Endonasal Resection Of Pituitary Adenomas Research Articles

Postoperative Hyponatremia After Endoscopic Endonasal Resection of Pituitary Adenomas: Historical Complication Rates and Risk Factors

Hyponatremia is a common complication following endoscopic endonasal resection (EER) of pituitary adenomas. We report a single center, multi-surgeon study detailing baseline clinical data, outcomes, and factors associated with postoperative hyponatremia. A retrospective cohort study of patients undergoing EER for pituitary adenoma at Tufts Medical Center was conducted. Most procedures were performed by the senior author (CBH). Cases were included if at least one postoperative sodium value was available and pathology confirmed pituitary adenoma. Hyponatremia was considered postoperative sodium <135 mEq/L. 272 patients underwent 310 EER procedures that met study criteria. Mean age was 53.3 years and mean tumor size was 18.8 mm. Postoperative hyponatremia occurred in 12.6% of cases, with 3.6% developing hyponatremia prior to discharge. Lower pre-operative sodium was associated with increased risk of developing any postoperative hyponatremia. Older age, prolactinoma pathology, and SSRI use were associated with moderate-severe hyponatremia (≤129 mEq/L), while lower preoperative sodium was associated with mild hyponatremia (130-134 mEq/L). Hyponatremia-related readmissions within 30 days occurred in 3.9% of patients. African-American race and postoperative hyponatremia were both associated with an increased risk of 30-day readmission. Mean nadir sodium for hyponatremic patients was 129.9 mEq/L. Growth hormone secreting pathology was associated with lower postoperative nadir sodium, while higher preoperative sodium was associated with higher postoperative nadir sodium. Hyponatremia is a common postoperative complication of EER for pituitary lesions that can cause significant morbidity, increase readmissions, and lead to increased healthcare costs.

A Predictive Model for Intraoperative Cerebrospinal Fluid Leak During Endonasal Pituitary Adenoma Resection Using a Convolutional Neural Network

Cerebrospinal fluid (CSF) leak during endoscopic endonasal transsphenoidal surgery can lead to postoperative complications. The clinical and anatomic risk factors of intraoperative CSF leak are not well defined. We applied a two-dimensional (2D) convolutional neural network (CNN) machine learning model to identify risk factors from preoperative magnetic resonance imaging. All adults who underwent endoscopic endonasal transsphenoidal surgery at our institution from January 2007 to March 2023 who had accessible preoperative stereotactic magnetic resonance imaging were included. A retrospective classic statistical analysis was performed to identify demographic, clinical, and anatomic risk factors of intraoperative CSF leak. Stereotactic T2-weighted brain magnetic resonance imaging scans were used to train and test a 2D CNN model. Of 220 included patients, 81 (36.8%) experienced intraoperative CSF leak. Among all preoperative variables, visual disturbance was the only statistically significant identified risk factor (P= 0.008). The trained 2D CNN model predicted CSF leak with 92% accuracy and area under receiver operating characteristic curve of 0.90 (sensitivity of 86% and specificity of 93%). Class activation mapping of this model revealed that anatomic regions of CSF flow were most important in predicting CSF leak. Further review of the class activation mapping gradients revealed regions of the diaphragma sellae, clinoid processes, temporal horns, and optic nerves to have anatomic correlation to intraoperative CSF leak risk. Additionally, visual disturbances from anatomic compression of the optic chiasm were the only identified clinical risk factor. Our 2D CNN model can help a treating team to better anticipate and prepare for intraoperative CSF leak.

500 Endoscopic Endonasal Resection of the Medial Wall of the Cavernous Sinus: Initial Experience and Impact on Pituitary Surgery Outcomes

INTRODUCTION: Invasion of the medial wall of the cavernous sinus (CS) by pituitary tumors is a factor associated with persistence of disease and subtotal resection of these tumors. Resection of the medial wall of the CSis therefore an option for maximum resection of such tumors, however, there is concern with potential complications associated with this technique and at this time, limited data is available in the literature. METHODS: Single center retrospective study evaluating patients that underwent endoscopic endonasal resection of pituitary adenomas and resection of the medial wall of the CS, between January 2022 and February 2023. Extent of resection, remission rates, complications and histopathological diagnosis were assessed. RESULTS: Out of a population of 120 pituitary surgeries, sixteen cases were eligible for this study. 5 (31.2%) patients had non-functional adenomas, and 11 (68.7%) had functional adenomas, including 4 adrenocorticotropic hormone, 3 prolactin, 3 growth-hormone, 1 pluri-hormonal (GH and prolactin)—secreting tumors. Complete tumor resection, based on intraoperative impression and postoperative MRI, was achieved in all cases. At last follow-up, complete biochemical remission (using current criteria) was seen in 11 cases (100%) of functional adenomas. One case developed pulmonary embolism and another one sino-nasal infection postoperatively. No fatalities, carotid injuries or cranial nerve palsies were reported. CONCLUSIONS: Resection of the medial wall of the cavernous sins, performed when there is potential tumor extension into the medial wall, is associated with high rates of disease control. It is particularly useful in cases of functioning but also has a role in non-functional adenomas adherent to the medial wall of the CS. Long term follow up is necessary to evaluate the durability of these results.

Side-firing intraoperative ultrasound applied to resection of pituitary macroadenomas and giant adenomas: A single-center retrospective case-control study.

Multiple intraoperative navigation and imaging modalities are currently available as an adjunct to endoscopic transsphenoidal resection of pituitary adenomas, including intraoperative CT and MRI, fluorescence guidance, and neuronavigation. However, these imaging techniques have several limitations, including intraoperative tissue shift, lack of availability in some centers, and the increased cost and time associated with their use. The side-firing intraoperative ultrasound (IOUS) probe is a relatively new technology in endoscopic endonasal surgery that may help overcome these obstacles. A retrospective analysis was performed on patients admitted for resection of pituitary adenomas by a single surgeon at the University of Mississippi Medical Center. The control (non-ultrasound) group consisted of twelve (n=12) patients who received surgery without IOUS guidance, and the IOUS group was composed of fifteen (n=15) patients who underwent IOUS-guided surgery. Outcome measures used to assess the side-firing IOUS were the extent of tumor resection, postoperative complications, length of hospital stay (LOS) in days, operative time, and self-reported surgeon confidence in estimating the extent of resection intraoperatively. Preoperative data analysis showed no significant differences in patient demographics or presenting symptoms between the two groups. Postoperative data revealed no significant difference in the rate of gross total resection between the groups (p = 0.716). Compared to the non-US group, surgeon confidence was significantly higher (p < 0.001), and operative time was significantly lower for the US group in univariate analysis (p = 0.011). Multivariate analysis accounting for tumor size, surgeon confidence, and operative time confirmed these findings. Interestingly, we noted a trend for a lower incidence of postoperative diabetes insipidus in the US group, although this did not quite reach our threshold for statistical significance. Incorporating IOUS as an aid for endonasal resection of pituitary adenomas provides real-time image guidance that increases surgeon confidence in intraoperative assessment of the extent of resection and decreases operative time without posing additional risk to the patient. Additionally, we identified a trend for reduced diabetes insipidus with IOUS.

ODP319 IGF-1 and BMI are Associated in Obese Patients with Acromegaly

Abstract Regulation of the growth hormone (GH) axis is complex and influenced by factors including age and nutritional status. Studies of individuals across the weight spectrum demonstrate an inverted U-shaped correlation between BMI and total IGF-1 levels; in both individuals with anorexia nervosa-range BMIs and those who are severely obese, total IGF-1 levels are low. Acromegaly is a disorder of the GH/IGF-1 axis characterized by IGF-1 excess secondary to autonomous GH secretion. The relationship between BMI and IGF-1 levels has not been well studied in acromegaly and whether the association between BMI and IGF-1 observed in non-acromegalic individuals is also present in acromegaly is not known. Patients who underwent endoscopic endonasal resection of pituitary adenomas at our institution between 1/2015-6/1/2021 were studied to investigate the association between BMI and preoperative IGF-1 in acromegaly. Ninety-nine patients were identified who either had evidence of preop biochemical hormone excess [elevated IGF-1 level and/or GH &amp;gt;1ng/ml following 75g oral glucose tolerance test] (n=40) or who had a clinically non-functioning, non-staining (NF) pituitary adenoma, or non-functioning GH-staining adenomas (n=59). We excluded anyone with a prior history of surgery/radiation, those on medical therapy (including somatostatin analogues, cabergoline), and those on oral contraceptives in the 3-months preceding surgery (n=8 in each group). Median age of acromegaly patients (n=32) was 39.5 years [29.3, 51.8], mean BMI was 30.2 +5.3 (SD) kg/m 2 (range: 20.9-40.4 kg/m 2) and 50% were female. Preoperative IGF-1 levels were measured using a clinically available assay. To control for differences in IGF-1 levels based on age/sex, we calculated % upper limit of normal (ULN) for IGF-1 based on age/sex determined normal ranges (mean %ULN IGF-1: 219.7+74.8%). In the acromegalic group, univariate analysis demonstrated a significant positive association between both BMI and IGF-1 (R=0.44, p=0. 01) as well as BMI and IGF-1%ULN (R=0.35, p=0. 047). In contrast, in the NF group (n=51 with 49% female and mean age: 56.4+16.7 years), there was no significant association between BMI (mean: 31.3+6.5 kg/m 2; range: 19.1-47 kg/m 2) and %ULN IGF-1 (median: 38.9% [26.8, 61.4]) (rho=0.15, p=0.30). However, in the subgroup of NF patients with severe obesity (BMI &amp;gt;35 kg/m 2; n=17), a significant inverse association between BMI and %ULN IGF-1 was observed (rho: -0.54; p=0. 03) . These data demonstrate that in contrast to the inverse relationship that is typically observed between total IGF-1 and BMI in obese individuals, which is preserved in a NF adenoma group, there is a significant positive association between %ULN IGF-1 and BMI in patients with acromegaly, including those with severe obesity. Further study is necessary to determine whether obese patients with acromegaly exhibit more severe symptoms related to their disease due to this positive association between BMI and IGF-1 or whether obesity is a secondary effect of their acromegaly. Presentation: No date and time listed

The Cost Effectiveness of Implementation of a Postoperative Endocrinopathy Management Protocol after Resection of Pituitary Adenomas.

Purpose After developing a protocol for evaluating, diagnosing, and treating postoperative endocrinopathy both during the hospitalization and during the immediate discharge period following resection of pituitary adenomas, we sought to assess the impact of this protocol on quality outcomes. Methods An IRB-exempt, quality improvement initiated, Health Insurance Portability and Accountability Act (HIPAA)-compliant retrospective comparison of a pre-and-post-protocol cohort of all patients undergoing endoscopic endonasal resection of pituitary adenomas at NYU Langone Medical Center from January 2013 to December 2018. Demographic characteristics of the patients and their tumors with their postoperative outcomes were recorded. Quality outcomes regarding number of laboratory studies sent, rate of diabetes insipidus, length of stay, and readmission rate were also recorded. Statistical analysis was performed between the pre- and post-protocol groups. Results There was a significant reduction in laboratory studies sent per patient (55.66 vs. 18.82, p <0.001). This corresponded with an overall cost reduction in laboratory studies of $255.95 per patient. There was a decrease in the overall number of patients treated with DDAVP (21.4% in the pre-protocol group vs. 8.9% in the post-protocol group, p = 0.04). All post-protocol patients requiring DDAVP at discharge were identified by 48 hours. There was no significant change in length of stay or need for hydrocortisone supplementation postoperatively between the two groups. Length of stay was driven mostly by need for reoperation during initial hospitalization. There was no significant change in the rate of 30-day readmission. Conclusion Implementation of a postoperative management protocol results in a more efficient diagnosis and management of endocrinopathy after pituitary adenoma surgery which translates to decreased cost.

The 5-factor modified frailty index predicts health burden following surgery for pituitary adenomas

Frailty is known to influence cost-related surgical outcomes in neurosurgery, but quantifying frailty is often challenging. Therefore, we investigated the predictive value of the 5-factor modified frailty index (mFI-5) on total hospital charges, LOS, and 90-day readmission for patients undergoing pituitary surgery. The medical records of all patients undergoing endoscopic endonasal resection of pituitary adenomas at an academic medical center between January 2017 and December 2018 were retrospectively reviewed. Bivariate statistical analyses were conducted using Fisher's exact test, chi-square test, and independent samples t-test. Linear and logistic regression models were used for multivariate analysis. Our cohort (n = 234) had a mean age of 53.8years (standard deviation 14.6years). Sex distributions were equal, and most patients were Caucasian (59%). On multivariate linear regression, with each one-point increase in mFI-5, total LOS increased by 0.64days in the overall cohort (p < 0.001), 1.08days in the Cushing disease cohort (p = 0.045), and 0.59days in non-functioning tumors cohort (p = 0.004). Total charges increased by $3954 in the whole cohort (p < 0.001), $10,652 in the Cushing disease cohort (p = 0.033), and $2902 in the non-functioning tumors cohort (p = 0.007) with each one-point increase in mFI-5. Greater mFI-5 scores were associated with greater odds of 90-day readmission in both overall and Cushing disease cohorts, but these associations did not reach statistical significance. A patient's mFI-5 score is significantly associated with increased length of stay and hospital charges for patients undergoing pituitary surgery. The mFI-5 may hold peri-operative value in patient counseling for pituitary adenoma surgery.

Ambulatory Surgery Protocol for Endoscopic Endonasal Resection of Pituitary Adenomas: A Prospective Single-arm Trial with Initial Implementation Experience

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.

The use of dehydrated amniotic membrane allograft for augmentation of dural repair in transsphenoidal endoscopic endonasal resection of pituitary adenomas.

In transsphenoidal endoscopic endonasal surgery (TEES), watertight separation of the sinonasal cavity and intracranial compartment is the primary goal of closure. However, even when meticulous closure technique is implemented, cerebrospinal fluid (CSF) leaks, dural scarring, and meningitis may result. Particularly when intraoperative CSF leak occurs, materials that facilitate the creation of a watertight seal that inhibits disease transition and minimizes inflammatory response after durotomy are sought. Dehydrated amniotic membrane (DAM) allograft appears to confer these attributes as studies have shown it augments epithelialization, facilitates wound healing, and minimizes and impedes bacterial growth. We detail the use of DAM allograft to augment sellar closures after TEES. We conducted a feasibility study, retrospectively reviewing our institution's database of TEES for resection of pituitary adenomas in which DAM was utilized to supplement sellar closure. One hundred twenty transsphenoidal surgery cases with DAM were used during sellar closure, with a 49.2% intraoperative CSF leak rate. Of this cohort, two patients experienced postoperative CSF leak (1.7%), and no patients developed meningitis. CSF leak rate for TEES-naïve patients was 0.9%. This feasibility study demonstrates that dehydrated amniotic membrane allograft can be safely utilized as an adjunct during sellar closures for TEES for pituitary adenoma resection with very low rates of CSF leak and meningitis.

Implementation of Free Mucosal Graft Technique for Sellar Reconstruction After Pituitary Surgery: Outcomes of 158 Consecutive Patients

Cerebrospinal fluid (CSF) leak is a common complication after surgeries involving sellar reconstruction. Various techniques, including the nasoseptal flap, have been developed to limit postoperative CSF leak. However, the nasoseptal flap causes complications owing to donor site morbidity. A free mucosal graft may be just as effective in reducing CSF leaks as well as reducing postoperative nasal discomfort. This study aimed to assess operative outcomes of free mucosal graft after pituitary resection. A retrospective chart review was performed for patients who underwent endoscopic endonasal resection of pituitary adenomas. The following data were collected: demographic data, intraoperative CSF leak, postoperative CSF leak, other complications, and mucosal graft healing at 1 month. Also, the Sinonasal Outcome Test-22 was administered preoperatively and 1 month and 3 months postoperatively. Charts of 158 patients were reviewed, including patients who underwent no mucosal reconstruction, free mucosal graft reconstruction, and nasoseptal flap reconstruction. There was a 7.4% postoperative CSF leak rate in patients who underwent no reconstruction (n= 27), whereas postoperative CSF leak rate was 0.82% in patients undergoing free mucosal graft reconstruction (n= 122) (P < 0.05). Sinonasal Outcome Test-22 scores for patients with free mucosal graft reconstruction showed no significant worsening postoperatively. The free mucosal graft is a simple and effective means of sellar reconstruction in patients undergoing endonasal endoscopic pituitary resection, and its efficacy is similar to nasoseptal flaps. The free mucosal graft technique does not worsen sinonasal morbidity postoperatively.

The value of immediate postoperative MR imaging following endoscopic endonasal pituitary surgery

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.

Outcomes following Purely Endoscopic Endonasal Resection of Pituitary adenomas

Background: The use of endoscope for the management of pituitary adenoma is not new. The better magnification and illumination provided by the endoscope gives better outcome than microscopic pituitary surgery. Objective: To find out the benefits of endoscope in relation to microscopic surgery. Materials and Methods: We performed 45 cases of pituitary adenoma surgery by endoscopic endonasal approach from July 2008 to July 2010. Results: Forty five cases underwent endoscopic transsphenoidal approach. Gross total removal was done in 35 cases and subtotal removal was done in 10 cases. Residual tumours were seen in 10 cases (22%) in postoperative follow-up MRI scan. Visual improvement was satisfactory, and hormonal improvement of functional adenoma was nice. Postoperative visual acuity and visual field were improved in 75% cases. There were 37% cases of temporary diabetes insipidus and about 4.5% cases of permanent diabetes insipidus. The average duration of follow-up was 20 months. One patient required reexploration to correct visual deterioration in the immediate postoperative period. There were 4.5% cases of CSF leak and 6.6% mortality. Mortality was due to electrolyte imbalance and improper management of infection and hydrocephalus. Conclusion: Endoscopic endonasal pituitary surgery now has become a gold standard surgery for most of the pituitary adenomas because of its better advantages in relation to microscopic surgery and less complications and less hospital stay. DOI: http://dx.doi.org/10.3329/jemc.v3i1.13869 J Enam Med Col 2013; 3(1): 18-23

Endoscopic endonasal transsphenoidal surgery for pituitary adenomas: evaluation of results and technical aspects

Introduction: The endoscopic surgery has been increasingly accepted for the treatment of pituitary adenomas. There is still controversy regarding the benefits of this new technique. A new surgical approach must be safe and effective. Objective: Analyze the results and technical aspects of the endoscopic endonasal transsphenoidal approach for pituitary adenomas. Method: Retrospective study of 30 consecutive patients that underwent endoscopic endonasal resection of pituitary adenomas with a follow up from 24 to 67 months. Results: There were 18 women and 12 men, mean age 44 years (range 17-65 yr). Among the 30 patients, 23 had macroadenomas and 7 microadenomas. Twelve patients had non-functioning tumors, 9 had ACTH-secreting tumors, and 8 had GH-secreting tumors and 1 prolactinoma. Complete resection and hormonal control was achieved in all microadenomas. Macroadenomas were completely removed in 6 patients, subtotal resection in 6 and partial resection in 11. Three patients had diabetes insipidus and 5 had CSF leaks treated with lumbar drainage. Conclusion: The endonasal endoscopic approach for pituitary microadenomas and macroadenomas restricted to the sella is effective and safe. Macroadenomas with suprasellar extensions and cavernous sinus invasion may require endoscopic extended approaches for complete removal. The endoscopic endonasal transsphenoidal approach offers excellent visualization of anatomical structures and preserves the nasal cavity.

Endoscopic endonasal transsphenoidal approach for pituitary adenomas: technical aspects and report of casuistic

Analyse technical aspects, effectiveness and morbidity of the endoscopic endonasal transphenoidal approach for pituitary adenomas. From January 2005 to September 2008, 30 consecutive patients underwent endoscopic endonasal resection of pituitary adenomas with a follow up from 3 to 36 months. Their medical charts were retrospectively analysed. There were 18 women and 12 men, mean age 44 years (range 17-65 yr). Among the 30 patients, 23 had macroadenomas and 7 microadenomas. Twelve patients had non-functioning tumors, 9 had ACTH-secreting tumors, 8 had GH-secreting tumors and 1 prolactinoma. Complete resection and hormonal control was achieved in all microadenomas. Macroadenomas were completely removed in 6 patients, subtotal resection in 6 and partial resection in 11. Three patients had diabetes insipidus and 5 had CSF leaks treated with lumbar drainage. The endonasal endoscopic approach for pituitary tumors is effective and has low morbidity.

Endonasal Resection of Pituitary Adenomas: Comparison of Microscopic Speculum-Based Approach Versus Dual-Surgeon Endoscopic Approach

Before February 2008, all TNTS operations performed at our institution were done using a speculum and microscope (SPEC). Subsequently, all were performed using a dual-surgeon endoscopic approach (ENDO). The endoscopic approach has several potential advantages, including improved direct visualization plus less constrained bimanual dissection, thereby facilitating a more complete resection and obviating “blind dissection,” the latter resulting in intraoperative CSF leaks. A potentially negative consequence of more aggressive tumor removal could be a higher incidence of pituitary dysfunction postoperatively.

Outcomes Following Purely Endoscopic, Endonasal Resection of Pituitary Adenomas: A Case Series

Introduction: The trans-sphenoidal approach (TSA) has been utilized for the resection of pituitary adenomas for almost a century, progressing with the application of technological advances. The endoscopic techniques developed through the combined efforts of otolaryngologists and neurosurgeons hold promise. However, outcomes must be compared with more traditional approaches.