Endoscopic Transsphenoidal Pituitary Surgery Research Articles

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

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

Multi-center study on sellar reconstruction after endoscopic transsphenoidal pituitary surgery.

Surgical techniques for sellar reconstruction include no reconstruction, use of synthetic materials, autologous grafts, and/or vascularized flaps. The aim of this study was to conduct a multi-center study comparing the efficacy and postoperative morbidity associated with different sellar reconstruction techniques. A retrospective chart review of patients who underwent endoscopic transsphenoidal surgery for pituitary tumors from five participating sites between January 2021 and March 2023 was performed. The variables included demographics, tumor characteristics, reconstruction technique, postoperative cerebrospinal fluid leak (CSF) leak, and 22-item Sino-Nasal Outcome Test (SNOT-22) scores. Comparisons of postoperative complications, SNOT-22 scores, and duration of surgery by type of onlay reconstruction were evaluated using Fisher's exact test, analysis of variance, and Kruskal‒Wallis test. Five hundred and one patients were identified. The median tumor size was 2.1cm, and 64% were non-functioning. Intraoperative CSF leak was identified in 38% of patients. A total of 89% of patients underwent onlay reconstruction: 49% were reconstructed with mucosal grafts, 35% with nasoseptal flaps, and 5% with other onlay techniques. Nasoseptal flaps were utilized more frequently in the setting of giant pituitary adenomas (>3cm), medial cavernous sinus wall resection, and high-flow intraoperative CSF leaks. Cases who utilized mucosal grafts had an overall shorter operating time (median: 183 min vs. 240 min; p<0.001). Five postoperative CSF leaks were identified, and therefore, statistical analysis could not be performed for this complication. The effectiveness and morbidity of different sellar reconstruction techniques are comparable. Vascularized flaps were utilized more frequently in the setting of larger tumors and high-flow intraoperative CSF leaks.

Comparison of Response First Technique with Reversal First Technique for Quality of Extubation in Patients Undergoing Transsphenoidal Pituitary Surgery: A Randomized Clinical Trial.

Early and smooth extubation following anesthesia is an important concern in patients undergoing transsphenoidal pituitary surgery to permit early neurological evaluation and prevent complications. The aim was to compare the RESPONSE FIRST and REVERSAL FIRST techniques for quality of extubation (QOE) in patients undergoing endoscopic transsphenoidal pituitary surgery. Fifty-six patients aged 18-60 years, with American Society of Anesthesiologists Physical Statuses I-II, and undergoing transsphenoidal surgery for pituitary tumors were randomized into either the RESPONSE FIRST group, in which neuromuscular reversal was given following the patient's response to oral commands, or the REVERSAL FIRST group, in which reversal of neuromuscular blockade (NMB) was given at the return of spontaneous respiration. QOE was the primary outcome. Hemodynamic response, jugular venous oxygen saturation (SjVO2), time to extubation, and awareness during emergence were assessed as secondary outcomes. The QOE in the RESPONSE FIRST group was significantly better than the REVERSAL FIRST group (mean (interquartile range (IQR)), 18 (17-19) vs 14 (12-14.75), P < 0.001). Heart rate (HR) and mean arterial pressure (MAP) were better in the RESPONSE FIRST group when compared to the REVERSAL FIRST group at the time of extubation, at 5 minutes, and 15 minutes following extubation (P < 0.05). SjVO2values were higher in the REVERSAL FIRST group as compared to the RESPONSE FIRST group during extubation and at 5 minutes after extubation (P < 0.01). There was no significant difference in the time to extubation between the groups (P = 0.73). The RESPONSE FIRST technique is associated with better QOE and preservation of systemic and cerebral hemodynamics during extubation in patients undergoing transsphenoidal pituitary surgery when compared to the REVERSAL FIRST technique.

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

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

Navigating the Surgical Landscape: A Comprehensive Analysis of Endoscopic vs. Microscopic Transsphenoidal Pituitary Surgery Outcomes.

Pituitary surgery, a critical intervention for various pituitary disorders, has sparked ongoing debates regarding the preference between endoscopic and microscopic transsphenoidal approaches. This systematic review delves into the outcomes associated with these techniques, taking into account the recent advancements in neurosurgery. The minimally invasive nature of endoscopy, providing improved visualization and reduced morbidity, stands in contrast to the well-established track record of the conventional microscopic method. Examining outcomes for disorders such as Cushing's disease and acromegaly, the review synthesizes evidence from Denmark, Bulgaria, and China. Noteworthy advantages of endoscopy encompass higher resection rates, shorter surgery durations, and fewer complications, endorsing its effectiveness in pituitary surgery. While emphasizing the necessity for prospective trials, the review concludes that endoscopic approaches consistently showcase favorable outcomes, influencing the ongoing discourse on the optimal surgical strategies for pituitary disorders.

A prospective-randomized placebo-controlled trial comparing the effects of nebulized dexmedetomidine v/s dexmedetomidine-lignocaine mixture on intraoperative hemodynamics and surgical field quality in patients undergoing endoscopic transnasal transsphenoidal pituitary tumor surgery

Background: During transnasal transsphenoidal pituitary surgery (TNTSS), the primary objective is to maintain stable hemodynamics while ensuring ideal surgical conditions. This study aimed to investigate the effect of nebulized dexmedetomidine on hemodynamic parameters and the quality of the surgical field during TNTSS. Methods: Seventy-five patients scheduled for TNTSS were randomized into three groups of 25 each and received preoperative nebulization with 5 mL of nebulizing fluid consisting of 1.5 μg/kg of dexmedetomidine with saline in dexmedetomidine (D) group; 1.5 μg/kg of dexmedetomidine with 2% lignocaine in dexmedetomidine-lignocaine (DL) group and normal saline in the control (S) group. Heart rate (HR), mean blood pressure, Formmers score, anesthetic requirement, and emergence were evaluated for each group. Results: Group S had significantly higher HR and mean arterial pressure than the other two groups across various time points during surgery (P &lt; 0.01). The total requirements for fentanyl, propofol, sevoflurane, and labetalol and the incidence of delayed emergence were significantly higher in the S group compared to the other two groups (P &lt; 0.01). The D and DL groups exhibited significantly better surgical field conditions than the S group. In all the parameters assessed, patients in the D group outperformed those in the DL group. Conclusion: The administration of nebulized dexmedetomidine, both alone and in combination with lignocaine, resulted in stable hemodynamics, favorable operative conditions, reduced anesthetic requirement, and facilitated prompt emergence during TNTSS. Nebulized dexmedetomidine proved superior to its combination with lignocaine across all evaluated parameters.

Internal carotid artery injury during endoscopic transsphenoidal pituitary surgery: risk factors, management

BackgroundTranssphenoidal surgeons should try to avoid internal carotid artery (ICA) injury but also be prepared to manage it. We analyzed our experience with ICA injury during endoscopic transsphenoidal pituitary surgery and present associated risk factors and a management protocol. MethodsWe retrospectively reviewed and analyzed the medical records of 1596 patients who underwent endoscopic transsphenoidal surgery for pituitary tumor resection in our institution from January 2009 to October 2022. ResultsSix patients experienced an ICA injury. All received timely and effective hemostasis with immediate direct tamponade followed by endovascular treatment. No serious postoperative complications occurred. ConclusionsWe proposed a treatment plan for ICA injuries encountered during endoscopic transsphenoidal surgery and described our hemostasis process, methods of endovascular treatment, and means of postoperative follow-up in detail.

Epidural Interlay Graft for Pituitary Surgery: A 4-Year Institutional Experience

Abstract Objective Sellar repair techniques with varying complexity and effectiveness have been employed to reduce the incidence of postoperative cerebrospinal fluid (CSF) leaks following endoscopic transsphenoidal pituitary surgery. This study describes our institutional experience with a minimalistic, highly effective approach to sellar repair. Methods The authors performed a retrospective review of consecutive cases of transsphenoidal pituitary surgery performed at our institution. All included subjects underwent sellar repair with an epidural interlay graft. Relationships between patient and tumor characteristics, incidence of CSF leak, adjunct repair techniques, and endocrine outcomes were examined. Results Three hundred and thirty-four (334) cases were included. Intraoperative CSF leak was encountered in 116 cases (34.7%), and postoperative CSF leak occurred only once (0.3%) early in the series. Seventy intraoperative CSF leaks were successfully repaired with an epidural interlay alone, including 13 high-flow leaks. Our rate of fat graft use (1.2%), nasoseptal flap (3.0%), and lumbar drain placement (6.6%) in the second half of the series showed a significant decline compared with the first half, indicating increased reliance on the interlay graft over time. Our 65% functional macroadenoma remission rate compares favorably with large historical series. Conclusions Simple sellar repair using an epidural interlay graft is highly effective in preventing postoperative CSF leaks, including cases of high-flow intraoperative leaks. More complex repair techniques are reserved for select high-risk cases or those with inadequate sellar bony ledges. With this technique, there has been no postoperative CSF leak at our institution in over 300 consecutive transsphenoidal pituitary surgeries.

Comparison of Cardiac Indices Using Two Different Concentrations of Topical Adrenaline during Endoscopic Transsphenoidal Pituitary Surgery: A Prospective Randomized Observational Study.

Introduction Adrenaline-soaked wicks are often employed to decongest nasal mucosa during transsphenoidal pituitary surgeries to ensure proper hemostasis and visibility of the operating field. Considerable debate exists regarding the optimum concentration of adrenaline that strikes a balance between hemostasis as well as the hemodynamic side effects of adrenaline. This study assessed cardiac indices like cardiac output and cardiac index using a FloTrac Vigileo cardiac output monitor to compare two different concentrations of adrenaline used for topical instillation. Materials and Methods 60 adult patients undergoing transsphenoidal pituitary surgery were randomly assigned to receive cotton wicks soaked in adrenaline solution (either 1:100,000 or 1:200,000) for nasal decongestion. Following a standardized anesthetic regime, a FloTrac Vigileo cardiac output monitor was attached with the invasive arterial line for precise monitoring and recording of cardiac indices (cardiac output and cardiac index). Additionally, quality of surgical field (as reported by the operating surgeon) blood loss, incidences of adverse hemodynamic events, and rescue drug usage were recorded. Results No difference in cardiac outputs and cardiac indexes of the patients was observed during baseline to 55 minutes and at 80 minutes and onward, whereas difference rose to statistical significance at the time points of 60 minutes and 70 minutes ( p < 0.05). Other parameters like stroke volume, stroke volume variation, and hemodynamic parameters were similar. Quality of the surgical fields (as reported by the surgeon), intraoperative bleeding, incidences of adverse effects, and frequency of rescue drugs usage were similar. Conclusion Instillation of 1:100,000 dilution of adrenaline solution compared with 1:200,000 for nasal decongestion is associated with significant rise in cardiac output and cardiac index at 60 and 70 minutes of the surgery with similar blood loss and hemodynamic variables. Therefore, the lower concentration of adrenaline can be recommended for usage during transsphenoidal pituitary surgeries.

THU063 Somatostatin Analog Neoadjuvant Treatment Before Endoscopic Surgery For Growth-Hormone Producing Pituitary Adenomas Invading The Cavernous Sinus: Case Series, Systematic Literature Review And Meta-analysis

Abstract Disclosure: B. Rapoport: None. A. Halstrom: None. A. Kelly: None. M. Roytman: None. J. Lantos: None. D. Phillips: None. R. Ramakrishna: None. T. Schwartz: None. G.A. Dobri: None. Background: Pituitary surgery remains the first line of treatment for acromegaly, yet 35-50% of patients with macroadenomas do not achieve biochemical remission postoperatively. Macroadenomas invading the cavernous sinus (Knosp grades 3 and 4) are particularly refractory to surgical management. Adjuvant therapy with somatostatin analogs in refractory cases is well established, but neoadjuvant use of these agents to consolidate invasive tumors prior to surgery remains controversial. Methods: We retrospectively analyzed our series of 84 consecutive cases of acromegaly treated with endoscopic transsphenoidal pituitary surgery between 2004 and 2020. We have used neoadjuvant pretreatment with somatostatin analogs for adenomas invading the cavernous sinus since 2017. We compared radiographic and long-term biochemical outcomes in the first 10 of these patients with a cohort of historical control patients who underwent resection only. We also performed a systematic review and meta-analysis of studies investigating neoadjuvant use of somatostatin analog therapy prior to transsphenoidal surgery for acromegaly. Results: Neoadjuvant therapy significantly reduced total tumor volume and volume of tumor in the cavernous sinus prior to surgery (mean reductions 30% and 48%, respectively, p&amp;lt;0.01), and was associated with trends toward increased rates of gross total resection and biochemical cure. Of those pretreated with neoadjuvant therapy, 60% were found to be in biochemical remission postoperatively compared to 50% in the control group, P 1. In addition, 70% of those pretreated had a gross total resection compared to 50% of controls, P 0.65. Gross total resection was achieved in all patients with Knosp grade 3 tumors, regardless of pretreatment status, and all of these patients entered biochemical remission. In patients with Knosp grade 4 tumors, gross total resection was achieved in 29% of surgery-only patients and 57% of pretreated patients; biochemical remission was achieved in 14% of surgery-only patients, and 29% of pretreated patients. The differences were not statistically significant. Conclusions: In this series of acromegalic patients with macroadenomas invading the cavernous sinus, neoadjuvant somatostatin analog therapy was associated with a trend toward increased rates of gross total resection and biochemical remission. Of note, those who were not in remission in the pretreatment group had a milder biochemical elevation and required lower-intensity medical therapy postoperatively. The systematic literature review and meta-analysis that we have performed confirm a statistically significant increase in remission rate in patients receiving neoadjuvant therapy. Presentation: Thursday, June 15, 2023

Endoscopic trans-sphenoidal pituitary surgery does not impact postoperative nasal quality of life

PurposeThe aim of this prospective longitudinal study was to assess both subjective quality of life using questionnaires and objective examination of nasal function with regard to olfaction, nasal air flow and mucociliary clearance in patients after minimally invasive, turbinate-preserving endoscopic transnasal trans-sphenoidal pituitary surgery.MethodsPatients undergoing endoscopic transnasal pituitary surgery were recruited prospectively and examined during three study visits, preoperatively and 3 and 6 months postoperatively. We examined nasal function using sniffin' sticks test, rhinomanometry, saccharin transit time test, and endoscopic and radiological scores. In addition, the influence on subjective quality of life and mental health was recorded using the Sinonasal-Outcome-Test-20 (SNOT-20) and the Hospital-Anxiety-and-Depression-Scale (HADS).Results20 patients undergoing endoscopic pituitary tumor resections were included. No significant changes in olfaction or mucociliary clearance were noted. Nasal air flow showed a tendency to increase in the postoperative course lacking significance. Both the endoscopy and the radiological scores showed a significant deterioration, especially after 3 months, with a trend towards improvement over time. However, neither the SNOT-20 nor the HADS showed significant changes compared to baseline.ConclusionsOur concept of minimally invasive endoscopic tumor resections on the pituitary gland with preservation of nasal turbinates shows low morbidity for the patient. Despite objectifiable surgery-associated changes in the nose, nasal physiology in terms of smell, airflow and mucociliary clearance can be preserved and the subjective quality of life of our patients remains stable.

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

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

The use of aprepitant for the prevention of postoperative nausea and vomiting in endoscopic transsphenoidal pituitary surgery.

Postoperative nausea and vomiting (PONV) are adverse effects after surgery, which may increase the risk of complications. Aprepitant is a neurokinin-1 receptor blocker and has been shown to reduce chemotherapy-related nausea and vomiting and PONV. However, its role in endoscopic skull base surgery remains unclear. The purpose of this study was to evaluate the effect of aprepitant in reducing PONV in endoscopic transsphenoidal (TSA) pituitary surgery. A retrospective chart review between July 2021 and January 2023 of 127 consecutive patients who underwent TSA was performed at a tertiary academic institution. Patients were divided into 2 groups based on preoperative aprepitant use. Two groups were matched based on known risk factors of PONV (age, sex, nonsmoking, and history of PONV). The primary outcome was the incidence of PONV. Secondary outcome measures included the number of anti-emetic use, length of stay, and postoperative cererebrospinal fluid (CSF) leak. After matching, 48 patients were included in each group. The aprepitant group demonstrated a significantly lower incidence of vomiting than the non-aprepitant group (2.1%vs 22.9%, p=0.002). The number of nausea episodes and anti-emetic use decreased with aprepitant use (p<0.05). There was no difference in the incidence of nausea, length of stay, or postoperative CSF leak. Multivariate analysis demonstrated that aprepitant decreased the incidence of postoperative vomiting with odds ratio of 0.107. Aprepitant may serve as a useful preoperative treatment to reduce PONV in patients undergoing TSA. Further studies are needed to evaluate its impact in other arenas of endoscopic skull base surgery.

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

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

Implementation of a Streamlined Care Pathway to Reduce Cost and Length of Stay for Patients Undergoing Endoscopic Transsphenoidal Pituitary Surgery.

We implemented a streamlined care pathway for patients undergoing endoscopic transsphenoidal (TSA) pituitary surgery. Select patients are recovered in the postanesthesia care unit and transferred to a step-down unit for intermediate neurologic care (INCU), with clinicians trained to manage cerebrospinal fluid leak, diabetes insipidus (DI), and other complications. We evaluated all TSA surgeries performed at 1 academic medical center from 7th January, 2017 to 30th March, 2020, collecting patient factors, tumor characteristics, cost variables, and outcomes. The INCU pathway was implemented on 7th January 2018. Pathway patients were compared with nonpathway patients across the study period. Outcomes were assessed using multivariate regression, adjusting for patient and surgical characteristics, including intraoperative cerebrospinal fluid leak, postoperative DI, and tumor dimensions. One hundred eighty-seven patients were identified. Seventy-nine were on the INCU pathway. Mean age was 53.5years. Most patients were male (66%), privately insured (62%), and white (66%). Mean total cost of admission was $27,276. Mean length of stay (LOS) was 3.97days. Use of the INCU pathway was associated with total cost reduction of $6376.33 (P < 0.001, 95% confidence interval [CI]: $3698.21-$9054.45) and LOS reduction by 1.27days (P= 0.008, 95% CI: 0.33-2.20). In-hospital costswere reduced across all domains, including $1964.87 invariable direct labor costs (P < 0.001, 95% CI: $1142.08-$2787.64) and $1206.52 in variable direct supply costs (P < 0.001, 95% CI: $762.54-$1650.51). Pathway patients were discharged earlier despite a higher rate of postoperative DI (25% vs. 11%, P= 0.011), with fewer readmissions (0% vs. 6%, P= 0.021). A streamlined care pathway following TSA surgery can reduce in-hospital costs and LOS without compromising patient outcomes.

Preservation versus resection of middle turbinate in endoscopic transnasal transsphenoidal pituitary surgery

BackgroundThe strategic position of the middle turbinate (MT) within the nasal cavity makes it the first kick start to resect pituitary pathology through Endoscopic Transnasal Transsphenoidal Surgery (ETTS). This research aimed to determine if the type of endonasal endoscopic approach, MT resection (MTres) versus MT preservation (MTpre), for pituitary surgery affects olfaction and sinonasal function within a subjective as well as objective manner. Patients & methodsA prospective cohort comparative study was conducted to compare the sinonasal and olfaction outcomes pre and post operatively for both groups. Sinonasal symptoms were evaluated subjectively by Sino-Nasal Outcome Test (SNOT-22), while objectively by Peri-Operative Sinus Endoscope Score (POSE) along with Lund-Mackay radiological scoring system (LMS), and a Sniffin Sticks Identification test (SIT) (Burghart, Germany) was used to measure the olfaction intensity. In both groups were used on a pre-operative period and after one, three, and six months post operatively. Results96 patients were recruited within predetermined criteria. It is found that there are no significant differences in SIT between both groups with a ρ value 0.439 post operatively. The average change in score (delta) was an increase of 0.3, with changes ranging from −3 to +4. There was no significant difference in sinonasal symptoms score among both groups, with ρ 0.07 posts operatively. There was a minor upsurge in POSE score and LMS in the preservation group but without remarkable differences with ρ value 0.1 and 0.2 subsequently. It is found that there are no significant differences in SIT between both groups with a ρ value 0.439 post operatively. ConclusionDespite these amendments to the nasal cavity, we approved that these changes do not affect the sinonasal functions.

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

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

Modified transseptal approach in endoscopic transsphenoidal pituitary surgery.

Transsphenoidal pituitary surgery is commonly performed via a direct transostial approach with a posterior septectomy. However, a technique via an endoscopic transseptal route has been described that avoids a posterior septectomy, but it comes with its own disadvantages. This paper describes a modification, and discusses its pros and cons. The initial incision in the mucosa is placed level with the anterior middle turbinate. The mucoperichondrial flap is raised ipsilaterally until the sphenoid sinus ostium. An incision is made at the osseocartilaginous junction, and the contralateral mucoperichondrial flap is raised. The bony septum and posterior aspect of this flap is excised. The size and position of this window can be adapted. At the end of the operation, the lateralised intact mucoperichondrial flap is moved back to the midline. Excision or deflection of the cartilaginous septum is not required. It maintains an intact septal mucosa on one side and avoids a septal perforation.

The volume-outcome relationship for endoscopic transsphenoidal pituitary surgery for benign neoplasm: analysis of an administrative dataset for England

Background Setting minimum annual volume thresholds for pituitary surgery in England is seen as one way of improving outcomes for patients and service efficiency. However, there are few recent studies from the UK on whether a volume-outcome effect exists, particularly in the era of endoscopic surgery. Such data are needed to allow evidence-based decision making. The aim of this study was to use administrative data to investigate volume-outcome effects for endoscopic transsphenoidal pituitary surgery in England. Methods Data from the Hospital Episodes Statistics database for adult endoscopic transsphenoidal pituitary surgery for benign neoplasm conducted in England from April 2013 to March 2019 (inclusive) were extracted. Annual surgeon and trust volume was defined as the number of procedures conducted in the 12 months prior to the index procedure. Volume was categorised as < 10, 10–19, 20–29, 30–39 and ≥40 procedures for surgeon volume and < 20, 20–39, 40–59, 60–79 and ≥80 procedures for trust volume. The primary outcome was repeat ETSPS during the index procedure or during a hospital admission within one-year of discharge from the index procedure. Results Data were available for 4590 endoscopic transsphenoidal pituitary procedures. After adjustment for covariates, higher surgeon volume was significantly associated with reduced risk of repeat surgery within one year (odds ratio (OR) 0.991 (95% confidence interval (CI) 0.982–1.000)), post-procedural haemorrhage (OR 0.977 (95% CI 0.967–0.987)) and length of stay greater than the median (0.716 (0.597–0.859)). A higher trust volume was associated with reduced risk of post-procedural haemorrhage (OR 0.992 (95% CI 0.985–0.999)), but with none of the other patient outcomes studied. Conclusions A surgeon volume-outcome relationship exists for endoscopic transsphenoidal pituitary surgery in England.

Retrospective analysis of anesthesia management in endoscopic transsphenoidal pituitary surgery

Retrospective analysis of anesthesia management in endoscopic transsphenoidal pituitary surgery