Endoscopic endonasal surgery for infradiaphragmatic craniopharyngiomas: the impact of diaphragma sellae resection

OBJECTIVE: Infradiaphragmatic craniopharyngiomas (ICs) are anatomically distinct lesions bounded by an elevated diaphragma sellae (DS). While endoscopic endonasal surgery (EES) has emerged as their primary treatment, achieving complete resection remains challenging due to frequent tumor-DS adhesions, potentially contributing to higher recurrence rates. Authors of this retrospective study evaluated the efficacy and safety of DS resection (DSR) during EES for IC. METHODS: The data for patients with ICs treated with EES between March 2011 and December 2024 were retrospectively reviewed. According to their intraoperative DSR status, patients were classified into the DSR group or non-DSR group. Comprehensive analyses were performed to compare demographics, clinical characteristics, and surgical and long-term outcomes between the resection groups, with additional comparison to contemporary published series. RESULTS: Forty-six patients with IC were included in the final cohort, with 29 in the DSR group and 17 in the non-DSR group. The DSR group tended to have larger tumor volumes (p = 0.050) and a significantly higher proportion had endocrine dysfunction (p = 0.022) and preoperative hypothalamic involvement (p = 0.002). Forty-three patients (93.5%) underwent complete tumor resection. There was no significant difference in the extent of resection (p = 0.628), endocrine outcomes, visual outcomes, and postoperative hypothalamic involvement (p = 0.258) between the 2 groups, whereas DSR increased the rate of pituitary stalk transection (p = 0.001) and operation times (p < 0.001). DSR did not significantly increase the risk of CSF leakage (p = 0.451), electrolyte imbalance (p = 0.108), or intracranial infections (p = 0.524). During a median 60.5 months of follow-up (IQR 27.8-90.3 months), the recurrence rate and hypothalamic syndrome rate were 4.3% and 6.5%, respectively, for the whole cohort, and they were not significantly different between the 2 resection groups. CONCLUSIONS: As the first dedicated analysis of DSR in the EES era, this study demonstrates that intentional DSR facilitates optimal tumor removal without substantially increasing complication risks. These findings support selective DSR use for ICs demonstrating significant DS adhesion, potentially improving long-term disease control while maintaining an acceptable safety profile.