolution of the endonasal approach for craniopharyngiomas","volume":"108","author":"Gardner","year":"2008"},{"key":"b11-focus16292","series-title":"J Neurosurg","first-page":"559","article-title":"Microsurgical resection of extensive craniopharyngiomas using a frontolateral approach: operative technique and outcome","volume":"120","author":"Gerganov","year":"2014"},{"key":"b12-focus16292","series-title":"J Neurosurg","first-page":"373","article-title":"Results after treatment of craniopharyngiomas: further experiences with 73 patients since 1997","volume":"116","author":"Hofmann","year":"2012"},{"key":"b13-focus16292","series-title":"Neurol Res","first-page":"796","article-title":"Effect of craniopharyngioma fluid on femoral vessels of rat","volume":"21","author":"Kamal","year":"1999"},{"key":"b14-focus16292","series-title":"J Neurosurg","first-page":"715","article-title":"Expanded endonasal approach, a fully endoscopic transnasal approach for the resection of midline suprasellar craniopharyngiomas: a new classification based on the infundibulum","volume":"108","author":"Kassam","year":"2008"},{"key":"b15-focus16292","series-title":"World Neurosurg","first-page":"329","article-title":"Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of craniopharyngiomas","volume":"77","author":"Komotar","year":"2012"},{"key":"b16-focus16292","series-title":"J Neurosurg","first-page":"1194","article-title":"Endoscopic endonasal surgery for craniopharyngiomas: surgical outcome in 64 patients","volume":"119","author":"Koutourousiou","year":"2013"},{"key":"b17-focus16292","series-title":"Neurosurgery","first-page":"614","article-title":"Endoscopic endonasal approach for resection of cranial base chordomas: outcomes and learning curve","volume":"71","author":"Koutourousiou","year":"2012"},{"key":"b18-focus16292","series-title":"Neurosurgery","first-page":"1205","article-title":"Endoscopic transsphenoidal pituitary surgery: evidence of an operative learning curve","volume":"67","author":"Leach","year":"2010"},{"key":"b19-focus16292","series-title":"Neurosurgery","first-page":"110","article-title":"Endoscopic, endonasal resection of craniopharyngiomas: analysis of outcome including extent of resection, cerebrospinal fluid leak, return to preoperative productivity, and body mass index","volume":"70","author":"Leng","year":"2012"},{"key":"b20-focus16292","series-title":"Surg Radiol Anat","first-page":"775","article-title":"Topographic variations of the optic chiasm and the pituitary stalk: a morphometric study based on midsagittal T2-weighted MR images","volume":"36","author":"Long","year":"2014"},{"key":"b21-focus16292","series-title":"Laryngoscope","first-page":"876","article-title":"Endoscopic repair of high-flow cranial base defects using a bilayer button","volume":"120","author":"Luginbuhl","year":"2010"},{"key":"b22-focus16292","series-title":"J Clin Neurosci","first-page":"348","article-title":"Subarachnoid hemorrhage and vasospasm following removal of craniopharyngioma","volume":"4","author":"Macdonald","year":"1997"},{"key":"b23-focus16292","series-title":"J Neurosurg","first-page":"1350","article-title":"Neurosurgical treatment of craniopharyngioma in adults and children: early and long-term results in a large case series","volume":"114","author":"Mortini","year":"2011"},{"issue":"6","key":"b24-focus16292","series-title":"Neurosurg Focus","first-page":"E10","article-title":"Comparison of endoscopic and microscopic removal of pituitary adenomas: single-surgeon experience and the learning curve","volume":"25","author":"O'Malley","year":"2008"},{"key":"b25-focus16292","series-title":"Acta Neurochir (Wien)","first-page":"2403","article-title":"Infundibulo-tuberal or not strictly intraventricular craniopharyngioma: evidence for a major topographical category","volume":"153","author":"Pascual","year":"2011"},{"key":"b26-focus16292","series-title":"J Neurosurg","first-page":"381","article-title":"Displacement of mammillary bodies by craniopharyngiomas involving the third ventricle: surgical-MRI correlation and use in topographical diagnosis","volume":"119","author":"Pascual","year":"2013"},{"key":"b27-focus16292","series-title":"J Neurosurg","first-page":"571","article-title":"Long-term quality of life after endonasal endoscopic resection of adult craniopharyngiomas","volume":"123","author":"Patel","year":"2015"},{"key":"b28-focus16292","series-title":"J Neurosci Rural Pract","first-page":"107","article-title":"Delayed cerebral vasospasm following surgery for craniopharyngioma","volume":"4","author":"Salunke","year":"2013"},{"key":"b29-focus16292","series-title":"Neurol Med Chir (Tokyo)","first-page":"666","article-title":"Symptomatic vessel narrowing caused by spontaneous rupture of craniopharyngioma cyst\u2014case report","volume":"38","author":"Shida","year":"1998"},{"key":"b30-focus16292","series-title":"Skull Base","first-page":"69","article-title":"Light at the end of the tunnel: the learning curve associated with endoscopic transsphenoidal skull base surgery","volume":"20","author":"Smith","year":"2010"},{"key":"b31-focus16292","series-title":"Laryngoscope","first-page":"699","article-title":"Acquisition of surgical skills for endonasal skull base surgery: a training program","volume":"117","author":"Snyderman","year":"2007"},{"key":"b32-focus16292","series-title":"Otolaryngol Clin North Am","first-page":"1223","article-title":"Training in neurorhinology: the impact of case volume on the learning 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