Endonasal Endoscopic Pituitary Surgery Research Articles

Collaborative Human-Computer Vision Operative Video Analysis Algorithm for Analyzing Surgical Fluency and Surgical Interruptions in Endonasal Endoscopic Pituitary Surgery: Cohort Study.

The endonasal endoscopic approach (EEA) is effective for pituitary adenoma resection. However, manual review of operative videos is time-consuming. The application of a computer vision (CV) algorithm could potentially reduce the time required for operative video review and facilitate the training of surgeons to overcome the learning curve of EEA. This study aimed to evaluate the performance of a CV-based video analysis system, based on OpenCV algorithm, to detect surgical interruptions and analyze surgical fluency in EEA. The accuracy of the CV-based video analysis was investigated, and the time required for operative video review using CV-based analysis was compared to that of manual review. The dominant color of each frame in the EEA video was determined using OpenCV. We developed an algorithm to identify events of surgical interruption if the alterations in the dominant color pixels reached certain thresholds. The thresholds were determined by training the current algorithm using EEA videos. The accuracy of the CV analysis was determined by manual review, and the time spent was reported. A total of 46 EEA operative videos were analyzed, with 93.6%, 95.1%, and 93.3% accuracies in the training, test 1, and test 2 data sets, respectively. Compared with manual review, CV-based analysis reduced the time required for operative video review by 86% (manual review: 166.8 and CV analysis: 22.6 minutes; P<.001). The application of a human-computer collaborative strategy increased the overall accuracy to 98.5%, with a 74% reduction in the review time (manual review: 166.8 and human-CV collaboration: 43.4 minutes; P<.001). Analysis of the different surgical phases showed that the sellar phase had the lowest frequency (nasal phase: 14.9, sphenoidal phase: 15.9, and sellar phase: 4.9 interruptions/10 minutes; P<.001) and duration (nasal phase: 67.4, sphenoidal phase: 77.9, and sellar phase: 31.1 seconds/10 minutes; P<.001) of surgical interruptions. A comparison of the early and late EEA videos showed that increased surgical experience was associated with a decreased number (early: 4.9 and late: 2.9 interruptions/10 minutes; P=.03) and duration (early: 41.1 and late: 19.8 seconds/10 minutes; P=.02) of surgical interruptions during the sellar phase. CV-based analysis had a 93% to 98% accuracy in detecting the number, frequency, and duration of surgical interruptions occurring during EEA. Moreover, CV-based analysis reduced the time required to analyze the surgical fluency in EEA videos compared to manual review. The application of CV can facilitate the training of surgeons to overcome the learning curve of endoscopic skull base surgery. ClinicalTrials.gov NCT06156020; https://clinicaltrials.gov/study/NCT06156020.

The Endonasal Endoscopic Approach to Different Sinonasal Fungal Balls.

Background Fungal ball sinusitis is a sinonasal fungus ball that usually affects immunocompetent adults with female predominance. The most affected sinus is the maxillary sinus. Aspergillus species is the most typically found fungus. Computed tomography (CT) scan is the gold standard tool in order to diagnose fungal ball sinusitis. The ultimate method for a fungal ball is functional endoscopic sinus surgery (FESS), which has a high success rate and a low morbidity rate. Objective This study aims to demonstrate the various clinical presentations of fungal ball sinusitis including isolated maxillary sinus, sphenoid sinus, simultaneous occurrence of maxillary and sphenoid fungal ball, and post endonasal endoscopic pituitary surgery fungal ball with various age groups. Also, this study aims to emphasize the importance of early diagnosis and treatment in such cases. Patients and Methods. A retrospective study that was carried in the otorhinolaryngology department of two hospitals: King Fahad Specialist Hospital and Qatif Central Hospital, Eastern Region, Saudi Arabia. The study was conducted on a total of 16 patients who were diagnosed with paranasal sinuses fungal ball in an 11-year period from January 2008 and November 2019. Results Out of 16 patients with paranasal sinuses fungal ball, 11 cases were female and 5 males, with age ranging between 16 and 46 years. Results showed eight isolated sphenoid (50%), six isolated maxillary fungal ball (38%), one simultaneous occurrence of the sphenoid and maxillary fungal ball (6%), and one post endonasal endoscopic pituitary surgery for pituitary adenoma (6%). CT scan was performed for all 16 cases which is the standard tool for the diagnosis of the fungal ball. Conclusion Fungal ball may present with variety of symptoms but most commonly with postnasal discharge (PND), headache, and facial pain. CT sinuses is the diagnostic radiological modality to confirm the diagnosis. The FESS functional endoscopic sinus surgery is the gold safe approach for patients with fungal ball to manage their symptoms, confirm the diagnosis, and removal of disease with no morbidities.

Aerosolisation in endonasal endoscopic pituitary surgery.

PurposeTo determine the particle size, concentration, airborne duration and spread during endoscopic endonasal pituitary surgery in actual patients in a theatre setting.MethodsThis observational study recruited a convenience sample of three patients. Procedures were performed in a positive pressure operating room. Particle image velocimetry and spectrometry with air sampling were used for aerosol detection.ResultsIntubation and extubation generated small particles (< 5 µm) in mean concentrations 12 times greater than background noise (p < 0.001). The mean particle concentrations during endonasal access were 4.5 times greater than background (p = 0.01). Particles were typically large (> 75 µm), remained airborne for up to 10 s and travelled up to 1.1 m. Use of a microdebrider generated mean aerosol concentrations 18 times above baseline (p = 0.005). High-speed drilling did not produce aerosols greater than baseline. Pituitary tumour resection generated mean aerosol concentrations less than background (p = 0.18). Surgical drape removal generated small and large particles in mean concentrations 6.4 times greater than background (p < 0.001).ConclusionIntubation and extubation generate large amounts of small particles that remain suspended in air for long durations and disperse through theatre. Endonasal access and pituitary tumour resection generate smaller concentrations of larger particles which are airborne for shorter periods and travel shorter distances.

Complication Avoidance in Endonasal Endoscopic Pituitary Surgery.

Endoscopic endonasal surgery for pituitary tumors can be performed safely with a good outcome. Complications are uncommon and relate most often to nearby structures at risk. The authors detail the nuances, tips and tricks useful in avoiding complications and their early detection and management.

Endonasal endoscopic pituitary surgery in the elderly.

OBJECTIVE Pituitary adenomas are benign, slow-growing tumors that cause symptoms either through mass effect or hormone overproduction. The decision to operate on a healthy young person is relatively straightforward. In the elderly population, however, the risks of complications may increase, rendering the decision more complex. Few studies have documented the risks of surgery using the endonasal endoscopic approach in a large number of elderly patients. The purpose of this study was to audit a single center's data regarding outcomes of purely endoscopic endonasal transsphenoidal resection of pituitary adenomas in elderly patients and to compare them to the current literature. METHODS A retrospective review of a prospectively acquired database of all endonasal endoscopic surgeries done by the senior authors was queried for patients aged 60-69 years and for those aged 70 years or older. Demographic and radiographic preoperative data were reviewed. Outcomes with respect to extent of resection and complications were examined and compared with appropriate statistical tests. RESULTS A total of 135 patents were identified (81 aged 60-69 years and 54 aged 70 years or older [70+]). The average tumor diameter was slightly larger for the patients in the 70+ age group (mean [SD] 25.7 ± 9.2 mm) than for patients aged 60-69 years (23.1 ± 9.8 mm, p = 0.056). There was no significant difference in intraoperative blood loss (p > 0.99), length of stay (p = 0.22), or duration of follow-up (p = 0.21) between the 2 groups. There was a 7.4% complication rate in patients aged 60-69 years (3 nasal and 3 medical complications) and an 18.5% complication rate in patients older than 70 years (4 cranial, 3 nasal, 1 visual, and 2 medical complications; p = 0.05 overall and 0.013 for cranial complications). Cranial complications in the 70+ age category included 2 postoperative hematomas, 1 pseudoaneurysm formation, and 1 case of symptomatic subdural hygromas. CONCLUSIONS Endonasal endoscopic surgery in elderly patients is safe, but there is a graded increase in complication rates with increasing age. The decision to operate on an asymptomatic or mildly symptomatic patient in these age groups should take this increasing complication rate into account. The use of a lumbar drain or lumbar punctures should be weighed against the risk of subdural hematoma in patients with preexisting atrophy.

Resection of pituitary tumors: endoscopic versus microscopic.

Transsphenoidal microscopic pituitary surgery has long been considered the gold standard in surgical treatment of pituitary tumors. Endonasal endoscopic pituitary surgery has come into prominence over the last two decades as an alternative to microscopic surgery. In this review, we use recent literature to discuss the advantages and disadvantages of each approach. Our review shows that for small intrasellar tumors, both approaches appear equally effective in experienced hands. For larger tumors with extrasellar extension, the endoscopic approach offers several advantages and may improve outcomes associated with the extent of resection and postoperative complications.

Endonasal Endoscopic Surgery for Pituitary Adenoma

Introduction: Since the first surgery for pituitary pathology was performed in 1889 by Sir Victor Horsley using a transcranial approach, numerous technical advancements have allowed for safer and more efficacious pituitary surgery.1 Currently, the transsphenoidal approach is used for the vast majority of pituitary adenomas. Over the past 20 years, there has been an evolution of the technique from a microscope-based approach using a sublabial or nasal speculum to a fully endoscopic approach without a speculum for the removal of pituitary adenomas and other parasellar tumors. The reason for this transition to an endoscopic approach is that it affords superior visualization over the microscope into the sellar and suprasellar areas as well as cavernous sinus areas. This superior visualization appears to translate into greater degrees of tumor removal, especially for larger macroadenomas over 2 cm in maximal diameter.2 Since 2009, the senior author has used a solely endoscopic approach for visualization during the endonasal pituitary surgery. This video is intended to illustrate the indications and some of the technical nuances of the endonasal endoscopic approach for pituitary adenomas. Materials and Methods: Endonasal endoscopic pituitary surgery at our center is performed using a two surgeon team. All operations are performed in the endoscopic operating suite, which is equipped with a high-definition operating endoscope camera/recording system and high-definition, ceiling-mounted liquid crystal display screens for each surgeon. Zero degree, 30°, and 45° angled endoscopes are used during the operations. Typically, an otolaryngologist performs the initial endonasal approach to the sphenoid sinus and raises bilateral nasal septal mucosal flaps that aim to preserve the sphenopalatine vascular pedicles to the septal mucosa and the olfactory mucosa. Next, the neurosurgeon, using endoscopic visualization by the otolaryngologist, uses a binostril approach to perform the remainder of the sphenoid sinus and sellar exposure, tumor removal, and sellar skull base reconstruction. Case Example and Results: An endonasal endoscopic pituitary surgery is demonstrated in a man with a nonfunctioning (endocrine-inactive) pituitary macroadenoma associated with hypopituitarism. The video demonstrates the endonasal approach, sphenoidotomy, sellar exposure, tumor removal, and sellar reconstruction. A gross total tumor resection was achieved in this patient, although microscopic tumor likely remains in the right cavernous sinus. The patient did well after the surgery with stable hypopituitarism at 3 months after the surgery; his MRI showed no obvious residual tumor. Conclusions: Endonasal endoscopic pituitary adenoma removal has been shown to be safe and effective with equivalent and possibly better tumor removal rates compared with the traditional microscopic approach. A team approach that includes both neurosurgery and otolaryngology is highly recommended for these technically challenging cases. Daniel F. Kelly receives royalties from Mizuho incorporated. The rest of the authors report no competing financial interests. Runtime of video: 10 mins 22 secs

Endoscopic Endonasal Pituitary and Skull Base Surgery

Here we describe the procedures of endoscopic pituitary and skull base surgery in our institute. We also review the literature to reveal recent advances in this field. Endonasal approach via the sphenoid ostium was carried out for pituitary lesions without the nasal speculum. Postoperative nasal packing was basically not needed in such cases. For meningiomas, craniopharyngiomas, and giant pituitary adenomas, which required intra-dural procedures, nasal procedures such as middle nasal conchotomy and posterior ethmoidectomy, and skull base techniques such as optic canal decompression and removal of the planum sphenoidale were carried out to gain a wider operative field. Navigation and ultrasonic Doppler ultrasonography were essential. Angled endoscopes allowed more successful removal of tumors under direct visualization extending into the cavernous sinus and lower clivus. If cerebrospinal fluid (CSF) leakage occurred during operation, the dural opening was covered with a vascularized mucoseptal flap obtained from the nasal septum. Lumbar drainage system to prevent postoperative CSF rhinorrhea was frequently not required. Angled suction tips, single-shaft coagulation tools, and slim and longer holding forceps, all of which were newly designed for endoscopic surgery, were essential for smoother procedures. Endonasal endoscopic pituitary surgery allows less invasive transsphenoidal surgery since no postoperative nasal packing and less dependence on lumbar drainage are needed. Endoscopic pituitary surgery will be more common and become a standard procedure. Endoscopic skull base surgery has enabled more aggressive removal of extrasellar tumors with the aid of nasal and skull base techniques. Postoperative CSF leakage is now under control due to novel methods which have been proposed to close the dural defect in a water-tight manner. Endoscopic skull base surgery is more highly specialized, so needs special techniques and surgical training. Patient selection is also important, which needs collaboration with ear, nose, and throat specialists. As a safe and successful procedure in skull base surgery, this complex procedure should be carried out only in specialized hospitals, which deal with many patients with skull base lesions.

Endonasal endoscopic pituitary surgery: is it a matter of fashion?

Dear Editor, We read with great interest the well-written review article by Michael Powell, Microscopic and endoscopic pituitary surgery, published in the July 2009 issue of Acta Neurochirurgica [5]. The author is to be particularly commended for completing a comprehensive overview of pituitary surgery based on a literature review and personal experience. The article nicely details common pituitary lesions, indications, and options for treatment. While we agree with most of the described concepts, we are concerned about the final statement of the “review” article: “No-one should change their style simply because of fashion.” As written by Powell, pituitary adenomas are “one of the most benign tumours to be found anywhere in the body,” and therefore outcome will not be dramatically changed depending upon the visualization tool used for their removal. Although not explicated by Powell, the key for increasing remission rates on the more challenging secreting pituitary adenomas (e.g., ACTH secreting) is to successfully perform an extracapsular dissection and removal of the lesion, as described by Oldfield and Vortmeyer [4], disregarding the use of the endoscope or the microscope. The dramatic difference between the endoscope and the microscope as surgical tools is related to the expanded endonasal approach. The expanded endonasal endoscopic approach is a new paradigm in skull base surgery that allows for more effective removal of ventrally located skull base lesions [3]. As an example, chordomas and chondrosarcomas can be completely removed by performing bilateral paraclival carotid mobilization with carotid canal resection, retrocarotid tumor removal, medial petrous apex drilling, abducens nerve decompression, and extradural posterior clinoid removal, if needed [2]. Craniopharyngiomas as well as diaphragmatic, tuberculum sellae and planum meningiomas can be removed with accurate preservation of vital arterial perforators, branches of the ICA, superior hypophyseal artery, and posterior communicating artery, which supply the optic apparatus and diencephalic structures [1]. Complex and invasive pituitary adenomas can spread away from the sella turcica and behave as the tumors cited above. The endoscopic approaches are far superior to microscopic ones when removing pituitary adenomas in the cavernous sinus, superior orbital fissure, Meckel’s cave, and other parasellar locations. The learning curve for such demanding surgical procedures should follow a clear pathway: intense endoscopic, microsurgical, and neuroanatomy laboratory training, dedicated observation of experienced surgeons, and progressive surgical experience. Mastering endoscopic pituitary surgery represents the mandatory requirement for pursuing expanded endonasal approaches. Is this a matter of fashion? We are convinced it is a matter of offering patients the safest and more effective surgical treatment for such challenging lesions. J. C. Fernandez-Miranda :D. M. Prevedello : P. Gardner : R. Carrau :C. H. Snyderman :A. B. Kassam Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

Irrigation-Suction Straw Sheath System for a Rigid Endoscope during Endonasal Endoscopic Pituitary Surgery

One of the most problematic conditions during endonasal endoscopic pituitary surgery is blurred endoscopic vision caused by blood or bone dust. To address this problem we used a new device, the irrigation-suction straw sheath system originally developed for endoscopic sinus surgery in rhinology, for the endoscopic pituitary surgery. The irrigation-suction straw system (K-endosheath; Koken Co., Tokyo, Japan) consists of a flattened disposable straw catheter which can be attached on a rigid endoscope. When the endoscope is inserted into the oblong catheter, two gaps remain on either side of the endoscope. Through each of these gaps irrigation and continuous suction are performed respectively. Clear vision could be immediately obtained by pressing the button to release the irrigation water onto the endoscope's front lens. Even targeted irrigation during drilling was possible. Above all, continuous suction was useful to clear the operative field of blood, smoke, or bone dust, ensuring the safety and uninterrupted progress of the procedure. This irrigation-suction system has proved to be very useful and easy to use for endonasal endoscopic pituitary surgery. Further development of such new devices and instruments specialized for endonasal endoscopic pituitary surgery will promote the increased use of this minimally invasive technique in neurosurgery.