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Li Y, Zhao S, Candiotti K, Su C. Risk Factors Associated with Postoperative Cerebrospinal Fluid Leaks After Intrathecal Drug Delivery System and an External Pump Implantation in Cancer Patients: A Retrospective Study. Pain Ther 2024; 13:637-650. [PMID: 38724744 PMCID: PMC11111433 DOI: 10.1007/s40122-024-00608-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/19/2024] [Indexed: 05/23/2024] Open
Abstract
INTRODUCTION To determine risk factors associated with postoperative cerebrospinal fluid leaks (CSFLs) after intrathecal drug delivery system (IDDS) and external pump implantation. METHODS The clinical data of 248 patients with advanced cancer who underwent IDDS implantation from January 2021 to December 2022 at the Department of Pain Medicine at the Hunan Cancer Hospital were retrospectively reviewed. Information regarding age, gender, height, weight, body mass index (BMI), tumour type, albumin levels, haemoglobin levels, history of diabetes and pre- and postoperative anti-tumour therapy was collected and analysed. RESULTS Postoperative CSFLs occurred in 7 of 231 patients (3.30%). Statistical analysis indicated that gender, age, height, weight, BMI, tumour type, albumin levels, haemoglobin levels, history of diabetes, pre- and postoperative chemotherapy, pre- and postoperative radiotherapy, preoperative immunotherapy and postoperative targeted therapy were not independent factors for CSFLs. Preoperative targeted therapy [odds ratio (OR): 16.64; 95% confidence interval (CI): 1.42, 195.56; P = 0.01] and postoperative immunotherapy (OR: 13.38; 95% CI: 1.60, 111.65; P = 0.017) were factors associated with an increased postoperative CSFL rate. Of the two locations where CSFLs can occur, the back (puncture site of catheter, n = 4) and the hypochondriac region (location of infusion port implanted, n = 3), back CSFLs occurred earlier than in the hypochondriac region (18.25 ± 6.45 vs 115 ± 62.02 days, P = 0.032). CONCLUSION Based on the data from our study, the timing of preoperative targeted therapy and postoperative immunotherapy should be considered to prevent the occurrence of CSFLs in cancer pain patients who have an IDDS and external pump.
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Affiliation(s)
- Yuan Li
- Department of Anesthesiology, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha, 410013, Hunan, China
| | - Shuwu Zhao
- Department of Anesthesiology, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha, 410013, Hunan, China
| | - Keith Candiotti
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Chen Su
- Department of Anesthesiology, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha, 410013, Hunan, China.
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Yan JL, Kan WC, Kuo YH, Chen MY, Chen PY, Fu KH. Impact of metabolic syndrome on postoperative outcomes of transsphenoidal pituitary surgery: analysis of U.S. nationwide inpatient sample data 2005-2018. Front Endocrinol (Lausanne) 2024; 15:1235441. [PMID: 38590825 PMCID: PMC10999562 DOI: 10.3389/fendo.2024.1235441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 02/19/2024] [Indexed: 04/10/2024] Open
Abstract
Introduction Transsphenoidal surgery (TSS) is the preferred surgical method for most pituitary adenomas owing to high efficacy and low mortality. This study aimed to evaluate the influence of metabolic syndrome (MetS) on postoperative outcomes of TSS for pituitary adenoma. Methods This population-based, retrospective observational study extracted data of adults 20-79 y receiving TSS for pituitary adenoma from the US Nationwide Inpatient Sample (NIS) between 2005-2018. Primary outcomes were pituitary-related complications, poor outcomes (i.e., in-hospital mortality or unfavorable discharge), prolonged length of stay (LOS), and patient safety indicators (PSIs). Univariate and multivariate regressions were performed to determine the associations between study variables and outcomes. Results 19,076 patients (representing a 93,185 US in-patient population) were included, among which 2,109 (11.1%) patients had MetS. After adjustment, pre-existing MetS was not significantly associated with presence of pituitary-related complications and poor outcomes. In contrast, MetS was significantly associated with an increased risk for prolonged LOS (adjusted OR (aOR) = 1.19; 95% CI: 1.05-1.34), PSIs (aOR = 1.31; 95% CI: 1.07-1.59) and greater hospital costs (adjusted β = 8.63 thousand USD; 95% CI: 4.98-12.29). Among pituitary-related complications, MetS was independently associated with increased risk of cerebrospinal fluid (CSF) rhinorrhea (aOR = 1.22, 95% CI: 1.01, 1.47) but lowered diabetes insipidus (aOR = 0.83, 95% CI: 0.71, 0.97). Discussion MetS does not pose excessive risk of in-hospital mortality or unfavorable discharge. However, MetS independently predicted having PSIs, prolonged LOS, greater hospital costs, and CSF rhinorrhea. Study findings may help clinicians achieve better risk stratification before TSS.
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Affiliation(s)
- Jiun-Lin Yan
- Department of Neurosurgery, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wan-Chin Kan
- Department of Radiology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yi-Hsien Kuo
- Department of Neurosurgery, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Mao-Yu Chen
- Department of Neurosurgery, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Pin-Yuan Chen
- Department of Neurosurgery, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kuan-Hao Fu
- Department of Neurosurgery, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
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Devarajan A, Vasan V, Dullea JT, Zhang JY, Vasa D, Schupper AJ, Nichols N, Ranti D, McCarthy L, Rao M, Sudhir S, Cho L, Rutland JW, Post KD, Bederson J, Shrivastava RK. Clinical and Operative Risk Factors Associated With Prolonged Length of Stay After Endoscopic Pituitary Adenoma Resection. Neurosurgery 2024:00006123-990000000-01072. [PMID: 38421190 DOI: 10.1227/neu.0000000000002890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 01/04/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Pituitary adenomas (PAs) are the most common intrasellar tumor. Clinically relevant adenomas have a prevalence of 1 per 1000 in the general population. Transsphenoidal surgery (TSS) is the most common surgical treatment and is the first-line management for most PAs. Most patients fare well postoperatively, but a subset of patients experience a prolonged length of stay (PLOS). In this article, we aim to identify demographic and clinical factors associated with PLOS after TSS for PA. METHODS Patients with sellar pathologies surgically treated at a single tertiary center from March 1, 2009, to May 31, 2020, were retrospectively reviewed. All patients older than 18 years receiving nonemergent endoscopic TSS for pituitary adenoma were included. Clinical and demographic characteristics were analyzed using χ2-tests and student t-tests. For those factors with a P-value less than .01, multivariate logistic regression and negative binomial regression models were constructed to estimate the adjusted odds of PLOS across predictive factors. RESULTS A total of 301 patients were included in the study. This cohort had an average age of 54.65 ± 15.06 years and an average body mass index of 29.47 ± 6.69. The median length of stay was 54.9 hours [25th-75th percentiles: 43.5-72.9]. Postoperative cerebrospinal fluid leak (P < .01), postoperative diabetes insipidus (DI) (P < .01), increased surgery duration (P = .01), and elevated maximal tumor dimension (P = .01) were predictive of PLOS in logistic regression. Increased surgery duration, previous pituitary radiation, intraoperative complications, and postoperative DI (all P < .01) were associated with increased rate of PLOS in negative binomial regression. CONCLUSION Patients undergoing endoscopic TSS for PA resection demonstrate prolonged lengths of stay if they have higher tumor burden, have lengthier surgeries with intraoperative complications, or develop postoperative complications such as cerebrospinal fluid leak or DI. Careful monitoring of these factors will allow for better resource optimization, reducing costs to both the hospital and the patient.
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Affiliation(s)
- Alex Devarajan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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4
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Sarkar S, Corrales CE, Laws ER, Smith TR. Intrasellar Arachnoid Diverticulae as a Risk Factor for Intraoperative Cerebrospinal Fluid Leakage in Patients Undergoing Endoscopic Transsphenoidal Surgery. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01057. [PMID: 38329346 DOI: 10.1227/ons.0000000000001079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/19/2023] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Intrasellar arachnoid diverticulae can often be identified on preoperative imaging in patients undergoing endoscopic transsphenoidal surgery. The objective of this study was to characterize arachnoid diverticulae both qualitatively and quantitatively in a large institutional cohort of patients with pituitary tumors and to evaluate its association with intraoperative cerebrospinal fluid (CSF) leak. METHODS Preoperative imaging studies of 530 patients who underwent primary endoscopic transsphenoidal resection of pituitary tumors were examined both quantitatively and qualitatively for the presence of an intrasellar arachnoid diverticulum. A matched cohort analysis was performed to compare patients with a "significant" (>50% sellar depth) diverticulum with those with nonsignificant/no diverticulum. Morphologically, diverticulae were separately classified as Type 1 (ventral CSF cleft with no tumor/gland tissue between sellar face and infundibulum) or Type 2 (central CSF cleft with tumor/gland tissue between sellar face and infundibulum). RESULTS Arachnoid diverticulae were noted in 40.2% of cases, and diverticulum depth was linearly correlated with tumor size and body mass index. A significant diverticulum was identified in 66 cases (12.5%) and was significantly associated with the functional tumor subtype (P = .005) and intraoperative CSF leak (P < .001). Type 1 clefts were associated with nonfunctional pathology (P = .034) and the presence of suprasellar extension (P = .035) and tended to be deeper than Type 2 clefts (P < .001), with a higher incidence of intraoperative CSF leak (P = .093). On logistic regression analysis, only the presence of a significant diverticulum was independently associated with intraoperative CSF leak (odds ratio 4.545; 95% CI 2.418-8.544; P < .001). CONCLUSION The presence of an intrasellar arachnoid diverticulum should alert the surgeon to an elevated risk of intraoperative CSF leak during transsphenoidal surgery for pituitary tumors. A relatively limited surgical exposure tailored to the craniocaudal extent of the sellar pathology should be considered in these patients.
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Affiliation(s)
- Sauradeep Sarkar
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Computatonal Neuroscience Outcomes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - C Eduardo Corrales
- Department of Otolaryngology, Head and Neck Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Edward R Laws
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Computatonal Neuroscience Outcomes Center, Harvard Medical School, Boston, Massachusetts, USA
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5
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Laing B, Best B, Aaronson D, Harrison G, Zwagerman N. Predictors and Complications of Cerebrospinal Fluid Leak after Endoscopic Endonasal Surgery: A Single Institution Retrospective Review. J Neurol Surg B Skull Base 2024; 85:9-14. [PMID: 38274482 PMCID: PMC10807963 DOI: 10.1055/a-1970-7970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 10/25/2022] [Indexed: 12/12/2022] Open
Abstract
Background The endoscopic endonasal approach (EEA) is a commonly used technique for resection of sellar, suprasellar, and anterior fossa masses. One of the most troublesome complications of this technique is cerebrospinal fluid (CSF) leak. In this study, we evaluate the risk factors and consequences of CSF leak on surgical outcomes. Methods The current study is a retrospective single-institution cohort study evaluating patients who underwent EEA for sellar and/or suprasellar masses from July 2017 to March of 2020. Risk factors for intraoperative and postoperative CSF leak were evaluated, including sellar defect size, tumor volume and pathology, age, body mass index, prior endoscopic endonasal surgery, lumbar drain placement, nasoseptal and mucosal graft use, year of surgery, and cavernous sinus invasion. Postoperative infection, perioperative antibiotic use, and length of stay were also evaluated. Results Our study included 175 patients. Sellar defect size ( p = 0.015) and intraoperative CSF leak ( p < 0.001) were significantly associated with an increased risk of postoperative CSF leak. Patients with nasoseptal flaps were more likely to have a postoperative CSF leak than those with free mucosal grafts ( p = 0.025). Intraoperative CSF leak, Cushing's disease, and lumbar drain placement were associated with an increased length of stay. Conclusion Sellar defect size, intraoperative CSF leak, and nasoseptal flap use were associated with an increased risk of postoperative CSF leak. Intraoperative CSF leak, Cushing's disease, and lumbar drain placement are all associated with an increased length of stay.
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Affiliation(s)
- Brandon Laing
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Benjamin Best
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Daniel Aaronson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Gillian Harrison
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Nathan Zwagerman
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
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Zhang H, Peeters S, Vengorivich G, Antoury L, Park KW, Wells C, Suh JD, Lee JT, Heaney A, Bergsneider M, Kim W, Wang MB. Risk Factors Associated with Postoperative CSF Leak in Extrasellar Tumors. J Neurol Surg B Skull Base 2024; 85:15-20. [PMID: 38274484 PMCID: PMC10807959 DOI: 10.1055/s-0042-1760355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/01/2022] [Indexed: 01/18/2023] Open
Abstract
Objective While postoperative cerebrospinal fluid (CSF) leak rates of pituitary tumors have been frequently studied, there are fewer studies examining postoperative CSF leak rates for extrasellar tumors. The purpose of this study was to identify risk factors for the development of postoperative CSF leak in patients undergoing endoscopic surgery for extrasellar tumors. Methods A retrospective chart review was done for patients who underwent endoscopic resection for extrasellar tumors between 2008 and 2020. Age, gender, tumor type, tumor location, tumor size, reconstruction technique, medical comorbidities, and other potential risk factors were identified. Data was analyzed to identify significant risk factors for development of postoperative CSF leak. Results There were 100 patients with extrasellar tumors who developed intraoperative CSF leaks. Seventeen patients (17%) developed postoperative CSF leaks. Leaks occurred at a median of 2 days following surgery (range 0-34 days). Clival tumors had a significantly higher incidence of postoperative leak than those in other sites ( p < 0.05). There were no significant differences in other locations, body mass index, tumor size, reconstruction technique, medical comorbidities, or other factors. There were nearly twice as many intraoperative grade III leaks in those who developed postoperative CSF leak, but this was not statistically significant ( p = 0.12). Conclusion Extrasellar tumors, particularly clival tumors, have a higher rate of postoperative CSF leak than pituitary tumors. Prophylactic lumbar drains can be considered for patients at high risk for developing postoperative CSF leak.
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Affiliation(s)
- Huan Zhang
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, United States
| | - Sophie Peeters
- Department of Neurosurgery, Los Angeles, California, United States
| | - Gennadiy Vengorivich
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, United States
| | - Layal Antoury
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, United States
| | - Ki Wan Park
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, United States
| | - Christine Wells
- Statistical Consulting Group, Los Angeles, California, United States
| | - Jeffrey D. Suh
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, United States
| | - Jivianne T. Lee
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, United States
| | - Anthony Heaney
- Division of Endocrinology, Diabetes, and Metabolism, Los Angeles, California, United States
| | | | - Won Kim
- Department of Neurosurgery, Los Angeles, California, United States
| | - Marilene B. Wang
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, United States
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7
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Zhao J, Wang S, Zhao X, Cui H, Zou C. Risk factors of cerebrospinal fluid leakage after neuroendoscopic transsphenoidal pituitary adenoma resection: a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2024; 14:1263308. [PMID: 38260170 PMCID: PMC10800519 DOI: 10.3389/fendo.2023.1263308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 11/23/2023] [Indexed: 01/24/2024] Open
Abstract
Introduction Cerebro spinal fluid (CSF) leakage is common and might lead to severe postoperative complications after endoscopic transsphenoidal pituitary adenoma resection. However, the risk factors of postoperative CSF leakage are still controversial. This article presents a systematic review to explore the explicit risk factors of CSF leakage after endoscopic transsphenoidal pituitary adenomere section. Methods PRISMA and AMSTAR guidelines were followed to assess the methodological quality of the systematic review. PubMed, Medline, Embase, Web of Science, Cochrane, Clinical Trails, CNKI, CBM, Wan Fang, and VIP databases were searched for all studies on postoperative CSF leak risk factors. The quality of the included studies was assessed by the Newcastle-Ottawa scale. Review Manager 5.4 software was used to calculate the pooled effect size of potential factors with statistical significance. Results A total of 6775 patients with pituitary adenoma across 18 articles were included, containing 482 cases of postoperative CSF leakage (accounting for 7.11%). All of the articles had a quality score > 5, indicating good quality. Meta-analysis showed that an increased risk of CSF leak was found for higher levels of BMI (MD=1.91, 95% CI (0.86,2.96), bigger tumor size [OR=4.93, 95% CI (1.41,17.26)], greater tumor invasion (OR=3.01, 95% CI (1.71, 5.31), the harder texture of tumor [OR=2.65, 95% CI (1.95,3.62)], intraoperative cerebrospinal fluid leakage [OR=5.61, 95% CI (3.53,8.90)], multiple operations [OR=2.27, 95% CI (1.60,3.23)]. Conclusion BMI, multiple operations, tumor size, tumor invasion, hard texture, and intraoperative cerebrospinal fluid leakage are the risk factors of postoperative CSF leakage. Clinical doctors should pay attention to these risk factors, and conduct strict skull base reconstruction and careful postoperative management.
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Affiliation(s)
| | | | | | | | - Cunyi Zou
- Department of Neurosurgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
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Drexler R, Rotermund R, Smith TR, Kilgallon JL, Honegger J, Nasi-Kordhishti I, Gardner PA, Gersey ZC, Abdallah HM, Jane JA, Marino AC, Knappe UJ, Uksul N, Rzaev JA, Galushko EV, Gormolysova EV, Bervitskiy AV, Schroeder HWS, Eördögh M, Losa M, Mortini P, Gerlach R, Azab M, Budohoski KP, Rennert RC, Karsy M, Couldwell WT, Antunes ACM, Westphal M, Ricklefs FL, Flitsch J. Defining benchmark outcomes for transsphenoidal surgery of pituitary adenomas: a multicenter analysis. Eur J Endocrinol 2023; 189:379-386. [PMID: 37668325 DOI: 10.1093/ejendo/lvad124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/14/2023] [Accepted: 08/01/2023] [Indexed: 09/06/2023]
Abstract
IMPORTANCE Benchmarks aid in improve outcomes for surgical procedures. However, best achievable results that have been validated internationally for transsphenoidal surgery (TS) are not available. OBJECTIVE We aimed to establish standardized outcome benchmarks for TS of pituitary adenomas. DESIGN A total of 2685 transsphenoidal tumor resections from 9 expert centers in 3 continents were analyzed. SETTING Patients were risk stratified, and the median values of each center's outcomes were established. The benchmark was defined as the 75th percentile of all median values for a particular outcome. The postoperative benchmark outcomes included surgical factors, endocrinology-specific values, and neurology-specific values. RESULTS Of 2685 patients, 1149 (42.8%) defined the low-risk benchmark cohort. Within these benchmark cases, 831 (72.3%) patients underwent microscopic TS, and 308 (26.8%) patients underwent endoscopic endonasal resection. Of all tumors, 799 (29.8%) cases invaded the cavernous sinus. The postoperative complication rate was 19.6% with mortality between 0.0% and 0.8%. Benchmark cutoffs were ≤2.9% for reoperation rate, ≤1.9% for cerebrospinal fluid leak requiring intervention, and ≤15.5% for transient diabetes insipidus. At 6 months, benchmark cutoffs were calculated as follows: readmission rate: ≤6.9%, new hypopituitarism ≤6.0%, and tumor remnant ≤19.2%. CONCLUSIONS This analysis defines benchmark values for TS targeting morbidity and mortality and represents the best outcomes in the best patients in expert centers. These cutoffs can be used to assess different centers, patient populations, and novel surgical techniques. It should be noted that the benchmark values may influence each other and must be evaluated in their own context.
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Affiliation(s)
- Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - John L Kilgallon
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Jürgen Honegger
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Isabella Nasi-Kordhishti
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Paul A Gardner
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Zachary C Gersey
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Hussein M Abdallah
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - John A Jane
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Alexandria C Marino
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Hospital Minden, Ruhr-University Bochum, Minden, Germany
| | - Nesrin Uksul
- Department of Neurosurgery, Johannes Wesling Hospital Minden, Ruhr-University Bochum, Minden, Germany
| | - Jamil A Rzaev
- Department of Neurosurgery, Federal Center of Neurosurgery, Novosibirsk, Russia
- Department of Neurosurgery, Novosibirsk State Medical University, Novosibirsk, Russia
| | - Evgeniy V Galushko
- Department of Neurosurgery, Federal Center of Neurosurgery, Novosibirsk, Russia
| | | | - Anatoliy V Bervitskiy
- Department of Neurosurgery, Federal Center of Neurosurgery, Novosibirsk, Russia
- Department of Neurosurgery, Novosibirsk State Medical University, Novosibirsk, Russia
| | - Henry W S Schroeder
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Márton Eördögh
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Rüdiger Gerlach
- Department of Neurosurgery, Helios Kliniken, Erfurt, Germany
| | - Mohammed Azab
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - Karol P Budohoski
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - Robert C Rennert
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - Michael Karsy
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - Apio C M Antunes
- Department of Neurosurgery, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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9
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Carretta A, Zoli M, Guaraldi F, Sollini G, Rustici A, Asioli S, Faustini-Fustini M, Pasquini E, Mazzatenta D. Endoscopic Endonasal Transplanum-Transtuberculum Approach for Pituitary Adenomas/PitNET: 25 Years of Experience. Brain Sci 2023; 13:1121. [PMID: 37509051 PMCID: PMC10377303 DOI: 10.3390/brainsci13071121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/16/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
The role of the endoscopic transplanum-transtuberculum approach (ETTA) in the treatment of pituitary adenomas/PitNETs (PAs) is sparsely analyzed in the literature, and its use is still debated in the current practice. The aim of this study was to report our experience with this approach. Our institutional registry was retrospectively reviewed, and patients who underwent ETTA for a PA from 1998 to 2022 were included. Fifty-seven cases were enrolled over a time span of 25 years, corresponding to 2.4% of our entire PA caseload. Radical resection was achieved in 57.9% of cases, with re-do surgery (p = 0.033) and vessel encasement/engulfment (p < 0.001) as predictors of partial resection. CSF leak incidence stood at 8.8%, with higher BMI (p = 0.038) as its only significant predictor. Partial or full improvement of the visual field deficits was achieved in 73.5% of cases. No surgical mortality was observed. According to our results, ETTA for the treatment of PAs is characterized by a satisfactory surgical outcome but with greater morbidity than the conventional endoscopic approach. Therefore, it should be reserved for the few selected cases otherwise unsuitable for the endoscopic trans-sphenoidal route, representing a valid alternative and an effective complementary route for the transcranial approach for these challenging PAs.
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Affiliation(s)
- Alessandro Carretta
- Department of Bio-Medical and Neuromotor Sciences (DIBINEM), University of Bologna, 40138 Bologna, Italy
| | - Matteo Zoli
- Department of Bio-Medical and Neuromotor Sciences (DIBINEM), University of Bologna, 40138 Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi-Pituitary Unit, 40139, Bologna, Italy
| | - Federica Guaraldi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi-Pituitary Unit, 40139, Bologna, Italy
| | - Giacomo Sollini
- ENT Unit, Bellaria Hospital, Azienda USL Bologna, 40139 Bologna, Italy
| | - Arianna Rustici
- Department of Bio-Medical and Neuromotor Sciences (DIBINEM), University of Bologna, 40138 Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Neuroradiology Unit, Ospedale Maggiore, 40139 Bologna, Italy
| | - Sofia Asioli
- Department of Bio-Medical and Neuromotor Sciences (DIBINEM), University of Bologna, 40138 Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy
| | - Marco Faustini-Fustini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi-Pituitary Unit, 40139, Bologna, Italy
| | - Ernesto Pasquini
- ENT Unit, Bellaria Hospital, Azienda USL Bologna, 40139 Bologna, Italy
| | - Diego Mazzatenta
- Department of Bio-Medical and Neuromotor Sciences (DIBINEM), University of Bologna, 40138 Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi-Pituitary Unit, 40139, Bologna, Italy
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10
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Huang Y, Zheng T, Liu Y, Fang R. Comparison of microscopic transsphenoidal surgery and neuroendoscopic transsphenoidal surgery in pituitary adenoma resection and the risk factors of postoperative cerebrospinal fluid leakage. Am J Transl Res 2023; 15:4746-4754. [PMID: 37560241 PMCID: PMC10408534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/08/2023] [Indexed: 08/11/2023]
Abstract
OBJECTIVE To compare microscopic transsphenoidal surgery (MTS) and neuroendoscopic transsphenoidal surgery (NTS) in pituitary adenoma (PA) resection and analyze the risk factors of postoperative cerebrospinal fluid leakage (CFL). METHODS The clinical data of 127 patients with PA treated in Xi'an International Medical Center Hospital from January 2019 to January 2021 were analyzed retrospectively. Among them, 54 patients treated by MTS for PA resection were assigned to the control group, while the rest of the 73 patients treated by NTS for PA resection were assigned to the study group. The total tumor resection rate, decrease of hormone levels after operation, alleviation of primary symptoms and complications were compared between the two groups. Logistics regression analysis was conducted to analyze the risk factors of CFL. RESULTS The control group experienced a shorter operation time than the study group (P<0.001). The resection rates of the control and study groups were comparable, but the study group showed a lower incidence of postoperative complications than the control group (P = 0.004). In addition, the study group showed better alleviation of primary symptoms than the control group (P = 0.013). After surgery, the two groups presented decreased levels of prolactin and growth hormone (P<0.001), and also showed decreased average adrenocorticotropic hormone (P<0.001). Moreover, the two groups were not significantly different in the levels of prolactin, growth hormone and adrenocorticotropic hormone after surgery (P>0.05). According to multivariate logistics regression analysis, body mass index (BMI) (P = 0.003, OR = 8.791, 95% CI: 2.050-37.693), intraoperative CFL (P = 0.002, OR = 21.614, 95% CI: 0.305-153.162) and therapeutic regimen (P = 0.011, OR = 7.060, 95% CI: 1.554-32.076) were independent risk factors for postoperative CFL. CONCLUSION Compared with MTS, endoscopic transsphenoidal surgery requires a notably longer time, but it can strongly improve the total resection rate of patients and reduce the incidence of postoperative complications. Endoscopic surgery is a protective factor of postoperative CFL.
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Affiliation(s)
- Yuanzhi Huang
- Department of Neurosurgery, Xi’an International Medical Center HospitalXi’an 710100, Shaanxi, China
| | - Tao Zheng
- Department of Neurosurgery, Xi’an International Medical Center HospitalXi’an 710100, Shaanxi, China
| | - Yang Liu
- Department of Neurosurgery, Xi’an International Medical Center HospitalXi’an 710100, Shaanxi, China
| | - Rongjin Fang
- Department of Neurosurgery, Ankang Hospital of Traditional Chinese MedicineAnkang 725000, Shaanxi, China
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11
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Fong KY, Lim MJR, Fu S, Low CE, Chan YH, Deepak DS, Xu X, Thong M, Jain S, Teo K, Gardner PA, Snyderman CH, Nga VDW, Yeo TT. Postsurgical outcomes of nonfunctioning pituitary adenomas: a patient-level meta-analysis. Pituitary 2023:10.1007/s11102-023-01335-2. [PMID: 37389776 DOI: 10.1007/s11102-023-01335-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Surgical resection is the main treatment for symptomatic nonfunctioning pituitary adenomas (NFPA). We aimed to analyze the impact of surgical approach, completeness of resection, and postoperative radiotherapy on long-term progression-free survival (PFS) of NFPA, using individual patient data (IPD) meta-analysis. METHODS An electronic literature searched was conducted on PubMed, EMBASE, and Web of Science from database inception to 6 November 2022. Studies describing the natural history of surgically resected NFPA, with provision of Kaplan-Meier curves, were included. These were digitized to obtain IPD, which was pooled in one-stage and two-stage meta-analysis to determine hazard ratios (HRs) and 95%CIs of gross total resection (GTR) versus subtotal resection (STR), and postoperative radiotherapy versus none. An indirect analysis of single-arm data between endoscopic endonasal (EES) and microscopic transsphenoidal (MTS) surgical technique was also performed. RESULTS Altogether, eleven studies (3941 patients) were retrieved. PFS was significantly lower in STR than GTR (shared-frailty HR 0.32, 95%CI 0.27-0.39, p < 0.001). Postoperative radiotherapy significantly improved PFS compared to no radiotherapy (shared-frailty HR 0.20, 95%CI 0.15-0.26, p < 0.001), including in the subgroup of patients with STR (shared-frailty HR 0.12, 95%CI 0.08-0.18, p < 0.001). Similar PFS was observed between EES and MTS (indirect HR 1.09, 95%CI 0.92-1.30, p = 0.301). CONCLUSIONS This systematic review and patient-level meta-analysis provides a robust prognostication of surgically treated NFPA. We reinforce current guidelines stating that GTR should be the standard of surgical resection. Postoperative radiotherapy is of considerable benefit, especially for patients with STR. Surgical approach does not significantly affect long-term prognosis. REGISTRATION PROSPERO CRD42022374034.
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Affiliation(s)
- Khi Yung Fong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mervyn Jun Rui Lim
- Division of Neurosurgery, University Surgical Centre, National University Hospital, Singapore, Singapore.
- Division of Neurosurgery, University Surgical Centre, National University Hospital, Level 8, National University Health Systems Tower Block, 1E Kent Ridge Rd, Singapore, 119228, Singapore.
| | - Shuning Fu
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Chen Ee Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Xinni Xu
- Division of Otolaryngology - Head & Neck Surgery, National University Hospital, Singapore, Singapore
| | - Mark Thong
- Division of Otolaryngology - Head & Neck Surgery, National University Hospital, Singapore, Singapore
| | - Swati Jain
- Division of Neurosurgery, University Surgical Centre, National University Hospital, Singapore, Singapore
| | - Kejia Teo
- Division of Neurosurgery, University Surgical Centre, National University Hospital, Singapore, Singapore
| | - Paul A Gardner
- Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Vincent Diong Weng Nga
- Division of Neurosurgery, University Surgical Centre, National University Hospital, Singapore, Singapore
| | - Tseng Tsai Yeo
- Division of Neurosurgery, University Surgical Centre, National University Hospital, Singapore, Singapore
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12
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Baig Mirza A, Boardman T, Okasha M, El-Hariri HM, Al Banna Q, Syrris C, Baig Mirza K, Vastani A, Visagan R, Shapey J, Maratos E, Barazi S, Thomas N. Fat in the Fossa and the Sphenoid Sinus: A Simple and Effective Solution to CSF Leaks in Transsphenoidal Surgery. Cohort Study and Systematic Review. J Neurol Surg B Skull Base 2023; 84:143-156. [PMID: 36895808 PMCID: PMC9991530 DOI: 10.1055/a-1757-3069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 01/30/2022] [Indexed: 10/19/2022] Open
Abstract
Objectives Cerebrospinal fluid (CSF) leak following endoscopic transsphenoidal surgery (TSS) remains a challenge and is associated with high morbidity. We perform a primary repair with f at in the pituitary f ossa and further fat in the s phenoid sinus (FFS). We compare the efficacy of this FFS technique with other repair methods and perform a systematic review. Design, Patients, and Methods This is a retrospective analysis of patients undergoing standard TSS from 2009 to 2020, comparing the incidence of significant postoperative CSF rhinorrhea (requiring intervention) using the FFS technique compared with other intraoperative repair strategies. Systematic review of current repair methods described in the literature was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Results In all, there were 439 patients, with 276 patients undergoing multilayer repair, 68 patients FFS repair, and 95 patients no repair. No significant differences were observed in baseline demographics between the groups. Postoperative CSF leak requiring intervention was significantly lower in the FFS repair group (4.4%) compared with the multilayer (20.3%) and no repair groups (12.6%, p < 0.01). This translated to fewer reoperations (2.9% FFS vs. 13.4% multilayer vs. 8.4% no repair, p < 0.05), fewer lumbar drains (2.9% FFS vs. 15.6% multilayer vs. 5.3% no repair, p < 0.01), and shorter hospital stay (median days: 4 [3-7] FFS vs. 6 (5-10) multilayer vs. 5 (3-7) no repair, p < 0.01). Risk factors for postoperative leak included female gender, perioperative lumbar drain, and intraoperative leak. Conclusion Autologous fat on fat graft for standard endoscopic transsphenoidal approach effectively reduces the risk of significant postoperative CSF leak with reduced reoperation and shorter hospital stay.
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Affiliation(s)
- Asfand Baig Mirza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Timothy Boardman
- GKT School of Medical Education, King's College London, London, United Kingdom
| | - Mohamed Okasha
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Qusai Al Banna
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Christoforos Syrris
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Amisha Vastani
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Ravindran Visagan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Jonathan Shapey
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom.,Department of Surgical and Interventional Engineering, School of Biomedical Engineering and Imaging Science, King's College London, United Kingdom
| | - Eleni Maratos
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Sinan Barazi
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Nick Thomas
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
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13
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Cutri RM, Shibata SB, Zhang H, Gantz BJ, Hansen MR. Incidence of Postoperative CSF Leaks in Class III Obese Patients Undergoing Middle Cranial Fossa Approach for Spontaneous CSF Leak Repair. Otol Neurotol 2023; 44:382-387. [PMID: 36791337 DOI: 10.1097/mao.0000000000003827] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
OBJECTIVE To determine the safety and effectiveness of the middle cranial fossa (MCF) approach for spontaneous cerebrospinal fluid leak (sCSF-L) repair in class III obese patients. To also assess the need for prophylactic lumbar drain (LD) placement in this patient population. STUDY DESIGN Retrospective cohort study. SETTING Tertiary Academic Center. PATIENTS All patients older than 18 years undergoing sCSF-L repair with an MCF approach. INTERVENTION An MCF craniotomy for sCSF-L repair. MAIN OUTCOME MEASURE Rate of complications and postoperative leaks. RESULTS There were no perioperative complications in 78.9% (56/71) of cases. The surgical complication rate was 12.5% (2/16), 10% (2/20), and 22.2% (6/27) in class I, class II, and class III obese patients. There was no statistically significant difference in complications among these three groups. The most common postoperative complication was a persistent CSF leak in the acute postoperative period with an overall rate of 9.9% (7/71) with six of the seven patients requiring postoperative LD placement. The percentage of postoperative CSF leaks in nonobese, class I, class II, and class III patients were 25% (2/8), 12.5% (2/16), 0% (0/20), and 11.1% (3/27), respectively. There was no statistically significant difference in the rate of postoperative CSF leaks among the four groups (chi-square, p = 0.48). In all cases, the acute postoperative CSF leaks resolved in the long term and did not require further surgical repair. CONCLUSIONS We determine that MCF craniotomy repair for sCSF-Ls is safe in patients with class III obesity, and the incidence of postoperative CSF leaks did not vary among other obesity classes. We also find that prophylactic placement of LDs is not routinely needed in this population.
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Affiliation(s)
- Raffaello M Cutri
- Keck School of Medicine, University of Southern California. Los Angeles, California
| | - Seiji B Shibata
- Department of Otolaryngology, University of Southern California. Los Angeles, California
| | - Huan Zhang
- Department of Otolaryngology, University of California Los Angeles. Los Angeles, California
| | - Bruce J Gantz
- Department of Otolaryngology-Head & Neck Surgery University of Iowa Hospitals & Clinics. Iowa City, Iowa
| | - Marlan R Hansen
- Department of Otolaryngology-Head & Neck Surgery University of Iowa Hospitals & Clinics. Iowa City, Iowa
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14
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Hirbo Guyolla Y, Biluts Mersha H, Tesfaye Abebe F. Predictors of cerebrospinal fluid leakage after elective cranial surgery. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2022.101704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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15
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Conrad J, Blaese M, Becker S, Huppertz T, Ayyad A, Ringel F. Sinonasal Outcome After Endoscopic Transnasal Surgery-A Prospective Rhinological Study. Oper Neurosurg (Hagerstown) 2023; 24:223-231. [PMID: 36701557 DOI: 10.1227/ons.0000000000000532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 09/17/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The sinonasal outcome after transnasal skull base surgery has often been neglected aside from major outcome criteria as extent of tumor resection, ophthalmological, and endocrinological parameters. OBJECTIVE To analyze rhinological outcome after endoscopic transnasal neurosurgery. METHODS Patients were treated using a middle turbinate-preserving transnasal endoscopic approach for sellar/parasellar lesions. As major variables, olfactory function and nose breathing ability were assessed. The study participants were investigated by odor testing ("Sniffin' sticks"), rhinomanometry, and endoscopic inspection of the nasal cavity before and 6 months after surgery. Furthermore, sinonasal-associated quality of life was measured before, immediately and 6 months after surgery with a standardized questionnaire (SNOT-20-GAV). RESULTS Eighty-two patients (47 male, 35 female, median age 55 years) matched the inclusion criteria. Before surgery, the average odor was found to be 30.75 (≥31 = normosmia); in the postinterventional examination at 6 months, the average increased to 33.08 (n.s.). Rhinomanometric examination of binostril nasal airflow showed an average of 590.42 mL/s on inspiration before and an increase to 729.78 mL/s at 6 months after surgery. SNOT-20 symptom scores had a maximum score right after and no difference at 6 months after surgery (scores 23.76 and 14.91 vs 15.53 before surgery). CONCLUSION Based on the study, the endoscopic transnasal technique preserving the middle turbinate has no significant negative effects on the rhinological outcome.
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Affiliation(s)
- Jens Conrad
- Department of Neurosurgery, University Medical Center Mainz, Germany
| | - Marco Blaese
- Department of Neurosurgery, University Medical Center Mainz, Germany
| | - Sven Becker
- Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Center Mainz, Germany
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Tübingen Medical Center, Tübingen, Germany
| | - Tilman Huppertz
- Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Center Mainz, Germany
| | - Ali Ayyad
- Department of Neurosurgery, University Medical Center Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, Germany
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16
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CSF rhinorrhoea after endonasal intervention to the skull base (CRANIAL): A multicentre prospective observational study. Front Oncol 2023; 12:1049627. [PMID: 36688936 PMCID: PMC9846732 DOI: 10.3389/fonc.2022.1049627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 10/24/2022] [Indexed: 01/09/2023] Open
Abstract
Objective Despite progress in endonasal skull-base neurosurgery, cerebrospinal fluid (CSF) rhinorrhoea remains common and significant. The CRANIAL study sought to determine 1) the scope of skull-base repair methods used, and 2) corresponding rates of postoperative CSF rhinorrhoea in the endonasal transsphenoidal approach (TSA) and the expanded endonasal approach (EEA) for skull-base tumors. Methods A prospective observational cohort study of 30 centres performing endonasal skull-base neurosurgery in the UK and Ireland (representing 91% of adult units). Patients were identified for 6 months and followed up for 6 months. Data collection and analysis was guided by our published protocol and pilot studies. Descriptive statistics, univariate and multivariable logistic regression models were used for analysis. Results A total of 866 patients were included - 726 TSA (84%) and 140 EEA (16%). There was significant heterogeneity in repair protocols across centres. In TSA cases, nasal packing (519/726, 72%), tissue glues (474/726, 65%) and hemostatic agents (439/726, 61%) were the most common skull base repair techniques. Comparatively, pedicled flaps (90/140, 64%), CSF diversion (38/140, 27%), buttresses (17/140, 12%) and gasket sealing (11/140, 9%) were more commonly used in EEA cases. CSF rhinorrhoea (biochemically confirmed or requiring re-operation) occurred in 3.9% of TSA (28/726) and 7.1% of EEA (10/140) cases. A significant number of patients with CSF rhinorrhoea (15/38, 39%) occurred when no intraoperative CSF leak was reported. On multivariate analysis, there may be marginal benefits with using tissue glues in TSA (OR: 0.2, CI: 0.1-0.7, p<0.01), but no other technique reached significance. There was evidence that certain characteristics make CSF rhinorrhoea more likely - such as previous endonasal surgery and the presence of intraoperative CSF leak. Conclusions There is a wide range of skull base repair techniques used across centres. Overall, CSF rhinorrhoea rates across the UK and Ireland are lower than generally reported in the literature. A large proportion of postoperative leaks occurred in the context of occult intraoperative CSF leaks, and decisions for universal sellar repairs should consider the risks and cost-effectiveness of repair strategies. Future work could include longer-term, higher-volume studies, such as a registry; and high-quality interventional studies.
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17
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Baussart B, Venier A, Jouinot A, Reuter G, Gaillard S. Closure strategy for endoscopic pituitary surgery: Experience from 3015 patients. Front Oncol 2023; 12:1067312. [PMID: 36686774 PMCID: PMC9846073 DOI: 10.3389/fonc.2022.1067312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/05/2022] [Indexed: 01/05/2023] Open
Abstract
Introduction Effective strategies are required to ensure optimal management of the crucial closure step in endoscopic pituitary surgery. Many surgical techniques have been reported but no significant consensus has been defined. Methods Between January 2006 and March 2022, 3015 adult patients with pituitary adenomas were operated on by a single expert neurosurgical team, using a mononostril endoscopic endonasal approach. Based of preoperative risk factors of and operative findings, a detailed closure strategy was used. Body mass index >40, sellar floor lysis, number of surgeries>2, large skull base destruction, prior radiotherapy were considered as preoperative risk factors for closure failure. All patients treated with an expanded endonasal approach were excluded. Results Patients were mostly women (F/M ratio: 1.4) with a median age of 50 (range: 18 -89). Intraoperative CSF leak requiring specific surgical management was observed in 319/3015 (10.6%) of patients. If intraoperative leak occurred, patients with predictive risk factors were managed using a Foley balloon catheter in case of sellar floor lysis or BMI>40 and a multilayer repair strategy with a vascularized nasoseptal flap in other cases. Postoperative CSF leak occurred in 29/3015 (1%) of patients, while meningitis occurred in 24/3015 (0.8%) of patients. In patients with intraoperative leak, closure management failed in 11/319 (3.4%) of cases. Conclusion Based on our significant 16-year experience, our surgical management is reliable and easy to follow. With a planned and stepwise strategy, the closure step can be optimized and tailored to each patient with a very low failure rate.
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Affiliation(s)
- Bertrand Baussart
- Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France,Université Paris Cité, Institut Cochin, CNRS, INSERM, Paris, France,*Correspondence: Bertrand Baussart, ;
| | - Alice Venier
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Anne Jouinot
- Université Paris Cité, Institut Cochin, CNRS, INSERM, Paris, France
| | - Gilles Reuter
- Department of Neurosurgery, Centre Hospitalier Universitaire (CHU) de Liège, Bat B35, Domaine Universitaire du Sart-Tilman, Liège, Belgium
| | - Stephan Gaillard
- Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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18
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Pai KK, Omiunu A, Vedula S, Chemas-Velez MM, Fang CH, Baredes S, Eloy JA. Impact of Prolonged Operative Time on Complications Following Endoscopic Sinonasal Surgery. Laryngoscope 2023; 133:51-58. [PMID: 35174505 DOI: 10.1002/lary.30057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 12/21/2021] [Accepted: 01/24/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine how prolonged operative time (POT) impacts 30-day outcomes in patients undergoing endoscopic sinonasal surgery (ESNS). STUDY DESIGN Retrospective study. METHODS Data from patients who underwent ESNS (nonsinus, sinus, and extended sinus) between 2005 to 2018 were collected from the American College of Surgeons National Surgical Quality Improvement database. Univariate and multivariate analyses were performed to evaluate the effect of POT on postoperative outcomes. RESULTS Among 1,994 ESNS cases, 495 nonsinus procedures, 1,191 sinus procedures, and 308 extended sinus procedures were identified. Median OT was 90 minutes (interquartile range [IQR], 51-165 minutes) for nonsinus procedures, 113 minutes (IQR, 66-189 minutes) for sinus procedures, and 187 minutes (IQR, 137-251 minutes) for extended sinus procedures. Other than older age (P = .008), POT was not significantly associated with baseline demographics and comorbidities for patients undergoing non-sinus procedures. Older age (P < .001), White and Black race (P < .001), ASA physical classifications III or IV (P < .001), and several preoperative comorbidities, including obesity (P = .045), and hypertension (P < .001) were associated with POT for sinus procedures. Older age (P = .030), male sex (P = .010), and lower body mass index (P = .004) were associated with POT for extended sinus procedures. After risk-adjustment, POT was independently associated with prolonged hospital stay (LOS) for all procedure categories, and associated with overall surgical complications and postoperative bleeding for sinus and extended sinus procedures specifically. CONCLUSION POT is independently associated with several adverse outcomes following ESNS, including prolonged LOS, overall surgical complications, and bleeding. Preoperative planning should include optimizing modifiable patient risk factors for POT and identifying surgeon-specific factors to enhance surgical efficiency. LEVEL OF EVIDENCE 4 Laryngoscope, 133:51-58, 2023.
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Affiliation(s)
- Kavya K Pai
- University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, U.S.A
| | - Ariel Omiunu
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Sudeepti Vedula
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Maria Manuela Chemas-Velez
- Department of Otolaryngology and Maxilofacial Surgery, Pontificia Universidad Javeriana, Bogota, Colombia
| | - Christina H Fang
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, U.S.A
| | - Soly Baredes
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Department of Otolaryngology and Facial Plastic Surgery, Saint Barnabas Medical Center-RWJBarnabas Health, Livingston, New Jersey, U.S.A
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19
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Endoscopic Endonasal Skull Base Surgery Complication Avoidance: A Contemporary Review. Brain Sci 2022; 12:brainsci12121685. [PMID: 36552145 PMCID: PMC9776068 DOI: 10.3390/brainsci12121685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/03/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
The endoscopic endonasal approach (EEA) provides a direct trajectory to ventral skull base lesions, avoidance of brain retraction, and clear visualization of cranial nerves as they exit skull base foramina. Despite these benefits, the EEA is not without complications. Here, we review published literature highlighting complications associated with the EEA including cerebrospinal fluid (CSF) leak, cranial nerve (CN) dysfunction, pituitary gland dysfunction, internal carotid artery (ICA) injury, infection, and others; we place special emphasis on discussing the prevention of these complications. As widespread adoption of the EEA continues, it becomes critical to educate surgeons regarding potential complications and their prevention while identifying gaps in the current literature to guide future research and advances in clinical care.
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Piscopo AJ, Dougherty MC, Woodiwiss TR, Ankrah N, Hughes T, Seaman SC, Walsh JE, Graham SM, Greenlee JDW. Endoscopic Reconstruction of the Anterior Skull Base Following Tumor Resection: Application of a Novel Bioabsorbable Plate. Laryngoscope 2022; 133:1092-1098. [PMID: 36477852 DOI: 10.1002/lary.30501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/30/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Endoscopic repair of skull base defects is required following resection of intracranial pathology via the endoscopic endonasal approach (EEA). Many closure techniques have been described, but choosing between techniques remains controversial. We report outcomes of 560 EEA procedures of skull base reconstruction performed on 508 patients over a 15-year-period. Halfway through this period, we adopted the use of a rigid, bioabsorbable extrasellar plate for reconstruction, enabling a comparison between this technique and those used previously. METHODS All patients undergoing EEA from 2005 to 2019 at our institution were retrospectively reviewed. Demographic information, surgical pathology, tumor dimensions and radiographic features, reconstructive technique, and patient-related outcomes were collected and analyzed with univariate and multivariate statistical modeling. RESULTS Five-hundred sixty procedures were performed on 508 patients. The series complication rate was 8.2%. Overall, cerebrospinal fluid (CSF) leak rate was 5.0% but varied significantly across closure techniques (p < 0.001). Critically, the CSF leak rate in the 272 cases prior to our 2013 adoption of the Resorb-X Plate (RXP) was 8.5%, whereas leak rate in the subsequent 288 cases was 1.7%. RXP was protective against CSF leak (p = 0.001), whereas gross total resection (GTR) correlated with increased leak rate (p = 0.001). Patient BMI was significantly associated with risk of leak (p = 0.047). Other variables did not impact leak risk. CONCLUSION Reconstructive technique, extent of resection, and patient BMI significantly contributed to CSF leak rate. GTR was associated with increased leak risk while the RXP was protective. The bioabsorbable RXP is an effective option for rigid skull base repair with comparatively few complications. LEVEL OF EVIDENCE 3 Laryngoscope, 133:1092-1098, 2023.
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Affiliation(s)
| | | | | | - Nii‐Kwanchie Ankrah
- Department of Radiation Oncology University of Alabama at Birmingham Birmingham Alabama USA
| | - Tyler Hughes
- Department of Neurosurgery University of Iowa Iowa City Iowa USA
| | - Scott C. Seaman
- Department of Neurosurgery University of Iowa Iowa City Iowa USA
| | - Jarrett E. Walsh
- Department of Otolaryngology University of Iowa Iowa City Iowa USA
| | - Scott M. Graham
- Department of Otolaryngology University of Iowa Iowa City Iowa USA
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Hanna G, Pando A, Saela S, Emami AP. Cerebrospinal fluid (CSF) leak after elective lumbar spinal fusion: Who is at risk? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:3560-3565. [PMID: 36094667 DOI: 10.1007/s00586-022-07383-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 06/26/2022] [Accepted: 09/04/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE CSF leaks are a known complication of lumbar fusion surgery. There is a scarcity of literature describing the incidence and risk factors associated with this complication. The aim of this study was to identify patients who are at risk of developing postoperative CSF leak. METHODS The Nationwide Inpatient Sample database was used to identify patients who had lumbar fusion in the US from 2002 to 2014. Inpatient outcomes included the incidence and risk of developing CSF leak based on selected patient-specific characteristics. Secondary outcomes included average length of stay, mean costs, and mortality rates. All statistical analyses were conducted based on multivariate regression models using the SPSS software. RESULTS A total of 439,220 patients who underwent elective lumbar fusion procedures were identified. Of these patients, 2.6% (11,636 /439,220) were found to have CSF leak. Independent important risk factors for CSF leak development included: older age (OR: 1.025; 95% CI: 1.02-1.03; p < 0.0001), posterior approach (OR: 1.71; 95% CI: 1.59-1.85; p < 0.0001) compared to anterior approach, chronic deficiency anemia (OR: 1.21; 95% CI:1.14-1.30; p < 0.0001), obesity (OR: 1.22; 95% CI: 1.15-1.30; p < 0.0001), and pulmonary circulatory disease (OR: 1.44; 95% CI: 1.18-1.75; p < 0.0001). CSF leak was associated with increased length of stay (5.39 ± 3.86 vs. 3.74 ± 2.55; p < 0.0001), hospitalization costs (120,129.0 ± 88,123.5 vs. 89,226.8 ± 65,350.3; p < 0.0001) and mortality (0.3% vs. 0.1%; p < 0.05). CONCLUSION Spine surgeons should be aware of certain patient and procedure-specific characteristics that increase the risk of developing postoperative CSF leak after lumbar fusion in order to improve patient outcomes.
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Affiliation(s)
- Gabriel Hanna
- Rutgers New Jersey Medical School, 140 Bergen Street, Newark, NJ, 07103, USA.
| | - Alejandro Pando
- Rutgers New Jersey Medical School, 140 Bergen Street, Newark, NJ, 07103, USA
| | - Stephen Saela
- Saint Joseph Regional Medical Center, Paterson, NJ, USA
| | - Arash P Emami
- Saint Joseph Regional Medical Center, Paterson, NJ, USA
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22
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Sharifi G, Bahranian A, Mohammadi E, Dilmaghani NA. Fat graft in cerebrospinal fluid leak repair after sellar and parasellar lesion surgery of 2000 patients; a multicenter study. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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23
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Villalonga JF, Solari D, Cuocolo R, De Lucia V, Ugga L, Gragnaniello C, Pailler JI, Cervio A, Campero A, Cavallo LM, Cappabianca P. Clinical application of the “sellar barrier’s concept” for predicting intraoperative CSF leak in endoscopic endonasal surgery for pituitary adenomas with a machine learning analysis. Front Surg 2022; 9:934721. [PMID: 36157423 PMCID: PMC9492953 DOI: 10.3389/fsurg.2022.934721] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Recently, it was defined that the sellar barrier entity could be identified as a predictor of cerebrospinal fluid (CSF) intraoperative leakage. The aim of this study is to validate the application of the sellar barrier concept for predicting intraoperative CSF leak in endoscopic endonasal surgery for pituitary adenomas with a machine learning approach. Methods We conducted a prospective cohort study, from June 2019 to September 2020: data from 155 patients with pituitary subdiaphragmatic adenoma operated through endoscopic approach at the Division of Neurosurgery, Università degli Studi di Napoli “Federico II,” were included. Preoperative magnetic resonance images (MRI) and intraoperative findings were analyzed. After processing patient data, the experiment was conducted as a novelty detection problem, splitting outliers (i.e., patients with intraoperative fistula, n = 11/155) and inliers into separate datasets, the latter further separated into training (n = 115/144) and inlier test (n = 29/144) datasets. The machine learning analysis was performed using different novelty detection algorithms [isolation forest, local outlier factor, one-class support vector machine (oSVM)], whose performance was assessed separately and as an ensemble on the inlier and outlier test sets. Results According to the type of sellar barrier, patients were classified into two groups, i.e., strong and weak barrier; a third category of mixed barrier was defined when a case was neither weak nor strong. Significant differences between the three datasets were found for Knosp classification score (p = 0.0015), MRI barrier: strong (p = 1.405 × 10−6), MRI barrier: weak (p = 4.487 × 10−8), intraoperative barrier: strong (p = 2.788 × 10−7), and intraoperative barrier: weak (p = 2.191 × 10−10). We recorded 11 cases of intraoperative leakage that occurred in the majority of patients presenting a weak sellar barrier (p = 4.487 × 10−8) at preoperative MRI. Accuracy, sensitivity, and specificity for outlier detection were 0.70, 0.64, and 0.72 for IF; 0.85, 0.45, and 1.00 for LOF; 0.83, 0.64, and 0.90 for oSVM; and 0.83, 0.55, and 0.93 for the ensemble, respectively. Conclusions There is a true correlation between the type of sellar barrier at MRI and its in vivo features as observed during endoscopic endonasal surgery. The novelty detection models highlighted differences between patients who developed an intraoperative CSF leak and those who did not.
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Affiliation(s)
- J. F. Villalonga
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina
- Correspondence: J. F. Villalonga
| | - D. Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
| | - R. Cuocolo
- Department of Advanced Biomedical Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
| | - V. De Lucia
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
| | - L. Ugga
- Department of Advanced Biomedical Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
| | - C. Gragnaniello
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
- Department of Neurological Surgery, Swedish Neuroscience Institute, Seattle, WA, United States
| | - J. I. Pailler
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina
| | - A. Cervio
- Departamento de Neurocirugía, FLENI, Buenos Aires, Argentina
| | - A. Campero
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina
| | - L. M. Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
| | - P. Cappabianca
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
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Li B, Zhao S, Fang Q, Nie D, Cheng J, Zhu H, Li C, Gui S, Zhang Y, Zhao P. Risk factors and management associated with postoperative cerebrospinal fluid leak after endoscopic endonasal surgery for pituitary adenoma. Front Surg 2022; 9:973834. [PMID: 36157406 PMCID: PMC9489931 DOI: 10.3389/fsurg.2022.973834] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/22/2022] [Indexed: 11/20/2022] Open
Abstract
Objective To determine risk factors and management for the development of a postoperative cerebrospinal fluid (CSF) leak after an endoscopic endonasal surgery (EES) for pituitary adenomas. Methods The clinical data of 400 patients who underwent EES for resection of pituitary adenomas from December 2018 to November 2019 in the Department of Neurosurgery of Beijing Tiantan Hospital were retrospectively reviewed. Age, gender, body mass index (BMI), tumor size, Knosp grade, suprasellar extension grade, sellar floor erosion grade, repeated transsphenoidal surgery, intraoperative CSF leak, use of pedicled nasoseptal flap and lumbar drain were collected and analyzed. Results Postoperative CSF leak occurred in 14 of 400 patients (3.5%). Age, gender, BMI, tumor size, Knosp grade and repeated transsphenoidal surgery were not risk factors for CSF leak. Suprasellar extension grade (≥B 6.0% vs. <B 1.4%; p = 0.024), sellar floor erosion grade (≥III 5.7% vs. <III 0.6%; p = 0.020) and intraoperative CSF leak (Yes 7.5% vs. No 2.0%; p = 0.009) were factors associated with an increased postoperative CSF leak rate. Conclusions Higher suprasellar extension grade, higher sellar floor erosion grade and intraoperative CSF leak were risk factors for postoperative CSF leak after endoscopic treatment of pituitary adenoma. Strict skull base reconstruction including use of a pedicled nasoseptal flap and perioperative lumbar drainage may avoid postoperative CSF leak.
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Affiliation(s)
- Bin Li
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Sida Zhao
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Qiuyue Fang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Ding Nie
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Jianhua Cheng
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Haibo Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chuzhong Li
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Songbai Gui
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yazhuo Zhang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Correspondence: Yazhuo zhang Peng Zhao
| | - Peng Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Correspondence: Yazhuo zhang Peng Zhao
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Al-Qurayshi Z, Bennion DM, Greenlee JDW, Graham SM. Endoscopic pituitary surgery: A national database review. Head Neck 2022; 44:2678-2685. [PMID: 36039744 DOI: 10.1002/hed.27179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 07/04/2022] [Accepted: 08/16/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pituitary tumors surgery is increasingly performed via endoscopic transsphenoidal approach (TSP). This study describes outcomes of TSP surgery in the United States. METHODS A retrospective cross-sectional analysis of adult patients with pituitary adenoma was performed using the Nationwide Readmissions Database, 2010-2015. RESULTS A total of 5891 patients were identified. The average age was 51.29 ± 0.29 years. The risk of postoperative epistaxis, diabetes insipidus, cerebrospinal fluid (CSF) leak, and other general postoperative complications was 0.71%, 10.20%, 8.35%, and 2.37%, respectively. Independent risk factors of CSF leak included: age <65-year, male, body mass index ≥25, and multiple comorbidities (p < 0.001 each). The prevalence of CSF leak was not associated with hospital TSP volume and teaching status. CONCLUSION This study provides a national epidemiological perspective on TSP in the United States. The risk of postoperative CSF leak appears to be associated with intrinsic patient factors rather than resource and expertise availability.
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Affiliation(s)
- Zaid Al-Qurayshi
- Department of Otolaryngology-Head & Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Douglas M Bennion
- Department of Otolaryngology-Head & Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Jeremy D W Greenlee
- Department of Otolaryngology-Head & Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Scott M Graham
- Department of Otolaryngology-Head & Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Factors Influencing Cerebrospinal Fluid Leaking following Pituitary Adenoma Transsphenoidal Surgery: A Meta-Analysis and Comprehensive Review. BIOMED RESEARCH INTERNATIONAL 2022; 2022:5213744. [PMID: 36017392 PMCID: PMC9398767 DOI: 10.1155/2022/5213744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/18/2022] [Accepted: 07/25/2022] [Indexed: 11/18/2022]
Abstract
Background Surgical resection is the main method to treat pituitary adenoma. Cerebrospinal fluid leakage (CSF Leak) is the main complication after transsphenoidal surgery. The impact of postoperative CSF Leak can be predicted in advance, and preventive measures can be taken in time. Clinically, a variety of factors may affect the occurrence of postoperative CSF Leak. In this study, meta-analysis was used to investigate the risk factors of postoperative CSF Leak as a clinical reference. Methods The databases PubMed, Medline, Embrase, Cochrane library, CNKI, and CBM were searched for all studies on the risk factors of postoperative CSF Leak. Studies were screened and finally included. The quality of the included studies was assessed by the Newcastle-Ottawa scale. We used Revman 5.4 software to conduct the pooled effect size of every potential statistically significant factor. Results 13 articles with a total of 5967 patients with pituitary adenoma and 405 cases of postoperative CSF Leak were finally included, accounting for 6.79%. All of the 13 articles had a quality score > 5, indicating good quality. Meta-analysis showed that patient age (OR = 0.71, 95% CI (0.41, 1.20), P = 0.20) was not a factor influencing postoperative CSF Leak, while BMI (MD = 2.26, 95% CI (1.31, 3.20), P < 0.00001), tumor size (MD = 1.35, 95% CI (0.22, 2.49), P = 0.02), whether a second operation was performed (OR = 2.20, 95% CI (1.45, 3.33), P = 0.0002), and intraoperative CSF Leak (OR = 8.88, 95% CI (3.64, 21.69), P < 0.00001) were risk factors for postoperative CSF Leak in patients. Discussion. BMI, tumor size, reoperation, and intraoperative CSF Leak are the risk factors of postoperative CSF Leak. However, not all the factors were covered in this study, it is still worth continuing to deeply investigate in this topic.
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Gong X, Zhuo Y, Yuan H, Yang K, Li C, Feng S, Zhang M, Li Z, Zhou H, Liu Z. Outcome of Endoscopic Transsphenoidal Surgery for Recurrent or Residual Pituitary Adenomas and Comparison to Non-Recurrent or Residual Cohort by Propensity Score Analysis. Front Endocrinol (Lausanne) 2022; 13:837025. [PMID: 35547003 PMCID: PMC9081813 DOI: 10.3389/fendo.2022.837025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/21/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the long-term outcomes and safety of endoscopic transsphenoidal surgery (ETS) in recurrent and residual pituitary adenomas (rrPAs), as well as the predictors of gross total resection (GTR) and intraoperative CSF leakage. Furthermore, to compare outcomes and complications with non-rrPAs cohort. METHODS Clinical and radiological characteristics of patients with rrPAs who underwent ETS were collected between 2017 and 2020. Data of patients with non-rrPAs were collected from 2019 to 2020. Logistic regression analyses were performed to investigate the factors influencing gross total resection (GTR) and intraoperative CSF leakage. Between-group comparisons of outcomes and complications were performed through propensity score analysis. RESULTS We enrolled 73 patients with rrPAs. GTR was achieved in 41 (56.1%) cases; further, GTR or near-total resection was achieved in 93.2% of patients. The mean tumor volumes for GTR and non-GTR cases were 6.2 ±7.2 cm3 and 11.1 ±9.1 cm3, respectively. Multivariate regression analysis of the GTR rate in patients with rrPAs revealed that Knosp grade was an independent factor (odds ratio [OR] = 0.324; p=0.005). Moreover, previous transcranial surgery and non-functional pituitary adenomas were risk factors for intraoperative CSF leakage in patients with rrPAs (OR=6.450, p=0.019 and OR=7.472, p=0.012, respectively). After propensity score matching, There was no significant difference in the GTR rate between patients with rrPAs and patients with non-rrPAs. Contrastingly, patients with rrPAs had a higher rate of intraoperative CSF leakage and longer postoperative hospital stay than patients with non-rrPAs. During the follow-up, vision improved in 9 (22.0%) and 24 (62.5%) patients with rrPAs and non-rrPAs, respectively. Although there was a trend that reoperation of rrPAs involved a lower hypopituitarism recovery rate and biochemical remission rate, as well as a higher hypopituitarism rate, there was no statistically significant between-group difference. CONCLUSIONS Knosp grade was an independent factor for GTR in endoscopic transsphenoidal surgery in patients with rrPAs. Previous transcranial surgery and non-functional PAs were risk factors for intraoperative CSF leakage. Although associated with longer hospital stay, rrPAs did not associate with lower GTR rate or more frequent postoperative complications than non-rrPAs cohort.
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Affiliation(s)
- Xuan Gong
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Yang Zhuo
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Huichun Yuan
- Department of Neurosurgery, The First People’s Hospital of Changde, Changde, China
| | - Kui Yang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Chuntao Li
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Songshan Feng
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Mingyu Zhang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Zhenyan Li
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Hongshu Zhou
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Zhixiong Liu, ; Hongshu Zhou,
| | - Zhixiong Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Zhixiong Liu, ; Hongshu Zhou,
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Wang M, Cai Y, Jiang Y, Peng Y. Risk factors impacting intra- and postoperative cerebrospinal fluid rhinorrhea on the endoscopic treatment of pituitary adenomas: A retrospective study of 250 patients. Medicine (Baltimore) 2021; 100:e27781. [PMID: 34889229 PMCID: PMC8663863 DOI: 10.1097/md.0000000000027781] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 10/28/2021] [Indexed: 01/05/2023] Open
Abstract
We aimed to identify the risk factors associated with intra- and postoperative cerebrospinal fluid (CSF) leakage in pituitary adenomas treated with endoscopic transsphenoidal surgery.This study is a retrospective analysis of 250 pituitary adenoma cases from January 2017 to December 2019 at our hospital. All patients underwent endoscopic endonasal transsphenoidal surgeries. Univariate and multivariate analyses were performed to investigate the risk factors associated with intra- and postoperative CSF rhinorrhea.Eighty (32.0%) and nine (3.6%) patients had intra- and postoperative CSF leakage, respectively. Tumor size was an independent risk factor for intraoperative CSF leakage (odds ratio [OR], 1.229; 95% confidence interval [CI], 1.133-1.334; P < .001); intraoperative CSF leakage was an independent risk factor for postoperative CSF leakage (OR, 7.707; 95% CI, 1.336-44.455; P = .022). Chronic respiratory disease (OR, 57.500; 95% CI, 8.031-411.682; P < .001) was also an independent risk factor for postoperative CSF leakage. Vascularized septal mucosal flap was a protective factor (OR, 0.107; 95% CI, 0.013-0.894; P = .039).Intraoperative CSF leakage is more likely to occur in large pituitary adenomas. In the presence of intraoperative CSF leakage, postoperative CSF rhinorrhea is very likely to occur. Patients with chronic respiratory disease are also more likely to develop postoperative CSF leakage. The sellar base reconstructed using vascularized nasal septal flaps can significantly decrease the risk. The Knosp grade, degree of tumor resection, and postoperative use of a lumbar subarachnoid drain did not have any effects on postoperative CSF rhinorrhea.
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Zhou Z, Zuo F, Chen X, Zhao Q, Luo M, Jiang X, Duan Y. Risk factors for postoperative cerebrospinal fluid leakage after transsphenoidal surgery for pituitary adenoma: a meta-analysis and systematic review. BMC Neurol 2021; 21:417. [PMID: 34706659 PMCID: PMC8555154 DOI: 10.1186/s12883-021-02440-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 10/12/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Postoperative cerebrospinal fluid (CSF) leakage represents a challenge even for experienced pituitary surgeons. We aimed to quantitatively synthesize data from studies regarding the risk factors for postoperative CSF leakage after transsphenoidal surgery (TSS) for pituitary adenoma (PA). METHODS PubMed, Web of Science, The Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), Wanfang database, and VIP database were searched for case-control and cohort studies, focusing on the risk factors associated with postoperative CSF leakage after TSS for PA. Pooled odds ratios (ORs) and 95% confidence intervals were calculated to determine the risk factors. RESULTS A total of 34 case-control and cohort studies involving a total of 9,144 patients with PA were included in this systematic review. The overall rate of postoperative CSF leakage after TSS for PA was 5.6%. Tumor size, adenoma consistency, revision surgery, and intraoperative CSF leakage were independent risk factors for postoperative CSF leakage (ORs, 3.18-6.33). By contrast, the endoscopic approach showed a slight protective benefit compared with the microscopic approach in TSS (OR, 0.69). CONCLUSIONS This review provides a comprehensive overview of the quality of the evidence base, informing clinical staff of the importance of screening risk factors for postoperative CSF leakage after TSS for PA. More attention should be paid to PA patients at high risk for CSF leakage after TSS to reduce complications and improve prognosis.
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Affiliation(s)
- Zhihuan Zhou
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
- Department of Neurosurgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
| | - Feifei Zuo
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
- Department of Neurosurgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
| | - Xiaoqun Chen
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
- Department of Neurosurgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
| | - Qinqin Zhao
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
- Department of Neurosurgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
| | - Mengna Luo
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, PR China
| | - Xiaobing Jiang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
- Department of Neurosurgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
| | - Yuyu Duan
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China.
- Department of Neurosurgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China.
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Nys C, Versyck G, Buelens E, Engelborghs K, Cornips E, Van Leeuwen-Wintjens H, Vankelecom H, Weyns F, Peuskens D. Transnasal transsphenoidal pituitary surgery in a large tertiary hospital, a retrospective study. Acta Chir Belg 2021; 123:272-280. [PMID: 34590931 DOI: 10.1080/00015458.2021.1988231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Pituitary adenomas (PAs), although being small tumours, can have quite an impact on patients' lives causing hormonal and visual disturbances, for which surgery must be performed. As a large peripheral hospital with specialists in pituitary surgery, an assessment of the efficacy and safety of transnasal transsphenoidal pituitary surgery was made. METHODS A retrospective analysis of neurosurgical reports as well as pre and postoperative imaging was made to evaluate the presenting symptoms, tumoural variables, peri-operative morbidity, and long-term outcome. RESULTS This cohort included 105 patients who were operated for PAs over a 9-year period, with a slight male predominance. Adenomas had a mean maximum diameter of almost 25 mm, with one-third of tumours presenting with a Knosp-grade 3 or 4. As expected, most patients presented with either visual (32.4%) or hormonal (40.0%) disturbances. After surgery, 85.3% had complete resolution of visual deficits, and 97.1% had normalisation of hormonal hypersecretion. Postoperative hormonal insufficiency requiring substitution was observed in 43.1% and was significantly more frequent in males and in non-functioning pituitary adenomas (NFAs). Postoperative cerebrospinal fluid (CSF) leakage was observed in 2.9%, and merely one patient developed meningitis. Tumour recurrence was significantly more frequent in patients with partial resection as compared to complete resection (25.6 vs. 7.9%). CONCLUSIONS This study demonstrates that transnasal transsphenoidal pituitary surgery can be performed safely and effectively in a large non-university hospital, improving visual and/or hormonal disturbances as well as providing long-term tumour control. Patients with larger adenomas are at an increased risk to develop postoperative hypopituitarism.
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Affiliation(s)
- Charlotte Nys
- Department of Development and Regeneration, Laboratory of Tissue Plasticity in Health and Disease, Cluster of Stem Cell and Developmental Biology, KU Leuven (University of Leuven), Leuven, Belgium
| | - Georges Versyck
- Department of Neurosurgery, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Eveleen Buelens
- Department of Neurosurgery, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| | - Koen Engelborghs
- Department of Neurosurgery, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| | - Erwin Cornips
- Department of Neurosurgery, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| | | | - Hugo Vankelecom
- Department of Development and Regeneration, Laboratory of Tissue Plasticity in Health and Disease, Cluster of Stem Cell and Developmental Biology, KU Leuven (University of Leuven), Leuven, Belgium
| | - Frank Weyns
- Department of Neurosurgery, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| | - Diederik Peuskens
- Department of Neurosurgery, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
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Omiunu A, Barinsky GL, Fang CH, Grube JG, Hsueh WD, Baredes S, Eloy JA. Factors Associated With Unanticipated Admission After Outpatient Endoscopic Sinonasal Surgery. Laryngoscope 2021; 132:518-522. [PMID: 34125437 DOI: 10.1002/lary.29687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/26/2021] [Accepted: 06/01/2021] [Indexed: 01/27/2023]
Abstract
OBJECTIVES/HYPOTHESIS To identify factors that may increase the risk of unplanned admission following elective outpatient endoscopic sinonasal surgery (ESS). STUDY DESIGN Retrospective analysis of the National Surgical Quality Improvement Program (NSQIP). METHODS All cases of ESS were extracted from the 2010 to 2018 NSQIP database using Current Procedural Terminology codes. Only cases coded as outpatient, elective, and nonemergent procedures were included. Unplanned admissions were defined as cases with a total hospital stay of 1 day or more. Univariate and multivariate analyses were performed to identify variables that independently predicted unanticipated admission. RESULTS A total of 971 cases met inclusion criteria, of which 274 (28.2%) were unanticipated admissions. Patients in the unplanned admission group were more likely to be older (46.8 vs. 41.1 years, P < .001), male (57.7% vs. 48.4%, P = .009), obese (54.8% vs. 43.8%, P = .003), and have hypertension (35.0% vs. 25.0%, P = .002). Unplanned admitted patients were also more likely to be included under American Society of Anesthesiologists (ASA) classification III-IV (43.1% vs. 27.2%, P < .001). There were no significant differences in race, smoking, diabetes, or chronic steroid use. Unplanned admitted patients had a higher rate of surgical complications (2.9% vs. 1.0%, P = .041). Upon multivariate analysis, independent preoperative risk factors for unplanned admission included age (OR: 1.018, P = .002), male gender (OR: 1.415, P = .025), obesity (OR: 1.527, P = .008), and ASA III-IV (OR 1.501, P = .018). CONCLUSIONS Factors independently associated with unplanned admission following outpatient ESS were older age, male gender, obesity, and higher ASA. Identification of patients at risk may reduce unanticipated hospital admission after ESS. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
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Affiliation(s)
- Ariel Omiunu
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Gregory L Barinsky
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Christina H Fang
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Jordon G Grube
- Division of Otolaryngology/Head and Neck Surgery, Department of Surgery, Albany Medical Center, Albany, New York, U.S.A
| | - Wayne D Hsueh
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Soly Baredes
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Jean Anderson Eloy
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Department of Otolaryngology and Facial Plastic Surgery, Saint Barnabas Medical Center - RWJBarnabas Health, Livingston, New Jersey, U.S.A
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32
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Villalonga JF, Solari D, Cavallo LM, Cappabianca P, Prevedello DM, Carrau R, Martinez-Perez R, Hardesty D, Fuchssteiner C, Saenz A, Abbritti RV, Valencia-Ramos C, Kaen A, Bernat AL, Cardenas E, Hirtler L, Gomez-Amador JL, Liu J, Froelich S, Cervio A, Campero A. The sellar barrier on preoperative imaging predicts intraoperative cerebrospinal fluid leak: a prospective multicenter cohort study. Pituitary 2021; 24:27-37. [PMID: 32918661 DOI: 10.1007/s11102-020-01082-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The type of sellar barrier observed between a pituitary tumor and cerebrospinal fluid (CSF) on preoperative magnetic resonance imaging (MRI) may predict intraoperative CSF leak during endonasal pituitary surgery. This is the first multicentric prospective cohort trial to study the sellar barrier concept and CSF leak rate during endoscopic pituitary surgery. METHODS This multi-center, international study enrolled patients operated for pituitary adenomas via fully endoscopic endonasal surgery over a period of 4 months. The independent variable was the subtype of sellar barrier observed on preoperative MRI (strong, mixed or weak); the dependent variable was the presence of an intraoperative CSF leak. The primary goal was to determine the association between a particular type of sellar barrier and the risk of intraoperative CSF leak. Appropriate statistical methods were then applied for data analysis. RESULTS Over the study period, 310 patients underwent endoscopic endonasal surgery for pituitary tumor. Preoperative imaging revealed a weak sellar barrier in 73 (23.55%), a mixed sellar barrier in 75 (24.19%), and a strong sellar barrier in 162 (52.26%) patients. The overall rate of intraoperative CSF leak among all patients was 69 (22.26%). A strong sellar-type barrier was associated with significantly reduced rate of intraoperative CSF leak (RR = 0.08; 95% CI 0.03-0.19; p < 0.0001), while a weak sellar barrier associated with higher rates of CSF leak (RR = 8.54; 95% CI 5.4-13.5; p < 0.0001). CONCLUSIONS The preoperative MRI of pituitary patients can suggest intraoperative CSF leak rates, utilizing the concept of the sellar barrier. Patients with a weak sellar barrier carry a higher risk for an intraoperative CSF leak, whereas a strong sellar barrier on MRI seems to mitigate intraoperative CSF leak. We propose that preoperatively assessment of the sellar barrier can prepare surgeons for intraoperative CSF leak repair.
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Affiliation(s)
- Juan F Villalonga
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Lamadrid 875, San Miguel de Tucumán, Tucumán, Argentina.
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Luigi M Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Paolo Cappabianca
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Daniel M Prevedello
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Ricardo Carrau
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Rafael Martinez-Perez
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Douglas Hardesty
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Christoph Fuchssteiner
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Amparo Saenz
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Lamadrid 875, San Miguel de Tucumán, Tucumán, Argentina
| | | | | | - Ariel Kaen
- Hospital Virgen del Rocío, Sevilla, Spain
| | - Anne-Laure Bernat
- Lariboisière University Hospital - Assistance Publique, Paris, France
| | | | - Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | | | - James Liu
- Rutgers New Jersey Medical School, Newark, NY, USA
| | | | | | - Alvaro Campero
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Lamadrid 875, San Miguel de Tucumán, Tucumán, Argentina
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CSF Rhinorrhoea After Endonasal Intervention to the Skull Base (CRANIAL) - Part 1: Multicenter Pilot Study. World Neurosurg 2021; 149:e1077-e1089. [PMID: 33444844 PMCID: PMC8105646 DOI: 10.1016/j.wneu.2020.12.171] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 01/29/2023]
Abstract
Background CRANIAL (CSF Rhinorrhoea After Endonasal Intervention to the Skull Base) is a prospective multicenter observational study seeking to determine 1) the scope of skull base repair methods used and 2) corresponding rates of postoperative cerebrospinal fluid (CSF) rhinorrhea in the endonasal transsphenoidal approach (TSA) and the expanded endonasal approach (EEA) for skull base tumors. We sought to pilot the project, assessing the feasibility and acceptability by gathering preliminary data. Methods A prospective observational cohort study was piloted at 12 tertiary neurosurgical units in the United Kingdom. Feedback regarding project positives and challenges were qualitatively analyzed. Results A total of 187 cases were included: 159 TSA (85%) and 28 EEA (15%). The most common diseases included pituitary adenomas (n = 142/187), craniopharyngiomas (n = 13/187). and skull base meningiomas (n = 4/187). The most common skull base repair techniques used were tissue glues (n = 132/187, most commonly Tisseel), grafts (n = 94/187, most commonly fat autograft or Spongostan) and vascularized flaps (n = 51/187, most commonly nasoseptal). These repairs were most frequently supported by nasal packs (n = 125/187) and lumbar drains (n = 20/187). Biochemically confirmed CSF rhinorrhea occurred in 6/159 patients undergoing TSA (3.8%) and 2/28 patients undergoing EEA (7.1%). Four patients undergoing TSA (2.5%) and 2 patients undergoing EEA (7.1%) required operative management for CSF rhinorrhea (CSF diversion or direct repair). Qualitative feedback was largely positive (themes included user-friendly and efficient data collection and strong support from senior team members), demonstrating acceptability. Conclusions Our pilot experience highlights the acceptability and feasibility of CRANIAL. There is a precedent for multicenter dissemination of this project, to establish a benchmark of contemporary practice in skull base neurosurgery, particularly with respect to patients undergoing EEA.
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Seaman SC, Moline MJ, Graham SM, Greenlee JD. Endoscopic extrasellar skull base reconstruction using bioabsorbable plates. Am J Otolaryngol 2021; 42:102750. [PMID: 33099231 DOI: 10.1016/j.amjoto.2020.102750] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 10/11/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Many techniques have been utilized for reconstruction of the anterior skull base. Each method has advantages and disadvantages with respect to effectiveness, morbidity, strength, and cost. Rigid reconstruction may provide advantages in certain patients. OBJECTIVE We evaluated all patients who had placement of rigid absorbable reconstruction plates in the anterior skull base in a variety of extrasellar locations and describe results and complications compared with other published techniques. METHODS A retrospective review was conducted of consecutive patients at a tertiary referral institution who underwent endoscopic extrasellar skull base reconstruction, 2012-2019, using resorbable poly (D,L) lactic acid plates (Resorb-X Sellar Wall Plate; KLS Martin; Jacksonville, FL). Data reviewed included demographic information, indication for surgery, location and size of defect, pathology, peri-operative use of cerebrospinal fluid (CSF) diversion, postoperative complications, post-operative CSF leak, adjuvant therapy, and length of follow-up. RESULTS Twenty-four subjects and 25 operative procedures met inclusion criteria. Mean age was 53 years (range 11-77). Average BMI was 34 kg/m2. Mean follow-up time was 30 months (range 1-78). Indications for surgery were CSF rhinorrhea (spontaneous, post-traumatic, or iatrogenic) or reconstruction after tumor resection. Four cases were revision procedures. Twenty patients had lumbar drains placed intraoperatively. Only two nasoseptal flaps and two free mucosal grafts were used. None of the patients had a postoperative CSF leak. There was no mortality or morbidity related to the skull base reconstruction or implanted material. CONCLUSION The Resorb-X resorbable rigid plate provides an effective, customizable, bioabsorbable option that is easily manipulated for skull base reconstruction of defects of a variety of sizes in diverse locations. Reconstruction incorporating this plate provides an effective alternative to other previously described techniques.
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35
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Seaman SC, Ali MS, Marincovich A, Li L, Walsh JE, Greenlee JDW. Minimally Invasive Approaches to Anterior Skull Base Meningiomas. Skull Base Surg 2020; 83:254-264. [DOI: 10.1055/s-0040-1716671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 08/04/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Objective Anterior skull base meningiomas include olfactory groove, planum sphenoidale, and tuberculum sellae lesions. Traditionally, standard craniotomy approaches have been used to access meningiomas in these locations. More recently, minimally invasive techniques including supraorbital and endonasal endoscopic approaches have gained favor; however there are limited published series comparing the use of these two techniques for these meningiomas. Using our patent database, we identified patients who underwent these two approaches, and conducted a retrospective chart review to compare outcomes between these two techniques.
Methods A total of 32 patients who underwent minimally invasive approaches were identified: 20 supraorbital and 11 endoscopic endonasal. Radiographic images, presenting complaints and outcomes, were analyzed retrospectively. The safety of each approach was evaluated.
Results The mean extent of resection through a supraorbital approach was significantly greater than that of the endoscopic endonasal approach, 88.1 vs. 57.9%, respectively (p = 0.016). Overall, preoperative visual acuity and anopsia deficits were more frequent in the endonasal group that persisted postoperatively (visual acuity: p = 0.004; anopsia: p = 0.011). No major complications including cerebrospinal fluid (CSF) leaks or wound-related complications were identified in the supraorbital craniotomy group, while the endonasal group had two CSF leaks requiring lumbar drain placement. Length of stay was shorter in the supraorbital group (3.4 vs. 6.1 days, p < 0.001).
Conclusion Anterior skull base meningiomas can be successfully managed by both supraorbital and endoscopic endonasal approaches. Both approaches provide excellent direct access to tumor in carefully selected patients and are safe and efficient, but patient factors and symptoms should dictate the approach selected.
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Affiliation(s)
- Scott C. Seaman
- Department of Neurological Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Muhammad S. Ali
- Department of Neurological Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Anthony Marincovich
- Department of Neurological Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Luyuan Li
- Department of Neurological Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Jarrett E. Walsh
- Department of Otolaryngology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Jeremy D. W. Greenlee
- Department of Neurological Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
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Sathaporntheera P, Saetia K. Risk factors associated with CSF leakage and complications after retrosigmoid surgery. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100865] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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37
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Wu S, Cui X, Zhang S, Tian W, Liu J, Wu Y, Wu M, Han Y. Economic burden of readmission due to postoperative cerebrospinal fluid leak in Chinese patients. J Comp Eff Res 2020; 9:1105-1115. [PMID: 33112181 DOI: 10.2217/cer-2020-0067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Aim: This real-world data study investigated the economic burden and associated factors of readmissions for cerebrospinal fluid leakage (CSFL) post-cranial, transsphenoidal, or spinal index surgeries. Methods: Costs of CSFL readmissions and index hospitalizations during 2014-2018 were collected. Readmission cost was measured as absolute cost and as percentage of index hospitalization cost. Factors associated with readmission cost were explored using generalized linear models. Results: Readmission cost averaged US$2407-6106, 35-94% of index hospitalization cost. Pharmacy costs were the leading contributor. Generalized linear models showed transsphenoidal index surgery and surgical treatment for CSFL were associated with higher readmission costs. Conclusion: CSFL readmissions are a significant economic burden in China. Factors associated with higher readmission cost should be monitored.
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Affiliation(s)
| | - Xin Cui
- Shanghai Information Center for Health, Shanghai, PR China
| | - Shaoyu Zhang
- Shanghai Information Center for Health, Shanghai, PR China
| | - Wenqi Tian
- Shanghai Information Center for Health, Shanghai, PR China
| | - Jiazhen Liu
- Shanghai Information Center for Health, Shanghai, PR China
| | - Yiqing Wu
- Johnson & Johnson Medical Shanghai, Shanghai, PR China
| | - Man Wu
- Johnson & Johnson Medical Shanghai, Shanghai, PR China
| | - Yi Han
- Health Economics Research Institute, Sun Yat-Sen University, Guangzhou, Guangdong Province, PR China
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Butenschoen VM, Schwendinger N, von Werder A, Bette S, Wienke M, Meyer B, Gempt J. Visual acuity and its postoperative outcome after transsphenoidal adenoma resection. Neurosurg Rev 2020; 44:2245-2251. [PMID: 33040306 PMCID: PMC8338826 DOI: 10.1007/s10143-020-01408-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 09/28/2020] [Accepted: 09/30/2020] [Indexed: 12/04/2022]
Abstract
Transsphenoidal surgery (TSS) represents the gold standard of pituitary adenoma resection, providing a safe and minimal invasive treatment for patients suffering from symptoms of mass effect. The aim of this study is to analyze the postoperative improvement of visual function after adenoma resection and to identify prognostic factors for the postoperative clinical recovery. We performed a retrospective analysis of all consecutive patients treated via a transsphenoidal approach for pituitary adenomas from April 2006 to December 2019 in a high-volume neurosurgical department. Our primary outcome was postoperative visual acuity and visual field impairment; the clinical findings were followed up to 3 months after surgery and correlated with clinical and radiographic findings. In total, 440 surgeries were performed in our department for tumors of the sella region in a time period of 13 years via transsphenoidal approach, and 191 patients included in the analysis. Mean age was 55 years, and 98% were macroadenomas. Mean preoperative visual acuity in patients with preoperative impairment (n = 133) improved significantly from 0.64/0.65 to 0.72/0.75 and 0.76/0.8 (right eye R/left eye L) postoperatively and at 3 months follow-up (p < 0.001). Visual acuity significantly depended on Knosp classification but not Hardy grading. The strongest predictor for visual function recovery was age. Transsphenoidal pituitary tumor resection remains a safe and effective treatment in patients with preoperative visual impairment. It significantly improves visual acuity and field defects after surgery, and recovery continues at the 3 months follow-up examination.
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Affiliation(s)
- Vicki M Butenschoen
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany.
| | - Nina Schwendinger
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Alexander von Werder
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Stefanie Bette
- Abteilung für Diagnostische und Interventionelle Radiologie, Klinikum Augsburg, Augsburg, Germany
| | - Maximilian Wienke
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
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Roca E, Penn DL, Safain MG, Burke WT, Castlen JP, Laws ER. Abdominal Fat Graft for Sellar Reconstruction: Retrospective Outcomes Review and Technical Note. Oper Neurosurg (Hagerstown) 2020; 16:667-674. [PMID: 30124966 DOI: 10.1093/ons/opy219] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 07/14/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The transsphenoidal approach is the standard of care for the treatment of pituitary adenomas and is increasingly employed for many anterior skull base tumors. Persistent postoperative cerebrospinal fluid (CSF) leaks can result in significant complications. OBJECTIVE To analyze our series of patients undergoing abdominal fat graft repair of the sellar floor defect following transsphenoidal surgery, describe and investigate our current, routine technique, and review contemporary and past methods of skull base repair. METHODS A recent consecutive series (2008-2017) of 865 patients who underwent 948 endonasal procedures for lesions of the sella and anterior skull base was retrospectively reviewed. Three hundred eighty patients underwent reconstruction of the sellar defect with an abdominal fat graft. RESULTS The diagnoses of the 380 patients receiving fat grafts were the following: 275 pituitary adenomas (72.4%), 50 Rathke cleft cysts (13.2%), 12 craniopharyngiomas (3.2%), and a variety of other sellar lesions. Fourteen patients had persistent postoperative CSF leak requiring reoperation and included: 5 pituitary adenomas (1.3%), 4 craniopharyngiomas (1.1%), 2 arachnoid cysts (0.53%), 2 prior CSF leaks (0.53%), and 1 Rathke cleft cyst (0.26%). Four patients (1.1%) developed minor abdominal donor site complications requiring reoperation: 1 hematoma, 2 wound complications, and 1 keloid formation resulting in secondary periumbilical infection. CONCLUSION Minimizing postoperative CSF leaks following endonasal anterior skull base surgery is important to decrease morbidity and to avoid a prolonged hospital stay. We present an evolved technique of abdominal fat grafting that is effective and safe and includes minimal morbidity and expense.
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Affiliation(s)
- Elena Roca
- Department of Neurosurgery, Spedali Civili Hospital of Brescia, University of Milan, Milan, Italy
| | - David L Penn
- Department of Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mina G Safain
- Department of Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - William T Burke
- Department of Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joseph P Castlen
- Department of Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edward R Laws
- Department of Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Khan DZ, Bandyopadhyay S, Patel V, Schroeder BE, Cabrilo I, Choi D, Cudlip SA, Donnelly N, Dorward NL, Fountain DM, Grieve J, Halliday J, Kolias AG, Mannion RJ, O'Donnell A, Phillips N, Piper RJ, Ramachandran B, Santarius T, Sayal P, Sharma R, Solomou G, Tysome JR, Marcus HJ, Alalade AF, Ahmed S, Al-Barazi S, Al-Mahfoudh R, Bahl A, Bennett D, Bhalla R, Bhatt P, Dow G, Giamouriadis A, Gilkes C, Gnanalingham K, Hanna B, Hayhurst C, Hempenstall J, Hossain-Ibrahim K, Hughes M, Javadpour M, Jenkins A, Kamel M, Habibullah Khan M, Lacy P, Maratos E, Martin A, Mathad N, Mendoza N, Mirza S, Muquit S, Nair R, Nicholson C, Paluzzi A, Paraskevopoulos D, Pathmanaban O, Pollock J, Ram B, Robertson I, Ross P, Shaw S, Shoakazemi A, Sinha S, Stapleton S, Statham P, Stew B, Thomas N, Tsermoulas G, Weir P, Williams A. CSF rhinorrhoea after endonasal intervention to the anterior skull base (CRANIAL): proposal for a prospective multicentre observational cohort study. Br J Neurosurg 2020; 35:408-417. [PMID: 32909855 DOI: 10.1080/02688697.2020.1795622] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The endonasal transsphenoidal approach (TSA) has emerged as the preferred approach in order to treat pituitary adenoma and related sellar pathologies. The recently adopted expanded endonasal approach (EEA) has improved access to the ventral skull base whilst retaining the principles of minimally invasive surgery. Despite the advantages these approaches offer, cerebrospinal fluid (CSF) rhinorrhoea remains a common complication. There is currently a lack of comparative evidence to guide the best choice of skull base reconstruction, resulting in considerable heterogeneity of current practice. This study aims to determine: (1) the scope of the methods of skull base repair; and (2) the corresponding rates of postoperative CSF rhinorrhoea in contemporary neurosurgical practice in the UK and Ireland. METHODS We will adopt a multicentre, prospective, observational cohort design. All neurosurgical units in the UK and Ireland performing the relevant surgeries (TSA and EEA) will be eligible to participate. Eligible cases will be prospectively recruited over 6 months with 6 months of postoperative follow-up. Data points collected will include: demographics, tumour characteristics, operative data), and postoperative outcomes. Primary outcomes include skull base repair technique and CSF rhinorrhoea (biochemically confirmed and/or requiring intervention) rates. Pooled data will be analysed using descriptive statistics. All skull base repair methods used and CSF leak rates for TSA and EEA will be compared against rates listed in the literature. ETHICS AND DISSEMINATION Formal institutional ethical board review was not required owing to the nature of the study - this was confirmed with the Health Research Authority, UK. CONCLUSIONS The need for this multicentre, prospective, observational study is highlighted by the relative paucity of literature and the resultant lack of consensus on the topic. It is hoped that the results will give insight into contemporary practice in the UK and Ireland and will inform future studies.
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Affiliation(s)
- Danyal Z Khan
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospitals Trust, Cambridge, UK
| | | | - Vikesh Patel
- Department of Neurosurgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Ivan Cabrilo
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - David Choi
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Simon A Cudlip
- Department of Neurosurgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Neil Donnelly
- Department of ENT Surgery, University of Cambridge and Cambridge University Hospitals, Cambridge, UK
| | - Neil L Dorward
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Daniel M Fountain
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK
| | - Joan Grieve
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Jane Halliday
- Department of Neurosurgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospitals Trust, Cambridge, UK
| | - Richard J Mannion
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospitals Trust, Cambridge, UK
| | - Alice O'Donnell
- Birmingham Medical School, University of Birmingham, Birmingham, UK
| | - Nick Phillips
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Clinical lead for Cranial Neurosurgery, Getting it Right First Time, UK
| | - Rory J Piper
- Department of Neurosurgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Bhavna Ramachandran
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospitals Trust, Cambridge, UK
| | - Thomas Santarius
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospitals Trust, Cambridge, UK
| | - Parag Sayal
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Rishi Sharma
- Department of ENT Surgery, University of Cambridge and Cambridge University Hospitals, Cambridge, UK
| | | | - James R Tysome
- Department of ENT Surgery, University of Cambridge and Cambridge University Hospitals, Cambridge, UK
| | - Hani J Marcus
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
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Abhinav K, Tyler M, Dale OT, Mohyeldin A, Fernandez-Miranda JC, Katznelson L. Managing complications of endoscopic transsphenoidal surgery in pituitary adenomas. Expert Rev Endocrinol Metab 2020; 15:311-319. [PMID: 32744080 DOI: 10.1080/17446651.2020.1800452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 07/21/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Over the last two decades there has been a gradual shift from the traditional microscopic approach toward the use of endoscopic endonasal approach for resection of pituitary adenomas. Multiple medical and surgical complications can occur following endoscopic transsphenoidal resection of adenomas. AREAS COVERED We discuss the evolution of the surgical practice from the use of the 'microscope' to the 'endoscope' in the resection of pituitary adenomas. We present a comprehensive review of the medical and surgical complications following surgery with particular emphasis on both the prevention and management of electrolyte disturbance, cerebrospinal fluid leak and the rare but dreaded complication of internal carotid injury (ICA). We also searched the PubMed database to identify relevant literature between 1984 and 2019. EXPERT OPINION Use of endoscope compared with microscope may be associated with better preservation of pituitary gland function with similar extent of resection. Overall medical and surgical complications can be safely managed in high volume centers in association with endocrinologists and skull base trained otolaryngologists. Understanding of anatomico-technical nuances and meticulous surgical technique are important toward preventing ICA injury. Ongoing surgical and technical developments coupled with imaging advances will likely lead to better future outcomes for patients with functioning and nonfunctioning adenomas.
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Affiliation(s)
- Kumar Abhinav
- Department of Neurosurgery, Institute of Clinical Neuroscience, Center for Endoscopic and Pituitary Skull Base Surgery, Southmead Hospital , Bristol, UK
| | - Matthew Tyler
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota , Minneapolis, MN, USA
| | - Oliver T Dale
- Department of ENT-Head and Neck Surgery, University Hospitals Bristol , Bristol, UK
| | - Ahmed Mohyeldin
- Department of Neurosurgery, Stanford University School of Medicine , Stanford, CA, USA
| | | | - Laurence Katznelson
- Department of Neurosurgery, Stanford University School of Medicine , Stanford, CA, USA
- Department of Medicine, Stanford University School of Medicine , Stanford, CA, USA
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Shahrestani S, Ballatori AM, Chen XT, Ton A, Strickland BA, Brunswick A, Zada G. Analysis of modifiable and nonmodifiable risk factors in patients undergoing pituitary surgery. J Neurosurg 2020; 134:1816-1823. [PMID: 32534499 DOI: 10.3171/2020.4.jns20417] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 04/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pituitary adenomas (PAs) are among the most common intracranial tumors. Understanding the clinical effects of various modifiable risk factors (MRFs) and nonmodifiable risk factors (NMRFs) is important in guiding proper treatment, yet there is limited evidence outlining the influence of MRFs and NMRFs on outcomes of PA resection. The aim of this study was to analyze MRFs and NMRFs in patients undergoing resection for PAs. METHODS Using the 2016 and 2017 National Readmission Database, the authors identified a cohort of 9472 patients undergoing microscopic or endoscopic resection of a PA. Patients with nonoverlapping MRFs and NMRFs were analyzed for length of stay (LOS), hospital cost, readmission rates, and postoperative complications. From the original cohort, a subset of 373 frail patients (as defined by the Johns Hopkins Frailty Index) were identified and propensity matched to nonfrail patients. Statistical analysis included 1-way ANOVA, Tukey multiple comparisons of means, odds ratios, Wald testing, and unpaired Welch 2-sample t-tests to compare complications, outcomes, and costs between each cohort. Perioperative outcomes and hospital readmission rates were tracked, and predictive algorithms were developed to establish precise relationships between relevant risk factors and neurosurgical outcomes. RESULTS Malnourished patients had significantly longer LOSs when compared to nonmalnourished patients (p < 0.001). There was a significant positive correlation between the number of MRFs and readmission at 90 days (p = 0.012) and 180 days (p = 0.020). Obese patients had higher rates of postoperative neurological injury at the 30-day follow-up (p = 0.048) compared to patients with normal BMI. Within this NMRF cohort, frail patients were found to have significantly increased hospital LOS (p < 0.001) and total inpatient costs compared to nonfrail patients (p < 0.001). Predictive analytics showed that frail patients had significantly higher readmission rates at both 90-day (p < 0.001) and 180-day follow-ups (p < 0.001). Lastly, rates of acute postsurgical infection were higher in frail patients compared to nonfrail patients (p < 0.001). CONCLUSIONS These findings suggest that both MRFs and NMRFs negatively affect the perioperative outcomes following PA resection. Notable risk factors including malnutrition, obesity, elevated lipid panels, and frailty make patients more prone to prolonged LOS, higher inpatient costs, and readmission. Further prospective research with longitudinal data is required to precisely pinpoint the effects of various risk factors on the outcomes of pituitary surgery.
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Predicting post-operative cerebrospinal fluid (CSF) leak following endoscopic transnasal pituitary and anterior skull base surgery: a multivariate analysis. Acta Neurochir (Wien) 2020; 162:1309-1315. [PMID: 32318930 DOI: 10.1007/s00701-020-04334-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/07/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Post-operative CSF leak is the major source of morbidity following endoscopic transsphenoidal surgery. The purpose of this study was to identify factors associated with post-operative CSF leak in patients undergoing this surgery and facilitate the prospective identification of patients at higher risk of this complication. METHODS A review of a prospectively maintained database containing details of 270 endoscopic transsphenoidal operations performed by the senior author over a 9-year period was performed. Univariate analysis was performed using the Chi-squared and Fisher's exact tests, as appropriate. A logistic regression model was constructed for multivariate analysis. RESULTS The rate of post-operative CSF leak in this series was 9%. On univariate analysis, previous surgery, resection of craniopharyngiomas, adenomas causing Cushing's disease and intra-operative CSF leaks were associated with an increased risk of post-operative CSF leak. The use of a vascularised nasoseptal flap and increasing surgical experience were associated with a decreased rate of CSF leak. On multivariate analysis, a resection of tumour for Cushing's disease (OR 5.79, 95% CI 1.53-21.95, p = 0.01) and an intra-operative CSF leak (OR 4.56, 95% CI 1.56-13.32, p = 0.006) were associated with an increased risk of post-operative CSF leak. Increasing surgical experience (OR 0.14, 95% CI 0.04-0.46, p = 0.001) was strongly associated with a decreased risk of post-operative CSF leak. CONCLUSIONS Increasing surgical experience is a strong predictor of a decreased risk of developing post-operative CSF leak following endoscopic transsphenoidal surgery. Patients with Cushing's disease and those who develop an intra-operative CSF leak should be managed with meticulous skull base repair and close observation for signs of CSF leak post-operatively.
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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Rotman LE, Alford EN, Davis MC, Vaughan TB, Woodworth BA, Riley KO. Preoperative radiographic and clinical factors associated with the visualization of intraoperative cerebrospinal fluid during endoscopic transsphenoidal resection of pituitary adenomas. Surg Neurol Int 2020; 11:59. [PMID: 32363054 PMCID: PMC7193202 DOI: 10.25259/sni_24_2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 03/07/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Intraoperative visualization of cerebrospinal fluid (CSF) during endoscopic endonasal resection of skull base tumors is the most common factor contributing to the development of postoperative CSF leaks. No previous studies have solely evaluated preoperative factors contributing to intraoperative CSF visualization. The purpose of this study was to identify preoperative factors predictive of intraoperative CSF visualization. Methods: Retrospective review of patients who underwent transsphenoidal resection of pituitary adenomas was conducted. Clinical and radiographic variables were compared for those who had CSF visualized to those who did not. Nominal logistic regression models were built to determine predictive variables. Results: Two hundred and sixty patients were included in the study. All significant demographic and radiographic variables on univariate analysis were included in multivariate analysis. Two multivariate models were built, as tumor height and supraclinoid extension were collinear. The first model, which considered tumor height, found that extension into the third ventricle carried a 4.60-fold greater risk of CSF visualization (P = 0.005). Increasing tumor height showed a stepwise, linear increase in risk; tumors >3 cm carried a 19.02-fold greater risk of CSF visualization (P = 0.003). The second model, which considered supraclinoid tumor extension, demonstrated that extension into the third ventricle carried a 4.38-fold increase in risk for CSF visualization (P = 0.010). Supraclinoid extension showed a stepwise, linear increase in intraoperative CSF risk; tumors with >2 cm of extension carried a 9.26-fold increase in risk (P = 0.017). Conclusion: Our findings demonstrate that tumor height, extension into the third ventricle, and extension above the clinoids are predictive of intraoperative CSF visualization.
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Affiliation(s)
- Lauren E Rotman
- Departments of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elizabeth N Alford
- Departments of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Matthew C Davis
- Departments of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - T Brooks Vaughan
- Departments of Endocrinology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bradford A Woodworth
- Departments of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kristen O Riley
- Departments of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
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London NR, Mohyeldin A, Montaser AS, Tanjararak K, Prevedello DM, Otto BA, Carrau RL. Contributing factors for delayed postoperative cerebrospinal fluid leaks and suggested treatment algorithm. Int Forum Allergy Rhinol 2020; 10:779-784. [DOI: 10.1002/alr.22544] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/22/2019] [Accepted: 02/05/2020] [Indexed: 12/26/2022]
Affiliation(s)
- Nyall R. London
- Department of Otolaryngology‒Head and Neck SurgeryThe Ohio State University Columbus OH
- Department of Otolaryngology–Head and Neck SurgeryJohns Hopkins University Baltimore MD
- National Institute on Deafness and Other Communication DisordersNational Institutes of Health Bethesda MD
| | - Ahmed Mohyeldin
- Department of NeurosurgeryThe Ohio State University Columbus OH
| | - Alla S. Montaser
- Department of NeurosurgeryAin Shams University Faculty of Medicine Cairo Egypt
| | - Kangsadarn Tanjararak
- Department of Otolaryngology Head and Neck SurgeryRamathibodi Hospital Faculty of MedicineMahidol University Bangkok Thailand
| | - Daniel M. Prevedello
- Department of Otolaryngology‒Head and Neck SurgeryThe Ohio State University Columbus OH
- Department of NeurosurgeryThe Ohio State University Columbus OH
| | - Bradley A. Otto
- Department of Otolaryngology‒Head and Neck SurgeryThe Ohio State University Columbus OH
- Department of NeurosurgeryThe Ohio State University Columbus OH
| | - Ricardo L. Carrau
- Department of Otolaryngology‒Head and Neck SurgeryThe Ohio State University Columbus OH
- Department of NeurosurgeryThe Ohio State University Columbus OH
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Xue H, Wang X, Yang Z, Bi Z, Liu P. Risk factors and outcomes of cerebrospinal fluid leak related to endoscopic pituitary adenoma surgery. Br J Neurosurg 2020; 34:447-452. [PMID: 32319826 DOI: 10.1080/02688697.2020.1754336] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Hai Xue
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingchao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhijun Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhiyong Bi
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Pinan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neural Reconstruction, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
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Sethi A, Didi M, Dharmaraj P, Ramakrishnan R, Senniappan S, Das U, Avula S, Sinha A, Mallucci C, Weerasinghe K, Daousi C, Gilkes C, Thorp N, Blair J. Obesity is common at diagnosis of childhood pituitary adenoma and may persist following successful treatment. Clin Endocrinol (Oxf) 2020; 92:323-330. [PMID: 31876026 DOI: 10.1111/cen.14146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 12/15/2019] [Accepted: 12/19/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE There is a paucity of data describing long-term outcomes of paediatric patients with pituitary adenoma. In this report, we describe clinical features, treatment and outcomes of a paediatric cohort. DESIGN Retrospective cohort study. PATIENTS Twenty-four white Caucasian patients aged <16 years from a single tertiary care centre in the United Kingdom at diagnosis followed for (median, range) 3.3, 0.7-8.4 years. MEASUREMENTS Clinical and radiological data at diagnosis and follow-up. RESULTS Thirteen patients had prolactinomas (54.1%, age: 15.2 years, 13.2-15.8 years; all females), including ten macroadenomas (11.0-35.0 mm). Patients presented with menstrual disorders (91%), headache (46%), galactorrhoea (46%) and obesity (body mass index [BMI] SDS > 2): (38%). Ten patients with prolactinoma were treated with dopamine agonist alone, 3 also required surgery and 2 patients, cabergoline, surgery plus radiotherapy. Five patients had Cushing's disease (20.8%, age: 14.0, 4.0-15.7 years; 2 female), including one macroadenoma (24 mm). Patients presented with obesity (100%), short stature (60%) and headache (40%). Transsphenoidal resection resulted in biochemical cure (09.00 cortisol < 50 nmol/L). Two patients relapsed 3- and 6 years following surgery, requiring radiotherapy. One patient also required bilateral adrenalectomy. Six patients had nonfunctioning pituitary adenoma (25.0%, age: 15.8, 12.5-16.0 years; 2 female), including two macroadenomas (20.0-53.0 mm). Patients presented with obesity (67%), visual field defects (50%) and headache (50%). Four required surgical resections; two recurred following surgery and required radiotherapy. On latest follow-up; 13 (54.1%) patients were obese (BMI 3.09 SDS; range: 2.05-3.73 SDS). CONCLUSION Obesity is common at diagnosis of pituitary adenoma in childhood and may persist despite successful treatment. Adenomas were larger, more resistant to treatment, and more likely to recur than in adult populations.
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Affiliation(s)
- Aashish Sethi
- Department of Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Mohammed Didi
- Department of Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Poonam Dharmaraj
- Department of Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | | | - Senthil Senniappan
- Department of Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Urmi Das
- Department of Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Shivaram Avula
- Department of Radiology, Alder Hey Children's Hospital, Liverpool, UK
| | - Ajay Sinha
- Department of Neurosurgery, Alder Hey Children's Hospital, Liverpool, UK
| | - Conor Mallucci
- Department of Neurosurgery, Alder Hey Children's Hospital, Liverpool, UK
| | | | | | - Catherine Gilkes
- Department of Endocrinology, Aintree University Hospital, Liverpool, UK
| | - Nicola Thorp
- Department of Clinical Oncology, Clatterbridge Cancer Centre, Bebington, UK
| | - Joanne Blair
- Department of Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
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Abstract
Tuberculum sellae meningiomas are challenging tumors that can cause significant morbidity for patients because of their proximity to critical neurovascular structures. By studying the anatomy of the tuberculum, the manner in which these tumors grow and cause deficits becomes apparent, as also the challenges associated with surgical removal and management. The necessary preoperative workup and grading scales for preoperative evaluation of tuberculum meningiomas are discussed. Traditional open cranial approaches for resection are discussed and contrasted with the endoscopic endonasal approach. Finally, postoperative management, patient outcomes, and adjuvant therapy for management of residual tumor are considered.
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Affiliation(s)
- Stephen T Magill
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
| | - Michael W McDermott
- Miami Neuroscience Institute, Baptist Health of South Florida, Miami, FL, United States; Division of Neuroscience, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, United States
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50
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Singh R, Siddiqui SH, Choi Y, Azmy MC, Patel NM, Grube JG, Hsueh WD, Baredes S, Eloy JA. Morbidity and mortality associated with ventral skull base surgery: analysis of the National Surgical Quality Improvement Program. Int Forum Allergy Rhinol 2019; 9:1485-1491. [DOI: 10.1002/alr.22433] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 07/29/2019] [Accepted: 07/29/2019] [Indexed: 01/13/2023]
Affiliation(s)
- Roshansa Singh
- Department of Otolaryngology–Head and Neck SurgeryRutgers New Jersey Medical School Newark NJ
| | - Sana H. Siddiqui
- Department of Otolaryngology–Head and Neck SurgeryRutgers New Jersey Medical School Newark NJ
| | - Yonghee Choi
- Department of Otolaryngology–Head and Neck SurgeryRutgers New Jersey Medical School Newark NJ
| | - Monica C. Azmy
- Department of Otolaryngology–Head and Neck SurgeryRutgers New Jersey Medical School Newark NJ
| | - Nirali M. Patel
- Department of Otolaryngology–Head and Neck SurgeryRutgers New Jersey Medical School Newark NJ
| | - Jordon G. Grube
- Department of Otolaryngology–Head and Neck SurgeryRutgers New Jersey Medical School Newark NJ
| | - Wayne D. Hsueh
- Department of Otolaryngology–Head and Neck SurgeryRutgers New Jersey Medical School Newark NJ
- Center for Skull Base and Pituitary SurgeryNeurological Institute of New JerseyRutgers New Jersey Medical School Newark NJ
| | - Soly Baredes
- Department of Otolaryngology–Head and Neck SurgeryRutgers New Jersey Medical School Newark NJ
- Center for Skull Base and Pituitary SurgeryNeurological Institute of New JerseyRutgers New Jersey Medical School Newark NJ
| | - Jean Anderson Eloy
- Department of Otolaryngology–Head and Neck SurgeryRutgers New Jersey Medical School Newark NJ
- Center for Skull Base and Pituitary SurgeryNeurological Institute of New JerseyRutgers New Jersey Medical School Newark NJ
- Department of Neurological SurgeryRutgers New Jersey Medical School Newark NJ
- Department of Ophthalmology and Visual ScienceRutgers New Jersey Medical School Newark NJ
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