Pure Endoscopic Endonasal Approach Research Articles

Usefulness of Opening the Diaphragma Sellae Before Transecting Interclinoidal Ligament for Endoscopic Endonasal Transoculomotor Triangle Approach: Technical Nuances and Surgical Outcomes

Opening the oculomotor triangle and removing the posterior fossa lesion by endoscopic endonasal approach (EEA) is challenging for even an experienced endoscopic neurosurgeon. We summarize the treatment experience and technical nuances with EEA for resection of pituitary neuroendocrine tumors and cavernous sinus (CS) meningiomas invading through the oculomotor triangle (OT). Between 2018 and 2022, eight cases, including five pituitary neuroendocrine tumors (PitNET) including three nonfunctioning and two somatotroph tumors with elevated growth hormone, and 3 CS meningiomas were treated using an endoscopic endonasal transoculomotor triangle approach. The critical surgical technique is continuously opening the diaphragma sellae from medial to lateral towards the interclinoidal ligament (ICL) and transecting it to enlarge the OT. We evaluated preoperative tumor size, previous surgical history, preoperative symptoms, extent of tumor resection, histopathology, and postoperative complications for all patients. The GTR(gross total resection)- defined as complete removal in 3 patients (38%), near-total resection(NTR) - defined as >95% removal in 4 patients (50%), and subtotal resection (STR)- defined as up to 90 % removal in one patient (12%)and gross-total resection of tumor invading through the OT was achieved in all patients through pure EEA. Two of three patients with visual deficit in Non-Functioning-PitNET improved, and the other remained stable postoperatively. One patient showed transient oculomotor nerve palsy. The Growth Hormone level of the two patients with somatotroph tumors declined to normal. For three patients with CS meningiomas, cranial nerve palsy improved in two patients, while the other patient developed increased facial numbness after surgery. Endoscopic endonasal transoculomotor triangle approach is an efficient surgical option for the tumor with CS invasion and OT penetration.

MRI-negative Cushing's Disease: Management Strategy and Outcomes in 15 Cases Utilizing a Pure Endoscopic Endonasal Approach.

BackgroundCushing’s disease (CD) is among the most common etiologies of hypercortisolism. Magnetic resonance imaging (MRI) is often utilized in the diagnosis of CD, however, up to 64% of adrenocorticotropic hormone (ACTH)-producing pituitary microadenomas are undetectable on MRI. We report 15 cases of MRI negative CD who underwent surgical resection utilizing a purely endoscopic endonasal approach.MethodsEndoscopic endonasal transsphenoidal surgery (EETS) was performed on 134 CD cases by a single surgeon. Fifteen cases met inclusion criteria: no conclusive MRI studies and no previous surgical treatment. Data collected included signs/symptoms, pre- and post-operative hormone levels, and complications resulting from surgical or medical management. Data regarding tumor diameter, location, and tumor residue/recurrence was obtained from both pre- and post-operative MRI. Immunohistochemistry was performed to assess for tumor hormone secretion.ResultsAside from a statistically significant difference (P = 0.001) in histopathological results between patients with negative and positive MRI, there were no statistically significant difference between these two groups in any other demographic or clinical data point. Inferior petrosal sinus sampling (IPSS) with desmopressin (DDAVP®) administration was performed on the 15 patients with inconclusive MRIs to identify the origin of ACTH hypersecretion via a central/peripheral (C/P) ratio. IPSS in seven, five and three patients showed right, left, and central side lateralization, respectively. With a mean follow-up of 5.5 years, among MRI-negative patients, 14 (93%) and 12 patients (80%) achieved early and long-term remission, respectively. In the MRI-positive cohort, over a mean follow-up of 4.8 years, 113 patients (94.9%) and 102 patients (85.7%) achieved initial and long-term remission, respectively.ConclusionsSurgical management of MRI-negative/inconclusive Cushing’s disease is challenging scenario requiring a multidisciplinary approach. An experienced neurosurgeon, in collaboration with a dedicated endocrinologist, should identify the most likely location of the adenoma utilizing IPSS findings, followed by careful surgical exploration of the pituitary to identify the adenoma.

Evaluation of Pure Endoscopic Endonasal Approach in Management of Giant Pituitary Adenoma

Abstract Background Giant pituitary adenoma represents one of the challenging tumor for neurosurgeons. Many microsurgical approaches in the past were used for its management. Recently and with evolution of the endoscopic equipment and instruments, extended endoscopic transsphenoidal approach become one of the preferable approaches for its surgical excision. Methods We prospectively document the clinical , surgical and follow up data for all patients presented with giant pituitary adenoma to Ain-Shams university hospital and Weill Cornell Medical College, Presbyterian hospital and were surgically treated with extended transsphenoidal approach from 2015 till 2019. Results Our group study formed of 44 patients with mean age 53.03 (range 14.7-82.4) and a male predominance (59%). The main presentation was visual problems in 75% followed by partial hypopituitarism in 31.81% while headache was in 13.64%. Only 4 patients had functioning adenoma (3 prolactinoma and 1 acromegaly). Average tumor volume was 26.95 ± 17.25 cm3, while the mean maximum tumor diameter was 4.73 cm (range 4.0-8.0 cm). Radiographic invasion was found in 97.73% to suprasellar cistern, 61.36% to the cavernous sinus and in 34% to the sphenoid sinus. GTR was achieved in 45.45% with Knosp score is the only significant predictor factor for resection rate (p = 0.04). Visual improvement achieved in 75.76%. 50% (2 patient) of the patients with functioning adenoma were cured. Complications included CSF leak in 3 patients, permanent DI in 4 patients and postoperative hematoma in 2 patients. Recurrence and progression rates without upfront radiation therapy were 5.00 % and 31.81% respectively after mean follow up period 57.90 months. Conclusions Extended endoscopic approaches for achieving maximum resection with minimal morbidity for giant pituitary adenoma are very effective. Lateral tumor extension with cavernous sinus invasion represents the limiting point in achieving gross total resection. Upfront radiation therapy for patients with residual adenoma can be avoided but regular follow up should be warranted.

Excision of Greater Superficial Petrosal Nerve Schwannoma Via a Pure Endoscopic Endonasal Approach.

Greater superficial petrosal nerve (GSPN) schwannomas are an exceedingly rare nerve sheath tumor. The current literature search was conducted using Medline and Embase database by key search terms. Only 31 cases have been reported in the literature so far. Facial palsy, hearing loss, and xerophthalmia accounted for 48.4% (15), 41.9% (13), and 29% (9) of all cases, respectively. The middle cranial fossa approach was used in all previous reports. A retrospective review of 2 GSPN schwannomas patients treated by endoscopic endonasal approach (EEA) in our center was collected. Clinical records, including clinical features, pre- and postoperative images, surgery, and follow-up information, were reviewed. In all cases, clinical features including facial numbness and headache were found, with tinnitus in case 1, hearing loss, xerophthalmia in case 2. Imaging studies showed a solid mass that originated in the anterior of the petrous bone. Two patients were treated by EEA. Furthermore, no recurrence was found during the follow-up period (15-29 months) in both of the 2 cases after the operation. Complete resection of GSPN schwannomas can be achieved via the pure EEA. Endoscopic endonasal approach for radical removal of tumors is safe and feasible.

Outcomes and Quality-of-Life Measures after Endoscopic Endonasal Resection of Kadish Stage C Olfactory Neuroblastomas

The endoscopic endonasal approach (EEA) has been applied in the treatment of olfactory neuroblastoma (ONB). However, there is a lack of research examining the impact of EEA on locally advanced ONB. This study assessed the outcomes of EEA in patients with locally advanced ONB and its impact on the quality of life (QOL). We retrospectively reviewed patients with Kadish stage C ONB who underwent EEA between December 2004 and October 2019 and assessed demographic data, histopathologic grade, the extent of resection, postoperative complications, and outcomes. Preoperative and postoperative QOL was assessed using the Sino-Nasal Outcome Test. Twenty-six patients (18 men, 8 women; aged 26-79 years) were enrolled, with 12 cases of Hyams grade II and III and 1 case of grade I and IV each. In total, 25 patients received radiotherapy and 16 patients received chemotherapy, of whom 11 received preoperative neoadjuvant chemotherapy. Postoperative nasal bleeding was observed in 2 patients. The follow-up ranged from 8 to 124 months (median, 42.3 months). The 1-year and 5-year overall survival were 96.2% and 84.8%, respectively. The 1-year and 5-year disease-free survival were 76.9% each. The analysis of the postoperative Sino-Nasal Outcome Test scores showed significant improvement in certain psychological and sleep-associated domains, compared with the preoperative scores. Our results showed that pure EEA followed by radiotherapy offered excellent outcomes in the management of selected patients with locally advanced ONB. The postoperative QOL was significantly improved. More research is required on neoadjuvant chemotherapy to establish its role.

Transbasal versus endoscopic endonasal versus combined approaches for olfactory groove meningiomas: importance of approach selection.

OBJECTIVE There has been much debate regarding the optimal surgical approach for resecting olfactory groove meningiomas (OGMs). In this paper, the authors analyzed the factors involved in approach selection and reviewed the surgical outcomes in a series of OGMs. METHODS A retrospective review of 28 consecutive OGMs from a prospective database was conducted. Each tumor was treated via one of 3 approaches: transbasal approach (n = 15), pure endoscopic endonasal approach (EEA; n = 5), and combined (endoscope-assisted) transbasal-EEA (n = 8). RESULTS The mean tumor volume was greatest in the transbasal (92.02 cm3) and combined (101.15 cm3) groups. Both groups had significant lateral dural extension over the orbits (transbasal 73.3%, p < 0.001; combined 100%), while the transbasal group had the most cerebral edema (73.3%, p < 0.001) and vascular involvement (66.7%, p < 0.001), and the least presence of a cortical cuff (33.3%, p = 0.019). All tumors in the combined group were recurrent tumors that invaded into the sinonasal cavity. The purely EEA group had the smallest mean tumor volume (33.33 cm3), all with a cortical cuff and no lateral dural extension. Gross-total resection was achieved in 80% of transbasal, 100% of EEA, and 62.5% of combined cases. Near-total resection (> 95%) was achieved in 20% of transbasal and 37.5% of combined cases, all due to tumor adherence to the critical neurovascular structures. The rate of CSF leakage was 0% in the transbasal and combined groups, and there was 1 leak in the EEA group (20%), resulting in an overall CSF leakage rate of 3.6%. Olfaction was preserved in 66.7% in the transbasal group. There was no significant difference in length of stay or 30-day readmission rate between the 3 groups. The mean modified Rankin Scale score was 0.79 after the transbasal approach, 2.0 after EEA, and 2.4 after the combined approach (p = 0.0604). The mean follow-up was 14.5 months (range 1-76 months). CONCLUSIONS The transbasal approach provided the best clinical outcomes with the lowest rate of complications for large tumors (> 40 mm) and for smaller tumors (< 40 mm) with intact olfaction. The role of EEA appears to be limited to smaller, appropriately selected tumors in which olfaction is already absent. EEA also plays an important adjunctive role when combined with the transbasal approach for recurrent OGMs invading the sinonasal cavity. Careful patient selection using an individualized, tailored strategy is important to optimize surgical outcomes.

Endoscopic Endonasal Transsphenoidal Pituitary Surgery: Experience of 80 Cases.

Surgical approaches to the pituitary have undergone numerous refinements over the last 100 years. The fully endoscopic transsphenoidal approach has gained widespread use all around the world. We report the results of a consecutive series of patients who underwent pituitary surgery using a pure endoscopic endonasal approach and the results of the evaluation of the efficacy and safety of this procedure. We retrospectively reviewed the hospital database of 80 consecutive pituitary adenomas that were resected with the purely endoscopic endonasal transsphenoidal technique. The preoperative clinical condition of the patients, hormone profile, visual field, computed tomography and magnetic resonance imaging findings, and the Hardy-Vezina and Knosp scores were evaluated and revealed the importance of the parameters for surgery. Surgical technique, postoperative clinical condition of the patients, hormone profile, complications and follow-up period were reviewed. Endonasal endoscopic pituitary surgery is a safe and effective surgical technique.

Early experience of resection of meningiomas in anterior skull base with intra-extracranial extension via a pure endoscopic endonasal approach

The early experience of treating anterior skull base meningiomas with intra-extracranial extension via pure endoscopic endonasal approach (EEA) was presented, the safety, feasibility and preliminary treatment outcomes were investigated. Eight patients with intra-extradural meningiomas who were admitted from October 2006 to October 2010 were operated on via EEA in one stage in Xuanwu hospital. In this study, the operative technique was described, the degree of resection, complications and the early clinical outcomes were discussed. The complete resection of meningiomas with intra-extracranial extension was achieved in all patients using EEA in one stage. Preoperative visual symptoms were improved or resolved in all cases who presented with preoperative visual complaints. No patient in our series experienced a new neurological deficit after surgery or recurrence and death related meningiomas in the follow-up period (33-75 months). One patient experienced postoperative cerebrospinal fluid leak, delayed meningitis and secondary hydrocephalus which responded to therapy. After treatment, the patient was cure. Our limited experience indicates that EEA is feasible and safe for the complete resection of anterior skull base meningiomas with intra- and extracranial extension in one stage in selected cases.

Gigantism Treated by Pure Endoscopic Endonasal Approach in a Case of McCune-Albright Syndrome with Sphenoid Fibrous Dysplasia: A Case Report

McCune-Albright syndrome (MAS) is an uncommon polyostotic manifestation of fibrous dysplasia in association with at least one endocrinopathy that is mostly associated with precocious puberty and hyperpigmented skin macules named café-au-lait spots. We present an atypical manifestation of McCune-Albright syndrome in a 19-year-old man with the uncommon association of polyostotic fibrous dysplasia and gigantism in the absence of café-au-lait spots and precocious puberty. He presented with a height increase to 202 cm in the previous 3 years, which had become more progressive in the few months prior. Physical examination revealed only a mild facial asymmetry; however, a computed tomography (CT) scan discovered vast areas of voluminous bones with ground-glass density and thickening involving the craniofacial bones and skull base. Magnetic resonance imaging (MRI) found a right stalk shift of the pituitary with a 20 mm pituitary adenoma. We describe the diagnostic and endoscopic endonasal transsphenoidal approach for excision of the tumor.

Sellar repair in endoscopic endonasal transsphenoidal surgery for pituitary adenoma: a report of 240 cases

Background and Objective: Cerebrospinal fluid (CSF) leak is a devastating complication after transsphenoidal surgical approach to pituitary adenoma and sellar repair has been postulated as crucial step in this approach. In this study, we describe our experience regarding sellar repair in pure endoscopic endonasal approach in 240 patients with pituitary adenoma. Methods: During April 2005 to April 2011, a total of 240 patients with pituitary adenomas underwent endoscopic endonasal approaches for tumor removal. The degree of intra-operative CFS leak was graded as followed: Grade 0: no leakage was observed; grade 1: leakage in form of drops; and grade 3: flow of CSF was observed. Repair was done according to degree of leak e.g. surgicel for grade 0, fat and fascia for grade 1, with adding synthetic sealant and/or lumbar drain for grade 2. The method of repair is discussed in each group and exceptions were also bolded. No sphenoid sinus obliteration was needed. Results: There were 208 macroadenomas and 32 microadenomas. One hundred and thirteen patients (55.4%) had grade 0 CSF leaks, 78 patients (32.5%) grade 1 CSF leaks, and 29 patients (12%) showed grade 2 leaks. There were 2 documented post operative CSF leak (0.8%) one of them was treated by lumbar drainage and the other with revision endoscopic repair. There was also one case of pneumocephalus (0.4%) with no obvious leak in nasal endoscopic exam which managed medically. There were also 2 cases of post-operation meningitis (0.8%) with no leak that one of them was due to outbreak of acinetobacter in ICU. Conclusion: Findings of this study showed that intra-operative CSF leak is an important factor determining the need and extend of sellar repair in endoscopic endonasal approach for pituitary adenoma. The low rate of post-operative CSF leak is in favor of the applicability of grading system and method chosen for repair.

Endoscopic Endonasal Surgery for Pituitary Adenoma

Objectives：Surgical approaches to the pituitary adenoma have undergone numerous refinements. Surgery on the pituitary adenoma is increasingly being performed through an endoscopic approach. The aim of this study is to report the results of a consecutive series of patients undergoing pituitary surgery using a pure endoscopic endonasal approach(EEA) and to evaluate the efficacy and safety of this procedure. Materials and Methods：We reviewed 24 consecutive patients with pituitary adenoma who underwent purely endoscopic transsphenoidal resection of their lesions. The patients’ clinical outcomes, including remission rates, degrees of tumor removal, and complications were evaluated. Results：Between September 2000 and August 2009, 76 patients with pituitary adenoma were operated on at Ewha University Mokdong Hospital. Of these, 24 patients were operated on using EEA. There were 18 nonfunctioning, 4 growth hormone-secreting, and 2 prolactin-secreting adenomas. Gross total removal was achieved in 62.5% of the cases after surgery. Visual disturbance was seen in 18 patients, which was improved in all patients. The main cause of failure of total removal was invasion to cavernous sinus. The remission results for patients with nonfunctioning adenomas was 83.3% and for functioning adenomas were 83.3%(75% for GH hormone-secreting, 100% for prolactin hormone-secreting), with no recurrence at the time of the last follow-up. Post-operative complications were present in 4(16.7%) cases. Three cases showed immediate postoperative CSF leakage, one case showed transient diabetes insipidus. There was no death related to the procedure in this series. Conclusion：The endoscopic endonasal approach for resection of pituitary adenomas, provides acceptable results representing a safe alternative procedure to the microscopic approach. This less invasive method, associated with a small number of complications, provides acceptable tumor removal rates and represents an important tool for the achievement of good results in the pituitary surgery.

Endoscopic endonasal transsphenoidal surgery: surgical results of 228 pituitary adenomas treated in a pituitary center

Pituitary tumors are challenging tumors in the sellar region. Surgical approaches to the pituitary have undergone numerous refinements over the last 100 years. The introduction of the endoscope have revolutionized pituitary surgery. The aim of this study is to report the results of a consecutive series of patients undergoing pituitary surgery using a pure endoscopic endonasal approach and to evaluate the efficacy and safety of this procedure. We reviewed the data of 228 consecutive patients who underwent endonasal transsphenoidal adenoma removal over an 10-year period. Pre- and post-operative hormonal status (at least 3 months after surgery) were analyzed and compared with clinical parameters presented by the patients. Tumor removal rate, endocrinological outcomes, and complications were retrospectively assessed in 228 patients with pituitary adenomas who underwent 251 procedures between December 1998 and December 2007. There were 93 nonfunctioning adenomas, 58 growth hormone-secreting, 41 prolactin-secreting, 28 adrenocorticotropin hormone secreting, 7 FSH-LH secreting and 1 thyroid-stimulating hormone-secreting adenomas. Gross total removal was achieved in 79.3% of the cases after a median follow-up of 61.5 months. The remission results for patients with nonfunctioning adenomas was 83% and for functioning adenomas were 76.3% (70.6% for GH hormone-secreting, 85.3% for prolactin hormone-secreting, 71.4% for ACTH hormone-secreting, 85.7% for FSH-LH hormone-secreting and 100% for TSH hormone-secreting), with no recurrence at the time of the last follow-up. Post-operative complications were present in 35 (13.9%) cases. The most frequent complications were temporary and permanent diabetes insipidus (six and two cases, respectively), syndrome of inappropriate antidiuretic hormone secretion (two cases) and CSF leaks (eight cases). There was no death related to the procedure in this series. The endoscopic endonasal approach for resection of pituitary adenomas, provides acceptable results representing a safe alternative procedure to the microscopic approach. This less invasive method, associated with a small number of complications, provides excellent tumor removal rates and represents an important tool for the achievement of good results in the pituitary surgery, mainly for the complete removal of large adenomas.

PURE ENDOSCOPIC ENDONASAL APPROACH FOR PITUITARY ADENOMAS

The aim of this study was to report the results of a consecutive series of patients undergoing pituitary surgery using a pure endoscopic endonasal approach and to evaluate the efficacy and safety of this procedure. We reviewed 200 consecutive patients with pituitary adenoma who underwent purely endoscopic transsphenoidal resection of their lesions. The patients' clinical outcomes, including remission rates, degrees of tumor removal, and complications, were evaluated and compared with a previous microscopic series. There were 111 nonfunctioning adenomas and 34 growth hormone-secreting, 27 adrenocorticotropin hormone-secreting, 25 prolactin-secreting, and 3 thyroid-stimulating hormone-secreting adenomas. The degree of gross total removal for tumors with suprasellar or parasellar extension and without cavernous sinus involvement was 96% and for intrasellar lesions was 98%. After a median follow-up period of 19 months, the remission results for patients with functioning adenomas were 71% for growth hormone-secreting, 81% for adrenocorticotropin hormone-secreting, and 88% for prolactin-secreting adenomas, with no recurrence at the time of the last follow-up. This compares with similar results reported from series using a standard microsurgical approach (growth hormone-secreting adenomas, 67%; adrenocorticotropin hormone-secreting adenomas, 78%; and prolactin-secreting adenomas, 62%). Endoscopic surgery for recurrent or residual nonfunctioning adenomas that had been previously treated using a microscopic approach revealed in the majority of cases a more limited exposure during the initial surgery, frequently with incomplete tumor removal. Complication rates have been low, and the average length of hospital stay was reduced. A purely endoscopic approach for pituitary adenoma treatment is a safe and effective alternative to the traditional microscopic procedure. Although our results reveal excellent tumor-removal rates, comparable remission rates in functioning tumors, and a very low rate of complications, additional studies with longer follow-up periods are required to confirm whether this approach should be considered the preferred procedure for pituitary surgery.

The Expanded Endoscopic Transnasal Approach for the Treatment of Clival Chordomas

Objective: We report our recent experience with the expanded pure endoscopic endonasal approach for the treatment of clival chordomas.