Endoscopic Adenoma Resection Research Articles

Complication avoidance protocols in endoscopic pituitary adenoma surgery: a retrospective cohort study in 514 patients

PurposeTo evaluate the impact of using consistent complication-avoidance protocols in patients undergoing endoscopic pituitary adenoma surgery including techniques for avoiding anosmia, epistaxis, carotid artery injury, hypopituitarism, cerebrospinal fluid leaks and meningitis.MethodsAll patients undergoing endoscopic adenoma resection from 2010 to 2020 were included. Primary outcomes included 90-day complication rates, gland function outcomes, reoperations, readmissions and length of stay. Secondary outcomes were extent of resection, short-term endocrine remission, vision recovery.ResultsOf 514 patients, (mean age 51 ± 16 years; 78% macroadenomas, 19% prior surgery) major complications occurred in 18(3.5%) patients, most commonly CSF leak (9, 1.7%) and meningitis (4, 0.8%). In 14 of 18 patients, complications were deemed preventable. Four (0.8%) had complications with permanent sequelae (3 before 2016): one unexplained mortality, one stroke, one oculomotor nerve palsy, one oculoparesis. There were no internal carotid artery injuries, permanent visual worsening or permanent anosmia. New hypopituitarism occurred in 23/485(4.7%). Partial or complete hypopituitarism resolution occurred in 102/193(52.8%) patients. Median LOS was 2 days; 98.3% of patients were discharged home. Comparing 18 patients with major complications versus 496 without, median LOS was 7 versus 2 days, respectively p < 0.001. Readmissions occurred in 6%(31/535), mostly for hyponatremia (18/31). Gross total resection was achieved in 214/312(69%) endocrine-inactive adenomas; biochemical remission was achieved in 148/209(71%) endocrine-active adenomas. Visual field or acuity defects improved in 126/138(91.3%) patients.ConclusionThis study suggests that conformance to established protocols for endoscopic pituitary surgery may minimize complications, re-admissions and LOS while enhancing the likelihood of preserving gland function, although there remains opportunity for further improvements.

Quantitative evaluation of vision-related and health-related quality of life after endoscopic transsphenoidal surgery for pituitary adenoma.

OBJECTIVE Endoscopic resection of pituitary adenomas has been reported to improve vision function in up to 80%-90% of patients with visual impairment due to these adenomas. It is unclear how these reported rates translate into improvement in visual outcomes and general health as perceived by the patients. The authors evaluated self-assessed health-related quality of life (HR-QOL) and vision-related QOL (VR-QOL) in patients before and after endoscopic resection of pituitary adenomas. METHODS The authors prospectively collected data from 50 patients who underwent endoscopic resection of pituitary adenomas. This cohort included 32 patients (64%) with visual impairment preoperatively. Twenty-seven patients (54%) had pituitary dysfunction, including 17 (34%) with hormone-producing tumors. Patients completed the National Eye Institute Visual Functioning Questionnaire and the 36-Item Short Form Health Survey preoperatively and 6 weeks and 6 months after surgery. RESULTS Patients with preoperative visual impairment reported a significant impact of this condition on VR-QOL preoperatively, including general vision, near activities, and peripheral vision; they also noted vision-specific impacts on mental health, role difficulties, dependency, and driving. After endoscopic resection of adenomas, patients reported improvement across all these categories 6 weeks postoperatively, and this improvement was maintained by 6 months postoperatively. Patients with preoperative pituitary dysfunction, including hormone-producing tumors, perceived their general health and physical function as poorer, with some of these patients reporting improvement in perceived general health after the endoscopic surgery. All patients noted that their ability to work or perform activities of daily living was transiently reduced 6 weeks postoperatively, followed by significant improvement by 6 months after the surgery. CONCLUSIONS Both VR-QOL and patient's perceptions of their ability to do work and perform other daily activities as a result of their physical health significantly improved by 6 months after endoscopic resection of pituitary adenoma. The use of multidimensional QOL questionnaires provides a precise assessment of perceived outcomes after endoscopic surgery.

Gastric Adenoma with Low-Grade Dysplasia: Two Countries, Two Outcomes

The use of endoscopic submucosal dissection (ESD) for the treatment of gastric neoplasms is rapidly increasing as judged by the large number of publications on the topic (1925 publications 1/1/2000–8/8/2013). Of these 1,925 publications, more than half originate from the countries with a high prevalence of gastric neoplasia such as South Korea and Japan (Fig. 1). To interpret this literature, the reader should know that the indications for ESD differ between two countries: gastric adenomas with either lowgrade dysplasia (LGD) or high-grade dysplasia (HGD) are usually endoscopically resected in Korea, whereas ESD is mostly reserved for early gastric cancers (EGCs) in Japan. This widely different treatment strategy is not related to fundamental differences in the intent of endoscopic therapy or major technical differences between the two countries, but rather due to marked differences in histologic classification, since gastric adenoma with dysplasia diagnosed by a Korean pathologist would be likely diagnosed as an EGC in Japan. In a Korean study performed by Kim et al. [1] reported in this issue of Digestive Diseases and Sciences, complete endoscopic resection revealed that 22 of 285 gastric adenomas initially reported as LGD by endoscopic biopsy were reclassified as having HGD, with 24 lesions reported as adenocarcinomas. They reported that a lesion size C2 cm, the presence of erythema, or depressed lesions were significantly associated with an upgraded histology, consistent with previous Korean studies reporting that EGC diagnosed initially with endoscopic biopsy can be underdiagnosed as LGD [2–5]. Yet, in Japan, where the term ‘‘adenoma with low-grade atypia’’ is used to describe a lesion, concerns might be raised about the endoscopic resection of adenomas with LGD. Although a high incidence of gastric neoplasm exists in Korea and Japan due to the high prevalence of Helicobacter pylori infection, the diagnosis, treatment, and prognosis differ between countries (Fig. 2). Japanese pathologists are reluctant to use the term ‘‘gastric adenoma with LGD’’ because in Japan ‘‘dysplasia’’ connotes ‘‘cancer’’. The term ‘‘adenoma with low-grade atypia’’ has been substituted for ‘‘dysplasia’’ in Japan because the Japanese histological classification of gastric well-differentiated tumors divides intraepithelial gastric neoplasia into adenoma or carcinoma with low and high-grade cytological atypia, unlike the Western criteria [6–9]. From the Japanese viewpoint, gastric adenomas with LGD diagnosed by Western criteria include typical adenomas of the small intestinal type and gastric foveolar type which often have papillary and tubular structures, and thus diagnosed as ‘‘carcinoma without invasion’’ in Japan. Therefore, lesions diagnosed as gastric adenomas in Japan rarely progress to cancer [10], unlike adenomas diagnosed in other countries [11, 12]. In Korea, pathological diagnosis is based on the Western criteria, and thus gastric neoplasia is classified as LGD, HGD, or adenocarcinoma, as reported by Kim et al. [1]. As a consequence, lesions with the same diagnosis are treated differently in Korea and in Japan due to differing histology. The second concern relates to category 4 Vienna classifications for gastrointestinal epithelial neoplasia: 4.1 is HGD, 4.2 is noninvasive carcinoma in situ, and 4.3 is suspicious for invasive carcinoma with intramucosal S.-Y. Lee (&) Department of Internal Medicine, Konkuk University School of Medicine, 120-1 Neungdong-ro, Gwangjin-gu, Seoul 143-729, South Korea e-mail: sunyoung@kuh.ac.kr 1 Institute for Scientific Information Web of Science.

Mo1332 Clinically Relevant Discordance Between Biopsies and Resection Specimen After Endoscopic Resection of Adenoma of the Papilla of Vater; Retrieving Tissue Is the Issue!

Mo1332 Clinically Relevant Discordance Between Biopsies and Resection Specimen After Endoscopic Resection of Adenoma of the Papilla of Vater; Retrieving Tissue Is the Issue!