Endoscopic Transsphenoidal Pituitary Surgery: Evidence of an Operative Learning Curve

Abstract BACKGROUND: The use of the fiberoptic endoscope is a recent innovation in pituitary surgery. OBJECTIVE: To investigate the evidence of an operative learning curve after the introduction of endoscopic transsphenoidal surgery in our unit. METHODS: The first 125 patients who underwent endoscopic transnasal transsphenoidal surgery for pituitary fossa lesions between 2005 and 2007 performed by 1 surgeon were studied. Changes in a number of parameters were assessed between 2 equal 15-month time periods: period 1 (53 patients) and period 2 (72 patients). RESULTS: There were 67 patients (54%) with nonfunctioning adenomas, 22 (18%) with acromegaly, and 10 (8%) with Cushing's disease. Between study periods 1 and 2, there was a decrease in the mean duration of surgery for nonfunctioning adenomas (from 120 minutes to 91 minutes; P < .01). This learning effect was not apparent for functioning adenomas, the surgery for which also took longer to perform. The proportion of patients with an improvement in their preoperative visual field deficits increased over the study period (from 80% to 93%; P < .05). There were nonsignificant trends toward improved endocrine remission rates for patients with Cushing's disease (from 50% to 83%), but operative complications, notably the rates of hypopituitarism, did not change. Overall length of hospital stay decreased between time periods 1 and 2 (from 7 to 4 days median; P < .01). CONCLUSION: The improvements in the duration of surgery and visual outcome noted after about 50 endoscopic procedures would favor the existence of an operative learning curve for these parameters. This further highlights the benefits of subspecialization in pituitary surgery.

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Management of Cushing's Disease After Failed Surgery - A Review

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s031716710012075x ◽

2011 ◽

Vol 38 (1) ◽

pp. 12-21 ◽

Cited By ~ 8

Author(s):

Nancy McLaughlin ◽

Amin B. Kassam ◽

Daniel M. Prevedello ◽

Daniel F. Kelly

Keyword(s):

Cushing’S Disease ◽

Stereotactic Radiotherapy ◽

Transsphenoidal Surgery ◽

Pituitary Surgery ◽

Cushing's Disease ◽

Close Collaboration ◽

Adjuvant Therapies ◽

Initial Surgery ◽

Transsphenoidal Adenomectomy ◽

Failed Surgery

Abstract:Selective transsphenoidal adenomectomy is generally recommended for initial treatment of Cushing's disease (CD) because it achieves a high (70-85%) rate of remission. However, if initial surgery is not successful, the approach to persistent or recurrent CD is more complex. Because residual or recurrent adenoma is typically found at the site of the original adenoma, repeat transsphenoidal surgery is recommended including selective adenomectomy, hemihypophysectomy or total hypophysectomy. If repeat pituitary surgery does not achieve remission, then possible adjuvant therapies include radiosurgery or stereotactic radiotherapy, bilateral adrenalectomy, and/or medical therapy. In all cases of persistent or recurrent CD, successful treatment requires close collaboration of endocrinologists, radiation oncologists and neurosurgeons.

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Repeat transsphenoidal surgery for Cushing's disease

Journal of Neurosurgery ◽

10.3171/jns.1989.71.4.0520 ◽

1989 ◽

Vol 71 (4) ◽

pp. 520-527 ◽

Cited By ~ 153

Author(s):

Robert B. Friedman ◽

Edward H. Oldfield ◽

Lynnette K. Nieman ◽

George P. Chrousos ◽

John L. Doppman ◽

...

Keyword(s):

Cushing’S Disease ◽

Transsphenoidal Surgery ◽

Ct Scanning ◽

Pituitary Surgery ◽

Cushing's Disease ◽

Repeat Surgery ◽

Content Type ◽

Preoperative Ct ◽

Pituitary Irradiation ◽

Fine Print

✓ Transsphenoidal resection of adrenocorticotrophic hormone (ACTH)-producing pituitary adenomas has the potential of curing most patients with Cushing's disease. However, transsphenoidal exploration of the pituitary is not always curative, and patients who have remission of hypercortisolism following surgery occasionally develop a recurrence. Whether repeat pituitary surgery should be performed for recurrent or persistent Cushing's disease has not been evaluated previously. To determine the efficacy of transsphenoidal surgery in recurrent or persistent Cushing's disease, we performed transsphenoidal surgery in 31 patients (22 women and nine men) who had previously undergone a transsphenoidal operation and two female patients who had had previous pituitary irradiation only. In 24 (73%) of the 33 patients, remission of hypercortisolism was achieved by surgery. Although preoperative computerized tomography (CT) scanning identified an adenoma in only three of the 33 patients, in 20 patients a discrete adenoma was identified at pituitary exploration. The incidence of remission of hypercortisolism was greatest if an adenoma was identified at surgery and the patient received selective adenomectomy (19, or 95% of 20 patients), if there was evidence at surgery or by preoperative CT scanning that the previous surgical exposure of the pituitary was incomplete (seven, or 78% of nine patients), if an adenoma was seen on preoperative CT scanning (three of three patients), or if the patient had had prior pituitary irradiation without surgery (two of two patients). In contrast, only five (42%) of 12 patients who received subtotal or total hypophysectomy had remission of hypercortisolism. Surgically induced hypopituitarism occurred in six (50%) of these 12 patients, but in only one (5%) of the 20 patients who underwent selective adenomectomy. Three (13%) of the 24 patients who were in remission from hypercortisolism following repeat surgery developed recurrent hypercortisolism 10 to 47 months postoperatively. Repeat transsphenoidal exploration of the pituitary and treatment limited to selective adenomectomy should be considered in patients with hypercortisolism despite previous pituitary treatment. If an adenoma is identified during surgery, the chance of remission of Cushing's disease is high and the risk of hypopituitarism is low; however, if no adenoma can be found and partial or complete hypophysectomy is performed, remission of hypercortisolism is less likely and the risk of hypopituitarism is about 50%.

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Delayed Remission after Transsphenoidal Surgery in Patients with Cushing’s Disease

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/jc.2009-1672 ◽

2010 ◽

Vol 95 (2) ◽

pp. 601-610 ◽

Cited By ~ 81

Author(s):

Elena Valassi ◽

Beverly M. K. Biller ◽

Brooke Swearingen ◽

Francesca Pecori Giraldi ◽

Marco Losa ◽

...

Keyword(s):

Cushing’S Disease ◽

Transsphenoidal Surgery ◽

Tertiary Care ◽

Case Series ◽

Expectant Management ◽

Pituitary Surgery ◽

Cushing's Disease ◽

Optimal Timing ◽

Retrospective Case

Abstract Background: Transsphenoidal surgery (TSS) is the treatment of choice for Cushing’s disease (CD). Postoperative hypercortisolemia mandates further therapy. Objective: The aim of the study was to characterize patients without immediate postoperative remission who have a delayed decrease to normal or low cortisol levels without further therapy. Design and Setting: A retrospective case series was conducted at three tertiary care centers. Patients and Intervention: We reviewed the records of 620 patients (512 females, 108 males; mean age, 38 ± 13 yr) who underwent transsphenoidal pituitary surgery for CD between 1982 and 2007. Results: Outcomes were classified into the following three groups based upon the postoperative pattern of cortisol testing: group IC (immediate control) included 437 of the 620 patients (70.5%) with hypocortisolism and/or cortisol normalization throughout the postoperative follow-up; group NC (no control) included 148 of 620 patients (23.9%) with persistent hypercortisolism; and group DC (delayed control) included 35 of 620 patients (5.6%) who had early elevated or normal UFC levels and developed a delayed and persistent cortisol decrease after an average of 38 ± 50 postoperative days. The total rate of recurrence was 13% at a median follow-up time of 66 months after TSS; the cumulative rate of recurrence at 4.5 yr was significantly higher in group DC vs. group IC (43 vs. 14%; P = 0.02). Conclusions: Hormonal assessment in the immediate postoperative period after TSS for CD may be misleading because delayed remission can occur in a subset of patients. Expectant management and retesting may spare some patients from unnecessary further treatment. Optimal timing to determine the need for further therapy after TSS remains to be determined.

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Persistent Cushing’s Disease after Transsphenoidal Surgery: Challenges and Solutions

Experimental and Clinical Endocrinology & Diabetes ◽

10.1055/a-1220-6056 ◽

2020 ◽

Author(s):

Adriana Albani ◽

Marily Theodoropoulou

Keyword(s):

Cushing’S Disease ◽

Transsphenoidal Surgery ◽

Tumor Resection ◽

Pituitary Surgery ◽

Primary Treatment ◽

Cushing's Disease ◽

Ectopic Acth ◽

Ectopic Acth Secretion ◽

Mortality And Morbidity ◽

Surgical Failure

AbstractTranssphenoidal surgery remains the primary treatment for Cushing’s disease (CD). However, despite the vast improvements in pituitary surgery, successful treatment of CD remains a great challenge. Although selective transsphenoidal removal of the pituitary tumor is a safe and effective procedure, the disease persists in around 22% of CD patients due to incomplete tumor resection. The persistence of hypercortisolism after pituitary surgery may also be the consequence of a misdiagnosis, as can occur in case of ectopic ACTH secretion or pseudo-Cushing. Considering the elevated mortality and morbidity characterizing the disease, a multidisciplinary approach is needed to minimize potential pitfalls occurring during the diagnosis, avoid surgical failure and provide the best care in those patients who have undergone unsuccessful surgery. In this review, we analyze the factors that could predict remission or persistence of CD after pituitary surgery and revise the therapeutic options in case of surgical failure.

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