Endoscopic endonasal trans-sphenoid surgery of pituitary adenoma

Use of a Novel Steerable Tip Suction Cannula in Large and Giant Pituitary Adenomas: A Cadaveric Feasibility Study

ObjectiveThe endoscopic transsphenoidal approach is commonly used for sellar and suprasellar pathologies. However, reaching above the diaphragma sella, especially for posterosuperior and retrocavernous orientation, still poses some challenges. We designed and developed a steerable tip suction cannula (STSC) that has distinct leverage for endoscopic resection of such pathologies.MethodsThe entire suction cannula is made of stainless steel. The instrument consists of a handle, vacuum tube, suction tip bed, suction tip, finger knuckle, wire path, countersunk headpin, and isolated steel wire. The working principle of the product is to enable the surgeon to move the aspiration tip in the desired direction by steering the finger knuckle. Five cadaveric specimens fixed with the saturated salt solution were used to evaluate the instrument and obtain measurements.ResultsIn the straight position, the STSC aspirated 2.67% slower than the control aspirator tip and 13.24% faster than that at 30° angulation. Based on the CT measurements, the mean angulation of the instrument from the frontobasal axis was 38.3°. The mean distance from the frontobasal axis was 1.3 cm. The average angulation of the tip of the instrument in the cranium was 25.5°.ConclusionThe designed STSC might effectively resect large to giant pituitary adenomas, especially those with supradiaphragmatic extension. Its suction capability is comparable to that of conventional suction tubes.

Staged Surgical Treatment of the Giant Pituitary Neuroendocrine Tumors

OBJECTIVE

To investigate the long-term clinical outcomes of staged surgical resection in giant Pituitary Neuroendocrine Tumors.

METHODS

We performed a retrospective analysis of the clinical data of 16 patients who underwent surgery. The patients were diagnosed and underwent surgery at the Department of Neurosurgery of Shiyan Taihe Hospital from January 2013 to March 2021. Among the cases, 12 patients underwent primarily transsphenoidal surgery followed by secondary transcranial surgery, while 4 patients underwent primarily transsphenoidal surgery followed by secondary transsphenoidal surgery. Before the surgery, all patients underwent a pituitary magnetic resonance imaging (MRI) scan, pituitary hormone level examination, visual acuity, and visual field examination. A pituitary MRI was rechecked within 1 week after the operation. A tumor resection rate of 100% on MRI was considered as a total resection, between 90% and 100% as a subtotal resection, and lower than 90% as a partial resection. After the surgery, regular clinical visits and telephone or internet platform follow-ups were conducted.

RESULTS

In our clinical investigation, after staged surgery 10 patients had a total resection, 5 had a subtotal resection, and 1 had a partial resection depending on the tumor size and invasion. The clinical outcomes showed that 1 case suffered from postoperative intracranial infection, 1 case had decreased visual acuity, and 6 cases experienced decreased pituitary function after surgery.Postoperative complications were cured after symptomatic treatment, except for 1 patient who experienced decreased vision and 1 patient sufferred hypopituitarism required long-term oral levothyroxine tablet treatment. No cases of intracranial hemorrhage or death were caused by intentionally staged resection surgery.

CONCLUSIONS

Staged surgery for giant Pituitary Neuroendocrine Tumors is a safe and effective clinical surgery strategy.

Predicting the Consistency of Pituitary Macroadenomas: The Utility of Diffusion-Weighted Imaging and Apparent Diffusion Coefficient Measurements for Surgical Planning

Understanding the consistency of pituitary macroadenomas is crucial for neurosurgeons planning surgery. This retrospective study aimed to evaluate the utility of diffusion-weighted imaging (DWI) and the apparent diffusion coefficient (ADC) as non-invasive imaging modalities for predicting the consistency of pituitary macroadenomas. This could contribute to appropriate surgical planning and therefore reduce the likelihood of incomplete resections. The study included 45 patients with pathologically confirmed pituitary macroadenomas. Conventional MRI sequences, DWIs, ADC maps, and pre- and post-contrast MRIs were performed. Two neuroradiologists assessed all of the images. Neurosurgeons assessed the consistency of the tumor macroscopically, and histopathologists examined it microscopically. The MRI findings were compared with postoperative data. According to the operative data, macroadenomas were divided into the two following categories based on their consistency: aspirable (n = 27) and non-aspirable tumors (n = 18). A statistically significant difference in DWI findings was found when comparing macroadenomas of different consistencies (p < 0.001). Most aspirable macroadenomas (66.7%) were hyperintense according to DWI and hypointense on ADC maps, whereas most non-aspirable macroadenomas (83.3%) were hypointense for DWI and hyperintense on ADC maps. At a cut-off value of 0.63 × 10-3 mm2/s, the ADC showed a sensitivity of 85.7% and a specificity of 75% for the detection of non-aspirable macroadenomas (AUC, 0.946). The study concluded that DWI should be routinely performed in conjunction with ADC measurements in the preoperative evaluation of pituitary macroadenomas. This approach may aid in surgical planning, ensure that appropriate techniques are utilized, and reduce the risk of incomplete resection.

Navigating the Surgical Landscape: A Comprehensive Analysis of Endoscopic vs. Microscopic Transsphenoidal Pituitary Surgery Outcomes

Pituitary surgery, a critical intervention for various pituitary disorders, has sparked ongoing debates regarding the preference between endoscopic and microscopic transsphenoidal approaches. This systematic review delves into the outcomes associated with these techniques, taking into account the recent advancements in neurosurgery. The minimally invasive nature of endoscopy, providing improved visualization and reduced morbidity, stands in contrast to the well-established track record of the conventional microscopic method. Examining outcomes for disorders such as Cushing's disease and acromegaly, the review synthesizes evidence from Denmark, Bulgaria, and China. Noteworthy advantages of endoscopy encompass higher resection rates, shorter surgery durations, and fewer complications, endorsing its effectiveness in pituitary surgery. While emphasizing the necessity for prospective trials, the review concludes that endoscopic approaches consistently showcase favorable outcomes, influencing the ongoing discourse on the optimal surgical strategies for pituitary disorders.

Comparison of the Novel Two-Hand Technique Using the Saraj Endocath with the Traditional Three-Hand Technique in Transnasal Endoscopic Pituitary Surgery: An Innovation for the Future

BACKGROUND

Endoscopic surgery has become the preferred treatment of sellar lesions because of its minimally invasive nature. Visualization is frequently obscured as a result of the frequent contact of the lens with blood and tissue debris. We seek to alleviate these problems and increase the efficiency and safety of neuroendoscopic surgery by introducing a new device (Saraj Endocath) combining the major function of suction with the endoscope.

METHODS

A total of 75 patients with pituitary macroadenoma who were eligible for transnasal transsphenoidal endoscopic excision were included in the study between January 2020 and January 2023. Forty-one patients were operated on by the traditional 3-hand technique and 34 patients were operated on using the Saraj Endocath. The duration of surgery, in-out frequency of the endoscope, number of wipes needed to clean the endoscopic lens, and outcomes were assessed. A questionnaire regarding assistance, ergonomics, and instrument handling compared the Saraj Endocath procedure with the traditional technique.

RESULTS

The 3-hand technique was converted into the 2-hand technique. The mean operative time using the novel technique with the Saraj Endocath was reduced significantly compared with the traditional technique. The mean number of in-out movements of the endoscope and the number of wipes per hour decreased significantly using the Saraj Endocath. There was no dependency on the assistant's expertise and skills.

CONCLUSIONS

The use of the Saraj Endocath can effectively reduce the mean operative time by decreasing the frequency of in-out movement and wiping off the lens of the endoscope. It reduces fatigue, avoids clustering of instruments and hands, and minimizes the dependency on assistants.

Management of a Growth Hormone-Secreting Pituitary Macroadenoma Associated With Idiopathic Intracranial Hypertension and an Empty Sella

Idiopathic intracranial hypertension (IIH) is a -condition associated with elevated intracranial pressure (ICP) and frequently presents with headaches, papilledema, and visual loss. Rarely, IIH has been reported in association with acromegaly. Although removal of the tumor may reverse this process, elevated ICP, especially in the setting of an otherwise empty sella, may result in a cerebrospinal fluid (CSF) leak that is exceedingly difficult to manage. We present the first case of a patient with a functional pituitary adenoma causing acromegaly associated with IIH and an otherwise empty sella and discuss our management paradigm for this rare condition.

The Prognostic-Based Approach in Growth Hormone-Secreting Pituitary Neuroendocrine Tumors (PitNET): Tertiary Reference Center, Single Senior Surgeon, and Long-Term Follow-Up

Postoperative deserved outcomes in acromegalic patients are to normalize serum insulin-like growth factor (IGF-1), reduce the tumoral mass effect, improve systemic comorbidities, and reverse metabolic alterations. Pituitary neuroendocrine tumors (PitNET) are characterized to present a heterogeneous behavior, and growth hormone (GH)-secreting PitNET is not an exception. Promptly determining which patients are affected by more aggressive tumors is essential to guide the optimal postoperative decision-making process [prognostic-based approach]. From 2006 to 2019, 394 patients affected by PitNET were intervened via endoscopic endonasal transsphenoidal approach by the same senior surgeon. A total of 44 patients that met the criteria to be diagnosed as acromegalic and were followed up at least for 24 months (median of 66 months (26-156) were included in the present study. Multiple predictive variables [age, gender, preoperative GH and IGF-1 levels, maximal tumor diameter, Hardy's and Knosp's grade, MRI. T2-weighted tumor intensity, cytokeratin expression pattern, and clinicopathological classification] were evaluated through uni- and multivariate statistical analysis. Sparse probability of long-term remission was related to younger age, higher preoperative GH and- or IGF-1, group 2b of the clinicopathological classification, and sparsely granulated cytokeratin expression pattern. Augmented recurrence risk was related to elevated preoperative GH levels, tumor MRI T2-weighted hyperintensity, and sparsely granulated cytokeratin expression pattern. Finally, elevated risk for reintervention was related to group 2b of the clinicopathological classification, Knosp's grade IV, and tumor MRI T2-weighted hyperintensity. In this study, the authors determined younger age, higher preoperative GH and- or IGF-1 levels, group 2b of the clinicopathological classification, Knosp's grade IV, MRI T2-weighted tumor hyperintensity and sparsely granulated cytokeratin expression pattern are related to worse postoperative outcomes in long-term follow-up patients affected with GH-secreting PitNET.

Surgical and Radiological Differences in Intersphenoid Sinus Septation and the Prevalence of Onodi Cells with the Endoscopic Endonasal Transsphenoidal Approach

Background and Objectives: Understanding the anatomical variation in the sphenoid sinus is important to fully expose the sellar floor and clivus. Materials and Methods: The Onodi cell and intersphenoid sinus septation based on preoperative paranasal sinus computed tomography (PNS CT) and the surgical records of 877 patients who underwent the endoscopic endonasal transsphenoidal approach (EETSA) were retrospectively reviewed. Results: An intersphenoid sinus septum (ISS) blocking the clivus was defined as a pseudoclivus. Complete and incomplete pseudoclivuses were found in 2.97% and 10.5% of patients, respectively. Intraoperative and PNS CT ISS findings differed in 17.1% of patients. Misconceptions regarding a ridge or vertical ISS and confusion between an incomplete pseudoclivus and a vertical ISS were common. Conclusions: Because intraoperative and PNS CT findings may differ, anatomical variation in the paraclival area should be evaluated carefully. A pseudoclivus mimicking the clivus is important to attain a fully exposed EETSA surgical view.

The Impact of Minimally Invasive Pituitary Surgery on Male and Female Sexual Dysfunction in Patients with Pituitary Adenoma

INTRODUCTION

In the present study, we prospectively investigated the impact of endoscopic transnasal trans-sphenoidal surgery (ETTS) on sexual function in male and female patients with pituitary adenoma.

METHODS

The study included a total of 40 consecutive patients (male, n = 28 and female, n = 12) aged 22-65 years, who underwent ETTS for pituitary adenoma in our center between March 2019 and August 2019. Twenty-seven (67.5%) and 13 (32.5%) patients had functioning and nonfunctioning pituitary adenomas, respectively. Routine preoperative hormone levels were obtained in every patient. The tests were repeated at the postoperative third month. Preoperatively and at the postoperative third month, the 5-item version of the International Index of Erectile Function and the Female Sexual Function Index (FSFI) was used in male and female patients, respectively.

RESULTS

Before surgery, 24 (85.7%) men had erectile dysfunction (ED), and 10 (83%) women had female sexual dysfunction. After surgery, all the patients' abnormal hormone parameters improved. All the male patients' ED degrees were positively affected by surgery. In women, the FSFI was significantly better than in the preoperative period.

DISCUSSION/CONCLUSION

Our results showed that both males and females with pituitary adenomas benefitted from minimally invasive pituitary surgery in terms of a high-remission rate and improvement in sexual dysfunction.

Collaborative Robotic Assistant Platform for Endonasal Surgery: Preliminary In-Vitro Trials

Endonasal surgery is a minimally invasive approach for the removal of pituitary tumors (sarcomas). In this type of procedure, the surgeon has to complete the surgical maneuvers for sarcoma resection with extreme precision, as there are many vital structures in this area. Therefore, the use of robots for this type of intervention could increase the success of the intervention by providing accurate movements. Research has focused on the development of teleoperated robots to handle a surgical instrument, including the use of virtual fixtures to delimit the working area. This paper aims to go a step further with a platform that includes a teleoperated robot and an autonomous robot dedicated to secondary tasks. In this way, the aim is to reduce the surgeon’s workload so that he can concentrate on his main task. Thus, the article focuses on the description and implementation of a navigator that coordinates both robots via a force/position control. Finally, both the navigation and control scheme were validated by in-vitro tests.

Transnasal Transsphenoidal Approach for Pituitary Tumors: An ENT Perspective

Endoscopic transnasal transsphenoidal (ETNTS) approach was first described in 1992 and is standard approach for the resection of benign pituitary adenomas. This prospective study aims in incidence and preoperative assessment of extent of the pituitary adenoma, peroperative findings of transnasal transsphenoidal excision, techniques of skull base repair, complications and its management in a tertiary centre. A prospective analysis from Jan 2017 to May 2019, of patients undergoing ETNTS approach of pituitary adenomas was made in terms of incidence in various age-groups, type of adenoma, operative findings including CSF leak, repair of the skull base defect, complications encountered and its management was done in a tertiary care centre and compared with the present literature. A total of 141 patients underwent ETNTS, with highest number of cases found in 41-50 years age-group with mean age of 42.6 years. Male: Female ratio was 1.6. Macroadenoma was in 123 patients while 18 had microadenoma, of these 63.74% were functional adenoma, highest of GH secreting, while 36.26% were non-functional. Mean surgical time was 98.4 min ± 21.2 min. Peroperative CSF leak was in 30.5% cases in various grades. Closure techniques included use of fat, multilayer techniques, Hadad's flap and gasket technique as per the type of CSF leak. Neurological and rhinological complications were 6.38% each. This study is focused on the ENT perspective of the endoscopic transnasal trans-sphenoidal approach for pituitary adenomas. The reduced rate of morbidity and complications is encouraging. The endoscopic skull base defect closure is challenging and requires skill, meticulous approach and synchronised team work in order to achieve a favourable outcome. The incidence of CSF leak can be minimised and if encountered has to be dealt in an organised manner, thus contributing to a reduced rate of complications. The complications encountered must be foreseen and managed with a proficient approach.

Perioperative nasal and paranasal sinus considerations in transsphenoidal surgery for pituitary disease

Endoscopic endonasal skull base surgery has emerged as the treatment modality of choice for a range of skull base lesions, particularly pituitary adenomas. However, navigation and manipulation of the nasal corridor and paranasal sinuses requires that surgeons are aware of effective techniques to maximize patient outcomes and avoid sinonasal morbidity postoperatively. This paper is a narrative review aimed to provide an updated and consolidated report on the perioperative management of the nasal corridor and paranasal sinuses in the setting of endoscopic skull base surgery for pituitary disease. Anatomic variants and common surgical techniques are discussed. Post-operative complications are evaluated in detail. Understanding the structural implications of the endonasal approach to the sphenoid is crucial to optimization of the surgical outcomes. We propose guidelines for perioperative management of endoscopic endonasal skull base surgery for pituitary diseases. Standardized treatment algorithms can improve patient satisfaction, and increase the comparability and the quality of reported information across research studies.

A Systematic Review of Prophylactic Antibiotic Use in Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Lesions

BACKGROUND

The benefit of prophylactic antibiotic use in endoscopic endonasal transsphenoidal surgery (EETS) for pituitary lesions is controversial. Many surgeons administer antibiotics perioperatively not based on clear guidelines but to be safe. The purpose of this study was to determine if antibiotic prophylaxis use reduces the risk of infection (e.g., meningitis, sinusitis) within 30 days after the surgery in adult patients with pituitary lesions undergoing EETS.

METHODS

A systematic review was performed to assess the effectiveness of perioperative antibiotic use in preventing infectious complications in patients undergoing EETS. Data sources included Ovid Databases, Scopus, PubMed, Cochrane Library, and Grey Literature. The inclusion criteria were randomized controlled trials, systematic reviews, observational studies, and case series of prophylactic antibiotic perioperative use for EETS. The study end points were the rates of meningitis and sinusitis as infectious complications after EETS.

RESULTS

A total of 282 articles were identified by the initial literature search. Four studies met the inclusion criteria: 3 retrospective cohort and 1 prospective case series studies. All patients included in each study received different antibiotic regimens perioperatively. The quality of studies did not permit performance of a meta-analysis.

CONCLUSIONS

Even though there are no clear practice guidelines regarding the antibiotic prophylaxis need in EETS, various antibiotic regimens have been used by surgeons. Our systematic review identified a limited number of published studies assessing this question, all observational. Randomized controlled trials are needed to evaluate the effectiveness of prophylactic antibiotic use in patients with pituitary lesions undergoing EETS.

Endoscopic Endonasal Surgery for Craniopharyngiomas: A Series of 60 Patients

OBJECTIVE

To report our experience of the management of 60 patients with craniopharyngioma with endoscopic endonasal surgery (EES) and evaluate the feasibility and safety of EES for craniopharyngiomas.

METHODS

The clinical data of 60 patients with craniopharyngioma who underwent EES between November 2014 and December 2017 were analyzed retrospectively. All patients had vascularized nasoseptal flaps, and the most recent 4 patients had "in situ bone flaps" for better skull base reconstruction. Visual improvements, tumor resection extents, recurrence rates, endocrine functional changes, and surgical complications were evaluated.

RESULTS

The resection rates were as follows: gross total, 68.3% (41 patients); near total (>95% of tumor removed), 15% (9 patients); subtotal (≥80% of tumor removed), 10% (6 patients); and partial (partial resection <80% of tumor removed), 6.7% (4 patients). Fifty-two patients presented with visual impairment; of these, 46 (88.5%) improved or returned to normal after surgery. Regarding the 32 patients with hypopituitarism before surgery, pituitary function was unchanged in 15 (46.8%), improved or normalized in 4 (12.5%), and deteriorated in 13 (40.6%). Eleven patients (18.3%) suffered from diabetes insipidus before treatment, and 27 more patients had this condition after surgery. Twenty-two patients had hyposmia postoperatively, and 17 patients experienced significant weight gain. Four patients had recent memory loss, and 2 of them had a temporary recent mental disorder. Three (5%) patients had cerebro-spinal fluid leakage after surgery. Three patients (5%) contracted meningitis and were cured with antibiotic treatment. One patient showed recurrence by magnetic resonance imaging re-examination, at the mean follow-up time of 22 months (range, 8-45 months; standard deviation, 11 months).

CONCLUSIONS

EES can provide surgeons with excellent exposure and can achieve a high extent of removal of most craniopharyngiomas, even those with intraventricular extensions, In our view, vascularized pedicled septal flaps and in situ bony flaps were used in skull base reconstruction.

[Complications after endoscopic endonasal transsphenoidal removal of pituitary adenomas]

The use of endoscopic technique has significantly extended the indications for surgery using the transsphenoidal approach. Currently, more than 90% of pituitary adenomas are operated on transsphenoidally. Transnasal removal of giant pituitary adenomas has become possible. Transition to the endoscopic endonasal approach in removal of pituitary adenomas changed the rate and structure of postoperative complications. We analyzed potential complications after endoscopic endonasal transsphenoidal removal of pituitary adenomas. These include complications of the approach itself (nasal bleeding, perforation of the nasal septum, impaired olfactory function, atrophic rhinitis, synechiae, mucoperiosteal flap necrosis, and external nasal deformities), infectious complications (meningitis, intracranial abscesses), cerebral circulation disorder (subarachnoid hemorrhage, cerebral vasospasm, injury to large vessels, intracranial hematomas), neuro-ophthalmological complications (visual and oculomotor disorders), endocrine (hypopituitarism, diabetes insipidus, hyponatremia) and somatic complications, and nasal liquorrhea. In conclusion, it should be noted that despite continuous improvement of the technique for endoscopic endonasal removal of pituitary adenomas, there is a risk of serious complications, which necessitates the development of techniques for prevention of these complications.

The Impact of Resident and Fellow Participation in Transsphenoidal Pituitary Surgery

OBJECTIVES/HYPOTHESIS

Postoperative complications is an important marker of healthcare quality. The aim of this study was to analyze the impact of resident and fellow participation on postoperative complications in transsphenoidal pituitary surgery in a multi-institutional setting.

STUDY DESIGN

Retrospective analysis of population-based surgical registry.

SETTING

Academic medical center.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was utilized to generate transsphenoidal pituitary surgery patient cohorts. The attending with resident and/or fellow group was compared to the attending alone based on demographics and preoperative and postoperative variables.

RESULTS

A total of 469 cases were included in the analysis, with 315 performed with resident participation and 154 by attendings alone. The attending group had higher rates of diabetics (20.1% vs. 11.7%, P = 0.015) and patients with a history of previous percutaneous coronary intervention (6.0 vs. 1.6%, P = 0.009). Although the attending group demonstrated higher rates of surgical complications, and the resident/fellow group showed increased incidence in medical and overall complication rates, there was no statistical difference between the two groups. Multivariate analysis further demonstrated lack of significance in complication rates between attendings and residents/fellows.

CONCLUSION

Resident and fellow participation in transsphenoidal surgery is not associated with significant differences in surgical complications, medical complications, mortality, operating time, reoperation rates, or readmission rates when compared to attendings.

LEVEL OF EVIDENCE

4 Laryngoscope, 128:2707-2713, 2018.

Endoscopic Endo-Nasal Trans-Sphenoidal Excision of Pituitary Tumors: An Institutional Experience

To analyze the clinical presentation, management and outcomes of patients with pituitary adenoma treated by Endoscopic Endo-nasal Trans-sphenoidal (EETS) excision. Study was conducted on the basis of medical records of 14 patients who had undergone EETS excision of pituitary adenomas. The data obtained was assessed for demographic and clinical characteristics, radiographic features and post-operative outcomes. Study included 10 males and 4 females. Mean age of patients was 46.43 years (range 16-70 Years). Most common presentation was diminished vision reported in 79% patients. Features of acromegaly encountered in 21% cases. Location of majority of tumors was sellar with supra-sellar extension (71%) followed by sellar (14%), sellar with para-sellar extension (7%) and sellar with supra-sellar and para-sellar extensions (7%). Total tumor resection was achieved in 64% cases and sub-total resection in 36% cases. One of the lesions on biopsy revealed granulomatous pathology. No post-operative complication was seen in 71% patients. Transient Diabetes Insipidus was observed in 21% cases that resolved within 3-4 days. One patient expired due to meningitis and septicemia. One patient had CSF leak that was effectively managed by placing lumbar drain. There was significant improvement in visual symptoms and hormonal levels. Average hospital stay was 13.54 days and mean follow up period was 13 months. EETS approach is safe, minimally invasive and effective surgical technique for resection of pituitary adenomas with low post-operative morbidity, reduced hospital stay and better remission of symptoms.

The learning curve for endoscopic trans-sphenoidal resection of pituitary macroadenomas. A single institution experience, Leeds, UK

BACKGROUND

The object of this study was to assess whether increasing operative experience results in greater endoscopic trans-sphenoidal resection of pituitary macroadenomas and lower complications.

METHODS

A retrospective single institution cohort study was performed. Subjects underwent endoscopic trans-sphenoidal resection of pituitary macroadenoma between July 2009 and July 2016 by three neurosurgeons. Following data collection, statistical analysis compared percentage of tumor resection and length of hospital stay (LOS) with experience. Complications including CSF leak are reported.

RESULTS

In total, 142 patients (87 male, 55 female) mean age 55.1 were included. Surgeon 1 performed 106 cases; surgeon 2 performed 23 cases; and surgeon 3 performed 13 cases. Mean pre-operative tumor volumes were 8.18 cm³, 6.52 cm³, and 3.47 cm³ and post-operative volumes were 2.21, 1.74, and 1.93 cm³ for surgeons 1, 2, and 3, respectively. Respective percentage resections were 74.3, 77.2, and 52.1%. Analysis demonstrated no difference in tumor resection with increasing experience for all three surgeons (p = 0.11, p = 0.17, and p = 0.26). Tumor consistency and cavernous sinus involvement did not appear to affect tumor resection. Mean LOS was 5 days, 4 days, and 3 days, respectively, with no significant correlation with experience for all three surgeons. Intraoperative CSF leak incidence was 19/106 (18%) for surgeon 1, 6/23(26%) for surgeon 2, and 2/13(15%) for surgeon 3. Primary closure rate was 96.3% and only three other complications occurred.

CONCLUSIONS

This study demonstrates that in our institution there is no statistically significant learning curve for the endoscopic resection of pituitary macroadenoma. However, there is a trend of improvement in tumor resection with experience for one surgeon. These findings suggest that the surgeons in our institution were capable of performing this procedure effectively with a low complication rate since adoption of the endoscopic technique in 2009.

Assessment of the extent of pituitary macroadenomas resection in immediate postoperative MRI

OBJECTIVE

To evaluate if it is possible to determine the extent of pituitary macroadenomas resection in the immediate postoperative pituitary magnetic resonance imaging (MRI).

MATERIAL AND METHODS

MRI of patient with pituitary macroadenomas from January 2010 until October 2014 were reviewed. Those patients who had diagnostic MRI, immediate post-surgical MRI and at least one MRI control were included. We evaluate if the findings between the immediate postsurgical MRI and the subsequent MRI were concordant. Cases which didn't have evolutionary controls and those who were reoperation for recurrence were excluded. The degree of tumor resection was divided into groups: total resection, partial resection and doubtful. All MRI studies were performed on a1.5T machine following the same protocol sequences for all cases. One morphological part, a dynamic contrast iv and late contrast part.

RESULTS

Of the 73 cases included, immediate postoperative pituitary MRI was interpreted as total resection in 38 cases and tumoral rest in 28 cases, uncertainty among rest or inflammatory changes in 7 cases. Follow- up MRI identified 41 cases total resection and tumoral rest in 32. Sensitivity and specificity of 0.78 and 0.82 and positive and negative predictive value (PPV and NPV) 0.89 and 0.89 respectively were calculated.

CONCLUSION

Immediate post-surgery pituitary MRI is useful for assessing the degree of tumor resection and is a good predictor of the final degree of real resection compared with the following MRI studies. It allows us to decide the most appropriate treatment at an early stage.

Indigenous Inexpensive Practice Models for Skill Development in Neuroendoscopy

Introduction:

Neurosurgery is a branch having a tough learning curve. Residents generally get very less hands-on exposure for advanced procedures like neuroendoscopy. With the limited number of cadavers available and ethical issues associated with animal models, practice models, and simulators are becoming the able alternative. Most of these simulators are very costly. We tried to build indigenous inexpensive practice models that can help in developing most of the skills of neuroendoscopy.

Materials and Methods:

Models were built for learning hand-eye coordination, dexterity, instrument manipulation, cutting, fine dissection, keyhole concept, drilling, and simulation of laminectomy and ligamentum flavum resection. These were shown in the neuroendoscopic fellowship program conducted in authors' institute, and trainees' responses were recorded.

Results:

Both novice and experienced neuroendoscopic surgeons validated the models. There was no significant difference between their responses (P = 0.791).

Conclusion:

Indigenous innovative models can be used to learn and teach neuroendoscopic skills. The presented models were reliable, valid, eco-friendly, highly cost-effective, portable, easily made and can be kept in one's chamber for practicing.

Learning neuroendoscopy with an exoscope system (video telescopic operating monitor): Early clinical results

CONTEXT

Steep learning curve is found initially in pure endoscopic procedures. Video telescopic operating monitor (VITOM) is an advance in rigid-lens telescope systems provides an alternative method for learning basics of neuroendoscopy with the help of the familiar principle of microneurosurgery.

AIMS

The aim was to evaluate the clinical utility of VITOM as a learning tool for neuroendoscopy.

MATERIALS AND METHODS

Video telescopic operating monitor was used 39 cranial and spinal procedures and its utility as a tool for minimally invasive neurosurgery and neuroendoscopy for initial learning curve was studied.

RESULTS

Video telescopic operating monitor was used in 25 cranial and 14 spinal procedures. Image quality is comparable to endoscope and microscope. Surgeons comfort improved with VITOM. Frequent repositioning of scope holder and lack of stereopsis is initial limiting factor was compensated for with repeated procedures.

CONCLUSIONS

Video telescopic operating monitor is found useful to reduce initial learning curve of neuroendoscopy.

Evaluation of the application of rhino-septal splints in endoscopic transsphenoidal skull base surgery

The endoscopic transnasal route for the surgical removal of tumors in the sellar region is frequently associated with nasal complications such as synechiae or impaired nasal breathing. In this study, we investigated the impact of septal splints on avoiding surgery-related co-morbidities. 49 patients in whom endoscopic transnasal, transsphenoidal surgery for sellar tumors was performed between 2012 and 2014 were studied. In 30 of these, nasal septal splints were applied at the end of surgery to both sides of the septum and left in situ for 10 days (group 1), 19 patients received no splints (group 2). A standardized postsurgical follow-up investigation with endoscopic nasal examination, rhinomanometry and olfactory testing was performed on average 2 months postoperatively. Patients' subjective nose-related discomfort at follow-up was assessed descriptively using a set of standardized self-rating statements on nasal problems. Synechias occurred less likely with nasal septal splints (n = 15; 50 %) than without (n = 16; 84.2 %). Moreover, multiple synechiae were predominantly observed in the group without septal splints (n = 10 vs. n = 2). Rhinomanometry showed improved flow-V150-inspiration scores when splints were used (with significant differences between groups for the left nostril: p = 0.039 and p = 0.022, resp.). In accordance, impaired nasal breathing after surgery was reported more frequently by 76.9 % of patients without splints, but only 56 % of patients with splints. Our results provide support for the application of nasal septal splints when operating endoscopically on tumors in the sellar region to reduce postoperative synechias and to improve nasal breathing.

Isolated double adrenocorticotropic hormone-secreting pituitary adenomas: A case report and review of the literature

Only a few cases of double or multiple pituitary adenomas have previously been reported in the literature; however, isolated double adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas are even more rare. The present study reports a rare case of a 50-year-old female patient who presented with typical clinical features of Cushing's disease and was diagnosed with isolated double ACTH-secreting pituitary adenomas. Endocrinological examination revealed an ACTH-producing pituitary adenoma, and preoperative magnetic resonance imaging (MRI) demonstrated a microadenoma with a lower intensity on the right side of the pituitary gland. The patient underwent endoscopic endonasal transsphenoidal surgery, which revealed another pituitary tumor in the left side of the pituitary gland. The two, clearly separated, pituitary adenomas identified in the same gland were completely resected. Immunohistochemistry and pathology revealed that the clearly separated double pituitary adenomas were positive for ACTH, thyroid-stimulating, growth and prolactin hormones. Postoperatively, the levels of ACTH and cortisol hormone decreased rapidly. The case reported in the present study is considerably rare, due to the presence of a second pituitary adenoma in the same gland, which was not detected by preoperative MRI scan, but was noticed during surgery. Intraoperative evaluation may be important in the identification of double or multiple pituitary adenomas.

Transsphenoidal Approach in Endoscopic Endonasal Surgery for Skull Base Lesions: What Radiologists and Surgeons Need to Know

In the last 2 decades, endoscopic endonasal transsphenoidal surgery has become the most popular choice of neurosurgeons and otolaryngologists to treat lesions of the skull base, with minimal invasiveness, lower incidence of complications, and lower morbidity and mortality rates compared with traditional approaches. The transsphenoidal route is the surgical approach of choice for most sellar tumors because of the relationship of the sphenoid bone to the nasal cavity below and the pituitary gland above. More recently, extended approaches have expanded the indications for transsphenoidal surgery by using different corridors leading to specific target areas, from the crista galli to the spinomedullary junction. Computer-assisted surgery is an evolving technology that allows real-time anatomic navigation during endoscopic surgery by linking preoperative triplanar radiologic images and intraoperative endoscopic views, thus helping the surgeon avoid damage to vital structures. Preoperative computed tomography is the preferred modality to show bone landmarks and vascular structures. Radiologists play an important role in surgical planning by reporting extension of sphenoid pneumatization, recesses and septations of the sinus, and other relevant anatomic variants. Radiologists should understand the relationships of the sphenoid bone and skull base structures, anatomic variants, and image-guided neuronavigation techniques to prevent surgical complications and allow effective treatment of skull base lesions with the endoscopic endonasal transsphenoidal approach.

Is image guidance accurate in children sinus surgery?

OBJECTIVES

To compare the precision of the calibration of a 3D navigation system for endoscopic sinus surgery in children and adults. To compare the complication and calibration failure rates of the system in both populations.

METHODS

The precision of the calibration of the Stryker navigation system (Stryker Neuronavigation ENT 2.0 Software) was found in the charts of children and adults operated on for various nasosinusal procedures between May 2008 and February 2013 in a tertiary care center. Demographic characteristics and complication rates were also noted.

RESULTS

Thirty-eight adults and 21 children were included in the study. No statistically significant difference was found between the two groups with an identical mean precision of 0.7mm (p=0.90). The rate of precision unreliability and calibration failures was not statistically different between the two groups (14% children vs 5% adults). No major complications occurred in both groups (p=1.00). No demographic characteristic predicted a failed calibration (height, weight, BMI, age).

CONCLUSION

The Stryker image-guided system can provide a precision level that is equivalent in both children and adults. This study also demonstrated an absent/low complication rate respectively for children and adults post endoscopic surgery.

Endoscopic endonasal trans-sphenoid management of craniopharyngiomas

Introduction:

Craniopharyngiomas treatment has been challenging because of their anatomical location. The endoscopic endonasal (EE) trans-sphenoidal approach is indicated in sellar, supra sellar, selected intraventricular lesions in adults and children. We are reporting our initial experience of 44 patients managed by EE approach.

Materials and Methods:

This is a retrospective study of 44 craniopharyngiomas. The goal of surgery was gross-total resection in all cases. All patients underwent pre- and post-operative comprehensive ophthalmological and endocrinological evaluation. Lumbar drain at the start of the operation was used in all cases with tumor larger than 3 cm maximum diameter. Binostril technique vascularized nasoseptal flap and multilayer closure of the dural defect were used. Wide sphenoidotomy, posterior ethmoidectomy, tuberculum selle, and planum removal were performed in all cases. Perioperative antibiotic prophylaxis was used for 72 h.

Results:

There were 44 patients of age ranging from 8 to 65 (mean: 42) years. Diameter of the tumor varied from 3.1 cm to 6.6 cm (average: 4.3 cm). Visual and pituitary dysfunctions were observed in 44 and 33, respectively, before surgery. Vision improvement, gross-total removal, cerebrospinal fluid (CSF) leak and recurrence were observed in 34, 26, four and six patients, respectively. Average follow-up was 19 months.

Conclusion:

Endoscopic endonasal trans-sphenoidal approach for craniopharyngioma is safe and effective alternative to transcranial approach in selected patients. Although this technique is associated with effective tumor removal and improved visual outcome, CSF leak, and endocrine dysfunctions remain a major challenge.

Endoscopic endonasal trans-sphenoidal approach for pituitary adenomas: is one nostril enough?

BACKGROUND

Over the past decade, the endoscopic endonasal trans-sphenoidal approach has been used to resect pituitary adenomas. However, in the use of this procedure, some research teams prefer a two-nostril method, whereas other groups are in favor of the one-nostril method. Here, we present a series of pituitary adenomas and try to confirm whether or not one nostril is enough for endoscopic resection of most pituitary adenomas.

METHODS

A total of 250 consecutive patients who underwent an endoscopic endonasal trans-sphenoidal approach were reviewed retrospectively, of which 200 were via the unilateral nostril (group 1) and 50 were via bilateral nostrils (group 2). Surgical and clinical outcomes were analyzed.

RESULTS

For microadenomas, intrasellar macroadenomas and macroadenomas with moderate extrasellar extension, the prevalence of gross total resection (GTR), hormonal outcome and visual improvement were similar between the two groups. The one-nostril group had better results for duration of surgery and blood loss, with fewer rhinological complications. However, for macroadenomas with extensive extrasellar invasion, GTR was obtained in two of seven patients in group 2 but none in group 1.

CONCLUSION

The one-nostril method, which is relatively fast and minimally invasive, is adequate for endoscopic resection of most pituitary adenomas with moderate extension.