Iatrogenic Hypoglossal Nerve Palsy after Endoscopic Transnasal Transsphenoidal Pituitary Surgery

Objective: Although various techniques have been defined for the surgical resection of pituitary adenomas, the endoscopic transnasal transsphenoidal approach is preferred due to its wider surgical field of view and minimal invasiveness, resulting in lower complication rates. This study aimed to retrospectively analyze postoperative complications following endoscopic transnasal transsphenoidal pituitary surgery. Methods: Medical records of 2598 patients who underwent endoscopic transnasal transsphenoidal pituitary surgery between January 2018 and December 2024 were retrospectively reviewed. Data of age, gender, adenoma type, anesthesia management, and complications (and rates) were analyzed. Results: Of the patients, 53.2% (1381 patients) were female. The postoperative complication rate was 10.9% (338 patients), with the most common complications being cerebrospinal fluid (CSF) leak (4.4%), diabetes insipidus (3.3%), and epistaxis (2.6%). Apoplexy was most frequently observed in patients with non-secretory adenomas. Postoperatively, 48 patients (1.5%) required intensive care unit admission due to respiratory failure. The postoperative mortality rate was 0.4%. Conclusion: Endoscopic transnasal transsphenoidal surgery is a minimally invasive method for the treatment of pituitary adenomas. However, complications such as CSF leak, diabetes insipidus, and epistaxis may occur postoperatively. Establishing a multidisciplinary team is crucial to reduce complication risks and manage them effectively. Keywords: Transsphenoidal pituitary surgery, postoperative complications, pituitary adenomas, general anesthesia

Endoscopic trans-nasal trans-sphenoidal hypophysectomy is a minimally invasive surgical procedure aimed at resection of pituitary tumors. This technique is widely practiced in developed countries but is presently gaining popularity in our environment. This study was aimed at presenting our preliminary outcomes as it relates to the technique of endoscopic trans-nasal trans-sphenoidal pituitary surgery in Kano, Nigeria. This was a retrospective study of patients with pituitary tumors that presented at a government tertiary and private specialist health institutions from October 2018 to December 2019. They all had excision of varying degrees of pituitary tumors via endoscopic trans-nasal trans-sphenoidal approach under general anesthesia. There were 4 females (66.7%) and 2 males (33.3%) and their ages ranged between 25 – 60 years. They presented with varying degrees of clinical symptoms such as gynaecomastia, galactorrhea, irregular menstruation, infertility, intermittent headache and visual impairment. Four (66.7%) had complete tumor excision and 2 (33.3%) had incomplete excision. Four (66.7%) had complete symptom relief and 2 (33.3%) had significant improvement in symptoms. The complications of surgery were nasal septal adhesion 1(16.7%), CSF leak 1(16.7%) and transient diabetes insipidus 2(33.3%). All complications were resolved during admission and at follow up visits. Histopathological analysis of specimens confirmed 5 cases of pituitary adenoma and a case of pituitary Rathkes cleft cyst. Endoscopic trans-nasal trans-sphenoidal pituitary surgery is feasible and has a favorable outcome in our setting with prospects for improvement to ensure safety. Keywords: Nasal endoscopy, Sinus surgery, Pituitary tumors, Skull base, Hypophysectomy.

Objective: The endoscopic transsphenoidal pituitary surgery has gained popularity and has shown excellent results with a more comfortable postoperative course. However, the quality of the early postoperative course is not well-established in endoscopic transsphenoidal pituitary surgery. We hypothesized that the quality of the early postoperative course would be improved when an enhanced recovery after surgery (ERAS) protocol and minimally invasive endoscopic transsphenoidal pituitary surgery is implemented.Methods: We implemented a perioperative management ERAS protocol for endoscopic transsphenoidal pituitary surgery by an experienced surgeon (Yuehui Ma) in our department from January 2018. From then the endoscopic transsphenoidal pituitary surgery was implemented with a minimally invasive technique, such as bony sella reconstruction and partial nasal packing. We compared the results of 78 endoscopic transsphenoidal pituitary surgery cases during the initiation of the ERAS protocol and minimally invasive technique implementation: 37 cases in the control group and 41 cases in the ERAS group. Outcomes assessed included the effectiveness and security of surgery, postoperative hospital length of stay (LOS), and postoperative status on postoperative day 1 (POD1).Results: Postoperative status on POD1, such as nasal ventilation, out of bed, headache score, and liquid supplement, had significant improvement (P < 0.05). The median postoperative LOS decreased from 8 days in the control group to 3 days in the ERAS group (P < 0.05). The ERAS group had better economic benefit with fewer hospital charges (P < 0.05). There was no difference in the early postoperative diabetes insipidus and 30-day readmission for epistaxis, hyponatremia, or other complications between the two groups.Conclusion: The quality of the early postoperative course was improved when a neurosurgical ERAS protocol and minimally invasive endoscopic transsphenoidal pituitary surgery with partially nasal packing were implemented. Endoscopic transsphenoidal pituitary day surgery could be recommended in some classes of patients though further evaluation in large case studies is warranted.

Objective To valuate the application of computed tomography virtual endoscopy (CTVE) for endoscopic transsphenoidal pituitary surgery.Method The CTVE was applied to a series of 38 patients with pituitary adenomas operated endoscopically via the transsphenoidal approach at the Wuxi Second Hospital Affiliated Nanjing Medical University between September 2010 and June 2011.Results CTVE can be applied to simulate the endoscopic endonasal transsphenoidal pituitary surgery,and indicate the anantomic structure through the endonasal transsphenoidal approach.CTVE can preoperatively assess the morphological images of the nasal,sphenoid sinus,sellar floor and around structure,which correlated well with the intraoperative endoscopic view.The degree of pneumatization of the sphenoid sinus,the size of the sella and the sept conditions may influence the application of CTVE.Conclusions CTVE can not only act as a training simulator for the endoscopic transsphenoidal pituitary surgery,but for the experienced surgeon,it can depict the individual patient's anatomical landmarks and variations,what may help make preoperative planning and increase the safety of the endoscopic endonasal transsphenoidal pituitary surgery. Key words: Neuroendoscopy; Pituitary adenoma; Virtual endoscopy; Endonasal transsphenoidal surgery

Preservation versus resection of middle turbinate in endoscopic transnasal transsphenoidal pituitary surgery

Background: During transnasal transsphenoidal pituitary surgery (TNTSS), the primary objective is to maintain stable hemodynamics while ensuring ideal surgical conditions. This study aimed to investigate the effect of nebulized dexmedetomidine on hemodynamic parameters and the quality of the surgical field during TNTSS. Methods: Seventy-five patients scheduled for TNTSS were randomized into three groups of 25 each and received preoperative nebulization with 5 mL of nebulizing fluid consisting of 1.5 μg/kg of dexmedetomidine with saline in dexmedetomidine (D) group; 1.5 μg/kg of dexmedetomidine with 2% lignocaine in dexmedetomidine-lignocaine (DL) group and normal saline in the control (S) group. Heart rate (HR), mean blood pressure, Formmers score, anesthetic requirement, and emergence were evaluated for each group. Results: Group S had significantly higher HR and mean arterial pressure than the other two groups across various time points during surgery (P &lt; 0.01). The total requirements for fentanyl, propofol, sevoflurane, and labetalol and the incidence of delayed emergence were significantly higher in the S group compared to the other two groups (P &lt; 0.01). The D and DL groups exhibited significantly better surgical field conditions than the S group. In all the parameters assessed, patients in the D group outperformed those in the DL group. Conclusion: The administration of nebulized dexmedetomidine, both alone and in combination with lignocaine, resulted in stable hemodynamics, favorable operative conditions, reduced anesthetic requirement, and facilitated prompt emergence during TNTSS. Nebulized dexmedetomidine proved superior to its combination with lignocaine across all evaluated parameters.

The endoscopic approach for pituitary tumors is a recent innovation and is said to reduce the nasal trauma associated with transnasal transsphenoidal surgery. The authors assessed the temporal changes in the rhinological symptoms following endoscopic transsphenoidal surgery for pituitary lesions, using the General Nasal Patient Inventory (GNPI). The GNPI was administered to 88 consecutive patients undergoing endoscopic transsphenoidal surgery at 3 time points (presurgery, 3-6 months postsurgery, and at final follow-up). The total GNPI score and the scores for the individual GNPI questions were calculated and differences between groups were assessed once before surgery, several months after surgery, and at final follow-up. Of a maximum possible score of 135, the mean GNPI score at 3-6 months postsurgery was only 12.9 ± 12 and was not significantly different from the preoperative score (10.4 ± 13) or final follow-up score (10.3 ± 10). Patients with functioning tumors had higher GNPI scores than those with nonfunctioning tumors for each of these time points (p < 0.05). Individually, a mild increase in symptom severity was seen for symptoms attributable to the nasal trauma of surgery, with partial recovery (nasal sores and bleeding) or complete recovery (nasal blockage, painful sinuses, and unpleasant nasal smell) by final follow-up (p < 0.05). Progressive improvements in symptom severity were seen for symptoms more attributable to tumor mass preoperatively (for example, headaches and painkiller use [p < 0.05]). In total, by final follow-up 8 patients (9%) required further treatment or advice for ongoing nasal symptoms. Endoscopic transsphenoidal surgery is a well-tolerated minimally invasive procedure for pituitary fossa lesions. Overall patient-assessed nasal symptoms do not change, but some individual symptoms may show a mild worsening or overall improvement.

Transsphenoidal microscopic pituitary surgery is an effective way of treating pituitary tumors. However, minimal invasive approach endoscopic transsphenoidal pituitary surgery has become much more prevalent these days. Endoscopic surgery resects the maximum tumour with less complications. As endoscopic surgery is much safer and less invasive as compared to the microscopic transsphenoidal surgery, selection of technology for the treatment of pituitary adenoma is becoming increasingly equivocal. The main aim of this systematic review was to assess the safety of endoscopic and microscopic transsphenoidal pituitary surgery in terms of postoperative complications. Relevant studies between January 1992 and January 2017 were searched in the Cochrane Library electronic databases, EMBASE and MEDLINE, through a systematic literature search. A total of 1,463 patients reviewed (microscopic group=684, endoscopic group=779), the proportion of diabetes insipidus, septal perforation and other complications related to surgery (include lip anesthesia, nasal anesthesia, deviated septum, saddle nose, sinusitis, synechiae, anosmia) in those patients who had endoscopic surgery were significantly lower (p<0.05). No significant difference emerged between the two approaches in the incidence rates of cerebrospinal fluid leak, meningitis, epistaxis or hypopituitarism (p>0.05). These results support the safety of endoscopic transsphenoidal pituitary adenoma surgery.

Intra-operative CSF leak during endoscopic trans-sphenoidal surgery is not uncommon. Surgical repair with a variety of autologous grafts, rigid buttresses and CSF diversion techniques that add time and complexity have been reported. To describe a simple and purely synthetic closure for low-grade CSF leaks following endoscopic trans-sphenoidal pituitary surgery. A retrospective review of all endoscopic trans-sphenoidal surgery undertaken for pituitary pathology between 2005 and 2010 was carried out. The grade of CSF leak and success of graded repair was noted. Patients with no CSF leak (grade 0) had gelatin sponge placed in the tumour cavity. In those with low-grade CSF leak through small arachnoid defects (grade 1), repair was carried out using gelatin sponge and hydrogel sealant overlay. CSF diversion was not employed for low-grade CSF leaks. Of the 255 endoscopic trans-sphenoidal surgeries, 158 (62%) had no leak (grade 0) and 74 (29%) had a low-grade leak (grade 1). Repairs in all cases were of grade 0, and all but two cases of grade 1 CSF leak were successful at a mean follow-up of 29 months. The 2 (2.7%) post-operative CSF leaks were seen within 6 weeks of surgery. Both cases were related to bouts of sneezing and were repaired using further trans-sphenoidal surgery and/or lumbar CSF diversion. A simple purely synthetic repair of low-grade CSF leaks is described. This repair is safe and comparable in efficacy whilst avoiding the morbidity related to more complex sellar reconstructions previously described.

Intraoperative high-field magnetic resonance imaging (iMRI) is a useful modality for immediate intraoperative quality control. With iMRI, a surgeon can confirm whether tumor remnants exist during surgery; which makes it possible to add further resection, obtain a higher resection rate, and improve the cure rate. It is sometimes difficult to evaluate the existence of tumor remnants when the tumor resection cavity is collapsed. In this study, we reported a simple technique for comparing pre- and intraoperative MR images. Thirty-five consecutive patients with pituitary adenoma underwent endoscopic endonasal transsphenoidal surgery using iMRI. Twenty-six patients had adenomas with suprasellar extension, and 9 had intrasellar adenomas. Nine adenomas had cavernous sinus invasion. Eight patients had endocrine-active, and 27 endocrine-inactive tumors. The simple technique included wet cotton pledgets inserted into the resection cavity to easily and precisely compare pre- and intraoperative MR images. Furthermore, we evaluated the efficacy of iMRI using our method on determining the extent of tumor resection in this study. The first iMRI scan showed that 12 of 35 patients had some tumor remnants, and 23 patients did not. Eight of these 12 patients with tumor remnants had cavernous sinus invasion. Three cases received further tumor resection after iMRI and had a gross total removal. We presented our initial results after using a simple method in high-field iMRI during endoscopic transnasal transsphenoidal pituitary surgery. This procedure allowed us to obtain valuable information to determine the extent of tumor resection and to precisely visualize the parasellar structures.

Objectives The aim of this study was to identify the reasons for patient messages, phone calls, and emergency department (ED) visits prior to the first postoperative visit following discharge after endoscopic transnasal transsphenoidal (eTNTS) surgery. Design This is a retrospective review of patients at a tertiary care academic center who underwent eTNTS for resection of a sellar region tumor between May 2020 and August 2021. Patient, tumor, and surgical characteristics were collected, along with postoperative, postdischarge, and readmission information. Regression analyses were performed to investigate risk factors associated with postdischarge phone calls, messages, ED visits, and readmissions. Main Outcome Measures The main outcomes were the number of and reasons for phone calls, patient messages, and ED visits between hospital discharge and the first postoperative visit. We additionally determined whether these reasons were addressed in each patient's discharge instructions. Results A total of 98 patients underwent eTNTS during the study period. The median length of hospital stay was 2 days (interquartile range [IQR]: 1-4 days), at which point most patients (82%) were provided with eTNTS-specific discharge instructions. First postoperative visit took place 9 days after discharge (IQR: 7-10 days). Within that time, 54% of patients made at least one phone call or sent at least electronic message and 17% presented to the ED. Most common reasons for call/message were nasal care, appointment scheduling, and symptom and medication questions. Conclusion Through this work, we highlight the most common reasons for resource utilization via patient phone calls, messages, and ED visits among our cohort to better understand any shortfall or gap in the discharge process that may reduce these events.

Introduction. Pituitary surgery has seen a recent shift from a microscopic to an endoscopic trans-sphenoidal approach. We present our early experience with endoscopic surgery and compare the outcome with our recent microscopic experience. Methods. From January 2008 until present time, 80 consecutive patients underwent trans-sphenoidal pituitary surgery in our institution. Until September 2009, all patients had a microscopic trans-septal approach. After this time, the patients underwent endoscopic trans-sphenoidal surgery. All patients underwent pre- and post-operative MRI and full endocrinological evaluation. Data was collected prospectively including tumour volume, endocrine function, visual function, length of stay and complications. Results. There were 40 patients in each group. In the microscopic group, there were 26 non-functioning tumours and 14 functioning tumours. In the endoscopic group, there were 24 non-functioning and 16 functioning tumours. There were significantly better results in terms of tumour resection (p = 0.002) and remission (p = 0.018) in the endoscopic group. In this group there was also a lower incidence of CSF leaks and a shorter length of stay for secreting tumours (p = 0.005). 1 patient in the endoscopic group died at day 43 post-operatively, having initially presented in a poor clinical state with pituitary apoplexy. Conclusion. Microscopic trans-sphenoidal surgery remains the benchmark for future surgical techniques. Our early results suggest that endoscopic trans-sphenoidal surgery provides favourable results in both tumour resection and control of secreting tumours in comparison with microscopic surgery. Further longer-term evaluation is required to ensure the outcome of endoscopic surgery.

Objective To analyze the outcomes of neuro endoscopic and microscopic pituitary adenoma surgery. Methods A total of 862 cases were enrolled in between October 2010 and October 2011, including 226 cases in endoscopic group and 636 in microscopic group. The extent of tumor resection, visual improvement, operation time and hospitalization days were compared between two groups. Results There was no statistical difference in the extent of tumor resection in microadenomas and giant pituitary adenomas between two groups. While endoscopic surgery resulted in superior resection in macroadenomas. Analyzed by Knosp grading, according to the removal rates, there was no significant difference showed at Knosp level 0-2 and level 4, while endoscopic surgery resulted in superior resection at level 3(P<0.05). The visual acuity and visual field were better in the endoscopic group. The operation time and length of stay in hospitals were both shorter in the endoscopic group than those in the microscopic group. Conclusions Endoscopic transsphenoidal resection of pituitary tumors was safe, with shorter operation time and length of stay. Endoscopic and microscopic transsphenoidal operations had their own advantages, and the advantage of endoscopic transsphenoidal surgery lied in the treatment of invasive adenoma of Knosp 3 grade. Key words: Neuroendoscopes; Microsurgery; Pituitary neoplasms; Prospective studies; Transnasal transsphenoidal approach

Endoscopic transnasal transsphenoidal (ETT) surgery has become the standard approach for pituitary adenoma resection, yet postoperative nasal morbidity remains a concern. This study aims to evaluate rhinologic outcomes after ETT surgery, characterize the types and frequencies of postoperative nasal complications, and assess the effectiveness of treatment strategies. The primary research question addresses the incidence and reversibility of nasal morbidity following ETT surgery. A retrospective review was performed on 414 patients who underwent ETT surgery for pituitary adenomas at our institution between August 2015 and August 2025. Postoperative nasal complaints and complications were documented, including epistaxis, sinusitis, nasal adhesions, olfactory disturbances, and crusting. Clinical outcomes following targeted treatments were analyzed. Seventeen patients (4.1%) experienced postoperative nasal complications. These included epistaxis (n = 2), isolated sphenoid sinusitis (n = 3), nasal adhesions (n = 4), olfactory disorders (n = 2), and nasal crusting (n = 6). All complications were managed conservatively or with minor interventions, and all affected patients experienced clinical improvement and symptom resolution during follow-up. Postoperative rhinologic complication rates following ETT surgery for pituitary adenomas are low and generally reversible with appropriate management. These findings support the safety of the ETT approach while emphasizing the importance of careful perioperative planning and postoperative nasal care.

Cerebral vasospasm (CVS) due to injuries to arteries of the circle of willies has been reported in transsphenoidal pituitary surgeries. However, the incidence of delayed vasospasm following endoscopic transsphenoidal surgery is rare. Total 569 pituitary adenomas were operated on by endoscopic transsphenoidal approach from January 2016 to February 2020. We retrospectively described two cases of vasospasm following pituitary surgery from our institution. To describe two cases of delayed cerebral vasospasm following endoscopic transsphenoidal surgery and review previous literature. Out of two patients, the Glasgow outcome score (GOS) of one patient was favorable and the other was unfavorable. CVS is rare after transsphenoidal pituitary surgery, which makes its predictability difficult. The clinician should maintain a high index of suspicion in patients with suprasellar extension of the tumor and postoperative hematoma in the tumor bed. Similarly, care should be taken in patients with a subarachnoid hemorrhage in basal cistern, intraoperative arachnoid breach, and postoperative meningitis.