Endoscopic endonasal trans-sphenoid surgery of pituitary adenoma

ABSTRACTEndoscopic endonasal trans-sphenoid surgery (EETS) is increasingly used for pituitary lesions. Pre-operative CT and MRI scans and peroperative endoscopic visualization can provide useful anatomical information. EETS is indicated in sellar, suprasellar, intraventricular, retro-infundibular, and invasive tumors. Recurrent and residual lesions, pituitary apoplexy and empty sella syndrome can be managed by EETS. Modern neuronavigation techniques, ultrasonic aspirators, ultrasonic bone curette can add to the safety. The binostril approach provides a wider working area. High definition camera is much superior to three-chip camera. Most of the recent reports favor EETS in terms of safety, quality of life and tumor resection, hospital stay, better endocrinological, and visual outcome as compared to the microscopic technique. Nasal symptoms, blood loss, operating time are less in EETS. Various naso-septal flaps and other techniques of CSF leak repair could help reduce complications. Complications can be further reduced after achieving the learning curve, good understanding of limitations with proper patient selection. Use of neuronavigation, proper post-operative care of endocrine function, establishing pituitary center of excellence and more focused residency and endoscopic fellowship training could improve results. The faster and safe transition from microscopic to EETS can be done by the team concept of neurosurgeon/otolaryngologist, attending hands on cadaveric dissection, practice on models, and observation of live surgeries. Conversion to a microscopic or endoscopic-assisted approach may be required in selected patients. Multi-modality treatment could be required in giant and invasive tumors. EETS appears to be a better surgical option in most pituitary adenoma.

Download Full-text

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.

Download Full-text

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.

Download Full-text

Surgical Outcomes of Endoscopic Endonasal Surgery in 29 Patients with Craniopharyngioma

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1713108 ◽

2020 ◽

Author(s):

Arad Iranmehr ◽

Mostafa Esmaeilnia ◽

Khashayar Afshari ◽

Seyed Mousa Sadrehosseini ◽

Azin Tabari ◽

...

Keyword(s):

Tumor Resection ◽

Visual Outcome ◽

Extent Of Resection ◽

Csf Leak ◽

Endoscopic Endonasal Surgery ◽

Endonasal Surgery ◽

Endoscopic Endonasal ◽

Pituitary Dysfunction ◽

Before And After

Abstract Background Recently the endoscopic endonasal surgery (EES) has been introduced as a modality for the treatment of patients with craniopharyngiomas. In this study, we describe our initial experience in treatment of 29 patients with craniopharyngiomas using this approach. Methods Twenty-nine consecutive patients with craniopharyngiomas who had undergone EES in a 5-year period were studied retrospectively. Patients underwent preoperative and postoperative endocrinologic and ophthalmologic evaluations. Radiologic characteristics of tumors and extent of resection were determined. The recurrence and complications were evaluated. Results Pituitary and visual dysfunction were observed preoperatively in 89.7 and 86% of patients, respectively. After EES, visual outcome either showed an improvement or else remained unchanged in 92.3% of the cases; however, pituitary function remained unchanged and even got worsened in 34.6% of the cases. Prevalence of diabetes insipidus before and after surgery was 58.6 and 69.2%. The rate of gross total resection was 62%. Moreover, 86.2% of the tumors were almost totally resected (more than 95% of the tumor size resected). After surgery, cerebrospinal fluid (CSF) leak and meningitis occurred in four (13.8%) and two (6.9%) patients, respectively. Perioperative mortality was seen in two of the cases (6.9%). The mean follow-up was 25 months and tumor recurrence was discovered in four patients (15.3%). Conclusion The EES with the goal of maximal and safe tumor resection could be used for the treatment of most craniopharyngiomas. Although the rates of visual improvement and gross tumor resection are high, CSF leak, pituitary dysfunction, and meningitis are serious concerns.

Download Full-text

Collision Tumor in the Pituitary, Concurrent Pituitary Adenoma, and Craniopharyngioma

Case Reports in Otolaryngology ◽

10.1155/2020/9584090 ◽

2020 ◽

Vol 2020 ◽

pp. 1-5

Author(s):

Zaid Shareef ◽

Connor Kerndt ◽

Trevor Nessel ◽

Devin Mistry ◽

Bryan Figueroa

Keyword(s):

Pituitary Adenoma ◽

Histopathological Examination ◽

Past History ◽

Third Ventricle ◽

Tumor Resection ◽

Optic Chiasm ◽

Collision Tumor ◽

Fat Graft ◽

Csf Leak ◽

Graft Harvest

Collision tumors are two independent, distinct tumors occupying the same anatomical space. This case presents a pituitary adenoma-craniopharyngioma collision tumor presenting with hemianopsia. A 60-year-old with a past history of a nonsecretory pituitary adenoma presented with progressive headaches, bitemporal hemianopsia, and nausea. Previously, in 2008, his adenoma was effectively treated with nasal septal flap and transsphenoidal pituitary resection. A magnetic resonance imaging (MRI) was ordered for concern of recurrence, given his history and neurologic complaints. The MRI revealed a suprasellar mass extending into the third ventricle with displacement of the hypothalamus and optic chiasm. Laboratory testing revealed no indicators of endocrinopathy. The neurosurgical and otolaryngologic teams were elected to perform tumor resection given the ongoing symptoms. An image-guided transsphenoidal tumor resection with abdominal fat graft harvest and septal mucosal flap CSF leak repair was performed. Histopathological examination revealed two tumor components within the resection including an adamantinomatous craniopharyngioma and recurrent pituitary adenoma.

Download Full-text

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.

Download Full-text

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

Download Full-text

Anterior Skull Base Meningioma: Surgical approach and complication avoidance

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/a-1733-9320 ◽

2022 ◽

Author(s):

Bhawan Nangarwal ◽

Jaskaran Singh Gosal ◽

Kuntal Kanti Das ◽

Deepak Khatri ◽

Kamlesh Singh Bhaisora ◽

...

Keyword(s):

Skull Base ◽

Tumor Resection ◽

Vascular Complications ◽

Good Alternative ◽

Anterior Skull Base ◽

Csf Leak ◽

Medical Complication ◽

Endoscopic Endonasal ◽

Olfactory Groove ◽

Skull Base Meningioma

Background: Endoscopic endonasal approach (EEA) and keyhole transcranial approaches are being increasingly used in anterior skull base meningioma (ASBM) surgery. Objective: We compare tumor resection rates and complication profiles of EEA and supraorbital key hole approach (SOKHA) against conventional transcranial approaches (TCA). Methods: Fifty-four patients with ASBM [olfactory groove (OGM), n=19 and planum sphenoidale/tuberculum sellae (PS/TSM), n=35) operated at a single centre over 7 years were retrospectively analyzed. Results: The overall rate of GTR was higher in OGM (15/19, 78.9%) than PS-TSM group (23/35, 65.7%, p=0.37). GTR rate with OGM was 90% and 75% with TCA and EEA. Death (n=1) following medical complication (TCA) and CSF leak requiring re-exploration (n=2, one each in TCA and EEA) accounted for the major complications in OGM. For the PS/TSM group, the GTR rates were 73.3% (n=11/15), 53.8% (n=7/13) and 71.4% (n=5/7) with TCA, EEA and SOKHA respectively. Seven patients (20%) of PS-TSM developed major postoperative complications including 4 deaths (one each in TCA, SOKHA and 2 in EEA group) and 3 visual deteriorations. Direct and indirect vascular complications were common in lesser invasive approaches to PS-TSM especially if the tumor has encased intracranial arteries. Conclusions: No single approach is applicable to all ASBMs. TCA is still the best approach to obtain GTR but has tissue trauma related problems. SOKHA may be a good alternative to TCA in selected PS-TSMs while EEA may be an alternate option in some OGMs. A meticulous patient selection is needed to derive reported results of EEA for PS-TSM.

Download Full-text

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

Journal of Nepal Health Research Council ◽

10.3126/jnhrc.v15i2.18209 ◽

2017 ◽

Vol 15 (2) ◽

pp. 174-177 ◽

Cited By ~ 1

Author(s):

Deepak Regmi ◽

Amit Thapa ◽

Bidur KC ◽

Bikram Shakya

Keyword(s):

Pituitary Adenoma ◽

Minimally Invasive ◽

Endoscopic Approach ◽

Transsphenoidal Approach ◽

Sinus Surgery ◽

Csf Leak ◽

Technical Failure ◽

Endoscopic Endonasal ◽

Ablative Surgery ◽

Surgical Cure

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: .

Download Full-text

Endoscopic endonasal pituitary adenoma surgery: our surgical experience in 116 patients

International Journal of Otorhinolaryngology and Head and Neck Surgery ◽

10.18203/issn.2454-5929.ijohns20204626 ◽

2020 ◽

Vol 6 (11) ◽

pp. 2029

Author(s):

Krishna Vikas Potdukhe ◽

Kalpesh Patel ◽

Rajesh Vishwakarma

Keyword(s):

Pituitary Adenoma ◽

Visual Outcome ◽

Primary Objective ◽

Partial Resection ◽

High Rate ◽

Endocrine Function ◽

Gross Total Resection ◽

Imaging Data ◽

Total Resection ◽

Endoscopic Endonasal

Background: The primary objective of this study was to evaluate the outcome of excision in terms of gross and partial resection rates compared to the grades of pituitary adenoma (based on Hardy-Vezina classification). We also evaluated the post-operative complications and the effect of resection on visual outcomes and endocrinological remission.Methods: We retrospectively analysed 116 patients who underwent surgical resection of pituitary adenoma via endonasal trans-sphenoidal approach at Civil Hospital (Ahmedabad) between March 2013 and March 2019 and collected pre-operative and post-operative data in terms of imaging, endocrine function and vision. Results: According to the postoperative imaging data and endocrine examination results, gross-total resection (GTR) was achieved in 79.3% (92 patients), and partial (PR) in 20.6% (24 patients) which was significant (p<0.05). Improvement in vision was seen in 62% (40 patients out of 64 patients). Out of 44 patients having endocrine dysfunction, endocrinological remission was achieved in 32 patients with functional adenomas (72.7%). Sinusitis followed by headache was the most common minor complication seen in the study.Conclusions: Endoscopic endonasal transsphenoidal surgery is a valuable treatment option for patients having grade 3 or lower pituitary adenomas, which leads to gross total resection in comparison to patients having grade 4 adenoma. It also results in high rate of surgical decompression and better visual outcome. Partial resection may result in endocrinological response in functional tumors.

Download Full-text

Endoscopic endonasal suturing of dural reconstruction grafts: a novel application of the U-Clip technology

Journal of Neurosurgery ◽

10.3171/jns/2008/108/2/0395 ◽

2008 ◽

Vol 108 (2) ◽

pp. 395-400 ◽

Cited By ~ 32

Author(s):

Paul Gardner ◽

Amin Kassam ◽

Carl Snyderman ◽

Arlan Mintz ◽

Ricardo Carrau ◽

...

Keyword(s):

Tumor Resection ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Tissue Graft ◽

Needle Driver ◽

Csf Leakage ◽

Suture Device ◽

Tissue Grafts ◽

Graft Migration ◽

Graft Reconstruction

✓ Cerebrospinal fluid (CSF) leakage following endoscopic endonasal skull base resection can be a significant problem. A method for securing tissue grafts is needed. In this paper the authors used an endonasal suturing device to secure the graft reconstruction following endonasal tumor resection. The U-Clip anastomotic device (Medtronic), developed for cardiovascular anastomoses, was used to secure the tissue graft to native dura. A specialized needle driver and hemoclip applier were used for the application and deployment of this device. No suture tying was necessary, facilitating its endonasal application. The graft was successfully secured in its desired position to native dura by using the U-Clip anastomotic device. The patient did not suffer a postoperative CSF leak, and postoperative imaging and endoscopy revealed that the graft was in a good position. There was no complication from the use of the device. The U-Clip anastomotic device can be used as a suture device during endonasal surgery. It may prevent tissue graft migration and help prevent CSF leakage.

Download Full-text