Transcranial approach for pituitary adenomas – An evaluation of surgical approaches over two decades and factors influencing peri-operative morbidity

Background Pulmonary complications after cardiac surgery are very common and lead to an increased incidence of post-operative morbidity and mortality. Several factors, either modifiable or non-modifiable, may contribute to the associated unfavorable consequences related to pulmonary function. This study was aimed to investigate the degree of alteration and factors influencing pulmonary function (forced expiratory volume in one second (FEV1) and forced vital capacity), on third, fifth, and seventh post-operative days following cardiac surgery. Methods This study was executed in 71 patients who underwent on-pump cardiac surgery. Pulmonary function was assessed before surgery and on the third, fifth, and seventh post-operative days. Data including surgical details, information about risk factors, and assessment of pulmonary function were obtained. Results The FEV1 and forced vital capacity were significantly impaired on post-operative days 3, 5, and 7 compared to pre-operative values. The reduction in FEV1 was 41%, 29%, and 16% and in forced vital capacity was 42%, 29%, and 19% consecutively on post-operative days 3, 5, and 7. Multivariate analysis was done to detect the factors influencing post-operative FEV1 and forced vital capacity. Discussion This study observed a significant impairment in FEV1 and forced vital capacity, which did not completely recover by the seventh post-operative day. Different factors affecting post-operative FEV1 and forced vital capacity were pre-operative FEV1, age ≥60, less body surface area, lower pre-operative chest expansion at the axillary level, and having more duration of cardiopulmonary bypass during surgery. Presence of these factors enhances the chance of developing post-operative pulmonary complications.

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Estimating Risk of Pituitary Apoplexy after Resection of Giant Pituitary Adenomas

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1722993 ◽

2021 ◽

Author(s):

John T. Butterfield ◽

Takako Araki ◽

Daniel Guillaume ◽

Ramachandra Tummala ◽

Emiro Caicedo-Granados ◽

...

Keyword(s):

Pituitary Adenomas ◽

Pituitary Apoplexy ◽

Residual Tumor ◽

Extent Of Resection ◽

Morbidity And Mortality ◽

Surgical Approaches ◽

Subtotal Resection ◽

Advantages And Disadvantages ◽

Cranial Nerve Palsies ◽

Giant Pituitary Adenomas

Abstract Background Pituitary apoplexy after resection of giant pituitary adenomas is a rare but often cited morbidity associated with devastating outcomes. It presents as hemorrhage and/or infarction of residual tumor in the postoperative period. Because of its rarity, its incidence and consequences remain ill defined. Objective The aim of this study is to estimate the rate of postoperative pituitary apoplexy after resection of giant pituitary adenomas and assess the morbidity and mortality associated with apoplexy. Methods A systematic review of literature was performed to examine extent of resection in giant pituitary adenomas based on surgical approach, rate of postoperative apoplexy, morbidities, and mortality. Advantages and disadvantages of each approach were compared. Results Seventeen studies were included in quantitative analysis describing 1,031 cases of resection of giant pituitary adenomas. The overall rate of subtotal resection (<90%) for all surgical approaches combined was 35.6% (95% confidence interval: 28.0–43.1). Postoperative pituitary apoplexy developed in 5.65% (n = 19) of subtotal resections, often within 24 hours and with a mortality of 42.1% (n = 8). Resulting morbidities included visual deficits, altered consciousness, cranial nerve palsies, and convulsions. Conclusion Postoperative pituitary apoplexy is uncommon but is associated with high rates of morbidity and mortality in subtotal resection cases. These findings highlight the importance in achieving a maximal resection in a time sensitive fashion to mitigate the severe consequences of postoperative apoplexy.

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Transcranial approaches for pituitary adenomas: current indications and clinical and radiological outcomes

Egyptian Journal of Neurosurgery ◽

10.1186/s41984-021-00117-x ◽

2021 ◽

Vol 36 (1) ◽

Author(s):

Mohamed M. Salama ◽

Mohamed Reda Rady

Keyword(s):

Pituitary Adenomas ◽

Third Ventricle ◽

Tumor Resection ◽

Subtotal Resection ◽

Combined Approach ◽

Total Resection ◽

Third Nerve Palsy ◽

Clinical And Radiological Outcome ◽

Transcranial Approach ◽

Anterior Fossa

Abstract Background The indications of transcranial approaches for pituitary adenomas have declined in the last decades with the widespread performance of endoscopic transsphenoidal approaches. The aim of the study was to review the current indications of transcranial approaches for pituitary adenomas and to evaluate the clinical and radiological outcome following these approaches. Patients and methods This study included 16 patients with fresh, residual, or recurrent pituitary adenomas operated upon by transcranial approaches alone or in combination with transsphenoidal approaches. The indication to perform a transcranial approach was reviewed for each patient. Postoperative clinical outcome and the extent of tumor resection were assessed. Results The indications of transcranial approaches were significant parasellar and/or anterior fossa extensions in 6 patients, failed previous transsphenoidal surgery in 3 patients, giant adenoma extending into the third ventricle in 3 patients, dumbbell-shaped adenoma in 2 patients, and doubtful diagnosis in 2 patients. Two patients with invasive giant adenomas were operated upon by a combined approach. There was a single mortality. Permanent complications included visual loss in one patient, third nerve palsy in one patient, hypopituitarism in two patients, and permanent diabetes insipidus in two patients. Gross total resection was achieved in one patient, subtotal resection in seven patients, and partial resection in eight patients. Conclusion Transcranial approaches are still needed for some complex pituitary adenomas particularly giant tumors with significant lateral, anterior, or superior extensions, tumors with fibrous consistency particularly after failure of transsphenoidal approach, and dumbbell-shaped tumors with severe constriction at the diaphragm.

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Spontaneous Temporal Lobe Encephalocele Within the Sphenoid Sinus

Annals of African Surgery ◽

10.4314/aas.v18i1.12 ◽

2021 ◽

Vol 18 (1) ◽

pp. 63-66

Author(s):

Mohammed Dhaha ◽

Abdelhafidh Sliman ◽

Nadhir Karmeni ◽

Sawsen Dhambri ◽

Jalel Kallel

Keyword(s):

Sphenoid Sinus ◽

Lateral Wall ◽

Middle Cranial Fossa ◽

Clinical Aspect ◽

Csf Leak ◽

Surgical Approaches ◽

Skull Defect ◽

Lethal Complications ◽

Transcranial Approach ◽

Cranial Fossa

Encephaloceles are herniation of cranial content arising from a skull defect. Encephaloceles of the lateral wall of the sphenoid sinus (ELWSS) are uncommon events. In most cases, these cranial hernias are secondary to trauma and craniofacial surgery. Spontaneous forms are evenrarer and not well understood. The most adopted hypothesis is a persisting Sternberg’s canal, an embryonic remnant connecting the middle cranial fossa and the nasopharynx. ELWSS are usually revealed by cerebrospinal fluid (CSF) leak. Diagnosis of this disease necessitates quick management due to the potential of lethal complications such as meningitis. We report the case of a spontaneous ELWSS in a 53-year-old woman revealed by CSF leak which was successfully managed with a conventional transcranial approach. We focus on the clinical aspect and pathogenesis of the disease, and discuss the main possible surgical approaches. Keywords: Spontaneous encephalocele, Sphenoid sinus, CSF leak, Transcranial approach

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Transcranial versus Endoscopic Transsphenoidal Approaches in Management of Recurrent Giant Pituitary Adenomas

Open Access Macedonian Journal of Medical Sciences ◽

10.3889/oamjms.2020.4213 ◽

2020 ◽

Vol 8 (B) ◽

pp. 273-280

Author(s):

Mohamed Ismail ◽

Omar Abdel Aleem Abdel Moneim Ragab ◽

Mohamed M. Salama ◽

Basim M. Ayoub ◽

Wael Elmahdy

Keyword(s):

Clinical Outcome ◽

Pituitary Adenomas ◽

Tumor Resection ◽

Transsphenoidal Approach ◽

Subtotal Resection ◽

Visual Improvement ◽

Group A ◽

Transcranial Approach ◽

Giant Pituitary Adenomas ◽

Group B

AIM: The aim of this study was to compare the transcranial and the endoscopic transsphenoidal approaches for patients with recurrent giant pituitary adenomas as regards the extent of tumor resection and the clinical outcome. METHODS: The study included 21 patients with recurrent giant pituitary adenomas divided into two groups; Group A included nine patients operated on by transcranial approaches and Group B included 12 patients operated on by the endoscopic transsphenoidal approach. Both groups were compared as regards the extent of tumor resection and the post-operative clinical outcome, particularly the visual and endocrinological outcomes, in addition to morbidity and mortality. RESULTS: There was a higher incidence of total and near-total resection in Group B (41.7%) and a higher incidence of subtotal resection in Group A (55.6%). The incidence of visual improvement was higher in Group B (55.6%) than in Group A (28.6%). Post-operative biochemical remission was achieved in 100% of Group B patients and in 50% of Group A patients with functioning adenomas. The incidence of post-operative complications was higher in Group A (77.8%) than in Group B (50%). CONCLUSION: The endoscopic transsphenoidal approach for recurrent giant pituitary adenomas is associated with a higher extent of tumor resection, better rates of visual improvement and endocrinological remission, and lower incidence of complications. The transcranial approach should be reserved for some adenomas with marked lateral or anterior extensions, fibrous tumors, and after the failure of the endoscopic transsphenoidal approach.

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Fronto - temporal approach in sellar and parasellar tumors

Romanian Neurosurgery ◽

10.2478/v10282-012-0024-z ◽

2013 ◽

Vol 20 (1) ◽

pp. 80-91 ◽

Cited By ~ 1

Author(s):

Bianca Pintea ◽

Andreea Mogyoros ◽

Zorinela Andrasoni ◽

I.St. Florian

Keyword(s):

Pituitary Adenomas ◽

Tumor Resection ◽

Cranial Base ◽

Motor Deficit ◽

Subtotal Resection ◽

Shortest Distance ◽

Surgeon Experience ◽

Csf Leakage ◽

Transcranial Approach ◽

Third Cranial Nerve Palsy

Abstract Introduction: The fronto-temporal approach represent the shortest distance to the ipsilateral optic nerve and carotid artery, and allow the direct verification of the optical nerves, the carotid arteries, the pituitary stalk, the tumor and its relationship with the suprasellar structures. Objective: The purpose of this study is to advocate an available cranial base technique for removing these tumors and to delineate the technique’s advantages that aid in achieving an improved extent of tumor resection and enhancing the patients’ overall outcome. Materials and methods: We present a retrospective study of a single surgeon experience on 355 consecutive cases with sellar and parasellar tumors admitted and operated by transcranial approaches in our department between January 2000 and December 2012. Results: Tumors in the sellar region represent 11, 8% of all tumors operated in our department. The most common type of tumor was pituitary adenomas, 165 of cases, followed by sellar and parasellar meningiomas, 128 of cases. Craniopharyngioma represent 12% of cases encountered in this region. All our cases underwent surgery by transcranial approach, unilateral frontotemporal in 252 of cases (71%). In pituitary adenomas total and near total resection was achieved in 100% of patients operated by transcranial approaches. For resection of craniopharyngiomas we have frequently chosen the extended fronto-temporal approach. The most common surgical related complications were: postoperative hematomas 9 of cases; wound infections, 6 of cases and CSF leakage, 12 of cases; transient visual alteration in 12 cases, transient third cranial nerve palsy in 6 of cases, transient motor deficit in 7 cases, hydrocephalus, 6 cases; transient diabetes insipidus in the large majority of pituitary adenomas and craniopharingiomas. Only 4 cases of pituitary adenomas and 6 of craniopharingiomas recurred after subtotal resection, requiring re-intervention. The mortality rate in our study was 2%. Conclusions: Our experience demonstrated that the management of the large suprasellar tumors via fronto-temporal approach remains the main route for these tumors with significant extrasellar extension, fibrous tumors, cases with unrelated pathology that might complicate a transsphenoidal approach and recurrent tumors after previous transsphenoidal surgery. In our opinion there is no need for larger osteotomies or extensive drilling of cranial base. “Instead of bone, remove the tumor; it's easier even for the patient”.

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Giant Frontoethmoid Mucocele with Intracranial Extension: Case Report

Ear Nose & Throat Journal ◽

10.1177/014556130308200115 ◽

2003 ◽

Vol 82 (1) ◽

pp. 50-52 ◽

Cited By ~ 10

Author(s):

Harun Cansiz ◽

Murat Yener ◽

M. Güven Güvenç ◽

Bülent Canbaz

Keyword(s):

Case Report ◽

Surgical Approaches ◽

Intracranial Extension ◽

Combined Approach ◽

Advantages And Disadvantages ◽

Left Orbit ◽

Transcranial Approach

We report the case of a 31-year-old woman who came to us with a giant frontoethmoid mass that had extended into the intracranial region and invaded the left orbit. We removed the lesion in its entirety via a combined intranasal and transcranial approach. We discuss the advantages and disadvantages of different surgical approaches, and we explain why we recommend a combined approach for the type of giant lesion that we encountered.

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Predictive factors for delayed hyponatremia after transsphenoidal surgery in patients with pituitary adenomas

Endocrine Connections ◽

10.1530/ec-21-0497 ◽

2021 ◽

Author(s):

Kunzhe Lin ◽

Lingling Lu ◽

Zhijie Pei ◽

Shuwen Mu ◽

Shaokuan Huang ◽

...

Keyword(s):

Regression Analysis ◽

Pituitary Adenoma ◽

Pituitary Adenomas ◽

Odds Ratio ◽

Transsphenoidal Surgery ◽

Post Surgery ◽

Factors Influencing ◽

Significant Difference ◽

Pituitary Thyroid Axis ◽

Thyroid Axis

Objective: To evaluate the incidence and duration of delayed hyponatremia and to assess the factors influencing the development of delayed hyponatremia after transsphenoidal surgery (TSS) in pituitary adenomas. Methods: We retrospectively analyzed the clinical data of patients with pituitary adenoma who underwent TSS. Univariable and multivariable statistics were carried out to identify factors independently associated with the occurrence of delayed hyponatremia. Results: Of the 285 patients with pituitary adenoma who underwent microscopic TSS, 44 (15.4%) developed postoperative delayed hyponatremia and 241 (84.6%) did not. The onset of delayed hyponatremia occurred an average of 5.84 days post-surgery and persisted for an average of 5.36 days. Logistic regression analysis showed the highest risk of delayed hyponatremia in patients with significant change in tumor cavity height (odds ratio [OR], 1.158; 95% confidence interval [CI], 1.062, 1.262; P = 0.001), preoperative hypothalamus-pituitary-thyroid axis hypofunction(OR, 3.112; 95% CI, 1.481, 6.539; P = 0.003), and significant difference in blood sodium levels before and 2 days after TSS(OR, 1.101; 95% CI, 1.005, 1.206; P = 0.039). Conclusions: Preoperative hypothyroidism, difference in blood sodium levels before and 2 days after TSS, and the change in tumor cavity height after TSS played important roles in predicting postoperative delayed hyponatremia onset in patients with pituitary adenomas.

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Clinical and pathogenetic aspects of the complications after surgical treatment of hepatic echinococcosis

Annaly khirurgicheskoy gepatologii = Annals of HPB surgery ◽

10.16931/1995-5464.2021-4-51-60 ◽

2021 ◽

Vol 26 (4) ◽

pp. 51-60

Author(s):

F. G. Nazyrov ◽

A. Kh. Babadjanov ◽

F. R. Yakubov

Keyword(s):

Surgical Treatment ◽

Biliary Fistula ◽

Surgical Approaches ◽

Fluid Accumulation ◽

Technical Aspects ◽

Stage Of Development ◽

Factors Influencing ◽

The Us ◽

Residual Cavity ◽

Hepatic Echinococcosis

Aim. To identify factors influencing effectiveness of surgical approaches in hepatic echinococcosis, depending on the location, size and stage of development of the cyst.Material and methods. From 2015 to 2017 the experience of surgical treatment of 98 patients with liver echinococcosis who underwent percutaneous (PAIR – 23 and PEVAC – 29 patients) and laparoscopic (46 patients) interventions was considered.Results. After the PAIR, a complication was noted in 1 (16.7%) case of isolated use with a CE3 cyst. Various complications were noted in 3 (60%) cases with a cyst puncture of more than 4 cm, and in 2 of them with CE2 and CE3. The average time for evacuating the cysts contents when performing the PEVAC technique was 5 days. Hemorrhagic fluid in drainage was noted in 6.9% of cases, biliary fistula – in 13.8%. Accumulation of fluid and suppuration in the residual cavity were identified in 34.5%. Taking into account the size of the cysts, the complication rate after PEVAC was 9.1% for cysts ≤6 cm vs 50% for cysts >6 cm. Various difficulties with manipulations during laparoscopic echinococcectomy were noted more often with CE2–4. So, difficulties with aspiration or removal of cyst contents more often arose with CE4. The incidence of complications after drainage removal was 17.9%, of which fluid accumulation was in 14.3% and residual cavity suppuration in 3.6% of cases.Conclusion. The US criteria, main indications and tactical and technical aspects for performing PAIR and PEVAC methods, as well as for performing laparoscopic echinococcectomy, and criteria for assessing the required volume of percytectomy for an adequate abdominalization of fibrous capsule have been clarified.

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