Endoscopic Transnasal Transsphenoidal Surgery Research Articles

Fatal antiphospholipid syndrome following endoscopic transnasal-transsphenoidal surgery for a pituitary tumor

Introduction:The fatal type of antiphospholipid syndrome is a rare but life-threating condition. It may be triggered by surgery or infection. Endoscopic transnasal-transsphenoidal surgery is a common procedure for pituitary tumor. We report a catastrophic case of a young woman died of fatal antiphospholipid syndrome following endoscopic transnasal-transsphenoidal surgery.Methods and Result:A 31-year-old woman of a history of stroke received endoscopic transnasal-transsphenoidal surgery for a pituitary tumor. The whole procedure was smooth. However, the patient suffered from acute delirium on postoperative day 4. Then, her consciousness became comatose state rapidly with dilatation of pupils. Urgent magnetic resonance imaging of brain demonstrated multiple acute lacunar infarcts. The positive antiphosphoipid antibody and severe thrombocytopenia were also noted. Fatal antiphospholipid syndrome was diagnosed. Plasma exchange, corticosteroids, anticoagulant agent were prescribed. The hemodynamic condition was gradually stable. However, the consciousness was still in deep coma. The patient died of organ donation 2 months later.Conclusion:If patients have a history of cerebral stroke in their early life, such as a young stroke, the APS and higher risk of developing fatal APS after major surgery should be considered. The optimal management of APS remains controversial. The best treatment strategies are only early diagnosis and aggressive therapies combing of anticoagulant, corticosteroid, and plasma exchange. The intravenous immunoglobulin is prescribed for patients with refractory APS.

Chronic nasal complication following endoscopic and microscopic direct transnasal transsphenoidal pituitary adenoma surgery

Aim and backgroundIntranasal transsphenoidal access to the sella turcica for removing pituitary gland tumors has been known since the beginning of the last century. It can be done either endoscopic or microscopic. Postoperative nasal complications may happen. The purpose of this study was to assess the frequency of chronic oronasal alterations.Methodology33 patients who had previously undergone adenomectomy with a hypophyseal transsphenoidal approach using either the endoscopic or the direct transnasal microscopic technique; these patients were operated in different neurosurgical units. Assessement of nasal complications after 6 months was done.Results33 patients among them 18 patients were done by endoscopy and the other 15 were done by microscopy. No postoperative nasal complications in the endoscopy group 6 months postoperative while it is present in 3 cases of the microscopic group after the same time.ConclusionDirect transnasal approach provides safe transsphenoidal access to the sella with a very low rate of nasal complications.

Gangliocytoma Combined with a Pituitary Adenoma: Reports of Three Cases and Literature Review

Objectives Sellar gangliocytomas are extremely rare. Since they present clinically and radiologically as pituitary adenomas, the preoperative diagnosis of these mixed tumors is very difficult. Here, we report three cases of gangliocytoma combined with pituitary adenoma and describe our findings. Methods The clinical data of the three cases of gangliocytoma combined with pituitary adenoma have been retrospectively analyzed, and the published literature has also been reviewed. Results All three patients underwent pure endonasal endoscopic surgery, and no recurrence was observed over a follow-up of at least 30 months. Growth hormone (GH)-hypersecreting adenoma and tumor calcification were detected in these mixed tumors. Conclusions Pure endoscopic transnasal transsphenoidal surgery may be an effective way for the treatment of this kind of tumor. Gross total resection of the tumor is recommended. In addition, calcification with GH-hypersecretion may serve as a preoperative diagnostic clue for gangliocytoma in the sella turcica.

Primary Endoscopic Transnasal Transsphenoidal Surgery for Giant Pituitary Adenoma

Giant pituitary adenoma (>4 cm) remains challenging because the optimal surgical approach is uncertain. Consecutive patients with giant pituitary adenoma who underwent endoscopic transnasal transsphenoidal surgery (ETTS) as the first and primary treatment were retrospectively reviewed. Inclusion criteria were tumor diameter ≥4 cm in at least 1 direction, and tumor volume ≥10 cm(3). Exclusion criteria were follow-ups <2 years and diseases other than pituitary adenoma. All the clinical and radiologic outcomes were evaluated. A total of 38 patients, average age 50.8 years, were analyzed with a mean follow-up of 72.9 months. All patients underwent ETTS as the first and primary treatment, and 8 (21.1%) had complete resection without any evidence of recurrence at the latest follow-up. Overall, mean tumor volume decreased from 29.7 to 3.2 cm(3) after surgery. Residual and recurrent tumors (n= 30) were managed with 1 of the following: Gamma Knife radiosurgery (GKRS), reoperation (redo ETTS), both GKRS and ETTS, medication, conventional radiotherapy, or none. At last follow-up, most of the patients had favorable outcomes, including 8 (21.1%) who were cured and 29 (76.3%) who had a stable residual condition without progression. Only 1 (2.6%) had late recurrence at 66 months after GKRS. The overall progression-free rate was 97.4%, with few complications. In this series of giant pituitary adenoma, primary (ie, the first) ETTS yielded complete resection and cure in 21.1%. Along with adjuvant therapies, including GKRS, most patients (97.4%) were stable and free of disease progression. Therefore, primary ETTS appeared to be an effective surgical approach for giant pituitary adenoma.

Remisión bioquímica de pacientes acromegálicos sometidos a cirugía endoscópica

&lt;span&gt;Objetivo. La cirugía transnasal hernia transesfenoidal endoscópica es la base del tratamiento para la acromegalia en nuestro centro. Realizamos un estudio retrospectivo de 2008-2011 para determinar si este abordaje induce remisión bioquímica, y comparamos nuestras observaciones con series publicadas. Métodos. Analizamos retrospectivamente nuestra base de datos, e identificamos los pacientes sometidos a cirugía transnasal transesfenoidal endoscópica como tratamiento primario de acromegalia. Valoramos las imágenes y perfiles endocrinológicos pre-operatorios, y utilizamos los criterios del Consenso de Acromegalia de 2009 para determinar la remisión bioquímica. Resultados. Ocho pacientes recibieron adenomectomía endoscópica primaria. Uno tenía un microadenoma, uno un macroadenoma no invasivo, y seis presentan macroadenomas invasivos. La media de los niveles del factor de crecimiento similar a la insulina tipo I tres meses post-cirugía fueron 633 ng/mL (199 ng/ml-1600 ng/mL), mientras que los de la hormona de crecimiento fueron 10,20ng/mL (0,96ng/mL-16,60ng/mL). Dos pacientes cumplieron criterios de remisión; un macroadenoma no invasivo y un microadenoma. Cuatro de los pacientes restantes tuvieron remisión con análogos de somatostatina. Conclusiones. Este es el primer reporte de cirugía transnasal transesfenoidal endoscópica como terapia primaria de acromegalia en Costa Rica. La cura en pacientes con macroadenomas grandes e invasivos puede ser difícil y requiere de terapia multimodal.&lt;/span&gt;

Primary Endoscopic Transnasal Transsphenoidal Surgery for Magnetic Resonance Image–Positive Cushing Disease: Outcomes of a Series over 14 Years

There are scant data of endoscopic transsphenoidal surgery (ETS) with adjuvant therapies of Cushing disease (CD). To report the remission rate, secondary management, and outcomes of a series of CD patients. Patients with CD with magnetic resonance imaging (MRI)-positive adenoma who underwent ETS as the first and primary treatment were included. The diagnostic criteria were a combination of 24-hour urine-free cortisol, elevated serum cortisol levels, or other tests (e.g., inferior petrosal sinus sampling). All clinical and laboratory evaluations and radiological examinations were reviewed. Forty consecutive CD patients, with an average age of 41.0 years, were analyzed with a mean follow-up of 40.2 ± 29.6 months. These included 22 patients with microadenoma and 18 with macroadenoma, including 9 cavernous invasions. The overall remission rate of CD after ETS was 72.5% throughout the entire follow-up. Patients with microadenoma or noninvasive macroadenoma had a higher remission rate than those who had macroadenoma with cavernous sinus invasion (81.8% or 77.8% vs. 44.4%, P = 0.02). After ETS, the patients who had adrenocorticotropic hormone-positive adenoma had a higher remission rate than those who had not (76.5% vs. 50%, P = 0.03). In the 11 patients who had persistent/recurrent CD after the first ETS, 1 underwent secondary ETS, 8 received gamma-knife radiosurgery (GKRS), and 2 underwent both. At the study end point, two (5%) of these CD patients had persistent CD and were under the medication of ketoconazole. For MRI-positive CD patients, primary (i.e., the first) ETS yielded an overall remission rate of 72.5%. Adjuvant therapies, including secondary ETS, GKRS, or both, yielded an ultimate remission rate of 95%.

Obstructive Hydrocephalus Caused by Pituitary Adenoma: A Case Report

Among pituitary tumors, prolactin (PRL)-secreting pituitary adenomas are by far the most frequent ones. The development of symptomatic hydrocephalus due to a pituitary adenoma is an exceptional event. The authors describe a 37-year-old man who had a pituitary adenoma associated with obstructive hydrocephalus that was managed by endoscopic transnasal transsphenoidal surgery. Postoperative CT and MRI scans showed resolution of the obstructive hydrocephalus and the foramen of Monro was open. Postoperatively, the patient had visual and headache improvement. Subsequently, the patient is a candidate for cranial surgery or medical therapy to complete the treatment. The present case highlights the fact that pituitary adenomas with obstructive hydrocephalus should be distinguished from other tumors especially colloid cysts.

Modifications to the Endoscopic Approach for Anterior Skull Base Lesions Improve Postoperative Sinonasal Symptoms

Background/Objective Our institution previously showed that patients experience significant postoperative sinonasal symptoms for the first few months after endoscopic transnasal transsphenoidal skull base surgery (eTNTS). Since our initial study we have modified our technique, discontinuing routine resection of the middle turbinate, maxillary antrostomies, and nasoseptal flaps. In this study, we analyze whether these technical modifications decrease postoperative sinonasal morbidity after eTNTS. Methods A retrospective review was performed of 93 consecutive patients who underwent eTNTS at a tertiary academic medical center from August 2011 to August 2012. Main Outcome Measures Sino-Nasal Outcome Test (SNOT)-20 and SNOT-22 scores preoperatively and after surgery. Results Compared with our previous study, our new cohort experienced a significant improvement (p < 0.05) in SNOT scores for the need to blow nose, runny nose, postnasal discharge, thick nasal discharge, wake up at night, reduced concentration, and frustrated/restless/irritable. Within the new cohort, patients who did not have a nasoseptal flap or middle turbinate resection had less worsening and faster improvement of nasal symptom scores after surgery. Conclusions Preserving normal sinonasal physiology during eTNTS by limiting middle turbinate resections, avoiding unnecessary maxillary antrostomies, and reducing the use of nasoseptal flaps when feasible results in less sinonasal morbidity and more rapid recovery during the postoperative period.

Practical Use of a Simple Technique, Insertion of Wet Cotton Pledgets into the Tumor Resection Cavity in Transsphenoidal Surgery of Pituitary Tumors, for a Better Comparison between Pre- and Intraoperative High-Field Magnetic Resonance Images

Intraoperative high-field magnetic resonance imaging (iMRI) is a useful modality for immediate intraoperative quality control. With iMRI, a surgeon can confirm whether tumor remnants exist during surgery; which makes it possible to add further resection, obtain a higher resection rate, and improve the cure rate. It is sometimes difficult to evaluate the existence of tumor remnants when the tumor resection cavity is collapsed. In this study, we reported a simple technique for comparing pre- and intraoperative MR images. Thirty-five consecutive patients with pituitary adenoma underwent endoscopic endonasal transsphenoidal surgery using iMRI. Twenty-six patients had adenomas with suprasellar extension, and 9 had intrasellar adenomas. Nine adenomas had cavernous sinus invasion. Eight patients had endocrine-active, and 27 endocrine-inactive tumors. The simple technique included wet cotton pledgets inserted into the resection cavity to easily and precisely compare pre- and intraoperative MR images. Furthermore, we evaluated the efficacy of iMRI using our method on determining the extent of tumor resection in this study. The first iMRI scan showed that 12 of 35 patients had some tumor remnants, and 23 patients did not. Eight of these 12 patients with tumor remnants had cavernous sinus invasion. Three cases received further tumor resection after iMRI and had a gross total removal. We presented our initial results after using a simple method in high-field iMRI during endoscopic transnasal transsphenoidal pituitary surgery. This procedure allowed us to obtain valuable information to determine the extent of tumor resection and to precisely visualize the parasellar structures.

Three-Dimensional High-Definition Neuroendoscopic Surgery: A Controlled Comparative Laboratory Study with Two-Dimensional Endoscopy and Clinical Application

The purpose of this research was to investigate the usefulness of three-dimensional (3D) endoscopy compared with two-dimensional (2D) endoscopy in neuroendoscopic surgeries in a comparative study and to test the clinical applications. Forty-three examinees were divided into three groups according to their endoscopic experience: novice, beginner, or expert. Examinees performed three separate tasks using 3D and 2D endoscopy. A recently developed 3D high-definition (HD) neuroendoscope, 4.7 mm in diameter (Shinko Optical Co., Ltd., Tokyo, Japan) was used. In one of the three tasks, we developed a full-sized skull model of acrylic-based plastic using a 3D printer and a patient's thin slice computed tomography data, and evaluated the execution time and total path length of the tip of the pointer using an optical tracking system. Sixteen patients underwent endoscopic transnasal transsphenoidal pituitary surgery using both 3D and 2D endoscopy. Horizontal motion was evaluated using task 1, and anteroposterior motion was evaluated with task 3. Execution time and total path length in task 3 using the 3D system in both novice and beginner groups were significantly shorter than with the 2D system (p < 0.05), although no significant difference between 2D and 3D systems in task 1 was seen. In both the novice and beginner groups, the 3D system was better for depth perception than horizontal motion. No difference was seen in the expert group in this regard. The 3D HD endoscope was used for the pituitary surgery and was found very useful to identify the spatial relationship of carotid arteries and bony structures. The use of a 3D neuroendoscope improved depth perception and task performance. Our results suggest that 3D endoscopes could shorten the learning curve of young neurosurgeons and play an important role in both general surgery and neurosurgery.

A new modified speculum guided single nostril technique for endoscopic transnasal transsphenoidal surgery: an analysis of nasal complications

The endoscopic transnasal, transsphenoidal surgical technique for pituitary tumour excision has generally been regarded as a less invasive technique, ranging from single nostril to dual nostril techniques. We propose a single nostril technique using a modified nasal speculum as a preferred technique. We initially reviewed 25 patients who underwent pituitary tumour excision, via endoscopic transnasal transsphenoidal surgery, using this new modified speculum-guided single nostril technique. The results show shorter operation time with reduced intra- and post-operative nasal soft tissue injuries and complications.

Modifications to the Endoscopic Approach for Anterior Skull Base Lesions Improve Postoperative Sinonasal Symptoms

Background: Our institution has previously shown that patients experience significant postoperative sinonasal symptoms after endoscopic transnasal transsphenoidal skull base surgery. On the Sinonasal Outcomes Test (SNOT)-20 questionnaire, postoperative scores significantly worsened for need to blow nose, sneezing, runny nose, postnasal discharge, thick nasal secretions, and facial pain and pressure. Patients’ complaints were worse in the first 3 months postoperatively, but then returned to near baseline by 6-9 months. Since this initial study, we have modified our surgical technique during the endoscopic approach in an attempt to decrease postoperative sinonasal complaints. We now rarely resect the middle turbinate, do not routinely perform a maxillary antrostomy, and have decreased the use of pedicled nasoseptal flaps for skull base reconstruction to minimize the disruption of normal sinonasal physiology.

Giant cell tumor of the sphenoid bone occurring during pregnancy: Successful tumor extirpation via endoscopic transnasal transsphenoidal surgery

Primary giant cell tumors (GCTs) are a rare type of bone umor. They usually occur in young adults with a female preominance. GCT of the cranium is extremely rare and preferably rises from the sphenoid bone and the petrous temporal bone. oreover, progression or recurrence of GCT is a rare comlication of pregnancy. To date, GCTs complicating pregnancy ave been reported mainly in the long bones and spine. We eport a rare case of GCT of the sphenoid occurring during regnancy.

Pituitary Metastases: What Is the Role of Surgery?

Metastasis to the pituitary gland is an unusual situation in clinical practice and is typically observed only in elderly patients, but its incidence is increasing because of the increased survival of patients with cancer. In most cases, such metastasis is found in patients aged 60–70 years, who usually present with various non-specific symptoms. The most common primary sites are breasts in women and lungs in men. The prognosis of patients with breast cancer metastasis is poor but it depends on the primary neoplastic extension. We report a case of a 63-year-old woman with a history of bilateral breast cancer with surgery 15 years ago on the left side and 8 years ago on the right side. A pituitary macroadenoma was first suspected because of a visual disturbance for months before a magnetic resonance imaging examination. The patient underwent resection of the pituitary tumor by endoscopic transnasal trans-sphenoidal surgery. The final histopathological and immunohistochemistry analysis confirmed a pituitary metastasis of breast mucinous carcinoma. Postoperative follow-up continued for 2.5 half years, and the subsequent clinical imaging studies did not show local recurrence of the primary malignancy. She is currently disease free and has a good performance status.

Effect of Previous Sinonasal Surgery on Long-Term Radiographic Incidence of Sinus Disease in Patients Following Endoscopic Skull Base Surgery

Objective: The purpose of this study was to determine whether prior history of sinonasal surgery affects the incidence of long-term radiographic sinus disease after endoscopic skull base surgery. Study Design: A retrospective review was conducted at a university medical center. Methods: All patients that underwent a transnasal transsphenoidal endoscopic approach to the skull base with both preoperative and postoperative imaging greater than 6 months after surgery were identified. Lund-Mackay scores for CT images and an analog scoring system for MRI were used to stage all images. Change in preoperative and postoperative imaging scores were calculated and compared between patients with and without a history of a previous sinonasal intervention (i.e., septoplasty, transnasal transsphenoidal skull base surgery, or endoscopic sinus surgery). Results: Eighty-five patients were included in the study, 37 patients without a history of prior surgery and 20 patients with a history of prior surgery. Patients with a history of prior surgery had worse mean preoperative imaging scores compared with the group undergoing primary surgery in the left maxillary sinus (difference = 0.5 vs. 0.1, P = <0.01), left frontal (difference = 0.1 vs. 0.0, P = 0.05), and left sphenoid (difference = 0.2 vs. 0.0, P = <0.01), and right sphenoid sinuses (difference = 0.3 vs. 0.0, P = <0.01). The mean postoperative changes in radiographic scoring of sinusitis differed between patients with prior surgery and those undergoing primary surgery in the right anterior ethmoids (difference = −0.05 vs., 0.3 P = 0.02), left posterior ethmoids (difference = −0.3 vs. 0.1, P = 0.01), right posterior ethmoids (difference = −0.3 vs. 0.2, P = 0.03), and left sphenoid sinus (difference = −0.05 vs. 0.2, P = 0.04). Patients with a prior sinonasal surgery showed no increase in incidence of radiographic sinusitis in the postoperative MRIs. In contrast, patients with no history of prior sinonasal surgery had worse radiographic scores in the right anterior ethmoids, right posterior ethmoids, left and right maxillary, and left and right sphenoid sinuses (P ≤ 0.01, 0.03, 0.02, <0.01, 0.02, respectively). Conclusion: Patients with a history of sinonasal surgery show no increased incidence of radiographic evidence of sinusitis after endoscopic transnasal transsphenoidal skull base surgery.

Endoscopic Transsphenoidal Pituitary Surgery: Evidence of an Operative Learning Curve

The use of the fiberoptic endoscope is a recent innovation in pituitary surgery. To investigate the evidence of an operative learning curve after the introduction of endoscopic transsphenoidal surgery in our unit. The first 125 patients who underwent endoscopic transnasal transsphenoidal surgery for pituitary fossa lesions between 2005 and 2007 performed by 1 surgeon were studied. Changes in a number of parameters were assessed between 2 equal 15-month time periods: period 1 (53 patients) and period 2 (72 patients). There were 67 patients (54%) with nonfunctioning adenomas, 22 (18%) with acromegaly, and 10 (8%) with Cushing's disease. Between study periods 1 and 2, there was a decrease in the mean duration of surgery for nonfunctioning adenomas (from 120 minutes to 91 minutes; P < .01). This learning effect was not apparent for functioning adenomas, the surgery for which also took longer to perform. The proportion of patients with an improvement in their preoperative visual field deficits increased over the study period (from 80% to 93%; P < .05). There were nonsignificant trends toward improved endocrine remission rates for patients with Cushing's disease (from 50% to 83%), but operative complications, notably the rates of hypopituitarism, did not change. Overall length of hospital stay decreased between time periods 1 and 2 (from 7 to 4 days median; P < .01). The improvements in the duration of surgery and visual outcome noted after about 50 endoscopic procedures would favor the existence of an operative learning curve for these parameters. This further highlights the benefits of subspecialization in pituitary surgery.

Letter to the editor of Experimental and Clinical Endocrinology and Diabetes

The article of Haap et al. in the Experimental and Clinical Endocrinology and Diabetes 117: 289–293 (2009) has drawn my attention. In their interesting work, the authors describe an ACTH producing microadenoma of the pituitary in coincidence with nodular ACTH cell hyperplasias of the anterior lobe, emphasizing that this combination has not been published before. Motivated from this observation, I reviewed the known older literature on this topic. Back in the 1970's I worked on ACTH cell hyperplasias in combination with ACTH cell adenomas, focusing on surgical specimens of patients with Cushing's disease [5] [6] [7] which had been operated with the– at that time just invented–endoscopic transnasal transsphenoidal surgery [2].

Micro CT analysis of sellar floor in pituitary adenomas, especially in Cushing's disease

Context. The aim of this study was to explore the prognostic significance correlation between the endocrinopathy and the size of the pituitary adenoma with the sellar floor bone mineral density values using microfocus computerized tomography (µCT) analysis. Subjects and Methods. 16 consecutive patients with pituitary adenomas had full endocrinological and radiological work up prior to endoscopic transnasal transsphenoidal surgery. Multiple bony samples were collected from the sellar floor during surgery, and labeled and analyzed in a double blind fashion. Each bone sample was analyzed for bone mineral density (BMD) and Hounsfield units (HU) with microfocus CT. Results. There was no correlation between adenoma size and BMD values of sella floor but grade IV macroadenomas were found to have lower BMD levels. Statistical analysis showed that the level of correlation between grouped BMD ( 1.0) data with ACTH ( 46), IGF ( 303), and PRL ( 29.93) levels were insignificant (P=.569, P=.315, and P=1.00, respectively) Conclusion. We have found no clinical relationship between sellar floor BMD values and endocrinopathy and the size of the adenoma. However, it was found out that preoperative conventional CT evaluation seemed insufficient in predicting the sellar floor bone integrity and may mislead the surgeon.

Endoscopic transnasal transsphenoidal surgery for pituitary tumors--intranasal procedures

We have been performing intranasal procedures and postoperative nasal treatments in patients undergoing microscopic transseptal pituitary surgery for the past twenty years. This surgery is safe and minimally invasive and has become the standard procedure for removing pituitary adenomas. Recent advances in optical technology have increased the use of endoscopy in endonasal sinus surgery. Several methods for endoscopic transnasal pituitary surgery have been reported. Here, we report the results for 31 patients (34 operations) who were treated with endoscopic transnasal pituitary surgery. This technique enables the area of surgery to be visualized without requiring a sublabial incision or septal ablation to be performed. Five of the cases were for recurrences after microscopic surgery. A transsphenoidal surgical approach via a unilateral nasal cavity was used in 32 cases. For the remaining two cases, a transsphenoidal surgical approach via bilateral nasal cavities was used in 1 case, and a transethmoidal-transsphenoidal surgical approach via a unilateral nasal cavity was used in 1 case. Excellent results comparable to those of microscopic transseptal surgery were obtained. Endoscopic transnasal transsphenoidal surgery was found to have the following advantages: low-invasiveness, a wide and clear surgical view, and a relatively short operating time in the nose and sinus, especially for recurrent cases. This endoscopic procedure should therefore be considered as the first choice for pituitary surgery.