Keywords
reoperation - glioma - dura substitute - surgical complication
Palavras-chave
reoperação - glioma - substituto dural - complicação cirúrgica
Introduction
Reoperations for recurrent low-grade gliomas (LGG) should be the standard of care.[1] Concerning high-grade gliomas (HGG), reoperation remains controversial, given the limited life expectancy and the aggressive/recurrent nature of these tumors, but there is crescent evidence of benefits with this treatment strategy.[2] Recent studies have shown that a second operation improves survival in patients with glioblastoma multiforme (GBM), with surgical complication rates similar to single-surgery patients.[3]
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Reopening the dura mater and releasing it from the cerebral cortex in a glioma reoperation can be difficult and increase the surgical time; besides, it may cause cortical injury. Due to the important role of reoperation in glioma patients, here we discuss our experience with inert expanded polytetrafluoroethylene (ePTFE) dura substitute in glioma surgeries to minimize the difficulties of reoperation.
Discussion
Low-grade glioma is a chronic disease of the brain, and should be treated with a personalized and long-term multistage therapeutic approach.[5] The importance of surgery and maximal extent of resection (EOR) is well-established in primary LGG management. There is increasing evidence to support maximal EOR for treating recurrent LGG as well, as it may improve progression free survival (PFS) after recurrence and overall survival (OS).[1] Reoperations of the patients with recurrent LGG have similar risk of neurological complications and sequelae when compared with the initial surgery.[6]
Regarding HGG, Lacroix et al have shown that the EOR improves survival.[7] Predictive factors of good prognosis after a second surgery include young age, high Karnofsky performance status (KPS) score, gross total resection, and longer time interval between operations.[8]
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[11] D'Amico et al showed recently a greater total survival in patients > 65 years old submitted to a second intervention than those submitted to a single surgery.[3] Moreover, systemic, local, or neurological complication rates were not significantly different between the single-surgery group and the reoperation group in that study.[3] Chen et al showed similar results and concluded that, in a select group of patients with recurrent grade IV glioblastomas, repeated craniotomy had a significant survival benefit without severely compromising functionality.[12]
The ePTFE dura substitute is indicated for use as prosthesis for the repair of the dura mater during neurosurgery. It has a porosity of < 1 µ, which provides excellent conformability and handling while minimizing fibrous tissue ingrowth. This dura substitute serves as an inert, watertight, full thickness dural graft that minimizes tissue attachment between the neural structures and other tissues.[13] Another advantage is that it becomes translucent after 3 to 4 months in vivo, which allows visualization of the underlying neural structures in reoperations.[14]
Besides avoiding tissue attachment and fibrosis in reoperation, we did not observe cerebrospinal fluid fistula or meningitis in patients with ePTFE dura substitute. This membrane has already been shown to be a safe and effective synthetic dura, without the complications observed with other synthetic and biological materials.[15]
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