Endoscopic Transsphenoidal Approach Research Articles

Causes and treatment of secondary sphenoid sinus infection post-endoscopic transsphenoidal approach.

This study analyzed the causes of sphenoid sinus (SS) infection (SSI) following endoscopic transsphenoidal skull base surgery and determined appropriate treatment methods. This study included 31 cases of secondary SSI following the endoscopic transsphenoidal approach (ETSA; SSI group) and 246 cases without SSI (non-SSI group). Data collected included post-ETSA pathological results, types of artificial skull base reconstruction materials, and SS patency. For the SSI group, data included time from ETSA to symptom onset, endoscopic and imaging findings, intraoperative conditions during the second surgery, and changes in visual analog scale (VAS) scores. The incidence of secondary SSI was 11.19%. In the SSI group, 26 patients (83.87%) reported headaches, and 24 (77.42%) had stenosis or closure of the SS ostium (SSO). The non-SSI group reported no symptoms, and 236 patients (95.93%) had well-opened SSOs. Centripetal hyperosteogeny (CHO) in the SS walls was observed in 20 patients (64.5%) in the SSI group. Absorbable materials were used in five cases (16.13%) and 215 cases (87.40%) in the SSI and non-SSI groups, respectively, while non-absorbable materials were used in 24 cases (77.42%) and 20 cases (8.13%), respectively. SSI risk was 9.42 times higher with non-absorbable synthetic materials. VAS scores for SSI symptoms and Lund-Kennedy scores significantly decreased at 3 and 12 months post-second surgery. Secondary SSI after ETSA can cause persistent symptoms. Non-absorbable synthetic repair materials should be avoided to prevent secondary SSI. Extended sphenoidectomy and removal of artificial materials can lead to rapid resolution of SSI symptoms. 4.

Variable anatomical features of acromegaly in the nasal cavity and paranasal sinuses: implications for endoscopic endonasal transsphenoidal surgery.

Growth hormone (GH)-secreting pituitary neuroendocrine tumors (PitNETs) are the most common cause of acromegaly. The endoscopic endonasal transsphenoidal approach (EEA) is commonly employed to remove them. Although morphological differences in the nasal cavity exist between acromegaly patients and those with other types of PitNET, few quantitative studies have been performed. This study aimed to evaluate the anatomical features of the nasal cavity and paranasal sinuses in patients with acromegaly. Preoperative computed tomography images of the nasal cavity and paranasal sinuses were compared between 20 patients with a GH-secreting PitNET (acromegaly group) and 22 with a non-functioning PitNET (control group). In the acromegaly group, the relationships between preoperative GH and/or insulin-like growth factor 1 (IGF-1) levels and anatomical characteristics were assessed. In the acromegaly group, the distance between the nostril and dorsum sellae was significantly longer and the distance between the parasellar internal carotid arteries was significantly shorter (p = 0.0022 and 0.0092, respectively). Pneumatization volume in the nasal cavity did not differ between the groups. Nasal mucosa and bony hypertrophy were observed in the acromegaly group. Preoperative GH level was correlated with the width of the piriform aperture (p = 0.0171). The nasal and paranasal changes associated with acromegaly can make EEA challenging to perform. Widening the surgical corridor anterior to the sphenoid sinus is important in these patients.

8301 A Rare Case of IgG4-Related Hypophysitis

Abstract Disclosure: P. Kesavan Chary: None. J.M. Silverstein: None. Background: IgG4-related disease (IgG4-RD) is an immune-mediated condition that presents as systemic inflammation and fibrosis of tissues, often affecting multiple organs. Isolated IgG4-related Hypophysitis is rare and characterized by lymphoplasmacytic infiltration of the pituitary gland by IgG4-positive plasma cells. A combination of clinical, serologic, radiologic, and histopathologic findings is used for diagnosis of IgG4-RD and approximately two-thirds of all patients have elevated serum IgG4 levels. We report a case of isolated IgG4-related Hypophysitis in a middle-aged woman serologically negative for IgG4-related disease. Case Report: A 52 year old female with history of steroid dependent severe persistent asthma, allergic rhinitis, and chronic sinusitis presented with one month of headache, polyuria, and polydipsia. MRI Brain demonstrated an enlarged, rounded pituitary gland 16 x 11 x 9 mm, with homogeneous enhancement, extension into the suprasellar cistern, and mild thickening of the infundibulum suspected to represent a pituitary adenoma. Lab evaluation revealed mild hyperprolactinemia (prolactin 83.2, normal 4.8-23.3 ng/mL) and secondary adrenal insufficiency based on an abnormal high-dose cosyntropin stimulation test in the setting of a low adrenocorticotrophic hormone (ACTH) level (<2.0 pg/mL). Remaining pituitary hormone levels were normal. Inpatient work-up for polyuria and polydipsia showed a low urine specific gravity of 1.003. An overnight water deprivation test was performed. Baseline urine osmolality (UOsm) was 95 mOsm/kg and serum sodium was 144 mmol/L; after 3 hours of water deprivation, serum Osm increased to 301 mOsm/kg (275-300 mOsm/kg) and UOsm only to 215 mOsm/kg, while her sodium increased to 145 mmol/L. Results were felt to be consistent with AVP deficiency (Central Diabetes Insipidus) and the patient was started on desmopressin. Because of the presence of AVP deficiency, further work-up was done to evaluate for an infiltrative process or malignancy. ANA, RPR, ESR, CRP, CBC, ACE level, T-SPOT, and IgG subclasses were unremarkable. Further imaging studies yielded a negative nuclear bone scan and PET/CT scan. For diagnostic purposes, the patient underwent biopsy via an endoscopic endonasal transsphenoidal approach. Pathology showed the presence of >10 IgG4+ plasma cells in a single high-power field, consistent with a diagnosis of IgG4-related Hypophysitis. Conclusion: Isolated IgG4-related Hypophysitis is the least common clinical presentation of IgG4-RD, which is itself a rare and relatively newly recognized condition. IgG4-related Hypophysitis should be suspected in patients presenting with AVP deficiency and pituitary stalk enlargement with an otherwise negative work up. Presentation: 6/2/2024

Prospective Evaluation of Transsphenoidal Pituitary Surgery in Patients with Cushing's Disease: Delayed Remission and the Role of Postsurgical Cortisol as a Predictive Factor.

Transsphenoidal surgery is the treatment of choice for Cushing's disease. Successful surgery is associated with subnormal postoperative serum cortisol concentrations and cortisoluria levels, which may guide decisions regarding immediate reoperation. Remission is defined as the biochemical reversal of hypercortisolism with the re-emergence of diurnal circadian rhythm. A single-center prospective cohort study was conducted among thirty-three patients who underwent transsphenoidal pituitary surgery for Cushing's disease. Postoperative surgical outcomes, daily morning cortisolemia, and 24 h urinary-free cortisol from the first to the fifth morning were evaluated. All patients underwent surgery, with a remission rate of 81.2%. Of the 26 patients who achieved early remission, 92% remained in remission. Two patients (7.7%) showed recurrence of Cushing's disease during a mean follow-up of 81.7 months. Early postoperative hypocortisolism suggests complete removal of the tumor, correlating with high rates of remission (p < 0.001). Also, in 12.5% of patients with early cortisol values >138 nmol/L, there was a gradual late remission. In our cohort of patients, the endoscopic transsphenoidal approach was safe and effective in the treatment of Cushing's disease. We demonstrated that serum and urinary cortisol concentrations did not experience significant fluctuations from the first to the fifth day. This constitutes an accurate predictor of durable remission, comprising a distinctive finding in the intermediate term by our team.

The oculomotor cistern and pituitary adenomas: anatomical and clinical study.

The oculomotor cistern (OMC) is a meningeal cuff filled with CSF that contains the oculomotor nerve (cranial nerve [CN] III) at the level of the lateral wall of the cavernous sinus. Only a few studies have investigated the involvement of the OMC by pituitary adenomas (pituitary neuroendocrine tumors [PitNETs]), mainly with relatively small case series. The aim of this study was to perform a histomorphological description of the OMC and systematically analyze its involvement by PitNETs from radiological, clinical, and surgical perspectives. Ten hemisellae from formalin-fixed specimens were studied with 3-µm sections. Digital image analysis software was used for morphological and quantitative assessments. Clinical, radiological, surgical, and histological data of patients undergoing endoscopic transsphenoidal surgery for PitNETs at the University of Brescia, Italy, between 2014 and 2021 were recorded. OMC involvement was graded as not compressed, compressed, and invaded. The same surgical team operated on all patients. The OMC had an elliptical shape with an average area of 3.1 mm2 and a length of 5.5 mm. No cisternal points of weakness were recognized in the histomorphological study. Of 315 patients, 246 had complete data: apoplexy and CN III palsy were documented in 6.9% and 8.5%, respectively. OMC compression and invasion were recorded in 106 (43.1%) and 23 (9.3%) patients. Significant associations between OMC involvement and PitNET dimensions (p < 0.001), Knosp grade (p < 0.001), preoperative oculomotor palsy (p < 0.001), Ki-67 percentage (p = 0.009), and recurrence/progression of residual tumor (p = 0.008) were found. A new postoperative CN III palsy was evident in 2%: transient in 4 cases, and persistent in 1 patient treated for a recurrent PitNET who experienced a local infection complication. Preoperative CN III palsy improved in 10 cases. Significant OMC involvement by PitNETs might be underrecognized, but it can be treated using the endoscopic transsphenoidal approach, and it affects patient outcomes.

Simultaneous combined keyhole mini-transcranial approach and endoscopic transsphenoidal approach to remove multi-lobulated pituitary neuroendocrine tumor with suprasellar extension

BackgroundTranssphenoidal surgery (TSS) is the main method to remove pituitary neuroendocrine tumor (PitNET), but large or multi-lobulated one is still challenging. ObjectiveThe less invasive simultaneous combined keyhole mini-transcranial approach and standard transsphenoidal approach was used to remove multi-lobulated or hourglass-shaped non-functioning PitNET to avoid the specific complications related to extended TSS. MethodsTwenty-one patients of large multi-lobulated or hourglass-shaped PitNET (6 patients were recurrent cases after TSS or transcranial approach) were treated by this simultaneous combined approach. The supraorbital or midline keyhole approach was performed under the operating microscope so that the fine arteries feeding optic apparatus were dissected from the tumor capsule safely and securely and the suprasellar part of the tumor was removed in the extra-capsular fashion in combination with transsphenoidal approach. ResultsVisual function improved after the surgery in 14 (74 %) of 19 patients with preoperative disturbance of the visual fields. Four patients (19 %) developed postoperative deterioration of pituitary endocrine functions requiring permanent hormonal replacement. One patient (4.2 %) suffered cortical laminar necrosis without permanent disorders and another patient (4.2 %) suffered cerebrospinal fluid rhinorrhea but neither was permanent. Postoperative computed tomography detected no subarachnoid hemorrhage in any patient. Gross total removal was achieved in 15 patients (71 %). Five patients (24 %) with subtotal removal and one patient (4.2 %) with partial removal had lateral tumor extension with Knosp classification 3 or 4. ConclusionThe combined method is an effective treatment option to remove complex PitNET safely and securely with dissecting fine arteries on the tumor capsule.

Pediatric abscessed craniopharyngioma: A case report and review of literature

BackgroundCraniopharyngiomas are rare sellar and suprasellar tumors affecting children and adults. The spontaneous abscessation of this lesion is an extremely rare occurrence with a total of 10 cases reported in the literature including 2 cases in the pediatric population. ObservationWe report a case of abscessed craniopharyngioma in a 10-year-old girl, revealed by intracranial hypertension and diabetes insipidus with a double component (solid and cystic) lesion of the sella visualized on cerebral MRI. The patient underwent surgical decompression via endoscopic endonasal transsphenoidal approach coupled with antibiotic treatment with an uneventful postoperative course and improvement of her symptoms. ConclusionAbscessed craniopharyngiomas are rare and challenging entities. We highlight through our case and literature review the importance of an in-depth patient’s history as well as a clinical-radiological correlation in allowing for a positive preoperative diagnosis even in patients with no meningeal or infection signs.

Augmented reality for endoscopic transsphenoidal surgery: evaluating design factors with neurosurgeons.

This study investigates the potential utility of augmented reality (AR) in the endoscopic transsphenoidal approach (TSA). While previous research has addressed technical challenges in AR for TSA, this paper explores how design factors can improve AR for neurosurgeons from a human-centred design perspective. Preliminary qualitative research involved observations of TSA procedures ( ) and semi-structured interviews with neurosurgeons ( ). These informed the design of an AR mockup, which was evaluated with neurosurgeons ( ). An interactive low-fidelity prototype-the "AR-assisted Navigation for the TransSphenoidal Approach (ANTSA)"-was then developed in Unity 3D. A user study ( ) evaluated the low-fidelity prototype of ANTSA through contextual interviews, providing feedback on design factors. AR visualisations may be beneficial in streamlining the sellar phase and reducing intraoperative errors such as excessive or inadequate exposure. Key design recommendations include a lean mesh rendering, an intuitive colour palette, and optional structure highlighting. This research presents user-centred design guidelines to improve sensemaking and surgical workflow in the sellar phase of TSA, with the goal of improving clinical outcomes. The specific improvements that AR could bring to the workflow are discussed along with surgeons' reservations and its possible application towards training less experienced physicians.

Comparison of Surgical Modalities for Giant Pituitary Adenoma: A Systematic Review and Meta-Analysis of 1413 Patients.

Giant pituitary adenomas (GPAs) are a challenging clinical entity, composing 5% to 15% of all pituitary adenomas. While the endoscopic endonasal transsphenoidal (EET) approach has surpassed the microsurgical transsphenoidal (MT) and transcranial (TC) approaches as the first-line surgical modality in most institutions, a systematic review comparing the 3 approaches has not been undertaken since 2012. Given growing adoption of EET and development of novel operative techniques over the past decade, an updated comparison of GPA surgical modalities is warranted. We identified all studies related to the surgical management of GPAs in PubMed, Embase, and Web of Science from inception to December 31, 2021. End points assessed included gross total resection (GTR) rates, postoperative visual improvement, mortality, and perioperative complications. After screening of 1701 studies, we identified 45 studies on the surgical management of GPAs for meta-analysis. Thirty-one used the EET approach (n = 1413), 11 studies used the MT approach (n = 601), and 10 used the TC approach (n = 416). The cumulative number of patients treated by EET did not exceed that of patients treated by the TC or MT approaches until 2014 and 2015, respectively. Despite patients undergoing EET having the highest average tumor diameter, pooled rates for GTR were significantly higher for EET (42%) than MT (33%, P < .001) and TC (8%, P < .001) and EET similarly exhibited superior rates of visual improvement (85%) than MT (73%, P < .001) and TC (56%, P < .001). Mortality rates were comparable between EET (0.6%) and MT (1.6%), but EET had significantly lower mortality than TC (2.7%, P < .001). Compared with MT, EET had lower rates of hypopituitarism (8.5% vs 14.9%, P = .012) but higher rates of diabetes insipidus (3.1% vs 0.5%, P = .001). In an updated meta-analysis of 1413 patients with GPA, EET resection conferred significantly higher rates of visual improvement and GTR, when compared with the MT and TC approaches.

Pituitary surgery and COVID.

An effect of the COVID-19 pandemic was the disruption of healthcare systems, especially surgical services provided to the community. Pituitary surgery was especially impacted, given the majority of cases were deemed non-urgent with very few exceptions, and the high risk of viral transmission conferred by the endoscopic endonasal transsphenoidal approach. Patients suffering from pituitary lesions with resultant endocrinopathy or visual symptoms saw their treatment delayed or altered, which had implications on their outcomes and care. This disruption extended to surgical training and the usual functioning of academic units, necessitating changes to curricula and implementation of novel methods of progressing surgical education. This review will explore the effect of the COVID pandemic on pituitary surgery, the experiences of various surgeons as well as the adaptations implemented on the frontlines. The lessons learned from the experience of the pandemic may assist specialists in gleaning insights regarding the care of patients in the future.

Surgical Outcome of the Endoscopic Endonasal Approach in Giant Pituitary Adenomas: A Systematic Review

Abstract Background Pituitary adenomas are the third most common intracranial tumors comprising about 10%–15% of all tumors. Giant pituitary adenomas (GPAs) are a subset of pituitary tumors. Most giant adenomas are slowly growing and histologically benign in nature despite the giant in size and difficulties to manage. Diverse surgical techniques including microscopic transsphenoidal, endoscopic transsphenoidal, transcranial transcavernous, and a combination of both suprasellar and infrasellar techniques have been developed to treat giant tumors with extension into surrounding structures. The development of the endonasal endoscopic approach for the resection of pituitary adenomas has been one of the most important advances for the treatment of pituitary tumors in the last decades since 1997. Aim of the Work analyze the collective outcomes from studies discussing endoscopic endonasal transsphenoidal approach in managing giant pituitary adenomas regarding extent of tumor resection, visual improvement and hormonal control. Methodology This systematic review included a discussion of all available studies meeting the eligible criteriaincluding: well conducted descriptive studies, cohort, articles, analytic studies and the literature of reviews. Results Surgical intent of gross or near total resection, primarily for the purpose of improving outcome, can be complicated by injuries that lead to a worse outcome and protracted clinical course. In this respect, patient-oriented outcomes (POEMs) are a point of emphasis in this review. Conclusion The endoscopic endonasal approach is an effective approach for giant pituitary adenomas with high rates of near or complete resection, visual improvement, and low rate of complications.

P.072 History of the endoscopic approach to the skull base with a highlight on Canada’s contributions

Background: The Endoscopic Transphenoidal Approach to the Skull Base (ETSS) is now used internationally for a wide variety of pathologies ranging from CSF leaks to complex brain tumours. Methods: Case illustrations. Historical review of the evolution of ETSS with a focus on Canada’s contributions. Results: Canadians have been major contributors in the development and advancement of surgery of the skull base, particularly through endoscopic means. These will be highlighted with particular emphasis of those of Hardy, Cusimano, Kassam, Gentili, and others. Conclusions: Canada has been and continues to be an international leader in development and treatment of patients with skull base lesions, particularly those with lesions of the skull base amenable to ETSS.

Pituitary metastasis from a high grade serous ovarian carcinoma presenting as hyponatremia with masked diabetes insipidus: A case report

BackgroundPituitary metastasis is a rare entity, with majority of the primary tumors reported from breast or lung origins. We present a case with pituitary metastasis as the first clinical presentation of underlying ovarian carcinoma. CaseA 48-year-old female presented with visual disturbances and hyponatremic episodes. After management of her hyponatremia and resulting diabetes insipidus, detailed imaging was carried out which revealed a 35 mm x 35 mm x 20 mm (TS x CC x AP) pituitary mass, extending into the cavernous sinuses and suprasellar compartment, causing compression of the optic chiasma. Debulking was performed via the endoscopic trans-sphenoidal approach, and biopsy was consistent with metastatic high-grade ovarian serous carcinoma (WT1 + and estrogen receptor+). A CT chest-abdomen-pelvis revealed a 10 cm right ovarian mass with bilateral adrenal nodules. Postoperatively, patient developed CSF rhinorrhea and meningitis. Despite, reconstructive efforts, the patient continued to decline and was referred to palliation. She succumbed to her illness during her hospital admission. ConclusionOur case underscores the importance of considering pituitary metastasis when encountering DI or pituitary insufficiency in a middle-aged patient with a sellar mass.

Morphometric Analysis of the Sella Turcica on Cone-Beam Computed Tomography Images.

Sella turcica is an important anatomic formation that contains the pituitary gland and is in a close neighborhood with many vital structures. It is important to know the morphometry of the sella turcica, as it is a transition point during surgical interventions such as the endoscopic endonasal transsphenoidal approach to the region. The findings obtained are thought to be useful in the examination of sella turcica and surrounding structures and will contribute to the literature by knowing the morphometry of the region for the surgical method. In this study, cone-beam computed tomography images of 400 individuals, 200 females and 200 males, aged between 18 and 65 years, who did not have craniofacial pathology, who applied to Gaziantep University, Faculty of Dentistry between 2015 and 2020 for any reason, were evaluated retrospectively. In the sagittal section, 8 parameters were examined, 6 of which were transverse. The length () of the sella turcica in the sagittal plane is 10.19±1.77mm, the diameter of the sella turcica is 11.6±1.69mm, the anterior height of the sella turcica is 7.88±1.56mm, the median height of the sella turcica 8.18±1.42mm, posterior height of sella turcica 6.98±1.31mm, width of sella turcica 11.10±1.6mm. The distance between anterior clinoid processes in the transverse plane was 24.93±2.57mm, and the distance between posterior clinoid processes was 14.92±2.46mm. It was determined that there was an increase in many parameters with age, and length of the sella turcica and anterior clinoid processes were statistically significantly higher in males.

The learning curve in endoscopic transsphenoidal skull-base surgery: a systematic review

BackgroundThe endoscopic endonasal transsphenoidal approach (EETA) has revolutionized skull-base surgery; however, it is associated with a steep learning curve (LC), necessitating additional attention from surgeons to ensure patient safety and surgical efficacy. The current literature is constrained by the small sample sizes of studies and their observational nature. This systematic review aims to evaluate the literature and identify strengths and weaknesses related to the assessment of EETA-LC.MethodsA systematic review was conducted following the PRISMA guidelines. PubMed and Google Scholar were searched for clinical studies on EETA-LC using detailed search strategies, including pertinent keywords and Medical Subject Headings. The selection criteria included studies comparing the outcomes of skull-base surgeries involving pure EETA in the early and late stages of surgeons’ experience, studies that assessed the learning curve of at least one surgical parameter, and articles published in English.ResultsThe systematic review identified 34 studies encompassing 5,648 patients published between 2002 and 2022, focusing on the EETA learning curve. Most studies were retrospective cohort designs (88%). Various patient assortment methods were noted, including group-based and case-based analyses. Statistical analyses included descriptive and comparative methods, along with regression analyses and curve modeling techniques. Pituitary adenoma (PA) being the most studied pathology (82%). Among the evaluated variables, improvements in outcomes across variables like EC, OT, postoperative CSF leak, and GTR. Overcoming the initial EETA learning curve was associated with sustained outcome improvements, with a median estimated case requirement of 32, ranging from 9 to 120 cases. These findings underscore the complexity of EETA-LC assessment and the importance of sustained outcome improvement as a marker of proficiency.ConclusionsThe review highlights the complexity of assessing the learning curve in EETA and underscores the need for standardized reporting and prospective studies to enhance the reliability of findings and guide clinical practice effectively.

Management of growth hormone-secreting pituitary adenomas causing acromegaly: a practical review of surgical and multimodal management strategies for neurosurgeons.

This review aimed to highlight the history, diagnostic criteria, preoperative prognostic factors, surgical management, and multimodal adjuvant therapies recommended to provide a comprehensive and multifaceted understanding of and clinical approach to treating growth hormone-secreting pituitary adenomas (GHPAs) in patients with acromegaly. The authors collated and reviewed published studies, many written by skull base neurosurgeons, endocrinologists, and radiation oncologists with expertise in pituitary adenoma management, to produce a practical and contemporary update pertaining to the optimal management of acromegaly for neurosurgeons. Acromegaly is a debilitating disease for which surgery can be curative in more than two-thirds of patients. Recent rates of hormonal remission by the authors' group and others following the resection of GHPAs are on the order of 70%-80%, and these increase to more than 85% with the addition of medical therapy in a minority of patients who do not achieve remission with surgery alone. Most tumors are accessible via a direct endoscopic endonasal transsphenoidal approach, which can be augmented with a variety of extended approaches to gain access to suprasellar, clival, and parasellar compartments as needed. Preoperative growth hormone levels, cavernous sinus invasion, and pituitary adenoma consistency are important factors in determining the extent of resection. In most patients with residual or recurrent disease, medical therapy (e.g., somatostatin analogs and dopamine agonists) can be used to help achieve hormonal remission. Repeat surgery can be safely performed in most cases if needed, whereas stereotactic radiosurgery is usually reserved for medically resistant tumors in surgically inaccessible compartments. The neurosurgeon has a primary and often definitive role in the management of acromegaly. The involvement of an integrated and multidisciplinary team consisting of experts from neurosurgery, otolaryngology, endocrinology, and radiation oncology optimizes the chances for a biochemical cure, even in large and aggressive GHPAs.

Efficacy of the Craniopharyngioma Resection via Expanded Endoscopic Endonasal Transsphenoidal Approach in the Treatment of Complex Craniopharyngioma and Its Effect on Pituitary Function and Complications of Patients.

Surgical resection is the most effective method for craniopharyngioma, with complex operations and a high incidence of complications, especially for complex craniopharyngioma. The study focuses on selecting a proper surgical method to treat complex craniopharyngioma. A clinical study was conducted in this direction to explore the efficacy of expanded endoscopic endonasal transsphenoidal approach (EETS) and transcranial approach (TCA) in the treatment of complex craniopharyngioma and their effects on pituitary function and complications of patients. The clinical data of 73 patients with complex craniopharyngioma in Baoding No.2 Central Hospital from December 2017 to December 2022 were retrospectively analyzed. 13 patients who did not meet the admission criteria were excluded, and 60 patients were finally included. The included patients were divided into the TCA and EETS groups according to the treatment method. The surgical conditions, total tumor resection rate, clinical remission rate, and complications of patients in two groups were compared. The pituitary function of all patients, including thyroid stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), and human growth hormone (hGH), was compared. A total of 60 patients were finally included in the study, including 30 cases in the EETS group and 30 cases in the TCA group. The two groups had no statistical difference in baseline demographic characteristics and pathological types (p > 0.05). Compared with the TCA group, the EETS group had less intraoperative blood loss, operation time, tumor resection time, and hospitalization time (p < 0.001) and had a significantly higher total tumor resection rate and clinical remission rate (p < 0.05). The EETS group had higher ACTH and hGH levels than the TCA group (p < 0.05). There was no statistical difference between the two groups incidence of complications and disease recurrence rate (p > 0.05). The craniopharyngioma resection via EETS has a significant therapeutic effect in complex craniopharyngioma with a high total tumor resection rate and clinical remission rate, which can protect the pituitary function of patients and provide more benefits for patients.

The Evolution of Pituitary Surgery in an Australian Health Care Framework

Abstract Background The outcomes in pituitary surgery have dramatically changed over the past 130 years. Endoscopic endonasal transsphenoidal approaches are now an accepted method for operating on pituitary tumors, a skillset which takes time to develop. The Australian health care framework provides a unique mixture of public and private care for a geographically dispersed population. In this article, we aim to examine how outcomes for patients in South Australia changed as endoscopic pituitary surgery was adopted and how the Australian health care framework influenced the development of a skull base team. Methods The case notes of all patients undergoing pituitary surgery between 2006 and 2020 in South Australia. All patients treated by this author group were included. Results A total of 428 pituitary adenomas were surgically treated. Overall, 182 out of 249 patients (70%) had a complete resection with no recurrence at follow-up, and 49 patients (19%) had a residual that was observed and did not require treatment. Therefore, 89% of patients between the years 2006 and 2020 did not require any further treatment following their pituitary surgery. Upon examination of the 142 patients with functional adenomas, 112 (79%) patients had no recurrence in hormonal dysfunction following surgery, and the remaining 30 (21%) patients required further treatment. Conclusion We have demonstrated that acceptable outcomes can be achieved in a low-to-moderate volume setting across multiple hospitals when a coordinated effort is made to consolidate these cases within a small group of subspeciality-trained surgeons, as opposed to a more generalist approach.

Endoscopic Endonasal Transsphenoidal Resection of Pituitary Adenomas in Patients Presenting With Monocular Blindness.

Suprasellar tumors, particularly pituitary adenomas (PAs), commonly present with visual decline, and the endoscopic endonasal transsphenoidal approach (EETA) is the primary management for optic apparatus decompression. Patients presenting with complete preoperative monocular blindness comprise a high-risk subgroup, given concern for complete blindness. This retrospective cohort study evaluates outcomes after EETA for patients with PA presenting with monocular blindness. Retrospective analysis of all EETA cases at our institution from June 2012 to August 2023 was performed. Inclusion criteria included adults with confirmed PA and complete monocular blindness, defined as no light perception, and a relative afferent pupillary defect secondary to tumor mass effect. Our cohort includes 15 patients (9 males, 6 females), comprising 2.4% of the overall PA cohort screened. The mean tumor diameter was 3.8 cm, with 6 being giant PAs (>4 cm). The mean duration of preoperative monocular blindness was 568 days. Additional symptoms included contralateral visual field defects (n = 11) and headaches (n = 10). Two patients presented with subacute PA apoplexy. Gross total resection was achieved in 46% of patients, reflecting tumor size and invasiveness. Postoperatively, 2 patients experienced improvement in their effectively blind eye and 2 had improved visual fields of the contralateral eye. Those with improvements were operated within 10 days of presentation, and no patients experienced worsened vision. This is the first series of EETA outcomes in patients with higher-risk PA with monocular blindness on presentation. In these extensive lesions, vision remained stable for most without further decline and improvement from monocular blindness was observed in a small subset of patients with no light perception and relative afferent pupillary defect. Timing from vision loss to surgical intervention seemed to be associated with improvement. From a surgical perspective, caution is warranted to protect remaining vision and we conclude that EETA is safe in the management of these patients.

504 Anterior-posterior Diameter Is a Key Driver of Resectability and Complications for Pituitary Adenomas With Suprasellar Extension in Endoscopic Transsphenoidal Surgery

INTRODUCTION: As endoscopic transsphenoidal approaches are more routinely selected for larger pituitary adenomas with parasellar extension, understanding potential anatomical factors that limit resection and contribute to complications becomes increasingly important. METHODS: A single-center retrospective review of all endoscopic transsphenoidal surgeries for pituitary adenomas with suprasellar extension from 2015-2020 was performed. Preoperative MRIs were systematically assessed to assign a Knosp classification, a Zurich Pituitary Score (ZPS), and to measure lesional suprasellar dimensions. Univariate comparisons and multivariate regression models were employed to assess the influence of these factors on extent of resection (EOR) and postoperative complications. RESULTS: Of the 96 patients with suprasellar pituitary adenomas who underwent endoscopic transsphenoidal surgery, 74 patients (77%) had a gross total resection (GTR). Neither Knosp grade nor ZPS were associated with GTR (Knosp 3A-4 versus Knosp 0-2, p = 0.069; ZPS III-IV versus ZPS I-II, p = 0.079). Multivariate regression identified suprasellar anterior-posterior tumor diameter (SSAP) as the only significant predictor of EOR (OR 0.951, 95% CI 0.905-1.000, p = 0.048*). Higher SSAP also showed the strongest association with an increased overall complication rate (p = 0.0003*) and intraoperative CSF leaks (p = 0.0012*). Further analysis of the regression model for GTR suggested an optimal cut point value for SSAP of 23.7 mm, above which predictability for failing to achieve GTR carried a sensitivity of 89% and specificity of 41%. CONCLUSIONS: This study is unique in its examination of endoscopic transsphenoidal surgical outcomes for pituitary adenomas with suprasellar extension. Our findings suggest that previously established grading systems based on lateral extension into the cavernous sinus lose their predictive value in lesions with suprasellar extension and, more specifically, with increasing suprasellar anterior-posterior diameter.