Endoscopic endonasal transsphenoidal approach: outcome analysis of 100 consecutive procedures

The learning curve in endoscopic transsphenoidal skull-base surgery: a systematic review

BACKGROUND

The endoscopic endonasal transsphenoidal approach (EETA) has revolutionized skull-base surgery; however, it is associated with a steep learning curve (LC), necessitating additional attention from surgeons to ensure patient safety and surgical efficacy. The current literature is constrained by the small sample sizes of studies and their observational nature. This systematic review aims to evaluate the literature and identify strengths and weaknesses related to the assessment of EETA-LC.

METHODS

A systematic review was conducted following the PRISMA guidelines. PubMed and Google Scholar were searched for clinical studies on EETA-LC using detailed search strategies, including pertinent keywords and Medical Subject Headings. The selection criteria included studies comparing the outcomes of skull-base surgeries involving pure EETA in the early and late stages of surgeons' experience, studies that assessed the learning curve of at least one surgical parameter, and articles published in English.

RESULTS

The systematic review identified 34 studies encompassing 5,648 patients published between 2002 and 2022, focusing on the EETA learning curve. Most studies were retrospective cohort designs (88%). Various patient assortment methods were noted, including group-based and case-based analyses. Statistical analyses included descriptive and comparative methods, along with regression analyses and curve modeling techniques. Pituitary adenoma (PA) being the most studied pathology (82%). Among the evaluated variables, improvements in outcomes across variables like EC, OT, postoperative CSF leak, and GTR. Overcoming the initial EETA learning curve was associated with sustained outcome improvements, with a median estimated case requirement of 32, ranging from 9 to 120 cases. These findings underscore the complexity of EETA-LC assessment and the importance of sustained outcome improvement as a marker of proficiency.

CONCLUSIONS

The review highlights the complexity of assessing the learning curve in EETA and underscores the need for standardized reporting and prospective studies to enhance the reliability of findings and guide clinical practice effectively.

Clinical and Surgical Outcomes of Endoscopic Endonasal Approach for Giant Pituitary Adenomas: Analysis of Predictive Factors

BACKGROUND

Giant pituitary adenomas (GPAs) are defined as tumors with ≥40 mm in any maximum diameter, and these tend to invade multiple intracranial compartments. Hence, treatment remains a surgical challenge.

OBJECTIVE

To describe the clinical and surgical outcomes of the endoscopic endonasal approach (EEA) for GPA in a pituitary referral center in Latin America and to analyze associated predictive factors.

METHODS

37 patients with histologically-confirmed GPA treated solely through the EEA between a 2-year period were included. Preoperative and postoperative clinical and neuroimaging findings; surgical morbidity and mortality; and binary logistic regression analysis to assess predictive factors were analyzed.

RESULTS

Preoperative visual impairment prevalence was 97.3%. Mean tumor volume was 32 cc and gross total resection rate was 40.5%. Favorable visual acuity and visual fields outcome rate was 75% and 82.9%, respectively. In the multivariate analysis, bilateral cavernous sinus invasion (P = 0.018) and postoperative cerebrospinal fluid (CSF) leak (P = 0.036) were associated with an unfavorable visual acuity outcome, while radiation therapy (P = 0.035) was for visual fields. Similarly, intraoperative CSF leak was a predictive factor for postoperative CSF leak (10.8%) (P = 0.042) and vascular injury (13.5%) (P = 0.048).

CONCLUSIONS

In this first Mexican clinical series, we demonstrated that the EEA is a safe and effective technique for GPA, although early diagnosis and prompt intervention may promote further visual function preservation without significant endocrine morbidity.

Learning Curve for Endoscopic Transsphenoidal Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Endoscopic transsphenoidal surgery (ETSS) is emerging as an effective, minimally invasive surgery technique for brain tumors of the pituitary fossa. Using a surgical endoscope, surgeons can obtain a broader, nearer, and more apparent visual field with minimal keyhole entrance. However, ETSS may require a steep learning curve to achieve technical competence and relevant outcomes. Moreover, there is no consensus on the learning process of ETSS. We aimed to review and determine the technical proficiency points of ETSS and discuss how to accelerate the learning curve.

METHODS

Core databases, including PubMed, Embase, and the Cochrane Library, were systematically searched for learning curve studies that demonstrated the clinical outcomes and learning status of ETSS for pituitary adenomas using numerical data. Quality assessments of the included articles were performed using the Newcastle-Ottawa scale. The cutoff points were evaluated based on various outcome measures.

RESULTS

Eleven full-text articles, representing 2780 cases, were selected from 317 screened studies. The outcome measures were operative time, tumor removal, endocrinological results, visual field, and surgical complications. The plateaus or cutoff points in the learning curve varied with a mean of 103 ± 139.43 (range, 9-500) cases.

CONCLUSIONS

ETSS is an efficient and minimally invasive alternative surgical option for pituitary tumors. Plateau points may differ according to outcome measures, patient selection, training status, and surgical conditions. Therefore, great care should be taken when interpreting the learning curve. A systematic training program is essential to improve the learning process of endoscopic neurosurgical procedures.

Application of binasal speculum in endoscopic endonasal surgery for lesions in sellar region

Objective

This study aims to access the efficacy of the binasal speculum in endoscopic endonasal surgery by evaluating clinical outcomes and examining its utility through process-based performance measures in both surgeons and assistants.

Methods

A total of 59 patients with lesions in sellar region who underwent endoscopic endonasal surgery with the binasal speculum between September 2020 and March 2023 were included in this study. We assessed the extent of resection and documented postoperative nasal condition. Both surgeons and assistants completed post-use surveys to exam the utility of the binasal speculum and provide an overall grading.

Results

Gross total resection (GTR) was successfully achieved in 94.9% (56/59) of patients, with subtotal resection (STR) observed in 5.1% (4/59) of patients. Intraoperative cerebrospinal fluid (CSF) leakage occurred in 23.7% (14/59) of cases, and nasoseptal flap (NSF) reconstruction was required in 55.9% (33/59) of cases. The nasal airway patency rapidly recovered within 14 days in a significant majority of patients (94.9%, 56/59). Moreover, olfactory function was regained within three months postoperatively by 91.5% (54/59) of patients. The overall post-use survey mean score was 26.4. Specifically, surgeons had a mean score of 26.5, while assistants had a slightly lower mean score of 26.2. The mean overall grading for the binasal speculum was 3. Both surgeons and assistants provided a mean overall grading of 3.

Conclusion

The binasal speculum provides nasal mucosa protection and reduces the risk of an endoscopic lens clouded by mucosa or blood. It plays a crucial role in accurate guidance and facilitates the swift delivery of surgical instruments, particularly in left-blinded nasal cavities. The binasal speculum reduces the learning curve, especially for endoscopic surgeons with limited experience, while enhancing collaboration and coordination between surgeons and assistants during surgery. Both surgeons and assistants rated the overall utility of the binasal speculum as "excellent."

Comparison of Cardiac Indices Using Two Different Concentrations of Topical Adrenaline during Endoscopic Transsphenoidal Pituitary Surgery: A Prospective Randomized Observational Study

Introduction  Adrenaline-soaked wicks are often employed to decongest nasal mucosa during transsphenoidal pituitary surgeries to ensure proper hemostasis and visibility of the operating field. Considerable debate exists regarding the optimum concentration of adrenaline that strikes a balance between hemostasis as well as the hemodynamic side effects of adrenaline. This study assessed cardiac indices like cardiac output and cardiac index using a FloTrac Vigileo cardiac output monitor to compare two different concentrations of adrenaline used for topical instillation. Materials and Methods  60 adult patients undergoing transsphenoidal pituitary surgery were randomly assigned to receive cotton wicks soaked in adrenaline solution (either 1:100,000 or 1:200,000) for nasal decongestion. Following a standardized anesthetic regime, a FloTrac Vigileo cardiac output monitor was attached with the invasive arterial line for precise monitoring and recording of cardiac indices (cardiac output and cardiac index). Additionally, quality of surgical field (as reported by the operating surgeon) blood loss, incidences of adverse hemodynamic events, and rescue drug usage were recorded. Results  No difference in cardiac outputs and cardiac indexes of the patients was observed during baseline to 55 minutes and at 80 minutes and onward, whereas difference rose to statistical significance at the time points of 60 minutes and 70 minutes ( p  < 0.05). Other parameters like stroke volume, stroke volume variation, and hemodynamic parameters were similar. Quality of the surgical fields (as reported by the surgeon), intraoperative bleeding, incidences of adverse effects, and frequency of rescue drugs usage were similar. Conclusion  Instillation of 1:100,000 dilution of adrenaline solution compared with 1:200,000 for nasal decongestion is associated with significant rise in cardiac output and cardiac index at 60 and 70 minutes of the surgery with similar blood loss and hemodynamic variables. Therefore, the lower concentration of adrenaline can be recommended for usage during transsphenoidal pituitary surgeries.

Current and Future Perspectives of Microscopic and Endoscopic Transsphenoidal Surgery for Pituitary Adenomas: A Narrative Review

Transsphenoidal resection remains the standard treatment for most pituitary adenomas. However, the ideal surgical approach to safely access these lesions, either microsurgical or endoscopic, continues to be debated. Since the introduction of endoscopic transsphenoidal surgery, centers around the world have increasingly adopted this technique, experiencing a shift away from the conventional microsurgical approach. Large series reporting the efficacy and safety of endoscopic surgery have fueled a growing interest in comparing clinical outcomes between both approaches. Still, proving superiority of either surgical approach remains an elusive task due to the inherent drawbacks of surgical observational studies, as we are still faced with a growing body of evidence reporting conflicting results. Thus, a comprehensive discussion regarding the reach and limitations of both techniques becomes necessary. In this narrative review, we perform a critical appraisal of the literature and provide an expert opinion on the state-of-the-art in transsphenoidal surgery for pituitary adenomas. The advantages and limitations of each approach are assessed and compared from a technical standpoint, and their reported outcomes evaluated in the framework of this transition phase. Available evidence should be interpreted in light of individual patient characteristics and within the context of each medical center, taking into consideration the known impact that surgical expertise and multidisciplinary management hold on clinical outcomes.

Evaluation of The Three-Dimensional Endoscopy in Basic and Extended Nasal Procedures: A Clinical and Cadaveric Study

Introduction  The three-dimensional (3D) endoscope is considered a new surgical tool used in different approaches in intranasal and anterior skull base surgical procedures. There are many advantages of 3D over two-dimensional (2D) endoscopy that have been demonstrated in clinical applications, surgical training, and different experimental studies. Objective  To show the difference between using the 3D and 2D endoscopes during endonasal and anterior skull base surgery and its importance. Methods  Our study is divided into two phases (clinical and cadaveric phases). In the clinical study we, have performed 52 endonasal and anterior skull base surgical procedures (26 study cases and 26 control cases). We recorded accuracy, duration, and intraoperative complication for each case. The cadaveric study was performed on three cadavers. Differences in accuracy and dissection time were recorded using 3D and 2D endoscopy for each side chosen by randomization. Results  In the clinical study, the cases done by 3D endoscope were significantly faster and more accurate with less intraoperative complications compared with cases done using 2D endoscope. In cadaveric dissection, while using 3D endoscope, there was better depth of perception regarding the anatomical landmarks compared with 2D endoscope. Conclusion  Three-dimensional endoscopy is an advanced instrument that allows better training for the coming generation of ear, nose, and throat surgeons. Both clinical and cadaveric studies offer a promising outcome in both endonasal and anterior skull base surgery.

Delayed nasoseptal flap reuse in patients with revision endoscopic endonasal anterior skull base surgery

The reuse of the nasoseptal flap represents a favorable option for skull base reconstruction in revision endoscopic anterior skull base surgery. This study demonstrated that a detached nasoseptal flap can remain viable for several days even if not immediately reattached.

Sphenoid Sinus Pneumatization Types and Correlation with Adjacent Neurovascular Structures Using Cone-Beam Computed Tomography

Aims: This study aimed to assess the sphenoid sinus pneumatization types and their correlation with adjacent neurovascular structures using cone-beam computed tomography (CBCT). Materials and methods: This cross-sectional study was conducted on 97 CBCT scans of patients over 18 years of age that were retrieved from the archives of the Oral & Maxillofacial Radiology Department of School of Dentistry. Type of sphenoid sinus pneumatization based on its relationship with sella turcica (conchal, presellar, sellar, and postsellar), the correlation of internal carotid artery (ICA) and optic nerve (ON) with the sinus cavity in the axial and coronal planes (smooth or prolonged type), and presence of Onodi cells and their correlation with the sphenoid sinus (lateral, superior, and superolateral) were all evaluated on CBCT sections. Data were analyzed by the Chi-square and Fisher's exact tests (alpha = 0.05). Results: Postsellar type was the most common sphenoid sinus pneumatization type (82.5%). The Smooth type was the most common form of correlation of ON and ICA with the sphenoid sinus. Onodi cells were noted in 28.9% of the cases; among which, the lateral type had the highest prevalence. Conclusion: Considering the high prevalence of sphenoid sinus pneumatization, Onodi cells, and ON and ICA protrusion in our study population, CBCT should be requested prior to trans-sphenoidal surgical procedures to prevent perioperative and postoperative complications.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03796-0.

Sinonasal Outcome After Endoscopic Transnasal Surgery-A Prospective Rhinological Study

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.

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.

Endoscopic endonasal approach to pituitary adenomas: Impact on adenohypophyseal function. Study of 231 cases

PURPOSE

To identify presurgical and surgical factors associated with the development of hypopituitarism and its recovery after endoscopic endonasal transsphenoidal (EET) resection of pituitary adenomas (PAs).

METHODS

Retrospective study of patients with PAs operated by the same neurosurgeon through an EET approach in two Spanish tertiary hospitals in ten years.

RESULTS

242 pituitary surgeries performed in 231 patients were analyzed. In the 154 surgeries performed in 146 patients with non-functioning PAs (NFPAs), 46.8% (n=72) presented presurgical hypopituitarism. After PAs resection, 41 of these (56.9%) normalized pituitary function and 11 of 82 patients with preoperative normal function (13.4%) developed new pituitary deficits. Patients with preoperative visual impairment (OR=3.9, p=0.046) and operated in the first four years of the neurosurgeon's learning curve (OR=5.7, p=0.016) presented a higher risk of developing postoperative hypopituitarism. Of the 88 surgeries in 85 patients with functioning PAs (FPAs), 23.9% presented presurgical hypopituitarism, and 47.6% of those recovered after surgery. 9% of the cases with preoperative normal function developed new pituitary deficit/s. Diabetic patients presented a higher risk of persistence of hypopituitarism (OR=10.5, p=0.024). Patients with presurgical visual impairment (OR=30.0, p=0.010) and PAs>3cm (OR=14.0, p=0.027) had higher risk of developing new pituitary deficits.

CONCLUSION

Approximately 50% of patients with PAs and preoperative hypopituitarism recover pituitary function after EET surgery. 10% of patients with normal function develop new deficits. Patients with NFPAs with visual involvement and operated in the first four years of neurosurgeon's learning curve, and FPAs patients with presurgical visual impairment and tumor size>3cm have a higher risk of postoperative hypopituitarism.

Extended endoscopic transorbital approach with superior-lateral orbital rim osteotomy: cadaveric feasibility study and clinical implications (SevEN-007)

OBJECTIVE

The endoscopic transorbital approach (ETOA) has been developed, permitting a new surgical corridor. Due to the vertical limitation of the ETOA, some lesions of the anterior cranial fossa are difficult to access. The ETOA with superior-lateral orbital rim (SLOR) osteotomy can achieve surgical freedom of vertical as well as horizontal movement. The purpose of this study was to confirm the feasibility of the ETOA with SLOR osteotomy.

METHODS

Anatomical dissections were performed in 5 cadaveric heads with a neuroendoscope and neuronavigation system. ETOA with SLOR osteotomy was performed on one side of the head, and ETOA with lateral orbital rim (LOR) osteotomy was performed on the other side. After analysis of the results of the cadaveric study, the ETOA with SLOR osteotomy was applied in 6 clinical cases.

RESULTS

The horizontal and vertical movement range through ETOA with SLOR osteotomy (43.8° ± 7.49° and 36.1° ± 3.32°, respectively) was improved over ETOA with LOR osteotomy (31.8° ± 5.49° and 23.3° ± 1.34°, respectively) (p < 0.01). Surgical freedom through ETOA with SLOR osteotomy (6025.1 ± 220.1 mm3) was increased relative to ETOA with LOR osteotomy (4191.3 ± 57.2 mm3) (p < 0.01); these values are expressed as the mean ± SD. Access levels of ETOA with SLOR osteotomy were comfortable, including anterior skull base lesion and superior orbital area. The view range of the endoscope for anterior skull base lesions was increased through ETOA with SLOR osteotomy. After SLOR osteotomy, the space for moving surgical instruments and the endoscope was widened. Anterior clinoidectomy could be achieved successfully using ETOA with SLOR osteotomy. The authors performed ETOA with SLOR osteotomy in 6 cases of brain tumor. In all 6 cases, complete removal of the tumor was successfully accomplished. In the 3 cases of anterior clinoidal meningioma, anterior clinoidectomy was performed easily and safely, and manipulation of the extended dural margin and origin dura mater was possible. There was no complication related to this approach.

CONCLUSIONS

The authors evaluated the clinical feasibility of ETOA with SLOR osteotomy based on a cadaveric study. ETOA with SLOR osteotomy could be applied to more diverse disease groups that do not permit conventional ETOA or to cases in which surgical application is challenging. ETOA with SLOR osteotomy might serve as an opportunity to broaden the indication for the ETOA.

Graded Reconstruction Strategy Using a Multilayer Technique Without Lumbar Drainage After Endoscopic Endonasal Surgery

OBJECTIVE

Sellar reconstruction following endoscopic endonasal surgery (EES) requires modification based on the degree of cerebrospinal fluid (CSF) leak. For high-flow (grade II or III according to Esposito et al. 2007) intraoperative CSF leak, lumbar drainage (LD), in addition to the multilayer closing technique, is generally recommended. However, LD occasionally has complications including postpuncture headache, overdrainage symptoms, and increased length of stay. We retrospectively evaluated the outcome of our graded reconstruction strategy using a multilayer technique with a novel material, without LD, after EES.

METHODS

Ninety-seven patients who underwent EES with grade II or III intraoperative CSF leak between June 2020 and March 2021 were retrospectively reviewed. For grade II CSF leak, fibrin sealant and a nasoseptal flap were placed; for grade III CSF leak, a multilayer technique was used in combination with collagen matrix, an acellular dermal graft, injectable hydroxyapatite (HXA), and a nasoseptal flap. Postoperatively, routine LD was not performed.

RESULTS

This study included 48 (49.5%) grade II and 49 (50.5%) grade III CSF leaks. At follow-up (mean, 8.7 months), no patient showed postoperative CSF leak in either group. No HXA-associated complications occurred.

CONCLUSIONS

A graded surgical repair strategy after EES could avoid postoperative CSF leak. Combined use of injectable HXA and acellular dermal grafts for high-flow CSF leak can limit LD requirement without significant risks.

Long-Term Quality of Life after Endoscopic Pituitary Adenoma Surgery with Nasoseptal Flap Reconstruction

INTRODUCTION

Endoscopic endonasal transsphenoidal surgery (EETS) on the pituitary gland is considered safe and efficacious. The nasoseptal flap (NSF) is sometimes used to prevent or repair postoperative cerebrospinal fluid (CSF) leaks. Few investigators have quantified long-term quality-of-life (QOL) outcomes regarding sinonasal measures after EETS, with or without involvement of the NSF. This study assesses whether the septal flap affects sinonasal QOL outcomes for patients receiving EETS for pituitary adenoma.

METHODS AND MATERIALS

This is a retrospective study of patients who underwent EETS between 2013 and 2018. A total of 62 adults completed the Sinonasal Outcome Test-22 (SNOT-22) at least one year after the surgery. Outcome measures were compared between patients who underwent EETS with and without septal flap reconstruction.

RESULTS

For the entire cohort, there were 14 patients (22.6%) who had septal flap reconstruction and 48 patients (77.4%) who did not. Patient demographics, tumor characteristics, surgical outcomes, and duration between surgery and completion of the questionnaire were similar for both groups. The mean SNOT-22 scores in the no reconstruction (NR) group and the nasoseptal flap reconstruction (NSFR) group were similar (P=0.9). In terms of SNOT-22 subdomains (rhinologic symptoms, extranasal rhinologic symptoms, ear/facial symptoms, psychological dysfunction, and sleep dysfunction), no significant differences were found when comparing the groups.

CONCLUSION

As compared with no reconstructive involvement, NSF utilization does not affect the QOL and nasal symptoms of patients undergoing EETS.

Cerebrospinal fluid leakage repair of various grades developing during endoscopic transnasal transsphenoidal surgery

Objectives

We describe the strategy used to repair intraoperative leaks of various grades and define factors for preventing postoperative cerebrospinal fluid leakage (CSF) after surgery via the endoscopic endonasal transsphenoidal approach (EETA).

Study design

Retrospective chart review at a tertiary referral center.

Methods

Patients who underwent surgery via EETA from January 2009 to May 2020 were retrospectively reviewed. Intraoperative CSF leakage was graded 0–3 in terms of the dural defect size; various repairs were used depending on the grade.

Results

A total of 777 patients underwent 869 operations via EETA; 609 (70.1%) experienced no intraoperative CSF leakage (grade 0) but 260 (29.9%) did. Leakage was of grade 1 in 135 cases (15.5%), grade 2 in 83 (9.6%), and grade 3 in 42 (4.8%). In 260 patients with intraoperative CSF leakage, a buttress was wedged into the sellar defect site in 178 cases (68.5%) and a pedicled flap was placed in 105 cases (40.4%). Autologous fat (108 cases, 41.5%) and a synthetic dural substitute (91 cases, 35%) were used to fill the dead space of the sellar resection cavity. Postoperative CSF leakage developed in 21 patients: 6 of grade 1, 7 of grade 2, and 8 of grade 3. Buttress placement significantly decreased postoperative leakage in grade 1 patients (p = 0.041). In patients of perioperative leakage grades 2 and 3, postoperative CSF leakage was significantly reduced only when both fat and a buttress were applied (p = 0.042 and p = 0.043, respectively).

Conclusion

A buttress prevented postoperative CSF leakage in grade 1 patients; both fat and buttress were required by patients with intraoperative leakage of grades 2 and 3.

Cone Beam Computed Tomography Analysis of Sphenoid Sinus Pneumatization and Relationship with Neurovascular Structures

Background

The sphenoid sinus is considered as the most variable pneumatized structure of the skull.

Purpose

The aim of the present study was to determine the prevalence of the Onodi cell as well as to evaluate the relationship between the sphenoid sinus type of pneumatization and the presence of surrounding neurovascular protrusion using cone beam computed tomography (CBCT).

Methods

The CBCT images of 500 patients/996 sides [203 males (40.6%) and 297 females (59.4%)] were analyzed in this study. The type of sphenoid sinus pneumatization, prevalence of internal carotid artery (ICA) and optic nerve (ON) protrusion and dehiscence, and also the frequency of Onodi cell were assessed.

Results

The percentages of the conchal, presellar, sellar, postsellar (a), and postsellar (b) types of pneumatization were 1%, 11.5%, 35.5%, 38.9%, and 13.1%, respectively. The more the sphenoid sinuses pneumatized, the greater the frequency of ON and ICA protrusion and dehiscence of their wall to the sinus. The prevalence of Onodi cell was 38.8%. A significant correlation was found between ON dehiscence and the presence of Onodi cells.

Conclusion

The present study demonstrated a significant relationship between the sinus type and frequency of neurovascular protrusions. Therefore, the sphenoid sinus extent of pneumatization might be useful in predicting the risk of iatrogenic damage to the surrounding structures.

Safety and Effectiveness of the Direct Endoscopic Endonasal Approach for Primary Sellar Pathology: A Contemporary Case Series of More Than 400 Patients

BACKGROUND

The direct endoscopic endonasal approach (EEA) has become the primary technique used for resection of sellar pathology, meriting investigation into the risk factors for complications and predictors of postoperative outcomes after direct EEA.

METHODS

We retrospectively analyzed the patient and tumor characteristics from 404 patients who had undergone direct EEA for sellar pathology at the USC Pituitary Center from September 2011 to December 2019.

RESULTS

Of the 404 pathologic entities included, 349 (86%) were pituitary adenomas (PAs), 29 (7%) were Rathke cleft cysts, and 26 (6%) were other sellar lesions. The mean lesion diameter was 2.3 cm, with 34 microadenomas (10%) and 315 macroadenomas (90%). Cavernous sinus invasion was present in 39% of the PAs. No patient died. The surgical complications included internal carotid artery injury without neurological sequelae (0.2%), vision loss (0.7%), meningitis (0.7%), cerebrospinal fluid leak (4%), epistaxis (4%), sinusitis (1%), transient cranial nerve paresis (0.5%), and postoperative abscess (0.25%). New hypopituitarism developed in 3%. Gross total resection was achieved in 208 PA cases (58%). Clinical improvement of headaches and visual deficits were reported for 67% and 76% of cases, respectively. Hormonal remission was achieved in 82% of patients with functional PAs. The median hospital stay was 2 days, with 34 patients (8%) readmitted within 30 days and 10 (3%) undergoing early reoperation. Disease recurrence or progression developed in 10% and was less likely in the case of gross total resection and apoplexy.

CONCLUSION

In the present, large, consecutive, mostly single-surgeon series, the patients experienced clinical improvement in most preoperative symptoms and had low rates of perioperative morbidity. We have demonstrated that direct EEA can be efficiently, safely, and successfully performed by a neurosurgical team.

Sellar Region Lesions and Intracranial Aneurysms in the Era of Endoscopic Endonasal Approach

In the clinical practice of neurosurgery, the endoscopic endonasal approach (EEA) has been the mainstream approach in the management of sellar region diseases. However, clinicians have come to realize that EEA procedure is associated with intraoperative hemorrhage. Due to the limited surgical field and poor proximal control under endoscope, massive hemorrhage always leads to severe complication or even perioperative death. Previously, intraoperative hemorrhage used to be attributed to endoscopic intervention of cavernous sinus or internal carotid artery, but our recent understanding of EEA indicated that preoperatively complicated intracranial aneurysms (IAs) may play a role. In this article, we retrospectively reviewed the baseline characteristics, treatment strategy, pathology, intraoperative findings, as well as radiological profiles of sellar region lesions complicated with IAs. With the focus put on the high comorbidity rate of sellar region lesions and IAs, we did further statistical analysis to sketch the outline of this coexisting circumstance and to emphasize the importance of computed tomography angiography (CTA) as routine EEA preoperative examination. Thorough patient-surgeon communication should be proceeded before the formulation of an individualized treatment strategy.

Endoscopic transsellar transdiaphragmatic approach for extensive suprasellar pituitary macroadenomas

OBJECTIVE

In pituitary macroadenomas with extensive suprasellar extension (SSE), suprasellar region can be approached by extending exposure either anteriorly by adding bone removal of the tuberculum sellae and planum sphenoidal or posteriorly from inside the sellar cavity through diaphragma sella. The later approach has been rapidly regressed in favor of the anteriorly extended approach, mainly due to the inadequate angled illumination. Benefiting from the continuous evolution of visualization, authors, in current series, tried to revive this technique in form of pure endoscopic trans-sellar trans-diaphragmatic approach (ETSDA) for extra-capsular resection of pituitary macroadenomas with extensive SSE.

METHODS

A prospective review including 10 patients of pituitary macroadenomas with extensive SSE more than 10 mm underwent extra-capsular resection via the ETSDA. The detailed technical nuances and surgical outcome of this approach were evaluated.

RESULTS

Six of 10 patients had SSE > 10 mm and 4 patients had SSE > 20 mm, grade B and C, respectively. Gross total resection was achieved in all cases. Postoperatively, visual field deficit was ameliorated to varying degrees in all patients. There were no serious intraoperative complications, and the clinically overt postoperative CSF rhinorrhea was not observed in any case.

CONCLUSION

Extra-capsular resection of pituitary macroadenomas with extensive SSE can be effectively and safely achieved using the ETSDA. Thus, it may be more preferable to the anteriorly extended approach that may potentially increase the risk for postoperative CSF rhinorrhea.

Endoscopic vs. microscopic transsphenoidal pituitary surgery: a single centre study

Endoscopic pituitary surgery has shown promising results. This study reports the experiences of experienced microscopic pituitary surgeons changing to the endoscopic technique, and the beneficial effects on the postoperative outcomes. 45 transsphenoidal endoscopic-assisted surgeries performed in 2016–2017 were compared with 195 microscope-assisted surgeries performed in 2007–2017 for pituitary adenoma. Tumour size, hormonal status and vision were assessed preoperatively and 3–5 months postoperatively. Cases were identified through electronic patient records. GTR was achieved in 39% of the endoscopic operations vs. 22% of microscopic operations, p = 0.018. Mean duration of surgery was 86 min (77–95) with the endoscopic technique vs. 106 min (101–111) with the microscopic technique, p < 0.001. New hypothalamus–pituitary–adrenal axis deficiencies were observed after 3% of endoscopic vs. 34% microscopic operations, p = 0.001, and overall fewer postoperative pituitary deficiencies were observed in the endoscope-assisted group. Complications within 30 days of surgery occurred in 17% of endoscopic operations vs. 27% of microscopic operations (p > 0.05). Normalization of visual impairment occurred in 37% of the cases with preoperative visual impairment in the endoscopic group vs. 35% of those in the microscopic group (p > 0.05). The endoscopic technique performed better as a surgical procedure for pituitary adenomas. We found no statistically significant differences in complication rate or visual improvement between the two techniques.

Volumetric Study of Nonfunctioning Pituitary Adenomas: Predictors of Gross Total Resection

OBJECTIVE

Despite the efforts made to determine the achieved resection grade after pituitary adenoma surgery, there is a high level of disagreement among all the available classifications and measurement methods used. Our objective is to identify the factors that preoperatively could predict a gross total resection (GTR) of a clinically nonfunctioning pituitary adenoma through an endoscopic endonasal approach.

METHODS

Across 100 surgeries, we analyzed epidemiologic and clinical data, radiologic relevant data, extent of resection (EOR), and postoperative outcomes. The EOR was measured objectively through an accurate volumetric analysis.

RESULTS

The median presurgical volume was 8.58 cm³ (range, 0.5-58 cm³), the median maximum diameter was 27.3 mm (range, 7-67 mm), and the Knosp grade was 0 in 1 patient, 1 in 23%, 2 in 31%, 3 in 23% and 4 in 22% of patients. In the multivariate logistic regression analysis, we found 3 factors that significantly predicted the chances of a successful GTR: previous sellar surgery, Knosp grade, and tumor signal in the T2-weighted magnetic resonance imaging scan. Another 10 radiologic variables were analyzed and had no effect on the EOR.

CONCLUSIONS

Knosp grade (P < 0.001; odds ratio [OR], 25.65; 95% confidence interval, 7.19-91.52) is the most predictive factor for performing a GTR of nonfunctioning pituitary adenoma. Previous pituitary surgery (P = 0.023; OR, 5.81) and an isointense T2-weighted signal (P = 0.034; OR, 3.75) also negatively influenced the chances of GTR. We highlight the influence of T2-weighted signal in the chances of GTR.

Persistent Cushing's Disease after Transsphenoidal Surgery: Challenges and Solutions

Transsphenoidal surgery remains the primary treatment for Cushing's disease (CD). However, despite the vast improvements in pituitary surgery, successful treatment of CD remains a great challenge. Although selective transsphenoidal removal of the pituitary tumor is a safe and effective procedure, the disease persists in around 22% of CD patients due to incomplete tumor resection. The persistence of hypercortisolism after pituitary surgery may also be the consequence of a misdiagnosis, as can occur in case of ectopic ACTH secretion or pseudo-Cushing. Considering the elevated mortality and morbidity characterizing the disease, a multidisciplinary approach is needed to minimize potential pitfalls occurring during the diagnosis, avoid surgical failure and provide the best care in those patients who have undergone unsuccessful surgery. In this review, we analyze the factors that could predict remission or persistence of CD after pituitary surgery and revise the therapeutic options in case of surgical failure.

Assessing the surgical outcome of the "chopsticks" technique in endoscopic transsphenoidal adenoma surgery

OBJECTIVE

The "chopsticks" technique is a 3-instrument, 2-hand mononostril technique that has been recently introduced in endoscopic neurosurgery. It allows a dynamic surgical view controlled by one surgeon only while keeping bimanual dissection. Being a mononostril approach, it requires manipulation of the mucosa of one nasal cavity only. The rationale of the technique is to reduce nasal morbidity without compromising surgical results and complication rates. There are, however, no data available on its results in endoscopic surgery (transsphenoidal surgery [TSS]) for pituitary adenoma.

METHODS

The authors performed a cohort analysis of prospectively collected data on 144 patients (156 operations) undergoing TSS using the chopsticks technique with 3T intraoperative MRI. All patients had at least 3 months of postoperative neurosurgical, endocrinological, and rhinological follow-up (Sino-Nasal Outcome Test-20 [SNOT-20] and Sniffin' Sticks). The surgical technique is described, and the achieved gross-total resection (GTR) and extent of resection (EOR) together with patients' clinical outcomes and complications are descriptively reported.

RESULTS

On 3-month postoperative MRI, GTR was achieved in 71.2% of patients with a mean EOR of 96.7%. GTR was the surgical goal in 122 of 156 cases and was achieved in 106 of 122 (86.9%), with a mean EOR of 98.7% (median 100%, range 49%-100%). There was no surgical mortality. At a median follow-up of 15 months (range 3-70 months), there was 1 permanent neurological deficit. As of the last available follow-up, 11.5% of patients had a new pituitary single-axis deficit, whereas 26.3% had improvement in endocrinological function. Three patients had new postoperative hyposmia. One patient had severe impairment of sinonasal function (SNOT-20 score > 40). The operation resulted in endocrine remission in 81.1% of patients with secreting adenomas.

CONCLUSIONS

This study shows that the chopsticks technique confers resection and morbidity results that compare favorably with literature reports of TSS. This technique permits a single surgeon to perform effective endoscopic bimanual dissection through a single nostril, reducing manipulation of healthy tissue and thereby possibly minimizing surgical morbidity.

Craniopharyngiomas: experience and results

INTRODUCTION

Craniopharyngiomas are a big challenge in the neurosurgical field. Because these lesions involve important systems, surgeons must weigh the risks of aggressive resection against the long-term challenges of recurrence. We present the outcomes of our patients based on clinical results, degree of resection, recurrence and disease-free survival.

MATERIALS AND METHODS

We reviewed medical records in all patients who had undergone surgical resection for craniopharyngioma at (Hospital Italiano de Buenos Aires) between 2007 and 2019. We considered ophthalmological examinations, imaging studies, endocrinological studies and surgical complications. Radical resections were planned in all of the patients. To help choose the correct surgical approach, craniopharyngiomas were classified based on tumor location.

RESULTS

Thirty cases of craniopharyngioma were analysed. 12.5% were classified as intrasellar, 12.5% as prechiasmatic, 43.75% as retrochiasmatic, and 31.25% as intraventricular. Overall, 38 cases involved a transcranial surgery (15 orbitozygomatic approach; 19 pterional approach and 4 transcallosal approach), seven involved a transsphenoidal approach, two microscopic transnasal approach and one ventricular endoscopy for emptying the craniopharyngioma cyst. Gross-total resection was achieved in 43.7% and near-total resection (more than 90%) in 25%. The mean follow-up period after resection was 4.7 years. Tumor recurrence occurred in 48%, with an average of 42.7 disease-free months.

CONCLUSION

Total tumor resection is the best treatment for craniopharyngioma. Due to its high morbidity and mortality, a multidisciplinary team is necessary for the management of these tumors.

Endoscopic Endonasal Transsphenoidal Surgery: History and Evolution

In previous decades, extensive and disfiguring transfacial and/or transcranial approaches were used to reach the sellar and parasellar areas. However, these surgical routes were burdened by severe complications and high mortality rates. Recently, the development of endoscopic endonasal techniques has revolutionized the surgical strategies for approaching the sella and adjacent areas and increased the development of transsphenoidal surgery. With these techniques, surgeons have been able to overcome the visual limitations of the open surgical approaches and access areas previously hidden from view. After the contributions of the Pittsburgh duo, Carrau and Jho, pioneers of pure endoscopic surgery, our school began to implement this technique, introducing technical innovations and variations, describing the anatomical details and defining new routes, and playing a key role in its widespread clinical application.

Outcomes following endoscopic endonasal resection of sellar and supresellar lesions in pediatric patients

PURPOSE

The endoscopic endonasal approach (EEA) is a credible surgical alternative for the resection of sellar and suprasellar lesions such as pituitary adenomas, craniopharyngiomas, and Rathke cleft cysts. However, its application to pediatric patients poses several unique challenges that have not yet been well evaluated. The authors evaluate the safety, efficacy, and outcomes associated with the use of the EEA for treatment of these pathologic entities in pediatric patients.

METHODS

Retrospective review of 30 patients between the ages of two and 24 who underwent endoscopic endonasal resection of sellar or suprasellar lesions between January 2010 and December 2015. Endocrinological and ophthalmological outcomes, as well as extent of resection and complications were all evaluated.

RESULTS

Gross total resection was achieved in eight of the nine pituitary adenomas, nine of the 12 craniopharyngiomas, and six of the nine Rathke cleft cysts. Of the 30 patients, 22 remained disease free at last follow-up. A total of six patients developed hypopituitarism and five developed diabetes insipidus. Eleven patients experienced improved vision, sixteen experienced no change, and one patient experienced visual worsening. Postoperative cerebrospinal fluid leak was seen in a single case and later resolved, vasospasm/stroke was experienced by 10% of patients, and new obesity was recorded in 10% of patients. There were no perioperative deaths.

CONCLUSIONS

Endoscopic endonasal resection is a safe and effective surgical alternative for the management of sellar and suprasellar pathologies in pediatric populations with excellent outcomes, minimal complications, and a low risk of morbidity.

The extended endoscopic approach to perisellar and skull base lesions: is one nostril enough?

The extended endonasal endoscopic approach to the skull base is still under investigation. The main advantage of using this technique is to approach lesions in a minimally invasive manner resulting without brain retraction. Here, the authors present the results of extended endonasal endoscopic surgery via one nostril. All skull base procedures performed via an endonasal approach at the author's Department between January 2011 and May 2017 were analysed prospectively. Special attention was paid to complications, radicality, advantages and disadvantages of the endoscopic technique. Additionally, the application of various telescopes and the technique of dural closure were analysed. Sixty-two patients were operated on various pathologies of the skull base via an extended endonasal approach. Seven pathologies were resected via binostril technique. All other pathologies could be exposed by the mononostril technique. In 2 of 62 cases, the authors had to switch to binostril technique. MRI revealed radical gross total resection in 93% of all cases when intended. Overall complication rate was 16% (9/55) in the mononostril and 57% (4/7) in the binostril cohort. Seven patients in the mononostril cohort (13%) versus three patients in the binostril cohort (43%) complained of postoperative nasal congestion. This clinical report shows that many extended skull base lesions can be treated by a mononostril endonasal approach. In selected cases, this technique might represent an alternative to the binostril approach. Nevertheless, the binostril technique offers a better range of manipulation and exposure and should be preferred in difficult and very extended cases.

Sinonasal quality-of-life outcomes after endoscopic endonasal skull base surgery

BACKGROUND

There are substantial gaps in our understanding of the influence of the endoscopic endonasal approach (EEA) for endoscopic skull base surgery on sinonasal-specific quality of life (QOL) as well as the instruments available for assessment. Our primary objective in this study was to characterize postoperative changes in sinonasal QOL, specifically using the 22-item Sino-Nasal Outcome Test (SNOT-22), with a secondary objective of delineating weaknesses in our current understanding of patient symptomatology after EEA for skull base surgery.

METHODS

A comprehensive literature review was conducted using PubMed, CINAHL, Cochrane Library, and SCOPUS for studies reporting SNOT-22 data pre- and postoperatively in patients who underwent EEA for skull base pathologies. Studies were limited to patients ≥18 years of age and excluded patients diagnosed with chronic rhinosinusitis (CRS).

RESULTS

Nineteen unique studies with 27 separate data sets and a total of 1025 patients were used in this meta-analysis. Overall SNOT-22 scores statistically improved at the 6-month (p = 0.0009) and 1-year (p = 0.002) time-points. Patients with preoperative SNOT-22 scores ≥20 achieved postoperative improvements at 12-week (p < 0.00001), 6-month (p < 0.0001), 1-year (p < 0.00001), and long-term follow-up (p < 0.0001). Patients with preoperative SNOT-22 scores <20 remained stable and did not worsen postoperatively.

CONCLUSION

Patients undergoing EEA for skull base pathologies who have impaired sinonasal QOL preoperatively demonstrated significant postoperative QOL improvements. Those patients with relatively normal preoperative sinonasal QOL remained asymptomatic postoperatively. This study supports the need for development of a contemporary disease- and approach-specific, validated QOL instrument for skull base pathologies.

Management of Giant Pituitary Adenomas: Role and Outcome of the Endoscopic Endonasal Surgical Approach

Giant adenomas represent a significant surgical challenge. Although traditionally several transcranial and transsphenoidal microscopic approaches have had a central role in their management, in the last 2 decades here have been increasing reports of the endoscopic endonasal approach for giant adenomas, citing its improved resection rates and lower complication profile. However, its role as the preferred approach has not been fully established and there is currently a paucity of evidence-based recommendations available in the literature. This article reviews the current literature and attempts to define the role and outcomes of the endoscopic endonasal surgical approach for giant pituitary adenomas.

7T MRI in epilepsy patients with previously normal clinical MRI exams compared against healthy controls

Objective

To compare by 7 Tesla (7T) magnetic resonance imaging (MRI) in patients with focal epilepsy who have non-lesional clinical MRI scans with healthy controls.

Methods

37 patients with focal epilepsy, based on clinical and electroencephalogram (EEG) data, with non-lesional MRIs at clinical field strengths and 21 healthy controls were recruited for the 7T imaging study. The MRI protocol consisted of high resolution T₁-weighted, T₂-weighted and susceptibility weighted imaging sequences of the entire cortex. The images were read by two neuroradiologists, who were initially blind to clinical data, and then reviewed a second time with knowledge of the seizure onset zone.

Results

A total of 25 patients had findings with epileptogenic potential. In five patients these were definitely related to their epilepsy, confirmed through surgical intervention, in three they co-localized to the suspected seizure onset zone and likely caused the seizures. In seven patients the imaging findings co-localized to the suspected seizure onset zone but were not the definitive cause, and ten had cortical lesions with epileptogenic potential that did not localize to the suspected seizure onset zone. There were multiple other findings of uncertain significance found in both epilepsy patients and healthy controls. The susceptibility weighted imaging sequence was instrumental in guiding more targeted inspection of the other structural images and aiding in the identification of cortical lesions.

Significance

Information revealed by the improved resolution and enhanced contrast provided by 7T imaging is valuable in noninvasive identification of lesions in epilepsy patients who are non-lesional at clinical field strengths.

Endoscopic Endonasal Excision of Large and Giant Pituitary Adenomas: Radiological and Intraoperative Correlates of the Extent of Resection

BACKGROUND

Despite the superb visualization offered by the endoscopic endonasal transsphenoidal approach, the resection rates of large and giant pituitary adenomas have remained much lower than those of smaller macroadenomas. Various tumor characteristics can influence the extent of resection (EOR) and have been variably reported. Additional understanding of these factors is mandatory to improve the results. We analyzed the radiological and intraoperative tumor characteristics influencing the EOR in a cohort of patients with large and giant pituitary macroadenomas undergoing endoscopic endonasal transsphenoidal excision under our care.

METHODS

Twenty-eight patients were included. Magnetic resonance images were retrospectively analyzed for pre- and postoperative tumor volumetric analysis; preoperative tumor volume calculation using the formula (A × B × C/2); preoperative radioanatomical characteristics, including tumor shape, radiological structure, contrast enhancement, and extension; and the EOR. Intraoperative data were retrieved and included.

RESULTS

The preoperative calculated tumor volume was 38.14 ± 23.02 cm³ and the preoperative measured tumor volume was 50.345 ± 17.36 cm³. A statistically significant difference was found between the calculated and measured tumor volumes for the whole cohort and for tumors with a maximum diameter >3.9 cm. A statistically significant difference in the EOR was found at a volume threshold of 26.2 cm³. Large cysts, heterogeneous enhancement, Knosp grade ≤2, soft tumor consistency, and tumor hemorrhage were significantly associated with gross total resection.

CONCLUSIONS

Volumetric analysis should replace 2-dimensional methods in determining the size of large and giant pituitary adenomas. Specific tumor characteristics were associated with the EOR and could help in predicting the EOR for these tumors.

Use of intraoperative intracavitary (direct-contact) ultrasound for resection control in transsphenoidal surgery for pituitary tumors: evaluation of a microsurgical series

BACKGROUND

Perisellar infiltration may be responsible for incomplete removal of pituitary tumors. Since intraoperative visualization of parasellar structures is difficult during transsphenoidal surgery, we are describing the use of intraoperative direct contact ultrasound (IOUS).

METHODS

Within 5 years, in 113 transsphenoidal operations (58 male, 55 female, age 14-81 years, 110 pituitary adenomas (mean diameter 26.6 mm, 69 non-secreting adenomas, 41 secreting adenomas), and 1 of each Rathke's cleft cyst, craniopharyngioma, and xanthogranuloma), IOUS was applied. After wide opening of the sellar floor and removal of the intrasellar tumor portions, a commercially available side fire ultrasound probe is introduced, and in direct contact to the sellar envelope, the perisellar space is scanned perpendicular to the axis of the working channel. We compared the results of IOUS to postoperative MRI after 3-6 months.

RESULTS

Identification of the intracavernous ICA, the anterior optic pathway, and the ACA, was possible, it was safe to operate close to them. In 65 operations (58%), further resection of tumor remnants was performed after IOUS. In this selected series, complete resection of tumors (stated by postoperative MRI after 3-6 months) was achieved in 75 operations (66%) and remission was achieved in 18 operations of secreting adenomas (44%). Compared to MRI after 3 to 6 months, the sensitivity of IOUS was 0.568 and the specificity was 0.907. No complications related to IOUS were seen.

CONCLUSIONS

Visualization of the perisellar compartments by IOUS is easy and fast to perform. It allows the surgeon to identify resectable tumor remnants intraoperatively, which otherwise could be missed.

Quality of life after extended versus transsellar endoscopic skull base surgery from 767 patients

OBJECTIVES/HYPOTHESIS

The aim of this study was to compare sinonasal-related quality of life (QOL) in patients treated by extended or transsellar endoscopic skull base surgery.

STUDY DESIGN

Prospective data analysis.

METHODS

Prospectively collected data from patients who underwent endoscopic skull base surgery between 2012 and 2017 were analyzed. Primary outcomes were preoperative Sino-Nasal Outcome Test-20 (SNOT-20) scores and then 1-month, 3-month, and 6-month follow-up. Comparative analysis was performed between the endoscopic transsellar approach (ETA) group (n = 647) and an extended endoscopic endonasal approach (EEEA) group (n = 120). In ETA group, the SNOT-20 score was compared between patients with a nasoseptal flap (NSF) (ETA-NSF) and without an NSF (ETA-no NSF).

RESULTS

The mean total SNOT-20 score was significantly worse in the EEEA than ETA group at 1, 3, and 6 months postoperatively (P < .05). Although there was no significant difference in total SNOT-20 score between the ETA-NSF and ETA-no NSF group at 3 and 6 months after surgery, the percentage of patients with significant change (≥0.8) in the SNOT-20 score was higher in the NSF used group at 1, 3, and 6 months postoperatively (22.92% vs. 13.51%, P = .029; 20.59% vs. 5.59%, P = .039; and 24.00% vs. 4.03%, P = .003, respectively). According to multivariate analysis conducted regarding factors that deteriorate sinonasal QOL at 6 months following surgery, only NSF usage is significantly associated with poor outcome (odds ratio: 4.371, P = .011) CONCLUSIONS: Sinonasal-related QOL was significantly worse in patients treated by the EEEA versus ETA. Use of an NSF is the only poor prognostic factor in sinonasal QOL after endoscopic skull base surgery.

LEVEL OF EVIDENCE

2b Laryngoscope, 129:1318-1324, 2019.

Quality of life outcomes after endoscopic approaches to intracranial tumors

PURPOSE OF REVIEW

To review the literature on quality of life (QOL) in endoscopic approaches to anterior and central intracranial skull-base disease. As endoscopic surgical techniques have gained widespread acceptance and complications and morbidity remain low and comparable with microscopic and open approaches, a shift to focusing on patients' perception of their own well being as an important outcome parameter has been made. In addition to the traditional measurements of surgical outcomes (extent of resection, recurrence rate, morbidity, survival, and complication rate), the success of a surgery can now be assessed using QOL measures.

RECENT FINDINGS

The main tools for assessing QOL in endoscopic skull-base surgery (anterior skull-base questionnaire and 22-item sinonasal outcome test) were not specifically designed for endoscopic skull-base approaches, and recently, a new tool was introduced and validated, the skull-base inventory, adding to our armamentarium, but it has not yet been widely employed. Endoscopic skull-base surgery leads to improved or sustained long-term QOL overall but it is significantly influenced by tumor disease. Specific endoscopic surgical technique (such as nasoseptal flap closure) appears to have less impact on QOL.

SUMMARY

It is becoming critical to assess therapeutic interventions in terms of impact on a patient's QOL. QOL can be useful in comparing efficacy of surgical interventions, and in the future, it will likely become a reportable indicator of surgical outcome and guide our surgical technique recommendations. Large-scale prospective multicenter trials would be beneficial.

The 100 Most-Cited Reports About Craniopharyngioma

OBJECTIVE

Our objective was to identify the 100 most-cited research reports on craniopharyngiomas.

METHODS

The Thomson Reuters Web of Science service was queried for the years 1900 to 2017 without language restrictions. The articles were sorted in descending order of the number of times they had been cited by other studies, and all titles and abstracts were screened to identify the research areas of the top 100 reports. The number of citations per year was calculated.

RESULTS

We identified the 100 most-cited articles on craniopharyngioma, which, collectively, had been cited 20,994 times at the time of our report. The top cited report had been cited 718 times, with an average of 144 citations annually since publication. The oldest article had been published in 1969 and the most recent in 2013; the most prolific decade was the 2000s, with 38 of the included articles published during that period. Thirty-two unique journals contributed to the 100 articles, with the Journal of Neurosurgery contributing most of the articles (n = 31). The most common country of article origin was the United States (n = 49), followed by United Kingdom (n = 12), Germany (n = 10), and Italy (n = 6).

CONCLUSIONS

The present study identified the 100 most-cited research articles in craniopharyngioma. These results highlight the multidisciplinary and multimodal nature of craniopharyngioma management. Recognition of important historical contributions to this field could guide future investigations.

Management of Pituitary Adenomas: Mononostril Endoscopic Transsphenoidal Surgery

Introduction:

The endoscopic transsphenoidal approach for pituitary adenomas and other sellar lesions is quickly becoming the procedure of choice in their surgical management. The most common approach is binostril three-hand technique which requires a large exposure and subjects both nasal cavities to potential trauma. To reduce nasal morbidity, we employ a mononostril two-hand technique with the help of the endoscope holder. In this research, we review our series to determine efficacy of this approach in the management of pituitary adenomas.

Methods:

We performed a retrospective analysis of our initial series of 64 consecutive patients with pituitary adenomas operated by the same surgical team from 2008 till 2014 using a mononostril endoscopic approach. After categorizing the lesions into microadenomas, noninvasive macroadenomas, and invasive macroadenomas, we reviewed the radiological and biochemical outcomes of the surgeries after 3 months, 12 months, and 18 months. We also assessed recurrences and complications. Extent of resection was divided into gross total resection, near total resection (>90% resection), and partial resection for the remaining.

Results:

Our results show resection rates comparable to most series in the literature, with a gross total resection of 87% in non-invasive macroadenomas, and surgical disease control in 75% of invasive nonfunctioning adenomas. The remission rate in Cushing’s disease was 81%, where it achieved up to 58% surgical remission in growth hormone secreting pituitary adenomas (including the invasive adenomas). The complication rate was very low.

Conclusion:

We conclude that the mononostril endoscopic approach is well suited for most pituitary tumor operations and carries comparable remission and resection rates to most endoscopic series with minimal complications and nasal morbidity.

Carotid canal and optic canal at sphenoid sinus

In the present study, we investigated the relationship between sphenoid sinus, carotid canal, and optic canal on paranasal sinus computed tomography (PNSCT). This study was performed retrospectively. PNSCT images of 300 adult subjects (159 male, 141 female). Sphenoid sinus (pneumatisation, dominancy, septation, inter-sinus septa deviation), anterior clinoid process pneumatisation, Onodi cell, carotid and optic canals (width, dehiscence, classification) were measured. In males, type 3 pneumatised sphenoid sinus (in both sides) and in females type 2 pneumatised sphenoid sinus (right side) and type 3 pneumatised sphenoid sinus (left side) were detected more. Anterior clinoid pneumatisation was present 47.2% in males and 39.7% in females. In male group, more septation (i.e. 22.6%, ≥ 3 septa) in sphenoid sinus were detected. Onodi cell was present 26.6 and 19.1% in males and females, respectively. Carotid canal protrudation to the sphenoid sinus wall was present 23.9-32.1% in males and 35.5-36.2% in females. Dehiscence in carotid canal was detected more in females (34%) compared to males (22%). Optic canal protrudation was 33.3 and 30.5% in males and females. Type 4 optic canal was detected more in both gender. Optic canal dehiscence was detected 11.3 and 9.9% in males and females. Carotid and optic canal diameters were higher in males. In pneumatised sphenoid sinuses and in females, type 3 carotid canal (Protrudation to SS wall) (bilaterally) and type 1 optic canal type (No indentation) (ipsilateral side) were detected more. In elderly patients, carotid and optic canal width increased. When carotid canal protrudation was detected, there was no indentation in optic canals In pneumatised SS, carotid canal protrudation was observed with a greater risk in surgery. However, type 1 (non indentation) optic canal was present in highly pneumatised SS with lower risk for the surgery. In women, the risk of carotid canal protruding (about 1/3) is greater than that of males, and carotid canal dehiscence rates are also higher in females. Therefore, physicians should be very careful during the preparatory stages of the sphenoid sinus surgery. Otherwise, it may not be possible to prevent lethal carotid artery bleeds.

Sinonasal outcome after endoscopic mononostril transsphenoidal surgery: A single center cohort study

OBJECTIVE

The endoscopic endonasal approach has been well established for skull base surgery. However, there are only few studies pointing out nasal complaints after surgery. In this study, the authors evaluated postoperative nasal complaints and complications after mononostril endoscopic procedures.

METHODS

All patients operated on parasellar and sellar pathologies at our department via an endoscopic mononostril transnasal transsphenoidal approach from January 2011 to May 2015 were analyzed. To assess specific postoperative nasal pathological conditions and complaints, a questionnaire was established. Applicable data of 79 patients with additional ENT follow-up could be included. Endpoints were the quantitative evaluation of complications and correlation of these data.

RESULTS

There was no vascular injury or worsening of visual function. Two patients had persisting CSF fistula and one of them meningitis. There was a significant decrease of nasal complaints during follow up after 2 years (p < 0.001). Further surgical treatment by ENT physician was necessary in 11.4%. Resurgery significantly increased the risk of postsurgical complaints (p < 0.005). The use of a tamponade significantly reduced the risk of postsurgical reduced nasal airflow (p = 0.026) and sinusitis (p = 0.002).

CONCLUSIONS

Endoscopic endonasal procedures to skull base lesions achieve high radicality with low complication rates. However, they induce temporary and permanent nasal complaints and complications. Thereby, resurgeries increase the risk of nasal complaints and the use of nasal tamponades might increase the sinonasal outcome. Further prospective studies are necessary to objectify the evaluation of postsurgical nasal complications.

Fully Endoscopic Transsphenoidal Resection of Pituitary Tumors: Technique and Results

Background

The aim of this study was to describe our two-surgeon fully endoscopic approach to pituitary surgery and to report results in terms of tumor remission, improvement in vision, and complications. A retrospective chart review was performed.

Methods

Our prospectively recorded surgical database was searched for all endoscopic transsphenoidal procedures between January 2001 and December 2005. Those patients who had surgery had their medical charts reviewed and presenting symptoms and signs, lesion characteristics, endocrine investigations, operative details, complications, and treatment outcomes recorded.

Results

Thirty-two patients were included in the study. Twenty-three patients had macroadenomas, five patients had microadenomas, and four patients had other pathologies. Most patients with macroadenomas had significant supra- or parasellar extension. Of the 14 patients who had visual loss at presentation, 13 had postoperative improvement. Two patients had postoperative cerebrospinal fluid leaks, which were successfully treated endoscopically. Eight patients required some form of hormone replacement after surgery. After a mean follow-up of 31 months, the overall remission rate for patients with macroadenomas was 82% and for patients with microadenomas was 100%.

Conclusion

The fully endoscopic transsphenoidal approach provides excellent visualization for tumor resection and results in acceptable remission rates.

Management of non-functioning pituitary adenomas: surgery

Non-functional pituitary adenomas (NFPAs) are benign tumors of the pituitary gland that do not over-secrete hormonal products, therefore, they are generally detected through symptoms of mass effect, including headache, vision loss, or hypopituitarism. There are multiple pathological subtypes of NFPAs, such as null cell adenomas, silent gonadotrophs, silent somatotrophs, silent corticotrophs, and silent subtype 3, all of which can be classified based on immunohistochemical studies and electron microscopy. Despite these numerous pathological subtypes, surgical resection remains the first-line treatment for NFPAs. Diagnosis is best made using high resolution MRI brain with and without gadolinium contrast, which is also helpful in determining the extent of invasion of the tumor and recognizing necessary sinonasal anatomy prior to surgery. Additional pre-operative work-up should include full laboratory endocrine evaluation with replacement of hormone deficiencies, and ideally, full neuro-ophthalmologic exam. Although transcranial surgical approaches to the pituitary gland can be performed, the most common approach used is the transnasal transsphenoidal approach with endoscopic or microscopic visualization. This approach avoids retraction of the brain and cranial nerves during tumor removal. Surgery for symptoms caused by mass effect, including headaches and visual loss, are successfully treated with surgical resection, resulting in improvement in pre-operative symptoms as high as 90% in some reports. Although the risk of complications is low, major and minor events, such as permanent hypopituitarism, persistent CSF leak, and carotid artery injury can occur at rates ranging from zero to about 9%.

Reaching the sellar region endonasally - One or both nostrils? A pilot study in body donors

INTRODUCTION

The purpose of this study was to evaluate the effect of posterior septectomy size on surgical exposure and surgical freedom during the endoscopic transsphenoidal approach to the sellar and parasellar region.

METHODS

A mononostril and binostril approach to the sellar region was performed on 4 formalin-fixed cadaveric heads. Predefined anatomical structures were identified. Additionally, a millimeter gauge was introduced into the surgical site and the extent of dorsal septectomy was analyzed for both approaches. Surgical freedom was defined as the distance between the ipsilateral and contralateral limit of opening of the sphenoid sinus.

RESULTS

The mean extent of dorsal septectomy was 15.7±5.7mm using a binostril approach to achieve adequate visualization of all relevant anatomical structures. Superior results were obtained via binostril technique with respect to the ability to identify the contralateral internal carotid artery or opticocarotid recessus. No such advantage was found for all other landmarks. Surgical freedom between the ipsilateral and contralateral limit of exposure of the sphenoid sinus was measured with 15±0.8mm in the mononostril and 19.2±0.9mm in the binostril group.

CONCLUSIONS

The surgical exposure increased significantly with progressively larger posterior septectomy in binostril approaches until a 20-mm posterior septectomy. Bilateral lateral opticocarotid recesses were accessible with a mean of 15mm for posterior septectomy. In the mononostril group no dorsal septectomy was necessary. Thus, the nasal mucosa is more preserved by this technique. However, the lateral exposure is partially limited and the use of angled endoscopes is recommended when adopting a mononostril approach to the sellar region.

Risk Factors Predicting Nasoseptal Flap Failure in the Endoscopic Endonasal Transsphenoidal Approach

OBJECTIVE

Reconstruction of the skull base using a pedicled nasoseptal flap (NSF) seems to be advantageous after the endoscopic endonasal transsphenoidal approach (EETSA). A few reports have evaluated the cause of flap failure in EETSA using NSFs. The aim of this study was to evaluate the perioperative risk factors for NSF failure.

STUDY DESIGN

Patient series.

SETTING

Retrospective review of medical records at a tertiary referral center.

METHODS

The study population comprised patients who underwent EETSA with NSF elevation between February 2009 and March 2014. The authors retrospectively reviewed the all patients' medical records, including operative findings.

RESULTS

Four hundred thirteen patients (203 males and 210 females) underwent EETSA, and 315 patients underwent EETSA with NSF elevation. The mean patient age was 48.0 years. The total number of patients of NSF failure was 6 (overall rate: 1.61%, 6/315; flap elevation: 0.31%, 1/315; flap reconstruction: 15.1%, 5/33). Two patients had diabetes mellitus. One patient had cardiovascular problems. Five patients were elderly (>60 years; mean age: 70 years). Five patients had postoperative nasal infection. One patient underwent preoperative radiation therapy.

CONCLUSION

Nasoseptal flap is a usually safe and effective technique for skull base reconstruction. However, the management of patients with diabetes mellitus, cardiovascular problems, advanced age, postoperative nasal infection, and radiation therapy may require more attention to improve NSF survival.

Microsurgical versus endoscopic transsphenoidal resection for acromegaly: a systematic review of outcomes and complications

PURPOSE

The aim of this systematic review is to evaluate the long-term endocrine outcomes and postoperative complications following endoscopic vs. microscopic transsphenoidal resection (TSR) for the treatment of acromegaly.

METHODS

A literature review was performed, and studies with at least five patients who underwent TSR for acromegaly, reporting biochemical remission criteria and long-term remission outcomes were included. Data extracted from each study included surgical technique, perioperative complications, biochemical remission criteria, and long-term remission outcomes.

RESULTS

Fifty-two case series from 1976 to 2016 met the inclusion criteria, comprising 4375 patients. Thirty-six reports were microsurgical (n = 3144) and 13 were endoscopic (n = 940). Three studies compared microsurgical (n = 111) to endoscopic TSR outcomes (n = 180). The overall initial and long-term remission rates were 58.2 vs. 57.4% and 69.2 vs. 70.2% for the microsurgical and endoscopic groups, respectively. For microadenomas, the initial and long-term remission rates were 77.6 vs. 82.2% and 76.9 vs. 73.5% for microsurgical and endoscopic approaches, respectively. For macroadenomas, the initial and long-term remission rates were 46.9 vs. 60.0% and 40.2 vs. 61.5% for microsurgical and endoscopic approaches, respectively. The rates of postoperative CSF leak were 3.0 vs. 2.3% for the microscopic and endoscopic groups, respectively. The rates of hypopituitarism and transient diabetes insipidus were 6.7 vs. 6.4% and 9.0 vs. 7.8% for the microscopic and endoscopic groups, respectively.

CONCLUSIONS

Both endoscopic and microsurgical approaches for TSR of growth hormone-secreting adenomas are viable treatment options for patients with acromegaly, and yield similarly high rates of remission under the most current consensus criteria.

Reoperation for growth hormone-secreting pituitary adenomas: report on an endonasal endoscopic series with a systematic review and meta-analysis of the literature

OBJECTIVE Surgery is generally the first-line therapy for acromegaly. For patients with residual or recurrent tumors, several treatment options exist, including repeat surgery, medical therapy, and radiation. Reoperation for recurrent acromegaly has been associated with poor results, with hormonal control usually achieved in fewer than 50% of cases. Extended endonasal endoscopic approaches (EEAs) may potentially improve the results of reoperation for acromegaly by providing increased visibility and maneuverability in parasellar areas. METHODS A database of all patients treated in the authors' center between July 2004 and February 2016 was reviewed. Cases involving patients with acromegaly secondary to growth hormone (GH)-secreting adenomas who underwent EEA were selected for chart review and divided into 2 groups: first-time surgery and reoperation. Disease control was defined by 2010 guidelines. Clinical and radiological characteristics and outcome data were extracted. A systematic review was done through a MEDLINE database search (2000-2016) to identify studies on the surgical treatment of acromegaly. Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the included studies were reviewed for surgical approach, tumor size, cavernous sinus invasion, disease control, and complications. Cases were divided into reoperation or first-time surgery for comparative analysis. RESULTS A total of 44 patients from the authors' institution were included in this study. Of these patients, 2 underwent both first-time surgery and reoperation during the study period and were therefore included in both groups. Thus data from 46 surgical cases were analyzed (35 first-time operations and 11 reoperations). The mean length of follow-up was 70 months (range 6-150 months). The mean size of the reoperated tumors was 14.8 ± 10.0 mm (5 micro- and 6 macroadenomas). The patients' mean age at the time of surgery was younger in the reoperation group than in the first-time surgery group (34.3 ± 12.8 years vs 49.1 ± 15.7 years, p = 0.007) and the mean preoperative GH level was also lower (7.7 ± 13.1 μg/L vs 25.6 ± 36.8 μg/L, p = 0.04). There was no statistically significant difference in disease control rates between the reoperation (7 [63.6%] of 11) and first-time surgery (25 [71.4%] of 33) groups (p = 0.71). Univariate analysis showed that older age, smaller tumor size, lower preoperative GH level, lower preoperative IGF-I level, and absence of cavernous sinus invasion were associated with higher chances of disease control in the first-time surgery group, whereas only absence of cavernous sinus invasion was associated with disease control in the reoperation group (p = 0.01). There was 1 case (9%) of transient diabetes insipidus and hypogonadism and 1 (9%) postoperative nasal infection after reoperation. The systematic review retrieved 29 papers with 161 reoperation and 2189 first-time surgery cases. Overall disease control for reoperation was 46.8% (95% CI 20%-74%) versus 56.4% (95% CI 49%-63%) for first-time operation. Reoperation and first-time surgery had similar control rates for microadenomas (73.6% [95% CI 32%-98%] vs 77.6% [95% CI 68%-85%]); however, reoperation was associated with substantially lower control rates for macroadenomas (27.5% [95% CI 5%-57%] vs 54.3% [95% CI 45%-62%]) and tumors invading the cavernous sinus (14.7% [95% CI 4%-29%] vs 38.5% [95% CI 27%-50%]). CONCLUSIONS Reoperative EEA for acromegaly had results similar to those for first-time surgery and rates of control for macroadenomas that were better than historical rates. Cavernous sinus invasion continues to be a negative prognostic indicator for disease control; however, results with EEA show improvement compared with results reported in the prior literature.

Preservation of hormonal function by identifying pituitary gland at endoscopic surgery

OBJECTIVE

The endonasal endoscopic approach has been established for perisellar tumor surgery with a higher resection rate and reduced complications. We analyzed the potential to identify the pituitary gland under endoscopic view, at surgery and see its relation to postoperative hormonal insufficiency in endonasal endoscopic procedures.

METHODS

Between January 2011 and January 2014, 70 cases of pituitary adenomas with preoperative intact pituitary function underwent endoscopic endonasal transsphenoidal procedures for intrasellar pathologies. Endocrinologists and neurosurgeons followed these patients prospectively. Special attention was paid to intraoperative identification of gland tissue, surgical complications, degree of resection and postoperative hormonal insufficiency.

RESULTS

The pituitary gland was identified in 57 out of 70 procedures (81.4%). Eleven percent (8 of 70 patients) had persistent pituitary insufficiency. Two of these 8 patients belonged to the group with pituitary gland identification (2 out of 57); thus, when the pituitary gland was identified during the procedure postoperative hormonal insufficiency was seen in 3.5% of cases. Failure of pituitary gland identification presented with hormonal insufficiency of 46.2%. In analysis with Fisher's exact test, there was a high significant correlation between the identification of the pituitary gland intraoperatively and normal pituitary function postoperatively (p<0.005). On follow up radical tumor resection was seen in 88% (62 of 70 patients).

CONCLUSIONS

This study indicates that identification and preservation of pituitary gland tissue and function is possible in endoscopic transsphenoidal surgery. This preservation of gland tissue is a positive predictor of postoperative normal pituitary function.

Endoscopic Assisted Supraorbital Keyhole Approach or Endoscopic Endonasal Approach in Cases of Tuberculum Sellae Meningioma: Which Surgical Route Should Be Favored?

OBJECTIVE

Keyhole approaches are under investigation for skull base tumor surgery. They are expected to have a low complication rate with the same successful resection rate compared with endoscopic endonasal procedures. In this study, we compare our current series of tuberculum sellae meningiomas resected via an endoscopic endonasal or microsurgical supraorbital keyhole approach.

METHODS

Between 2011 and 2016, 16 patients were treated using the supraorbital keyhole procedure and 6 patients received an endoscopic endonasal procedure. Both surgical techniques were analyzed and compared concerning complications, surgical radicality, endocrinologic, and ophthalmologic outcome and recurrences in patients' follow-up.

RESULTS

The 2 different approaches yielded similar rates of gross total resection (endonasal 83% [5 of 6] vs. supraorbital 87% [14 of 16]), near total resection (17% [1 of 6] vs. 13% [2 of 16]), and visual recovery (endonasal 66% [2 of 3] vs. supraorbital 60% [3 of 5]). An extension lateral to the internal carotid artery was noted in 81% (13 of 16) of the supraorbital cases and in none of the endonasal cases. Tumor volume was 14.9 cm³ (±8.2 cm³) for supraorbital tumors versus 2.1 cm³ (±0.8 cm³) for the endonasal approach.

CONCLUSIONS

Both approaches provide minimally invasive surgical routes accessing meningiomas of the sellar region. The ideal approach should be tailored to the individual patient considering the tumor anatomy, lateral extension, and the experience of the surgeon with both surgical approaches. We suggest using the supraorbital approach for larger meningiomas of sellar region with far lateral extension or broad vascular encasement.