phenylephrine-hydrochloride and Pituitary-Neoplasms

Advances in endoscopic surgical technique have ushered in a new era of pituitary surgery with improved rates of resection and minimized operative morbidity and burden. Anatomically, endoscopic transnasal transsphenoidal pituitary surgery is split into nasal, sphenoidal, and sellar stages, each with unique considerations. Recent developments in knowledge and technology seek to build on the success of the endoscope in pituitary surgery, while expanding its capabilities.

Topics: Endoscopes; Endoscopy; Humans; Nose; Otolaryngologists; Pituitary Neoplasms

Prolactinomas are the most common secretory tumor of the pituitary gland. Clinical symptoms may be due to prolactin oversecretion, localized mass effect, or a combination of both. Although the mainstay of prolactinoma management is medical therapy with dopamine agonists, endoscopic endonasal or transcranial surgery, radiation therapy, or a combination of these is an important treatment option in select cases. This article discusses prolactinoma phenotypes, clinical presentations, and clinically pertinent medical and surgical considerations when managing these tumors.

Topics: Dopamine Agonists; Humans; Nose; Pituitary Neoplasms; Prolactin; Prolactinoma

Pituitary surgery has undergone rapid advancements in the last 30 years, secondary to improved surgical techniques and technologies, including those that allow endoscopic approaches. Although the endoscopic endonasal approach (EEA) offers minimally invasive access to the region of the pituitary gland, complications are a significant consideration for the combined otolaryngology-neurosurgery team that is preparing for a case. In this article, we discuss various complications related to the EEA in pituitary surgery and explore ways to plan for and avoid them during surgery.

Topics: Endoscopy; Humans; Neurosurgical Procedures; Nose; Pituitary Gland; Pituitary Neoplasms

The extended endoscopic endonasal approach(EEA)has been expanding in recent years with the development of instruments and surgical techniques. Basically, sela, extradural, and intranasal lesions such as pituitary tumor, craniopharyngioma, chordoma, chondrosarcoma, and cholesterol granuloma are indicated. Intradural lesions or lesions that extend laterally or downward to the craniocervical junction are more difficult to operate. In addition, cases of hard tumor with calcification of the tumor, cases in which the tumor involves important blood vessels, re-operative cases, and cases after radiotherapy are also difficult cases and should be considered preoperatively. In recent years, we have been trying to keep the nasal structures as much as possible without removing nasal structure, but in cases where the tumor has invaded and destroyed the nasal structures, extended EEA is necessary. The anatomy of the extended EEA is complicated and not common among neurosurgeons. In this chapter, we present the basic anatomy and surgical cases to be understood in extended EEA and explain the pitfalls.

Topics: Chordoma; Humans; Nose; Pituitary Neoplasms; Postoperative Complications

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.

Topics: Endoscopy; Humans; Nose; Paranasal Sinuses; Pituitary Neoplasms; Skull Base

Craniopharyngiomas are locally aggressive neuroepithelial tumors infiltrating nearby critical neurovascular structures. The majority of published surgical series deal with childhood-onset craniopharyngiomas, while the optimal surgical management for adult-onset tumors remains unclear. The aim of this paper is to summarize the main principles defining the surgical strategy for the management of craniopharyngiomas in adult patients through an extensive systematic literature review in order to formulate a series of recommendations.. The MEDLINE database was systematically reviewed (January 1970-February 2019) to identify pertinent articles dealing with the surgical management of adult-onset craniopharyngiomas. A summary of literature evidence was proposed after discussion within the EANS skull base section.. The EANS task force formulated 13 recommendations and 4 suggestions. Treatment of these patients should be performed in tertiary referral centers. The endonasal approach is presently recommended for midline craniopharyngiomas because of the improved GTR and superior endocrinological and visual outcomes. The rate of CSF leak has strongly diminished with the use of the multilayer reconstruction technique. Transcranial approaches are recommended for tumors presenting lateral extensions or purely intraventricular. Independent of the technique, a maximal but hypothalamic-sparing resection should be performed to limit the occurrence of postoperative hypothalamic syndromes and metabolic complications. Similar principles should also be applied for tumor recurrences. Radiotherapy or intracystic agents are alternative treatments when no further surgery is possible. A multidisciplinary long-term follow-up is necessary.

Topics: Adult; Consensus; Craniopharyngioma; Humans; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Complications; Practice Guidelines as Topic; Societies, Medical

The advent of endonasal endoscopic skull base surgery (ESBS) has redefined the management of pediatric sellar and suprasellar lesions. To date, the outcomes of these procedures have not been systematically reviewed. This study performed a systematic review with meta-analysis of surgical outcomes for pediatric patients undergoing ESBS for sellar and suprasellar lesions.. PubMed (National Library of Medicine, National Institutes of Health), Scopus (Elsevier), and Cochrane Library (Wiley).. Articles reporting on pediatric patients undergoing ESBS for craniopharyngiomas, pituitary adenomas, and Rathke's cleft cysts were reviewed. The primary outcome was postoperative cerebrospinal fluid (CSF) leak. Secondary outcomes included endocrine, visual, and other complications.. Twenty-five articles reporting on 554 patients were included. Overall postoperative CSF leak rate was 8.6%, with tumor-specific rates of 10.6% in craniopharyngiomas, 6.5% in pituitary adenomas, and 7.2% in Rathke's cleft cysts (. ESBS for pediatric sellar and suprasellar lesions is overall an effective management approach with an increasingly favorable risk-benefit profile. Younger children may be more susceptible to postoperative CSF leak as compared with older pediatric patients. Tumor type does not appear to be an independent risk factor for postoperative CSF leak in this population.

Topics: Adenoma; Central Nervous System Cysts; Child; Craniopharyngioma; Humans; Natural Orifice Endoscopic Surgery; Nose; Pituitary Neoplasms; Sella Turcica

Over the last two decades there has been a gradual shift from the traditional microscopic approach toward the use of endoscopic endonasal approach for resection of pituitary adenomas. Multiple medical and surgical complications can occur following endoscopic transsphenoidal resection of adenomas.. We discuss the evolution of the surgical practice from the use of the 'microscope' to the 'endoscope' in the resection of pituitary adenomas. We present a comprehensive review of the medical and surgical complications following surgery with particular emphasis on both the prevention and management of electrolyte disturbance, cerebrospinal fluid leak and the rare but dreaded complication of internal carotid injury (ICA). We also searched the PubMed database to identify relevant literature between 1984 and 2019.. Use of endoscope compared with microscope may be associated with better preservation of pituitary gland function with similar extent of resection. Overall medical and surgical complications can be safely managed in high volume centers in association with endocrinologists and skull base trained otolaryngologists. Understanding of anatomico-technical nuances and meticulous surgical technique are important toward preventing ICA injury. Ongoing surgical and technical developments coupled with imaging advances will likely lead to better future outcomes for patients with functioning and nonfunctioning adenomas.

Topics: Adenoma; Cerebrospinal Fluid Leak; Humans; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Sphenoid Bone; Treatment Outcome

Germ cell tumors are rare malignant tumors frequently located in the suprasellar region. Definitive treatment is chemotherapy and radiation. However, in some circumstances, surgery is indicated for biopsy or resection. There are limited reports of the role of the endonasal endoscopic approach (EEA) in the management of this tumor. We present two cases in which EEA was utilized for successful management of germ cell tumor. The most challenging aspect of germ cell tumor management for the treating physician is knowing the proper indications for surgery. In this paper, we highlight two specific instances, namely diagnosis and tumor refractory to chemoradiation. Given the suprasellar location, EEA is an ideal approach.

Topics: Adolescent; Adult; Humans; Male; Natural Orifice Endoscopic Surgery; Neoplasms, Germ Cell and Embryonal; Nose; Pituitary Neoplasms

Knosp grade 4 adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma is a rare cause of Cushing disease. After the 1st surgery, the remission rate among these patients is extremely low.. We presented a case of a 33-year-old female with classical Cushingoid symptoms. Further investigations revealed ATCH-dependent hypercortisolemia, as well as a Knosp grade 4 pituitary macroadenoma.. Cushing disease, caused by a Knosp grade 4 pituitary macroadenoma.. The patient underwent endoscopic endonasal transsphenoidal surgery with the assistance of intraoperative transsphenoidal Doppler and image-guidance devices.. Pathologic examinations confirmed that the lesion was an ACTH-secreting pituitary adenoma. The patient was in biochemical remission after surgery. Her postoperative magnetic resonance imaging showed gross-total tumor resection. There was no evidence of recurrence during the 1-year follow-up.. With intraoperative Doppler and image-guidance, gross-total resection and biochemical remission can be achieved in Cushing disease when the internal carotid artery is completely encased by the pituitary adenoma.

Topics: ACTH-Secreting Pituitary Adenoma; Adenoma; Adult; Female; Humans; Magnetic Resonance Imaging; Natural Orifice Endoscopic Surgery; Neoplasm Recurrence, Local; Nose; Pituitary ACTH Hypersecretion; Pituitary Gland; Pituitary Neoplasms; Sphenoid Bone; Treatment Outcome; Ultrasonography, Interventional

Since the description of a transnasal approach for treatment of pituitary tumors, transsphenoidal surgery has undergone continuous development. Hirsch developed a lateral endonasal approach before simplifying it to a transseptal approach. Cushing approached pituitary tumors using a transsphenoidal approach but transitioned to the transcranial route. Transsphenoidal surgery was not "rediscovered" until Hardy introduced the surgical microscope. An endoscopic transsphenoidal approach for pituitary tumors has been reported and further advanced. We describe the principles of pituitary surgery including the key elements of surgical decision making and discuss the technical nuances distinguishing the endoscopic from the microscopic approach.

Topics: Endoscopy; Humans; Magnetic Resonance Imaging; Nose; Otorhinolaryngologic Surgical Procedures; Pituitary Gland; Pituitary Neoplasms; Tomography, X-Ray Computed

Endoscopic endonasal approaches to the skull base pathology have developed and evolved dramatically over the past 2 decades, particularly with collaboration between neurosurgery and otolaryngology physicians. These advances have increased significantly the use of such approaches beyond just resection of pituitary adenomas, including a variety of skull base pathologies. As the field has evolved, so has our understanding of the complications accompanying endoscopic skull base surgery, as well as techniques to both avoid and manage these complications. These are discussed here.

Topics: Anti-Bacterial Agents; Cerebrospinal Fluid Leak; Cranial Nerve Diseases; Endoscopy; Humans; Intraoperative Complications; Magnetic Resonance Imaging; Meningitis; Neurosurgical Procedures; Nose; Otolaryngology; Pituitary Neoplasms; Postoperative Complications; Professional Corporations; Skull Base; Tomography, X-Ray Computed

Endoscopic skull base surgery is becoming more popular as an approach to the anterior skull base for tumors and cerebrospinal fluid (CSF) fistulae. It offers the advantages of better cosmesis and improved quality of life after surgery. We reviewed the complication rates reported in the literature.. A literature search was performed in the electronic database Ovid MEDLINE (1950 to August 25, 2015) with the search item "([Anterior] AND Skull base surgery) AND endoscopic.". We identified 82 relevant studies that included 7460 cases. An average overall complication rate of 17.1% (range 0%-68.0%) and a mortality rate of 0.4% (0%-10.0%) were demonstrated in a total of 82 studies that included 7460 cases. The average CSF leak rate for all studies was 8.9% (0%-40.0%) with meningiomas and clival lesions having the greatest CSF leak rates. The most frequent benign pathology encountered was pituitary adenomas (n = 3720, 49.8% of all cases) and the most frequent malignant tumor was esthesioneuroblastoma (n = 120, 1.6% of all cases). Studies that included only CSF fistula repairs had a lower average total complication rate (12.9%) but a greater rate of meningitis compared with studies that reported mixed pathology (2.4% vs. 1.3%). A trend towards a lower total complication rate with increasing study size was observed.. The endoscopic approach is an increasingly accepted technique for anterior skull base tumor surgery and is associated with acceptable complication rates. Increasing experience with this technique can decrease rates of complications.

Topics: Adenoma; Cerebrospinal Fluid Leak; Esthesioneuroblastoma, Olfactory; Fistula; Humans; Meningeal Neoplasms; Meningioma; Meningitis; Mortality; Nasal Cavity; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Nose; Nose Neoplasms; Pituitary Neoplasms; Postoperative Complications; Skull Base; Skull Base Neoplasms

Over the past several decades, the endoscopic endonasal transsphenoidal approach (EETA) has gradually become a preferred option of pituitary adenomas surgery because of its minimal invasiveness and high efficiency. However, some EETA operations were performed through one nostril (mononostril), while other EETA operations were performed through both nostrils (binostril). Therefore, we conducted this study to compare the pros and cons of these two methods in an attempted to confirm which method is more effective.. We executed a systematic literature search of PubMed, the Cochrane Library, and the Web of Science and Medline (1992-2015). The language is limited to English and all studies should meet the inclusion criteria. Comparisons were made for postoperative outcomes, complications, and other relevant parameters between the mononostril and the binostril group. Statistical analyses of categorical variables were undertaken by the use of Stata 12.0 and SPASS 19.0.. Thirty studies, involving 4805 patients, were included. The two groups had similar results in GTR rate (included GTR rate of macroadenomas), hormonal remission rate, improvement in visual function, postoperative CSF leak, permanent diabetes insipidus, meningitis, and sinusitis. The binostril group had less temporary diabetes insipidus (2.9% vs. 5.3%, p = 0.022), less anterior pituitary insufficiency (2.3% vs. 6.4%, p = 0.000) and few hospitalization days (3.2 days vs. 4.4 days, p<0.05) than the mononostril group. However, the mononostril group had less rate of epistaxis (0.4% vs. 1.5%, p = 0.008) than the binostril group. For invasive macroadenomas, the binostril group seem to demonstrate a tendency towards better outcomes though there was no subgroup analysis between the two groups.. The binostril approach had less temporary diabetes insipidus, anterior pituitary insufficiency, and a shorter length of hospital stay, although they demonstrated a higher rate of epistaxis than the mononstril group. Additionally, the binostril group seemed to suggest a tendency towards better outcomes for invasive macroadenomas.

Topics: Adenoma; Adolescent; Adult; Aged; Aged, 80 and over; Child; Endoscopy; Female; Humans; Male; Middle Aged; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Treatment Outcome; Young Adult

Cerebral vasospasm following a transsphenoidal resection of a pituitary adenoma is a devastating occurrence that can lead to delayed cerebral ischemia and poor neurologic outcome if not diagnosed and treated in a timely manner. The etiology of this condition is not well understood but can lead to significant arterial vasospasm that causes severe ischemic insults. In this paper, we identify common presenting symptoms and essential management strategies to treat this harmful disease.. A retrospective case report and literature review of presentation, treatment, and outcome of cerebral vasospasm following transsphenoidal surgery.. We present 1 case and review 12 known cases in the literature on vasospasm following transsphenoidal surgery. Mean age was 48 (±13.8) years. There were 46.2% male patients. Factors associated with vasospasm, such as cerebral spinal fluid leaks following surgery, were seen in 38.5% of cases, and postoperative subarachnoid hemorrhage (SAH) was seen in 84.6% of cases. Hemiparesis was the presenting symptom of delayed cerebral ischemia in 61.5% of cases. For management, maintaining at least a euvolemic volume status was used in 76.9%, induced hypertension was used in 61.5%, and nimodipine was administered in 46.2% of cases. Patients returned to their neurologic baseline in 61.5% of cases, had new permanent deficits in 7.7% of cases, and died in 30.8% of cases.. Cerebral vasospasm following transsphenoidal surgery is a dangerous disease that can lead to a high likelihood of mortality if not identified and treated. Early postoperative events, such as peritumoral subarachnoid hemorrhage and hemiparesis, may be factors associated with post-transsphenoidal surgery vasospasm. Effective treatment options used in patients that regained complete neurologic recovery were by inducing hypertension, maintaining euvolemia, and administering nimodipine.

Topics: Adenoma; Adult; Aged; Endoscopes; Female; Humans; Magnetic Resonance Angiography; Magnetic Resonance Imaging; Middle Aged; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Complications; Sphenoid Bone; Vasospasm, Intracranial

Despite the substantial impact of cavernous sinus invasion (CSI) in pituitary adenoma surgery, its radiologic determination has been inconsistent and variable, and the role of endonasal endoscopic surgery has been unclear. This is a systematic review and pooled data meta-analysis of the literature to ascertain the best radiologic criteria for CSI and verify the efficacy and safety of an endonasal endoscopic approach.. We searched the MEDLINE database (1993-2015) to identify studies on radiologic criteria for CSI and endonasal surgery. Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the studies included were reviewed for CSI criteria, gross total resection (GTR), endocrine remission, cranial nerve deficits, carotid injury, and other complications.. The prevalence of CSI was 43% radiographically compared with 18% intraoperatively (P < 0.001). The radiologic criteria of inferolateral venous compartment obliteration and Knosp 3-4 had the highest correlation with intraoperative CSI and the lowest correlation with GTR. Microscopy had significantly overestimated intraoperative CSI compared with endoscopy (P < 0.001) for each Knosp grade. Endoscopy had significantly higher GTR than did microscopy particularly for Knosp 3-4 (47% vs. 21%; P = 0.001). Carotid injury and cranial nerve deficits occurred in 0.9% and 5%, respectively, with endoscopy. Among endoscopic series with CSI, GTR% showed significant correlation with number of patients in the series (P ≤ 0.01) but no correlation with complications, indicating the relative safety of endonasal endoscopy in experienced hands for removing tumors with CSI.. Knosp 3-4 remains the best objective indicator of CSI. Microscopy tends to overestimate intraoperative CSI compared with endoscopy. Among pituitary adenomas with CSI, GTR in endoscopic series is higher than microscopy and improves with experience without significant additional morbidity.

Topics: Adenoma; Cavernous Sinus; Humans; Microsurgery; Natural Orifice Endoscopic Surgery; Neoplasm Invasiveness; Neuroendoscopy; Neurosurgical Procedures; Nose; Pituitary Neoplasms

The management of giant and large pituitary adenomas with wide intracranial extension or infrasellar involvement of nasal and paranasal cavities is a big challenge for neurosurgeons and the best surgical approach indications are still controversial. Endoscopic extended endonasal approaches have been proposed as a new surgical technique for the treatment of such selected pituitary adenomas. Surgical series coming from many centers all around the world are flourishing and results in terms of outcomes and complications seem encouraging. This technique could be considered a valid alternative to the transcranial route for the management of giant and large pituitary adenomas.

Topics: Adenoma; Humans; Nasal Mucosa; Nasal Septum; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Nose; Pituitary Neoplasms; Surgical Flaps; Tumor Burden

The endoscopic endonasal approach for craniopharyngiomas is increasingly used as an alternative to microsurgical transsphenoidal or transcranial approaches. It is a step forward in treatment, providing improved resection rates and better visual outcome. Especially in retrochiasmatic tumors, this approach provides better lesion access and reduces the degree of manipulations of the optic apparatus. The panoramic view offered by endoscopy and the use of angulated optics allows the removal of lesions extending far into the third ventricle avoiding microsurgical brain splitting. Intensive training is required to perform this surgery. This article summarizes the surgical technique, outcome, and complications.

Topics: Craniopharyngioma; Humans; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Nose; Pituitary Neoplasms

Endoscopic transsphenoidal surgery is emerging as a minimally invasive and maximally effective procedure for pituitary adenomas. In this report we analyzed the complications in 624 procedures of endonasal transsphenoidal endoscopic surgery in the treatment of 570 patients with pituitary adenomas. The leading author (MB) operated pituitary adenomas via pure endoscopic endonasal transsphenoidal surgery between January 2006 and August 2011 at the Hacettepe University, Department of Neurosurgery in Ankara. Complications were assessed in 624 surgical procedures under five groups; rhinological, CSF leaks, infection, vascular and endocrinologic complications. We observed a total of 76 complications (12.1%). Rhinological complications occurred in 8 patients (1.3%): 4 epistaxis (0.6%) and 4 hyposmia (0.6%). Postoperative CSF leaks occurred in 8 patients (1.3%), and infectious complications occurred in 8 patients: 3 cases of sphenoidal sinusitis (0.4%), 5 cases of meningitis (0.8%). Only 1 case of internal carotid aneurysm rupture during the opening of sellar floor (0.16%) was observed. Endocrinologic complications occurred in 51 (8.1%) patients: Anterior pituitary deficiency in 12 (1.9%), transient diabetes insipidus (DI) in 29 (4.6%), permanent DI in 3 (0.4%) and inappropriate antidiuretic hormone secretion syndrome occurred in 7 (1.1%). There was no mortality directly related to the surgical procedure. The complication rates observed in our study suggests that the endoscopic pituitary surgery is at least as safe as microscopic transphenoidal surgery. These rates were obtained with due experience and well-coordinated teamwork. To further improve these rates, new technological developments will be helpful.

Topics: Adenoma; Adolescent; Adult; Cerebrospinal Fluid Rhinorrhea; Diabetes Insipidus; Endoscopy; Female; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Nose; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Sphenoid Sinusitis

The endoscope has been used in paranasal sinus surgery for many years. More recently, cooperation between neurosurgeons and ear, nose, and throat (ENT) surgeons has resulted in an extension of use of the endoscope to resection of lesions in the sella turcica region. The procedure described herein involves insertion of the endoscope and surgical instruments through one nostril to provide improved visualization of the pituitary gland and an economy of perioperative trauma. As compared with the traditional sublabial, transseptal approach, endonasal pituitary tumor resection is more direct, less traumatic, and allows excellent exposure of the tumor. These improvements result in reduced morbidity, shorter length of stay, and greater patient satisfaction.

Topics: Craniopharyngioma; Endoscopy; Humans; Neurosurgical Procedures; Nose; Perioperative Nursing; Pituitary Neoplasms; Prolactinoma

Topics: Acromegaly; Adenoma; Animals; History, 19th Century; History, 20th Century; Humans; Hypophysectomy; Nose; Pituitary Neoplasms; Surgical Flaps

Sinonasal Outcomes Test-22 (SNOT-22) is used widely as a patient-reported sinonasal quality-of-life (QOL) instrument for endoscopic endonasal pituitary surgery. However, it has never been validated in this population. This study explores the psychometric validity of SNOT-22 to determine if it is a valid scale in patients undergoing endoscopic pituitary surgery.. Multicenter prospective trial.. Adult patients (n = 113) with pituitary tumors undergoing endoscopic surgery were enrolled in a multicenter study. Patient-reported QOL was assessed using SNOT-22 and the Anterior Skull Base Nasal Inventory-12. Face validity, internal consistency, responsiveness to clinical change, test-retest reliability, and concurrent validity were determined using standard statistical methods.. Internal consistency using Cronbach's alpha at baseline and 2 weeks postoperatively were 0.911 and 0.922, indicating SNOT-22 performed well as a single construct. Mean QOL scores were significantly worse at 2 weeks than baseline (16.4 ± 15.1 vs. 23.1 ± 16.4, P < .001), indicating the scale is responsive to clinical change. However, only 11/22 items demonstrated significant changes in mean scores at 2 weeks. Correlation between scores at 2 and 3 weeks was high, suggesting good test-retest reliability, r(107) = 0.75, P < .001. Factor analysis suggests the five-factor solution proposed for the SNOT-22 in rhinosinusitis patients is not valid in pituitary surgery patients.. The SNOT-22 is a valid QOL instrument in patients undergoing endoscopic pituitary surgery. However, because it includes 22 items, can be applied only as a single construct, 50% of the items do not demonstrate changes after surgery, and is not as sensitive to change as other scales, shorter instruments developed specifically for this patient population may be preferable.. 2 Laryngoscope, 131:E2757-E2763, 2021.

Topics: Adult; Aged; Endoscopy; Factor Analysis, Statistical; Female; Humans; Male; Middle Aged; Neurosurgical Procedures; Nose; Pituitary Gland; Pituitary Neoplasms; Postoperative Period; Prospective Studies; Psychometrics; Quality of Life; Reproducibility of Results; Sino-Nasal Outcome Test; Treatment Outcome

Endoscopic endonasal transsphenoidal resection has been accepted as a routine therapy for pituitary adenoma, but the postoperative hospital stay is typically several days long. With the advantages of reduced cost and improved patient satisfaction, the application of ambulatory surgery (AS) has developed rapidly. However, AS was still rarely adopted in neurosurgery. Here we designed an AS treatment protocol for pituitary adenoma with the endoscopic endonasal approach (EEA), and reported our initial experiences regarding the safety and efficacy of the AS protocol. 63 patients who presented with pituitary adenoma were screened at the Department of Neurosurgery, Tangdu Hospital from July to September, 2017. A total of 20 pituitary adenoma patients who met the inclusion criteria underwent EEA surgery using this evidence-based AS protocol, which emphasized adequate assessment for eligibility, full preparation to minimize invasiveness, enhanced recovery, and active perioperative patient education. Of the 20 patients enrolled, 18 were discharged on the afternoon of the operation day with a median total length of stay (LOS) of 31 hours (range, 29-32) hours. The median LOS after surgery was 6.5 (range, 5-8) hours. Two patients were transferred from the AS protocol to conventional care due to intraoperative cerebrospinal fluid leakage (one case) and an unsatisfying post-anesthetic discharge score (one case). Complications included transient and reversible mild postoperative nausea and vomiting [visual analog scale (VAS) score <3], headache (VAS score <3) after the operation or early after discharge. No patient was readmitted. Our results supported the safety and efficacy of the AS protocol for pituitary adenoma patients undergoing EEA resection among eligible patients, and further evaluation of this protocol in controlled studies with a larger sample size is warranted.

Topics: Adenoma; Adult; Aged; Ambulatory Surgical Procedures; China; Endoscopy; Female; Humans; Length of Stay; Male; Middle Aged; Nasal Cavity; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Prospective Studies; Treatment Outcome

The pituitary gland is located in the sella turcica. Pituitary tumors constitute approximately 15% of intracranial benign tumors. "Endo nasal endoscopic trans-sphenoidal" method is an appropriate surgical technique to remove this tumor. In this operation an endoscope enters the nasal cavity through the nostril to reach the floor of the sella turcica. The aim of this study was an anthropometric evaluation of the route of endoscope in this surgery. Two hundred twenty-seven patients (116 women, 111 men) were divided into ≥30, 31 to 61, and ≥61-year age groups. Lateral scanograms of skull were used to measure 3 linear distances and 1 angle. While the mean of the linear variables was significantly higher in men (P <0.001), this difference was not significant in angular measurement between sexes. More detail evaluation of the age groups showed age- and sex-specific differences in measurements. The authors concluded that it needs to consider the anthropometrical indexes in pituitary surgery.

Topics: Adult; Anthropometry; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Diseases; Pituitary Gland; Pituitary Neoplasms; Reproducibility of Results; Sella Turcica; Tomography, X-Ray Computed

Videoendoscopic endonasal-transsphenoidal pituitary surgery is a modern minimally invasive surgical technique, which requires interdisciplinary cooperation between ENT and neurosurgery.. Between December 2006 and July 2008, 25 patients (13 male, 12 female, average age 55 years old) suffering from pituitary adenomas were operated on with the abovementioned method. All operations were done four-handed with the ENT surgeon carrying out the sphenoidectomy and the neurosurgeon the adenomectomy. An optoelectronic system (Vector Vision) was used for navigation using CT and MRI scans that were fused together.. Of the patients 21 suffered from a macroadenoma and 3 from a microadenoma. Primary surgery was carried out on 22 patients and 3 underwent recurrence surgery. The adenoma could be resected without any intraoperative complications in all cases. In five cases postoperative liquorrhoea occurred, which in one case was combined with a pneumocephalus due to strong nose blowing and revision surgery was required in three cases. Oculomotor nerve palsy due to neuroborreliosis was observed in one case on the third postoperative day, which receded completely under antibiotics within 1 week. Navigation worked well in all cases, thus there was no need for a C-bow. Additional functional endoscopic sinus surgery (FESS) was necessary in one case due to nasal polyposis. The endoscopic panorama view was advantageous because of the possibility to view the operation cavity. The changeover from microscopic to endoscopic techniques was performed due to the interdisciplinary approach without an intensive learning phase.. The newly developed videoendoscopic endonasal pituitary surgery as an interdisciplinary operation between neurosurgery and rhinosurgery by means of modern navigation systems proved to be an excellent method.

Topics: Adult; Aged; Endoscopy; Female; Humans; Hypophysectomy; Male; Microsurgery; Middle Aged; Nose; Pituitary Neoplasms; Treatment Outcome

One hundred four patients with pituitary tumours were treated using the direct transnasal approach. The data of these patients were analysed prospectively with regard to duration of surgery and occurrence of complications and compared with retrospective data from 52 patients in whom the traditional sublabial trans-sphenoidal approach was performed. Using the direct transnasal approach, mean operative time was significantly lower than with the sublabial technique. In addition, even though major complications were observed in neither treatment group, minor complications were significantly less frequent after the direct transnasal approach. Due to minimised dissection of normal tissue, this approach is less time-consuming and less traumatic, and the rate of minor complications is significantly lower than with the sublabial procedure.

Topics: Humans; Lip; Minimally Invasive Surgical Procedures; Nose; Pituitary Neoplasms; Prospective Studies; Retrospective Studies; Sella Turcica; Time Factors

Endonasal endoscopy is a promising minimally invasive surgery for the treatment of pituitary adenomas; it is also a good alternative to traditional sublabial microsurgery. In this study, we compared endoscopic surgery with microsurgery and evaluated both for their safety and effectiveness. We chose prolactinomas for study because their hormone and symptomatic changes facilitated the comparison.. During the past five years, 44 randomized prolactinoma patients underwent pituitary adenomectomy. Group A (22 patients) underwent endonasal endoscopic surgery for prolactinomas. Group B (22 patients) underwent sublabial transsphenoidal microsurgery for prolactinomas.. In groups A and B, patients with prolactinoma exhibited significantly reduced postoperative prolactin levels, return of menstrual cycle, and relief of galactorrhea, (Wilcoxon signed rank test) (p < 0.001). But there were no statistically significant differences in the effectiveness of the procedures used in group A and group B. Visual improvement in cases of macroadenoma was satisfactory in both groups. Hospital stay in group A ranged from 2-5 days, with a mean of 3.2 days. Hospital stay in group B ranged from 4-8 days with a mean of 5.3 days. The hospital stay for group A patients was shorter (2.1 days) than for group B (Student t test, p < 0.05). The operative time was shorter by 1 hour in Group A (mean: 1.7 hours vs. mean: 2.7 hours, p < 0.05). There were fewer complications in group A (4.5%) than in group B (27%), p < 0.05.. The endoscopic era of pituitary surgery may be coming. Endonasal endoscopic surgery may have the same effectiveness as traditional microsurgery. However, endoscopic surgery may shorten hospital stay and operative time, and lead to fewer complications. It seems to be a good minimally invasive surgical technique for prolactinomas.

Topics: Adolescent; Adult; Endoscopy; Female; Humans; Labial Frenum; Length of Stay; Male; Microsurgery; Middle Aged; Nose; Outcome Assessment, Health Care; Pituitary Neoplasms; Postoperative Complications; Prolactin; Prolactinoma

The endonasal approach for transsphenoidal hypophysectomy is a simple technique for exposing the floor of the sella turcica. In our institution we have operated 162 patients (64 microadenomas and 98 macroadenomas), over a ten-year period, by using that approach. The floor of the sella turcica is exposed through an incision performed posteriorly to the nostril at the junction of cartilaginous and bony septum. Postoperative rhinological complications are less frequently observed after unilateral endonasal approach than after sublabial one, and it is more comfortable for the patient. The morbidity of unilateral endonasal transsphenoidal approach is comparable to that of other series.

Topics: Adenoma; Adolescent; Adult; Aged; Aged, 80 and over; Female; Humans; Hypophysectomy; Male; Middle Aged; Nose; Pituitary Neoplasms; Sella Turcica

Sellar metastases are rare lesions. Recent improvements in diagnosis and treatment strategies have prolonged survival but increased the probability of metastatic tumors. Evaluation with clinical symptomatology and meticulous laboratory examination is crucial. We present our multicenter national study on sellar metastases to evaluate and underline the main clinical, endocrine, and radiological considerations regarding the diagnosis and endonasal endoscopic management of such rare lesions.. A medical literature-based retrospective study was planned across 13 neurosurgical centers in Turkey, where a data survey was conducted to collect information regarding sellar metastases surgically treated using the endoscopic endonasal approach, including clinical presentation, radiographic features, primary tumor origin, histopathological confirmation, time to metastasis, treatment, and patient outcomes.. Between 2010 and 2020, 54 patients (22 women [40.7%] and 32 men [59.3%]) who underwent surgery with the endonasal endoscopic approach and had pathologically proven sellar metastases (overall incidence, 0.54%) were included. Of the patients, 59.3% had no known malignancy and presented with new-onset symptoms, 79.6% reported headache, 51.9% complained of some degree of visual deficits, and 50% had cranial nerve symptoms. Tissue biopsy was performed in 7.4% of the patients, whereas gross or subtotal resection was achieved in the remaining patients.. To our knowledge, this is the largest series of patients surgically treated with the endonasal endoscopic approach for sellar metastases. For these patients, the treatment focus should be on management modalities for increasing quality of life instead radical treatment options with survival benefit.

Topics: Endoscopy; Female; Humans; Male; Nose; Pituitary Neoplasms; Quality of Life; Retrospective Studies; Treatment Outcome

Endoscopic transnasal surgery for tumors in the sellar region has become popular across the globe. However, postoperative nasal outcomes related to endoscopic transnasal surgery have yet to be described in detail.. Here, we introduce a modified microscopic-endoscopic bilateral transseptal approach for the surgical treatment of tumors in the sellar region. This technique yielded satisfactory postoperative nasal outcomes without any loss of the visual advantages associated with endoscopy.. The modified microscopic-endoscopic bilateral transseptal approach described herein is a minimally invasive endoscopic transnasal approach and results in satisfactory postoperative outcomes in terms of nasal structure and olfactory function.

Topics: Adenoma; Endoscopy; Humans; Nose; Pituitary Neoplasms; Retrospective Studies; Treatment Outcome

Infradiaphragmatic craniopharyngiomas (ICs) represent a distinct subtype, harboring a sellar-suprasellar origin and generally growing in the extra-arachnoidal space contained by the diaphragma sellae. They have been considered ideal for surgical removal through the transsphenoidal approach since the 1960s. The authors present a multicentric national study, intending to selectively analyze IC behavior and the impact of the transsphenoidal endoscopic endonasal approach (EEA) on surgical outcomes.. Craniopharyngiomas that were intraoperatively recognized as infradiaphragmatic and removed with standard EEA between 2000 and 2021 at 6 Italian neurosurgical departments were included in the study. Clinical, radiological, and surgical findings and outcomes were evaluated and reviewed.. In total, 84 patients were included, with 45.23% identified as pediatric cases and 39.28% as having recurrent tumors. The most common presenting symptoms were endocrine (75%), visual (59.52%), and hypothalamic (26.19%) disorders. ICs were classified as extending below (6 intrasellar and 41 occupying the suprasellar cistern) or above (26 obliterating the anterior recesses of the third ventricle and 11 extending up to the foramina of Monro) the chiasmatic cistern. Gross-total resection (GTR) was achieved in 54 cases (64.28%). Tumor extension above the chiasmatic cistern and calcifications were associated with lower likelihood of GTR. The cumulative rate of postoperative complications was 34.53%, with CSF leak being the most common (14.28%). Endocrine, visual, and hypothalamic functions deteriorated postoperatively in 41/78 patients (52.56%), 5/84 (5.95%), and 14/84 (16.67%), respectively. Twenty-eight patients (33.33%) had recurrence during follow-up (mean 63.51 months), with a mean 5-year progression-free survival (PFS) rate of 58%. PFS was greater in patients who achieved GTR than patients with other extent of resection.. This is the largest series in the literature to describe ICs removed with standard EEA, without the need for additional bone and dural opening over the planum sphenoidale. EEA provides a direct route to ICs, the opportunity to manage lesions extending up to the third ventricle without breaching the diaphragma, and high rates of GTR and satisfactory clinical outcomes. Increased surgical complexity and morbidity should be expected in patients with extensive suprasellar extension and involvement of the surrounding vital neurovascular structures.

Topics: Child; Craniopharyngioma; Humans; Neoplasm Recurrence, Local; Neuroendoscopy; Nose; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Treatment Outcome

To determine the in-hospital cost implications of an expanded endoscopic endonasal approach (EEEA) for craniopharyngioma resection relative to the traditional open transcranial approach.. All craniopharyngioma surgeries performed at a single institution over a period from January 1st 2001 to October 31th 2017 were evaluated. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables associated with each hospital stay and univariate regression analysis was performed using R software.. Thirty-six patients met study criteria, including 22 undergoing an open approach and 14 undergoing an EEEA. There was a significantly longer average length of stay among patients undergoing open resection (21.5 vs. 10.6 days, p = 0.024). The average total in-hospital cost of a patient undergoing an EEEA was $58979.3 compared to $89142.3 for an open approach (p = 0.127). On univariate regression analysis, the total in-hospital cost for a patient undergoing an open approach relative to an EEEA was $30163.0 (p = 0.127). The open approach was exclusively performed from study onset until April 2010 (16 patients). From April 2010 to August 2013, 6 open approaches and 5 EEEA were performed. The EEEA has been exclusively performed from August 2013 until the conclusion of our study period (9 patients).. There has been a shift toward surgical resection of craniopharyngioma via an EEEA approach for amenable tumors. Our study demonstrates that the EEEA has become the preferred surgical approach at our institution, and shows that the EEEA is associated with shorter postoperative length of stay and lower total in-hospital cost. Laryngoscope, 133:83-87, 2023.

Topics: Craniopharyngioma; Hospital Costs; Humans; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Retrospective Studies

We present the case of a 16-year-old with short stature, fatigue, memory impairment, and pituitary gland failure. Imaging and cerebrospinal fluid (CSF) studies supported the diagnosis of a suprasellar nongerminomatous germ cell tumor with no clear radiologic disease in the spine; however, a single atypical cell was present in the CSF. After a period of external drainage via an Ommaya device, he was treated with chemotherapy, followed by craniospinal radiation. Three months post completion of chemoradiotherapy, he had ongoing residual macroscopic enhancing disease anatomically located in the basal third ventricle and intimately related to pituitary stalk and basal thalamoperforators. In order to maximize his chance of progression-free survival, a decision was made to surgically resect the lesion via an expanded endoscopic endonasal approach with planned stalk sacrifice because of the known pituitary gland failure. In Video 1, the technical nuances underpinning the use of an expanded endoscopic endonasal transtuberculum transchiasmatic sulcus approach to resect the adherent lesion in a postradiated field in its entirety are presented. We emphasize the strategies for perforator preservation including thalamoperforators and superior hypophyseal arteries to avoid ischemic injury and visual dysfunction, respectively. Postoperative scans demonstrated gross total resection without any ischemic injury. The patient was discharged without any neurologic deficit, visual dysfunction, or CSF leak.

Topics: Adolescent; Endoscopy; Humans; Male; Neoplasms, Germ Cell and Embryonal; Nose; Pituitary Neoplasms; Treatment Outcome; Vision Disorders

Craniopharyngiomas are benign sellar lesions. Surgical excision of craniopharyngiomas is difficult because of the surrounding important neurovascular structures. The choice of surgery depends on the histological type, location, hormonal status, and size of the craniopharyngioma, surrounding neurovascular structures, and invasion of the brain parenchyma.. We describe the resection of an adamantinomatous craniopharyngioma using an extended endoscopic endonasal approach and discuss the relevant surgical anatomy, indications, limitations, and possible complications.. The extended endoscopic endonasal approach allows successful removal of the craniopharyngioma and poses little risk to surrounding neurovascular structures.

Topics: Craniopharyngioma; Endoscopy; Humans; Neuroendoscopy; Neurosurgical Procedures; Nose; Pituitary Neoplasms

Craniopharyngiomas remain surgically challenging because of the strong adhesion to vital neurovascular structures. We propose a system for the selection of surgical approaches based on the optic recess (OR) displacement pattern to facilitate surgical planning and obtain optimum visual and endocrinologic outcomes.. Craniopharyngiomas were divided into 3 types based on the OR displacement pattern: superior, anterior, and involvement types. Selected surgical approaches and patient outcome were retrospectively reviewed according to these classifications. Visual and endocrinologic outcomes were compared among the groups.. This study included 26 patients with primary craniopharyngiomas who underwent surgery at our institution, classified into 11 anterior, 11 superior, and 4 involvement types. The extended endoscopic endonasal approach provided excellent exposure inferodorsal aspect of the chiasm for manipulation of the dissection plane in the anterior and superior types with midline location. A unilateral subfrontal approach was required for tumor of the superior type with lateral extension. An interhemispheric translamina terminalis approach could provide safe dissection under direct vision of strong adhesion at the superior aspect of the chiasm in the involvement type. Visual and endocrinologic outcomes were better in the involvement type compared with the superior and anterior types. Visual outcome was significantly correlated with preoperative visual function.. Craniopharyngiomas with the involvement type are indicated for the translamina terminalis approach to achieve the best visual and endocrinologic outcome. Our classification of the OR displacement pattern is useful to select the optimal surgical approach for craniopharyngiomas more accurately and concisely, especially in cases with third ventricular extension.

Topics: Craniopharyngioma; Humans; Nose; Pituitary Neoplasms; Retrospective Studies; Third Ventricle

Craniopharyngioma is a benign but surgically challenging brain tumor. Controversies exist regarding its ideal treatment strategy, goals of surgery, efficacy of radiation, and the long-term outcomes of these decisions. The authors of this study performed a detailed analysis of factors predictive of the extent of resection and recurrence in large series of craniopharyngiomas removed via an endoscopic endonasal approach (EEA) with long-term follow-up.. From a prospective database of all EEAs done at Weill Cornell Medical College by the senior author from 2004 to 2022, a consecutive series of histologically proven craniopharyngiomas were identified. Gross-total resection (GTR) was generally the goal of surgery. Radiation was often given if GTR had not been achieved. The stalk was preserved if not infiltrated with tumor but was sacrificed to achieve GTR. Intentional subtotal resection (STR) was performed in select cases to avoid hypothalamic injury.. Among the 111 identified cases were 88 adults and 23 children. Newly diagnosed cases comprised 58.6% of the series. GTR was attempted in 77.5% of the patients and among those cases was achieved in 89.5% of treatment-naive tumors and 72.4% of recurrent tumors. An inability to achieve GTR was predicted by prior surgical treatment (OR 0.13, 95% CI 0.03-0.6, p = 0.009), tumor diameter ≥ 3.5 cm (OR 0.11, 95% CI 0.02-0.53, p = 0.006), and encasement of the optic nerve or a major artery (OR 0.11, 95% CI 0.01-0.8, p = 0.03). GTR with stalk preservation maintained some anterior pituitary function in 64.5% of cases and prevented diabetes insipidus in 25.8%. After a median follow-up of 51 months (IQR 17-80 months), the recurrence rate after GTR was 12.5% compared with 38.5% after non-GTR. The median recurrence-free survival was 5.5 years after STR, 8.3 years after near-total resection (≥ 98%), and not reached after GTR (p = 0.004, log-rank test). GTR was the strongest predictor of recurrence-free survival (OR 0.09, 95% CI 0.02-0.42, p = 0.002), whereas radiation did not show a statistically significant impact (OR 1.17, 95% CI 0.45-3.08). In GTR cases, the recurrence rate was higher if the stalk had been preserved (22.6%) as opposed to a sacrificed stalk (4.9%; OR 5.69, 95% CI 1.09-29.67).. The study data show that GTR should be the goal of surgery in craniopharyngiomas if it can be achieved safely. Although stalk preservation can maintain some endocrine function, the risk of recurrence is higher in such cases. Radiation may not be as effective as previously reported.

Topics: Adult; Child; Craniopharyngioma; Endoscopy; Humans; Neoplasm Recurrence, Local; Neuroendoscopy; Nose; Pituitary Neoplasms; Retrospective Studies; Treatment Outcome

The giant pituitary adenoma (GPA)> 4 cm is considered a surgical challenging pathology and associated with higher surgical complications compared to non-giant pituitary adenoma [1]. These tumors are invasive and had extension to nearby neurovascular structures including cranial nerves and internal carotid artery. Endoscopic endonasal approach (EEA) is increasingly used in the last two decades, however tumors with significant height extension in the supraseller region makes surgeons in favor of transcranial approaches or combined approaches [2]. The accompanied symptoms arise from compression of neighboring structures as well as hypopituitarism [3]. In this video we present 65 year old male with PMH significant for HTN who presented with 2-3 months retro-orbital headaches, confusion, gait instability, urinary/fecal incontinence, found to have 5.1 × 2.1 × 2 cm sellaer-suprasellar mass compressing the floor of the third ventricle, mammillary body, and optic apparatus. The mass was associated with hydrocephalus. The endoscopic endonasal skull base approach (trans-sellar, transtubercular) was performed with significant tumor resection without a need for trans cranial approach. A titanium clips was used to reconstruct the diaphragma sella which was very helpful technique to change high flow CSF leak to low flow. The postoperative course of the patient was smooth with improved gait, memory, and vision. He was kept on a hormonal replacement for hypopituitarism.

Topics: Aged; Humans; Hypopituitarism; Male; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Retrospective Studies; Treatment Outcome

Headache is a common symptom in patients with pituitary adenomas. Research on whether resection of pituitary adenomas via the endoscopic endonasal approach (EEA) affects headaches is limited, and the pathophysiology of headaches associated with pituitary adenomas remains unclear. This study aimed to determine if resection of pituitary adenomas via the EEA improves headaches and investigate factors that may be associated with headaches in patients with pituitary adenoma.. A prospectively collected database of 122 patients undergoing resection of pituitary adenoma via the EEA was analyzed. Patient-reported headache severity was collected prospectively using the Headache Impact Test (HIT-6) at preoperative baseline and 4 postoperative time points (3 weeks, 6 weeks, 3 months, and 6 months).. Adenoma size and subtype, cavernous sinus invasion, and hormonal status were not associated with preoperative headache burden. In patients with preoperative headaches (HIT-6 score >36), significant decreases in HIT-6 score were observed postoperatively at 6 weeks (5.5-point improvement, 95% CI 1.27-9.78, P < 0.01), 3 months (3.6-point improvement, 95% CI 0.01-7.18, P < 0.05), and 6 months (7.5-point improvement, 95% CI 3.43-11.46, P < 0.01). The only factor associated with headache improvement was cavernous sinus invasion (P = 0.003). Adenoma size and subtype and hormonal status were not associated with postoperative headache burden.. Resection via the EEA is associated with significant improvement in headache-related impact on patient functioning from ≥6 weeks after surgery. Patients with cavernous sinus invasion are more likely to experience improvement in headaches. The mechanism of headaches associated with pituitary adenoma still requires clarification.

Topics: Adenoma; Endoscopy; Headache; Humans; Nose; Pituitary Neoplasms; Retrospective Studies; Treatment Outcome

In a single-center cohort of pituitary adenoma patients, non-White race independently predicted larger tumor size at initial presentation. Uninsured patients suffered a significantly higher rate of pituitary apoplexy at initial presentation. Geographically distant care appeared to present a greater barrier for non-White and Hispanic patients relative to their White and non-Hispanic counterparts.

Topics: Adenoma; Humans; Nose; Pituitary Neoplasms; Retrospective Studies

The endoscopic endonasal transtuberculum approach grants access to suprasellar and retrochiasmatic lesions with hypothalamic involvement. Here, we present a case of a 13-year-old boy with a history of stunted growth, decreased vision, headaches, and low energy with a tuberoinfundibular craniopharyngioma. The patient consented to the procedure.. Evaluation of the sphenoid sinus pneumatization, internal carotid artery disposition, presence of clinoidal rings, variations of the infrachiasmatic corridor (optic chiasm location, height of dorsum sella), and location of the pituitary stalk are crucial for surgical strategy.. Harvesting of nasoseptal flap and access to the sphenoid sinus; drilling the sella, tuberculum, and chiasmatic sulcus up to the limbus sphenoidalis and laterally exposing the clinoidal carotid artery segment; wide dural opening to the level of distal rings inferolaterally and falciform ligaments superolaterally; identification and coagulation of superior hypophyseal branches providing tumor supply; intracapsular dissection and debulking and subpial sharp dissection at the hypothalamic tumor interface to achieve complete removal; and reconstruction with inlay collagen, fascia lata, and nasoseptal flap.. Preservation of the superior hypophyseal arteries and stalk is essential for preventing pituitary dysfunction. Preoperative reckoning of hypothalamic invasion and identification of adequate interface aids in avoiding complications. To reduce CSF leak risk, multilayer reconstruction was performed and lumbar drain placed postoperatively.. For retroclival extension, intradural pituitary transposition should be considered to expand the corridor; in patients with preoperative hypopituitarism, pituitary sacrifice is most effective to increase retroclival access.

Topics: Adolescent; Craniopharyngioma; Humans; Male; Nose; Optic Chiasm; Pituitary Gland; Pituitary Neoplasms

To analyze the perioperative course and clinical outcome of patients with large (lPA) and giant (gPA) pituitary adenoma who underwent endoscopic endonasal transsphenoidal surgery (EETS) using either two-dimensional (2D-E) or three-dimensional (3D-E) endoscopic systems. Single-center retrospective study of consecutive patients with lPA and gPA who underwent EETS between November 2008 and January 2023. LPA were defined as ≥ 3 cm and < 4 cm in diameter in at least one dimension and a volume of ≥ 10ccm; gPA were defined as larger than 4 cm in diameter and with a greater volume than 10ccm. Patient data (age, sex, endocrinological and ophthalmological status) and tumor data (histology, tumor volume, size, shape, cavernous sinus invasion according to the Knosp classification) were analyzed. 62 patients underwent EETS. 43 patients were treated for lPA (69.4%) and 19 patients for gPA (30.6%). 46 patients (74.2%) underwent surgical resection using 3D-E and 16 patients 2D endoscopy (25.8%). Statistical results are referred to the comparison between 3D-E and 2D-E. Patients' age ranged from 23-88 years (median 57), 16 patients were female (25.8%), 46 male (74.2%). Complete tumor resection was possible in 43.5% (27/62), partial resection in 56.5% (35/62). Resection rates did not differ between 3D-E (27 patients [43.5%]) and 2D-E (7 patients [43.8%], (p = 0.985). Visual acuity improved in 30 of 46 patients with preoperative deficit (65.2%). In the 3D-E group 21 of 32 patients (65.7%) improved, compared to 9 of 14 patients in the 2D-E group (64.3%). Improvement of visual field was achieved in 31 of 50 patients (62.0%; 22 of 37 patients in the 3D-E group [59.4%] and 9 of 13 patients in the 2D-E group [69.2%]). CSF leak was the most frequent complication and occurred in 9 patients (14.5%, [8 patients 17.4% 3D-E]) without statistical significance. Other surgical complications like postoperative bleeding, infection (meningitis) and deterioration of visual acuity and field were detected without statistical difference. New pituitary anterior lobe dysfunction was observed in 30 of 62 patients (48.4%, 8 patients [50.0%] in the 2D-E group and 22 patients [47.8%] in the 3D-E group). A transient deficit of posterior lobe was detected in 22.6% (14/62). No patient died within 30 days of surgery. Although 3D-E may improve surgical dexterity, in this series of lPA and gPA it was not associated with higher resection rates compared to 2D-E. However, 3D-E visualization during resection of

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Endoscopy; Female; Humans; Male; Middle Aged; Nose; Pituitary Neoplasms; Retrospective Studies; Treatment Outcome; Young Adult

As the population ages, the number of elderly patients with an indication for pituitary surgery is rising. Information on the outcome of patients aged over 75 is limited. This study reports a large series assessing the feasibility of surgical resection in this specific age range, focusing on surgical complications and postoperative results.. A retrospective cohort study of patients with pituitary adenomas and Rathke's cleft cysts was conducted. All patients were aged 75 years or over and treated by a single expert neurosurgical team. A control population included 2379 younger adult patients operated by the same surgeons during the same period.. Between 2008 and 2022, 155 patients underwent surgery. Indication was based on vision impairment in most patients (79%). Median follow-up was 13 months (range: 3-96). The first surgery was performed with an endoscopic transsellar approach, an extended endonasal transtuberculum approach and a microscopic transcranial approach in 96%, 3%, and 1% of patients, respectively. Single surgery was sufficient to obtain volume control in 97% of patients. From Kaplan-Meier estimates, 2-year and 5-year disease control with a single surgery were 97.3% and 86.2%, respectively. Resection higher than 80% was achieved in 77% of patients. No vision worsening occurred. In acromegaly and Cushing's disease, endocrine remission was obtained in 90% of non-invasive adenomas. Surgical complications were noted in 5% of patients, with 30-day mortality, hematoma, cerebrospinal fluid leak, meningitis, and epistaxis occurring in 0.6%, 0.6%, 1.9%, 0.6%, and 1.3% respectively. New endocrine anterior deficits occurred in only 5%, while no persistent diabetes insipidus was noted. Compared with younger patients, the complication rate was not statistically different.. Surgery beyond the age of 75, mainly relying on an endoscopic endonasal transsellar approach, is effective and safe, provided that patients are managed in tertiary centers.

Topics: Adenoma; Adult; Aged; Endoscopy; Humans; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Treatment Outcome

Topics: Aged; Endoscopy; Hematoma; Humans; Male; Nose; Pituitary Neoplasms; Sphenoid Sinus

The aim of this study was to report the authors' experience developing a Lean Six Sigma clinical care pathway (CCP) for endoscopic endonasal transsphenoidal operations.. Using Lean Six Sigma quality improvement principles-including the define, measure, analyze, improve, and control framework-the authors developed a CCP for endoscopic endonasal transsphenoidal operations, incorporating preoperative, intraoperative, and inpatient and outpatient postoperative phases of care. Efficacy and quality metrics were defined as postoperative length of stay (LOS), presentation to the emergency department (ED) or readmission within 30 days of discharge, and hospital charges. The study included all adult patients who underwent elective endoscopic endonasal resection for pituitary adenoma, Rathke's cleft cyst, craniopharyngioma, pituicytoma, or arachnoid cyst during the sampling period (April 1, 2018, to December 31, 2022).. Two hundred twenty-eight patients met criteria and were included; 94 were treated before and 134 were treated after implementation of the CCP. Differences between groups in age, gender, race, BMI, American Society of Anesthesiologists classification, geographic distribution, preoperative serum sodium, tumor size, adenoma functional status, and prior surgery were not significant. The mean postoperative LOS significantly decreased from 4.5 to 1.7 days following CCP implementation (p < 0.0001); LOS variability also decreased, with the standard deviation declining from 3.1 to 1.5 days. The proportion of patients discharged on postoperative day (POD) 1 significantly increased from 0% to 61.9% (p < 0.0001). Fewer than one-quarter of the patients (23.4%) were discharged by POD 2 prior to the CCP, while 88.8% of were discharged by POD 2 after CCP implementation (p < 0.0001). Rates of 30-day ED presentations or readmissions were not significantly different (2.1% vs 6.0%, p = 0.20, and 7.5% vs 6.7%, p > 0.99, respectively). Mean per-patient hospital costs declined from $38,326 to $26,289 (p < 0.0001), with an associated change in cost variability from a standard deviation of $16,716 to $12,498.. CCP implementation significantly improved LOS and costs of endoscopic endonasal resection, without adversely impacting postoperative ED presentations or readmissions.

Topics: Adenoma; Adult; Craniopharyngioma; Endoscopy; Humans; Nose; Pituitary Gland; Pituitary Neoplasms; Postoperative Complications; Quality Improvement; Retrospective Studies; Treatment Outcome

Prolapse of the optic system into an empty sella is an unusual complication of the management of pituitary tumors.. We described the technical nuances for an endoscopic endonasal chiasmopexy, the indications for the procedure, and the caveats on the diagnosis of optic chiasm prolapse.. The endoscopic endonasal chiasmopexy provides a direct route to lift the optic system. In most cases, the procedure may be achieved extradurally, protecting the chiasm from manipulation and postoperative fibrosis.

Topics: Endoscopy; Humans; Neurosurgical Procedures; Nose; Optic Chiasm; Pituitary Neoplasms; Prolapse

Topics: Adenoma; Endoscopy; Humans; Nose; Pituitary Neoplasms; Surgical Instruments

Large pituitary adenomas (LPAs), which constitute ∼5%-14% of all pituitary adenomas, are considered challenging tumors owing to their locally aggressive behavior, low gross total resection rate, and high prevalence of visual deficits and hypopituitarism. We evaluated the utility of various extended endoscopic endonasal approaches in maximizing the resection of LPAs and studied the factors affecting the extent of surgical resection.. A retrospective study of all LPAs (defined as a minimum diameter >3 cm and tumor volume >10 cm. The present study included 106 patients with LPAs. The mean extent of the resection volume was 79.18 ± 21.75 cm. Extended endoscopic endonasal approaches can safely and effectively be used for gross total resection of LPAs. However, we found that the preoperative tumor volume and Knosp grade were significant factors affecting the extent of tumor resection. The use of multiple endoscopic endonasal corridors can increase the volumetric extent of resection for LPAs.

Topics: Adenoma; Endoscopy; Humans; Nose; Pituitary Neoplasms; Retrospective Studies; Treatment Outcome

Third ventricle craniopharyngioma (TVC) refers to the tumor originating from the tuberoinfundibular, and completely located in the third ventricle; unlike most TVCs, the retrochiasmatic-infundibulum corridor is too narrow to expose the tumor with anterior extension via an endoscopic endonasal approach.. Retrospective analysis of two TVCs via an endoscopic endonasal combined pre-retrochiasmatic approach.. The tumor inside the third ventricle can be satisfactorily exposed through a combined pre-retrochiasmatic approach and be completely removed with the lowest injury of the hypothalamus and optic nerve.

Topics: Craniopharyngioma; Humans; Nose; Pituitary Neoplasms; Retrospective Studies; Third Ventricle

With relevant surrounding neurological structures and potential involvement of the hypothalamus, the surgical management of craniopharyngiomas is complex. Compared to the transcranial approach, the expanded endoscopic endonasal approach provides direct access to the supradiaphragmatic and retrochiasmatic areas without crossing nerves and arteries.. Based on our substantial experience of 68 patients operated on between 2008 and 2022 by endoscopic surgery, our strategy has evolved such that all of our midline infundibular craniopharyngiomas with hypothalamic involvement are currently treated with an expanded endonasal route, except for tumours isolated to the third ventricle. Vascularized mucosal nasoseptal flaps are required for closure. Fine details of the related anatomy and surgical technique are described.. Expanded endoscopic endonasal approach is a safe and effective route for resection of midline suprasellar craniopharyngiomas with hypothalamic involvement in centres of expertise.

Topics: Craniopharyngioma; Humans; Hypothalamus; Neuroendoscopy; Nose; Pituitary Neoplasms

Topics: Adenoma; Endoscopy; Humans; Nose; Pituitary Neoplasms; Surgical Instruments

Surgery is currently the first-line treatment of Cushing's disease. Surgery for Cushing's patients requires technical specificity, especially if no adenoma is identified on dedicated preoperative pituitary MRI.. From 2006 to 2020, 683 patients with Cushing's disease were operated on with a mononostril endoscopic endonasal approach by the same two senior neurosurgeons. Here, we report the particularities of this challenging surgery.. A rigorous and planned surgical strategy avoids the pitfalls of Cushing's disease surgery and leads to a high rate of endocrine remission.

Topics: Adenoma; Humans; Magnetic Resonance Imaging; Nose; Pituitary ACTH Hypersecretion; Pituitary Gland; Pituitary Neoplasms

To report the results of a consecutive series of pituitary adenomas resected through endoscopic endonasal approach (EEA) with minimal nasal injury.Retrospectively review tumor characteristics and surgical outcomes of a consecutive series of EEA pituitary adenomas resection performed mainly by a single author between March 2018 and June 2019.A total of 75 endoscopic endonasal approach pituitary adenoma resections were performed by the authors' team. Of the 75 patients, 28 through mononostril EEA, 47 through Binonostril EEA. Hadad-Bassagasteguy vascularized nasoseptal flap was harvested in only 4 (5.3%) patients with a high risk of postoperative cerebrospinal fluid leak, and one side middle turbinate only been resected in 2 (2.7%) patients, other patients preserved bilateral middle turbinate. Of the 75 patients, gross total resection is 74.7%, near-total resection is 16.0%. Endocrinological remission was achieved in 76.9% of GH-secreting adenomas, 61.5% of prolactin-secreting adenomas. The postoperative cerebrospinal fluid leak rate was 2.7%. Two patients had suprasellar hemorrhage, 1 patient had perioperative stroke, 2 patients had permanent diabetes insipidus, no cranial nerve deficits, internal carotid artery injury, anosmia, and death. The sino-nasal function was measured with the Sino-Nasal Outcome Test-22 and visual analog scale for olfaction preoperatively and postoperatively, and there was no statistically significant difference.The EEA is an effective approach to resect pituitary adenomas, the gross total resection and near-total resection rate and endocrinological remission rate are satisfactory. The EEA is a safe approach, as the complication rate is acceptable compared with those reported in the previous series of microscopic and endoscopic approaches. These results can be achieved with minimal nasal injury.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Cerebrospinal Fluid Leak; Endoscopy; Female; Humans; Male; Middle Aged; Nasal Cavity; Natural Orifice Endoscopic Surgery; Nose; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Treatment Outcome

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.

Topics: Chordoma; Computed Tomography Angiography; Craniopharyngioma; Female; Humans; Intracranial Aneurysm; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Retrospective Studies

Most surgical teams currently consider that endoscopy has become the "gold standard" technique for the transsphenoidal approach to pituitary surgery. Pituitary adenomas are commonly benign tumours and should benefit from the least invasive approach.. In Foch Hospital, from 2006 to 2020, 2835 patients with pituitary adenomas were treated with a mononostril endoscopic endonasal approach. Here we describe the fine details of the nasal, sphenoidal and sellar steps of this technique.. Complete preservation of the nasal corridor, luxation of the nasal septum and tailored sellar bone resection are essential for safe resection of pituitary adenomas.

Topics: Adenoma; Adult; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Gland; Pituitary Neoplasms

Facial abnormality is the most significant feature in acromegaly patients. However, it is unclear whether and how patient facial appearance improves after treatment. This study aimed to identify 3D facial changes in acromegaly patients after surgical treatment.. This study included 30 acromegaly patients who underwent resection of a pituitary GH adenoma. The location and extent of facial changes were identified by comparing baseline and 2-year follow-up 3D images of the face. Relationships between facial changes and GH and IGF-1 were evaluated with simple or multivariable linear regression models.. Significant soft tissue improvements were observed in acromegaly patients with complete remission, especially in the nose and lip region. Significant reductions in nasal width (3.46 mm, P < 0.001), tip protrusion (1.18 mm, P = 0.003), face curve length (3.89 mm, P = 0.004) and vermilion area (1.42 cm3, P = 0.001) were observed at the 2-year follow-up. Further, changes in nasal width were associated with decreases in GH (β = 4.440, P = 0.017), the GH nadir (β = 4.393, P = 0.011) and IGF-1 (β = 5.263, P = 0.002). The associations were maintained after adjusting for confounders.. Acromegaly patients achieved considerable facial improvements after surgical treatment. The change in nose width was associated with GH and IGF-1 decrease. Better control of patient hormone levels after surgery improves patient facial recovery.

Topics: Acromegaly; Adenoma; Adolescent; Adult; Aged; China; Cohort Studies; Face; Female; Follow-Up Studies; Human Growth Hormone; Humans; Insulin-Like Growth Factor I; Male; Middle Aged; Nose; Pituitary Neoplasms; Prognosis; Remission Induction; Treatment Outcome; Young Adult

Using the expanded endoscopic transtuberculum approach (EETA), the nuances of this technique have rendered a safe, direct, and feasible ventral corridor for the treatment of extending suprasellar pathologies. This study illustrates surgical landmarks and strategies of paramount importance for complications avoidance.. This study presents the surgical anatomy and nuances of EETA, which can be used to remove large pituitary adenomas with suprasellar extension. Special references to cadaveric dissections highlight anatomical landmarks and surgical key points for complications avoidance.. The EETA represents a versatile route for the treatment of sellar/suprasellar pathologies. Although, sizeable extrasellar pituitary tumors still pose a threat due to displacement/encasement of surrounding structures, necessitating accurate knowledge of correlative operative anatomy with traditional landmarks. Complete resection of extrasellar components is essential to avoid postoperative apoplexy.

Topics: Adenoma; Endoscopy; Humans; Neuroendoscopy; Nose; Pituitary Apoplexy; Pituitary Neoplasms; Postoperative Complications

Pituitary surgery has shifted in recent years from microscopic surgery(MS) to endoscopic endonasal surgery (EES). However, the comparative long-term outcome of these surgical approaches, including the need for subsequent re-operation has never been reported. We present our experience in a high-volume referral center experienced in both endoscopic and microscopic approaches to compare the need for re-operation after initial resection of non-functioning pituitary macroadenomas using these surgical approaches.. 684 patients (398 with NF adenomas) underwent trans-sphenoidal pituitary surgery in our institution between 2006 and 2017. Complete follow-up (mean 72 months, minimum two years) was available in 87 newly diagnosed patients with non-functioning pituitary macroadenomas (NFPMA; 48-microscopic and 39-endoscopic). The EES approach has been used almost exclusively since 2012. The need for repeat operation for tumor resection during the follow-up period was assessed as the primary end-point of the study. Extracted data included various demographic and clinical parameters, radiographic findings as well as the extent of resection (EOR).. The EOR was similar for both groups, with a trend towards better EOR in the EES group. The rate of surgical complications was also similar for both groups. There was a strong trend towards lower need for re-operation in the EES group compared to the MS group (12.8% vs. 29.2%, p = 0.056). In a multivariate analysis, only EOR and Knosp grade were independently associated with the need for re-operation surgery.. Our data indicate that EES in NFPMA tends to be associated with a lower need for re-operation compared to the MS approach, with a similar rate of EOR and complications.

Topics: Adenoma; Adult; Aged; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Nose; Pituitary Neoplasms; Postoperative Complications; Reoperation; Retrospective Studies; Sphenoid Sinus

Superb knowledge of surgical anatomy and nuances to remove the natural barriers preventing full access to the paramedian skull base determines the ease of using the expanded sellar/parasellar approaches as the main gateway for all the parasagittal modules during endoscopic endonasal access (EEA) to pituitary tumors with cavernous sinus (CS) invasion.. Throughout stepwise-cadaveric dissections and pertinent intraoperative analysis, we describe surgical pearls and pitfalls of the parasellar-EEA with special references to the utility of various lines/classifications on neuroimaging correlated with strategies to enhance surgical safety and tumor resection.. EEA to invasive parasellar pathologies needs to address strict bleeding control and displacement of neurovascular structures inside the CS, posing a chance for neurologic morbidities/ICA injury. Meticulous utilization of operative landmarks and strategies can help avoid and mitigate surgical complications.

Topics: Anatomic Landmarks; Cadaver; Cavernous Sinus; Dissection; Endoscopy; Humans; Nose; Pituitary Neoplasms; Postoperative Complications

The infrachiasmatic corridor is the most important surgical access route for craniopharyngiomas and was identified and used in clinical series. The aims of this study were to describe the characteristics that assist dissection and resection rates in endoscopic surgery of solid, cystic, and recurrent cases and their importance in the infrachiasmatic corridor in endoscopic surgery.. One hundred operations on 84 patients with pathologically identified craniopharyngioma were included in the study. The MRI findings were evaluated, and the location of the lesions was classified as (1) infrasellar; (2) sellar; or (3) suprasellar. In the sagittal plane, we measured the longest diameter of cystic and solid components and the height of chiasm-sella. Images were assessed for the extent of resection and were classified as gross total resection. This was deemed as the absence of residual tumor and subtotal resection, which had residual tumor.. The infrasellar location was reported in 7/84 (8.3%) patients, the sellar location in 8/84 (9.5%), and the suprasellar location in 69/84 (82.1%) patients. The narrow and high chiasm-sella were observed in 28/69 (40.5%) and 41/69 patients (59.4%), respectively. The mean distance of the chiasm-sella was 9.46± 3.76. Gross total tumor resection was achieved in 60/84 (71.4%) and subtotal tumor resection was performed in 24/84 (28.6%) patients. The results revealed that suprasellar location (OR: 0.068; p = 0.017) and recurrent cases (OR: 0.011; p<0.001) were negative predictive factors on GTR. Increasing the experience (OR: 42,504; p = 0.001) was a positive predictor factor for GTR.. An EETS approach that uses the infrachiasmatic corridor is required for skull base lesions extending into the suprasellar area. The infrachiasmatic corridor can determine the limitations of endoscopic craniopharyngioma surgery. This corridor is a surgical safety zone for inferior approaches.

Topics: Craniopharyngioma; Endoscopy; Humans; Neuroendoscopy; Nose; Pituitary Neoplasms; Retrospective Studies; Skull Base; Treatment Outcome

Intraoperative ultrasound during transsphenoidal surgery (TSS) for pituitary tumors has been reported. In reports of endonasal ultrasound (US), Doppler US vessel images were informative and effective in endoscopic TSS. We performed endoscopic US imaging with high flow mode, which is a novel technology, to visualize small vessels during endonasal endoscopic TSS. Six patients (five with pituitary adenomas and one with Rathoke's cleft cyst) underwent endoscopic US-assisted TSS. A small endoscopic US probe (Olympus, BF-UC260FW; diameter, 6.9 mm) was inserted transsphenoidally to the sellar floor and into the sella turcica, and endoscopic US monitoring was performed. By rotating the endoscopic US probe, the internal carotid artery, anterior cerebral artery, middle cerebral artery, various small vessels, optic nerve, and residual tumor were clearly visualized on the endoscopic US images. Real-time animated vessel images around the tumor could be generated when needed during TSS. The tumors were removed without leakage of cerebrospinal fluid in the six patients, and their visual acuity was restored. Endoscopic US with high flow mode can visualize not only main cerebral arteries but also intracranial small vessels on B-mode US images. Pituitary tumors were clearly recognized and removed safely and precisely by monitoring the cerebral artery and its small branches as landmarks.

Topics: Adenoma; Adult; Cerebrospinal Fluid Leak; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Nose; Pituitary Neoplasms; Postoperative Complications; Sella Turcica; Ultrasonography

Adult craniopharyngiomas are low-grade tumors of the pituitary infundibulum that can be locally aggressive and frequently present with profound visual deficits and endocrinopathies. Surgical resection remains the preferred initial treatment for these lesions, and recently endoscopic endonasal approaches (EEAs) have become increasingly used. However, minimal data exist comparing these techniques with traditional transcranial (TC) methods. The purpose of this study was to evaluate perioperative differences in EEA and TC approaches for adult craniopharyngiomas over the past several decades.. Craniopharyngioma surgeries in the Nationwide Inpatient Sample from 1998 to 2014 were identified. Complication rates, mortality rates, and annual treatment trends were stratified by procedure. Annual caseload was assessed with linear regression, and multivariate logistic regression models were created to determine predictors of inpatient mortality and perioperative complications.. From 1998-2014, a significant increase in EEAs for craniopharyngiomas (+4.36/year, r. Over the past several decades, utilization of EEAs to resect adult craniopharyngiomas has increased. EEAs appear to be associated with lower rates of perioperative mortality and complications. However, long-term, prospective studies controlling for tumor size, location, and preoperative symptomatology are needed to determine when one approach should be used preferentially over the other.

Topics: Adult; Craniopharyngioma; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Nose; Pituitary Neoplasms; Postoperative Complications

Giant pituitary adenomas (GPAs) with subarachnoid extension can be challenging to achieve a gross total resection through a single endonasal or transcranial approach, and any residual tumor is at risk for postoperative apoplexy. Intraoperative venous congestion of the suprasellar tumor can occur following resection of the sellar tumor, limiting tumor descent, and leading to suprasellar residual. We propose a technique for resecting the suprasellar component first, which we call the "second floor" strategy (SFS) for GPA.. A retrospective review of cases from 2010-2020 identified 586 endoscopic endonasal approaches (EEAs) for pituitary adenoma resection. We report the rate of postoperative apoplexy and describe the SFS technique used in 2 cases.. Of 586 cases, 2 developed symptomatic postoperative apoplexy (0.3%), and a third transferred to our care after undergoing postoperative apoplexy. All 3 cases had subarachnoid extension of a pituitary adenoma, underwent EEA, and had residual suprasellar tumor. All 3 had permanent morbidity due to the postoperative apoplexy including blindness, stroke, or death, despite undergoing reoperation. The SFS was used for reoperation on 1 of these patients and as a primary strategy in a fourth patient who presented with a GPA with subarachnoid extension. We describe the SFS technique and demonstrate it with a 2-dimensional operative video.. Postoperative apoplexy of residual adenoma is a rare but serious complication after GPA resection. The proposed SFS allows early access to the suprasellar tumor and may improve the ability to safely achieve a gross total resection without need for additional procedures.

Topics: Adenoma; Aged, 80 and over; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Nose; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Stroke; Young Adult

Topics: Craniopharyngioma; Endoscopy; Humans; Nose; Pituitary Neoplasms

Sellar and parasellar regions are anatomically complex region and in close relationship with important neurovascular structures. Hence, surgical treatment of recurrent aggressive pituitary adenomas invading the cavernous sinus represents an operative challenge, given the lack of landmarks that are missed because of the scar tissue and previous interventions.. We describe in detail the surgical technique of the transpterygoid transcavernous approach (TPTCa) for the surgical re-operation of a recurrent pituitary adenoma invading the left cavernous sinus in the context of a Nelson syndrome after bilateral adrenalectomy. We highlight the main anatomical key elements involved in this approach as well as the technical aspects for avoiding surgical complications.. The TPTCa is a versatile approach that uses the endoscopic transsphenoidal route and thereby, avoids brain retraction. Anatomic landmarks offer a good sense of the area that is exposed in reoperations and reduce the risk of injury of important neurovascular structures located within the cavernous sinus and the parasellar region.

Topics: Adenoma; Adult; Cavernous Sinus; Humans; Neuroendoscopy; Nose; Pituitary Neoplasms; Reoperation

The efficacy of the endoscopic transcortical transventricular approach (ETTA) for craniopharyngioma in the third ventricle with hydrocephalus has been reported focusing on its reduced invasiveness. On the other hand, suprasellar craniopharyngioma without ventriculomegaly is generally surgically managed by craniotomy or the endoscopic endonasal approach (EEA). Here, we report an elderly patient who received cyst fenestration and Ommaya reservoir placement in ETTA for recurrent suprasellar cystic craniopharyngioma without ventriculomegaly. The ETTA as a less invasive procedure is feasible in patients not only with intraventricular craniopharyngioma but also with suprasellar craniopharyngioma without hydrocephalus provided a navigational system is applied and the surgeon has ample experience with transcranial endoscopic procedures.

Topics: Aged; Brain Neoplasms; Central Nervous System Cysts; Craniopharyngioma; Craniotomy; Cysts; Drug Delivery Systems; Female; Humans; Hydrocephalus; Male; Neuroendoscopy; Nose; Otologic Surgical Procedures; Pituitary Neoplasms; Prostheses and Implants; Third Ventricle

The management of pituitary apoplexy, caused by acute hemorrhage and/or infarction of a pituitary adenoma, is debated.. To analyze clinical characteristics of patients undergoing endoscopic endonasal approaches (EEAs) for pituitary apoplexy.. A retrospective review of patients at our institution from 2012 to 2018 undergoing EEA for pituitary apoplexy diagnosed clinically and with imaging/pathologic findings. Analysis included demographics, symptoms, neuroendocrine deficits, neuroimaging, complications, symptom resolution, and follow-up details.. Fifty patients (mean age, 53 years) were included. Preoperative symptoms included headache (86%), vision loss (62%), and cranial nerve paresis (40%). Mean tumor diameter was 2.7 cm and extrasellar extension was observed in 96% of tumors. Twenty-eight tumors were hemorrhagic (76%), 24 were necrotic (65%), and 13 (35%) had both features. Magnetic resonance imaging showed gross total resection in 58% of patients. Headache and vision loss improved in 87% and 86% of presenting patients. Cranial nerve paresis resolved in 72% of patients, partially improved in 11%, and remained unchanged in 17%. There were no deaths or carotid artery injuries. Surgical complications included postoperative cerebrospinal fluid leak (n = 4, 8%), epistaxis (n = 2, 4%), postoperative abscess (n = 1, 2%), and transient postoperative vision loss requiring reoperation (n = 1, 4%). Endocrinopathies improved in 21% of patients and panhypopituitarism persisted in 48% and developed in 6% of patients. Mean follow-up time was 26 months; 2 patients experienced recurrence.. EEA for pituitary apoplexy is effective in rapidly improving headache and visual symptoms. Although neuro-ophthalmic deficits often improve over time, panhypopituitarism persists in most patients after surgical resection.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Nose; Pituitary Apoplexy; Pituitary Neoplasms; Retrospective Studies; Young Adult

Skull base reconstruction after extended endoscopic endonasal approaches (EEAs) can be challenging. In addition to the nasoseptal flap, which has been adopted by most centers, autologous fascia lata is also often utilized. Harvesting of fascia lata requires a separate thigh incision, may prolong recovery, and results in a visible scar. In principal, the use of non-autologous materials would be preferable to avoid a second incision and maintain the minimally invasive nature of the approach, assuming the CSF leak rate is not compromised.. To assess the efficacy of acellular dermal matrix (ADM) as a non-autologous alternative to autologous fascia lata graft for watertight closure of the cranial base following EEAs.. A retrospective chart review of extended EEAs performed before and after the transition from fascia lata to ADM was performed. Cases were frequency matched for approach, pathology, BMI, use of lumbar drainage, and tumor volume. Power analysis was performed to estimate the sample size needed to demonstrate non-inferiority.. ADM was used for watertight closure of the cranial base in 19 consecutive extended endoscopic endonasal approaches (16 gasket-seals and 3 buttons) with 1 postoperative CSF leak at the last follow-up (median 5.3, range 1.0-12.6 months). All patients had high-flow intraoperative leaks. The cohort included 8 meningiomas, 8 craniopharyngiomas, 2 chordomas, and 1 pituicytoma ranging in size from 0.2 to 37.2cm. Preliminary results suggest that ADM provides a non-inferior non-autologous alternative to fascia lata for watertight gasket-seal and button closures following extended EEAs, potentially reducing or eliminating the need to harvest autologous tissue.

Topics: Acellular Dermis; Adult; Aged; Craniopharyngioma; Drainage; Fascia Lata; Female; Humans; Male; Meningeal Neoplasms; Meningioma; Middle Aged; Nose; Pituitary Neoplasms; Plastic Surgery Procedures; Retrospective Studies; Skull Base; Surgical Flaps; Treatment Outcome

Despite the rise of studies in the neurosurgical literature suggesting that patients with Medicaid insurance have inferior outcomes, there remains a paucity of data on the impact of insurance on outcomes after endonasal endoscopic transsphenoidal surgery (EETS). Given the increasing importance of complications in quality-based healthcare metrics, the objective of this study was to assess whether Medicaid insurance type influences outcomes in EETS for pituitary adenoma.. The authors analyzed a prospectively acquired database of EETS for pituitary adenoma from 2005 to 2018 at NewYork-Presbyterian Hospital, Weill Cornell Medicine. All patients with Medicaid insurance were identified. As a control group, the clinical, socioeconomic, and radiographic data of all other patients in the series with non-Medicaid insurance were reviewed. Statistical significance was determined with an alpha < 0.05 using Pearson chi-square and Fisher's exact tests for categorical variables and the independent-samples t-test for continuous variables.. Of 584 patients undergoing EETS for pituitary adenoma, 57 (10%) had Medicaid insurance. The maximum tumor diameter was significantly larger for Medicaid patients (26.1 ± 12 vs 23.1 ± 11 mm for controls, p < 0.05). Baseline comorbidities including diabetes mellitus, hypertension, smoking history, and BMI were not significantly different between Medicaid patients and controls. Patients with Medicaid insurance had a significantly higher rate of any complication (14% vs 7% for controls, p < 0.05) and long-term cranial neuropathy (5% vs 1% for controls, p < 0.05). There were no statistically significant differences in endocrine outcome or vision outcome. The mean postoperative length of stay was significantly longer for Medicaid patients compared to the controls (9.4 ± 31 vs 3.6 ± 3 days, p < 0.05). This difference remained significant even when accounting for outliers (5.6 ± 2.5 vs 3.0 ± 2.7 days for controls, p < 0.05). The most common causes of extended length of stay greater than 1 standard deviation for Medicaid patients were management of perioperative complications and disposition challenges. The rate of 30-day readmission was 7% for Medicaid patients and 4.4% for controls, which was not a statistically significant difference.. The authors found that larger tumor diameter, longer postoperative length of stay, higher rate of complications, and long-term cranial neuropathy were significantly associated with Medicaid insurance. There were no statistically significant differences in baseline comorbidities, apoplexy, endocrine outcome, vision outcome, or 30-day readmission.

Topics: Adenoma; Adult; Aged; Body Mass Index; Comorbidity; Cranial Nerve Diseases; Databases, Factual; Endoscopy; Female; Humans; Length of Stay; Male; Medicaid; Middle Aged; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Patient Readmission; Pituitary Neoplasms; Postoperative Complications; Prospective Studies; Sphenoid Bone; Treatment Outcome; United States; Vision Disorders

Post-operative CSF leak is the major source of morbidity following endoscopic transsphenoidal surgery. The purpose of this study was to identify factors associated with post-operative CSF leak in patients undergoing this surgery and facilitate the prospective identification of patients at higher risk of this complication.. A review of a prospectively maintained database containing details of 270 endoscopic transsphenoidal operations performed by the senior author over a 9-year period was performed. Univariate analysis was performed using the Chi-squared and Fisher's exact tests, as appropriate. A logistic regression model was constructed for multivariate analysis.. The rate of post-operative CSF leak in this series was 9%. On univariate analysis, previous surgery, resection of craniopharyngiomas, adenomas causing Cushing's disease and intra-operative CSF leaks were associated with an increased risk of post-operative CSF leak. The use of a vascularised nasoseptal flap and increasing surgical experience were associated with a decreased rate of CSF leak. On multivariate analysis, a resection of tumour for Cushing's disease (OR 5.79, 95% CI 1.53-21.95, p = 0.01) and an intra-operative CSF leak (OR 4.56, 95% CI 1.56-13.32, p = 0.006) were associated with an increased risk of post-operative CSF leak. Increasing surgical experience (OR 0.14, 95% CI 0.04-0.46, p = 0.001) was strongly associated with a decreased risk of post-operative CSF leak.. Increasing surgical experience is a strong predictor of a decreased risk of developing post-operative CSF leak following endoscopic transsphenoidal surgery. Patients with Cushing's disease and those who develop an intra-operative CSF leak should be managed with meticulous skull base repair and close observation for signs of CSF leak post-operatively.

Topics: Adenoma; Adult; Cerebrospinal Fluid Leak; Craniopharyngioma; Female; Humans; Male; Middle Aged; Multivariate Analysis; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Complications; Skull Base; Skull Base Neoplasms

Topics: Diving; Endoscopy; Humans; Nose; Pituitary Neoplasms

Topics: Diving; Endoscopy; Humans; Nose; Pituitary Neoplasms

Accurate diagnosis and treatment of sellar and parasellar inflammatory lesions is difficult. We report six patients with sellar and parasellar inflammatory lesions and impaired visual function, who underwent endonasal endoscopic surgery. These patients included one with aspergillosis, one with hypertrophic pachymeningitis, one patient with abscess, and three with idiopathic granulomatous lesions. Following surgery and medication, visual function improved in patients with aspergillosis, hypertrophic pachymeningitis, and abscess. In patients with idiopathic granulomatous inflammation, visual function improved in one out of three patients. The treatment outcome for sellar and parasellar inflammatory lesions with impaired visual function depends on the surgery as well as on the reaction to postoperative medication. In the present study, the functional prognosis of patients with idiopathic granulomatous lesions was relatively poor when compared with that of patients with other inflammatory lesions.

Topics: Endoscopy; Granuloma; Humans; Nose; Pituitary Neoplasms; Treatment Outcome

Surgical resection of skull base tumors in children is increasingly accomplished through an expanded endonasal approach (EEA). We aim to evaluate the potential effect of the EEA on midfacial growth as a result of iatrogenic damage to nasal growth zones.. We performed a retrospective review of children undergoing craniopharyngioma resection via an open transcranial or EEA. Pre- and postoperative magnetic resonance imaging was evaluated for growth in four midfacial measurements based on established cephalometric landmarks: anterior midface height, posterior midface height, palatal length, and sella-nasion distance. Statistical analysis was conducted using a mixed-effects linear regression model.. Twenty-two patients underwent an EEA (n = 12) or open transcranial approach (n = 10) for tumor resection with 3 years of imaging follow-up. There was no difference in midfacial growth between groups for each measurement. Compared to the open group, patients undergoing EEA demonstrated relative anterior midface height growth of -0.42 mm (P = 0.880), posterior midface height growth of -0.44 mm (P = 0.839), palatal length growth of 0.35 mm (P = 0.894), and sella-nasion distance growth of -2.16 (P = 0.365).. We found no difference in midfacial growth measurements between patients undergoing craniopharyngioma resection via an EEA and the open transcranial route after 3 years of imaging follow-up. Preliminary results on midfacial growth demonstrate that the EEA is a safe alternative to traditional transcranial approaches for the pediatric population. Further investigation with larger sample size and longer duration of follow-up is warranted to more thoroughly investigate the long-term implications of the EEA to the skull base.. 3 Laryngoscope, 130:338-342, 2020.

Topics: Adolescent; Child; Child, Preschool; Craniopharyngioma; Female; Humans; Male; Maxillofacial Development; Nose; Orthopedic Procedures; Pituitary Neoplasms; Retrospective Studies; Skull Base

To avoid deterioration of visual function, extended endoscopic endonasal transsphenoidal surgery (TSS) for craniopharyngioma was performed with visual evoked potential (VEP) monitoring using light-emitting diodes (LEDs).. The position of the optic chiasm was carefully evaluated on the preoperative midsagittal magnetic resonance (MR) images. Intraoperatively, direct and sharp dissection of the tumor from the optic chiasm was performed under VEP monitoring with LEDs through extended endoscopic endonasal TSS. If the VEP finding changed and became unstable, the operator were informed and stopped the surgical manipulation for the optic chiasm to recover. After 5-10 min, recovery of VEP findings was checked and the procedure resumed.. Extended endoscopic endonasal TSS with VEP monitoring was performed in consecutive 7 adult patients with newly diagnosed suprasellar craniopharyngiomas with maximum diameters of 25-41 mm (mean 33.7 mm). VEPs were stable throughout the surgery in 5 cases, but showed temporary instability and amplitude decrease in 2 cases, although the VEPs had recovered at the end of the surgery. Visual function, evaluated using visual impairment score, was improved after surgery in all patients. Gross total removal was achieved in 5 cases, and subtotal removal (90%) in 2 cases.. Intraoperative VEP monitoring is the only way to test visual function during surgery, and may be important and helpful in extended endoscopic endonasal TSS, which requires direct dissection between the optic nerve and craniopharyngioma under the endoscope.

Topics: Adult; Aged; Craniopharyngioma; Evoked Potentials, Visual; Female; Humans; Intraoperative Neurophysiological Monitoring; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Nose; Pituitary Neoplasms

Olfactory dysfunction is a significant postoperative complication related to endoscopic transsphenoidal surgery (TSS). This study aimed to determine the impact of endoscopic TSS on olfactory function.. We conducted a prospective study of 32 patients with sellar or parasellar tumors who were treated with endoscopic TSS between December 2013 and October 2016. TSS was performed via a right transseptal approach. We performed the Toyota and Takagi olfactometer test and the venous olfaction test for the evaluation of olfactory function preoperatively and at 1 and 3 months postoperatively.. The results of the Toyota and Takagi test showed that olfactory function deteriorated in 4 of 32 (12.5%) patients 1 month postoperatively and improved to preoperative baseline levels in all patients 3 months after the procedure. Olfactory function deteriorated in 1 of 31 (3.2%) patients 3 months after the procedure. The venous olfaction test revealed no response in 1 of 31 (3.2%) patients 1 month postoperatively, with no improvement 3 months after the procedure.. Endoscopic single-nostril transseptal TSS for sellar or parasellar tumor resection has minimal impact on olfactory function.

Topics: Adult; Aged; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Nose; Olfaction Disorders; Pituitary Neoplasms; Postoperative Complications

With a rapidly expanding elderly population in the United States, the incidence of pituitary adenomas in elderly will continue to rise. In this study, we aim to evaluate the safety and efficacy of transsphenoidal endoscopic endonasal resection for pituitary adenomas in the elderly population.. A retrospective review of 131 consecutive patients who underwent transsphenoidal endoscopic endonasal resection for pituitary adenomas at the University of Miami Hospital between 2012 and 2016 was performed. Preoperative, intraoperative, and surgical outcomes were analyzed in elderly (>70 years) versus nonelderly (<70 years) patients.. Of the 131 patients, 23 of them were >70 years (18%), of which 14 were septuagenarians and 9 were octogenarians. Elderly patients were more likely to present with vision loss (80.8% vs. 56.6%; P = 0.013) and larger tumors on imaging (2.7 ± 1.0 cm vs. 2.4 ± 1.3 cm; P = 0.042). Overall surgical and endocrinologic outcomes between the 2 groups were similar. However, patients <70 years old were more likely to have a gross total resection (86.7% vs. 65.4%; P = 0.011), as well as transient diabetes insipidus (54.3% vs. 26.9% P = 0.012) and intraoperative cerebrospinal fluid leak (83.5% vs. 58.5%; P = 0.013). However, permanent postoperative complication rates were similar including rate of permanent diabetes insipidus (4.3% elderly vs. 12.1% adult), cerebrospinal fluid leak (8.7% elderly vs. 8.4% adult), and meningitis (4.3% elderly vs. 2.8% adult). There were no medical complications or deaths in our cohort.. The transsphenoidal endoscopic endonasal approach can be a safe and effective technique for resection of pituitary adenomas in patients >70 years old with appropriate patient selection.

Topics: Adenoma; Adult; Age Factors; Aged; Aged, 80 and over; Cohort Studies; Endoscopy; Female; Humans; Hyperlipidemias; Magnetic Resonance Imaging; Male; Middle Aged; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Sphenoid Bone; Tomography Scanners, X-Ray Computed; Treatment Outcome; Valsalva Maneuver; Vision Disorders; Young Adult

The amount of parasellar extension is a known limitation for gross total resection (GTR) of pituitary adenomas. Endoscopic technique seems to improve resection of adenomas extending laterally. Knosp classification is used to evaluate the extent of parasellar invasion: increasing Knosp grades correspond with lower rates of GTR. The 4-quadrant method could help to estimate the risk of partial resection in adenomas with parasellar extension. The objective of this study was to compare the rate of GTR between microsurgical and endoscopic techniques in pituitary adenomas with parasellar extension. The secondary aim was to compare the predictive value of Knosp classification and of the 4-quadrant classification regarding GTR.. This was a retrospective comparison of GTR in different Knosp grades and per quadrant in 55 consecutive patients who underwent microsurgical (n = 28, 2001-2008) or endoscopic (n = 27, 2008-2016) resection of a pituitary adenoma with parasellar extension.. The endoscopic group (19/27 patients) had a significant higher rate of GTR than the microsurgical group (8/28 patients) (P = 0.005). This was evident in all patients but those with Knosp grade 4. Using the quadrant classification, the endoscopic group had a significantly higher rate of GTR than the microsurgical group in all but the inferolateral quadrant. The 2 classifications showed similar sensitivity in predicting subtotal resection (78% quadrant vs. 82% Knosp), with limited specificity (both 25%).. GTR of macroadenomas with parasellar extension is significantly enhanced by the endoscopic approach. The 4-quadrant classification appears as sensitive as the Knosp classification and could be a simple adjunct to predict surgical radicality, in particular in cases of inferolateral quadrant invasion.

Topics: Adenoma; Adult; Aged; Endoscopy; Female; Humans; Magnetic Resonance Imaging; Male; Microsurgery; Middle Aged; Nose; Pituitary Neoplasms; Radiology; Retrospective Studies; ROC Curve; Sphenoid Bone; Treatment Outcome

The endoscopic endonasal approach is widely used for treating giant pituitary adenomas. However, a small subset of tumors is still challenging to treat, and the risk of complications increases when an endoscopic endonasal approach alone is used. The simultaneous combined endoscopic endonasal and transcranial approach is a surgical option for such difficult adenomas; however, very few studies have described the technical nuances and benefits of this approach.. We treated 3 patients with giant pituitary adenoma and 1 patient with pituicytoma. Radiologic findings and clinical outcomes were retrospectively reviewed.. All patients had preoperative visual disturbances. A pterional approach was combined with an endoscopic endonasal approach to treat all the patients. Near-total and subtotal tumor removal was accomplished in 3 patients; however, only partial tumor removal was possible in 1 patient. Postoperative visual function improved in 3 patients, but there were no changes in 1 patient. There were no major complications; however, each patient developed either adrenocorticotropic hormone (ACTH) and thyroid-stimulating hormone deficiency or ACTH deficiency and persistent diabetes. Importantly, no cerebrospinal fluid leakage was observed in the patients.. Our simultaneous combined endoscopic and transcranial approach offers safe tumor resection and a low rate of complications. In this procedure, it is important that tumor debulking be performed by the main surgeon via a single surgical route and not by 2 surgeons using the simultaneous endonasal and transcranial approach, to avoid interference in the surgical field. This approach may be considered as a surgical option for carefully selected tumors in the sellar region.

Topics: Adenoma; Aged; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Neoplasms

Currently, due to the rarity of pathology, there are limited data surrounding outcomes of pediatric skull base surgery. Traditionally, surgeons have proceeded with caution when electing endonasal endoscopic transsellar/transplanum approaches to the skull base in pediatric patients due to poor sphenoid pneumatization. In this study, we review outcomes of endoscopic pediatric skull base surgery based on sphenoid pneumatization patterns.. Retrospective chart review.. A review of all cases of pediatric (age < 18 years) craniopharyngioma managed via an endoscopic endonasal approach at a tertiary academic medical center.. A total of 27 patients were included in the analysis. The median age was 8 years. Nineteen (70%) patients were male. Presellar, sellar/postsellar, and conchal sphenoid pneumatizations were found in 6, 11, and 10 patients, respectively. There was no significant association between sphenoid pneumatization pattern and extent of resection (gross vs. subtotal, P = .414), postoperative cerebrospinal fluid (CSF) leak (P = .450), intraoperative estimated blood loss (P = .098), total operative time (P = .540), and length of stay (P = .336). On multivariate analysis, after accounting for age, sex, preoperative cranial nerve involvement, and cavernous sinus invasion, there remained no significant association between sphenoid pneumatization pattern and extent of resection (P = .999) and postoperative CSF leak (P = .959).. Sphenoid pneumatization pattern does not appear to affect outcomes in endoscopic skull base surgery in the pediatric population. Importantly, lack of sphenoid pneumatization does not impede gross total resection or increase complications. Thorough knowledge of the anatomy during the endoscopic approach is critical to optimize outcomes.. 4 Laryngoscope, 129:832-836, 2019.

Topics: Air; Child; Craniopharyngioma; Endoscopy; Female; Humans; Male; Nose; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Skull Base; Sphenoid Bone; Treatment Outcome

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.. 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.. The preoperative calculated tumor volume was 38.14 ± 23.02 cm. 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.

Topics: Adenoma; Adult; Female; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Neuroendoscopy; Nose; Pituitary Neoplasms; Retrospective Studies; Treatment Outcome; Tumor Burden

Oculomotor cistern extension (OMCE) of pituitary adenoma through the oculomotor triangle may be one of the major characteristics of multi-lobulated adenoma. The OMCE may be hard to remove only through the endonasal approach.. We applied the simultaneous combined supra-infrasellar approach to remove pituitary adenoma with relatively large OMCE. Four (7.3%) of 55 consecutive patients with initially operated pituitary macroadenoma (> 10 mm) had OMCE. The combined supra-infrasellar approach was adopted in two cases with relatively large OMCE.. The simultaneous combined supra-infrasellar approach was performed with the transcranial microscopic transsylvian anterior temporal approach and the nasal endoscopic approach. The medial main mass was removed through the nasal side. The lateral OMCE was also removed through the nasal side by pushing the tumor in the sellar direction from the transcranial side. The oculomotor nerve was confirmed with electrical nerve stimulation. The main medial mass and the OMCE were mostly removed in both cases. Remnant tumor in the cavernous sinus was treated by gamma knife radiosurgery. Endoscopic transsphenoidal removal was performed in the other two cases with relatively small OMCE.. Pituitary macroadenomas with OMCE are a newly recognized form of progression with important implications for surgical strategy. The combined supra-infrasellar approach performed with the transcranial microscopic transsylvian anterior temporal approach using electrical nerve stimulation and the nasal endoscopic approach may be useful for this type of multi-lobulated pituitary adenoma.

Topics: Adenoma; Adult; Cavernous Sinus; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Oculomotor Nerve; Pituitary Neoplasms; Postoperative Complications

Clinical examination, including pre- and postoperative assessment of olfaction function, should be included in evaluating surgical outcomes in patients with pituitary adenomas. Most of the studies are lacking assessment of olfactory function.. A prospective study of 143 patients who underwent surgical resection of pituitary adenomas from January 2014 to December 2017 was performed. Data on clinical presentation, pre- and postoperative neurologic, endocrinologic, and ophthalmologic examinations, complications, and follow-up outpatient examinations were recorded. Olfactory function was assessed using the Sniffin' Sticks odor identification test preoperatively, postoperatively (3 months), and 1 year after surgery.. Normosmia was present preoperatively in 93.7% of patients, postoperatively in 95.8% of patients, and in 95.1% 1 year postsurgery. Hyposmia was present preoperatively in 4.2% of patients, postoperatively in 2.1% of patients, and in 1.4% 1 year after surgery. Anosmia was present preoperatively in 2.1% of patients, postoperatively in 2.1% of patients, and in 3.5% 1 year after surgery. In patients with preoperative normosmia, postoperative hyposmia and anosmia were present in 1.5% of patients. There were no differences according to age, sex, size, or type of pituitary adenoma.. Assessment of olfactory function should be included in the analysis of pituitary adenoma surgery results. This prospective study showed low risk of olfaction deterioration if an endoscopic endonasal approach is used without any mucosal flaps for skull base reconstruction. Further studies that include objective olfaction assessment are warranted.

Topics: Adenoma; Adolescent; Adult; Aged; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Nose; Olfaction Disorders; Pituitary Neoplasms; Postoperative Complications; Prospective Studies; Young Adult

OBJECTIVE Tumors with cavernous sinus (CS) invasion represent a neurosurgical challenge. Increasing application of the endoscopic endonasal approach (EEA) requires a thorough understanding of the CS anatomy from an endonasal perspective. In this study, the authors aimed to develop a surgical anatomy-based classification of the CS and establish its utility for preoperative surgical planning and intraoperative guidance in adenoma surgery. METHODS Twenty-five colored silicon-injected human head specimens were used for endonasal and transcranial dissections of the CS. Pre- and postoperative MRI studies of 98 patients with pituitary adenoma with intraoperatively confirmed CS invasion were analyzed. RESULTS Four CS compartments are described based on their spatial relationship with the cavernous ICA: superior, posterior, inferior, and lateral. Each compartment has distinct boundaries and dural and neurovascular relationships: the superior compartment relates to the interclinoidal ligament and oculomotor nerve, the posterior compartment bears the gulfar segment of the abducens nerve and inferior hypophyseal artery, the inferior compartment contains the sympathetic nerve and distal cavernous abducens nerve, and the lateral compartment includes all cavernous cranial nerves and the inferolateral arterial trunk. Twenty-nine patients had a single compartment invaded, and 69 had multiple compartments involved. The most commonly invaded compartment was the superior (79 patients), followed by the posterior (n = 64), inferior (n = 45), and lateral (n = 23) compartments. Residual tumor rates by compartment were 79% in lateral, 17% in posterior, 14% in superior, and 11% in inferior. CONCLUSIONS The anatomy-based classification presented here complements current imaging-based classifications and may help to identify involved compartments both preoperatively and intraoperatively.

Topics: Adenoma; Carotid Artery, Internal; Cavernous Sinus; Humans; Magnetic Resonance Imaging; Natural Orifice Endoscopic Surgery; Neoplasm Invasiveness; Nose; Pituitary Neoplasms; Retrospective Studies; Vascular Neoplasms

The minimal clinically important difference (MCID) is defined as the smallest change in health-related quality of life (QOL) that patients consider meaningful. The MCID is essential for determining clinically significant changes, rather than simply statistically significant changes, in QOL scores. The Anterior Skull Base Nasal Inventory-12 (ASK Nasal-12), a site-specific sinonasal QOL instrument, has emerged as a standard instrument for assessing QOL in patients who have undergone endonasal transsphenoidal surgery.. To determine the MCID for the ASK Nasal-12.. Distribution- and anchor-based methods were used to determine the MCID for the ASK Nasal-12 based on raw data from a multicenter prospective QOL study of 218 patients.. Two distribution-based statistical methods, the one-half standard deviation method and the effect-size method, both yielded MCIDs of 0.37 (medium effect). The first anchor-based method, using the 2-wk postoperative overall nasal functioning item as the anchor, yielded an MCID of 0.31. The second anchor-based method, using the 2-wk postoperative Short Form Health Survey 8 bodily pain item as the anchor, yielded an MCID of 0.29.. The largest MCID obtained for the ASK Nasal-12 using 4 statistical methods 2 wk postoperatively was 0.37. This information provides clinicians with an essential context for determining the clinical significance of changes in QOL scores after interventions. Our results will help clinicians better interpret QOL scores and design future studies that are powered to detect meaningful QOL changes.

Topics: Adult; Aged; Female; Health Surveys; Humans; Male; Middle Aged; Minimal Clinically Important Difference; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Complications; Prospective Studies; Quality of Life; Sella Turcica; Skull Base; Young Adult

Extension of a pituitary adenoma to the oculomotor cistern harbors the risk of oculomotor nerve impairment and further extension into the interpeduncular cistern. The role of endoscopic endonasal surgery for those lesions was investigated.. The medical records were retrospectively analyzed. Attention was paid to the oculomotor nerve function and removal rate of the tumor within the oculomotor and interpeduncular cisterns.. Six patients were eligible for the study, including 2 with oculomotor nerve palsy. The tumor from the oculomotor and interpeduncular cistern was removed in all except on one side of the case with bilateral tumor extension. The oculomotor nerve palsy demonstrated partial recovery in both cases during the 3-month follow-up.. The pituitary adenoma extending to the oculomotor cistern can be removed under the endoscope. Improvement of oculomotor nerve palsy can be achieved, and further tumor extension into the interpeduncular cistern can be prevented.

Topics: Adenoma; Adult; Aged; Cavernous Sinus; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neoplasm Recurrence, Local; Nose; Oculomotor Nerve; Oculomotor Nerve Diseases; Pituitary Neoplasms; Retrospective Studies; Treatment Outcome

Endoscopic endonasal surgery for pituitary adenomas is being performed more frequently worldwide in the recent years. This first bibliometric analysis was conducted aiming to have a microscopic view of research activities about endoscopic endonasal surgery for pituitary adenomas. The original articles about endoscopic endonasal surgery for pituitary adenomas were extracted from the Web of Science (WoS) and analyzed concerning their distributions. We also explored the potential correlations between publications of different countries and their gross domestic product (GDP) via Pearson correlation test. The total number of original articles retrieved from WoS was 307 from 1997 to 2017. The number of original articles published in the last decade has increased by 530.95% compared with that published in the former decade. The United States has published 124 articles (40.391%), followed by Italy with 40 (13.029%) and Japan with 27 articles (8.795%). The journal that published the highest number of original articles was Journal of Neurosurgery with 31 (10.098%), followed by Neurosurgery (n = 23, 7.492%), World Neurosurgery (n = 23, 7.492%), and Neurosurgical Focus (n = 15, 4.886%). There was a strong correlation between publication numbers and GDP of different countries (r = 0.889, P < 0.001). There is a skyrocket trend of endoscopic endonasal surgery for pituitary adenomas during the last 2 decades, and countries with high GDP tend to make more contributions to this field.

Topics: Bibliometrics; Endoscopy; Humans; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Publications

The authors presented our institutional experience with skull base reconstruction techniques and developed a stratified algorithm for different causes of cerebrospinal fluid (CSF) leak. This is a retrospective review of patients who were diagnosed as CSF leak treated with skull base reconstruction or who underwent endoscopic transsphenoidal surgery for sellar and parasellar lesions at our department from August 2012 to April 2017. The authors totally identified 57 (59 operations in total) patients who were divided into 3 groups according to the causes of CSF leak and different reconstruction techniques. All patients underwent skull base reconstruction with specific focus on diagnosis, reconstruction techniques and strategies, and clinical outcome. The reconstruction technique we adopted was the classical multiple-layer technique, as known as "sandwich" technique, with combination of fat tissue, septal bone, autologous fascia lata, artificial dura, and nasoseptal flap (NSF). The NSF was selectively harvested for large defects according to our protocol. The reconstruction failure rate is 4.4% (2 of 45) in patients underwent endoscopic surgery for sellar and parasellar lesions. Reconstruction for postoperative iatrogenic, traumatic, and spontaneous CSF leak achieved 100% success rate; 54.2% (32 of 59) operations were done with "sandwich" plus NSF. The overall failure rate of all reconstructions was 3.4% (2 of 59). A stratified approach with multiple-layer technique and NSF is reliable for skull base reconstruction.

Topics: Adult; Aged; Algorithms; Cerebrospinal Fluid Leak; Endoscopy; Female; Humans; Male; Middle Aged; Nasal Septum; Nose; Pituitary Neoplasms; Plastic Surgery Procedures; Retrospective Studies; Skull Base; Surgical Flaps; Young Adult

Topics: Endoscopy; Humans; Nose; Pituitary Apoplexy; Pituitary Neoplasms; Tertiary Care Centers

Topics: Endoscopy; Humans; Nose; Pituitary Apoplexy; Pituitary Neoplasms; Tertiary Care Centers

Endoscopic endonasal trans-sphenoidal surgery has become the gold standard for the surgical treatment of pituitary adenomas and many other pituitary lesions. Refinements in surgical techniques, technological advancements, and incorporation of neuronavigation have rendered this surgery minimally invasive. The complication rates of this surgery are very low while excellent results are consistently obtained through this approach. This paper focuses on the step-by-step surgical approach to pituitary adenomas, which is based on personal experience, and details the results obtained with this minimally invasive surgery.

Topics: Adenoma; Adult; Aged; Endoscopy; Female; Humans; Male; Middle Aged; Minimally Invasive Surgical Procedures; Nose; Pituitary Neoplasms

To compare sinonasal complications after microscopic and endoscopic approaches for pituitary adenomas.. At our clinic, sinonasal complications occurred in 31 patients who underwent microscopic transsphenoidal surgery between 2007 and 2014 and in 32 patients who underwent endoscopic transsphenoidal surgery between 2014 and 2016. We statistically compared the complications observed during endoscopic sinonasal examination performed by an otorhinolaryngologist.. Sinonasal pathology occurred in 22 of the 31 patients (70.9%) in the microscopy group (Group 1) and 19 of the 32 (59.3%) in the endoscopy group (Group 2). Of the 31 patients in Group 1, 13 had nasal septal perforation, 13 had nasal synechiae, three had anosmia, two had hyposmia and one had saddle nose deformity. In Group 2, no patient had nasal septal perforation, whereas eight had nasal synechiae, one had anosmia, 11 had hyposmia, and 4 had infection.. There were no statistically significant differences in sinonasal complications (e.g. synechiae, anosmia, deformity, and sinusitis) between the two groups. Although the perforation rate (especially for perforations in the middle portion of the septum) was statistically greater in Group 1 than in Group 2, the hyposmia rate was statistically greater in Group 2 than in Group 1.

Topics: Adenoma; Adult; Aged; Female; Humans; Male; Microsurgery; Middle Aged; Neuroendoscopy; Nose; Olfaction Disorders; Pituitary Gland; Pituitary Neoplasms; Prospective Studies; Sinusitis

Craniopharyngiomas are dysontogenic tumors with benign histology but aggressive behavior. The surgical challenges posed by the tumor are well recognized. Neuroendoscopy has recently contributed to its surgical management. This study focuses on our experience in managing craniopharyngiomas in recent years, highlighting the role of combined endoscopic trans-ventricular and endonasal approach.. Ninety-two patients have been treated for craniopharyngioma from 2000 to 2016 by the senior author. A total of 125 procedures, microsurgical (58) and endoscopic (67), were undertaken. Combined endoscopic approach was carried out in 18 of these patients, 16 children and 2 young adults. All of these patients presented with a large cystic suprasellar mass associated with hydrocephalus. In the first instance, they were treated with a transventricular endoscopic procedure to decompress the cystic component. This was followed by an endonasal transsphenoidal procedure for excision within the next 2 to 6 days. All these patients improved after the initial cyst decompression with relief of hydrocephalus while awaiting remaining tumor removal in a more elective setting. Gross total resection could be done in 84% of these patients. Diabetes insipidus was the most common postsurgical complication seen in 61% patients in the immediate period but was persistent in only two patients at 1-year follow-up. None of the children in this group developed morbid obesity. There was one case of CSF leak requiring repair after initial surgery. Peri-operative mortality was seen in one patient secondary to ventriculitis.. The patients who benefit most from the combined approach are those who present with raised intracranial pressure secondary to a large tumor with cyst causing hydrocephalus. Intraventricular endoscopic cyst drainage allows resolution of hydrocephalus with restoration of normal intracranial pressure, gives time for proper preoperative work up, and has reduced incidence of CSF leak after transnasal surgery.. Combined endoscopic approach thus gives a unique opportunity to remove these lesions more radically with less morbidity.

Topics: Adolescent; Adult; Child; Craniopharyngioma; Disease Management; Female; Humans; Magnetic Resonance Imaging; Male; Microsurgery; Neuroendoscopy; Nose; Pituitary Neoplasms; Retrospective Studies; Treatment Outcome

Despite advances in endoscopic techniques, retrochiasmatic craniopharyngiomas (CPs) are difficult to remove completely, because the low-lying optic chiasm often provides an obstacle to an endoscopic endonasal approach. This study aimed to identify the endoscopic surgical outcomes of the retrochiasmatic CP and resolve the issues related to low-lying optic chiasm.. We reviewed 154 consecutive patients with CP who underwent endonasal endoscopic resection from February 2009 to April 2017 at 2 independent institutions. The topographic relationship of the tumor with the third ventricle, stalk, and optic chiasm and clinical outcomes were investigated.. Retrochiasmatic CPs were found in 142 of 154 patients (92.2%). The median follow-up time was 25 months. Gross total resection and near-total resection were achieved in 113 patients (79.6%) and 21 patients (13.8%), respectively. Postoperative cerebrospinal fluid leaks were found in 16 patients (11.3%). Low-lying and high-lying chiasms were found in 44 patients (31.0%) and 98 patients (69.0%), respectively. Low-lying chiasm did not affect clinical outcomes including the extent of resection. Patients with low-lying chiasm showed a marginal trend for postoperative visual deterioration. The ventricular growth pattern representing the origin of the tumor and previous surgery were significantly associated with the position of the optic chiasm (P = 0.007 and 0.001, respectively).. An endoscopic endonasal approach is an effective surgical approach for retrochiasmatic CP, even in tumors with low-lying chiasm. However, a thorough and careful dissection is necessary to prevent visual deterioration.

Topics: Adolescent; Adult; Aged; Cerebrospinal Fluid Rhinorrhea; Craniopharyngioma; Female; Humans; Imaging, Three-Dimensional; Male; Middle Aged; Neuroendoscopy; Nose; Ophthalmology; Optic Chiasm; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Statistics, Nonparametric; Tomography Scanners, X-Ray Computed; Young Adult

Giant pituitary adenomas represent a surgical challenge. We present the results of the endoscopic endonasal approach (EEA) for giant pituitary adenomas.. We retrospectively reviewed the medical records of 55 patients with giant pituitary adenomas (>4 cm in maximum diameter) who underwent surgery with an EEA between 2008 and 2016. Factors affecting the extent of resection were evaluated.. The mean patient age was 55.5 years. Tumors were nonfunctional in all but 4 patients, including 2 with growth hormone-secreting tumors, 1 with an adrenocorticotropic hormone-secreting tumor, and 1 with prolactinoma. Gross total resection was achieved in 24 patients (44%), and near-total resection (>90%) was achieved in 26 patients (47%). A multilobular configuration (P = 0.002) and cavernous sinus invasion (P = 0.044) negatively affected the extent of resection, whereas tumor size, intraventricular, and anterior or posterior fossa extension did not. Ten patients underwent adjuvant radiotherapy. All patients with hormone-secreting adenomas required adjuvant medical and/or radiotherapy to achieve biochemical remission. Postoperative vision was improved or normalized in 32 patients (66%), stable in 15 patients (31%), and worsened in 1 patient. A new hormonal deficit occurred in 8 patients (17%), whereas recovery of an existing hormonal deficit occurred in 6 patients (20%). The mean duration of follow-up was 41 months. Tumor recurrence/progression occurred in 6 patients (11%). Complications included apoplexy of residual tumor resulting in ischemic stroke in 1 patient, postoperative cerebrospinal fluid leak in 1 patient, and permanent diabetes insipidus in 4 patients (7%).. Surgery with the EEA is an excellent option for managing giant pituitary adenomas. It results in superior clinical outcomes to those obtained using traditional microscopic transsphenoidal and transcranial approaches as reported in the literature.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Endoscopy; Female; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Nose; Pituitary Neoplasms; Retrospective Studies; Tomography Scanners, X-Ray Computed; Treatment Outcome; Young Adult

Topics: Craniopharyngioma; Endoscopy; Humans; Nose; Pituitary Neoplasms

OBJECTIVE The aim of this study was to analyze the outcomes of transsphenoidal surgery (TSS) in a single-center clinical series of pediatric craniopharyngioma patients treated with gross-total resection (GTR). METHODS The authors retrospectively reviewed the surgical outcomes for 65 consecutive patients with childhood craniopharyngiomas (28 girls and 37 boys, mean age 9.6 years) treated with TSS (45 primary and 20 repeat surgeries) between 1990 and 2015. Tumors were classified as subdiaphragmatic or supradiaphragmatic. Demographic and clinical characteristics, including extent of resection, complications, incidence of recurrence, pre- and postoperative visual disturbance, pituitary function, and incidence of diabetes insipidus (DI), as well as new-onset obesity, were analyzed and compared between the primary surgery and repeat surgery groups. RESULTS Of the 45 patients in the primary surgery group, 26 (58%) had subdiaphragmatic tumors and 19 had supradiaphragmatic tumors. Of the 20 patients in the repeat surgery group, 9 (45%) had subdiaphragmatic tumors and 11 had supradiaphragmatic tumors. The only statistically significant difference between the 2 surgical groups was in tumor size; tumors were larger (mean maximum diameter 30 mm) in the primary surgery group than in the repeat surgery group (25 mm) (p = 0.008). GTR was accomplished in 59 (91%) of the 65 cases; the GTR rate was higher in the primary surgery group than in the repeat surgery group (98% vs 75%, p = 0.009). Among the patients who underwent GTR, 12% experienced tumor recurrence, with a median follow-up of 7.8 years, and recurrence tended to occur less frequently in primary than in repeat surgery patients (7% vs 27%, p = 0.06). Of the 45 primary surgery patients, 80% had deteriorated pituitary function and 83% developed DI, whereas 100% of the repeat surgery patients developed these conditions. Among patients with preoperative visual disturbance, vision improved in 62% but worsened in 11%. Visual improvement was more frequent in primary than in repeat surgery patients (71% vs 47%, p < 0.001), whereas visual deterioration was less frequent following primary surgery than repeat surgery (4% vs 24%, p = 0.04). Among the 57 patients without preoperative obesity, new-onset postoperative obesity was found in 9% of primary surgery patients and 21% of repeat surgery patients (p = 0.34) despite aggressive resection, suggesting that hypothalamic dysfunction was rarely associated with GTR by TSS in this

Topics: Adolescent; Body Mass Index; Child; Child, Preschool; Craniopharyngioma; Diagnostic Techniques, Ophthalmological; Endoscopes; Female; Hormones; Humans; Infant; Magnetic Resonance Imaging; Male; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Retrospective Studies; Sphenoid Bone; Tomography Scanners, X-Ray Computed; Treatment Outcome

Radiation therapy is often advocated for residual or recurrent craniopharyngioma following surgical resection to prevent local recurrence. However, radiation therapy is not always effective and may render tumors more difficult to remove. If this is the case, patients may benefit more from reoperation if gross total resection can be achieved. Nevertheless, there is little data on the impact of radiation on reoperations for craniopharyngioma. In this study, we sought to analyze whether a history of previous radiation therapy (RT) affected extent of resection in patients with recurrent craniopharyngiomas subsequently treated with reoperation via endoscopic endonasal approach (EEA).. The authors reviewed a prospectively acquired database of EEA reoperations of craniopharyngiomas over 13 years at Weill Cornell, NewYork-Presbyterian Hospital. All procedures were performed by the senior author. The operations were separated into two groups based on whether the patient had surgery alone (group A) or surgery and RT (group B) prior to recurrence.. A total of 24 patients (16 male, 8 female) who underwent surgery for recurrent craniopharyngioma were identified. The average time to recurrence was 7.64 ± 4.34 months (range 3-16 months) for group A and 16.62 ± 12.1 months (range 6-45 months) for group B (p < 0.05). The average tumor size at recurrence was smaller in group A (1.85 ± 0.72 cm; range 0.5-3.2) than group B (2.59 ± 0.91 cm; range 1.5-4.6; p = 0.00017). Gross total resection (GTR) was achieved in 91% (10/11) of patients in group A and 54% (7/13) of patients in group B (p = 0.047). There was a near significant trend for higher average Karnofsky performance status (KPS) score at last follow-up for group A (83 ± 10.6) compared with group B (70 ± 16.3, p = 0.056).. While RT for residual or recurrent craniopharyngioma may delay time to recurrence, ability to achieve GTR with additional surgery is reduced. In the case of recurrent craniopharyngioma, if GTR can be achieved, consideration should be given to endonasal reoperation prior to the decision to irradiate residual or recurrent tumor.

Topics: Adult; Aged; Craniopharyngioma; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neoplasm Recurrence, Local; Neuroendoscopy; Nose; Pituitary Neoplasms; Postoperative Complications

This study aimed to report the authors' single-center clinical experience about craniopharyngiomas and discuss surgical outcomes of these patients according to the type of surgical approach (endoscopic endonasal or open microscopic transcranial approach).Twenty-four patients diagnosed with craniopharyngiomas between May 2013 and April 2017 were considered for inclusion. The patients were divided into 2 groups according to the surgical approach (open transcranial microscopic approach [group A] and endoscopic endonasal approach [group B]). These groups were compared in terms of postoperative surgical outcome scores (extent of tumor removal, visual deficit, hydrocephalus, metabolic disorders, and Glasgow coma scale) and hospitalization interval.There was no patient of mortality in both groups. In this study, 4 of the 13 patients in group A and 9 of the 11 patients in group B underwent gross total resection. However, 1 patient in group B underwent repair because of cerebrospinal fluid leakage postoperatively. In addition, 1 patient in group A had a wound healing problem postoperatively. The postoperative outcome scores were 9.5 in group A and 11.5 in group B. The hospitalization interval in group A (range, 7-9 days) was longer than that in group B (range, 5-7 days).The endoscopic endonasal approach should be considered the first-line surgical treatment modality in patients with a preliminary diagnosis of craniopharyngioma in terms of low complication risk, minimal invasiveness, and better outcome scores. Open microscopic transcranial procedures may be combined with this approach in a single session for challenging cases.

Topics: Adolescent; Adult; Aged; Child; Craniopharyngioma; Craniotomy; Female; Humans; Male; Microsurgery; Middle Aged; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Period; Tomography, X-Ray Computed; Treatment Outcome; Young Adult

 Over the past few years bipolar electrocoagulation techniques in neurosurgery have been continually improving. However, limited access during endoscopic endonasal transsphenoidal surgery (EETS) for central skull base pathologies and the requirement of very precise coagulation in that dedicated anatomical area requires further refinement of bipolar coagulation instruments. We describe our experience (effectiveness of coagulation, intraoperative handling, and the use as a dissecting tool) with a new type of coagulation forceps, the Calvian endo-pen (Sutter Medizintechnik, Freiburg, Germany) during EETS..  From June to August 2015, 12 patients with central skull base lesions (9 with a pituitary adenoma and 1 each with epidermoid, hemangioma, and juvenile angiofibroma) were operated on with the Calvian endo-pen..  The application of the Calvian endo-pen was feasible in all cases. The angled thin tips proved to be very effective and precise for soft tissue coagulation to achieve hemostasis. Even very small vessels could be occluded selectively. It was also helpful for outward dissection in separating normal from tumor tissue..  The use of the Calvian endo-pen is safe and effective during EETS for central skull base pathologies. Its ease in intraoperative handling (maneuverability, cleaning) and precise coagulation makes it a promising instrument for EETS.

Topics: Germany; Humans; Natural Orifice Endoscopic Surgery; Nose; Pituitary Neoplasms; Skull Base; Skull Base Neoplasms; Sphenoid Sinus; Surgical Instruments

Endoscopic endonasal transsphenoidal surgery (EETS) is a common treatment for patients with pituitary adenomas (PAs). A disadvantage of endoscopic surgery has been the lack of stereoscopic vision and depth perception. Recent developments offer high-definition 3-dimensional (3D-HD) visualization with a higher resolution and better image quality compared with 3D standard endoscopy (3D-SD). In this study, we compared treatment results of surgically treated patients with PAs using 3 different visualization systems: 2-dimensional (2D)-HD, 3D-SD, and 3D-HD.. Data from patients with primary PAs that were surgically treated between December 2008 and December 2017 were analyzed. Preoperative and postoperative tumor size and location, perioperative complications, and ophthalmologic, endocrine, and clinical outcomes were compared.. A total of 170 patients underwent endoscopic resection of a primary PA (54 patients with 2D-HD, 75 with 3D-SD, and 41 with 3D-HD). Preoperatively, no statistical differences were found for tumor size, extension, and endocrine and ophthalmologic status. Tumor resection was not statistically different among the 3 groups. Complete resection was performed in 33 patients (80%) in the 3D-HD group, 54 patients (72%) in the 3D-SD group, and 39 patients (72%) in the 2D-HD group. The number of complications was not different across the groups (P = 0.436). Ophthalmologic outcomes did not differ based on EETS technique. The rate of new pituitary insufficiency was slightly lower in the 3D-HD group compared with 2D-HD and 3D-SD groups (4.8%, 16.6%, and 12%, respectively; P = 0.290).. Although the resection rate was higher in the 3D-HD group, and subjective advantages of the 3D-HD endoscopes were noted, there were no significant differences in terms of gross total resection or new hormonal deficits among the 3 groups.

Topics: Adenoma; Female; Humans; Image Processing, Computer-Assisted; Magnetic Resonance Imaging; Male; Nose; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Transanal Endoscopic Microsurgery; Treatment Outcome; Visual Acuity; Visual Fields

Topics: Endoscopy; Humans; Nasal Cavity; Neuroendoscopes; Neuroendoscopy; Nose; Pituitary Neoplasms

Prolactinomas affect patients' quality of life and even endanger lives. The study aimed to investigate the effect of the endoscopic endonasal transsphenoidal approach (EETA) on 52 patients with prolactinomas.. A total of 52 patients with prolactinomas who had previously undergone EETA in the People's Hospital of Xinjiang Uygur Autonomous Region between January 2013 and December 2017 were retrospectively analyzed. Factors affecting the extent of resection and postoperative remission rates were also investigated.. All the patients were pathologically diagnosed with prolactinomas. Compared with giant adenomas, the total removal rate of microadenomas and macroadenomas was significantly increased (P < .05). In addition, the total removal rate of patients with noninvasive prolactin adenomas was significantly higher than patients with invasive prolactinadenomas (P < .05). Furthermore, there were no significant differences in postoperative remission rates among patients with prolactin adenomas from different ethnic groups (P > .05). Also preoperative administration of bromocriptine and preoperative prolactin (PRL) levels did not significantly affect therapeutic outcomes postsurgery (P > .05). Postoperative menstruation was improved or normalized in 20 (38.5%) female patients, vision was improved or normalized in 15 (28.8%) patients, and headaches were improved or normalized in 22 (42.3%) patients. Sexual function was improved in 2 male patients following surgery. A total of 6 patients exhibited a recurrence following surgery. A number of patients suffered from postoperative complications, including transient diabetes insipidus in 5 (9.6%) patients and postoperative transient cerebrospinal fluid leakage in 2 (3.8%) patients.. The results of this study demonstrated that tumor size, preoperative PRL levels, and invasion of adenomas represent independent factors that can affect the success of surgery. The results suggested that EETA represents a therapeutic strategy for the treatment of patients with prolactinoma with high remission rates and low complication rates. Therefore, EETA should be considered a primary treatment for patients with prolactinomas who are not responsive to treatment with medical therapy.

Topics: Adult; Aged; Female; Follow-Up Studies; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neuroimaging; Neurosurgical Procedures; Nose; Pituitary Gland; Pituitary Neoplasms; Postoperative Complications; Prolactin; Prolactinoma; Retrospective Studies; Sphenoid Bone; Treatment Outcome

In this study, we analyze and discuss the treatments of postoperative nasal complications after endonasal transsphenoidal resection of pituitary neoplasms (PNs). We performed 129 endonasal transsphenoidal resections of PNs and analyzed and treated cases with nasal complications. After endonasal transsphenoidal resection of PNs, there were 26 cases of postoperative nasal complications (20.1%), including nasal hemorrhage (4.8%), cerebrospinal fluid rhinorrhea (6.9%), sphenoid sinusitis (2.3%), atrophic rhinitis (1.6%), olfactory disorder (1.6%), perforation of nasal septum (0.8%), and nasal adhesion (2.3%). All patients clinically recovered after therapy, which included treatment of the cavity through nasal endoscopy, intranasal corticosteroids, and nasal irrigation. We propose that regular nasal endoscopic review, specific nasal medications, and regular nasal irrigation can effectively clear nasal mucosal hyperemia-induced edema and nasal/nasoantral secretions, as well as promote regeneration of nasal mucosa, prevent nasal adhesion, maintain the sinus cavity drainage, and accelerate the recovery of the physiological function of the paranasal sinus. Timely treatment of patients with nasal complications after endonasal transsphenoidal resections of PNs could greatly relieve the clinical symptoms. Nasal cleaning is very beneficial to patients after surgery recovery.

Topics: Adolescent; Adult; Aftercare; Aged; Cerebrospinal Fluid Rhinorrhea; Child; Epistaxis; Female; Humans; Male; Middle Aged; Nasal Lavage; Nasal Mucosa; Nasal Septal Perforation; Nasal Surgical Procedures; Natural Orifice Endoscopic Surgery; Nose; Nose Diseases; Olfactory Nerve Diseases; Paranasal Sinuses; Pituitary Neoplasms; Postoperative Complications; Recovery of Function; Retrospective Studies; Rhinitis, Atrophic; Sphenoid Sinus; Sphenoid Sinusitis; Tissue Adhesions; Young Adult

The endoscopic endonasal approach is considered an alternative minimally invasive approach for suprasellar craniopharyngiomas. However, the complicated surgical manipulations required by this approach have limited its application. We evaluate whether the approach features a learning curve. Thirty-three patients were retrospectively reviewed and grouped as early (17 patients) and late (16 patient) groups. The operation time, extent of removal, ophthalmology, endocrinology, reconstruction and modifications of standard technique were evaluated. Between the two groups, the operation time decreased from 201.1±105.3min in the early group to 107.6±90.0min in the late group (p<0.05). Regarding clinical outcomes, non-significantly increasing trends toward the rate of gross total resection, visual improvement and (from 76.5% to 87.5%, 73.3% to 93.3%), significantly decreasing trends toward the rate of tumor recurrence (from 23.5% to 0% p<0.05) and non-significantly decreasing trends toward the rate of hypopituitarism recovery (26.7% to 0%) were observed between the two groups. With respect to complications, non-statistically significant decreasing trends toward transient cranial nerve paralysis (from 5.9% to 0%) and non-statistically significant increasing trends toward rate of CSF leakage, meningitis and new hypothyroidism (from 11.8% to 25%, 11.8% to 31.3%, 0 to 3%) were observed. We identified a learning curve for the endoscopic endonasal approach for suprasellar craniopharyngiomas. The exact number of patients necessary to establish a significant improvement in the clinical outcomes and decrease in the complications warrants further investigation. The outcomes of tumor recurrence may be associated with duration of follow-up. The CSF leakage represented the most common complication.

Topics: Adult; Aged; Cerebrospinal Fluid Rhinorrhea; Craniopharyngioma; Female; Humans; Learning Curve; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Nose; Pituitary Neoplasms; Postoperative Complications

To determine the predictive factors for endocrinological remission of patients with growth hormone (GH)-secreting pituitary adenomas.. In 47 patients with GH-secreting pituitary adenomas who underwent endoscopic endonasal transsphenoidal surgery with intraoperative GH measurements from 2002 to 2011, the relationship between the intraoperative GH levels and postoperative remission was analyzed, and 2 items that predicted remission (GH half-life obtained 30 minutes or less after removal and a minimum surgical GH level less than 2.5 ng/mL) were determined. In addition, 2 surgical observations (endoscopic confirmation of no tumor remnants and pathologic confirmation of the absence of tumor remnants in the bordering tissue) were also considered. Positive items resulted in one point, and scores ranged from 0 to 4. For 27 patients who underwent surgery from 2012 onwards, this scoring system was applied by 3 independent operators, and the remission rates and predictive values were estimated.. Twenty-six of the 47 (55.3%) patients achieved remission. The remission rates were significantly different for different scores. In the 27 patients treated from 2012 onward, repeat residual tumor examinations were performed if the GH score did not reach 2 at the end of the removal. Nine patients had final scores of 3 or 4. All of these patients achieved remission. In 16 patients with final scores of 2 or less, only 2 with Knosp grades of 0 and 1 achieved remission.. Our scoring system, which incorporated GH measurements and surgical observations, predicted postoperative remission. Complete tumor removal was critical to achieve intraoperative scores over 3.

Topics: Adenoma; Adolescent; Adult; Aged; Female; Growth Hormone; Humans; Male; Middle Aged; Monitoring, Intraoperative; Nose; Pituitary Neoplasms; Postoperative Complications; Postoperative Period; Predictive Value of Tests; Retrospective Studies; Sphenoid Bone; Transanal Endoscopic Microsurgery; Young Adult

Cushing disease is a relatively rare cause of Cushing syndrome secondary to a hyperfunctioning pituitary adenoma. In addition to signs and symptoms of hypercortisolism, Cushing disease may present with diverse otolaryngic manifestations, which may guide diagnosis and management. We performed a retrospective chart review of patients who were found to have Cushing disease and who underwent transnasal transsphenoidal surgery for pituitary adenomas between January 1, 2007, and July 1, 2014, at a tertiary academic medical center. There were 37 consecutive patients in this series with Cushing disease caused by a pituitary adenoma. Fifteen (41%) patients complained of visual changes. Five (14%) patients suffered from obstructive sleep apnea. Four (11%) patients had thyroid disease. Other symptoms included hearing loss, vertigo, tinnitus, epistaxis, dysphagia, and salivary gland swelling. Although Cushing disease traditionally presents with classic "Cushingoid" systemic features, it also may present with various otolaryngic manifestations. A thorough workup by otolaryngologists is critical in the comprehensive management of these patients.

Topics: Adolescent; Adult; Aged; Child; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Nose; Otorhinolaryngologic Diseases; Pituitary ACTH Hypersecretion; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Young Adult

The excellent visualization and minimally invasive approach employed in endoscopic endonasal procedures has now revolutionized the pituitary surgery, replacing the transnasal microscopic technique worldwide. However, it involves major shift in hand-eye co-ordination from static 3 dimensional images of microscope to 2 dimensional endoscopic images hence demands training and inter-disciplinary approach. Here we present our experiences in learning and developing a safe endonasal transsphenoidal endoscopic approach to resect pituitary adenomas.. This prospective study was jointly conducted in the departments of ENT and Neurologicals surgery Kathmandu Medical College, Nepal, from September 2014 to August 2016. The endoscopic approach to the sphenoid sinus was performed by an Otolaryngologist and ablative surgery by Neurosurgeon. The ease of procedure, intra operative challenges, surgical cure, post-operative cerebro spinal fluid (CSF) leaks and postoperative complaints were analyzed.. Sixteen consecutive patients with pituitary adenoma (macro adenoma=13, micro adenoma =3) were analyzed. There were three intraoperative CSF leak, managed successfully. Two patients developed transient diabetes insipidus and surgical cure rate was 90%. No case had to be switched over to traditional microscopic route due to technical failure. There was no mortality.. The endoscopic endonasal transsphenoidal approach to pituitary tumors is a safe and minimally invasive procedure, which can be employed safely in any of our centers in Nepal, equipped with endoscopic sinus surgery and endoscopically trained ENT and Neurosurgeons. A multi disciplinary approach provides good access, greater tumor excision and excellent postoperative follow up.

Topics: Adenoma; Adolescent; Adult; Aged; Endoscopy; Female; Humans; Male; Middle Aged; Nepal; Nose; Pituitary Neoplasms; Postoperative Complications; Prospective Studies; Retrospective Studies; Young Adult

This study aimed to assess the efficacy of endoscopic endonasal surgery, conducted by a team of neurosurgeons and otolaryngologists.. We studied 40 patients who were undergoing surgery for primary non-functional pituitary adenomas with Knosp grades 1 to 3, at Keio University Hospital between 2005 and 2012. We compared the endoscopic endonasal transsphenoidal approach (team-eTSS; T-eTSS), with a microscopic transsphenoidal approach (mTSS). Analyses were conducted for differences between the two groups in tumor resection rates, operating durations, and complications from the non-functional pituitary adenomas. We also compared the heminostril and binostril approaches for T-eTSS.. Tumor resection rates were higher when the surgeries were conducted by T-eTSS than mTSS. In particular, when the maximum tumor diameter was more than 25 mm, resection rates were significantly higher for T-eTSS than for mTSS. There were no unexpected complications in either group. There was no significant difference in resection rates between the heminostril and binostril approaches when T-eTSS was performed.. T-eTSS is an efficacious surgical option for non-functional pituitary adenomas, particularly when the adenoma is of large size. Benefits of the heminostril approach are evident.

Topics: Adenoma; Adult; Aged; Endoscopy; Female; Humans; Male; Middle Aged; Neurosurgeons; Nose; Otolaryngologists; Patient Care Team; Pituitary Neoplasms; Retrospective Studies; Treatment Outcome

Primary lactotroph disinhibition, or stalk effect, occurs when mechanical compression of the pituitary stalk disrupts the tonic inhibition by dopamine released by the hypothalamus. The resolution of pituitary stalk effect-related hyperprolactinemia postoperatively has not been studied in a large cohort of patients. We performed a retrospective review to investigate the time course of recovery of lactotroph disinhibition after transsphenoidal surgery.. Medical records were retrospectively reviewed for all patients undergoing transsphenoidal surgery with the senior author from April 2008 to November 2014.. Of 556 pituitary adenomas, 289 (52.0%) were eliminated: 77 (13.9%) had an immunohistochemically confirmed prolactinoma, 119 (21.4%) patients had previous surgery, 93 (16.7%) had incomplete medical records, leaving 267 patients (48.0%) for final analysis. Of these patients, 72 (27.0%) had increased serum prolactin levels (≥23.3 ng/mL), suggestive of pituitary stalk effect (maximum prolactin level = 148.0 ng/mL). Patients with stalk effect were more likely than those with normal serum prolactin levels to present with menstrual dysfunction (29.7% vs. 19.4%; P < 0.01) and galactorrhea (11.1% vs. 2.1%; P < 0.01). Patients with lactotroph disinhibition were more likely to harbor macroadenomas than were patients who did not show lactotroph disinhibition (81.9% vs. 70.2%; P = 0.06). Among patients with increased preoperative prolactin, 77.8% experienced normalization of serum prolactin postoperatively, galactorrhea improved in 100%, sexual dysfunction resolved in 66.6%, and menstrual dysfunction among premenopausal females normalized in 73.3% at last follow-up (mean, 5.35 years; range, 0.1-10 years).. Transsphenoidal surgery can provide durable normalization of serum prolactin levels and related symptoms caused by pituitary stalk compression-related lactotroph disinhibition.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cohort Studies; Female; Galactorrhea; Humans; Hyperprolactinemia; Male; Middle Aged; Neurosurgical Procedures; Nose; Pituitary Gland; Pituitary Neoplasms; Pregnancy; Prolactin; Prolactinoma; Reoperation; Sphenoid Bone; Treatment Outcome; Young Adult

Microscopic transnasal transsphenoidal surgery (MTTS) has been a time-confirmed effective treatment for pituitary adenomas; however, the data supporting its use in pediatric patients is limited. In this study, the authors summarize the authors' 5-year experience of pituitary adenomectomy via MTTS in a pediatric population. The authors retrospectively reviewed the medical records of 35 patients aged ≤18 years who underwent microscopic transnasal transsphenoidal approach for pituitary adenomas between January 2011 and December 2015. Age, sex, symptoms, tumor size, extent of tumor resection, surgical outcomes, and complications were reviewed. All patients underwent MTTS 39 times. Total resection was obtained in 31 (88.6%) patients, while subtotal resection was achieved in 4 (11.4%) and no patient had partial resection. For the 21 patients with preoperative visual impairment, 18 (85.7%) resolved and 3 (14.3%) obtained subjective improvement. Of the 33 patients with preoperative hyperhormonal levels, endocrine function reduced to normal reference range in 28 (84.8%), decreased in 3 (9.1%) and 2 (6.1%) patients had no change. Diabetes insipidus occurred in 4 (11.4%) patients, of whom 1 patient (2.9%) developed persistent diabetes insipidus that was treated with Minirin. One patient incurred postoperative cerebrospinal fluid leakage that was resolved by lumbar drainage. Hypopituitarism occurred in 3 patients, of whom 1 patient developed permanent hypopituitarism that required hormone replacement therapy. There were no patients of death, intracranial hematoma, or meningitis. In conclusion, MTTS is a safe and effective surgical option for pediatric pituitary adenomas with minimal morbidity and excellent outcomes.

Topics: Adenoma; Adolescent; Cerebrospinal Fluid Rhinorrhea; Child; Diabetes Insipidus; Female; Humans; Hypopituitarism; Male; Natural Orifice Endoscopic Surgery; Nose; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Sphenoid Sinus; Treatment Outcome; Vision Disorders

The routine use of intraoperative magnetic resonance imaging (iMRI) helps to achieve gross total resection in transsphenoidal pituitary surgery. We compared the added value of iMRI for extent of resection in endoscopic versus microsurgical transsphenoidal adenomectomy.. A total of 96 patients with pituitary adenoma were included. Twenty-eight consecutive patients underwent endoscopic transsphenoidal tumor resection. For comparison, we used a historic cohort of 68 consecutive patients treated microsurgically. We evaluated the additional resection after conducting iMRI using intraoperative and late postoperative volumetric tumor analysis 3 months after surgery. Demographic data, clinical symptoms, and complications as well as pituitary function were evaluated.. We found significantly fewer additional resections after conducting iMRI in the endoscopic group (P = 0.042). The difference was even more profound in Knosp grade 0-2 adenomas (P = 0.029). There was no significant difference in Knosp grade 3-4 adenomas (P = 0.520). The endoscopic approach was associated with smaller intraoperative tumor volume (P = 0.023). No significant difference was found between both techniques in postoperative tumor volume (P = 0.228). Satisfactory results of pituitary function were significantly more often associated with an endoscopic approach in the multiple regression analysis (P = 0.007; odds ratio, 17.614; confidence interval 95%, 2.164-143.396).. With the endoscopic approach, significantly more tumor volume reduction was achieved before conducting iMRI, decreasing the need for further resection. This finding was even more pronounced in adenomas graded Knosp 0-2. In the case of extensive and invasive adenomas with infiltration of cavernous sinus and suprasellar or parasellar extension, additional tumor resection and increase in the extent of resection was achieved with iMRI in both groups. The endoscopic approach seems to result in better endocrine outcomes, especially in Knosp grade 0-2 pituitary adenomas.

Topics: Adenoma; Adolescent; Adult; Aged; Child; Cohort Studies; Endoscopy; Female; Humans; Male; Microsurgery; Middle Aged; Nose; Pituitary Neoplasms; Sphenoid Bone; Treatment Outcome; Young Adult

To assess outcomes after endoscopic endonasal surgery for recurrent or residual pituitary adenomas.. We retrospectively analyzed 61 patients from 2009 to 2016 who underwent endoscopic endonasal surgery for recurrent or residual pituitary adenomas after previous microscopic or endoscopic transsphenoidal operation.. The previous surgical approach was endoscopic endonasal in 55.7% and microscopic in 44.2% of patients. The mean preoperative maximal tumor diameter was 2.3 cm. Tumor commonly invaded the suprasellar cistern (63.9%). Gross total resection (GTR) was achieved in 31 patients (51.7%). GTR rate was 68.4% and 21.7% for Knosp grade 0-2 and grade 3-4 tumors, respectively (P < 0.001). GTR was 73.1% and 35.3% for patients with previous microscopic and endoscopic transsphenoidal surgery, respectively (P = 0.002). On multivariate analysis, smaller tumor size (odds ratio [OR], 1.1 per cm; P = 0.007), Knosp grade 0-2 (OR, 9.7; P = 0.002), and previous microscopic approach (OR, 12.7; P = 0.007) were independent predictors of GTR. Preoperative visual deficit outcome was improved in 32.5%, unchanged in 62.5%, and worse in 5.0%. New postoperative endocrinopathies included adrenal insufficiency (6.5%), hypothyroidism (8.1%), hypogonadism (6.5%), and diabetes insipidus (4.9%). Complications included postoperative cerebrospinal fluid leak (4.9%), meningitis (1.6%), medical complications (4.9%), and postoperative hematoma requiring re-exploration (3.2%).. The endoscopic endonasal approach provides a safe and effective option for recurrent pituitary adenomas. Smaller tumor size, absence of cavernous sinus invasion, and previous microscopic approach were independent predictors of GTR. This finding might suggest that inadequate exposure or limited viewing angle may adversely affect extent of resection in primary microscopic surgeries.

Topics: Adenoma; Adolescent; Adult; Aged; Aged, 80 and over; Endocrine System; Endoscopy; Female; Follow-Up Studies; Humans; Male; Middle Aged; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Treatment Outcome; Vision Disorders; Young Adult

OBJECT Both endoscopic and microscopic transsphenoidal approaches are accepted techniques for the resection of pituitary adenomas. Although studies have explored patient outcomes for each technique individually, none have prospectively compared sinonasal and quality of life outcomes in a concurrent series of patients at the same institution, as has been done in the present study. METHODS Patients with nonfunctioning adenomas undergoing transsphenoidal surgery were assessed for sinonasal function, quality of life, and pain using the Sino-Nasal Outcome Test-20 (SNOT-20), the short form of the Nasal Obstruction Symptom Evaluation (NOSE) instrument, the SF-36, and a headache scale. Eighty-two patients undergoing either endoscopic (47 patients) or microscopic (35 patients) surgery were surveyed preoperatively and at 24-48 hours, 2 weeks, 4 weeks, 8 weeks, and 1 year after surgery. RESULTS Patients who underwent endoscopic and microscopic transsphenoidal surgery experienced a similar recovery pattern, showing an initial increase in symptoms during the first 2 weeks, followed by a return to baseline by 4 weeks and improvement beyond baseline functioning by 8 weeks. Patients who underwent endoscopic surgery experienced better sinonasal outcomes at 24-48 hours (SNOT total p = 0.015, SNOT rhinologic subscale [ssRhino] p < 0.001), 2 weeks (NOSE p = 0.013), and 8 weeks (SNOT total p = 0.032 and SNOT ssRhino p = 0.035). By 1 year after surgery, no significant differences in sinonasal outcomes were observed between the 2 groups. Headache scales at 1 year improved in all dimensions except duration for both groups (total result 73%, p = 0.004; severity 46%, p < 0.001; frequency 53%, p < 0.001), with 80% of either microscopic or endoscopic patients experiencing improvement or resolution of headache symptoms. Endoscopic and microscopic patients experienced reduced vitality preoperatively compared with US population norms and remained low postoperatively. By 8 weeks after surgery, both groups experienced significant improvements in mental health (13%, p = 0.005) and vitality (15%, p = 0.037). By 1 year after surgery, patients improved significantly in mental health (14%, p = 0.03), role physical (14%, p = 0.036), social functioning (16%, p = 0.009), vitality (22%, p = 0.002), and SF-36 total (10%, p = 0.024) as compared with preoperative measures. There were no significant differences at any time point between the 2 groups for the total SF-36 or for any of the 8 subscales.

Topics: Adenoma; Adult; Aged; Endoscopy; Female; Humans; Male; Middle Aged; Nose; Pituitary Neoplasms; Postoperative Period; Prospective Studies; Sphenoid Bone

Little is known about the long-term effects of either transnasal transsphenoidal endoscopic approach (TTEA) or expanded endonasal approach (EEA). This study assessed the long-term impact of endoscopic skull base surgery on olfaction, sinonasal symptoms, mucociliary clearance time (MCT), and quality of life (QoL). Patients with pituitary adenomas underwent TTEA (n = 38), while patients with other benign parasellar tumours who underwent an EEA with vascularised septal flap reconstruction (n = 17) were enrolled in this prospective study between 2009 and 2012. Sinonasal symptoms (Visual Analogue Scale), subjective olfactometry (Barcelona Smell Test-24, BAST-24), MCT (saccharin test), and QoL (short form SF-36, rhinosinusitis outcome measure/RSOM) were evaluated before, and 12 months after, surgery. At baseline, sinonasal symptoms, MCT, BAST-24, and QoL were similar between groups. Twelve months after surgery, both TTEA and EEA groups experienced smell impairment compared to baseline. Moreover, EEA (but not TTEA) patients reported increased posterior nasal discharge and longer MCTs compared to baseline. No significant changes in olfactometry or QoL were detected in either group 12 months after surgery. Over the long-term, expanded skull base surgery, using EEA, produced more sinonasal symptoms (including loss of smell) and longer MCTs than pituitary surgery (TTEA). EEA showed no long-term impact on smell test or QoL.. IIb.

Topics: Adult; Aged; Aged, 80 and over; Female; Follow-Up Studies; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Prospective Studies; Quality of Life; Skull Base; Time Factors; Treatment Outcome; Young Adult

OBJECTIVE Over the past 2 decades, endoscopy has become an integral part of the surgical repertoire for skull base procedures. The present clinical evaluation and cadaver study compare binostril and mononostril endoscopic transnasal approaches and the surgical techniques involved. METHODS Forty patients with pituitary adenomas were treated with either binostril or mononostril endoscopic surgery. Neurosurgical, endocrinological, ophthalmological, and neuroradiological examinations were performed. Ten cadaver specimens were prepared, and surgical aspects of the preparation and neuroradiological examination were documented. RESULTS In the clinical evaluation, 0° optics were optimal in the nasal and sphenoidal phase of surgery for both techniques. For detection of tumor remnants, 30° optics were superior. The binostril approach was significantly more time consuming than the mononostril technique. The nasal retractor limited maneuverability of instruments during mononostril approaches in 5 of 20 patients. Endocrinological pituitary function, control of excessive hormone secretion, ophthalmological outcome, residual tumor, and rates of adverse events, such as CSF leaks and diabetes insipidus, were similar in both groups. In the cadaver study, there was no significant difference in the time required for dissection via the binostril or mononostril technique. The panoramic view was superior in the binostril group; this was due to the possibility of wider opening of the sella in the craniocaudal and horizontal directions, but the need for removal of more of the nasal septum was disadvantageous. CONCLUSIONS Because of maneuverability of instruments and a wider view in the sphenoid sinus, the binostril technique is superior for resection of large tumors with parasellar and suprasellar expansion and tumors requiring extended approaches. The mononostril technique is preferable for tumors with limited extension in the intra- and suprasellar area.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Cadaver; Endoscopy; Female; Humans; Male; Middle Aged; Nose; Pituitary Gland; Pituitary Neoplasms; Retrospective Studies; Sphenoid Bone; Young Adult

To investigate the role of endoscopic endonasal transsphenoidal surgery and the pseudocapsule in the treatment of growth hormone adenomas.. The study included 43 patients (age range, 21-64 years) with growth hormone adenomas treated with an endoscopic endonasal approach. We compared the tumor characteristics and surgical outcomes of cases with (group A, 21 cases, from November 2013 to January 2015) and without (group B, 22 cases, from October 2011 to October 2013) extra-pseudocapsule resection.. The preoperative demographics, tumor characteristics, and surgical complications were not significantly different between groups A and B. Postoperative remission without adjuvant therapy was achieved in 18 of 21 cases (85.7%) in group A, which was significantly greater than that observed in group B (12 of 22 cases [54.4%]). In group A, the pseudocapsules were verified by endoscopy and histopathology. The pseudocapsule was removed en bloc with the whole adenoma in only 5 cases (23.8%). For the remaining 16 patients (76.2%), following extra-pseudocapsule dissection, incomplete pseudocapsule removals with intracapsule procedures were achieved.. The combination of extra-pseudocapsule resection and endoscopy led to a high rate of gross total tumor resection and endocrinologicl remission in acromegalic patients compared with the group with intracapsular resection. Extra-pseudocapsule resection resulted in no additional postoperative complications.

Topics: Acromegaly; Adenoma; Adult; Female; Follow-Up Studies; Human Growth Hormone; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Neuroendoscopy; Nose; Pituitary Neoplasms; Postoperative Complications; Sphenoid Bone; Tomography, X-Ray Computed; Treatment Outcome; Young Adult

The evolution of skull base surgery over the past decade has been influenced by advancement in visualization technology. Recently, as a result of such improvements, three-dimensional (3-D) scopes have been widely used during endoscopic endonasal approaches. In the present study, we describe the use of 3-D stereoscopic endoscope for the treatment of a variety of skull base lesions.. From January 2010 to June 2015, a 3-D endoscopic endonasal approach (4 and 4.9 mm, 0°, and 30° rigid endoscopes) was performed in 70 patients with the following lesions: 42 large extrasellar pituitary macroadenomas, seven tuberculum sellae meningiomas, seven clivus chordomas, five craniopharyngiomas, three fibrous dysplasia of the clivus, three sinonasal malignancies, one orbital lymphangioma, one trigeminal neurinoma, one primary suprasellar lymphoma.. Total tumor removal was obtained in 50 patients (71.4 %) while in 14 (20 %), subtotal removal was possible in six (8.6 %) only partial removal was achieved. Overall complications included diabetes insipidus in eight patients (11.4 %), hypopituitarism in seven patients (10 %), CSF leak in five patients (7.1 %), cranial nerve injury in two patients (2.8 %), panhypopituitarism in two patients (2.8 %), meningitis in one (1.4 %) and one postoperative central retinal artery occlusion (1.4 %). There was no mortality in the series. The mean follow-up time was 39 months (range, 6-72 months).. In our experience, the 3-D endoscope represents a critical development in visualization, thus enabling improved hand-eye coordination and depth perception, which are mandatory for the management of complex intradural neurovascular structures during tumor removal surgery.

Topics: Adolescent; Adult; Aged; Craniopharyngioma; Female; Humans; Male; Meningeal Neoplasms; Meningioma; Middle Aged; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Complications; Skull Base Neoplasms

Transsphenoidal selective adenectomy is considered the treatment of choice in patients with Cushing's disease given the possibility for high remission and low complication rates. The endoscopic endonasal surgical nuances for Cushing's disease are not well illustrated in the neurosurgical technique and video collections.. We describe the technical nuances of microadenoma resection for two cases of Cushing's disease, one in which the adenoma is visualized on imaging and one in which the pre-operative MRI is negative.. Transsphenoidal endoscopic selective adenectomy is a safe and effective surgery for patients with Cushing's disease regardless of preoperative MRI findings.

Topics: Adenoma; Humans; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary ACTH Hypersecretion; Pituitary Neoplasms; Postoperative Complications

Narrow band imaging (NBI) is an endoscopic technology that enhances the visualization of the superficial and submucosal vasculature. The aim of the present study was to evaluate the feasibility of NBI in visualizing the normal pituitary gland during the endoscopic endonasal removal of pituitary adenoma.. A total of 25 patients with pituitary adenoma underwent endoscopic endonasal transsphenoidal surgery using a rigid endoscope with conventional imaging. The NBI of the surgical field was conducted under air and/or continuous irrigation of artificial cerebrospinal fluid using a flexible videoscope before and/or after the gross removal of the tumor.. The capillaries of the normal pituitary gland had a characteristic appearance that could be confirmed in 16 cases. In contrast, the adenomas exhibited no characteristic vascular enhancement under NBI. The reasons why NBI failed to visualize the pituitary gland included the presence of a blood clot or a certain amount of tumor obscuring the normal pituitary gland and difficulty in steering the videoscope within the sella to approach the assumed site of the residual pituitary gland.. NBI observation during the endoscopic endonasal removal of pituitary adenoma may be useful for visualizing the normal pituitary gland after the gross removal of the tumor. The absence of a typical vascular pattern suggests the presence of a residual tumor, which may justify further exploration in cases where gross total removal is considered necessary.

Topics: Adenoma; Adult; Aged; Female; Humans; Male; Middle Aged; Narrow Band Imaging; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Gland; Pituitary Neoplasms

Endoscopic endonasal surgery to access the anterior skull base has evolved in many centres worldwide and provides a minimally invasive alternative, with better patient experience, to open techniques.. We present a basic approach to a midline lesion that is the fundamental starting point for wider access to the skull base.. The nuances of this technique illustrated here have been developed in many centres to provide a safe procedure that has a low incidence of complications and excellent potential.

Topics: Humans; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Complications

The collection of the greatest possible amount of pathologic tissue is of paramount importance in neurosurgery to achieve the most accurate histopathologic diagnosis, to perform all of the necessary biomolecular tests on the pathologic specimen, and to collect biological material for basic or translational science studies. This problem is particularly relevant in pituitary surgery because of the possible small size and soft consistency of tumors, which make them suitable for removal through suction, reducing the amount of available pathologic tissue. To solve this issue, we adopted a filter connected to the suction tube, which allows the surgeon to collect all of the tissue aspirated during surgery.. Our experience of 1734 endoscopic endonasal procedures, performed adopting this device since 1998 to December 2015, has been revised to assess its advantages and limitations.. This system is easy-to-use, does not impair the surgical maneuvers, and does not add any relevant cost to the surgery. The tissue collected through the filter proved useful for diagnostic histologic and biomolecular analyses and for research purposes, without any relevant artifacts as a result of this method of collection.. The use of a filter has allowed us to obtain the greatest amount possible of pathologic tissue at each surgery. This surgical material has revealed to be helpful both for diagnostic and basic science purposes. The use of the filter has proven to be of particular importance for microadenomas, soft tumors, and supradiaphragmatic or skull base lesions with heterogeneous features, improving the accuracy of histopathologic diagnosis.

Topics: Adenoma; Central Nervous System Cysts; Central Nervous System Neoplasms; Chondrosarcoma; Chordoma; Cranial Fossa, Posterior; Craniopharyngioma; Glioma; Humans; Hypothalamic Neoplasms; Meningeal Neoplasms; Meningioma; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Nose; Pituitary Neoplasms; Plasmacytoma; Retrospective Studies; Skull Base Neoplasms; Suction

The zenith of surgical interest in the cavernous sinus peaked in the 1980s, as evidenced by reports of 10 surgical triangles that could access the contents of the lateral sellar compartment (LSC). However, these transcranial approaches later became marginalized, first by radiosurgery's popularity and lower morbidity, and then by clinical potential of endoscopic corridors noted in several qualitative studies. Our anatomic study, taking a contemporary look at the medial extra-sellar corridor, gives a detailed qualitative-quantitative analysis for its use with increasingly popular endoscopic endonasal approaches to the cavernous sinus.. In 20 cadaveric specimens, we re-examined the anatomic landmarks of the medial corridor into the LSC with qualitative descriptions and measurements. An illustrative case highlights a recurrent symptomatic pituitary adenoma that invaded the cavernous sinus approached through the medial corridor.. The corridor's shape varied from tetrahedron to hexahedron. Comparing right and left sides, width averaged 3.6 ± 4.5 mm and 4.0 ± 4.4 mm, and height averaged 2.3 mm and 2.1 mm, respectively. About 35% of sides showed ample space for access into the cavernous sinus. Our case report of successful outcome lends support for the safety and efficacy of this endoscopic approach.. Our re-examination of this particular surgical access into the LSC refines the understanding of the medial extra-sellar corridor as a main endoscopic access route to this compartment. Achieving safe access to the contents of the LSC, this 11th triangle is clinically relevant and potentially superior for select lesions in this region.

Topics: Adenoma; Adult; Cadaver; Cavernous Sinus; Endoscopy; Female; Humans; Magnetic Resonance Imaging; Nasal Cavity; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Skull Base

To assess the efficacy of the combined use of a gasket seal closure and a vascularized pedicle nasoseptal flap (VP-NSF) multilayered reconstruction technique for high-flow cerebrospinal fluid (CSF) leaks resulting from endonasal endoscopic skull base surgery.. From October 2009-June 2011, a VP-NSF multilayered reconstruction technique was used (single technique group) for patients with intraoperative high-flow CSF leaks; from July 2011-February 2013, a combination of a gasket seal closure and a VP-NSF multilayered reconstruction technique was used (combined technique group). A lumbar drain was placed after the operation. The rates of postoperative CSF leaks and repair-related complications in the 2 groups were analyzed.. The single technique group comprised 18 patients with a mean follow-up of 31.7 months; there were 5 postoperative CSF leaks (27.7%). The combined technique group comprised 15 patients with a mean follow-up of 13.6 months; no CSF leaks occurred (P < 0.05). The rate of intracranial infection in the single technique group was significantly higher than in the combined technique group.. The combined use of a gasket seal closure and a VP-NSF multilayered reconstruction technique for high-flow CSF leaks after endonasal endoscopic skull base surgery may significantly reduce the rates of postoperative CSF leaks and intracranial infections. Lumbar drainage after the operation is a necessary auxiliary method.

Topics: Adult; Aged; Cerebrospinal Fluid Leak; Craniopharyngioma; Drainage; Female; Follow-Up Studies; Humans; Lumbosacral Region; Magnetic Resonance Imaging; Male; Middle Aged; Nasal Septum; Neuroendoscopy; Nose; Pituitary Neoplasms; Plastic Surgery Procedures; Retrospective Studies; Skull Base; Surgical Flaps; Treatment Outcome; Wound Closure Techniques

To report the results of a series of patients undergoing pure endoscopic endonasal pituitary surgery and to evaluate the efficacy and safety of this procedure.. The data of 1,166 patients that underwent endoscopic endonasal transsphenoidal adenoma removal between December 2006 and June 2013 were retrospectively reviewed. Pre- and postoperative hormonal status (3 months after surgery) were analyzed and compared with the clinical parameters originally presented by the patients. The incidences of tumor removal, hormonal control, and tumor removal complications were retrospectively analyzed.. Out of 577 nonfunctioning adenomas, 180 were growth hormone (GH) secreting, 308 prolactin (PRL) secreting, 26 mixed GH/PRL adenomas, 68 adrenocorticotropin secreting, and 7 thyroid-stimulating hormone-secreting adenomas. The gross total removal of pituitary adenomas was achieved in 98 % of microadenomas, 92 % of macroadenomas, and 76 % of giant adenomas. Hormonal control was achieved in 47 (69 %) cases of ACTH adenomas, 119 (66 %) GH adenomas, 262 (85 %) PRL adenomas, and 6 (86 %) TSH adenomas. Postoperative complications were observed in 168 (14.4 %) patients. The most frequent complications were diabetes insipidus (7 %), epistaxis (1.7 %), hyposmia (1.5 %), anterior lobe insufficiency (1.3 %) ,and CSF leaks (0.6 %).. The pure endoscopic approach is a safe, efficacious, and minimally invasive technique for the removal of pituitary adenomas. A higher gross total resection rate is vital for non-functional and functional adenomas. For patients with functional adenomas, while hormonal remission is unlikely to be achieved by surgery, the use of adjuvant therapy is advocated to obtain long-term hormonal control.

Topics: Adenoma; Adult; Female; Follow-Up Studies; Humans; Male; Natural Orifice Endoscopic Surgery; Nose; Pituitary Neoplasms; Retrospective Studies; Sphenoid Sinus; Time Factors; Treatment Outcome

Topics: Adenoma; Female; Humans; Male; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Sphenoid Bone

Novel robots have recently been developed specifically for endonasal surgery. They can deliver several thin, tentacle-like surgical instruments through a single nostril. Among the many potential advantages of such a robotic system is the prospect of telesurgery over long distances.. To describe a phantom pituitary tumor removal done by a surgeon in Nashville, Tennessee, controlling a robot located approximately 800 km away in Chapel Hill, North Carolina, the first remote telesurgery experiment involving tentacle-like concentric tube manipulators.. A phantom pituitary tumor removal experiment was conducted twice, once locally and once remotely, with the robotic system. Robot commands and video were transmitted across the Internet. The latency of the system was evaluated quantitatively in both local and remote cases to determine the effect of the 800-km distance between the surgeon and robot.. We measured a control and video latency of < 100 milliseconds in the remote case. Qualitatively, the surgeon was able to carry out the experiment easily and observed no discernable difference between the remote and local cases.. Telesurgery over long distances is feasible with this robotic system. In the longer term, this may enable expert skull base surgeons to help many more patients by performing surgeries remotely over long distances.

Topics: Aged; Feasibility Studies; Female; Humans; Male; Neuroendoscopy; Nose; Phantoms, Imaging; Pituitary Neoplasms; Robotics; Skull Base; Telemedicine

To avoid disorientation during endoscopic endonasal transsphenoidal surgery (ETSS), the confirmation of anatomical landmarks is essential. Neuronavigation systems can be pointed at exact sites, but their spatial resolution power is too low for the detection of vessels that cannot be seen on MR images. On Doppler ultrasonography the shape of concealed arteries and veins cannot be visualized. To address these problems, the authors evaluated the clinical usefulness of the indocyanine green (ICG) endoscope.. The authors included 38 patients with pituitary adenomas (n = 26), tuberculum sellae meningiomas (n = 4), craniopharyngiomas (n = 3), chordomas (n = 2), Rathke's cleft cyst (n = 1), dermoid cyst (n = 1), or fibrous dysplasia (n = 1). After opening the sphenoid sinus and placing the ICG endoscope, the authors injected 12.5 mg of ICG into a peripheral vein as a bolus and observed the internal carotid arteries (ICAs), cavernous sinus, intercavernous sinus, and pituitary.. The ICA was clearly identified by a strong fluorescence signal through the dura mater and the covering thin bone. The intercavernous and cavernous sinuses were visualized a few seconds later. In patients with tuberculum sellae meningiomas, the abnormal tumor arteries in the dura were seen and the vague outline of the attachment was identified. At the final inspection after tumor removal, perforators to the brain, optic nerves, chiasm, and pituitary stalk were visualized. ICG fluorescence signals from the hypophyseal arteries were strong enough to see and spread to the area of perfusion with the passage of time.. The ICA and the patent cavernous sinus were detected with the ICG endoscope in real time and at high resolution. The ICG endoscope is very useful during ETSS. The authors suggest that the real-time observation of the blood supply to the optic nerves and pituitary helps to predict the preservation of their function.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Brain Neoplasms; Child; Coloring Agents; Female; Fluorescence; Humans; Indocyanine Green; Male; Middle Aged; Neuroendoscopy; Nose; Pituitary Neoplasms; Retrospective Studies; Skull Base Neoplasms; Sphenoid Bone; Young Adult

Despite the increasing application of endoscopic transsphenoidal surgery for pituitary lesions, the prognostic factors that are associated with sinonasal quality of life (QOL) and nasal morbidity are not well understood. The authors examine the predictors of sinonasal QOL and nasal morbidity in patients undergoing fully endoscopic transsphenoidal surgery.. An exploratory post hoc analysis was conducted of patients who underwent endoscopic pituitary surgery and were enrolled in a prospective multicenter QOL study. End points of the study included patient-reported sinonasal QOL and objective nasal endoscopy findings. Multivariate models were developed to determine the patient and surgical factors that correlated with QOL at 2 weeks through 6 months after surgery.. This study is a retrospective review of a subgroup of patients studied in the clinical trial "Rhinological Outcomes in Endonasal Pituitary Surgery" (clinical trial no. NCT01504399, clinicaltrials.gov ). Data from 100 patients who underwent fully endoscopic transsphenoidal surgery were included. Predictors of a lower postoperative sinonasal QOL at 2 weeks were use of nasal splints (p = 0.039) and female sex at the trend level (p = 0.061); at 3 months, predictors of lower QOL were the presence of sinusitis (p = 0.025), advancing age (p = 0.044), and use of absorbable nasal packing (p = 0.014). Health status (multidimensional QOL) was also predictive at 2 weeks (p = 0.001) and 3 months (p < 0.001) and was the only significant predictor of sinonasal QOL at 6 months (p < 0.001). A Kaplan-Meier analysis was performed to study time to resolution of nasal crusting, mucopurulence, and synechia as observed during nasal endoscopy after surgery. The mean time (± SEM) to absence of nasal crusting was 16.3 ± 2.1 weeks, mucopurulence was 6.2 ± 1.1 weeks, and synechia was 4.4 ± 0.5 weeks. Use of absorbable nasal packing was associated with more severe mucopurulence.. Sinonasal QOL following endoscopic pituitary surgery reaches a nadir at 2 weeks and recovers by 3 months postoperatively. Use of absorbable packing and nasal splints, while used in a minority of patients, negatively correlates with early sinonasal QOL. Sinonasal QOL and overall health status are well correlated in the postoperative period, suggesting the important influence of sinonasal QOL on the patient experience.

Topics: Adenoma; Adult; Aged; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Nose; Nose Diseases; Paranasal Sinuses; Pituitary Gland; Pituitary Neoplasms; Quality of Life; Retrospective Studies; Treatment Outcome

To determine the pediatric age groups viable for nasoseptal flap (NSF) reconstruction of endoscopic endonasal approaches (EEA) to intracranial pathology of suprasella neoplasms.. Retrospective cohort study.. Retrospective review of 16 pediatric patients who underwent EEA with NSF reconstruction for a suprasellar defect from 2012 to 2014. Radioanatomic analysis was utilized to assess feasibility of NSF reconstruction of suprasellar neoplasms approached via EEA. Computed tomography (CT) measurements for defect size and potential flap coverage were measured by preoperative maxillofacial CT. Radiographic measurements and surgical outcomes were compared to determine if flap size would be sufficient to cover said defects in two pediatric age groups: those>10 years of age (mean age 14 years) and those<10 years (mean age 6 years).. Of all patients encountered in this cohort, one postoperative cerebrospinal fluid leak was identified in the >10 years of age population, and this was not due to insufficient flap coverage. Average potential flap length and width are sufficient to cover average suprasellar defect length and width in both age groups (P<.05 in all age groups).. Patient selection is critical for successful pediatric EEA. Preoperative radiographic assessment of NSF feasibility is a critical to ensure adequate flap coverage for suprasellar defects. NSF appears to provide a sufficient and reliable coverage option in reconstruction of suprasellar defects in pediatric patients.. 4.

Topics: Adolescent; Cerebrospinal Fluid Leak; Child; Cohort Studies; Craniopharyngioma; Endoscopy; Humans; Nasal Septum; Nose; Pituitary Neoplasms; Plastic Surgery Procedures; Postoperative Complications; Retrospective Studies; Skull Base Neoplasms; Surgical Flaps; Tomography, X-Ray Computed

We describe a supra-diaphragmatic ectopic pituitary adenoma that was safely removed using the extended endoscopic endonasal approach, and discuss the value of three-dimensional (3D) endoscopy and intra-operative magnetic resonance imaging (MRI) to this type of procedure. A 61-year-old-man with bitemporal hemianopsia was referred to our hospital, where MRI revealed an enhanced suprasellar tumor compressing the optic chiasma. The tumor extended on the planum sphenoidale and partially encased the right internal carotid artery. An endocrinological assessment indicated normal pituitary function. The extended endoscopic endonasal approach was taken using a 3D endoscope in the intraoperative MRI suite. The tumor was located above the diaphragma sellae and separated from the normal pituitary gland. The pathological findings indicated non-functioning pituitary adenoma and thus the tumor was diagnosed as a supra-diaphragmatic ectopic pituitary adenoma. Intra-operative MRI provided useful information to minimize dural opening and the supra-diaphragmatic ectopic pituitary adenoma was removed from the complex neurovascular structure via the extended endoscopic endonasal approach under 3D endoscopic guidance in the intra-operative suite. Safe and effective removal of a supra-diaphragmatic ectopic pituitary adenoma was accomplished via the extended endoscopic endonasal approach with visual information provided by 3D endoscopy and intra-operative MRI.

Topics: ACTH Syndrome, Ectopic; Adenoma; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Nose; Pituitary Neoplasms

To assess the effectiveness of continuous lumbar drainage (LD) for management of postoperative cerebrospinal fluid leaks after endoscopic endonasal transsphenoidal approach for resection of pituitary adenoma. Three hundred eighty-four medical records of patients who were admitted to our institute during a 2.5-year period were retrospectively reviewed, 33 of them experienced low-flow cerebrospinal fluid leak postoperatively. If LD was used, all patients with low-flow cerebrospinal fluid leak were classified into 2 groups, lumbar drained group and conservatively treated group. The age, sex, management of cerebrospinal fluid leaks, and related complications were reviewed. Statistical comparisons between the 2 groups were made using SPSS 19.0 (IBM Corp, Armonk, NY). The differences were considered statistically significant if the P value was less than 0.05.Thirty-three of 384 (8.6%) experienced low-flow postoperative cerebrospinal fluid leaks. Cured rate of cerebrospinal fluid leak was 94.4% (17/18) in continuous lumbar drained group, and 93.3% (14/15) in control group. There were 2 (11.2%) patients who developed meningitis in the LD group and 1 (5.6%) patient in the control group. One patient required endoscopic repair of skull base because of persistent cerebrospinal fluid leak in both groups, with the rates of 5.6% and 6.7%, respectively. There was no significant difference noted in each rate in both groups.Placement of LD may not be necessary for the management of low-flow postoperative cerebrospinal fluid leak after using endoscopic endonasal transsphenoidal approach to pituitary adenoma.

Topics: Adenoma; Adult; Aged; Cerebrospinal Fluid Leak; Drainage; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Nose; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Young Adult

To analyze the safety and efficacy of surgical removal of recurrent or regrowing pituitary adenomas by endoscopic endonasal transsphenoidal approach.. The clinical data were retrospectively reviewed for 28 patients undergoing endoscopic endonasal transsphenoidal surgery for recurrent or regrowing pituitary adenomas between April 2010 and December 2013. There were 9 males and 19 females with a mean age of 44. 2 (11 - 73) years. The maximal tumor diameter ranged from 2. 1 to 6.9 cm. The Knosp grades were 1 -2 (n = 11), 3 (n =8) and 4 (n =9). Fifteen tumors were endocrinically functional and the remainder endocrinically nonfunctional. All operations were performed with an assistance of intraoperative neuronavigation. Neuro-ophthalmological, neuroimaging and endocrinological results were followed up postoperatively. And surgical outcomes and risk factors were analyzed for incomplete tumor resection in previous operations.. The mean follow-up period was 19. 1 (3 - 45) months. Gross total resection(n = 18, 64. 3%), subtotal resection(n = 6, 21. 4%) and partial resection(n = 4, 14. 3%) were achieved. Postoperatively, visual acuity improved in 11 patients (73. 3%) and 6 patients (40. 0%) showed endocrine remission. Qne patient had short-term postoperative leakage of cerebrospinal fluid (CSF).. Endoscopic endonasal transsphenoidal surgery is both safe and effective for recurrent or regrowing pituitary adenomas.

Topics: Adenoma; Adolescent; Adult; Aged; Child; Female; Humans; Laryngoscopy; Male; Middle Aged; Neuroimaging; Neuronavigation; Nose; Pituitary Neoplasms; Postoperative Complications; Postoperative Period; Recurrence; Retrospective Studies; Treatment Outcome; Young Adult

To explore the efficacies of neuronavigation-guided pure endoscopic endonasal transsphenoidal approach for removing pituitary adenomas.. Retrospective analyses were conducted for the clinical data of 139 patients undergoing pure endoscopic endonasal transsphenoidal surgery for pituitary adenomas between July 2011 and July 2014. There were 55 males and 84 females with a mean age of 48. 9 (21 - 73) years. The classifications of Hardy-Wilson were I (n =16), II (n = 39), III (n = 48) and IV (n = 36). Neuronavigation was used in all patients. And neuro-ophthalmological, neuroimaging and endocrinological follow-ups were conducted postoperatively.. Total (n = 95, 68. 3%), subtotal (n = 33, 23. 7%) and partial (n = 11, 7. 9%) removals were achieved. For Hardy-Wilson I, gross total removal was achieved (n = 16, 100%); Hardy-Wilson II (n = 35, 89. 7%), Hardy-Wilson III (n = 34, 70. 8%) and Hardy-Wilson IV (n = 10, 27. 8%). Postoperative visual acuity improved (92. 1%, 70/76) and endocrine remission was observed (59. 6%, 53/89). The postoperative complications included cerebrospinal fluid (CSF) leakage (n = 8, 5. 8%), meningitis (n = 3), sellar hematoma (n = 5) and delayed carotid artery rupture (n = 1). And the patient of hemorrhagic shock underwent emergency interventional procedures and was discharged successfully.. Pure endoscopic endonasal transsphenoidal approach for removing pituitary adenoma is both safe and effective. And its efficacies may further increased through combined neuronavigation.

Topics: Adenoma; Adult; Aged; Cerebrospinal Fluid Leak; Female; Humans; Laryngoscopy; Male; Middle Aged; Neuroimaging; Neuronavigation; Nose; Pituitary Neoplasms; Postoperative Complications; Postoperative Period; Retrospective Studies; Young Adult

To analyze the clinical and imaging characteristics of patients with cystic lesions in sella region and to describe the experience of endoscopic transsphenoidal surgery.. Fourty-six cases of cystic lesions in sella region confirmed by surgery and pathology between June 2003 and September 2013 were retrospectively analysed. The clinical features, imaging, surgical technique and postoperative recurrence in 46 cases were presented.. All lesions were resected through transsphenoidal endoscopic endonasal approach. Followed up lasted from 6 months to 6 years. Postoperatively, headache was recovered in 26 cases and wasn't recovered in 8 cases, visual was improved in 12 cases and wasn't improved in 2 cases, hypopituitarism was relieved in 18 cases and wasn't relieved in 15 cases, polyuria was disappeared in 8 cases and wasn't disappeared in 4 cases. Seven cases recurred, including 4 cases of craniopharyngioma, 2 cases of pituitary abscess, 1 case of cystic adenoma. There were no death and serious complication. The small age of onset, visual acuity and visual field symptoms, tumor in suprasellar, third ventricle compression was easy to occur in craniopharyngioma; cystic tumor, cavernous sinus invasion, the solid part homogeneous enhancement could be seen in cystic adenoma; Rathke cyst showed simple cystic, lighter clinical symptoms and a short course. Prone to diabetes insipidus, low multiple hormone level and the lesions of annular enhancement was more common in pituitary abscess.. The clinical features and imaging of cystic lesions in sella region feature overlap each other, but there are certain specificity. Transsphenoidal endoscopic endonasal approach for the surgery of cystic lesions in sella is effective and safe.

Topics: Abscess; Adenoma; Craniopharyngioma; Cysts; Endoscopy; Headache; Humans; Hypopituitarism; Neoplasm Recurrence, Local; Nose; Pituitary Diseases; Pituitary Neoplasms; Retrospective Studies; Sella Turcica

The purpose of this study was to examine the current indications for transsphenoidal surgery in the prolactinoma patient population, and to determine the outcomes of patients who undergo such operations. Transsphenoidal surgery may be indicated in prolactinoma patients who are resistant and/or intolerant to dopamine agonist (DA) therapy. We performed a retrospective review of the medical records of prolactinoma patients over a 6 year period (April 2008 to April 2014) at a large volume academic center. The median follow-up time was 12.0 months (range: 3-69). All patients who were included in the study (n=66) were treated with DA therapy and subsequently underwent an endonasal transsphenoidal operation. Of the 66 patients, 44 were women (mean age 34.2 years) and 22 were men (mean 41.7 years). There were 29 (43.9%) intolerant patients and 29 (43.9%) resistant patients. Postoperatively, 18 intolerant patients (66.7%) had normalized prolactin levels without the need for DA therapy, and five (17.2%) required DA to normalize their prolactin levels (p=0.02). Six patients (20.6%) had persistently elevated prolactin levels but were no longer receiving DA treatment (p<0.001). Postoperatively, 10 resistant patients (35.7%) had normal prolactin levels without DA therapy, and seven patients (25%) were treated with DA therapy to normalize their prolactin levels (p=0.22). Eight patients (28.6%) had supraphysiologic prolactin levels but were no longer taking a DA (p<0.001). Three patients (10.7%) were hyperprolactinemic, despite postoperative treatment with DA (p<0.001). After an appropriate treatment interval with multiple DA, radiographic follow-up, and careful clinical evaluation, prolactinoma patients can be offered surgery as an effective therapeutic option.

Topics: Adult; Aged; Aged, 80 and over; Dopamine Agonists; Female; Follow-Up Studies; Humans; Male; Middle Aged; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Period; Prolactinoma; Retrospective Studies; Sphenoid Sinus

To evaluate the safety and efficacy of the endoscopic endonasal transsphenoidal approach (EETA) for nonfunctioning pituitary adenoma (NFPA) in the elderly population.. We performed a retrospective review of operative cases over a 7-year period, in which 158 elderly patients (age 65 years and older) who underwent a pure EETA to remove a pituitary adenoma were identified and compared with a series of 155 younger patients (age 40-55 years) who underwent the same procedure during the same period. The medical charts of the patients were reviewed to collect demographic information, such as age, sex, clinical symptoms, tumor size, the extent of tumor resection, clinical outcome, and complications.. In the elderly group, total resection was achieved in 120 patients (75.9%), and 124 patients (78.5%) achieved significant postsurgical visual remission. In the younger group, total resection was achieved in 119 patients (76.8%), with 126 patients (81.2%) achieving significant postsurgical visual remission. Regarding surgical complications in the elderly group, transient diabetes insipidus occurred postoperatively in 28 (17.8%) patients, and permanent diabetes insipidus occurred in 7 (4.4%) patients. Six (6.4%) patients experienced postoperative cerebrospinal fluid leakage, and new developments of anterior hypopituitarism occurred in 15 (9.5%) cases. In the younger group, 21 (13.6%) patients developed transient diabetes insipidus postoperatively, and 5 (3.2%) patients experienced permanent diabetes insipidus. Six (3.9%) patients reported postoperative cerebrospinal fluid leaks, and 13 (8.4%) patients developed a new anterior hypopituitarism. There were no cases of either carotid artery injury or death in either group. During the follow-up (mean, 32 months), 11 (6.9%) patients experienced tumor recurrence in the elderly group compared with 24 (15.5%) patients in the younger group. Of the 15 elderly patients who developed new hypopituitarism, 13 (86.7%) recovered without hormone replacement; accordingly, the rate of hypopituitarism remission was 84.6% in the younger patients.. NFPAs in the elderly can be resected via a pure endoscopic technique with low morbidity and mortality.

Topics: Adenoma; Adult; Aged; Aging; Cerebrospinal Fluid Leak; Diabetes Insipidus; Female; Hormone Replacement Therapy; Humans; Hypopituitarism; Incidence; Male; Middle Aged; Neuroendoscopy; Nose; Pituitary Neoplasms; Retrospective Studies; Sphenoid Sinus; Treatment Outcome

Endoscopic endonasal (transnasal) transsphenoidal approach (EETA) for management of sellar lesions has gained popularity as a reliable and atraumatic method. Most reported studies of EETA have focused on surgical outcome in adult patients; and there are few reports to describe outcome in pediatric patients. The authors report our early experience of 11 patients aged 14 to 18 years managed with EETA to evaluate the safety and effectiveness of EETA in the pediatric.. Retrospective review of hospital records of 11 pediatric patients who underwent endonasal endoscopic transsphenoidal approach for resection of sellar region lesion over 2 years. Age, sex, symptoms, tumor size, extent of tumor resection, clinical outcome, and surgical complications were reviewed.. Total resection was achieved in 9 (81.8%) patients, subtotal resection in 2 (18.2%), and no patient had partial or insufficient resection. All (100%) patients achieved visual remission, 7 (87.5%) of 8 patients with hyperhormone preoperative had endocrinological remission. Two (18.2%) patients incurred temporary diabetes insipidus (DI) postoperatively. One (9.1%) patient incurred postoperative cerebrospinal fluid (CSF) leakage which resolved following lumbar drainage. Three (27.3%) patients developed hypopituitarism needed hormone replacement therapy. There were no cases of meningitis, intracranial hematoma, or death.. Endoscopic endonasal (transnasal) transsphenoidal approach (EETA) provides a safe and effective surgical option with low morbidity and mortality in pediatric patients.

Topics: Adolescent; Cerebrospinal Fluid Leak; Cohort Studies; Diabetes Insipidus; Female; Follow-Up Studies; Humans; Hypopituitarism; Male; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Complications; Remission Induction; Retrospective Studies; Safety; Spinal Puncture; Treatment Outcome

Surgical approaches to the pituitary have undergone numerous refinements over the last 100 years. The fully endoscopic transsphenoidal approach has gained widespread use all around the world. We report the results of a consecutive series of patients who underwent pituitary surgery using a pure endoscopic endonasal approach and the results of the evaluation of the efficacy and safety of this procedure.. We retrospectively reviewed the hospital database of 80 consecutive pituitary adenomas that were resected with the purely endoscopic endonasal transsphenoidal technique.. The preoperative clinical condition of the patients, hormone profile, visual field, computed tomography and magnetic resonance imaging findings, and the Hardy-Vezina and Knosp scores were evaluated and revealed the importance of the parameters for surgery. Surgical technique, postoperative clinical condition of the patients, hormone profile, complications and follow-up period were reviewed.. Endonasal endoscopic pituitary surgery is a safe and effective surgical technique.

Topics: Adenoma; Adult; Aged; Female; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Neuroendoscopy; Nose; Pituitary Gland; Pituitary Neoplasms; Retrospective Studies; Tomography, X-Ray Computed; Treatment Outcome; Young Adult

Although the value of early MR imaging has been justified for microscopic transphenoidal surgery, there is no literature evaluating immediate postoperative MR imaging following endoscopic endonasal resection of pituitary adenomas. We hypothesized that MRI of the pituitary gland performed on the first postoperative day is just as effective at detecting residual disease and/or reconstruction materials as the MRI at 3 months following surgery.. We retrospectively evaluated 102 consecutive patients who underwent endoscopic endonasal surgery for presumed pituitary adenomas. Sixty-four patients met the inclusion criteria with immediate and 3 months MR imaging. Imaging was evaluated by two sets of observers. The following parameters were assessed: enhancement pattern of the pituitary gland, pituitary stalk, nodular enhancement (residual tumor) or linear enhancement (non-tumoral) and residual reconstruction/packing materials.. Gross total resection of the tumors with no cavernous sinus involvement was achieved in 49 out of 52 (94%) patients. Eleven out of 12 remaining patients with cavernous sinus invasion had residual cavernous sinus component visible on both immediate and 3 month MR imaging. The pituitary gland, position of stalk, and nasoseptal flap could be identified on both post-operative MRIs in all patients. The sensitivity and specificity for residual tumor detection on immediate MRI was 100% and 97.9%, respectively. The kappa index evaluating interobserver agreement for identification of residual tumor and packing/reconstruction material on immediate MR was 0.83 and 0.72 indicating near perfect and substantial agreement, respectively.. Immediate MR imaging performed following endoscopic endonasal resection of pituitary lesions provides accurate and reliable information regarding the presence of residual tumor compared to reconstruction and packing materials.

Topics: Adenoma; Endoscopy; Humans; Magnetic Resonance Imaging; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Period; Retrospective Studies; Time Factors

This paper discusses a new class of robots known as concentric tube robots and their application to transnasal skull base surgery. The endonasal approach has clear benefits for patients, but the surgery presents challenges that strongly motivate the use of robotic tools. In this paper, the concentric tube robot concept is described, and preliminary experimental results for transnasal skull base surgery are reviewed. Just as the da Vinci robot has revolutionized many laparoscopic surgeries, we expect concentric tube robots will enable the advancement of skull base surgery and the development of other minimally invasive procedures that require access through constrained paths.

Topics: Clinical Trials as Topic; Humans; Needles; Nose; Pituitary Neoplasms; Robotics; Skull Base; Surgery, Computer-Assisted

Resection of the cavernous sinus (CS) lesions has been a surgical challenge because the anatomy of the CS presents a high grade of complexity. This report describes the feasibility of the purely endoscopic endonasal approach to the CS. Twenty-five patients with intracavernous sinus tumors were treated with a purely endoscopic endonasal approach. The indications, efficacy, surgical techniques, and complications of this approach were discussed. Gross total resection occurred in 19 cases (76%), subtotal resection occurred in 2 cases (8%), and partial resection occurred in 4 cases (16%) including pituitary adenoma in 10 cases (total 70%; subtotal 10%; partial 20%), meningioma in 6 cases (total 66.6%; subtotal 16.7%, partial 16.7%), schwannoma in 5 cases (100%, total 5), malignant tumor in 4 cases (total 75%; subtotal 25%). All patients experienced resolution or improvement of symptoms. No patient experienced intraoperative complication and new neurological deficit. Only 1 case of postoperative cerebrospinal fluid leakage repaired via endoscopic endonasal approach on the 14th day after the surgery. The purely endoscopic endonasal approach to the CS in appropriately evaluated patients can be used to address a wide variety of benign and malignant tumor pathology with favorable outcomes and a low incidence of complications.

Topics: Adenoma; Adult; Aged; Cavernous Sinus; Feasibility Studies; Female; Follow-Up Studies; Humans; Male; Maxillary Sinus; Meningeal Neoplasms; Meningioma; Middle Aged; Natural Orifice Endoscopic Surgery; Neurilemmoma; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Complications; Skull Base Neoplasms; Treatment Outcome; Young Adult

In the past 10 years, endoscopic resection of pituitary adenomas has become an alternative to microsurgical resection with the additional advantage of increasing the patient's postoperative comfort. This analysis explored whether endoscopic resection can reduce the risk of postoperative neurohypophyseal dysfunction.. We rated and compared the need to administer desmopressin during the first four postoperative days and with the need after a follow-up of at least 3 months (chronic administration).. Three groups of patients were compared: Patients in group 1 were operated on microscopically. Patients in group 2 were operated on endoscopically. Patients in group 3 were operated on endoscopically with intraoperative magnetic resonance imaging (iMRI).. Group 1 was made up of 50 patients treated in 1999; group 2 comprised 50 patients operated on from 2006 to 2007; and Group 3 comprised 50 patients operated on in 2008.. In group 1 the need to use desmopressin postoperatively occurred in eight patients; three needed chronic treatment. In group 2 the need for postoperative application of desmopressin occurred in four patients; none required chronic treatment. In group 3 desmopressin had to be administered postoperatively in five patients but only temporarily.. Endoscopic surgery is a safe and effective method for the resection of pituitary adenomas. The rate of chronic desmopressin application was reduced. In conjunction with iMRI and navigation, the endoscopic technique allows increased radicality together with fewer adverse effects.

Topics: Adenoma; Female; Humans; Male; Middle Aged; Monitoring, Intraoperative; Natural Orifice Endoscopic Surgery; Nose; Pituitary Gland, Posterior; Pituitary Neoplasms; Treatment Outcome

OBJECT.: While the use of endoscopic approaches has become increasingly accepted in the resection of pituitary adenomas, limited evidence exists regarding the success of this technique for patients with large and giant pituitary adenomas. This study reviews the outcomes of a large cohort of patients with large and giant pituitary adenomas who underwent endoscopic endonasal transsphenoidal surgery at the authors' institution and focuses on identifying factors that can predict extent of resection and hence aid in developing guidelines and indications for the use of endoscopic endonasal transsphenoidal surgery versus open craniotomy approaches to large and giant pituitary adenomas.. The authors reviewed 487 patients who underwent endoscopic endonasal transsphenoidal resection of sellar masses. From this group, 73 consecutive patients with large and giant pituitary adenomas (defined as maximum diameter ≥ 3 cm and tumor volume ≥ 10 cm(3)) who underwent endoscopic endonasal transsphenoidal surgery between January 1, 2006, and June 6, 2012, were included in the study. Clinical presentation, radiological studies, laboratory investigations, tumor pathology data, clinical outcomes, extent of resection measured by volumetric analysis, and complications were analyzed.. The mean preoperative tumor diameter in this series was 4.1 cm and the volume was 18 cm(3). The average resection rate was 82.9%, corresponding with a mean residual volume of 3 cm(3). Gross-total resection was achieved in 16 patients (24%), near-total in 11 (17%), subtotal in 24 (36%), and partial in 15 (23%). Seventy-three percent of patients experienced improvement in visual acuity, while 24% were unchanged. Visual fields were improved in 61.8% and unchanged in 5.5%. Overall, 27 patients (37%) experienced a total of 32 complications. The most common complications were sinusitis (14%) and CSF leak (10%). Six patients underwent subsequent radiation therapy because of aggressive tumor histopathology. No deaths occurred in this cohort of patients. Statistically significant predictors of extent of resection included highest Knosp grade (p = 0.001), preoperative tumor volume (p = 0.025), preoperative maximum tumor diameter (p = 0.002), hemorrhagic component (p = 0.027), posterior extension (p = 0.001), and sphenoid sinus invasion (p = 0.005).. Endoscopic endonasal transsphenoidal surgery is an effective treatment method for patients with large and giant pituitary adenomas, which results in high (> 80%) rates of resection and improvement in visual function. It is not associated with high rates of major complications and is safe when performed by experienced surgeons. The preoperative Knosp grade, tumor volume, tumor diameter, hemorrhagic components on MRI, posterior extension, and sphenoid sinus invasion may allow a prediction of extent of resection and in these patients a staged operation may be required to maximize extent of resection.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Retrospective Studies; Sphenoid Bone; Treatment Outcome; Young Adult

Despite their benign histological appearance, craniopharyngiomas can be considered a challenge for the neurosurgeon and a possible source of poor prognosis for the patient. With the widespread use of the endoscope in endonasal surgery, this route has been proposed over the past decade as an alternative technique for the removal of craniopharyngiomas.. The authors retrospectively analyzed data from a series of 103 patients who underwent the endoscopic endonasal approach at two institutions (Division of Neurosurgery of the Università degli Studi di Napoli Federico II, Naples, Italy, and Division of Neurosurgery of the Bellaria Hospital, Bologna, Italy), between January 1997 and December 2012, for the removal of infra- and/or supradiaphragmatic craniopharyngiomas. Twenty-nine patients (28.2%) had previously been surgically treated.. The authors achieved overall gross-total removal in 68.9% of the cases: 78.9% in purely infradiaphragmatic lesions and 66.3% in lesions involving the supradiaphragmatic space. Among lesions previously treated surgically, the gross-total removal rate was 62.1%. The overall improvement rate in visual disturbances was 74.7%, whereas worsening occurred in 2.5%. No new postoperative defect was noted. Worsening of the anterior pituitary function was reported in 46.2% of patients overall, and there were 38 new cases (48.1% of 79) of postoperative diabetes insipidus. The most common complication was postoperative CSF leakage; the overall rate was 14.6%, and it diminished to 4% in the last 25 procedures, thanks to improvement in reconstruction techniques. The mortality rate was 1.9%, with a mean follow-up duration of 48 months (range 3-246 months).. The endoscopic endonasal approach has become a valid surgical technique for the management of craniopharyngiomas. It provides an excellent corridor to infra- and supradiaphragmatic midline craniopharyngiomas, including the management of lesions extending into the third ventricle chamber. Even though indications for this approach are rigorously lesion based, the data in this study confirm its effectiveness in a large patient series.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cerebrospinal Fluid Rhinorrhea; Child; Child, Preschool; Craniopharyngioma; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Retrospective Studies; Treatment Outcome; Young Adult

Topics: Adenoma; Cerebrospinal Fluid Rhinorrhea; Humans; Intraoperative Period; Neuroendoscopy; Nose; Pituitary Neoplasms; Postoperative Period; Sphenoid Bone

Pituitary adenomas account for approximately 15% of intracranial benign tumors. The neurosurgical results achieved since the endoscopic endonasal transsphenoidal (EET) approach was introduced in our center in 2005 are reported here.. A retrospective analysis of 121 patients with sellar lesions (58% females, age 55.7 ± 16 years, range 18-82) who underwent EET surgery from February 2005 to January 2012 and were followed up for a mean time of 4.58 years (range 1.08-8.58).. Six Rathke cleft cysts (3 intra-suprasellar, 1 intrasellar, 2 suprasellar); 114 pituitary adenomas (16 microadenomas, 98 macroadenomas), and 1 case of normal MRI were included. Baseline findings included hormonal changes in 59 patients (48,7%) and visual field changes in 38 patients (31%); in 7 patients (5.8%), clinical presentation was pituitary apoplexy. Complete resection was achieved in 77 patients (63.6%), subtotal resection in 29 (23.9%), and partial resection in 15 (12.3%). In patients with Grade 3 and 4 cavernous sinus invasion, resection was subtotal in 30% (12/39) and complete in 46% (18/39). Hormonal remission was achieved in 16 patients with Cushing disease (84%), 18 patients with prolactinoma (78.2%), and 18 patients with acromegaly (85,7%). There were 12 cases (9%) of cerebrospinal fluid leak, 4 cases of diabetes insipidus, and 3 cases with transient SIADH/hyponatremia. Seven patients developed panhypopituitarism. Postoperative mortality rate was 2.4%. One hundred and three patients (85.3%) were discharged from the hospital less than 48 hours after surgery.. Our results are similar to those reported by renowned pituitary units. Results achieved using an endoscopic approach in pituitary neurosurgery are better than those of microneurosurgery for cavernous sinus invasion.

Topics: Adenoma; Adolescent; Adult; Aged; Aged, 80 and over; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Retrospective Studies; Treatment Outcome; Young Adult

The aim of this study was to evaluate the effectiveness of the extended endoscopic endonasal transsphenoidal approach (TSA) for recurrent or residual craniopharyngiomas, focusing on the extent of tumor resection and complications resulting from surgery at a single institution.. Twelve adult patients (six men and six women) underwent extended endoscopic endonasal TSA for a recurrent or residual craniopharyngioma after a previous surgical intervention at a single institution by a single surgeon. The mean number of surgeries patients had undergone before TSA was 1.3 (range, 1-3). The mean period between patients' most recent surgery and extended TSA was 55.9 months (range, 1-184). The mean preoperative (that is, pre-extended TSA) tumor volume was 2.87 cm³. The mean follow-up period was 15.8 months (range, 4-32). We reviewed clinical and radiological features in each case, focusing on the degree of tumor resection as well as endocrinological and ophthalmological outcomes.. Gross total resection was achieved in ten patients (83.3 %), and the mean resection rate was 87 % in the other two cases. There were no significant differences between pre- and postoperative endocrine function, except in one patient who suffered postoperative panhypopituitarism resulting in pituitary stalk resection, which was necessary because of obvious tumor involvement. Three patients suffered transient diabetic insipidus (DI). With respect to ophthalmological outcomes, three patients showed improvement, two others showed decline, and the remainder showed no significant changes.. The extended endoscopic endonasal transsphenoidal approach is an effective and safe surgical approach for treating recurrent or residual craniopharyngioma.

Topics: Adult; Craniopharyngioma; Female; Humans; Hypopituitarism; Male; Middle Aged; Neuroendoscopy; Neurosurgical Procedures; Nose; Pituitary Gland; Pituitary Neoplasms; Postoperative Period; Recurrence; Treatment Outcome; Tumor Burden

We describe a modification of the combined transseptal/transnasal binostril approach using a two-surgeon, four-handed technique (modified Stamm's approach) for pituitary lesions in patients with narrow nasal spaces. This approach comprises of a transseptal route through one nostril and a transnasal route without harvesting a pedicled nasoseptal flap (NSF) through the other. On the transseptal side, the nasal septum was removed using an endoscopic septoplasty technique. On the transnasal side, the mucosa containing the septal branch of the sphenopalatine artery over the face of the sphenoid and nasal septum was preserved for harvesting the NSF if an intraoperative cerebrospinal fluid leak was encountered. This approach was performed in six patients with pituitary lesions, including four non-functioning macroadenomas, one growth hormone-producing macroadenoma, and one Rathke's cleft cyst, all of which were associated with a severe deviation of the nasal septum and/or narrow nasal space. The meticulous and comfortable manipulation of an endoscope and instruments were achieved in all six patients without surgical complications. Our findings, although obtained in a limited number of cases, suggest that the modified Stamm's approach may be useful for selected patients, particularly those with a severe deviation of the nasal septum, without considerable damage to the nasal passages.

Topics: Adenoma; Adult; Central Nervous System Cysts; Cooperative Behavior; Endoscopy; Female; Hand-Assisted Laparoscopy; Humans; Interdisciplinary Communication; Male; Middle Aged; Nasal Septum; Nose; Pituitary Neoplasms; Postoperative Care; Sphenoid Sinus; Surgical Flaps

The interpeduncular cistern, including the retrochiasmatic area, is one of the most challenging regions to approach surgically. Various conventional approaches to this region have been described; however, only the endoscopic endonasal approach via the dorsum sellae and the transpetrosal approach provide ideal exposure with a caudal-cranial view. The authors compared these 2 approaches to clarify their limitations and intrinsic advantages for access to the interpeduncular cistern.. Four fresh cadaver heads were studied. An endoscopic endonasal approach via the dorsum sellae with pituitary transposition was performed to expose the interpeduncular cistern. A transpetrosal approach was performed bilaterally, combining a retrolabyrinthine presigmoid and a subtemporal transtentorium approach. Water balloons were used to simulate space-occupying lesions. "Water balloon tumors" (WBTs), inflated to 2 different volumes (0.5 and 1.0 ml), were placed in the interpeduncular cistern to compare visualization using the 2 approaches. The distances between cranial nerve (CN) III and the posterior communicating artery (PCoA) and between CN III and the edge of the tentorium were measured through a transpetrosal approach to determine the width of surgical corridors using 0- to 6-ml WBTs in the interpeduncular cistern (n = 8).. Both approaches provided adequate exposure of the interpeduncular cistern. The endoscopic endonasal approach yielded a good visualization of both CN III and the PCoA when a WBT was in the interpeduncular cistern. Visualization of the contralateral anatomical structures was impaired in the transpetrosal approach. The surgical corridor to the interpeduncular cistern via the transpetrosal approach was narrow when the WBT volume was small, but its width increased as the WBT volume increased. There was a statistically significant increase in the maximum distance between CN III and the PCoA (p = 0.047) and between CN III and the tentorium (p = 0.029) when the WBT volume was 6 ml.. Both approaches are valid surgical options for retrochiasmatic lesions such as craniopharyngiomas. The endoscopic endonasal approach via the dorsum sellae provides a direct and wide exposure of the interpeduncular cistern with negligible neurovascular manipulation. The transpetrosal approach also allows direct access to the interpeduncular cistern without pituitary manipulation; however, the surgical corridor is narrow due to the surrounding neurovascular structures and affords poor contralateral visibility. Conversely, in the presence of large or giant tumors in the interpeduncular cistern, which widen the spaces between neurovascular structures, the transpetrosal approach becomes a superior route, whereas the endoscopic endonasal approach may provide limited freedom of movement in the lateral extension.

Topics: Craniopharyngioma; Humans; Interpeduncular Nucleus; Nose; Pituitary Neoplasms; Sella Turcica

Endoscopic expanded endonasal approaches (EEAs) to the skull base are increasingly being used to address a variety of skull base pathologies. Postoperative CSF leakage from the large skull base defects has been well described as one of the most common complications of EEAs. There are reports of associated formation of delayed subdural hematoma and tension pneumocephalus from approximately 1 week to 3 months postoperatively. However, there have been no reports of immediate complications of high-volume CSF leakage from EEA skull base surgery. The authors describe two cases of EEAs in which complications related to rapid, large-volume CSF egress through the skull base surgical defect were detected in the immediate postoperative period. Preventive measures to reduce the likelihood of these immediate complications are presented.

Topics: Adenoma; Aged; Aged, 80 and over; Cerebrospinal Fluid Leak; Endoscopy; Female; Humans; Magnetic Resonance Imaging; Male; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Complications; Skull Base; Tomography Scanners, X-Ray Computed

Topics: Endoscopy; Humans; Natural Orifice Endoscopic Surgery; Nose; Pituitary Neoplasms; Quality of Life; Sphenoid Sinus

To evaluate the feasibility of reaching the interpeduncular cistern (IC) through an endoscopic endonasal approach that leaves the pituitary gland in place.. In a series of 10 injected cadaver heads, the transtuberculum ("above") and transclival ("below") approaches were combined, without pituitary transposition. Using 0-degree, 30-degree, and 45-degree endoscopes, the extent of overlap and if a blind spot occurred were determined. Also, the visualization of the IC was compared with the transposition of the pituitary gland approach. Nonparametric statistics were used to evaluate the results. The approach was implemented in 2 patients.. For both the "above" and "below" views, there was a statistically significant increase in field of view when comparing the 0-degree endoscope with either the 30-degree endoscope (P < 0.05) or the 45-degree endoscope (P < 0.05). There was no difference between the 30-degree endoscope and the 45-degree endoscope (P > 0.05) in the "below" approach, but there was a difference (P < 0.05) in the "above" approach. There was no blind spot with any combination of endoscopes. There was no practical statistically significant difference between the transposition approach and the "above and below" approach. The "above and below" approach was used successfully in 2 surgeries.. It is possible to work both "above" and "below" the pituitary gland to reach the IC through an endoscopic endonasal approach. The advantages are the maintenance of normal pituitary and parasellar anatomy and the minimization of the size of the skull base defect. There is no blind spot using this approach that would be revealed with a pituitary transposition. The feasibility of this approach has been confirmed in 2 patients.

Topics: Adenoma; Adult; Cadaver; Cranial Fossa, Posterior; Female; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Neuroendoscopy; Nose; Pituitary Gland; Pituitary Gland, Posterior; Pituitary Neoplasms; Sella Turcica; Skull Base Neoplasms; Sphenoid Bone; Third Ventricle

Abstract The endoscopic transnasal, transsphenoidal surgical technique for pituitary tumour excision has generally been regarded as a less invasive technique, ranging from single nostril to dual nostril techniques. We propose a single nostril technique using a modified nasal speculum as a preferred technique. We initially reviewed 25 patients who underwent pituitary tumour excision, via endoscopic transnasal transsphenoidal surgery, using this new modified speculum-guided single nostril technique. The results show shorter operation time with reduced intra- and post-operative nasal soft tissue injuries and complications.

Topics: Adolescent; Adult; Aged; Endoscopy; Female; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Nasal Cavity; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Complications; Prospective Studies; Sphenoid Sinus; Surgery, Computer-Assisted; Surgical Instruments; Treatment Outcome; Young Adult

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

Topics: Adenoma; Adult; Aged; Endoscopy; Female; Humans; Male; Middle Aged; Nasal Cavity; Nose; Pituitary Neoplasms; Retrospective Studies; Sphenoid Bone; Treatment Outcome; Young Adult

Pituitary adenomas are often encased in a histological pseudocapsule that separates the tumor from the normal gland. Transsphenoidal adenoma resection may be performed either in an intra- or an extracapsular technique. The extracapsular fashion offers anatomical orientation, removal of a security margin, reduced risk of opening the arachnoid layer with subsequent CSF flow and identification of invasion.. The sella turcica is approached through the classic endoscopic endonasal route. After opening the dura of the sellar floor, the interface between the compressed tissue and the normal gland is used as a surgical plane for dissection. Performing slight counter-traction with the suction tube, the cleavage plane is identified and stepwise unsealed in an atraumatic fashion with the cotton swab. Once the cleavage plane is partially loosened, repeated twisting movements are performed with the cotton swab to enucleate the pseudocapsule and adenoma.. Both micro- and macroadenomas presenting a pseudocapsule may be resected in the extracapsular dissection technique with the cotton swab. Operating in an endoscopic three- to four hands technique enables to visualize the anatomic planes and perform twisting movements with the cotton swab separating pseudocapsule and tumor in order to enucleate the adenoma.

Topics: Adenoma; Dura Mater; Endoscopy; Humans; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Sphenoid Bone; Treatment Outcome

The proximity of craniopharyngiomas to vital neurovascular structures and their high recurrence rates make them one of the most challenging and controversial management dilemmas in neurosurgery. Endoscopic endonasal surgery (EES) has recently been introduced as a treatment option for both pediatric and adult craniopharyngiomas. The object of the present study was to present the results of EES and analyze outcome in both the pediatric and the adult age groups.. The authors retrospectively reviewed the records of patients with craniopharyngioma who had undergone EES in the period from June 1999 to April 2011.. Sixty-four patients, 47 adults and 17 children, were eligible for this study. Forty-seven patients had presented with primary craniopharyngiomas and 17 with recurrent tumors. The mean age in the adult group was 51 years (range 28-82 years); in the pediatric group, 9 years (range 4-18 years). Overall, the gross-total resection rate was 37.5% (24 patients); near-total resection (> 95% of tumor removed) was 34.4% (22 patients); subtotal resection (≥ 80% of tumor removed) 21.9% (14 patients); and partial resection (< 80% of tumor removed) 6.2% (4 patients). In 9 patients, EES had been combined with radiation therapy (with radiosurgery in 6 cases) as the initial treatment. Among the 40 patients (62.5%) who had presented with pituitary insufficiency, pituitary function remained unchanged in 19 (47.5%), improved or normalized in 8 (20%), and worsened in 13 (32.5%). In the 24 patients who had presented with normal pituitary function, new pituitary deficit occurred in 14 (58.3%). Nineteen patients (29.7%) suffered from diabetes insipidus at presentation, and the condition developed in 21 patients (46.7%) after treatment. Forty-four patients (68.8%) had presented with impaired vision. In 38 (86.4%) of them, vision improved or even normalized after surgery; in 5, it remained unchanged; and in 1, it temporarily worsened. One patient without preoperative visual problems showed temporary visual deterioration after treatment. Permanent visual deterioration occurred in no one after surgery. The mean follow-up was 38 months (range 1-135 months). Tumor recurrence after EES was discovered in 22 patients (34.4%) and was treated with repeat surgery (6 patients), radiosurgery (1 patient), combined repeat surgery and radiation therapy (8 patients), interferon (1 patient), or observation (6 patients). Surgical complications included 15 cases (23.4%) with CSF leakage that was treated with surgical reexploration (13 patients) and/or lumbar drain placement (9 patients). This leak rate was decreased to 10.6% in recent years after the introduction of the vascularized nasoseptal flap. Five cases (7.8%) of meningitis were found and treated with antibiotics without further complications. Postoperative hydrocephalus occurred in 7 patients (12.7%) and was treated with ventriculoperitoneal shunt placement. Five patients experienced transient cranial nerve palsies. There was no operative mortality.. With the goal of gross-total or maximum possible safe resection, EES can be used for the treatment of every craniopharyngioma, regardless of its location, size, and extension (excluding purely intraventricular tumors), and can provide acceptable results comparable to those for traditional craniotomies. Endoscopic endonasal surgery is not limited to adults and actually shows higher resection rates in the pediatric population.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Child; Child, Preschool; Combined Modality Therapy; Craniopharyngioma; Endoscopy; Female; Follow-Up Studies; Humans; Male; Middle Aged; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Complications; Radiosurgery; Retrospective Studies; Treatment Outcome

Patients undergoing pituitary adenoma or Rathke cleft cyst (RCC) removal are often administered perioperative glucocorticoids regardless of lesion size and preoperative adrenocorticotropic hormone/cortisol levels. To minimize unnecessary glucocorticoid therapy, we describe a protocol in which patients with normal preoperative serum cortisol and adrenocorticotropic hormone levels are given glucocorticoids only if postoperative day 1 or 2 (POD1 or POD2) cortisol levels decrease below normal.. A total of 207 consecutive patients undergoing endonasal surgery for an adenoma or RCC were considered for study. Of these, 68 patients with preoperative adrenal insufficiency or Cushing disease were excluded. Glucocorticoids were withheld unless POD1 or POD2 morning cortisol values were below normal (≤4 μg/dL). Subsequent adrenal status was assessed through follow-up biochemical and clinical evaluations.. The 139 patients included 119 with macroadenomas, 14 microadenomas, and 6 RCCs (follow-up, 3-41 months; median, 10 months). Nine patients (6.5%), all with macroadenomas (mean diameter, 26 ± 10 mm) had low POD1 or POD2 cortisol values and received glucocorticoids; of these, five patients were weaned off within 3-28 weeks of surgery. Overall, 12 of 139 patients (8.6%) were treated for early (n = 9) or delayed (n = 3) adrenal insufficiency but only 5 patients (3.6%) remain on glucocorticoid replacement. No patient experienced an adrenal crisis. Using morning POD1 or POD2 cortisol values >4 μg/dL as a measure of adequate hypothalamic-pituitary-adrenal axis function, yields a sensitivity of 96%, a specificity of 57%, and a positive predictive value of 98%.. In patients with normal preoperative cortisol levels undergoing endonasal removal of a pituitary adenoma or RCC, normal morning cortisol values on POD1 and POD2 reliably predicts adequate and safe adrenal function in 98% of patients. This simple protocol of withholding postoperative glucocorticoids avoids unnecessary steroid exposure and poses minimal risk to the well-informed closely monitored patient.

Topics: Adenoma; Adrenocorticotropic Hormone; Adult; Aged; Biomarkers; Central Nervous System Cysts; Circadian Rhythm; Female; Follow-Up Studies; Glucocorticoids; Humans; Hydrocortisone; Male; Middle Aged; Nose; Pituitary ACTH Hypersecretion; Pituitary Neoplasms; Postoperative Period; Predictive Value of Tests; Sensitivity and Specificity; Sphenoid Bone

Topics: Cranial Fossa, Anterior; Craniopharyngioma; History, 20th Century; History, 21st Century; Humans; Meningioma; Neuroendoscopy; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Skull Base; Skull Base Neoplasms; Sphenoid Bone

Endoscopy as a visual aid (endoscope assisted) or as the sole visual method (fully endoscopic) is increasingly used in pituitary adenoma surgery. Authors of this study assessed the value of endoscopic visualization for finding and removing residual adenoma after initial microscopic removal.. Consecutive patients who underwent endoscope-assisted microsurgical removal of pituitary adenoma were included in this study. The utility of the endoscope in finding and removing residual adenoma not visualized by the microscope was noted intraoperatively. After maximal tumor removal under microscopic visualization, surgeries were categorized as to whether additional tumor was removed via endoscopy. Tumor removal and remission rates were also noted. Patients undergoing fully endoscopic tumor removal during this same period were excluded from the study.. Over 3 years, 140 patients (41% women, mean age 50 years) underwent endoscope-assisted adenoma removal of 30 endocrine-active microadenomas and 110 macroadenomas (39 endocrine-active, 71 endocrine-inactive); 16% (23/140) of patients had prior surgery. After initial microscopic removal, endoscopy revealed residual tumor in 40% (56/140) of cases and the additional tumor was removed in 36% (50 cases) of these cases. Endoscopy facilitated additional tumor removal in 54% (36/67) of the adenomas measuring ≥ 2 cm in diameter and in 19% (14/73) of the adenomas smaller than 2 cm in diameter (p < 0.0001); additional tumor removal was achieved in 20% (6/30) of the microadenomas. Residual tumor was typically removed from the suprasellar extension and folds of the collapsed diaphragma sellae or along or within the medial cavernous sinus. Overall, 91% of endocrine-inactive tumors were gross-totally or near-totally removed, and 70% of endocrine-active adenomas had early remission.. After microscope-based tumor removal, endoscopic visualization led to additional adenoma removal in over one-third of patients. The panoramic visualization of the endoscope appears to facilitate more complete tumor removal than is possible with the microscope alone. These findings further emphasize the utility of endoscopic visualization in pituitary adenoma surgery. Longer follow-ups and additional case series are needed to determine if endoscopic adenomectomy translates into higher long-term remission rates.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Diabetes Insipidus; Female; Follow-Up Studies; Humans; Hypopituitarism; Incidence; Magnetic Resonance Imaging; Male; Middle Aged; Neoplasm Recurrence, Local; Neoplasm, Residual; Neuroendoscopy; Nose; Pituitary Neoplasms; Radiotherapy, Adjuvant; Retrospective Studies; Risk Factors; Sphenoid Sinus; Stroke; Treatment Outcome; Vision Disorders

Topics: Adenoma; Female; Humans; Male; Neoplasm, Residual; Neuroendoscopy; Nose; Pituitary Neoplasms; Sphenoid Sinus

Giant pituitary adenomas (> 4 cm in maximum diameter) represent a significant surgical challenge. Endoscopic endonasal surgery (EES) has recently been introduced as a treatment option for these tumors. The authors present the results of EES for giant adenomas and analyze the advantages and limitations of this technique.. The authors retrospectively reviewed the medical files and imaging studies of 54 patients with giant pituitary adenomas who underwent EES and studied the factors affecting surgical outcome.. Preoperative visual impairment was present in 45 patients (83%) and partial or complete pituitary deficiency in 28 cases (52%), and 7 patients (13%) presented with apoplexy. Near-total resection (> 90%) was achieved in 36 patients (66.7%). Vision was improved or normalized in 36 cases (80%) and worsened in 2 cases due to apoplexy of residual tumor. Significant factors that limited the degree of resection were a multilobular configuration of the adenoma (p = 0.002) and extension to the middle fossa (p = 0.045). Cavernous sinus invasion, tumor size, and intraventricular or posterior fossa extension did not influence the surgical outcome. Complications included apoplexy of residual adenoma (3.7%), permanent diabetes insipidus (9.6%), new pituitary insufficiency (16.7%), and CSF leak (16.7%, which was reduced to 7.4% in recent years). Fourteen patients underwent radiation therapy after EES for residual mass or, in a later stage, for recurrence, and 10 with functional pituitary adenomas received medical treatment. During a mean follow-up of 37.9 months (range 1-114 months), 7 patients were reoperated on for tumor recurrence. Three patients were lost to follow-up.. Endoscopic endonasal surgery provides effective initial management of giant pituitary adenomas with favorable results compared with traditional microscopic transsphenoidal and transcranial approaches.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Diabetes Insipidus; Female; Follow-Up Studies; Humans; Hypopituitarism; Incidence; Magnetic Resonance Imaging; Male; Middle Aged; Neoplasm Recurrence, Local; Neoplasm, Residual; Neuroendoscopy; Nose; Pituitary Neoplasms; Radiotherapy, Adjuvant; Retrospective Studies; Risk Factors; Sphenoid Sinus; Stroke; Treatment Outcome; Vision Disorders

Topics: Adenoma; Female; Humans; Male; Neuroendoscopy; Nose; Pituitary Neoplasms; Sphenoid Bone

The objective of this study was to measure the related parameters of intercarotid artery (ICA) in the operative plane of endonasal transsphenoidal approach for hypophyseal surgeries. Nine parameters of the ICA were examined in the computed tomographic angiographic (CTA) scan of 101 patients. The shortest distance between the middle point of the nasal columella and the projective point of the ICA (D(3)) was 85.50 (5.79) mm. The shortest distance between the anterior wall of the sphenoid sinus and the projective point of the ICA (D(4)) was 16.93 (3.50) mm. The distance between the bilateral projective points of the ICA (D(5)) was 21.60 (3.45) mm. The shortest distance from the anterior wall of the sphenoid sinus to the line between the bilateral projective points of the ICA (D(6)) was 12.1 (3.91) mm. The shortest distance between the middle point of nasal columella and the anterior wall of the sphenoid sinus (D(7)) was 72.67 (5.99) mm. The width of the angle between the bilateral ICA projective point from the middle point of the nasal columella (A(1)) was 14.9 (2.32) degrees. The width of the angle between the bilateral ICA projective points from the anterior-most point of sphenoid sinus (A(2)) was 85.49 (18.12) degrees. Clinically, it is relatively safe to work within the distances and angles measured in this research, and these results may provide information for clinical surgery of pituitary tumor.

Topics: Adult; Aged; Angiography; Carotid Artery, Internal; Endoscopy; Female; Humans; Male; Middle Aged; Nose; Pituitary Neoplasms; Radiographic Image Interpretation, Computer-Assisted; Reference Values; Sphenoid Sinus; Tomography, X-Ray Computed

Since the introduction of the endoscopic endonasal approaches in the field of skull base surgery during the last two decades, several variants of the sella turcica endoscopic surgery have been described. The aim of this study is to provide a stepwise description of one of these variants in a minimally invasive/maximally efficient perspective.. For the majority of our sella turcica pathologies, we have progressively adopted a uninostril endoscopic approach that is very conservative towards the nasal mucosa with a very limited mucosal incision, resection of the vomer and allowing an almost ad integrum sellar floor reconstruction, without compromising the efficacy and completeness of both surgical oncologic and endocrine targets.. The uninostril trans-sphenoidal endoscopic endonasal approach to sella turcica is tailored to ally maximal efficiency and minimal invasiveness.

Topics: Endoscopy; Humans; Laser Therapy; Nasal Cavity; Nasal Mucosa; Neurosurgical Procedures; Nose; Pituitary Gland; Pituitary Neoplasms; Sella Turcica; Skull Base

The removal of hypophyseal tumor by transsphenoidal pituitary surgery using microsurgical instruments was first performed over 100 years ago. Operating techniques for this surgery are constantly being renewed, first by using a microscope and later on with the use of an endoscop. The authors provide an overview of the minimal invasive posterior transseptal-transsphenoidal aproach with the combined utilization of classical techniques with the assistance of the endoscop.. Sixty-one patients (33 female, 28 male, 21-84 yrs) were treated for sellar region tumor resection using an endonasal transsphenoidal aproach with the help of an endoscope. Follow ups were performed within 2-21 months.. Total tumor resection was successful in 91.8%, and partial resection in 8.2% of the patients. The rate of complications using the endoscopic method was not higher compared to that of the classical microscopic method. There was no major bleeding in any of the cases. Adverse events such as minor epistaxis occurred in 4.9%, transitional diabetes insipidus in 6.5%, inraoperative CSF leak in 16.67%, postoperative CSF leak in 11.5% and meningitis in 8.2% of the patients. After the operation the pathological hormonal production stoped in all patients except in two patients who were acromegalic. However their GH level normalized and they did not require further treatment, the IGF-1 still remained high.. The success of the surgical treatment is based on both, the proficient pre- and postoperative endocrinological care, and the minimal invasive surgical technique. The endoscope was used partially or continuously during the operation for better visualization of the operation field in multiple angles (30 degrees, 45 degrees). It was useful in differentiating between normal and tumorous glandular tissue, and also offered an enhanced view of the intrasellar (via hydroscopy) and parasellar region. Moreover the endoscopic method is able to decrease the operating time, reduce blood loss. In different stages of the surgery, depending on the anatomical and pathological situation, switching back and forth from microscope to endoscope technique, gives us the benefit of a clearer view in each situation.

Topics: Adult; Aged; Aged, 80 and over; Cerebrospinal Fluid Rhinorrhea; Diabetes Insipidus; Epistaxis; Female; Humans; Learning Curve; Male; Meningitis; Middle Aged; Neuroendoscopes; Neuroendoscopy; Nose; Pituitary Gland, Posterior; Pituitary Neoplasms; Sphenoid Sinus

Endonasal approaches have become the gold standard intervention for many anterior and middle skull base tumors. The authors aimed to define some of the existing limitations of these approaches by reviewing their experience with complex sellar region tumors that were initially considered for both transsphenoidal and open skull base approaches and were thus deemed tumors at "the edge of the envelope.". Between April 2008 and April 2010, 250 transsphenoidal operations were performed at Brigham and Women's Hospital. All cases were retrospectively reviewed to identify patients with complex sellar region tumors that were initially considered for, or soon thereafter required, an open craniotomy as the definitive treatment. The anatomical tumor characteristics that posed limitations to performing safe and effective endonasal skull base operations were reviewed.. Thirteen cases exemplifying some of the existing limitations to achieving optimal surgical outcomes via transsphenoidal-based approaches are presented. The following 8 factors are separately discussed that repeatedly limited the extent of resection, increased the risk of the operation, and contributed to perioperative complications: significant suprasellar extension, lateral extension, retrosellar extension, brain invasion with edema, firm tumor consistency, involvement or vasospasm of the arteries of the circle of Willis, and encasement of the optic apparatus or invasion of the optic foramina.. Although the ability to approach and resect complex tumors using endonasal skull base techniques has evolved dramatically in recent years, several inherent tumor characteristics mandate extensive preoperative consideration. In selected cases these characteristics may lend support to selecting an open craniotomy as the initial operation.

Topics: Adult; Aged; Child; Craniotomy; Endoscopy; Female; Humans; Male; Meningioma; Middle Aged; Nose; Patient Selection; Pituitary Neoplasms; Retrospective Studies; Skull Base Neoplasms; Sphenoid Bone; Treatment Outcome

Pituitary adenomas with extensive suprasellar extension are a therapeutic challenge. The efficacy and safety of the endoscopic endonasal approach for non-functioning giant pituitary adenoma was evaluated retrospectively. A total of 43 consecutive patients with pituitary adenomas with a suprasellar extension of >20mm underwent tumor resection with a purely endoscopic endonasal approach, and their surgical outcomes were analyzed. At surgery, irrespective of the size and shape of the adenoma, every effort was made to perform intracapsular resection under direct visual control using an angled-lens endoscope. Gross total removal was achieved in 20 out of 43 patients. Postoperatively, 42 patients showed varying improvement of both visual field defects and impaired visual acuity. In two patients who presented with gait disturbance and cognitive dysfunction due to obstructive hydrocephalus, these symptoms were completely resolved. There were no serious operative complications. The results indicate that intracapsular resection via the endoscopic approach can be a safe and effective treatment for giant pituitary adenomas.

Topics: Adenoma; Adult; Aged; Female; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Nose; Pituitary Neoplasms; Retrospective Studies; Treatment Outcome

Whereas most pituitary adenomas are removable via the transsphenoidal approach, certain cases, such as dumbbell-shaped or suprasellar adenomas and recurrent and/or fibrous tumors, remain difficult to treat. The authors present their experience with the extended endoscopic endonasal approach to the suprasellar area in managing this subset of tumors, which are classically treated through a transcranial route.. From June 1997 to December 2008, 615 patients underwent endoscopic endonasal transsphenoidal surgery for pituitary adenomas in the Department of Neurosurgery of the Università degli Studi di Napoli Federico II. Of this group, 20 patients with pituitary adenomas needed an extended endoscopic endonasal transtuberculum/transplanum approach for tumor removal. Two surgical corridors were used during the transsphenoidal approach: 1) the conventional endosellar extraarachnoidal corridor and 2) a suprasellar transarachnoidal corridor.. The extent of resection was gross total in 12 (60%) of the 20 patients, near total in 4 (20%), subtotal in 3 (15%), and partial in 1 (5%). Postoperative CSF leakage occurred in 1 patient. One patient experienced worsening of temporal hemianopsia.. The authors' initial results with the extended endoscopic approach to the suprasellar area for selected pituitary adenomas are promising and may justify a widening of the current classical indications for transsphenoidal surgery.

Topics: Adenoma; Adult; Aged; Female; Humans; Male; Middle Aged; Neuroendoscopy; Nose; Pituitary Neoplasms; Sphenoid Bone; Treatment Outcome

The authors investigate the complications of transnasal transsphenoidal endoscopic surgery in the treatment of 301 patients with pituitary adenomas. A retrospective analysis of complications in 301 patients submitted to transsphenoidal transnasal endoscopic surgery at the General Hospital of Fortaleza, Brazil between January 1998 and December 2009. The complications were divided in two groups: anatomical (oronasofacial, sphenoid sinus, intrasellar, suprasellar and parasellar) and endocrinological complications (anterior and posterior pituitary dysfunctions). We observed a total of 81 complications (26.9%) in our series. Anatomical complications occurred in 8.97% (27 cases): 8 CSF postoperative leaks (2.6%), 6 cases (1.9%) of delayed nasal bleeding, 5 cases (1.6%) of sphenoidal sinusitis, 3 cases (0.9%) of carotid artery lesion, 2 cases of meningitis (0.6%) and one case (0.3%) of each of the uncommon following complications: intrasella-suprasella hematoma, pontine hematoma and chiasmaplexy. Endocrinological complications occurred in 17.9% (54 cases): additional postoperative anterior lobe insufficiency in 35 cases (11.6%), and postoperative diabetes insipidus in 19 cases (6.3%). In our series, 3 cases of deaths (not directly related to the procedure) were also observed. Endoscopic transsphenoidal surgery represents an effective option for the treatment of patients with pituitary tumor. Complications still occur and must be reduced as much as possible. Successful endoscopic pituitary surgery requires extensive training in the use of an endoscope and careful planning of the surgery. Additional improvement can be expected with greater experience and new technical developments.

Topics: Adenoma; Adolescent; Adult; Aged; Child; Cohort Studies; Endoscopy; Female; Humans; Male; Middle Aged; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Sphenoid Bone; Treatment Outcome; Young Adult

Accessing intra- and extradural tumors via an endonasal approach requires working safely in a relatively narrow area with unobstructed visibility. The authors describe their experience to highlight the utility of a side-cutting aspiration device for endoscopic endonasal resection of skull base tumors.. The authors used this device in 13 nonconsecutive endoscopic endonasal procedures for different skull base tumors (8 pituitary macroadenomas, 2 craniopharyngiomas, 1 chordoma, 1 recurrent ependymoma, and 1 lymphoma). Illustrative cases and video are presented to demonstrate its use.. The instrument was easy to use and effective in the removal of the lesions presented in this series. In 10 patients (77%), gross-total resection was possible; in the other 3 patients (23%), more than 80% of the tumor was resected. No collateral tissue damage or any other complication resulted from device-related debulking or aspiration.. The side-cutting tissue resector is a safe, easy to use, and effective tool for internal debulking and extracapsular dissection of nonvascularized tumors that are too firm for bimanual suction or blunt ring curette dissection. It is particularly useful when working through a deep and narrow corridor such as is encountered in endoscopic endonasal skull base surgery.

Topics: Adenoma; Aged; Craniopharyngioma; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Neuroendoscopy; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Sphenoid Bone

Retrochiasmatic craniopharyngiomas are challenging tumors to remove given their deep location and proximity to critical neurovascular structures. Complete surgical removal offers the best chance of cure and prevention of recurrence. The endoscopic endonasal extended transsphenoidal approach offers direct midline access to the retrochiasmatic space through a transplanum transtuberculum corridor. Excellent visualization of the undersurface of the optic chiasm and hypothalamus can be obtained to facilitate bimanual extracapsular dissection to permit complete removal of these formidable tumors. In this report the authors review the endoscopic endonasal extended transsphenoidal approach, with specific emphasis on technical operative nuances in removing retrochiasmatic craniopharyngiomas. An illustrative intraoperative video demonstrating the technique is also presented.

Topics: Craniopharyngioma; Endoscopy; Female; Humans; Hypophysectomy; Magnetic Resonance Imaging; Middle Aged; Nose; Optic Chiasm; Pituitary Neoplasms; Sphenoid Sinus

Endoscopic endonasal transsphenoidal approach (EETA) is an acceptable procedure as truly minimally invasive neurosurgery in handling pituitary tumor. EETA can serve many patients in many aspects especially the hospital stay and the scarification. However EETA still has some limitations that can cause serious complications. These complications such as cerebrospinal fluid leakage and bleeding control are less likely to occur ifneurosurgeons use conventional approach named as Pterional approach which was described by Yarsargil. To gain the benefit of both pterional approach and minimally invasive surgery Keyhole Supraorbital Approach (KSA) was proposed by Perneczky in 1999. This approach has not the mentioned limitation. However, there are many controversies between these two approaches in that what is the better minimally invasive surgery in pituitary surgery? The present article, by clearing the pro and con of each approach, can help neurosurgeons select the most appropriate way in handling pituitary surgery.

Topics: Humans; Minimally Invasive Surgical Procedures; Neuroendoscopy; Neurosurgical Procedures; Nose; Orbit; Pituitary Neoplasms; Postoperative Complications; Sphenoid Bone

Topics: Adenoma; Adolescent; Adult; Aged; Child; Child, Preschool; Endoscopes; Endoscopy; Female; Humans; Male; Middle Aged; Nose; Pituitary Neoplasms; Retrospective Studies; Sella Turcica; Treatment Outcome; Young Adult

Giant pituitary adenomas (> or =40 mm) pose a major management challenge. We describe the experience of a single surgeon and a dedicated neuro-endocrine team with multimodality treatment of these tumours in three specialized institutions.. Retrospective data set analyses.. Fifty-one consecutive patients with a giant adenoma (39 endocrine-inactive, 12 endocrine-active; mean tumour diameter 45 mm) treated over 10 years by an endonasal transsphenoidal approach were included. All patients had surgical resection followed by radiotherapy and/or medical therapy as judged necessary.. Hormonal and visual status, extent of resection, tumour control rates, complications and use of medical and radiotherapy were evaluated.. Surgery resulted in gross total, near total and subtotal removal in21 (41%), 10 (20%) and 20 (39%) patients respectively. Complete tumour removal was associated with absence of cavernous sinus invasion (P < 0.001). Long-term endocrine function improved in 49% of patients and new endocrinopathy occurred in 14.6%; 76% required long-term hormone replacement therapy. Vision improved in 81.5% of the patients and there was no visual worsening. At the last follow up (median 30 months), tumour control was achieved in 96% of patients: 59% with surgery alone, 20% with surgery plus focussed radiotherapy, 18% with surgery and medical therapy and two with all three modalities.. Endonasal surgery provides effective initial treatment for patients with giant adenomas. Multimodality therapy was needed in almost 50% of patients and this rate will likely increase with longer follow up. Close collaboration of neurosurgeons with endocrinologists and radiation oncologists is essential for optimal treatment of patients with these challenging tumours.

Topics: Adenoma; Adult; Combined Modality Therapy; Female; Humans; Male; Middle Aged; Neuroendoscopy; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Retrospective Studies

Given that the transnasal endoscopic approach to the sella involves resection of anatomical structures known to contain olfactory neuroepithelium, the effect of this approach on olfaction was evaluated.. Case series with planned data collection.. Single tertiary care institution.. Adults diagnosed with a pituitary mass and scheduled to undergo transnasal endoscopic resection underwent preoperative olfactory evaluation using the University of Pennsylvania Smell Identification Test (UPSIT). Repeat testing was performed at one and three months postoperatively. Paired Student t tests were used to compare preoperative and postoperative scores.. A total of 57 consecutive patients were enrolled. Fifty patients (24 males, 26 females) completed olfactory evaluation at one month. Forty-five (23 males, 22 females) completed a three-month evaluation. The average UPSIT score (out of 40) was 31.8 preoperatively, 30.5 at one month, and 32.6 at three months. A significant difference was found between preoperative and one-month scores (P = 0.01) but not three-month scores (P = 0.08).. A transient difference was found between preoperative and one month UPSIT scores. At three months, no clinically significant difference was found on repeat olfactory testing. Although the transnasal endoscopic approach to the sella removes structures known to contribute to olfactory function, it has no clinically significant effect on olfaction.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Endoscopy; Female; Humans; Male; Middle Aged; Nose; Pituitary Neoplasms; Smell; Young Adult

Topics: Diabetes Insipidus; Humans; Length of Stay; Magnetic Resonance Imaging; Microsurgery; Minimally Invasive Surgical Procedures; Neuroendoscopy; Nose; Pituitary Gland; Pituitary Neoplasms; Sphenoid Sinus; Time Factors

The endoscopic endonasal transsphenoidal approach (EETA) to the pituitary is performed by ear, nose, and throat (ENT) surgeons in collaboration with neurosurgeons but also by neurosurgeons alone even though neurosurgeons have not been trained in rhinological surgery.. To register the frequency of endonasal anatomical variations and to evaluate whether these variations hinder the progress of EETA and require extra rhinological surgical skills.. A prospective cohort study of 185 consecutive patients receiving an EETA through a binostril approach was performed. All anatomical endonasal variations were noted and the relevance for the progress of surgery evaluated.. In 48% of patients, anatomical variations were recognized, the majority of which were spinae septi and septum deviations. In 5% of patients, the planned binostril approach had to be converted into a mononostril approach; whereas in 18% of patients with an anatomical variation, a correction had to be performed. There was no difference between the ENT surgeon and the neurosurgeon performing the approach. Complications related to the endonasal phase of the surgery occurred in 3.8%. Fluoroscopy or electromagnetic navigation has been used during 6.5% of the surgeries.. Although endonasal anatomical variations are frequent, they do not pose a relevant obstacle for EETA.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Central Nervous System Cysts; Child; Cohort Studies; Craniopharyngioma; Endoscopy; Female; Humans; Male; Middle Aged; Nasal Septum; Neuroendoscopes; Neuronavigation; Nose; Pituitary Diseases; Pituitary Neoplasms; Prospective Studies; Sphenoid Sinus; Tomography, X-Ray Computed; Young Adult

To recognize the causes, methods of prevention and cure of sinusitis complicated by endoscopic transnasal approach in surgical treatment of pituitary adenomas.. The data of 187 patients who underwent surgical treatments of pituitary adenomas through endoscopic transnasal approach were collected, and the surgical complications were analyzed.. Endoscopic transnasal transsphenoidal approach were used successfully in 187 cases, twelve cases (6.4%) were suffered from sinusitis complication after surgery. The most frequent sinusitis complication was sphenoiditis, 9 cases (4.8%) were suffered, 2 cases (1.1%) were suffered from ethmoidal sinusitis, 1 case (0.5%) was suffered from maxillary sinusitis. Ten cases were treated with correspond medication in clinic. Two cases were ineffective with expectant treatment, and cured by second endoscopic sinusitis operation at last.. Endoscopic transnasal transsphenoidal approach offered a simple and rapid access to the sella, and also, it is a safe, valuable and efficient procedure for removing pituitary adenomas. It was obviously that timely accurate diagnosis for the sinusitis complication and comprehensive perioperative management may lead to less incidence of postoperative sinusitis complication in surgical treatment of pituitary adenomas through endoscopic transnasal approach, increase the achievement rate and improve survival quality obviously.

Topics: Adult; Aged; Endoscopy; Female; Humans; Hypophysectomy; Male; Middle Aged; Nose; Pituitary Neoplasms; Postoperative Complications; Sinusitis; Sphenoid Sinus; Treatment Outcome

To describe the experience with surgical treatment of pituitary adenomas via a fully transnasal endoscopic approach.. Clinical records of 375 cases with pituitary adenomas underwent pure endoscopic operations between December 2006 and December 2009 were carefully assembled. Among 375 pure endoscopic operations of pituitary adenomas, 201 cases were nonfunctional adenomas and 174 cases were functional adenomas. There were 27 giant pituitary adenomas (7.2%) and 41 pituitary adenoma invaded cavernous sinus (10.9%). Intraoperative 1.5 T MRI and neuro-navigation system were used during some operations. The postoperative and follow-up data of patients were analyzed.. There were 234 (79.3%) cases of total resection, 56 (19.0%) cases of subtotal resection, 5 (1.7%) cases of partial resection. Sixty-eight patients had vision improved in 73 patients with vision decreasing before operation. Sixty-eight (77.3%) patients got normal endocrine in 88 hyper-prolactin patient. Fifty-five (84.1%) patients got normal growth hormone in 63 patients with somatotrophinomas. Eighteen (78.2%) patients got normal in 23 patients with corticotrophinoma. These was no death case in this group. One case (0.3%) suffered post-operative coma. Transient decreasing of vision occurred in 2 cases (0.5%). Transient palsy of oculomotor nerve or abducens nerve occurred in 7 cases of operations involved cavernous sinus. Three (0.8%) patients had cerebral meningitis. Two patients (0.5%) suffered from cerebrospinal fluid leak but none underwent operation to repair. Fourteen patients (3.7%) had transient diabetes insipidus. Six patients (1.6%) had nose bleeding.. Trans-nasal endoscopy provides a new device for operation of pituitary adenomas which is effective and safe. Comparing with microscope, endoscopic visual field is clearer, closer and wider.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Child; Endoscopy; Female; Follow-Up Studies; Humans; Hypophysectomy; Male; Middle Aged; Nose; Pituitary Neoplasms; Retrospective Studies; Sphenoid Sinus; Treatment Outcome; Young Adult

Topics: Adult; Aged; Endoscopy; Female; Humans; Hypophysectomy; Male; Microsurgery; Middle Aged; Nose; Pituitary Neoplasms; Treatment Outcome

Aim of this report is to describe the long-term results of endoscopic endonasal repair of cerebrospinal fluid leak using a septal mucoperichondrial graft. A case series of 52 patients operated for cerebrospinal fluid rhinorrhea between 1990 and 2006 is presented. All patients underwent surgical treatment for endoscopic endonasal closure of a cerebrospinal fluid leak using a septal mucoperichondrial graft. No lumbar drain and fluorescein tests were used. The intra-operative localization of the fistula was aided by Valsalva's manoeuvre by the anaesthetist. The success rate, after the first attempt, was 88.5% (46/52 patients); for the remaining 11.5% (6/52 patients), a second attempt was necessary which proved successful in 5 cases, raising the overall success rate to 98.1% (51/52 patients). Relapse occurred in only one case (1.9%), after the second attempt. In conclusion, a free mucoperichondrial graft offered good results for cerebrospinal fluid leak repair. In the Authors' experience, a high success rate can be achieved without the use of intrathecal fluorescein and lumbar drain.

Topics: Adolescent; Cerebrospinal Fluid Rhinorrhea; Endoscopy; Female; Fistula; Follow-Up Studies; Humans; Iatrogenic Disease; Male; Nasal Septum; Nose; Pituitary Neoplasms; Postoperative Complications; Severity of Illness Index; Sinusitis; Tomography, X-Ray Computed; Transplantation, Autologous; Valsalva Maneuver; Young Adult

To examine the use of computer-assisted surgery in transnasal pituitary gland surgery.. Twenty cases of transnasal pituitary gland surgery using a computer-assisted navigation system, carried out between 2002 and 2004, were retrospectively studied. The subjects consisted of 7 men and 13 women aged between 27 and 77 years of ages. The pituitary tumours included 18 macroadenomas, a microadenoma and a craniopharyngioma. Ten of the cases presented with visual field and/or visual acuity disturbances. Seven of the cases presented with endocrine disorders. A computed tomography scanner destined for navigation purposes was carried out 24 hours before the operation. The computer-assisted system used was the Digipointeur (Collin ORL) based on a system of spatial localization in electromagnetic fields.. Tumour removal was complete in 50% of cases and partial, as judged by MRI 3 months after the procedure, in 45% of the cases. In 40% of cases, the preoperative visual disturbances had completely disappeared at 3 months. A considerable clinical improvement was observed in all of the other cases. Peroperative complications were limited to two breaches of the meninges and one peroperative hemorrhage during the excision of a macroadenoma invading the cavernous sinus, necessitating the suspension of the operation.. In our experience, the use of a computer-assisted system in transseptal pituitary surgery gives reliable millimetric surgical precision in the localization of vital internal anatomical structures, optimizes surgical resection and increases levels of safety.

Topics: Adenoma; Adult; Aged; Female; Humans; Male; Middle Aged; Nose; Pituitary Neoplasms; Retrospective Studies; Surgery, Computer-Assisted

To discuss the indication, efficacy and safety of endoscopic minimally invasive surgery technique in the management of nasal skull-base neoplasms.. Thirty-six patients with nasal skull base neoplasms were treated from January 2000 to Jun 2004 under nasal endoscopy, including 16 nasopharyngeal fibroangioma, 8 sinus osteofibroma, 8 pituitary adenoma, 4 olfactory neuroblastoma. Pathology lab procedures were performed pre or post-operatively. The feeding artery of nasopharyngeal fibroangioma was selectively embolized with gelatin sponge before operation. All olfactory neuroblastoma and 2 pituitary adenoma received radiotherapy after operation.. Total or most of nasopharyngeal fibroangioma, sinus osteofibroma, olfactory neuroblastoma and pituitary adenoma were excised. Three cases presented complications of cerebrospinal fluid leakage, 2 cases were successfully mended with middle turbinate and muscle tissue respectively, another one gained self-healing after reducing the intracranial pressure and anti-inflammation. Followed up 4 to 8 years without recurrence for all patients. Seldom serious complications accrued.. When the indications are selected appropriately, nasal skull-base neoplasms, including benign and malignant, can be well treated with nasal endoscopic minimally invasive surgery.

Topics: Adolescent; Adult; Aged; Child; Endoscopy; Female; Fibroma, Ossifying; Humans; Male; Middle Aged; Minimally Invasive Surgical Procedures; Nasopharyngeal Neoplasms; Neuroblastoma; Nose; Olfactory Nerve; Pituitary Neoplasms; Skull Base Neoplasms; Young Adult

Results of clinical examination and surgical treatment of 1022 patients with tumors of the hypophysis were analyzed. All the patients were operated upon by transsphenoidal endoscopic approach during the recent 10 years. Complications were observed in 76 (7.4%) patients. Most serious of them were: intraoperative mechanical injury of the right internal carotid artery and contact rupture of a large aneurysm of the internal carotid artery falsely diagnosed as craniopharyngioma. In both cases urgent intravascular interventions were necessary which resulted in relief of symptoms and recovery of the patients.

Topics: Adult; Carotid Artery Injuries; Carotid Artery, Internal; Cerebral Arteries; Embolization, Therapeutic; Endoscopy; Female; Follow-Up Studies; Humans; Iatrogenic Disease; Magnetic Resonance Imaging; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Tomography, Spiral Computed

The microscopic trans-sphenoidal approach has been the treatment of choice of different sellar lesions over the last thirty years. However, due to several advantages brought by the endoscope, which provides a panoramic and close up view of all the anatomic landmarks either in the sphenoid sinus and in the sellar region, an increasing interest for the trans-sphenoidal approach to the sellar and suprasellar region is being noticed in the recent past years. Since the endoscopic approach drives the surgeon through a corridor whose walls were previously hidden by the nasal speculum, the precise knowledge of the endoscopic anatomy and the anatomical landmarks of the surgical approach are essential to better explore the mentioned advantages.. The endoscopic endonasal approach to the sellar region was performed in 40 adult fresh cadavers, with the aim of describing the anatomical landmarks for a safe realization of the surgical approach.. The anatomic features and the variations of the sphenoid ostia, sphenoid sinus and septae, sella turcica, optic and carotid protuberances and their relationships have been described, as well as supra and parasellar neurovascular structures.. The endoscopic endonasal trans-sphenoidal approach provides a straight approach to the sellar region, where it offers a multiangled and close-up view of all the relevant neurovascular structures.

Topics: Adenoma; Adult; Cadaver; Endoscopy; Female; Humans; Male; Neurosurgical Procedures; Nose; Pituitary Gland; Pituitary Neoplasms; Sella Turcica; Sphenoid Bone

Reconstruction of the sellar floor after pituitary tumor removal is sometimes difficult because the repair graft is difficult to handle in the narrow space. This is especially problematic if the endonasal endoscopic approach is used. The authors devised a technique to facilitate this procedure by placing a suture knot on the repair splint. This allows the material to be grasped securely with forceps and improves manipulation even within the narrow nasal cavity. This technique has proved useful when performing the endonasal endoscopic approach, and it is also expected to be useful when conducting the conventional sublabial transsphenoidal approach.

Topics: Endoscopy; Humans; Nose; Pituitary Neoplasms; Sella Turcica; Splints; Sutures

To assess the feasibility of passive marker computer-aided surgery in a single institution, we performed 22 procedures in 21 patients with disorders including sinonasal tumors (n = 9), fungal sinusitis (n = 4), recurrent polyps (n = 3), chronic sinusitis (n = 3), and cerebrospinal fluid rhinorrhea (n = 2). Passive marker computer-aided surgery was successful in 19 of the 21 patients. The accuracy was on the order of 1.35 mm. Probe conversion, rotation, and cordlessness were helpful in all 19 cases. The system helped with landmarks (n = 14), margins (n = 7), skull base (n = 6), orbit (n = 5), and approach (n = 4). Computer-aided surgery accurately confirmed the location of an instrument and demonstrated tumor-normal tissue interfaces. It aided the surgeon in procedures on the sinonasal area and cranial base. The potential advantages of a passive marker system as compared with other available technologies center around the ability to convert and/or rotate virtually any instrument to a cordless imaging probe on demand during the operation.

Topics: Angiofibroma; Cerebrospinal Fluid Otorrhea; Cerebrospinal Fluid Rhinorrhea; Craniopharyngioma; Endoscopy; Humans; Magnetic Resonance Imaging; Meningeal Neoplasms; Meningioma; Nasopharyngeal Neoplasms; Nose; Otorhinolaryngologic Surgical Procedures; Paranasal Sinuses; Pituitary Neoplasms; Safety; Sinusitis; Skull Base; Surgery, Computer-Assisted; Tomography, X-Ray Computed

Sublabial approach has been widely used as the standard technique for transsphenoidal pituitary surgery. But it has several possible drawbacks, such as; postoperative flat nose deformity, hypesthesia of upper gum, and feeding difficulty until 2 to 3 weeks after surgery. As an alternative, an endonasal approach was adopted for patients who had large nostrils, such as white or acromegalic patients. In patients with small nostrils, especially oriental people, it requires an additional tension release incision that leaves a definitely visible scar at the base of nose.. We applied the transcolumellar approach, which modified the external rhinoplasty approach on the 136 cases of transsphenoidal pituitary surgery that were performed from 1994 to June 1999.. In all patients, we found we could reach the anterior portion of nasal septum in 7 to 8 mm in depth from the skin surface and eliminate the disadvantages of sublabial and endonasal approach. Also, this method can markedly reduce the surgical dissection time and blood loss.. We concluded that this technique was relatively simple and more than adequate in most transsphenoidal pituitary surgery, even in patients with small nostrils.

Topics: Asian People; Cicatrix; Dissection; Edema; Endoscopy; Follow-Up Studies; Humans; Hypophysectomy; Nose; Pituitary Neoplasms; Rhinoplasty; Surgical Flaps; Suture Techniques; Treatment Outcome

Submucosal dissection of the nasal septum is often performed as part of the transseptal approach to the sella. To evaluate whether this submucosal dissection is a necessary component of this operation, we compared the morbidity of a direct transmucosal endonasal approach to that of the transseptal approach in patients undergoing pituitary surgery.. Forty-one consecutive patients undergoing pituitary surgery from January 1996 to March 1999 were included in this study. The first 21 patients underwent the standard transseptal operation through either a sublabial or columellar incision. The latter 20 patients were operated on through an endoscopically guided, direct endonasal exposure, without any submucosal dissection of the nasal septum. The operative morbidity, the duration of surgery, and the length of hospitalization for each group were compared.. The sphenoid sinus exposure obtained through the endonasal route was comparable with the transseptal approach and was adequate for resection of most pituitary tumors. Although the morbidity of the two approaches was similar, patients undergoing the endonasal operation had less postoperative facial pain. Furthermore, the endonasal approach significantly decreased the length of the operation (116 minutes vs. 161 minutes, p = 0.002) and the duration of hospitalization (3.6 vs. 5.1 days, p = 0.003) as compared with the transseptal route.. Morbidity of the endonasal approach to the sphenoid sinus is comparable to that of a conventional transseptal approach. By eliminating the submucosal dissection, the endonasal approach reduces postoperative facial discomfort and decreases length of surgery and hospitalization.

Topics: Adenoma; Adult; Carcinoma, Renal Cell; Central Nervous System Cysts; Craniopharyngioma; Endoscopy; Female; Fibrosis; Germinoma; Humans; Male; Middle Aged; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Treatment Outcome

We have been performing intranasal procedures and postoperative nasal treatments in patients undergoing microscopic transseptal pituitary surgery for the past twenty years. This surgery is safe and minimally invasive and has become the standard procedure for removing pituitary adenomas. Recent advances in optical technology have increased the use of endoscopy in endonasal sinus surgery. Several methods for endoscopic transnasal pituitary surgery have been reported. Here, we report the results for 31 patients (34 operations) who were treated with endoscopic transnasal pituitary surgery. This technique enables the area of surgery to be visualized without requiring a sublabial incision or septal ablation to be performed. Five of the cases were for recurrences after microscopic surgery. A transsphenoidal surgical approach via a unilateral nasal cavity was used in 32 cases. For the remaining two cases, a transsphenoidal surgical approach via bilateral nasal cavities was used in 1 case, and a transethmoidal-transsphenoidal surgical approach via a unilateral nasal cavity was used in 1 case. Excellent results comparable to those of microscopic transseptal surgery were obtained. Endoscopic transnasal transsphenoidal surgery was found to have the following advantages: low-invasiveness, a wide and clear surgical view, and a relatively short operating time in the nose and sinus, especially for recurrent cases. This endoscopic procedure should therefore be considered as the first choice for pituitary surgery.

Topics: Adenoma; Adolescent; Adult; Aged; Child; Endoscopy; Female; Humans; Hypophysectomy; Male; Middle Aged; Nose; Pituitary Neoplasms

To assess the advantages and disadvantages of an endoscopic transnasal approach to pituitary surgery for a select group of clinically nonfunctioning macroadenomas and to compare results of this approach with the sublabial transseptal approach at a single institution.. We retrospectively reviewed the records of 26 patients with clinically nonfunctioning pituitary macroadenomas approached endoscopically and 44 matched control patients with the same tumors approached sublabially between January 1, 1995, and October 31, 1997.. At baseline, the groups were not significantly different for age, sex distribution, number of comorbid conditions, visual field defects, degree of anterior pituitary insufficiency, or preoperative assessment of tumor volume or invasiveness. Mean (SD) operative times were significantly reduced in the endoscopic group vs the sublabial group: 2.7 (0.7) hours vs 3.4 (0.9) hours (P < .001). Postoperative assessment of surgical resection and postoperative alterations of anterior pituitary function or visual fields were not significantly different between groups, and complication rates were similar in both groups.. This endoscopic transnasal approach to pituitary resection results in significantly shorter operative time without compromising the extent of tumor resection. The distinct disadvantage of this approach is an off-center view of the sella and a diminished working channel to the sella turcica. For these reasons, the endoscopic approach or its variation is an alternative to the sublabial approach but should be considered only by experienced pituitary neurosurgeons.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Endoscopy; Female; Humans; Lip; Male; Medical Records; Middle Aged; Neoplasm Staging; Nose; Pituitary Neoplasms; Retrospective Studies; Treatment Outcome

Different distances related to the nasal transphenoidal approach were measured on the hemiheads of eighteen cadavers in order to study its limits and advantages. The main mean measures obtained (mm) were: major diameter of the nostril 15.18: height of the nasal cavity 44.11, nostril-sella turcica distance 71.71. These results show that the nasal approach is wide and direct to the sella turcica. The present study demonstrate the possibility of preservation of the cartilaginous septum and other structures which are usually damaged when the sublabial approach is employed.

Topics: Humans; Nose; Pituitary Neoplasms; Surgical Procedures, Operative

Topics: Endoscopy; Humans; Nose; Pituitary Gland; Pituitary Neoplasms; Sphenoid Sinus

Topics: Acromegaly; Adenoma, Chromophobe; Adolescent; Adult; Aged; Child; Cushing Syndrome; Female; Humans; Male; Middle Aged; Neoplasm Recurrence, Local; Nose; Pituitary Neoplasms; Postoperative Complications; Tomography, X-Ray Computed; Vision, Ocular

Transseptal transsphenoidal approach to the pituitary fossa is a well-described and effective procedure. This article relates our experience with this procedure with specific emphasis on the nasal septum, both before and after surgery. It has been our experience that this surgery has minimal local complications in the nose and it would appear to improve septal alignment with subjective improvement in nasal function as reported by the patient. A total of 55 patients undergoing a sublabial transseptal transsphenoidal approach to the pituitary fossa were included in this study. All other approaches to the pituitary gland were excluded. Visual changes and headaches were the most common presenting symptoms, occurring alone or in combination in 28 (51%) patients. Twelve (22%) patients reported symptoms of nasal obstruction before surgery and only one (2%) after surgery. A moderately or severely deviated septum was noted in 30 (54%) patients before surgery and 4 (7%) patients after surgery. The septum was straight in 21 (38%) patients before the procedure and 49 (89%) patients after the surgery. Sinusitis developed in two patients, and one patient subsequently required surgery. No synechiae or septal perforations were noted.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Female; Follow-Up Studies; Headache; Humans; Hypophysectomy; Male; Middle Aged; Nasal Obstruction; Nasal Septum; Nose; Pituitary Neoplasms; Retrospective Studies; Sphenoid Bone; Sphenoid Sinus; Sphenoid Sinusitis; Vision Disorders

An approach to transnasal transsphenoidal debulking of pituitary tumors using endoscopic guidance is presented.. Technical details of this approach using an endoscope inserted through one nostril and operating instruments inserted through a submucosal tunnel created via the other nostril are discussed.. Ten patients who had operations are tabulated. Illustrative cases are presented.. Endoscopic debulking of pituitary tumors can provide good results with minimal operative morbidity.

Topics: Adenoma; Adult; Aged; Endoscopes; Female; Humans; Hypophysectomy; Magnetic Resonance Imaging; Male; Nose; Pituitary Function Tests; Pituitary Neoplasms; Prolactinoma; Surgical Instruments

In order to sum up the experience of transsphenoidal resection of pituitary tumors, 60 cases operated between 1984 and 1995 were reviewed. The operation was performed via a columella nasi "V" incision and transseptal-sphenoidal approach. 0 degree and 30 degrees endoscopes were used in 16 cases and the cryotherapy was used to destroy the remnant tumor cells in 51 cases. The duration of freezing was only one minute each time and it was repeated once again after thawing. The advantages of this method were as follows: (1) wider operative field and better illumination; (2) magnified operative pictures and TV monitoring; (3) wide and changeable visual angle; (4) lack of complications such as hemorrhage, optic nerve injury, permanent diabetes insipidus. The proper applications of endoscopy and cryosurgery were recommended for transsphenoidal removal of pituitary tumors.

Topics: Adenoma; Adolescent; Adult; Cryosurgery; Endoscopy; Female; Humans; Hypophysectomy; Male; Middle Aged; Nose; Pituitary Neoplasms

Nowadays, nonsecreting pituitary adenomas are usually operated on by means of a transsphenoidal approach, and the transseptal way is the most widely used. Since 1982 we have been using lateral rhinotomy instead, resecting bone in the piriform aperture up to the orbit to obtain a good intrasellar view during surgery. In all, 48 patients were operated on between 1982 and 1987, and all of them have since been evaluated in a 5-year follow-up. The only recurrence occurred in the only patient previously operated on transcranially. Computed tomography was performed in 44 patients (92%) after an average of 4 years and revealed no signs of tumor in any of them. New pituitary insufficiencies developed in six (12%). An improvement in vision was observed in 38 patients (79%), none of whom suffered an impaired visual field or acuity. The frequency of new hormonal insufficiencies and improvement of vision that we observed in our patients is comparable with that reported by other investigators, but the recurrence rate is lower and the optic nerves and chiasma were never damaged thereby causing an impairment of vision. These benefits can most probably be explained by the surgical approach we used, in which the tumor and surrounding structures are very well visualized because the operative field is broader and closer than it is with the transseptal approach, which is normally used for this kind of tumor.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Combined Modality Therapy; Female; Follow-Up Studies; Humans; Male; Maxilla; Middle Aged; Neoplasm Recurrence, Local; Neoplasm Staging; Nose; Orbit; Pituitary Diseases; Pituitary Gland; Pituitary Neoplasms; Postoperative Complications; Survival Rate; Visual Acuity

The results of transsphenoidal microsurgery for growth hormone (GH)-secreting pituitary adenomas in a series of 47 patients are presented. A modified transsphenoidal approach with lateral rhinotomy was employed for the access to the sphenoid sinus. Remission, defined as mean GH concentration less than 2.5 ng/ml, was achieved in 79% of the patients. Macroadenoma size of the tumour and a GH concentration more than 50 ng/ml were factors unfavourable for the outcome. The experience of the lateral rhinotomy approach in transsphenoidal surgery of acromegaly has been favourable. The distance from the incision to the sella is shorter than in rhinoseptal approaches, where the depth of the operative field is determined by the distance from the nasal spine to the sella. The lateral rhinotomy also allowed an exposure of the sella of adequate width in all patients. These aspects of the procedure facilitated adenoma removal.

Topics: Adenoma; Female; Growth Hormone; Humans; Insulin-Like Growth Factor I; Male; Microsurgery; Middle Aged; Nose; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Sphenoid Bone

Since 1960 we have performed stereotactic transsphenoidal cryohypophysectomy in 70 patients with pituitary adenomas, 42 women and 28 men, aged 11-59 years. The dominant clinical syndrome was acromegaly in 50 patients, galactorrhea in 9, amenorrhea in 5, adiposogenital dystrophy in 4 and gigantism with mild endocrine symptomatology in 2 patients. In 67 patients the histological structure of the tumor was established by biopsy (50 patients with eosinophil adenoma, 10 with mixed-type adenoma, 4 with chromophobe adenoma and 3 with basophil adenoma). Somatotropic hormone, human growth hormone, prolactin, ACTH and 17-ketosteroid levels indicated active/inactive adenomas. In 42 cases the adenoma was only intrasellar, which was confirmed by contrast X-ray investigations, CT scanning, angiography and ophthalmological investigation. Transnasal stereotactic cryohypophysectomy was performed in all 70 cases using a stereotactic apparatus especially designed for operations on the pituitary. All patients (except 2) tolerated the operation well. No complications occurred. Vision deteriorated after operation in 1 patient. Thrombosis of the left middle cerebral artery developed in another patient. All the other patients noted improvement directly after operation - rapid diminution of signs of acromegaly and rapid restoration of normal values in hormonal tests. Six patients with continuing growth of the tumor underwent a second operation 1.5-6 years after the first operation. We conclude from our own clinical experience and information from the literature that transnasal stereotactic cryodestruction is highly effective and relatively safe in the management of pituitary adenoma.

Topics: Acromegaly; Adenoma; Adolescent; Adult; Child; Cryosurgery; Female; Humans; Hypophysectomy; Male; Middle Aged; Nose; Pituitary Neoplasms; Stereotaxic Techniques; Treatment Outcome

The direct transnasal transsphenoidal approach to the pituitary fossa has been used in our unit since 1987. We describe the procedure and report its use in 48 patients with pituitary lesions. Successful access to the pituitary fossa was made in 46 out of 50 operations (92%). In two cases, repeat transnasal exploration was successfully performed for recurrent tumour 3 and 5 years following an initial trans-nasal exploration. This approach is straightforward, quick and does not require dissection of nasal mucosa or removal of septal cartilage. There was a 5.8% rate of major post-operative complications, and this compares favourably with other routes of access to the pituitary fossa. No long-term nasal, septal or dental complications have occurred, such as may happen with the other routes to the sphenoid sinus and pituitary fossa.

Topics: Adenoma; Adolescent; Adult; Aged; Child; Craniopharyngioma; Craniotomy; Female; Follow-Up Studies; Histiocytic Sarcoma; Humans; Male; Middle Aged; Neoplasm Recurrence, Local; Nose; Pituitary Diseases; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Sphenoid Sinus

Topics: Brain; Humans; Intubation, Gastrointestinal; Male; Meningitis; Methods; Middle Aged; Nose; Pituitary Neoplasms; Pneumocephalus; Reoperation; Sphenoid Sinus

Many modifications of extracranial transsphenoidal hypophysectomy exist, but knowledge of the rhinological implications of these procedures is rare. At our institution the transseptal approach is performed as a joint rhinosurgical and neurosurgical procedure. Three hundred nineteen patients were operated on from 1979 to 1984, 113 of whom had a rhinological follow-up for 5 years. Most of the complications were asymptomatic. Thirteen percent of the patients had septal perforations, 3.5% epistaxis, and 36% complained of mild dryness of the nose. An improvement in breathing was noted in 24% of the patients. There was no difference in rhinological complaints between patients who underwent the sublabial approach and those operated via a transnasal approach. Twenty percent of the patients operated on with the sublabial approach had additional temporary complaints in the upper lip; therefore, the transnasal-transseptal approach is currently our procedure of choice.

Topics: Adolescent; Adult; Aged; Consumer Behavior; Female; Follow-Up Studies; Humans; Hypophysectomy; Male; Maxilla; Middle Aged; Nasal Mucosa; Nasal Septum; Nose; Nose Diseases; Pituitary Neoplasms; Sella Turcica; Sphenoid Sinus

Topics: Humans; Hypophysectomy; Nose; Patient Care Team; Pituitary Neoplasms

We report two cases of massive invasive pituitary adenoma with the unusual presentation of nasal obstruction. In both cases the diagnosis was only made when the obstructing tissue was removed. Cases reported previously have usually presented with severe focal neurological signs or a long history of neurological symptoms. These two cases are unusual in having minimal neurological deficits despite the extension of tumour into the nasopharynx and the middle and posterior cranial fossae. These extensions were well illustrated by computerised tomography. This unusual presentation is discussed with reference to the literature.

Topics: Adenoma, Chromophobe; Adult; Airway Obstruction; Apudoma; Female; Humans; Male; Middle Aged; Neoplasm Invasiveness; Nose; Pituitary Neoplasms; Tomography, X-Ray Computed

The transsphenoidal approach to the sella turcica is nowadays more often used than the transcranial. The disadvantages of the transantral and transseptal approaches are a narrow and distant operative field and various complications. A fluoroscope often has to be used for orientation. With our lateral rhinotomy technique, no fluoroscope is needed as the whole sphenoid can be inspected. Furthermore, the operative field is wide and closer to the surgeon, few instruments are needed, bleeding is easily controlled, the anterior wall of the sella can be properly sealed, CSF rhinorrhoea prevented and the sphenoidal mucosa restored. The whole operation can be performed within 2 h. Fifty-seven patients were operated upon with good results and few complications.

Topics: Adenoma; Female; Humans; Hypophysectomy; Male; Nose; Pituitary Neoplasms; Sella Turcica; Sphenoid Bone

The transsphenoidal route to the pituitary gland is well established in neurosurgical practice, and several approaches to the sphenoidal air sinus have been described. In this paper, the authors describe a technique that utilizes a direct route through the nasal cavity, thereby minimizing disruption of normal tissues.

Topics: Humans; Nose; Pituitary Neoplasms; Sphenoid Sinus

Topics: Endoscopes; Humans; Hypophysectomy; Nose; Pituitary Neoplasms

The results of transnasal-transsphenoidal surgery in 31 patients with craniopharyngioma are evaluated. To assess the value of transnasal surgery in cases with visual impairment, the results are compared to cases operated transcranially. There was only one death occurred on the 5th postoperative day. Two patients developed rhinoliquorrhoea, and one a transient oculomotor palsy. Recurrences leading to re-operation occurred frequently after mere cyst aspiration and only once after subtotal tumour removal. Normal glandotrope functions of the hypophysis were preserved in 75%, disturbed functions were normalized in 19% of primary transnasal surgery. Visual disturbances were normalized or improved in 94% cases after transnasal surgery, whereas an improvement was observed in only 65% after transcranial surgery. A deterioration never appeared after transnasal surgery, but in 26% after transcranial operations.

Topics: Adolescent; Adult; Aged; Child; Craniopharyngioma; Cysts; Female; Humans; Male; Middle Aged; Neoplasm Recurrence, Local; Nose; Pituitary Hormones; Pituitary Neoplasms; Postoperative Complications; Quality of Life; Vision Disorders

The skeletal deformities associated with acromegaly are not reversed by correction of abnormal growth hormone dynamic. We describe a patient with acromegaly in whom facial reconstruction was undertaken after successful removal of a pituitary adenoma.

Topics: Acromegaly; Adult; Bone Transplantation; Facial Bones; Growth Hormone; Humans; Male; Mandible; Maxilla; Nose; Osteotomy; Pituitary Neoplasms; Surgery, Plastic; Tongue

Topics: Adult; Female; Humans; Hypophysectomy; Male; Nose; Pituitary Neoplasms; Septum Pellucidum; Sphenoid Sinus

Present methods of pituitary surgery had their inception in the late 1890s. The methods of Halsted, Cushing, and Hirsch of the early 1900s have been developed and refined for continued use today. The advent of the operating microscope and microsurgical operative techniques stimulated a renaissance of interest in transsphenoidal methods for resecting pituitary tumors. Various transsphenoidal approaches are in use today, the most popular being the sublabial transseptal method and the intranasal transseptal approach. These tedchniques lend themselves well to the resection of small intrasellar lesions, such as the prolactin-secreting microadenoma.

Topics: Humans; Methods; Nose; Pituitary Neoplasms; Sella Turcica; Sphenoid Sinus

Two groups of 12 patients were studied to determine the causes of hypertension during trans-sphenoidal resection of pituitary microadenomas. Two concentrations of lidocaine, 0.5 and 1.0 per cent with epinephrine 1/200,000, were used to infiltrate the nose and upper gingiva. Heart rate, electrocardiogram lead II and systolic and diastolic arterial blood pressures were monitored. Three stages were observed for changes in above parameters: nasal infiltration, nasal dissection and sellar exploration. Highly significant reductions in arterial blood pressure and pulse rate responses to infiltration and nasal dissection were achieved by increasing the lidocaine concentration used for infiltration from 0.5 to 1.0 per cent (p < 0.05). Our findings implicate reflex from nasal stimulation as the main cause of the adverse cardiovascular effects. Only minimal changes accompanied the progress of the intrasellar dissection in both groups.

Topics: Adenoma; Adult; Anesthesia; Blood Pressure; Epinephrine; Female; Humans; Hypertension; Lidocaine; Microsurgery; Middle Aged; Nose; Pituitary Neoplasms; Pulse; Sphenoid Sinus

Since the early days of pituitary surgery, a variety of transnasal approaches have been used to gain access to the sella turcica. Each of these approaches requires crossing the sphenoid sinus, hence the transsphenoidalnoidal designation of these methods. Since the growth and refinement of microsurgery as a distinct surgical discipline, there has been a coincidental maturation of transsphenoidal microsurgical techniques for the management of a variety of pituitary disorders. The present paper reviews the historical events leading to the current methods of transphenoidal pituitary surgery. Detailed descriptions of each method are given, with the advantages and disadvantages of each. The author's method is described and illustrated in a step-by-step manner, and the criteria which determine operability by transsphenoidal versus transfrontal craniotomy are discussed. The advantages which transsphenoidal techniques offer over transfrontal methods are emphasized. The paper deals with pituitary disorders on a clinical and pathological basis. The work-up of pituitary lesions is discussed, with a detailed presentation of the endocrine evaluation. Further emphasis is given to the value of tomography of the sphenosellar complex in planning operative approaches for removal of pituitary lesions, particularly when the lesion is a so-called "microadenoma," producing no obvious expansion nor erosion of the cellar floor. The author's experience in the management of 125 lesions of the pituitary or associated sella turcica is presented and complications are discussed. Because of the relatively brief period of follow-up, no conclusive evidence can be offered regarding cures in the author's series. However, on the basis of reported experience by others working in the same area, one may expect acceptable long-term improvement or cures in selected pituitary lesions operated on by transshpenoidal methods. The team management of pituitary disorders is stressed. In particular, emphasis is given to the contributions which the current day otorhinolaryngologist can make, because of his knowledge and experience in rhinological and microsurgical techniques. There is no other surgical specialty so uniquely qualified to provide operative treatment of pituitary lesions using transsphenoidal surgical pathways.

Topics: Adenoma; Cortisone; Ethmoid Bone; Fascia; History, 19th Century; History, 20th Century; Humans; Hypophysectomy; Hypopituitarism; Maxillary Sinus; Methods; Nasal Septum; Nose; Otolaryngology; Palate; Pituitary Function Tests; Pituitary Gland, Anterior; Pituitary Hormones, Anterior; Pituitary Neoplasms; Sella Turcica; Sphenoid Bone; Transplantation, Autologous

Topics: Humans; Nose; Paranasal Sinus Diseases; Pituitary Neoplasms; Sella Turcica; Sphenoid Sinus

Topics: Adenoma; Humans; Methods; Nose; Pituitary Diseases; Pituitary Gland; Pituitary Neoplasms; Postoperative Care; Sphenoid Sinus

Topics: Anesthesia, General; Humans; Hypophysectomy; Methods; Nose; Pituitary Neoplasms

Topics: Adenoma; Carotid Artery, Internal; Cerebral Arteries; Cerebral Ventriculography; Contrast Media; Female; Humans; Male; Methods; Nose; Pituitary Neoplasms; Postoperative Care; Postoperative Complications; Preoperative Care; Prognosis; Sphenoid Sinus

Topics: Adenoma; Adult; Brachial Artery; Brain; Cerebral Angiography; Female; Follow-Up Studies; Humans; Nose; Orbital Neoplasms; Paranasal Sinuses; Pituitary Gland; Pituitary Irradiation; Pituitary Neoplasms; Stereotaxic Techniques; Surgical Procedures, Operative; Yttrium Isotopes

Topics: Humans; Methods; Nose; Pituitary Neoplasms; Visual Acuity; Visual Fields

Topics: Autopsy; Catheterization; Elasticity; Humans; Models, Theoretical; Nose; Optic Chiasm; Pituitary Neoplasms; Visual Fields

Topics: History, 19th Century; History, 20th Century; Nose; Pituitary Neoplasms

Topics: Eye; Humans; Neoplasms; Nose; Pituitary Gland; Pituitary Neoplasms; Radiotherapy; Stereotaxic Techniques

Topics: Brain; Humans; Nose; Pituitary Diseases; Pituitary Gland; Pituitary Neoplasms

Topics: Humans; Neoplasms; Nose; Nose Neoplasms; Pituitary Gland; Pituitary Neoplasms