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Senior BA, Dubin MG, Sonnenburg RE, Melroy CT, Ewend MG. Increased Role of the Otolaryngologist in Endoscopic Pituitary Surgery: Endoscopic Hydroscopy of the Sella. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/194589240501900211] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The aim of this study was to discuss the use of nasal irrigation and suction systems in endoscopic pituitary surgery to examine the sella and facilitate tumor removal. We describe a new technique of sellar exploration. Methods Following the endoscopic approach to the pituitary by the otolaryngology team, pituitary masses are resected. Then, the ClearESS nasal irrigation and suction system is used by the otolaryngology team to visualize the sella (“hydroscopy”). The combination of this ClearESS technology and angled endoscopes is used to scrutinize previously inaccessible areas of the tumor bed. Results Over 50 patients have undergone minimally invasive pituitary surgery via the endoscopic approach with postresection hydroscopy of the sella. The use of angled endoscopes in combination with the ClearESS technology greatly increased visualization of the sella, thereby facilitating complete tumor removal. There have been no complications associated with the use of hydroscopy. Conclusion The use of angled endoscopes in conjunction with hydroscopy increases visualization of the sella. The otolaryngologist plays a critical role in this examination with manipulation of the angled endoscopes. Therefore, the role of the otolaryngologist is extended beyond the approach to the pituitary.
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Affiliation(s)
- Brent A. Senior
- Department of Otolaryngology–Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Marc G. Dubin
- Department of Otolaryngology–Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Robert E. Sonnenburg
- Department of Otolaryngology–Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Christopher T. Melroy
- Department of Otolaryngology–Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Matthew G. Ewend
- Division of Neurosurgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Abstract
Background Sellar reconstruction is practiced routinely during the transsphenoidal approach to pituitary tumor resection. This practice exposes the patient to risks of donor site complications and may interfere with measuring postoperative tumor reduction. We propose that it is not a necessary component of transsphenoidal pituitary surgery in the absence of intraoperative cerebrospinal fluid (CSF) leak. Methods A retrospective chart review of 45 cases of minimally invasive pituitary surgery were reviewed. Twenty-eight cases were identified with no sellar reconstruction being performed. Age, sex, revision surgery, postoperative CSF leak, days with lumbar drain, meningitis, ophthalmoplegia, visual acuity loss, postoperative epistaxis, diabetes insipidus, development of empty sella syndrome, and length of stay were investigated in these cases. Results Twenty-three cases were the primary procedure and five cases were revision surgery. Complication rates were low and compared favorably with those reported in the literature. Five cases of transient diabetes insipidus occurred. There was one postoperative CSF leak that required 4 days with a lumbar drain. No cases of empty sella syndrome developed. There were no cases of meningitis. The average length of stay was 2.9 days. Conclusion Sellar reconstruction during transsphenoidal approach to pituitary tumor resection is not required for patients without evidence of an intraoperative CSF leak. This practice exposes the patient to the risks of donor site complications without reducing the rate of postoperative complications.
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Affiliation(s)
- Robert E. Sonnenburg
- Departments of Otolaryngology—Head and Neck Surgery, and Neurosurgery, University of North Carolina, Chapel Hill, North Carolina
| | - David White
- Departments of Otolaryngology—Head and Neck Surgery, and Neurosurgery, University of North Carolina, Chapel Hill, North Carolina
| | - Matthew G. Ewend
- Departments of Otolaryngology—Head and Neck Surgery, and Neurosurgery, University of North Carolina, Chapel Hill, North Carolina
| | - Brent Senior
- Departments of Otolaryngology—Head and Neck Surgery, and Neurosurgery, University of North Carolina, Chapel Hill, North Carolina
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Sonnenburg RE, White D, Ewend MG, Senior B. The Learning Curve in Minimally Invasive Pituitary Surgery. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/194589240401800412] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Minimally invasive pituitary surgery (MIPS) is performed via an endoscopic transnasal transsphenoidal approach. This provides excellent illumination, visualization, and magnification of the operative field, in addition to avoiding complications associated with other approaches. In this study we examined the first 45 cases of MIPS to determine if a learning curve exists for this technique. Methods A retrospective chart review was performed of the first 45 cases of MIPS at a major academic medical center. Cases were divided into three groups of 15 patients each. Group characteristics including age, sex, and revision surgery were compared. Complication rates investigated included death, intracerebral hemorrhage, intraoperative cerebrospinal fluid leak, postoperative cerebrospinal fluid leak, use of lumbar drain, meningitis, postoperative epistaxis, ophthalmoplegia, visual impairment, and diabetes insipidus. Other factors examined included intraoperative blood loss, length of stay, and tumor histology. One way analysis of variance statistical analysis was used to determine the significance of differences between groups. Results Groups were comparable in respect to characteristics studied. Statistically significant (p < 0.05) differences in complication rates and other factors between groups were not shown. Complication rates are low. Conclusion This study does not establish a learning curve for our first 45 cases of MIPS. This finding supports the concept that an otolaryngology/neurosurgery team skilled in endoscopic techniques and pituitary surgery can safely transition from open approaches to an endoscopic approach in pituitary surgery.
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Affiliation(s)
| | - David White
- Department of Otolaryngology—Head and Neck Surgery, Chapel Hill, North Carolina
| | - Matthew G. Ewend
- Division of Neurosurgery, University of North Carolina, Chapel Hill, North Carolina
| | - Brent Senior
- Department of Otolaryngology—Head and Neck Surgery, Chapel Hill, North Carolina
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Bastos RVS, Silva CMDM, Tagliarini JV, Zanini MA, Romero FR, Boguszewski CL, Nunes VDS. Endoscopic versus microscopic transsphenoidal surgery in the treatment of pituitary tumors: systematic review and meta-analysis of randomized and non-randomized controlled trials. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2016; 60:411-419. [PMID: 27598981 PMCID: PMC10118634 DOI: 10.1590/2359-3997000000204] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 04/29/2016] [Indexed: 11/21/2022]
Abstract
We conducted a systematic review and meta-analysis of randomized and non-randomized controlled trials that compared pure endoscopic with microscopic transsphenoidal surgery (TSS) in the resection of pituitary tumors. Embase, PubMed, Lilacs, and Central Cochrane were used as our data sources. The outcomes were total tumor resection, achievement of biochemical control of functioning adenomas, hospital stay and surgery complications. The randomized trials were analyzed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Two randomized and three prospective controlled non-randomized studies were included. Two studies, including 68 patients, evaluated total tumor resection and the meta-analysis did not show differences between the groups [RR: 1.45 (95% CI: 0.87, 2.44)]. Three studies involving 65 patients analyzed the achievement of biochemical control and no statistical difference was found [RR: 0.94 (95% CI: 0.7, 1.26)]. All five studies compared the frequency of postoperative complications between intervention and control group and meta-analysis favored for a low rate of postoperative complications in the endoscopic TSS group [(RR: 0.37 (95% CI: 0.16, 0.83)]. Due to the low evidence level and low number of observations, the results of our meta-analysis should not be viewed as a final proof of inferiority or superiority of one approach in relation to the other. More data including higher numbers of observations are needed.
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Outcomes and Complications of Endoscopic Versus Microscopic Transsphenoidal Surgery in Pituitary Adenoma. J Craniofac Surg 2016; 27:1015-20. [DOI: 10.1097/scs.0000000000002684] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Oosmanally N, Paul JE, Zanation AM, Ewend MG, Senior BA, Ebert CS. Comparative analysis of cost of endoscopic endonasal minimally invasive and sublabial-transseptal approaches to the pituitary. Int Forum Allergy Rhinol 2011; 1:242-9. [PMID: 22287427 DOI: 10.1002/alr.20048] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Revised: 12/09/2010] [Accepted: 01/04/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND Two surgical approaches to the pituitary are commonly used: the sublabial-transseptal (SLTS) approach using microscopy and the endonasal endoscopic minimally invasive (MIPS) approach. Although outcomes are similar for both procedures, MIPS has become increasingly prevalent over the last 15 years. Limited cost analysis data comparing the 2 alternatives are available. METHODS A retrospective analysis of cost and volume data was performed using data from the published literature and University of North Carolina at Chapel Hill (UNC) Hospitals. A sensitivity analysis of the parameters was used to evaluate the uncertainty in parameter estimates. RESULTS The total cost in real dollars ranges from $11,438 to $12,513 and $18,095 to $21,005 per patient per procedure for MIPS and SLTS, respectively, with a cost difference ranging between $5582 and $9567 per patient per procedure. The sensitivity analysis indicates that the total cost for MIPS is most sensitive to: (1) average length of stay, (2) nursing costs, and (3) number of total complications, whereas the total cost for SLTS is most sensitive to: (1) average length of stay, (2) nursing cost, and (3) operating time. MIPS is less costly than SLTS between 94% and 98% of the time. CONCLUSION The results indicate that MIPS is less costly than SLTS at a large academic center. Future research should compare the outcomes and quality of life (QoL) associated with the 2 surgeries to improve the data used to determine the cost-effectiveness of MIPS compared to SLTS.
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Affiliation(s)
- Nadine Oosmanally
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
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Sinonasal quality-of-life before and after endoscopic, endonasal, minimally invasive pituitary surgery. Int Forum Allergy Rhinol 2011; 1:161-6. [DOI: 10.1002/alr.20029] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2010] [Revised: 10/15/2010] [Accepted: 10/21/2010] [Indexed: 11/07/2022]
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Yang I, Wang MB, Bergsneider M. Making the Transition from Microsurgery to Endoscopic Trans-Sphenoidal Pituitary Neurosurgery. Neurosurg Clin N Am 2010; 21:643-51, vi. [DOI: 10.1016/j.nec.2010.07.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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9
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[Videoendoscopic endonasal-transsphenoidal surgery of pituitary adenomas from a rhinological viewpoint]. HNO 2009; 57:774-80. [PMID: 19421726 DOI: 10.1007/s00106-009-1932-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Videoendoscopic endonasal-transsphenoidal pituitary surgery is a modern minimally invasive surgical technique, which requires interdisciplinary cooperation between ENT and neurosurgery. PATIENTS AND METHODS Between December 2006 and July 2008, 25 patients (13 male, 12 female, average age 55 years old) suffering from pituitary adenomas were operated on with the abovementioned method. All operations were done four-handed with the ENT surgeon carrying out the sphenoidectomy and the neurosurgeon the adenomectomy. An optoelectronic system (Vector Vision) was used for navigation using CT and MRI scans that were fused together. RESULTS Of the patients 21 suffered from a macroadenoma and 3 from a microadenoma. Primary surgery was carried out on 22 patients and 3 underwent recurrence surgery. The adenoma could be resected without any intraoperative complications in all cases. In five cases postoperative liquorrhoea occurred, which in one case was combined with a pneumocephalus due to strong nose blowing and revision surgery was required in three cases. Oculomotor nerve palsy due to neuroborreliosis was observed in one case on the third postoperative day, which receded completely under antibiotics within 1 week. Navigation worked well in all cases, thus there was no need for a C-bow. Additional functional endoscopic sinus surgery (FESS) was necessary in one case due to nasal polyposis. The endoscopic panorama view was advantageous because of the possibility to view the operation cavity. The changeover from microscopic to endoscopic techniques was performed due to the interdisciplinary approach without an intensive learning phase. CONCLUSIONS The newly developed videoendoscopic endonasal pituitary surgery as an interdisciplinary operation between neurosurgery and rhinosurgery by means of modern navigation systems proved to be an excellent method.
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Abstract
OBJECTIVES/HYPOTHESIS Surgical approaches to the pituitary have undergone numerous refinements over the last 100 years. The introduction of the endoscope and the advent of minimally invasive pituitary surgery (MIPS) have revolutionized pituitary surgery. This study aims to compile and evaluate outcomes of all of the MIPS performed at our institution. STUDY DESIGN Retrospective, cases series of 176 consecutive patients undergoing MIPS. METHODS Patient demographics, tumor characteristics, and intraoperative or postoperative complications for of 176 consecutive patients undergoing MIPS were complied. Statistical analysis for categorical variables and incidence across series were conducted using Pearson's chi test and Fisher's exact tests. Odd ratios were calculated to relate the discrete variables to outcomes and designing clinical prediction of risk. RESULTS One hundred seventy-six patients who underwent 193 procedures. Pathologic evaluation revealed 147 of the tumors to be pituitary adenomas. Only one death occurred (mortality rate of 0.5%). The rate of diabetes insipidus occurred in 20.2% of the procedures. Vascular complications occurred in 5.2% of the procedures. Intraoperative cerebrospinal fluid (CSF) leaks were identified in 19.7% whereas postoperative CSF leak was noted in 10.3%. Resection of Rathke's cleft cyst correlated higher risk of both intraoperative and postoperative CSF leak (OR = 2.6, P <.001). Resection of tumors other than adenomata correlated with significantly higher risk of CSF leak (OR = 9.0, P = <.001). Sinusitis occurred after eleven resections (5.7%). Meningitis occurred in 2 of 193 resections (1.0%) in our series. Two neurologic complications occurred in our series, pneumocephalus and cranial neuropathy (1.0%). No other complications occurred. CONCLUSIONS MIPS is a safe and efficacious marriage of the endoscope to the transsphenoidal approach. Thus, a brightness and clarity of vision is combined with the unique ability to explore the tumor bed with angled views and hydroscopy. Outcomes and complication rates comparable to traditional transsphenoidal approaches have resulted but with less dissection and tissue manipulation, reduced need for packing, and greater patient comfort and acceptance.
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Prevedello DM, Doglietto F, Jane JA, Jagannathan J, Han J, Laws ER. History of endoscopic skull base surgery: its evolution and current reality. J Neurosurg 2007; 107:206-13. [PMID: 17639897 DOI: 10.3171/jns-07/07/0206] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓The history of the endoscope exemplifies the manner in which technological advances influence medicine and surgery. Endoscopic systems have evolved and improved, and they currently provide detailed visualization of a variety of deep organ structures. Otorhinolaryngological surgeons have used the endoscope for more than 30 years. In the 1990s, a number of influential neurosurgeons and otorhinolaryngological surgeons began performing purely endoscopic pituitary surgery. Endoscopic transsphenoidal operations are now extending beyond the sella. The collaboration between otorhinolaryngologists and neurosurgeons has produced a new subspecialty of “endoscopic skull base surgery.” There is a great deal of progress still to be made in developing skills, instruments, and improving skull base repair. The extended skull base approaches allow surgical exposures from the olfactory groove to C-2 and to the infratemporal region and jugular fossa laterally. This article discusses the history of the endoscope, the pivotal technological advances, and the key figures in the burgeoning field of endoneurosurgery.
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Affiliation(s)
- Daniel M Prevedello
- Department of Neurological Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia, USA
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Koc K, Kenan K, Anik I, Ihsan A, Ozdamar D, Dilek O, Cabuk B, Burak C, Keskin G, Gurkan K, Ceylan S, Savas C. The learning curve in endoscopic pituitary surgery and our experience. Neurosurg Rev 2006; 29:298-305; discussion 305. [PMID: 16937143 DOI: 10.1007/s10143-006-0033-9] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2005] [Revised: 12/20/2005] [Accepted: 04/16/2006] [Indexed: 11/26/2022]
Abstract
Experience is the important point in reduction of the complications and in the effectiveness of the surgical procedure in pituitary surgery. Endoscopic pituitary surgery differs from microscopic surgery, since it requires a steep learning curve for endoscopic skills. In this article, we evaluate our learning curve in two groups, as early and late experience. Purely endoscopic transsphenoidal operations were performed on 78 patients, which were retrospectively reviewed and grouped as early and late experience groups. We used the purely endoscopic endonasal approach to the sella that was performed via an anterior sphenoidotomy, without the use of a transsphenoidal retractor. All patients with adenomas were evaluated considering operation time, endocrinology, ophthalmology, total removal and, especially, modifications of standard technique. On the basis of the experience gained with the use of the endoscope in transphenoidal surgery over the years, modifications can be performed on the different phases of the endoscopic approach. Reviewing our cases in two groups of period due to our experience showed that the effectiveness of endoscopic surgery increases and operation time decreases. In our study, we identified a learning curve in endoscopic pituitary surgery.
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Affiliation(s)
- Kenan Koc
- Department of Neurosurgery, Kocaeli University, School of Medicine, 41900 Izmit, Kocaeli, Turkey.
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Doglietto F, Prevedello DM, Jane JA, Han J, Laws ER. Brief history of endoscopic transsphenoidal surgery--from Philipp Bozzini to the First World Congress of Endoscopic Skull Base Surgery. Neurosurg Focus 2005; 19:E3. [PMID: 16398480 DOI: 10.3171/foc.2005.19.6.4] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Since its inception, one of the major issues in transsphenoidal surgery has been the adequate visualization of anatomical structures. As transsphenoidal surgery evolved, technical advancements improved the surgical view of the operative field and the orientation. The operating microscope replaced Cushing's headlight and Dott's lighted speculum retractor, and fluoroscopy provided intraoperative imaging. These advances led to the modern concept of microsurgical transsphenoidal procedures in the early 1970s. For the past 30 years the endoscope has been used for the treatment of diseases of the sinus and, more recently, in the surgical treatment of pituitary tumors. The collaboration between neurological and otorhinolaryngological surgeons has led to the development of novel surgical procedures for the treatment of various pathological conditions in the skull base. In this paper the authors review the history of the endoscope--its technical development and its application--from the first endoscope described by Philipp Bozzini to the First World Congress of Endoscopic Skull Base Surgery held in 2005 in Pittsburgh, Pennsylvania. Specifically, in this review the history of endoscopy and its application in endonasal neurosurgery are presented.
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Affiliation(s)
- Francesco Doglietto
- Department of Neurological Surgery, University of Virginia Health Systems, Charlottesville, Virginia, USA
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Abstract
Since the beginnings of medicine, physicians have sought minimally invasive ways to peer into body cavities. It is only in the last several decades that the promises of endoscopy have begun to be answered. What follows is a brief outline of the development of endoscopic technology and its application to the nervous system both for diagnostic and therapeutic procedures.
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Affiliation(s)
- Rick Abbott
- Clinical Neuroendoscopy, INN, Beth Israel Medical Center, 170 East End Avenue, New York, NY 10128, USA.
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Lasio G, Ferroli P, Felisati G, Broggi G. Image-guided endoscopic transnasal removal of recurrent pituitary adenomas. Neurosurgery 2002; 51:132-6; discussion 136-7. [PMID: 12182410 DOI: 10.1097/00006123-200207000-00020] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To assess the role that neuronavigation plays in assisting endoscopic transsphenoidal reoperations for recurrent pituitary adenomas. METHODS During a 45-month period, 19 endoscopic endonasal transsphenoidal reoperations were performed for recurrent pituitary adenomas. In 11 of 19 patients, the procedure was performed with the aid of an optically guided system. Clinical records were reviewed retrospectively, with attention to the following: comparison of baseline clinical data, the duration of surgery, and the postoperative course and complications of both image-guided and non-image-guided endoscopic reoperations. In addition, to test the reliability of the neuronavigation system, we made measurements of intraoperative accuracy in five additional transnasal endoscopic procedures in "virgin" noses and sphenoidal sinuses. RESULTS In both groups studied, we found no difference with regard to either morbidity or mortality, which were null. The mean setup time was 13 minutes shorter in non-image-guided procedures (P = 0.021), and the operative time was 36 minutes shorter in image-guided procedures (P = 0.038). No other statistically significant differences were found between the two groups. In all cases, we found that the system performed without malfunction. Continuous information regarding instrument location and trajectory was provided to the surgeon. Measurements of the intraoperative accuracy in the axial, coronal, and sagittal planes indicated a mean intraoperatively verified system error of 1.6 +/- 0.6 mm. CONCLUSION Neuronavigation can be applied during endonasal transsphenoidal endoscopic surgery and requires a minimal amount of time. It makes reoperation easier, faster, and probably safer.
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Affiliation(s)
- Giovanni Lasio
- Department of Neurosurgery, Istituto Nazionale Neurologico C. Besta, Milan, Italy
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Abstract
Over the past few years, significant contributions have been made to the understanding, diagnosis, and treatment of pituitary tumors. This article reviews recent advances in the areas of biology, diagnostic imaging, medical diagnosis and treatment, surgical results and technique, and adjuvant therapy in the form of radiotherapy and radiosurgery. Of particular note are the roles of endoscopy, intraoperative magnetic resonance imaging, radiosurgery, and radiation for nonfunction tumors, the diagnosis of Cushing's disease, the management of "incidentalomas," and new medication therapies.
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Affiliation(s)
- Paul L Penar
- Division of Neurosurgery, University of Vermont College of Medicine, Fletcher Allen Health Care-MCHV campus, 507 Fletcher House, 111 Colchester Avenue, Burlington, VT 05401, USA.
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