Endonasal Transsphenoidal Pituitary Surgery Research Articles

Sinonasal Complications of Combined Transseptal–Transnasal and Bilateral Transnasal Approaches for Endoscopic Endonasal Transsphenoidal Pituitary Surgery

BackgroundThe endoscopic combined transseptal–transnasal technique for pituitary adenoma excision is notable for enhanced postoperative functional outcomes. Our study compared the incidence of anterior nasal septal perforation and the resulting sinonasal complications between this method and the bilateral transnasal approach. MethodsUtilizing a retrospective cohort from a preeminent tertiary referral center, we analyzed 141 cases of endoscopic endonasal transsphenoidal surgery performed between March 2018 and May 2023. Outcomes for the transseptal–transnasal group (n = 71) and the conventional bilateral transnasal group (n = 70) were compared. Nasal endoscopy and computed tomography were used to assess anterior nasal septal perforation. Functional outcomes were assessed preoperatively and at 6 months postoperatively using the Connecticut Chemosensory Clinical Research Center (CCCRC) test, Cross-Cultural Smell Identification Test (CCSIT), Sino-Nasal Outcome Test-22 (SNOT-22), and nasal obstruction symptom evaluation (NOSE) ResultsThe transseptal–transnasal approach exhibited reduced rates of postoperative ear fullness (p < 0.001), along with fewer subjective complaints of smell/taste loss (p = 0.022) and thick nasal discharge (p = 0.008), compared to the conventional approach. However, objective smell test results were not significantly different between the two approaches (p = 0.243 and p = 0.454 for CCCRC and CCSIT, respectively). Additionally, although statistically insignificant, a higher incidence of anterior septal perforation was observed with the transseptal–transnasal approach (p = 0.067). ConclusionFor the surgical treatment of pituitary adenomas, the transseptal–transnasal approach offers several advantages over the bilateral transnasal method, particularly in reducing postoperative complications. However, this technique requires careful attention for preventing the occurrence of anterior septal perforation.

Effectiveness of a Sellar Reconstruction Algorithm in Transsphenoidal Pituitary Surgery: Insights from 490 Cases

Rhinorrhea is a common complication after endoscopic endonasal transsphenoidal pituitary surgery (EETPS). This study evaluates the effectiveness of our sellar reconstruction technique in preventing rhinorrhea. From June 2020 to March 2024, a surgical team performed 490 EETPS procedures on 458 pituitary adenoma patients. Demographic data, surgery status, and radiological and histopathological classifications were retrospectively analyzed. 4 grades for sellar reconstruction were defined based on intraoperative cerebrospinal fluid (CSF) leakage and diaphragm sella defect size. Grade 0: no CSF leakage; cavity filled with absorbable material. Grade 1: small defect; covered with fat and fascia lata grafts. Grade 2: large defect; added lumbar drainage. Grade 3: extended approach; added nasoseptal flap. Of the 490 operations, 433 were primary and 57 recurrent. Patients were 50.2% male, mean age 49.01years. Follow-up averaged 20.5months. Postoperative rhinorrhea occurred in 8 cases (1.6%). In 404 surgeries (82.5%) without intraoperative CSF leakage, 3 cases (0.7%) developed postoperative rhinorrhea. CSF leakage was detected in 86 cases (17.5%), with postoperative rhinorrhea in 5 cases (5.8%). The risk of rhinorrhea was 8.3 times higher with intraoperative CSF leakage (P= 0.005). Rhinorrhea rates: 0.7% in Grade 0, 3% in Grade 1, 8.7% in Grade 2, and 0% in Grade 3 (P= 0.017). Meningitis occurred in 8 patients (1.7%) and pneumocephalus in 4 (0.9%), with one death (0.2%). The average hospital stay was 17.4days with rhinorrhea and 5.2 without (P= 0.024). Intraoperative CSF leakage is highly correlated with rhinorrhea. Multilayered and graded closure strategies significantly reduce postoperative rhinorrhea rates in EETPS.

Risk Factors for Isolated Sphenoid Sinusitis after Endoscopic Endonasal Transsphenoidal Pituitary Surgery.

(1) Background: Transsphenoidal pituitary surgery can be conducted via microscopic or endoscopic approaches, and there has been a growing preference for the latter in recent years. However, the occurrence of rare complications such as postoperative sinusitis remains inadequately documented in the existing literature. (2) Methods: To address this gap, we conducted a comprehensive retrospective analysis of medical records spanning from 2018 to 2023, focusing on patients who underwent transsphenoidal surgery for pituitary neuroendocrine tumors (formerly called pituitary adenoma). Our study encompassed detailed evaluations of pituitary function and MRI imaging pre- and postsurgery, supplemented by transnasal endoscopic follow-up assessments at the otolaryngology outpatient department. Risk factors for sinusitis were compared using univariate and multivariate logistic regression analyses. (3) Results: Out of the 203 patients included in our analysis, a subset of 17 individuals developed isolated sphenoid sinusitis within three months postoperation. Further scrutiny of the data revealed significant associations between certain factors and the occurrence of postoperative sphenoid sinusitis. Specifically, the classification of the primary tumor emerged as a notable risk factor, with patients exhibiting nonfunctioning pituitary neuroendocrine tumors with 3.71 times the odds of developing sinusitis compared to other tumor types. Additionally, postoperative cortisol levels demonstrated a significant inverse relationship, with lower cortisol levels correlating with an increased risk of sphenoid sinusitis postsurgery. (4) Conclusions: In conclusion, our findings underscore the importance of considering tumor classification and postoperative cortisol levels as potential predictors of postoperative sinusitis in patients undergoing transsphenoidal endoscopic pituitary surgery. These insights offer valuable guidance for clinicians in identifying at-risk individuals and implementing tailored preventive and management strategies to mitigate the occurrence and impact of sinusitis complications in this patient population.

Prediction of intraoperative cerebrospinal fluid leaks in endoscopic endonasal transsphenoidal pituitary surgery based on a deep neural network model trained with MRI images: a pilot study.

This study aimed to investigate the reliability of a deep neural network (DNN) model trained only on contrast-enhanced T1 (T1CE) images for predicting intraoperative cerebrospinal fluid (ioCSF) leaks in endoscopic transsphenoidal surgery (EETS). 396 pituitary adenoma (PA) cases were reviewed, only primary PAs with Hardy suprasellar Stages A, B, and C were included in this study. The T1CE images of these patients were collected, and sagittal and coronal T1CE slices were selected for training the DNN model. The model performance was evaluated and tested, and its interpretability was explored. A total of 102 PA cases were enrolled in this study, 51 from the ioCSF leakage group, and 51 from the non-ioCSF leakage group. 306 sagittal and 306 coronal T1CE slices were collected as the original dataset, and data augmentation was applied before model training and testing. In the test dataset, the DNN model provided a single-slice prediction accuracy of 97.29%, a sensitivity of 98.25%, and a specificity of 96.35%. In clinical test, the accuracy of the DNN model in predicting ioCSF leaks in patients reached 84.6%. The feature maps of the model were visualized and the regions of interest for prediction were the tumor roof and suprasellar region. In this study, the DNN model could predict ioCSF leaks based on preoperative T1CE images, especially in PAs in Hardy Stages A, B, and C. The region of interest in the model prediction-making process is similar to that of humans. DNN models trained with preoperative MRI images may provide a novel tool for predicting ioCSF leak risk for PA patients.

Tips and Tricks to Safely Perform an Endoscopic Endonasal Trans-Sphenoidal Pituitary Surgery: A Surgeon's Checklist.

The authors aimed to develop an extensive preoperative checklist of CT scan findings during endoscopic access to the ventral skull base and implement it in clinical practice. A comprehensive literature review was conducted to identify the radiological landmarks crucial to endoscopic skull base surgery. Four electronic databases were searched: PubMed, MEDLINE, EMBASE, and Google Scholar using search terms/keywords such as "radiological landmarks," "endoscopic skull base surgery," "CT scan," "pituitary surgery," "anatomical variations," "internal carotid," "optic nerve," "sphenoid sinus," "pneumatization," "dehiscence," and "protrusion". Inclusion criteria were limited to original articles and systematic reviews published in English, between the years 2000 and 2021, which pertained to the radiological landmarks to be identified during endoscopic skull base surgery. Full-text articles were retrieved and collated into a narrative review focused on a 12-item checklist the authors agreed upon. The mnemonic "O ROAD TO SELLA" was used to represent the checklist and include the following landmarks: Sphenoid Ostium, Sphenoid Rostrum, Onodi cells, Anatomic variations of the sphenoid sinus, Distance between the carotids, Tumor characteristics, Optic nerve dehiscence/protrusion, Septation/insertion of the sphenoid sinus, Entrance to the sellar floor, Lateral recess of the sphenoid sinus, cLinoid process pneumatization, and internal carotid Artery dehiscence/protrusion. The checklist is designed to be used by attending physicians, fellows, and residents and the authors intend to implement it into electronic medical records at the institution's medical center to monitor the outcomes of EEPS after implementation.

Endoskopik Endonazal Transsfenoidal Hipofiz Cerrahisinde Farklı End Tidal CO2 Değerlerinin Hemodinami ve Cerrahiye Etkileri

Objective : We aimed to examine the effect of different intervals of end tidal CO2 ( etCO2 ) values on hemodynamics and surgery in endoscopic endonasal transsphenoidal pituitary surgery. Material and Methods: Two groups were evaluated retrospectively according to the maximum etCO2 values at the time of sellar resection. Group 1: 21 patients, etCO 2 =25-37 mmHg and Group 2: 21 patients, etCO 2=38-50 mmHg. The demographic characteristics, mean arterial pressure (MAP), heart rate (HR), etCO2 , pCO2 at the time of anesthesia induction, sellar excision moment and pre-extubation periods , total amount of bleeding, ease of surgery (good-moderate-bad) obtained from computer records, anesthesia receipts and surgical reports. Results: There was no difference between the two groups in terms of demographic data, complications or bleeding. A relationship was found between arterial pCO2 at the time of sellar excision. Surgical satisfaction was evaluated as "good" in 9 patients in Group 1 and 12 patients in Group 2. Conclusion: High etCO 2 values (38-50 mmHg) facilitated surgical excision of the mass and did not affect hemodynamics. Surgery has increased satisfaction. Keeping EtCO2 slightly higher than normal may be a good choice in these cases. Well-designed prospective studies are needed.

Postoperative Oral Antibiotics and Sinonasal Outcomes Following Endoscopic Transsphenoidal Surgery for Pituitary Tumors Study: A Multicenter, Prospective, Randomized, Double-Blinded, Placebo-Controlled Study.

Postoperative prophylactic antibiotics are commonly used in pituitary surgery, but evidence supporting their use is lacking, which has implications for antibiotic stewardship. To evaluate whether receipt of postoperative oral antibiotics results in superior sinonasal quality of life (QOL) compared with placebo among patients who undergo endoscopic endonasal transsphenoidal pituitary surgery. Patients were randomized to receive either oral placebo or cefdinir (trimethoprim-sulfamethoxazole in patients intolerant to cefdinir) for 7 d after surgery. They were monitored for 12 wk. The primary outcome measure was sinonasal QOL at 2 wk on the Anterior Skull Base Nasal Inventory-12. Supplementary end points included sinonasal QOL reported on the Sinonasal Outcome Test-22 and objective endoscopy scores to assess nasal healing according to the Lund-Kennedy method. A total of 461 patients were screened, 131 were randomized, and 113 (placebo arm: 55; antibiotic arm: 58) were analyzed. There was no clinically meaningful or statistically significant difference in sinonasal QOL at any measured time point (P≥.24) using either instrument. Nasal cavity endoscopy scores were not significantly different at 1 to 2 wk after surgery (P=.25) or at 3 to 4 wk after surgery (P=.08). Postoperative prophylactic oral antibiotics did not result in superior sinonasal QOL compared with placebo among patients who underwent standard endoscopic transsphenoidal surgery.

Endoscopic ultrasound imaging with high flow mode for endonasal transsphenoidal pituitary surgery

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.

Outcomes of intraoperative ultrasound for endoscopic endonasal transsphenoidal pituitary surgery in adenomas with parasellar extension

BackgroundPituitary adenomas with parasellar extension present a technical challenge for adequate visualization and gross total resection (GTR). The endoscope improves identification of parasellar extension, however, additional intraoperative imaging adjuncts can further augment visualization. Intraoperative ultrasound (iUS) may provide a viable and cost-effective solution for intraoperative imaging. We sought to assess the ability of intraoperative ultrasound to predict extent of resection on 3-month postoperative magnetic resonance imaging (MRI) in pituitary adenomas with parasellar extension. MethodsTwenty consecutive patients undergoing endoscopic endonasal transsphenoidal surgery for pituitary adenomas with the assistance of intraoperative ultrasound were prospectively collected. Intraoperative ultrasound findings were recorded during each case. 3-month postoperative MRI studies were reviewed in a blinded fashion to assess for residual tumor and compared with the intraoperative ultrasound findings. ResultsMedian preoperative Knosp grade was 2. Cavernous sinus invasion was encountered intraoperatively in 3 patients, all of whom were Knosp grade 3 preoperatively. Median operative time was 152 min. Based on iUS findings, 17 patients were expected to have a GTR while 3 patients underwent subtotal resection. 18 patients completed a 3-month postoperative MRI. The iUS and MRI findings were concordant in 16 cases (88.9%) with only two instances of discordance. ConclusionIntraoperative ultrasound can reliably predict tumor resection as assessed by 3-month postoperative MRI in pituitary adenomas with parasellar extension. Image capture and interpretation may vary based on operator experience. Ultrasound provides reliable immediate assessment of extent of resection, identification of normal pituitary gland and other important neurovascular structures.

Deployment of a bioabsorbable plate as the rigid buttress for skull base repair after endoscopic pituitary surgery.

Bioresorbable alloplastic implants have become desirable as a rigid buttress for reconstructing skull base defects. This study aimed to describe the use of a biodegradable plate (PolyMax RAPID) in skull base repair of endoscopic endonasal pituitary surgery and to investigate the clinical outcome and safety of this novel method. Between January 2019 and January 2020, 22 patients with pituitary adenomas who underwent endoscopic skull base repair with a Polymax RAPID plate were included. After endonasal transsphenoidal surgery, a trimmed bioresorbable plate was placed in the position between the dura and the bone of the skull base to reconstruct the sellar floor and buttress the pituitary gland and sellar packing. The patient demographics, radiologic imaging, and postoperative outcomes were carefully reviewed. All patients were followed up by a routine nasal endoscopic assessment and radiologic examinations. The present study comprised 10 (45.5%) males and 12 (54.4%) females with an average age of 51.9 years. There were 7 (31.8%) growth hormone (GH) secreting adenomas, 2 (9.1%) thyroid stimulating hormone (TSH) secreting adenomas, and 13 (59.1%) non-functioning adenomas. Enlarged sellar floor and paranasal sinusitis were seen in 13 (59.1%) and 11 (50.0%) cases shown by preoperative computed tomography (CT) or magnetic resonance imaging (MRI), respectively. There were 6 (27.3%) grade-1 and 16 (72.7%) grade-0 cases by intraoperative cerebrospinal fluid (CSF) leak grading. None of these patients received lumbar drains postoperatively and no postoperative CSF rhinorrhea was detected in our series. The PolyMax RAPID plates which could be clearly identified on postoperative CT or sagittal T1-weighted MRI were shown to provide an ideal rigid buttress for sellar repair. The Polymax RAPID plate can be an optimal implant to achieve rigid repair of sellar floor defects after endonasal transsphenoidal pituitary surgery.

Case report: 2 cases of cardiac arrest caused by rhino-cardiac reflex while disinfecting nasal cavity before endonasal transsphenoidal endoscopic pituitary surgery

BackgroundTrigeminal-cardiac reflex (TCR) is a brainstem vagus reflex that occurs when any center or peripheral branch of the trigeminal nerve was stimulated or operated on. The typical clinical manifestation is sudden bradycardia with or without blood pressure decline. The rhino-cardiac reflex which is one type of TCR is rare in clinical practice. As the rhino-cardiac reflex caused by disinfection of the nasal cavity is very rare, we report these two cases to remind other anesthesiologists to be vigilant to this situation.Case presentationThis case report describes two cases of cardiac arrest caused by rhino-cardiac reflex while disinfecting nasal cavity before endoscopic transsphenoidal removal of pituitary adenomas. Their heart rate all dropped suddenly at the very moment of nasal stimulation and recovered quickly after stimulation was stopped and the administration of drugs or cardiac support.ConclusionAlthough the occurrence of rhino-cardiac reflex is rare, we should pay attention to it in clinical anesthesia. It is necessary to know the risk factors for preventing it. Once it occurs, we should take active and effective rescue measures to avoid serious complications.

Endoscopic Versus Microscopic Pituitary Adenoma: Comparative Study of Two Different Approaches

Abstract Background: The comparisons in both techniques' out-comes, complications, and hospital stay were the study ques-tions in this article. Aim of Study: The study included two arms: Group A: Microscopic sublabial pituitary surgery was done for 18 patients. Group B: Endoscopic surgery was done for 20 patients. Patients and Methods: A retrospective comparative ob-servational trial held at two places. Microscopic sublabial pituitary surgery casesarmed as group A (n=18). While endo-scopic endonasal transsphenoidal pituitary surgery cases were abbreviated as group B (n=20). Statistical analysis: The variables of interest included age, sex, symptomatology, tumor sizes in (cm3), resection, operative time, hospital stay, blood loss, and postoperative complications using Statistical Package of Social Sciences version 25 (Chicago, IL, USA). Categorical data were presented as percentages and compared using the Chi-square t-test. Numerical data were presented as mean and standard deviation and compared by using Student's t-test. A p-value below 0.05 was regarded as statistically significant. Results: The total resection rate in group A was found in 14/18 (77.7%) which is not statistically different from group B 15/20 (75%) with p-value=0.852. As regard operative time, group A had a longer duration in comparison to group B with a slightly significant difference (2.15±0.24 vs. 1.75±0.8 hrs, p=0.049). As regard complications, It has been noticed that postoperative sinusitis/septal problems are higher in group A than group B. Conclusion: Microscopic sublabial pituitary surgery is not superior to the endoscopic approach as regard resectability in the field of purely sellar lesions. However, higher rates of postoperative complications in the naso-septal apparatus may affect patients' quality of life.

New Approach for Endoscopic Endonasal Transsphenoidal Pituitary Surgery: Modified Nasoseptal Rescue Flap.

Endoscopic endonasal approach has become popularly preferred for pituitary surgery in recent years. In this study we described a new technique which is developed by the first author and which is modified from The Rivera-Serrano "salvage" flap approach. With this new technique the septum morbidity was completely prevented and a wider and more comfortable vision was provided for the operation. This study consists 7 patients who underwent endoscopic endonasal transsphenoidal pituitary surgery (EETPS) with the described technique (modified salvage flap technique) between 2017 and 2019 and 13 patients underwent EETPS using salvage flap technique. The follow-up period was at least 6 months (24-6 months) for septal integrity. Intraoperative septum integrity was observed in all 7 patients who were treated with modified rescue flap technique. In 9 of 13 patients who had salvage flap technique, intraoperative septum posterior defects were observed. In postoperative follow-up (min postop 3 months), endoscopic examination showed no septal perforation in 6 patients who were treated with modified rescue flap technique, and 1 patient had 2 × 2 mm perforation posteriorly. In postoperative endoscopic follow-up of 13 patients who underwent salvage flap technique (min postop 3 months), 4 patients had complete septal integrity, while 9 patients had different sizes of posterior septal perforation. According to other described approach techniques, our modification using a pedicle and septum protective-transposition technique provides improved access to the downstream side of the sphenoid sinus and clivus, allowing the pedicle to slide down and take a more horizontal position. The improved maneuverability of the pedicle created in the case of cerebrospinal fluid leakage as a complication also allows it to be used as a bilateral wing to cover the exposed bone. We think that this technique is the best method to be used for EETPS with modified saline flap technique.

Vascularised Sphenoid Mucosal Flap: A Go to Flap in Endoscopic Endonasal Trans-Sphenoidal Pituitary Surgery

Vascularised Sphenoid Mucosal Flap: A Go to Flap in Endoscopic Endonasal Trans-Sphenoidal Pituitary Surgery

The manufacturing procedure of 3D printed models for endoscopic endonasal transsphenoidal pituitary surgery.

BACKGROUND: Endoscopic endonasal transsphenoidal pituitary surgery is usually difficult and risky. With limited sources of cadaveric skulls, traditional methods of using virtual images to study the surgery are difficult for neurosurgeons and students because the surgery requires spatial imagination and good understanding of the patient’s conditions as well as practical experience. The three-dimensional (3D) printing technique has played an important role in clinical medicine due to its advantages of low cost, high-efficiency and customization.OBJECTIVE: CT images are used as the source data of 3D printing. The data obtained directly from the CT machine has limited accuracy, which cannot be printed without processing. Some commercial platforms can help build an accurate model but the cost and customization are not satisfactory. In this situation, a tactile, precise and low-cost 3D model is highly desirable.METHODS: Three pieces of computer software are used in the manufacturing of medical 3D models and the processing procedure is easy to understand and operate.RESULTS: This study proposes a practical and cost-effective method to obtain the corrected digital model and produce the 3D printed skull with complete structures of the nasal cavity, sellar region and different levels of pituitary tumors. The model is used for the endoscopic endonasal transsphenoidal pituitary surgery preparation.CONCLUSION: The 3D printed medical model can directly help neurosurgeons and medical students to practice their surgery skills on both general and special cases with customized structures and different levels of tumors.

Study on Closure of Skull Base Defect Post-Endoscopic Endonasal Transsphenoid Pituitary Surgery: A Novel Flap Design.

Objective This study was aimed to compare the closure of skull base defect in endoscopic endonasal transsphenoid surgery of pituitary tumors, using bipedicled nasal septal flap versus fascial closure. The study hypothesis being that bipedicled nasal septal flap is better, compared with fascial closure of skull base defect post-endoscopic endonasal transsphenoid surgery of pituitary tumors. Methods All the eligible patients were randomly divided into two groups and then randomly allocated to the surgeons. In one group, fat and fascia lata was used for closure of the skull base defect and nasal septal flap was not harvested whereas in the other, nasal septal flap was used for closure. Results There was a statistically significant difference in postoperative cerebrospinal fluid leak between the two groups. Patients who had undergone flap repair had lower incidence of postoperative cerebrospinal fluid (CSF) leak. Duration of postoperative hospital stay was also less among the group who underwent flap repair (statistically significant). Conclusion Bipedicled nasal septal flap serves an excellent cover for the skull base defect following endoscopic endonasal transsphenoidal pituitary surgery. It can prevent postoperative CSF leak even in cases where tissue glue is not used.

Effects of propofol, desflurane, and sevoflurane on respiratory functions following endoscopic endonasal transsphenoidal pituitary surgery: a prospective randomized study

BackgroundGeneral anesthesia with intravenous or inhalation anesthetics reduces respiratory functions. We investigated the effects of propofol, desflurane, and sevoflurane on postoperative respiratory function tests.MethodsThis single-center randomized controlled study was performed in a university hospital from October 2015 to February 2017. Ninety patients scheduled for endoscopic endonasal transsphenoidal pituitary surgery were randomly categorized into either of these three groups: propofol (n = 30, the Group TIVA), desflurane (n = 30, the Group D) or sevoflurane (n = 30, the Group S). We analyzed the patients before, after, and 24 h following surgery, to identify the following parameters: forced expiratory volume in 1 second (FEV1) %, forced vital capacity (FVC) %, FEV1/FVC, and arterial blood gases (ABG). Furthermore, we also recorded the intraoperative dynamic lung compliance and airway resistance values.ResultsWe did not find any significant differences in FEV1 values (primary outcome) among the groups (P = 0.336). There was a remarkable reduction in the FEV1 and FVC values in all groups postoperatively relative to the baseline (P < 0.001). The FVC, FEV1/FVC, ABG analysis, compliance, and airway resistance were similar among the groups. Intraoperative dynamic compliance values were lower at the 1st and 2nd hours than those immediately after intubation (P < 0.001).ConclusionsWe demonstrated that propofol, desflurane, and sevoflurane reduced FEV1 and FVC values postoperatively, without any significant differences among the drugs.

Sphenoid Sinus Mucocele Caused by Complications After Transsphenoidal Pituitary Surgery.

The purpose of this study was to review the clinical characteristics, treatment methods, and surgical outcomes of sphenoid sinus mucocele after transsphenoidal pituitary surgery. A total of 404 patients who underwent transsphenoidal pituitary surgery between January 2010 and December 2016 were identified. Among them, 5 patients with sphenoid sinus mucocele were included in this study. In our hospital, a single-nostril endonasal endoscopic wide sphenoidotomy is routinely used for pituitary tumor surgery. The occurrence rate of sphenoid sinus mucocele was 1.2% (5/404). Of the 5 patients, 2 were males and 3 were females. Four lesions (80.0%) were located in the right sphenoid sinus and 1 lesion (20.0%) was located in the left sphenoid sinus. Endoscopic marsupialization for sphenoid sinus mucocele was performed under local anesthesia in all patients. There were no major complications resulting from the surgical intervention, and there was no recurrence at the time of the last follow-up. Sphenoid sinus mucocele after endonasal transsphenoidal pituitary surgery is an extremely rare complication. Nasal endoscopy and MRI are useful for diagnosing this lesion. Endoscopic marsupialization is a safe and effective procedure for sphenoid sinus mucocele after endonasal transsphenoidal pituitary surgery.

Identification and repair of intraoperative cerebrospinal fluid leaks in endonasal transsphenoidal pituitary surgery: surgical experience in a series of 1002 patients.

OBJECTIVE Cerebrospinal fluid (CSF) rhinorrhea is among the most common complications following transsphenoidal surgery for sellar region lesions. The aim of this study was to review the authors' institutional experience in identifying, repairing, and treating CSF leaks associated with direct endonasal transsphenoidal operations. METHODS The authors performed a retrospective review of cases involving surgical treatment of pituitary adenomas and other sellar lesions at the University of Southern California between December 1995 and March 2016. Inclusion criteria included all pathology of the sellar region approached via a direct microscopic or endoscopic endonasal transsphenoidal approach. Demographics, pathology, intraoperative and postoperative CSF leak rates, and other complications were recorded and analyzed. A literature review of the incidence of CSF leaks associated with the direct endonasal transsphenoidal approach to pituitary lesions was conducted. RESULTS A total of 1002 patients met the inclusion criteria and their cases were subsequently analyzed. Preoperative diagnoses included pituitary adenomas in 855 cases (85.4%), Rathke's cleft cyst in 94 (9.4%), and other sellar lesions in 53 (5.2%). Lesions with a diameter ≥ 1 cm made up 49% of the series. Intraoperative repair of an identified CSF leak was performed in 375 cases (37.4%) using autologous fat, fascia, or both. An additional 92 patients (9.2%) underwent empirical sellar reconstruction without evidence of an intraoperative CSF leak. Postoperative CSF leaks developed in 26 patients (2.6%), including 13 (1.3% of the overall group) in whom no intraoperative leak was identified. Among the 26 patients who developed a postoperative CSF leak, 13 were noted to have intraoperative leak and underwent sellar repair while the remaining 13 did not have an intraoperative leak or sellar repair. No patients who underwent empirical sellar repair without an intraoperative leak developed a postoperative leak. Eight patients underwent additional surgery (0.8% reoperation rate) for CSF leak repair, and 18 were successfully treated with lumbar drainage or lumbar puncture alone. The incidence of postoperative CSF rhinorrhea in this series was compared with that in 11 other reported series that met inclusion criteria, with incidence rates ranging between 0.6% and 12.1%. CONCLUSIONS In this large series, half of the patients who developed postoperative CSF rhinorrhea had no evidence of intraoperative CSF leakage. Unidentified intraoperative CSF leaks and/or delayed development of CSF fistulas are equally important sources of postoperative CSF rhinorrhea as the lack of employing effective CSF leak repair methods. Empirical sellar reconstruction in the absence of an intraoperative CSF leak may be of benefit following resection of large tumors, especially if the arachnoid is thinned out and herniates into the sella.

Does Onodi cell limit the exposure of sella during transsphenoidal pituitary surgery?

This study aims to evaluate the association between the presence of Onodi cell and sella exposure during endonasal endoscopic transsphenoidal pituitary surgery (EETPS). Forty-two patients who underwent EETPS for a pituitary adenoma with the collaboration of Neurosurgery and Otorhinolaryngology Departments at Katip Çelebi University Atatürk Training and Research Hospital between February 2011 and March 2014 were retrospectively analyzed. Preoperative paranasal sinus tomography and intraoperative findings were evaluated for the presence of Onodi cells. The location of the Onodi cell and its relation with sella exposure during surgery were also assessed. The incidence of Onodi cell was 19%. The Onodi cells were observed in eight of 42 patients on preoperative paranasal sinus computed tomography. The Onodi cells were unilateral in five patients and bilateral in three. Intraoperative findings were correlated with tomographic findings. In seven patients, Onodi cells limited the exposure of sellar floor and the inferior-medial wall of these cells were removed and connected with the sphenoid sinus and the entire sellar floor was exposed. In the remaining one patient, the Onodi cell was smaller and located superolaterally. This cell was not removed, as it did not limited the sellar exposure. The Onodi cell may limit the sella exposure during transsphenoidal surgery. Onodi cell should be removed and connected with the sphenoid sinus cavity for the entire sellar floor exposure.