Endoscopic Endonasal Transsphenoidal Approach to Pituitary Adenoma: A Multi-disciplinary Approach

Background: The excellent visualization and minimally invasive approach employed in endoscopic endonasal procedures has now revolutionized the pituitary surgery, replacing the transnasal microscopic technique worldwide. However, it involves major shift in hand-eye co-ordination from static 3 dimensional images of microscope to 2 dimensional endoscopic images hence demands training and inter-disciplinary approach. Here we present our experiences in learning and developing a safe endonasal transsphenoidal endoscopic approach to resect pituitary adenomas.Methods: This prospective study was jointly conducted in the departments of ENT and Neurologicals surgery Kathmandu Medical College, Nepal, from September 2014 to August 2016. The endoscopic approach to the sphenoid sinus was performed by an Otolaryngologist and ablative surgery by Neurosurgeon. The ease of procedure, intra operative challenges, surgical cure, post-operative cerebro spinal fluid (CSF) leaks and postoperative complaints were analyzed.Results: Sixteen consecutive patients with pituitary adenoma (macro adenoma=13, micro adenoma =3) were analyzed. There were three intraoperative CSF leak, managed successfully. Two patients developed transient diabetes insipidus and surgical cure rate was 90%. No case had to be switched over to traditional microscopic route due to technical failure. There was no mortality.Conclusions: The endoscopic endonasal transsphenoidal approach to pituitary tumors is a safe and minimally invasive procedure, which can be employed safely in any of our centers in Nepal, equipped with endoscopic sinus surgery and endoscopically trained ENT and Neurosurgeons. A multi disciplinary approach provides good access, greater tumor excision and excellent postoperative follow up.Keywords: .

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Extended Endonasal Solo Endoscopic Approach for the Resection of Craniopharyngiomas

Bangladesh Journal of Neuroscience ◽

10.3329/bjn.v29i2.56179 ◽

2013 ◽

Vol 29 (2) ◽

pp. 108-114

Author(s):

Samsul Alam ◽

A N Wakil Uddin ◽

Anis Ahmed ◽

Moshiur Rahman Mojumder ◽

Kamrunnessa Hossain ◽

...

Keyword(s):

Visual Acuity ◽

Pituitary Adenoma ◽

Diabetes Insipidus ◽

Bacterial Infections ◽

Third Ventricle ◽

Endoscopic Approach ◽

Transsphenoidal Approach ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Extended Transsphenoidal Approach

Background: Extended endonasal solo endoscopic approach for the non-pituitary lesions of the sellar and suprasellar regions are not new in the field of neurosurgery. Following endoscopic surgical approach of the pituitary adenoma, endoscopic neurosurgeon is eager to develop the skill for non-pituitary sellar & suprasellar lesions. Common sellar & suprasellar lesions are pituitary adenoma, craniopharyngioma, tuberculumselle meningioma and suprasellar germinoma. Objective: Traditional transsphenoidal approach gives exposure to the pituitary fossa, whereas extended approach provides exposure to the optic nerve, chiasm, acom complex and basal frontal lobe ,mammillary body, mid brain and laterally to the cavernous sinuses. Material & method: From November 2007 to March 2012, 12 cases of done by extended endonasal solo endoscopic approach among 12 cases of craniopharyngiomas. Patient’s history, clinical findings, pre-operative and post-operative visual acuity, visual field and radiological data were collected and analyzed. All patients underwent solo endoscopic extended transsphenoidal approach with or without nasoseptal flap technique for closure. Most of the patients were given lumbar drain as a treatment for CSF leak. Result: All patients were of age group of 10 to 60 years. Male were 8 (66.67%), female were 4 (33.33%) in number. Gross total removals were done in 7 cases out of 12 (58.33%) craniopharyngiomas and subtotal removal done in 5 (41.67%) cases. Visual acuity and field of vision were improved in all cases of craniopharyngiomas. One case (8.33%) of craniopharyngioma had prolong period of unconsciousness probably from hypothalamic disturbance. CSF leak developed in 2 (16.67%) cases. Patients with craniopharyngioma were required thyroxin and cortisol for replacement. Permanent diabetes insipidus developed in 5 cases (41.67%). Three patients required permanent CSF diversion via a ventriculoperitoneal shunt after documentation of postoperative HCP. There was one case of chemical meningitis, and two cases confirmed bacterial infections. Craniopharyngioma can be successfully resected via a purely endoscopic, endonasal approach. Craniopharyngioma have a higher rate of perioperative hydrocephalus and postoperative CSF leak compared with other tumor types in the same area. Conclusion: Extended transsphenoidal approach is an excellent alternative of skull base approach for the removal of most of the craniopharyngioma.The endoscopic endonasal route provides a good exposure, especially of the sub-chiasmatic and retro-chiasmatic areas, as well as of the stalk– infundibulum axis and the third ventricle chamber. It gives better visualization, improved postoperative visual outcome for less manipulation and low complication then craniotomy. However CSF leak and diabetes insipidus is common known complications which have to be manage promptly and appropriately. Bangladesh Journal of Neuroscience 2013; Vol. 29 (2) : 108-114

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Pediatric Pituitary Adenoma: Case Series, Review of the Literature, and a Skull Base Treatment Paradigm

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1625984 ◽

2018 ◽

Vol 79 (01) ◽

pp. 091-114 ◽

Cited By ~ 19

Author(s):

Avital Perry ◽

Christopher Graffeo ◽

Christopher Marcellino ◽

Bruce Pollock ◽

Nicholas Wetjen ◽

...

Keyword(s):

Systematic Review ◽

Pituitary Adenoma ◽

Skull Base ◽

Pituitary Adenomas ◽

Pediatric Population ◽

Csf Leak ◽

Persistent Disease ◽

Treatment Paradigm ◽

Surgical Cure

Background Pediatric pituitary adenoma is a rare skull base neoplasm, accounting for 3% of all intracranial neoplasms in children and 5% of pituitary adenomas. Compared with pituitary tumors in adults, secreting tumors predominate and longer disease trajectories are expected due to the patient age resulting in a natural history and treatment paradigm that is complex and controversial. Objectives The aims of this study were to describe a large, single-institution series of pediatric pituitary adenomas with extensive long-term follow-up and to conduct a systematic review examining outcomes after pituitary adenoma surgery in the pediatric population. Methods The study cohort was compiled by searching institutional pathology and operative reports using diagnosis and site codes for pituitary and sellar pathology, from 1956 to 2016. Systematic review of the English language literature since 1970 was conducted using PubMed, MEDLINE, Embase, and Google Scholar. Results Thirty-nine surgically managed pediatric pituitary adenomas were identified, including 15 prolactinomas, 14 corticotrophs, 7 somatotrophs, and 4 non-secreting adenomas. All patients underwent transsphenoidal resection (TSR) as the initial surgical treatment. Surgical cure was achieved in 18 (46%); 21 experienced recurrent/persistent disease, with secondary treatments including repeat surgery in 10, radiation in 14, adjuvant pharmacotherapy in 11, and bilateral adrenalectomy in 3. At the last follow-up (median 87 months, range 3–581), nine remained with recurrent/persistent disease (23%).Thirty-seven publications reporting surgical series of pediatric pituitary adenomas were included, containing 1,284 patients. Adrenocorticotropic hormone (ACTH)-secreting tumors were most prevalent (43%), followed by prolactin (PRL)-secreting (37%), growth hormone (GH)-secreting (12%), and nonsecreting (7%). Surgical cure was reported in 65%. Complications included pituitary insufficiency (23%), permanent visual dysfunction (6%), chronic diabetes insipidus (DI) (3%), and postoperative cerebrospinal fluid (CSF) leak (4%). Mean follow-up was 63 months (range 0–240), with recurrent/persistent disease reported in 18% at the time of last follow-up. Conclusion Pediatric pituitary adenomas are diverse and challenging tumors with complexities far beyond those encountered in the management of routine adult pituitary disease, including nuanced decision-making, a technically demanding operative environment, high propensity for recurrence, and the potentially serious consequences of hypopituitarism with respect to fertility and growth potential in a pediatric population. Optimal treatment requires a high degree of individualization, and patients are most likely to benefit from consolidated, multidisciplinary care in highly experienced centers.

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Endoscopic Transsphenoidal, Transclival Resection of an Enterogenous Cyst Located Ventral to the Brainstem: Case Report

Operative Neurosurgery ◽

10.1227/neu.0b013e3181fa24f4 ◽

2010 ◽

Vol 67 (suppl_2) ◽

pp. onsE522-onsE526

Author(s):

William S. Cobb ◽

Gregor Makosch ◽

Vijay K. Anand ◽

Theodore H. Schwartz

Keyword(s):

Minimally Invasive ◽

Posterior Fossa ◽

Cranial Nerves ◽

Transsphenoidal Approach ◽

Direct Access ◽

Invasive Technique ◽

Enterogenous Cyst ◽

Gadolinium Contrast ◽

Endoscopic Endonasal ◽

Prepontine Cistern

ABSTRACT BACKGROUND AND IMPORTANCE: Enterogenous cysts are rare tumors found most commonly in the spine, but they have also been reported intracranially. Cases of enterogenous cysts located within the posterior fossa have traditionally been resected via difficult craniotomies that require prolonged retraction and risk injury to cranial nerves. We describe a method for resection of an enterogenous cyst located anterior to the brainstem via the endoscopic transsphenoidal approach. CLINICAL PRESENTATION: A 37-year-old man was found to have a 2-cm mass anterior to the brainstem during routine screening after a trauma. The mass was located within the prepontine cistern, enhanced with gadolinium contrast, and showed no restrictive diffusion. This lesion was most consistent with an enterogenous cyst. A minimally invasive endoscopic endonasal transsphenoidal transclival approach was performed for gross total resection of the tumor. CONCLUSION: We discuss the endoscopic transsphenoidal approach used for the resection of an enterogenous cyst in the posterior fossa anterior to the brainstem. The transsphenoidal approach provides direct access to lesions in this location using a minimally invasive technique while avoiding excessive brain retraction or injury to cranial nerves. In addition, we provide an updated review of the literature for enterogenous cysts located within the posterior fossa.

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Extended Endoscopic Approach for Resection of Craniopharyngiomas

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0037-1620244 ◽

2018 ◽

Vol 79 (S 02) ◽

pp. S201-S202 ◽

Cited By ~ 1

Author(s):

João Almeida ◽

Suganth Suppiah ◽

Claire Karekezi ◽

Miguel Marigil-Sanchez ◽

Jay Wong ◽

...

Keyword(s):

Surgical Technique ◽

Endoscopic Resection ◽

Cystic Lesion ◽

Endoscopic Approach ◽

Csf Leak ◽

Cystic Lesions ◽

Endoscopic Endonasal Surgery ◽

Endonasal Surgery ◽

Endoscopic Endonasal ◽

Extended Endoscopic Approach

Objectives Extended endoscopic approaches are useful for resection of selected craniopharyngiomas. Midline, extraventricular, and predominantly cystic lesions are good candidates for endoscopic resection. In this video, we demonstrate the endoscopic endonasal resection of a large suprasellar craniopharyngioma and discuss the nuances of the surgical technique. Design/Setting Surgical video of an extended endoscopic approach for resection of a suprasellar craniopharyngioma. Results We report the case of a 56-year-old woman who presented with bitemporal hemianopsia and visual acuity deterioration secondary to a large suprasellar solid–cystic lesion. The patient underwent an extended endoscopic transtuberculum approach for resection of the lesion, which was diagnosed as a papillary craniopharyngioma. This video discusses the anatomy and surgical technique applied for endoscopic resection of such lesions. Conclusion Endoscopic endonasal surgery is a useful technique for management of craniopharyngiomas. It is associated with good clinical outcomes in selected cases. Complications, such as postoperative CSF leak, may occur and should be carefully managed.The link to the video can be found at: https://youtu.be/EneOCiQE7yo.

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Universal Sellar Anatomical Reconstruction Using the Sellar Floor Flap after Endoscopic Pituitary Adenoma Surgery

Otolaryngology ◽

10.1177/0194599818756861 ◽

2018 ◽

Vol 158 (4) ◽

pp. 774-776 ◽

Cited By ~ 2

Author(s):

Zixiang Cong ◽

Kaidong Liu ◽

Guodao Wen ◽

Liang Qiao ◽

Handong Wang ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Pituitary Adenoma ◽

Csf Leak ◽

Anatomical Reconstruction ◽

Endoscopic Endonasal ◽

Reconstructive Technique ◽

Sellar Reconstruction ◽

Sellar Floor ◽

Csf Leaks

Postoperative cerebrospinal fluid (CSF) leaks still occur in patients without intraoperative CSF leaks after endoscopic endonasal pituitary adenoma surgery. We propose a reconstructive technique, the sellar floor flap (SFF), for universal sellar anatomical reconstruction. A total of 113 patients without intraoperative CSF leaks after endoscopic endonasal pituitary adenoma surgery from July 2013 to June 2016 were reviewed: 43 underwent sellar reconstruction with the SFF (the SFF group) and 70 underwent sellar packing only (the nonreconstruction group). No case of postoperative CSF leak was reported in the SFF group, whereas 7 cases were reported in the nonreconstruction group ( P < .05). The SFF is suitable for universal reconstruction after endoscopic endonasal pituitary adenoma surgery and may decrease postoperative CSF leak.

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Predictive Factors, 30-Day Clinical Outcomes, and Costs Associated with Cerebrospinal Fluid Leak in Pituitary Adenoma Resection

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1679896 ◽

2019 ◽

Vol 81 (01) ◽

pp. 043-055 ◽

Cited By ~ 1

Author(s):

Adish Parikh ◽

Arjun Adapa ◽

Stephen E. Sullivan ◽

Erin L. McKean

Keyword(s):

Cerebrospinal Fluid ◽

Multivariate Analysis ◽

Pituitary Adenoma ◽

Demographic Data ◽

Cerebrospinal Fluid Leak ◽

Hospital Charges ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Financial Variables ◽

Clinical Complications

AbstractCerebrospinal fluid (CSF) leak is a complication of endoscopic endonasal pituitary adenoma resection. Previous studies examining complications of pituitary adenoma resection have not examined associations of an exhaustive list of clinical and financial variables with CSF leak. We designed a retrospective analysis of 334 consecutive patients that underwent endoscopic endonasal pituitary adenoma resection at a single institution over 5 years, analyzing associations between CSF leak and demographic data, operative data, comorbidities, clinical complications and outcomes, costs, charges, and payments. Of the 20 preoperative variables studied, none were positively associated with CSF leak in between-groups comparison, although multivariate analysis revealed an association with a history of radiation to the skull base (odds ratio [OR], 8.67; 95% confidence interval [CI], 0.94–57.03; p < 0.05). CSF leak was associated with a significantly higher rate of postoperative diabetes insipidus (Δ = 33.4%, p = 0.040) and increased length of stay after operation in between-groups comparison. Multivariate analysis on postoperative variables revealed significant associations between CSF leak and intracerebral hemorrhage (OR, 17.44; 95% CI, 0.65–275.3; p < 0.05) and postoperative intracranial infection (OR, 28.73; 95% CI, 2.04–438.7; p < 0.05). Also, CSF leak was associated with significantly higher costs (Δ = $15,643, p < 0.05) and hospital charges (Δ = $46,026, p < 0.05). Operating room time, room and board, and supplies and implants were the strongest cost drivers. This study highlights the difficulty of utilizing preoperative variables to predict CSF leak, the clinical complications and outcomes of leak, and the financial subcategories that drive the costs, charges, and payments associated with this complication.

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Endoscopic endonasal resection of midline cranial base tumors

JBNC - JORNAL BRASILEIRO DE NEUROCIRURGIA ◽

10.22290/jbnc.v19i2.1521 ◽

2018 ◽

Vol 19 (2) ◽

pp. 7-17

Author(s):

Enrico De Divitiis ◽

Felice Esposito ◽

Paolo Cappabianca ◽

Luigi M. Cavallo ◽

Oreste De Divitiis ◽

...

Keyword(s):

Skull Base ◽

Cranial Base ◽

Transsphenoidal Approach ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Visual Deficits ◽

Extended Transsphenoidal Approach ◽

Anterior Cranial Base ◽

Subtotal Removal

Objective: The advent of the endoscope in transsphenoidalsurgery has permitted to expand the indications of such approach also for the treatment of on tumors located in supra, para, retro and infrasellar regions, enabling the neurosurgeon to work under direct visual control in a minimally invasive way. Since 2004 we have started to use the extended endonasal transsphenoidal approach for a variety of lesions involving the midline skull base and, in particular, the suprasellar area, the cavernous sinus and the retroclival prepontine region. Methods: Over a 36-month period, sixty-four procedures have been performed. The series consisted of 29 males and 35 females, aged from 24 to 80 years (median 49.8 years). The mean follow-up was of 18 months (ranging from 3 to 36 months). Among the patients with midline lesions, who were 90.6 % of the total, seven patients had a pituitary adenoma, sixteen patients were affected by a craniopharyngioma, six patients had a suprasellar Rathke’s cleft cyst, seven subjects had a tuberculum sellae meningioma, four had an olfactorygroove meningioma, and six a clival tumor. Other lesions ofthe midline skull base were, 1 chiasmatic astrocytoma, 1 neuroendocrine tumor, 4 post-traumatic cerebro-spinal fluid rhinorrhea, and one optic nerve glioma. Three other patients had anterior cranial base meningoencephaloceles. Results: Overall, gross total removal of the lesion was achieved in 30/49 tumoral lesions (61.2%); subtotal removal was achieved in 12/49 cases (24.5%). The three cases of meningoencephaloceles were all successfully treated. Among the patients with preoperative visual deficits, most of them fully recovered or improved and only two worsened in one eye. Major complications consisted in 2 deaths (one not directly related with the surgical procedure), 6 postoperative CSF leak (one complicated with bacterial meningitis), one ICA injury, and 6 cases of permanent diabetes insipidus.Conclusion: The extended transsphenoidal approach tothe supra and parasellar lesions seems Endoscopy; Transsphenoidal surgery; Extended approach; Parasellar; Tumors; Anterior skull base. A promising minimally invasivetechnique for the removal of lesions affecting these areas,once thought to be suitable only of the transcranial routes.Concerning the lesion removal and the recurrence rate compared with the transcranial routes, it is too early to pose a definitive word, since the follow-up is still too short.

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Risk factors for postoperative intracranial infections in patients with pituitary adenoma after endoscopic endonasal transsphenoidal surgery: pneumocephalus deserves further study

Neurosurgical FOCUS ◽

10.3171/2019.5.focus19269 ◽

2019 ◽

Vol 47 (2) ◽

pp. E5 ◽

Cited By ~ 2

Author(s):

Kang Guo ◽

Lijun Heng ◽

Haihong Zhang ◽

Lei Ma ◽

Hui Zhang ◽

...

Keyword(s):

Risk Factors ◽

Pituitary Adenoma ◽

Pituitary Adenomas ◽

Transsphenoidal Surgery ◽

Bubble Diameter ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Cns Infections ◽

Endoscopic Endonasal Transsphenoidal Surgery ◽

Intracranial Infections

OBJECTIVEThe authors sought to identify the relevance between pneumocephalus and postoperative intracranial infections, as well as bacteriological characteristics and risk factors for intracranial infections, in patients with pituitary adenomas after endoscopic endonasal transsphenoidal surgery.METHODSIn total, data from 251 consecutive patients with pituitary adenomas who underwent pure endoscopic endonasal transsphenoidal surgeries from 2014 to 2018 were reviewed for preoperative comorbidities, intraoperative techniques, and postoperative care.RESULTSThis retrospective study found 18 cases of postoperative pneumocephalus (7.17%), 9 CNS infections (3.59%), and 12 CSF leaks (4.78%). Of the patients with pneumocephalus, 5 (27.8%) had CNS infections. In patients with CNS infections, the culture results were positive in 7 cases and negative in 2 cases. The statistical analysis suggested that pneumocephalus (maximum bubble diameter of ≥ 1 cm), diaphragmatic defects (intraoperative CSF leak, Kelly grade ≥ 1), and a postoperative CSF leak are risk factors for postoperative CNS infections.CONCLUSIONSIn pituitary adenoma patients who underwent pure endoscopic endonasal transsphenoidal surgeries, intraoperative saddle reconstruction has a crucial role for patients with postoperative intracranial infections. Additionally, postoperative pneumocephalus plays an important role in predicting intracranial infections that must not be neglected. Therefore, neurosurgeons should pay close attention to the discovery of postoperative intracranial pneumocephalus because this factor is as important as a postoperative CSF leak. Pneumocephalus (maximum bubble diameter of ≥ 1 cm), diaphragmatic defects (an intraoperative CSF leak, Kelly grade ≥ 1), and a postoperative CSF leak were risk factors predictive of postoperative intracranial infections. In addition, it is essential that operative procedures be carefully performed to avoid diaphragmatic defects, to reduce exposure to the external environment, and to decrease patients’ suffering.

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Outcomes following Purely Endoscopic Endonasal Resection of Pituitary adenomas

Journal of Enam Medical College ◽

10.3329/jemc.v3i1.13869 ◽

2013 ◽

Vol 3 (1) ◽

pp. 18-23

Author(s):

Shamsul Alam ◽

ATM Mosharef Hossain ◽

AN Wakil Uddin ◽

Tariqul Islam ◽

Rezaul Amin ◽

...

Keyword(s):

Pituitary Adenoma ◽

Diabetes Insipidus ◽

Pituitary Adenomas ◽

Pituitary Surgery ◽

Electrolyte Imbalance ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Microscopic Surgery ◽

Subtotal Removal

Background: The use of endoscope for the management of pituitary adenoma is not new. The better magnification and illumination provided by the endoscope gives better outcome than microscopic pituitary surgery. Objective: To find out the benefits of endoscope in relation to microscopic surgery. Materials and Methods: We performed 45 cases of pituitary adenoma surgery by endoscopic endonasal approach from July 2008 to July 2010. Results: Forty five cases underwent endoscopic transsphenoidal approach. Gross total removal was done in 35 cases and subtotal removal was done in 10 cases. Residual tumours were seen in 10 cases (22%) in postoperative follow-up MRI scan. Visual improvement was satisfactory, and hormonal improvement of functional adenoma was nice. Postoperative visual acuity and visual field were improved in 75% cases. There were 37% cases of temporary diabetes insipidus and about 4.5% cases of permanent diabetes insipidus. The average duration of follow-up was 20 months. One patient required reexploration to correct visual deterioration in the immediate postoperative period. There were 4.5% cases of CSF leak and 6.6% mortality. Mortality was due to electrolyte imbalance and improper management of infection and hydrocephalus. Conclusion: Endoscopic endonasal pituitary surgery now has become a gold standard surgery for most of the pituitary adenomas because of its better advantages in relation to microscopic surgery and less complications and less hospital stay. DOI: http://dx.doi.org/10.3329/jemc.v3i1.13869 J Enam Med Col 2013; 3(1): 18-23

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