Transsphenoidal Approach Research Articles

Evaluation of Surgical Freedom for One-and-a-Half Nostril, Mononostril, and Binostril Endoscopic Endonasal Transsphenoidal Approaches.

Objective This article determines which of the one-and-a-half nostril, mononostril, and binostril endoscopic endonasal transsphenoidal approaches provide a superior manipulation during surgery. Methods The three approaches were orderly performed on 10 silicon-injected cadaveric heads to quantitatively assess surgical freedom and attack angle for sella. Measurements were determined with a standardized method under neuronavigation system using data of computed tomography. Results The one-and-a-half nostril endoscopic transsphenoidal approach (OETA) offered superior exposed area than that of the mononostril approach (META), and similar to that of the binostril approach (BETA). For surgical freedom at anatomic targets, the OETA showed greater surgical flexibility at pituitary center, the right medial optic carotid recess (R-mOCR), the left mOCR, the medial intersection of the right cavernous internal carotid artery, and extension line of upper margin of the clivus (R-mICC) than those of the META, and similar to those of the BETA. For sagittal angle of attack to the R-mOCR, R-mICC, and L-mOCR, the OETA can provide better angular freedom for surgeon than that of the META, and similar to that of the BETA. The OETA had the same axial attack to the pituitary center with the BETA. The OETA and the META had limited surgical freedom at L-mICC, and both inferior to the BETA. Conclusion The OETA has similar exposed area, surgical freedom, and attack angle for most anatomic targets to the BETA without resecting contralateral nasal septal mucosa, and obviously superior to the META.

Transclival approaches for intradural pathologies: historical overview and present scenario

Recently, endoscopic transsphenoidal transclival approaches have been developed and their role is widely accepted for extradural pathologies. Their application to intradural pathologies is still debated, but is undoubtedly increasing. In the past five decades, different authors have reported various extracranial, anterior transclival approaches for intradural pathologies. The aim of this review is to provide a historical overview of transclival approaches applied to intradural pathologies. PubMed was searched in October 2018 using the terms transcliv*, cliv* intradural, transsphenoidal transcliv*, transoral transcliv*, transcervical transcliv*, transsphenoidal brainstem, and transoral brainstem. Exclusion criteria included not reporting reconstruction technique, anatomical studies, reviews without new data, and transcranial approaches. Ninety-one studies were included in the systematic review. Since 1966, transcervical, transoral, transsphenoidal microsurgical, and, recently, endoscopic routes have been used as a corridor for transclival approaches to treat intradural pathologies. Each approach presents a curve that follows Scott's parabola, with evident phases of enthusiasm that quickly faded, possibly due to high post-operative CSF leak rates and other complications. It is evident that the introduction of the endoscope has led to a significant increase in reports of transclival approaches for intradural pathologies. Various reconstruction techniques and materials have been used, although rates of CSF leak remain relatively high. Transclival approaches for intradural pathologies have a long history. We are now in a new era of interest, but achieving effective dural and skull base reconstruction must still be definitively addressed, possibly with the use of newly available technologies.

Transnasal Transsphenoidal Approach for Pituitary Tumors: An ENT Perspective.

Endoscopic transnasal transsphenoidal (ETNTS) approach was first described in 1992 and is standard approach for the resection of benign pituitary adenomas. This prospective study aims in incidence and preoperative assessment of extent of the pituitary adenoma, peroperative findings of transnasal transsphenoidal excision, techniques of skull base repair, complications and its management in a tertiary centre. A prospective analysis from Jan 2017 to May 2019, of patients undergoing ETNTS approach of pituitary adenomas was made in terms of incidence in various age-groups, type of adenoma, operative findings including CSF leak, repair of the skull base defect, complications encountered and its management was done in a tertiary care centre and compared with the present literature. A total of 141 patients underwent ETNTS, with highest number of cases found in 41-50years age-group with mean age of 42.6years. Male: Female ratio was 1.6. Macroadenoma was in 123 patients while 18 had microadenoma, of these 63.74% were functional adenoma, highest of GH secreting, while 36.26% were non-functional. Mean surgical time was 98.4min ± 21.2min. Peroperative CSF leak was in 30.5% cases in various grades. Closure techniques included use of fat, multilayer techniques, Hadad's flap and gasket technique as per the type of CSF leak. Neurological and rhinological complications were 6.38% each. This study is focused on the ENT perspective of the endoscopic transnasal trans-sphenoidal approach for pituitary adenomas. The reduced rate of morbidity and complications is encouraging. The endoscopic skull base defect closure is challenging and requires skill, meticulous approach and synchronised team work in order to achieve a favourable outcome. The incidence of CSF leak can be minimised and if encountered has to be dealt in an organised manner, thus contributing to a reduced rate of complications. The complications encountered must be foreseen and managed with a proficient approach.

Systematic review and network meta-analysis assess the comparative efficacy and safety of transsphenoidal surgery for pituitary tumor.

To quantitatively synthesize the comparative efficacy and safety of the most common surgical approaches including endonasal transsphenoidal endoscopic surgery (ETES), sublabial transsphenoidal microsurgery (STMS) and endonasal transsphenoidal microsurgery (ETMS) for all kinds of pituitary tumors. This systematic review and network meta-analysis was performed on randomized controlled trials (RCTs) and comparison studies from databases of Pubmed, EMBASE, and the Cochrane library. We selected the rate of gross complete resection as our primary outcome of efficacy. And the incidence of all complications, cerebrospinal fluid (CSF) leak, diabetes insipidus, nasal septal perforation, death, and bleeding were designed as our primary outcomes of safety. Twenty-seven studies with 2618 patients were included in this network meta-analysis. On efficacy, there was no statistical difference among the three methods including ETES, STMS, and ETMS. As for safety, results indicated that the incidence of total complications of STMS (OR = 4.74; 95% CI 1.03, 40.14) is significantly superior to ETES. And the incidence of diabetes insipidus of ETMS (OR = 2.21; 95% CI 1.31, 3.81) was significantly superior to that of ETES. Besides, there was no statistical difference in the other complications including CSF leak, nasal septal perforation, death, and bleeding. We clarified the overpraise of the efficacy of endoscopy especially the endonasal transsphenoidal approach, and verified that all the approaches owned similar efficacy. Moreover, we recommended the endoscopy to be the first choice for pituitary tumors, because it demonstrated the best safety.

Comparative Efficacy of Transsphenoidal Endonasal Endoscopic and Microscopic Pituitary Surgery at Single Center of a Developing Country.

Objective This study was aimed to compare comparative efficacy of transsphenoidal endonasal endoscopic and microscopic pituitary surgery at single center of a developing country. Methods This study included 198 patients in which 50 patients were studied prospectively and 148 patients were studied retrospectively, diagnosed with pituitary adenoma who presented to neurosurgery department at Sawai Man Singh hospital in Jaipur, India, and were operated via transsphenoidal route between 2013 and 2018. Patients' records were reviewed and relevant clinical and surgical data were collected. Patients were divided into two groups based on the surgical procedure performed, endoscopic endonasal transsphenoid approach (group 1) and microscopic transsphenoidal approach (group 2). Outcomes, in terms of efficacy and the resulting complications of each procedure were compared and analyzed. Results A total of 198 patients with pituitary adenoma were operated during the study period. Among them, 119 (60.1%) patients were operated by endoscopic and 79 (39.9%) patients were operated by microscopic transsphenoidal approach. In endoscopic group, intraoperative cerebrospinal fluid (CSF) leak was present in 39 patients (32.77%) and 23 (29.11%) in microscopic group. Complete tumor removal was achieved in 69.75% in endoscopic and 48.13% in microscopic group ( p = 0.004). Endocrine control was achieved in 78.94% (30 out of 38) in endoscopic and 68.18% (15 out of 22 patients) in microscopic group. Conclusion The transsphenoidal approaches for resection of pituitary adenoma, both endoscopic and microscopic approach, are minimally invasive and effective for disease control. Both the approaches lead to similar endocrine control, visual symptoms, complications, and long-term outcome. Therefore, the selection of the final approach should be individualized, ultimately depending on the surgeons' comfort, experience, and familiarity with the particular technique.

Endoscopic subperichondrial transseptal transsphenoidal approach is safe and efficient for non-extended pituitary surgery.

To report the results of a series of patients undergoing the endoscopic subperichondrial transseptal (STRAS) approach for pituitary surgery and to evaluate the efficiency and the safety of this approach. This is a single-centre retrospective study including all patients undergoing pituitary lesion resection through the STRAS approach from January 2002 to December 2017 by a multidisciplinary surgical team (ENT and neurosurgeon). Demographic data, tumour type, complication rate and pre- and post-operative visual, endocrine and tumour status were retrospectively analysed. 119 patients were included in the study, 80 (67%) presenting macroadenoma, 24 (20%) microadenoma (20%) and 6 (5%) giant adenoma. 61 (51%) patients had secreting adenoma and 51 (42%) patient had non-functioning adenoma. The STRAS approach allowed a good visualization of intrasphenoidal and intrasellar anatomical landmarks in all cases and no patient needed turbinate resection. No patient died or had neurological deficit. Endocrine remission or control was achieved in 90.5% of hormone-secreting microadenomas and in 84.2% of hormone-secreting macroadenomas. Gross-total resection was achieved for 39 patients (48.8%) of the 80 macroadenomas. Nasal complication rate was very low, with no septal perforation and two epistaxis (1.7%) medically treated. The STRAS approach is an elegant approach to the sphenoid sinus that enables a good exposure of the intrasphenoidal anatomical landmarks with a maximal preservation of the nasal mucosa. This approach allows an intrasellar work with great comfort and safety for the surgeon using a two-hand or a four-hand technique.

Contemporary Management of Clinically Non-functioning Pituitary Adenomas: A Clinical Review.

Non-functioning pituitary adenomas (NFPAs) are benign pituitary tumours that constitute about one-third of all pituitary adenomas. They typically present with symptoms of mass effects resulting in hypopituitarism, visual symptoms, or headache. Most NFPAs are macroadenomas (>1 cm in diameter) at diagnosis that can occasionally grow quite large and invade the cavernous sinus causing acute nerve compression and some patients may develop acute haemorrhage due to pituitary apoplexy. The progression from benign to malignant pituitary tumours is not fully understood; however, genetic and epigenetic abnormalities may be involved. Non-functioning pituitary carcinoma is extremely rare accounting for only 0.1% to 0.5 % of all pituitary tumours and presents with cerebrospinal, meningeal, or distant metastasis along with the absence of features of hormonal hypersecretion. Pituitary surgery through trans-sphenoidal approach has been the treatment of choice for symptomatic NFPAs; however, total resection of large macroadenomas is not always possible. Recurrence of tumours is frequent and occurs in 51.5% during 10 years of follow-up and negatively affects the overall prognosis. Adjuvant radiotherapy can decrease and prevent tumour growth but at the cost of significant side effects. The presence of somatostatin receptor types 2 and 3 (SSTR3 and SSTR2) and D2-specific dopaminergic receptors (D2R) within NFPAs has opened a new perspective of medical treatment for such tumours. The effect of dopamine agonist from pooled results on patients with NFPAs has emerged as a very promising treatment modality as it has resulted in reduction of tumour size in 30% of patients and stabilization of the disease in about 58%. Despite the lack of long-term studies on the mortality, the available limited evidence indicates that patients with NFPA have higher standardized mortality ratios (SMR) than the general population, with women particularly having higher SMR than men. Older age at diagnosis and higher doses of glucocorticoid replacement therapy are the only known predictors for increased mortality.

Pituitary tuberculosis: a diagnosis not to be ignored

The first description of pituitary abscess dates back to 1914, for ten cases listed in the literature. Despite its rarity, tuberculosis pituitary abscess must be evoked in the face of a clinical picture of intracranial hypertension, pituitary hormonal dysregulation and an infectious context and the notion of tuberculosis contagion, the diagnosis is confirmed by the anatomo-pathological study. Pituitary MRI shows a process occupying the sellar compartment with heterogeneous hypersignal in T2 and isosignal in T1, enhanced in T1, enhanced in the periphery. Filling of the optochiasmatic cistern. The physiological hypersignal of the post-physiological pituitary cannot be individualized. The most common medications used to treat tuberculosis if early diagnosis without visual repercussions if not associated surgery via the transsphenoidal approach.

Morphometry of sphenoid air sinus and its ostium for surgical relevance: A cadaveric study

Introduction: The sphenoid air sinuses and their ostia are highly variable structures. The ostia are located on either side of the midline. The exact location of the sphenoid ostium is very much essential in endoscopic sinus surgeries as well as for the transsphenoidal hypophyseal approach. The present study was done to determine the anatomical location of the sphenoid sinus ostium in relation to the surrounding landmarks. It is a descriptive study. Material and Methods: The study was carried out in the Department of Anatomy, VMKV Medical College and Hospital, Salem, on forty sagittal head and neck sections of adult formalin-fixed cadavers. The length and width of the sinus were measured. The shape and type of the sphenoid sinus ostia were also noted. The distance of the sinus ostium from various landmarks was measured using Vernier calipers. The morphometric parameters were compared by Student's t-test on both sides. Results: Most of the specimens showed sellar variety than presellar variety on both right and left sides. The shape of the sphenoid sinus ostia was predominantly round shape, followed by oval and slit shape. The length and width of the sinus on the right side were less when compared to the left side. The distance between the sphenoidal ostia and several landmarks showed no significant difference except the distance from ostium to superior concha. Discussion and Conclusion: During the endoscopic approach of the sphenoid sinus ostium, it is not always easy to locate the ostium. The present morphometric study will serve as a guideline for the endoscopic surgical approach of the sphenoid sinus ostium using the various anatomical landmarks.

Intercarotid distance variations in pituitary adenomas: a cone-beam computed tomographic study

Introduction Transnasal trans-sphenoidal surgery has become the most popular procedure to approach different sellar lesions. Internal carotid artery injury during this approach could be minimized by accurate preoperative assessment of its course and detection of anatomical variations. Patients and methods This study was conducted on 24 cases with pituitary adenomas. The intercarotid distance (ICD) was measured by cone-beam computed tomography, and defined as the minimal distance between the inner walls of the carotid sulcus of the horizontal parasellar internal carotid artery. Comparison of measurements in the study group with that of healthy individuals of the control group was done. Aim The aim of this study was to detect variations in ICD with pituitary adenomas. Results This study showed that ICD was statistically significantly higher in the study than control groups (P=0.01). A statistically significant correlation between lesion size and ICD was found (P=0.04). A statistically significant difference between the ICD with the type of sellar pathology was found. The widest distance was found with suprasellar lesions (mean = 8.93 ± 2.09, P1 = 0.009) and the least in sellar lesions (mean = 16.58 ± 1.94). Conclusion Preoperative measurement of ICD is applicable and helpful in operative planning for the trans-sphenoid approach to pituitary lesions. The size of the adenomas directly affects the ICD with larger adenomas showing wider distance.

Early outcome of endoscopic trans-nasal trans-sphenoidal pituitary surgery in Kano, Nigeria

Endoscopic trans-nasal trans-sphenoidal hypophysectomy is a minimally invasive surgical procedure aimed at resection of pituitary tumors. This technique is widely practiced in developed countries but is presently gaining popularity in our environment. This study was aimed at presenting our preliminary outcomes as it relates to the technique of endoscopic trans-nasal trans-sphenoidal pituitary surgery in Kano, Nigeria. This was a retrospective study of patients with pituitary tumors that presented at a government tertiary and private specialist health institutions from October 2018 to December 2019. They all had excision of varying degrees of pituitary tumors via endoscopic trans-nasal trans-sphenoidal approach under general anesthesia. There were 4 females (66.7%) and 2 males (33.3%) and their ages ranged between 25 – 60 years. They presented with varying degrees of clinical symptoms such as gynaecomastia, galactorrhea, irregular menstruation, infertility, intermittent headache and visual impairment. Four (66.7%) had complete tumor excision and 2 (33.3%) had incomplete excision. Four (66.7%) had complete symptom relief and 2 (33.3%) had significant improvement in symptoms. The complications of surgery were nasal septal adhesion 1(16.7%), CSF leak 1(16.7%) and transient diabetes insipidus 2(33.3%). All complications were resolved during admission and at follow up visits. Histopathological analysis of specimens confirmed 5 cases of pituitary adenoma and a case of pituitary Rathkes cleft cyst. Endoscopic trans-nasal trans-sphenoidal pituitary surgery is feasible and has a favorable outcome in our setting with prospects for improvement to ensure safety. Keywords: Nasal endoscopy, Sinus surgery, Pituitary tumors, Skull base, Hypophysectomy.

Application and Care of Two Kinds of Sphenoid Sinus Packing Materials after Pituitary Tumor Resection with the Transnasal Endoscopic Approach

Background: Neuroendoscopic transsphenoidal approach for resection of pituitary adenomas has the advantages of less damage, fewer complications, and a faster recovery than the traditional approach and has beening favored by neurosurgeons. However, there has no standard method of selecting suitable packing materials after the operation to relieve pain in patients and achieve the ideal hemostatic effect. We compared the postoperative complications and treatment effects of two different packing materials in patients with pituitary adenomas. Objective: To investigate the advantages and disadvantages of using a catheter balloon and iodoform gauze for hemostasis in patients undergoing pituitary tumor resection by neuroendoscopic transsphenoidal approach. Materials and Methods: We retrospectively analyzed these data of 48 cases treated with pituitary adenoma resection by the single nasal approach from January 2018 to October 2019 in Sun Yat-sen University Cancer Center. According to the type of sphenoid sinus packing material used, these patients were divided into balloon tamponade oppression group (24 cases) and tela iodoformum oppression group (24 cases), respectively. The balloon tamponade oppression group received catheter balloon tamponade oppression hemostasis, and the tela iodoformum oppression group underwent tela iodoformum oppression hemostasis. The outcomes and complications were compared between the two groups in which two kinds of sphenoid sinus packing materials were used for hemostasis after tumor resection by transnasal endoscopic approach. For the catheter balloon compression hemostasis method, on account of the plasticity of the balloon, the volume of water in the balloon can be adjusted according to the size of the patient’s own sphenoid cavity. The amount of bleeding and several complications in terms of discomfort during placement and removal of the packing material, rebleeding after removal of the packing, cerebrospinal fluid rhinorrhea and electrolyte disturbance are compared between the two groups. Results: 48 patients were enrolled. The two groups’ data of patients were similar in age structure, sex ratio, tumor size at baseline and so on. No complications, such as abscess formation, were found in both groups. The success rate in the compression with catheter balloon group was 100% (24 of 24 patients); and in the iodoform gauze group 83.33% (20 of 24 patients). A catheter balloon was more successful in stopping bleeding at early stage than iodoform gauze. There were no statistically significant differences in the hospitalization stay time, operating day to discharge day and tampon indwelling time (P > 0.05). There were also no significant differences in pairwise comparison between the catheter balloon group and iodoform gauze groups in the incidence of cerebrospinal fluid rhinorrhea or electrolyte disturbance between the two groups (P > 0.05). The incidence of headache in the catheter balloon group was statistically significantly lower than that in the iodoform gauze group (P

A Stiffness Adjustable 6-DOF Robotic System for Pituitary Tumor Resection Under MRI

Magnetic resonance imaging offers better visualization for tumors present in the delicate parts of the human body. A pituitary tumor is one of the common types of brain-related tumors located underside the brain. It can be accessed through the nostrils and visualized better using magnetic resonance imaging (MRI). In this work, we present a 6-degree-of-freedom (DOF) robotic system for pituitary tumor resection via a transsphenoidal approach designed specifically for a commercially available 3T MRI scanner. The robotic system is designed to follow the anatomical and surgical constraints and to work inside the bore of the MRI to allow image acquisition during the surgical procedure. It has a 6-DOF manipulator consisting of a concentric tube and a tendon-driven bendable section. Both mechanisms are merged to have stiffness changing capability, and payload capacity to aid the surgical task. The manipulator is attached to a flexure shaft to bend it at the desired surgical angles. The materials used for development are analyzed in MRI and exhibit signal-noise ratio (SNR) reduction of less than 10%. The experimental results show that the stiffness can be changed more than ten times for safe navigation to the surgical site without damaging the surrounding tissues. Also, it can provide a maximum lifting force of more than 2N. The presented system is the preliminary version of the pituitary tumor resection system under development and shows the feasibility to be used in a real surgical environment.

Recent Developments in Endoscopic Endonasal Approach for Pituitary Adenomas.

Endoscopic endonasal transsphenoidal approach has become the workhorse for pituitary adenomas. The residual rates and complications continue to present as challenges for the pituitary surgeons. To review the recent developments in endoscopic pituitary surgeries for improving patient outcomes and safety rates. A search of the last ten years, on PubMed and Google Scholar was performed with the keywords "Pituitary and Neuroendoscopy". A total of 345 articles were found (44 review, 193 original). Relevant articles were chosen. Substantial improvement has taken place in the field of endoscopic pituitary surgery in the last decade. These include 3D printing, 3D endoscopes, 3D neuronavigation, multi-modal neuronavigation, ultra-high-definition endoscopes, optical fluorescence agents, intraoperative MRI, to name a few. The technological advancements have increased the resection rates, improved patient outcomes, and helped in the training of younger surgeons. A higher cost remains a concern.

Fat and Fibrin Glue: Quo Vadis?

To analyze the effectiveness of fat and fibrin glue to prevent postoperative cerebrospinal fluid (CSF) leak in pituitary surgery. Two hundred and eleven patients affected by pituitary adenoma entered this study. Patients that underwent a microscopic transsphenoidal approach between January 2013 and April 2019 were included. All the patients that developed intraoperative CSF leak were treated with fat and fibrin glue. The presence or absence of postoperative CSF leak was considered as a parameter to test the effectiveness of the intraoperative reconstruction technique used. Postoperative CSF leak was observed in 5 patients (2.4%). Among patients with an intraoperative low- grade CSF leak (1 or 2), 97.9% did not develop a postoperative CSF leak. In contrast, those who presented an intraoperative CSF leak of grade 3, had a worse prognosis. Fat and fibrin glue is currently an effective method in the treatment of low-grade intraoperative CSF leak. In case of intraoperative CSF leak of grade 3, it should be used combined with the nasoseptal flap technique to obtain a safer reconstruction.

The Importance of Long Term Follow Up After Endoscopic Pituitary Surgery: Durability of Results and Tumor Recurrence.

Endoscopic endonasal approach (EEA) has become the preferred surgical approach for resection of pituitary adenomas in most centers. This technique has a number of advantages such as improved visualization and maneuverability, when compared to microscopic transsphenoidal approach. However, the long-term results of this approach are still scarce. Ten years ago, we published our initial series of patients having undergone an endoscopic removal of their pituitary adenomas reporting favorable short-term results. This project aims to revisit the results of that series, addressing the long-term results regarding recurrence of pituitary adenomas. A retrospective analysis of consecutive, endoscopically managed pituitary adenomas in a single center from 2004-2007. Only patients with >5 years of follow up (FU) and complete follow up data were included in this study. Recurrences were defined as evidence of any new tumor growth or enlargement of previously noted residual adenoma and/or biochemical recurrence of disease activity, in cases of functioning adenomas. A total of 98 patients matched the inclusion criteria for this study. The median follow-up period was 144 months. Nonfunctioning adenoma was the most common subtype (n = 66, 67.3%), followed by GH-secreting tumors (n = 19, 19.4%), ACTH-secreting tumors (n = 7, 7.1%), prolactinomas (n = 4, 4.1%) and TSH-secreting adenomas (n = 2, 2%). Age ranges from 23 to 82 years, with median age of 53 years. Preoperative visual deficits were observed in 46 patients (46.9%) and hormonal deficits were identified in 31% of cases. 22.4% of patients had undergone a previous pituitary adenomas resection prior to treatment in our center. Surgery achieved gross total resection (GTR) and near total resection (NTR) in 89 cases (90.8%) (56.1% and 34.7%, respectively). A total of 37 cases had recurrences during FU (mean recurrence free survival: 80 months). Recurrences were observed in 34% of patients who had had GTR while recurrences were observed in 39.5% of cases that underwent subtotal resection. Most recurrences occurred after 5 years of FU and univariate analysis demonstrated previous surgery (P = 0.005), cavernous sinus invasion (P = 0.05) and Ki-67 >5% (P = 0.01) to be factors associated with higher chance of recurrence. Multivariate Cox-regression analysis demonstrate that previous surgery and Ki-67 >5% are factors associated with recurrences. Surgery and/or radiation were utilized for management of recurrences in 29/37 cases. Long-term FU analysis demonstrates that progression/recurrence of previously resected adenomas is observed in a significant number of patients, especially in those with previous/multiple surgical resections, elevated ki-67 and cavernous sinus invasion. Short-term FU may shadow real tumor control rates achieved after EEA and underscores the importance of long-term FU in these patients. Therefore, long-term FU should be pursued in all cases.

Endoscopic Untethering of Tight Filum Terminale: An Operative Technique.

To demonstrate the various technical advantages of minimally invasive endoscopic untethering of tight filum terminale for the treatment of tethered cord syndrome (TCS). In five pediatric cases of TCS, we performed untethering by using the endoscopic technique. The age of the patients were 6, 7, 8, 9, and 12 years old. We used a nasal speculum of the transsphenoidal approach during the endoscopic surgical procedure. All the procedures were performed uneventfully, except for one case with a split cord malformation that showed neurologic deterioration caused by excision of the diastematomyelic fibrous septum at the thoracic level (unrelated to the endoscopic procedure at the L5-S1 level). This patient was referred to a rehabilitation clinic 5 days after surgery and showed significant improvement by the third postoperative month. The other four patients were discharged 1 day after the operation. Endoscopic release of filum terminale is a safe technique especially if it is performed with neuromonitoring. This technique may shorten the length of hospital stay and reduce perioperative blood loss. However, futher studies with a larger number of patients and long-term follow-up are needed.

Comparative Study between Microscopic and Endoscopic Trans-Sphenoidal Surgery for Growth Hormone-Secreting Pituitary Adenomas with Super-Sellar Extension

Background: Advances in the era of modern micro-neurosurgery enabled a reduction of surgical invasiveness and brain retraction which has been defined as minimally invasive or keyhole surgery. Sinonasal endoscopy has brought radical changes in the concepts of pathophysiology and treatment of sinonasal aliments as well as surgical techniques. Aim of the Study: To compare between the use of endoscopic and microscopic trans-sphenoidal approach in resection of growth hormone-secreting pituitary adenomas with Suprasellar Extension. Patients and Methods: This is a prospective study. It had been conducted upon 20 patients having growth hormone secreting pituitary adenoma admitted to Neurosurgery department in Alzar University hospitals and Nasr City Insurance hospital from 2015 to 2018, divided into 2 groups; group A (10 cases) underwent endoscopic endonasal trans-sphenoidal pituitary adenoma resection, while group B (10 cases) operated upon using the standard microscopic trans-sphenoidal pituitary adenoma resection. The inclusion criteria were included: All patients with growth hormone secreting pituitary adenomas showing manifestations of acromegaly, mass effect or hormonal disturbance. Results: This study showed that improvement in outcome was higher in endoscopic group opposed to microscopic group (100% vs. 71% improved headache, 80% vs. 60% visual improvement, 75% vs. 20% fundus improvement and 60% vs. 30% field improvement). Conclusion: We concluded that fully endoscopic procedure result in improved rates of complete tumor removal and a reduced incidence of complications, when compared to the microscopic approach.

Visual Improvement after Endoscopic Endonasal Transsphenoidal Excision of Pituitary Gland Tumor

Objective: To evaluate the frequency of improved visual acuity after Endoscopic Endonasal Transsphenoidal excision of pituitary gland tumor.Study Design: Descriptive case series.Materials and Methods: In our study, Pre-operative visual acuity was noted by using the Snellen’s chart. Then patients underwent pituitary gland excision though Endoscopic Endonasal Transsphenoidal approach under general anesthesia. After surgery, patients were shifted in postsurgical wards and then will be discharged from there and were examinedfor 3 months in OPD. Snellen’s chart was used to evaluate patents for visual acuity after 3 months by an experienced ophthalmologist having at least 4 years residency experience If visual acuity increased ? 1 line, then improved visual acuity was labeled.Results: Improved visual acuity after pituitary gland tumor excision was seen in 59(89.39%) patients. Age and gender of patients did not show any statistically significant association for improved visual acuity.Conclusions: Results of this study showed that pituitary gland tumor excision through Endoscopic Endonasal Transsphenoidal approach is effective in terms of visual acuity improvement. Our main objectives in pituitary surgery are protection and reinstatement of vision and this surgical approach give maximum cover to vision restoration.

Olfactory bulb volume changes associated with trans-sphenoidal pituitary surgery.

ObjectiveThe trans-sphenoidal approach is most frequently used for pituitary adenoma (PA) enucleation. However, effects of this surgery on neighboring structures have received little attention so far. In particular, no investigations on olfactory bulb (OB) anatomy after trans-sphenoidal surgery have been reported. Because impairment of olfaction has been shown in small groups following trans-sphenoidal surgery we hypothesized that the transnasal approach is likely to alter OB volume which is associated with changes of olfactory function.MethodsThe study comprised 33 patients with pituitary adenoma (14 women and 19 men, mean age 50 years). Comprehensive assessment of olfactory function was conducted with the "Sniffin' Sticks" test kit. Based on magnetic resonance imaging scans OBs were measured before and approximately one year after trans-sphenoidal PA enucleation.ResultsOwing to postoperative non-compliance and MRI artifacts partly due to drill friction complete evaluation of “Sniffin' Sticks” in term of obtaining the TDI score was possible pre- and postoperatively in 21 patients whereas OB volumes were available in 32 patients. Approximately one year after surgery olfactory function was not significantly different from baseline. However, left- and right-sided OB volume in patients treated via trans-sphenoidal surgery decreased (p = 0.001). The side of the surgical approach did not affect OB volume in a side-specific manner. Changes in odor threshold were significantly correlated to changes in right-sided OB volume (r = 0.45, p = 0.024).ConclusionOverall olfactory performance one year after surgery was not significantly different from baseline. However, changes in OB volume are associated with changes in olfactory performance and OB volumes decreased in patients.