Pioneers in the development of transsphenoidal surgery: Theodor Kocher, Oskar Hirsch, and Norman Dott

2001 ◽  
Vol 95 (6) ◽  
pp. 1097-1103 ◽  
Author(s):  
Giuseppe Lanzino ◽  
Edward R. Laws
Keyword(s):  
Transsphenoidal Surgery ◽  
Transsphenoidal Approach ◽  
Scientific Concepts ◽  
Content Type ◽  
Theodor Kocher ◽  
Fine Print

✓ The development of new scientific concepts and techniques is usually the result of a progressive evolution. The transsphenoidal approach to pituitary lesions is no exception. Several pioneers contributed to its development and its eventual and nearly unconditional acceptance. In this historical vignette, the contributions of three master surgeons, Theodor Kocher, Oskar Hirsch, and Norman Dott, are reviewed.

Novel closure technique for the endonasal transsphenoidal approach

2004 ◽  
Vol 100 (1) ◽  
pp. 161-164 ◽  
Author(s):  
James K. Liu ◽  
Richard R. Orlandi ◽  
Ronald I. Apfelbaum ◽  
William T. Couldwell
Keyword(s):  
Transsphenoidal Surgery ◽  
Nasal Packing ◽  
Transsphenoidal Approach ◽  
Closure Technique ◽  
Content Type ◽  
Submucosal Dissection ◽  
Sellar Lesions ◽  
Parasellar Region ◽  
Transsphenoidal Microsurgery ◽  
Fine Print

✓ Transsphenoidal microsurgery has been the standard approach to sellar lesions since the repopularization of the technique with modifications by Dott, Guiot, and Hardy. The endonasal transseptal transsphenoidal approach, as introduced by Hirsch, is still commonly used by pituitary surgeons to remove lesions of the sellar and parasellar region. One disadvantage of this approach is that the submucosal dissection requires postoperative nasal packing, which is a source of discomfort in patients who undergo transsphenoidal surgery. The authors describe a novel closure technique for the unilateral endonasal transsphenoidal approach that eliminates the need for full nasal packing, minimizing postoperative rhinological morbidity. This technique has been performed in 67 patients harboring sellar and parasellar lesions. All patients recovered rapidly without significant rhinological sequelae.

Transsphenoidal surgery in Cushing disease: 10 years of experience in 34 consecutive cases

2004 ◽  
Vol 100 (4) ◽  
pp. 634-638 ◽  
Author(s):  
Charlotte Höybye ◽  
Eva GrenbäcK ◽  
Marja Thorén ◽  
Anna-Lena Hulting ◽  
Lars Lundblad ◽  
...  
Keyword(s):  
Mr Imaging ◽  
Transsphenoidal Surgery ◽  
Cushing Syndrome ◽  
Preoperative Evaluation ◽  
Clinical Signs ◽  
Pituitary Hormone ◽  
Years Of Experience ◽  
Cushing Disease ◽  
Content Type ◽  
Fine Print

Object. Cushing disease is a rare disorder. Because of their small size the adrenocorticotropic hormone (ACTH)—producing tumors are often not detectable on neuroimaging studies. To obtain a cure with transsphenoidal surgery (TSS) may therefore be difficult. In this report the authors present 10 years of experience in the treatment of patients with Cushing disease who were followed up with the same protocol and treated by the same surgeon. Methods. Thirty-four patients, 26 of them female and eight of them male (mean age 40 years, range 13–74 years) were studied. All had obvious clinical signs and symptoms of Cushing syndrome. Magnetic resonance (MR) imaging was performed in all patients, and inferior petrosal sinus (IPS) sampling was done in 14. In 12 patients MR imaging indicated a pituitary tumor; 10 were microadenomas and two were macroadenomas. In six patients with no visible tumor, the results of IPS sampling supported the diagnosis. All patients underwent TSS; the mean follow-up duration was 6 ± 0.5 years. Selective adenomectomy was performed in 32 and hemihypophysectomy in the other two patients. A cure was obtained in 31 patients (91%) after one TSS and in two more patients after further TSS; one patient was not cured despite two TSSs and one underwent bilateral adrenalectomy. Disease recurrence was seen in two patients after 3 years, and they were successfully treated with stereotactic gamma knife surgery. Half of the patients had an ACTH deficiency postoperatively, whereas one third had other pituitary hormone insufficiencies. There were no serious complications attributable to the surgical intervention. Conclusions. Transsphenoidal surgery with selective adenomectomy is an effective and safe treatment for Cushing disease. In the patients presented in this study, the surgical outcome seemed to depend on careful preoperative evaluation and the surgeon's experience. For optimal results in this rare disease the authors therefore suggest that the endocrinological, radiological, and surgical procedures be coordinated in a specialized center.

The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors

2005 ◽  
Vol 102 (5) ◽  
pp. 832-841 ◽  
Author(s):  
Joshua R. Dusick ◽  
Felice Esposito ◽  
Daniel F. Kelly ◽  
Pejman Cohan ◽  
Antonio DeSalles ◽  
...  
Keyword(s):  
Residual Tumor ◽  
Transsphenoidal Approach ◽  
Total Removal ◽  
Content Type ◽  
Patients Âgés ◽  
Extended Transsphenoidal Approach ◽  
Planum Sphenoidale ◽  
Dural Defects ◽  
Fine Print ◽  
Csf Leaks

Object. The extended transsphenoidal approach, which requires a bone and dural opening through the tuberculum sellae and posterior planum sphenoidale, is increasingly used for the treatment of nonadenomatous suprasellar tumors. The authors present their experiences in using the direct endonasal approach in patients with nonadenomatous suprasellar tumors. Methods. Surgery was performed with the aid of an operating microscope and angled endoscopes were used to assess the completeness of resection. Bone and dural defects were repaired using abdominal fat, collagen sponge, titanium mesh, and, in most cases, lumbar drainage of cerebrospinal fluid (CSF). Twenty-six procedures for tumor removal were performed in 24 patients (ages 9–79 years), including two repeated operations for residual tumor. Gross-total removal could be accomplished in only 46% of patients, with near-gross-total removal or better in 74% of 23 patients (five of eight with craniopharyngiomas, six of seven with meningiomas, five of six with Rathke cleft cysts, and one of two with a dermoid or epidermoid cyst); a patient with a lymphoma only underwent biopsy. Of 13 patients with tumor-related visual loss, 85% improved postoperatively. The complications that occurred included five patients (21%) with postoperative CSF leaks, one patient (4%) with bacterial meningitis; five patients (21%) with new endocrinopathy; and two patients (8%) who needed to undergo repeated operations to downsize suprasellar fat grafts. The only permanent neurological deficit was anosmia in one patient; there were no intracranial vascular injuries. Conclusions. The direct endonasal skull-base approach provides an effective minimally invasive means for resecting or debulking nonadenomatous suprasellar tumors that have traditionally been approached through a sublabial or transcranial route. Procedures in the supraglandular space can be performed effectively with excellent visualization of the optic apparatus while preserving pituitary function in most cases. The major challenge remains developing consistently effective techniques to prevent postoperative CSF leaks.

Unilateral septal technique for transsphenoidal microsurgical approach to the sella turcica

1978 ◽  
Vol 49 (1) ◽  
pp. 138-142 ◽  
Author(s):  
George T. Tindall ◽  
William F. Collins ◽  
John A. Kirchner
Keyword(s):  
Nasal Mucosa ◽  
Nasal Septum ◽  
Sella Turcica ◽  
Practical Approach ◽  
Transsphenoidal Approach ◽  
Content Type ◽  
Microsurgical Approach ◽  
Septal Perforations ◽  
Fine Print

✓ A modification of the transseptal, transsphenoidal approach to the sella turcica is described; it consists of a unilateral separation of the nasal mucosa from the nasal septum. Experience with the technique in 215 cases has indicated that it is a useful, practical approach. The advantages are that the septum is spared, reoperation is made easier, and the procedure is quicker than the bilateral septal procedure. Asymptomatic nasal septal perforations (less than 3 mm) were seen in eight of 215 cases, and represented the only complication related to the operation.

Radiosurgery for Cushing's disease after failed transsphenoidal surgery

2000 ◽  
Vol 93 (5) ◽  
pp. 738-742 ◽  
Author(s):  
Jonas M. Sheehan ◽  
Mary L. Vance ◽  
Jason P. Sheehan ◽  
Dilantha B. Ellegala ◽  
Edward R. Laws
Keyword(s):  
Gamma Knife ◽  
Cushing’S Disease ◽  
Tumor Size ◽  
Transsphenoidal Surgery ◽  
Gamma Knife Radiosurgery ◽  
Magnetic Resonance Images ◽  
Cushing's Disease ◽  
Content Type ◽  
Fine Print

Object. Although transsphenoidal surgery has become the standard of care for Cushing's disease, it is often unsuccessful in normalizing cortisol production. In this study the authors investigate the safety and efficacy of gamma knife radiosurgery (GKRS) for Cushing's disease after failed transsphenoidal surgery.Methods. The records of all patients who underwent GKRS at the authors' institution after unsuccessful transsphenoidal surgery for Cushing's disease were retrospectively reviewed. Successful treatment was considered a normal or below-normal 24-hour urinary free cortisol (UFC) level. Records were also evaluated for relapse, new-onset endocrine deficiencies, interval change in tumor size, and visual complications.Forty-three patients underwent 44 gamma knife procedures with follow up ranging from 18 to 113 months (mean 39.1, median 44 months). Normal 24-hour UFC levels were achieved in 27 patients (63%) at an average time from treatment of 12.1 months (range 3–48 months). Three patients had a recurrence of Cushing's disease at 19, 37, and 38 months, respectively, after radiosurgery. New endocrine deficiencies were noted in seven patients (16%). Follow-up magnetic resonance images obtained in 33 patients revealed a decrease in tumor size in 24, no change in nine, and an increase in size in none of the patients. One patient developed a quadrantanopsia 14 months after radiosurgery despite having received a dose of only 0.7 Gy to the optic tract.Conclusions. Gamma knife radiosurgery appears to be safe and effective for the treatment of Cushing's disease refractory to pituitary surgery. Delayed recurrences and new hormone deficiencies may occur, indicating the necessity for regular long-term follow up.

Long-term surgical outcome in 16 patients with thyrotropin pituitary adenoma

2000 ◽  
Vol 93 (2) ◽  
pp. 194-200 ◽  
Author(s):  
Naoko Sanno ◽  
Akira Teramoto ◽  
R. Yoshiyuki Osamura
Keyword(s):  
Cavernous Sinus ◽  
Pituitary Adenomas ◽  
Transsphenoidal Surgery ◽  
Term Outcome ◽  
Long Term Outcome ◽  
Content Type ◽  
Primary Hyperthyroidism ◽  
Fine Print

Object. Thyrotropin-secreting pituitary adenomas are rare lesions of the endocrinological system. Although introduction of a hypersensitive radioimmunoassay for thyrotropin enables the recognition of inappropriate secretion of this hormone, the aforementioned lesions remain uncommon and unfamiliar to most neurosurgeons. It has been reported previously that surgical cure of thyrotropin-secreting adenomas is more difficult than in other functional adenomas because of the large size and invasive features of the former. However, the long-term outcome after surgery has not been well documented. The authors report on a surgical series of 16 patients with thyrotropin adenoma and the results of long-term follow up.Methods. Sixteen patients ages 23 to 62 years (12 women and four men) underwent transsphenoidal removal of thyrotropin adenomas between 1983 and 1999. These patients had the syndrome of inappropriate thyrotropin secretion (SITS) with pituitary mass lesions. Four of the patients had undergone previous subtotal thyroidectomy and/or radioiodine thyroid ablation, and 11 had been treated with antithyroid medication. Radiological investigations demonstrated macroadenomas in 14 patients, and 10 of those had cavernous sinus invasion. Surgical findings showed unusually fibrous and firm tumors in 13 (81.2%) of 16 patients. Preoperative octreotide administration was revealed to be effective for serum thyrotropin reduction as well as tumor shrinkage. Transsphenoidal surgery was performed with no morbidity resulting. Surgical remission was achieved in 10 (62.5%) of 16 patients, and total remission was achieved in 14 patients (87.5%) with a combination of additional radiation or medical therapy. In the other two patients, SITS persisted because of tumor rests in the cavernous sinus. Therefore, radiation and/or antithyroid therapy was administered. In the mean follow-up period of 7.5 years (range 11 months–15.8 years), no recurrence of tumor was observed on magnetic resonance images, whereas recurrence of SITS was found in two patients with no tumor regrowth. In addition, coexistent primary hyperthyroidism was found in two other patients despite remission of SITS after surgery.Conclusions. Transsphenoidal surgery can achieve a good long-term outcome in patients with thyrotropin-secreting pituitary adenomas if surgery is performed before these become larger, invasive tumors. In the authors' experience, thyrotropin-secreting adenomas are fibrous and firm, which makes it difficult to achieve surgical remission. In addition, even satisfactory resection of the tumor sometimes results in recurrence of SITS or hyperthyroid symptoms due to coexistent primary hyperthyroidism. It is emphasized that a careful follow-up review is necessary after surgery, especially in patients with a long preoperative history of hyperthyroidism.

Retraction system for transsphenoidal surgery

1985 ◽  
Vol 62 (2) ◽  
pp. 307-309 ◽  
Author(s):  
Shigeaki Kobayashi ◽  
Kenichiro Sugita ◽  
Toshiki Takemae ◽  
Yoshio Tanizaki
Keyword(s):  
Transsphenoidal Surgery ◽  
The Self ◽  
Venous Sinus ◽  
Content Type ◽  
Tumor Bed ◽  
Tumor Tissues ◽  
Dural Venous Sinus ◽  
Diaphragma Sellae ◽  
Fine Print

✓ A retraction system has been developed for transsphenoidal surgery to use together with a conventional self-retaining speculum. The system comprises an attachment to the speculum, a self-retaining retractor, and a slim tapered brain spatula and pronged hook. The spatula or hook is secured with the self-retaining retractor and the attachment. The retractor can also be fixed to the Sugita multipurpose head frame. The system may be used to retract the bulging diaphragma sellae and tumor tissues, and to stop bleeding from the dural venous sinus or tumor bed, so the surgeon can continue the procedure with both hands.

Thickening of sphenoid sinus mucosa during the acute stage of pituitary apoplexy

2001 ◽  
Vol 95 (5) ◽  
pp. 897-901 ◽  
Author(s):  
Kazunori Arita ◽  
Kaoru Kurisu ◽  
Atushi Tominaga ◽  
Kazuhiko Sugiyama ◽  
Fusao Ikawa ◽  
...  
Keyword(s):  
Transsphenoidal Surgery ◽  
Sphenoid Sinus ◽  
Pituitary Apoplexy ◽  
Sella Turcica ◽  
Acute Stage ◽  
Mr Images ◽  
Content Type ◽  
Subepithelial Layer ◽  
Sinus Mucosa ◽  
Fine Print

✓ The authors treated two patients with pituitary apoplexy in whom magnetic resonance (MR) images were obtained before and after the episode. Two days after the apoplectic episodes, MR imaging demonstrated marked thickening of the mucosa of the sphenoid sinus that was absent in the previous studies. The relevance of this change in the sphenoid sinus was investigated. Retrospective evaluations were performed using MR images obtained in 14 consecutive patients with classic pituitary apoplexy characterized by acute onset of severe headache. The mucosa of the sphenoid sinus had thickened predominantly in the compartment just beneath the sella turcica, in nine of 11 patients, as ascertained on MR images obtained within 7 days after the onset of apoplectic symptoms. This condition improved spontaneously in all four patients who did not undergo transsphenoidal surgery. The sphenoid sinus mucosa appeared to be normal on MR images obtained from three patients at the chronic stage (> 3 months after onset). The incidence of sphenoid sinus mucosal thickening during the acute stage was significantly higher in the patients with apoplexy than that in the 100 patients without apoplexy. A histological study conducted in four patients who underwent transsphenoidal surgery during the early stage showed that the subepithelial layer of the sphenoid sinus mucous membrane was obviously swollen. The sphenoid sinus mucosa thickens during the acute stage of pituitary apoplexy. This thickening neither indicates infectious sinusitis nor rules out the choice of the transsphenoidal route for surgery.

Surgical treatment of clival chordomas: the transsphenoidal approach revisited

1996 ◽  
Vol 85 (5) ◽  
pp. 784-792 ◽  
Author(s):  
Giulio Maira ◽  
Roberto Pallini ◽  
Carmelo Anile ◽  
Eduardo Fernandez ◽  
Fabrizio Salvinelli ◽  
...  
Keyword(s):  
Spinal Metastasis ◽  
Postoperative Radiotherapy ◽  
Primary Treatment ◽  
Transsphenoidal Approach ◽  
Total Removal ◽  
Partial Removal ◽  
Content Type ◽  
Mortality And Morbidity ◽  
Lower Clivus ◽  
Fine Print

✓ This is a report of 12 cases of clival chordomas that were surgically treated at the Catholic University Medical School, Rome, Italy, over a 7-year period. The study emphasizes the role of the transsphenoidal approach. The study group included seven men and five women whose ages ranged from 26 to 80 years (mean 49.8 years). Diplopia was the most common presenting symptom (eight cases). The tumor involved the upper and middle clivus in five cases, the middle clivus in five, and the lower clivus in two cases. One patient developed spinal metastasis. On histological examination, eight cases proved to be typical chordomas, three cases had a chondroid component, and one case of chordoma had atypical features. Immunohistological staining for vimentin and epithelial membrane antigen was positive in all cases. Follow-up periods ranged from 14 to 86 months (mean 40.2 months). The primary treatment consisted of surgery. Ten patients with chordomas of the upper and middle clivus underwent a total of 13 transsphenoidal procedures. Total tumor removal was achieved in seven cases, subtotal removal in two, and partial removal in one case. In the two cases of lower clival chordomas, total removal was accomplished in one and partial removal in the other. After total removal, no recurrence was noted at 14 to 86 months (mean 37.5 months). In the cases undergoing operation via a transsphenoidal approach, there was zero morbidity and one cerebrospinal fluid fistula that resolved without surgery. The tumor recurred in two patients after subtotal and partial removal, respectively. The authors opted to reoperate in cases of recurrence. Postoperative radiotherapy was administered in only two cases in which further surgery was not indicated because of medical reasons or because such a procedure was contrary to the patient's wishes. When mortality and morbidity rates of this group are compared to those of chordoma patients who were treated with extensive skull-base surgery, the results prompt a reappraisal of the transsphenoidal approach in the treatment of clival chordomas.

Differential effects of octreotide treatment and transsphenoidal surgery on growth hormone—binding protein levels in patients with acromegaly

1999 ◽  
Vol 90 (4) ◽  
pp. 647-650 ◽  
Author(s):  
Irma Hernandez ◽  
Daniela Soderlund ◽  
Ana Laura Espinosa-de-los-Monteros ◽  
Raquel Ochoa ◽  
Arturo Zarate ◽  
...  
Keyword(s):  
Growth Hormone ◽  
Transsphenoidal Surgery ◽  
Binding Protein ◽  
Hormone Binding ◽  
Content Type ◽  
Growth Hormone Binding Protein ◽  
Igf I ◽  
Octreotide Treatment ◽  
Hormone Binding Protein ◽  
Fine Print

Object. The high-affinity growth hormone—binding protein (GHBP) represents the extracellular portion of the growth hormone (GH) receptor, and its serum levels are a reflection of the tissue receptor status. Levels of GHBP are decreased in patients with active acromegaly, probably because of downregulation of GH receptors. However, there are no studies of patients with acromegaly in which the effects of medical (that is, administration of somatostatin analogs) and surgical therapy on GHBP levels have been compared. That is the task the authors set out to accomplish in this study.Methods. The authors studied seven patients in whom acromegaly had been recently diagnosed. They examined these patients at baseline, 2 months after octreotide treatment (subcutaneous administration of 100 µg octreotide three times per day), and 1 month after transsphenoidal surgery. Growth hormone—binding activity was measured, as well as the following biochemical markers of the somatotropic axis: GH suppression induced by oral administration of glucose, insulin-like growth factor-I (IGF-I), and insulin-like growth factor—binding protein-3 (IGFBP3). Although octreotide treatment induced a decrease in the levels of GH, IGF-I, and IGFBP3, as well as an increase in the level of GHBP, these biochemical markers did not reach normal levels. On the other hand, after transsphenoidal surgery, GHBP levels became normal, particularly in those patients in whom serum GH could be suppressed to an undetectable level after glucose loading.Conclusions. The authors conclude that persistently low GHBP levels in patients with acromegaly are normalized by successful pituitary surgery and correlate well with disease activity.

Sign in / Sign up

Export Citation Format

Share Document