Endoscopic Endonasal Transsphenoidal Research Articles

Endoscopic Endonasal Transsphenoidal Approach for Apoplectic Pituitary Tumor: Surgical Outcomes and Complications in 45 Patients.

Objective To assess the safety and effectiveness of the endoscopic endonasal transsphenoidal approach (EETA) for apoplectic pituitary adenoma. Design A retrospective study. Setting Qilu Hospital of Shandong University; Brain Science Research Institute, Shandong University. Participants Patients admitted to Qilu Hospital of Shandong University who were diagnosed with an apoplectic pituitary tumor and underwent EETA for resection of the tumor. Main Outcome Measures In total 45 patients were included in a retrospective chart review. Data regarding patient age, sex, presentation, lesion size, surgical procedure, extent of resection, clinical outcome, and surgical complications were obtained from the chart review. Results In total, 38 (92.7%) of 41 patients with loss of vision obtained visual remission postoperatively. In addition, 16 patients reported a secreting adenoma, and postsurgical hormonal levels were normal or decreased in 14 patients. All other symptoms, such as headache and alteration of mental status, recovered rapidly after surgery. Two patients (4.4%) incurred cerebrospinal fluid leakage. Six patients (13.3%) experienced transient diabetes insipidus (DI) postoperatively, but none of these patients developed permanent DI. Five patients (11.1%) developed hypopituitarism and were treated with replacement of hormonal medicine. No cases of meningitis, carotid artery injury, or death related to surgery were reported. Conclusion EETA offers a safe and effective surgical option for apoplectic pituitary tumors and is associated with low morbidity and mortality.

Endoscopic Endonasal Transsphenoidal Pituitary Tumors Approach: Nuances of Neurosurgical Technique

Pituitary tumors are responsible for 7 to 17% of all intracranial lesions. Over the past decade, advances in endoscopic microsurgical techniques have resulted in an increasingly aggressive endonasal approach to tumors of the midline skull base. We present our series emphasizing technical nuances of endoscopic endonasal transsphenoidal approach to treat pituitary adenomas.

Endoscopic Endonasal Transsphenoidal Surgery for Microprolactinomas and Mesoprolactinomas as an Alternative to Dopamine Agonist Therapy

Objective: Dopamine agonist therapy remains the gold standard of treatment for prolactinomas because of its high success rates of normalization of hyperprolactinemia and tumor control, but it is not without its disadvantages. Medical treatment is a life long commitment where withdrawal of the drug often results in recurrence of hyperprolactinemia and related clinical symptoms. A moderate percentage of those on dopamine agonist therapy are unresponsive or are intolerant to many of its adverse side effects. Surgical intervention is typically indicated for those who have failed medical therapy or demonstrate progressive symptoms such as visual loss due to the tumor. As surgical techniques become more refined, surgery is increasingly chosen as primary treatment by patients. We aimed to evaluate the biochemical cure rate of small prolactinomas surgically treated by endoscopic endonasal transsphenoidal surgery, and to identify factors that predict a favorable surgical outcome.

Endoscopic endonasal surgery for pituitary tumors. Results in a series of 121 patients operated at the same center and by the same neurosurgeon

Abstract Introduction Pituitary adenomas account for approximately 15% of intracranial benign tumors. The neurosurgical results achieved since the endoscopic endonasal transsphenoidal (EET) approach was introduced in our center in 2005 are reported here. Patients and methods A retrospective analysis of 121 patients with sellar lesions (58% females, age 55.7 ± 16 years, range 18–82) who underwent EET surgery from February 2005 to January 2012 and were followed up for a mean time of 4.58 years (range 1.08–8.58). Results Six Rathke cleft cysts (3 intra-suprasellar, 1 intrasellar, 2 suprasellar); 114 pituitary adenomas (16 microadenomas, 98 macroadenomas), and 1 case of normal MRI were included. Baseline findings included hormonal changes in 59 patients (48.7%) and visual field changes in 38 patients (31%); in 7 patients (5.8%), clinical presentation was pituitary apoplexy. Complete resection was achieved in 77 patients (63.6%), subtotal resection in 29 (23.9%), and partial resection in 15 (12.3%). In patients with Grade 3 and 4 cavernous sinus invasion, resection was subtotal in 30% (12/39) and complete in 46% (18/39). Hormonal remission was achieved in 16 patients with Cushing disease (84%), 18 patients with prolactinoma (78.2%), and 18 patients with acromegaly (85.7%). There were 12 cases (9%) of cerebrospinal fluid leak, 4 cases of diabetes insipidus, and 3 cases with transient SIADH/hyponatremia. Seven patients developed panhypopituitarism. Postoperative mortality rate was 2.4%. One hundred and three patients (85.3%) were discharged from the hospital less than 48 h after surgery. Conclusion Our results are similar to those reported by renowned pituitary units. Results achieved using an endoscopic approach in pituitary neurosurgery are better than those of microneurosurgery for cavernous sinus invasion.

Cirugía endoscópica endonasal en tumores de hipófisis. Resultados en una serie de 121 casos operados en un mismo centro y por un mismo neurocirujano

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

Analysis of the Bacterial Flora in the Nasal Cavity and the Sphenoid Sinus Mucosa in Patients Operated on with an Endoscopic Endonasal Transsphenoidal Approach

The aim of this study was to analyze the bacterial flora in the nasal cavity and sphenoid sinus and evaluate the sensitivity of these bacteria to antibiotics that can be used to prevent postoperative meningitis. Bacteria of the preoperative nasal cavity and intraoperative sphenoid sinus mucosa were cultured and analyzed in 40 patients (20 men and 20 women; mean age, 52.2 years) who underwent endoscopic transsphenoidal surgery. The sensitivity of these bacteria to cephalosporin, a representative prophylactic antibiotic, was examined. Staphylococcus epidermidis was the most frequently detected species in both spaces; 24 (38.7%) of 62 isolates in the nasal cavity and 26 (37.1%) of 70 isolates in the sphenoid sinus. In contrast, Corynebacterium species were found mainly in the nasal cavity, and anaerobic bacteria were found only in the sphenoid sinus. Bacteria that were resistant to cephalosporin were found in the nasal cavity in 3.2% of patients and in the sphenoid sinus in 20% of patients. In conclusion, the composition of bacterial flora, including bacteria that are resistant to prophylactic antibiotics, differs between the nasal cavity and the sphenoid sinus.

Endoscopic Endonasal Transsphenoidal Resection for Pituitary Apoplexy during the Third Trimester of Pregnancy.

Pituitary apoplexy is an uncommon phenomenon typically characterized by vascular insufficiency or acute hemorrhage into a pituitary adenoma. The overall incidence of pituitary apoplexy ranges between 1 and 25% of all pituitary adenomas. With the widespread use of MRI technology, the diagnosis of asymptomatic intratumoral hemorrhage is closer to 10%. The authors report a case of a 27-year-old female in her 36th week of pregnancy who presented with severe onset headache and acute left-sided vision loss. MRI of the brain revealed a large hemorrhagic mass occupying the sella turcica. The patient underwent an emergent endoscopic endonasal transsphenoidal resection for pituitary apoplexy. Postoperatively, the patient's neurologic deficit resolved. Minimally invasive endoscopic endonasal transsphenoidal resection of pituitary apoplexy can be safely utilized in third trimester pregnant women presenting with acute severe neurologic deficits.

The Development of a Virtual Simulator for Training Neurosurgeons to Perform and Perfect Endoscopic Endonasal Transsphenoidal Surgery

AbstractBACKGROUND:A virtual reality (VR) neurosurgical simulator with haptic feedback may provide the best model for training and perfecting surgical techniques for transsphenoidal approaches to the sella turcica and cranial base. Currently there are 2 commercially available simulators: NeuroTouch (Cranio and Endo) developed by the National Research Council of Canada in collaboration with surgeons at teaching hospitals in Canada, and the Immersive Touch. Work in progress on other simulators at additional institutions is currently unpublished.OBJECTIVE:This article describes a newly developed application of the NeuroTouch simulator that facilitates the performance and assessment of technical skills for endoscopic endonasal transsphenoidal surgical procedures as well as plans for collecting metrics during its early use.METHODS:The main components of the NeuroTouch-Endo VR neurosurgical simulator are a stereovision system, bimanual haptic tool manipulators, and high-end computers. The software engine continues to evolve, allowing additional surgical tasks to be performed in the VR environment. Device utility for efficient practice and performance metrics continue to be developed by its originators in collaboration with neurosurgeons at several teaching hospitals in the United States. Training tasks are being developed for teaching 1- and 2-nostril endonasal transsphenoidal approaches. Practice sessions benefit from anatomic labeling of normal structures along the surgical approach and inclusion (for avoidance) of critical structures, such as the internal carotid arteries and optic nerves.CONCLUSION:The simulation software for NeuroTouch-Endo VR simulation of transsphenoidal surgery provides an opportunity for beta testing, validation, and evaluation of performance metrics for use in neurosurgical residency training.

The Development of a Virtual Simulator for Training Neurosurgeons to Perform and Perfect Endoscopic Endonasal Transsphenoidal Surgery

A virtual reality (VR) neurosurgical simulator with haptic feedback may provide the best model for training and perfecting surgical techniques for transsphenoidal approaches to the sella turcica and cranial base. Currently there are 2 commercially available simulators: NeuroTouch (Cranio and Endo) developed by the National Research Council of Canada in collaboration with surgeons at teaching hospitals in Canada, and the Immersive Touch. Work in progress on other simulators at additional institutions is currently unpublished. This article describes a newly developed application of the NeuroTouch simulator that facilitates the performance and assessment of technical skills for endoscopic endonasal transsphenoidal surgical procedures as well as plans for collecting metrics during its early use. The main components of the NeuroTouch-Endo VR neurosurgical simulator are a stereovision system, bimanual haptic tool manipulators, and high-end computers. The software engine continues to evolve, allowing additional surgical tasks to be performed in the VR environment. Device utility for efficient practice and performance metrics continue to be developed by its originators in collaboration with neurosurgeons at several teaching hospitals in the United States. Training tasks are being developed for teaching 1- and 2-nostril endonasal transsphenoidal approaches. Practice sessions benefit from anatomic labeling of normal structures along the surgical approach and inclusion (for avoidance) of critical structures, such as the internal carotid arteries and optic nerves. The simulation software for NeuroTouch-Endo VR simulation of transsphenoidal surgery provides an opportunity for beta testing, validation, and evaluation of performance metrics for use in neurosurgical residency training. CTA, cognitive task analysisVR, virtual reality.

Surgical management of pituicytomas: case series and comprehensive literature review

Pituicytomas are rare neoplasms that typically present as solid, noninfiltrative tumors occupying the sella and/or suprasellar space for which there is no consensus on optimal surgical management. We aimed to define a preferred surgical strategy for these tumors based on our clinical experience and comprehensive review of the world literature. Case series and review of the literature. We documented the clinical, radiographic, and surgical findings of three patients with pituicytoma treated at our institution, as well as complications and long-term outcomes. A comprehensive review of the medical literature identified all cases of pituicytoma for which data regarding surgical approach, outcome and complications could be extracted. We compared our results with published data. All three cases at our institution achieved gross total removal. Two patients underwent an expanded endoscopic endonasal transsphenoidal and transplanum (EETS-TP) approach, while one tumor was removed via craniotomy. Post-operatively all patients developed pan-hypopitutarism. The patient undergoing craniotomy suffered profound visual loss but no other neurological complications were noted. A literature review identified 67 reported cases of pituicytoma. Surgical data was available in 60 cases. Surgical approach was documented in 57 patients. Sixty-three surgeries were performed in which approach and extent of resection was available. Gross total removal was obtained in 33 % of craniotomies, 42 % of transsphenoidal procedures, and 100 % of expanded transsphenoidal procedures. Neurological complications including visual loss, hemiparesis and cranial nerve palsies were reported after craniotomy, but not after transsphenoidal approaches. Overall EETS-TP approaches were associated with the highest rate of gross total removal and no visual or neurological complications. EETS-TP surgery is the preferred strategy for surgical removal of pituicytoma. EETS-TP and transsphenoidal approaches are associated with higher rates of gross total removal and lower rates of neurological complications than craniotomy. Gross total removal should be the intended goal of surgery.

The Use of a Simple Self-Retaining Retractor in the Endoscopic Endonasal Transsphenoidal Approach to the Pituitary Macroadenomas

During tumor removal in the endoscopic endonasal approach to pituitary adenomas with a significant suprasellar extension, the early descent of diaphragma sellae obscuring the visualization of the surgical field is a surgical challenge. To describe a simple diaphragma retraction technique to eliminate this problem. A transparent flexible material (a strip of polypropylene) was used as a self-retaining retractor to elevate the redundant diaphragma and to maintain the diaphragma elevation. This technique was performed in 3 patients who had pituitary adenoma with suprasellar extension. The degree of tumor removal was determined by a combination of surgeon's intraoperative impression and the postoperative magnetic resonance imaging obtained 3 months later. The technique was performed very easily and no complication was observed owing to this technique and self-retaining retractor. Total tumor removal was achieved in 2 patients with this technique and subtotal removal in 1 patient. This technique was effective and practicable to elevate the diaphragma sellae during the tumor removal phase of transsphenoidal surgery. This simple self-retaining retractor may support the neurosurgeon's skill by providing control of the entire surgical field and adequate working space. It may also eliminate the risks of blind curettage during surgery.

Endoscopic Endonasal Transsphenoidal Approach to Large and Giant Pituitary Adenomas: Institutional Experience and Predictors of Extent of Resection

Objective: While the use of endoscopic approaches has become increasingly accepted in the resection of pituitary adenomas, limited evidence exists regarding the success of this technique for patients with large and giant pituitary adenomas. This study presents the outcomes of a large cohort of patients with large and giant pituitary adenomas who underwent endoscopic endonasal transsphenoidal surgery (EETS) at our institution. It focuses on identifying factors that can predict extent of resection, and hence aid in developing guidelines and indications for the use of EETS versus open craniotomy approaches to large and giant pituitary adenomas.

Endoscopic Endonasal Transsphenoidal Treatment of Pituitary Apoplexy: Outcomes in a Series of 20 Patients

Purpose: Pituitary apoplexy is a rare clinical entity, and few cases treated with an endonasal endoscopic approach (EEA) have been reported. We report our experience of treating pituitary apoplexy using an EEA approach.

経蝶形骨洞下垂体腫瘍摘出に有用な微小解剖

経蝶形骨洞下垂体腫瘍摘出に有用な微小解剖

Minimizing Intraoperative CSF Leaks in Endonasal Endoscopic Transsphenoidal Pituitary Surgery: Technical Considerations and Case Series Review

Minimizing Intraoperative CSF Leaks in Endonasal Endoscopic Transsphenoidal Pituitary Surgery: Technical Considerations and Case Series Review

The Unilateral Endoscopic Endonasal Transsphenoidal Approach to the Pituitary: A Return to the Beginning for Nasal Preservation

Introduction: The endoscopic endonasal transsphenoidal approach to the pituitary is currently widely employed using the “four -handed” technique, an endoscope positioned in one nasal cavity and the instruments in the opposite nasal cavity. This technique provides a wide working corridor to the sellar region, but it requires the sacrifice of the sphenopalatine artery bilaterally during the sphenoidotomy and precludes the ability to subsequently raise a nasoseptal flap for reconstruction at the time of surgery or during possible future surgeries. The unilateral approach, originally described by Carrau and Jho, can be performed using a single nasal corridor to access the pituitary. This allows not only for improved preservation of nasal anatomy but also preservation of one intact sphenopalatine artery–nasoseptal flap unit.

Endoscopic endonasal craniopharyngioma resection.

The authors present the case of a 21-year-old female with a progressive bitemporal hemianopsia. Cranial MR imaging revealed a large cystic suprasellar, retrochiasmatic lesion consistent with craniopharyngioma. The lesion was fully resected through an endoscopic endonasal transsphenoidal and transplanum approach. Closure of the resultant dural defect was performed with a bilayer fascia lata button and autologous mucoperichondrial nasoseptal flap. Each portion of this procedure was recorded and is presented in an edited high-definition format. The video can be found here: http://youtu.be/i3-qieLlbVk .

Endoscopic transsphenoidal approach versus microscopic approach in children

Objectives To confirm the efficacy and safeness of the endoscopic endonasal transsphenoidal (ETS) approach in the treatment of sellar and parasellar lesions in children compared with the conventional microscopic transsphenoidal approach (CTS). Study design Case series with chart review. Setting A. Gemelli – University Hospital – Catholic University of Sacred Heart – Rome. Subject and methods We retrospectively evaluate 21 children (mean age 8.3 years) affected by sellar/parasellar lesions: 11 were treated via microscopic sublabial approach between 1995 and 2005 and 10 were treated with ETS approach between 2006 and 2009. Results The past series (group A) comprised all sellar/suprasellar lesions and we observed: gross total surgical excision in 81.2% of cases, permanent morbidity in 1/11 patients, CSF fistula in 1/11 patients, mean hospitalization time of 5.8 days and PICU was required. The present series (group B) included 8 sellar/suprasellar and 2 clival lesions and we observed: GTS excision in 80% of the cases, no permanent morbidity, a mean hospitalization time of 4.1 days ( P = 0.01), CSF fistula in 2/10 patients and the PICU was not required. 10/11 patient of group A underwent to blood transfusion vs 4/10 of the group B ( P = 0.008). The mean pain score of group A was 5.8 ± 1.7 on the contrary in the group B it was 4.1 ± 1.5 ( P = 0.006). Conclusion The ETS approach to the sellar and parasellar region has proved its reliability and effectiveness in the adults. The minimal invasiveness makes it ideal for the treatment of pediatric lesion of this region, in which it is essential to preserve the integrity of the hypothalamic-pituitary axis and of the naso-facial structures to assure the correct growth of the child.

Hemorrhagic Pituitary Macroadenoma: Characteristics, Endoscopic Endonasal Transsphenoidal Surgery, and Outcomes

This study aims to assess the effect of endoscopic endonasal transsphenoidal surgery (EETSS) of hemorrhagic pituitary macroadenoma (HPMA). We retrospectively reviewed 52 cases with HPMA collected from the Xijing Hospital from April 1995 to April 2009. There were 39 males and 13 females, ranging in age from 18 to 79 years (average 51.6 years). Patients presented with headache or acute ophthalmological symptoms after adenoma hemorrhage. Computed tomography (CT) scan and magnetic resonance imaging (MRI) showed pituitary macroadenoma with hemorrhage in all cases. Twenty-eight adenomas showed marked suprasellar extension, 19 showed moderate extension, and another 5 showed slight extension. All patients were promptly treated by emergency EETSS, usually within 24 h after hospitalization. Total removal of tumor was achieved in 46 cases (88.5%), and subtotal removal in 6 cases (11.5%). Postoperative radiotherapy and reoperation of the tumor were required in five patients with either residual or relapsed tumors. Follow-up ranged from 8 to 93 months (mean 41.6 months) for 43 cases. Visual acuity and visual field recovery and improvement was recorded in 92.1% and 94.3% of patients who had preoperative visual symptoms, respectively. The majority of macroadenomas are hemorrhagic, and they often occur in middle-aged, male subjects. Detection by imaging in the setting of pituitary apoplexy accurately predicts the nature of the apoplectic process and helps to guide the type and timing of surgery. Early EETSS is the most effective therapy and significantly improves visual outcomes and systemic conditions.

Combined endoscopic endonasal and posterior cervical approach to a clival chordoma

Chordomas in the clival-cervical region present challenges to the neurosurgical team due to their encroaching nature, proximity to critical neurovascular structures and often large size due to late presentation. This report illustrates the utility of a staged approach when confronted with such a pervasive tumour. We describe the adaptive combination of two approaches, the endoscopic endonasal transsphenoidal plus posterior cervical approaches, in the surgical management of a clival chordoma extending inferiorly to C3 in an 18-year-old male.