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The impact of obesity on rates of post-operative CSF leak following endoscopic skull base surgery: results from a prospective international multi-centre cohort study. Front Endocrinol (Lausanne) 2024; 15:1353494. [PMID: 38899009 PMCID: PMC11185995 DOI: 10.3389/fendo.2024.1353494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 05/07/2024] [Indexed: 06/21/2024] Open
Abstract
Aims Post-operative CSF leak is the major source of morbidity following transsphenoidal approaches (TSA) and expanded endonasal approaches (EEA) to lesions of the sella turcica and the ventral skull base. There are conflicting reports in the literature as to whether obesity (BMI ≥30) is a risk factor for this complication. We aimed to evaluate data collected as part of prospective multi-centre cohort study to address this question. Methods The CRANIAL (CSF Rhinorrhoea After Endonasal Intervention to the Skull Base) study database was reviewed and patients were divided into obese and non-obese cohorts. Data on patient demographics, underlying pathology, intra-operative findings and skull base repair techniques were analysed. Results TSA were performed on 726 patients, of whom 210 were obese and 516 were non-obese. The rate of post-operative CSF leak in the obese cohort was 11/210 (5%), compared to 17/516 (3%) in the non-obese cohort, which was not statistically significant (χ2 = 1.520, p=0.217). EEA were performed on 140 patients, of whom 28 were obese and 112 were non-obese. The rate of post-operative CSF leak in the obese cohort was 2/28 (7%), which was identical to the rate observed in the non-obese cohort 8/112 (7%) Fisher's Exact Test, p=1.000). These results persisted following adjustment for inter-institutional variation and baseline risk of post-operative CSF leak. Conclusion CSF leak rates following TSA and EEA, in association with modern skull base repair techniques, were found to be low in both obese and non-obese patients. However, due to the low rate of post-operative CSF leak, we were unable to fully exclude a small contributory effect of obesity to the risk of this complication.
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Pecorari IL, Qama E, Akbar N, Colley P, Fang CH, Agarwal V. The Effect of Preoperative Cabergoline on Prolactinoma Fibrosis: A Case Series. J Neurol Surg Rep 2024; 85:e66-e73. [PMID: 38751869 PMCID: PMC11095984 DOI: 10.1055/s-0044-1786740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/08/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction Prolactinomas are a common intracranial neoplasm and constitute most pituitary tumors. Although patients can present with variable hormone dysregulation and symptom severity, the use of dopamine agonists remains a first-line treatment. While bromocriptine has been found to increase tumor fibrosis, the effect of cabergoline on collagen deposition has been disputed. The aim of this article is to understand the influence of cabergoline on tumor fibrosis prior to resection. Case Presentations Four male patients who underwent prolactinoma resection were included in this report. The average age was 39.8 years (range: 26-52 years). Pre-treatment prolactin levels ranged from 957.8 to 16,487.4 ng/mL. Three patients received cabergoline for at least 1 month prior to surgery (treatment range: 1-6 months). One patient had surgery without prior cabergoline use. Pathology reports confirmed each tumor to be of lactotroph origin. For each sample, Masson's trichrome staining was performed and the percentage of sample fibrosis was quantified using an artificial intelligence imaging software. Among those who received preoperative cabergoline, the extent of tumor fibrosis was in the range of 50 to 70%. In contrast, specimen fibrosis was approximately 15% without cabergoline use. Conclusion This report demonstrates that a short duration of preoperative cabergoline can cause significant prolactinoma fibrosis. Understanding the effect of cabergoline on tumor consistency prior to surgery is essential as increased fibrosis can lead to more difficult tumor removal, reduce the extent of resection, and increase surgical complications. Considering these effects, further studies regarding the use of surgery prior to cabergoline for prolactinoma management are warranted.
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Affiliation(s)
- Isabella L. Pecorari
- Department of Neurological Surgery, Albert Einstein College of Medicine, Bronx, New York, United States
- Department of Neurological Surgery, Montefiore Medical Center, Bronx, New York, United States
| | - Eros Qama
- Department of Pathology, Albert Einstein College of Medicine, Bronx, New York, United States
- Department of Pathology, Montefiore Medical Center, Bronx, New York, United States
| | - Nadeem Akbar
- Department of Otorhinolaryngology – Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, United States
- Department of Otorhinolaryngology – Head and Neck Surgery, Montefiore Medical Center, Bronx, New York, United States
| | - Patrick Colley
- Department of Otorhinolaryngology – Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, United States
- Department of Otorhinolaryngology – Head and Neck Surgery, Montefiore Medical Center, Bronx, New York, United States
| | - Christina H. Fang
- Department of Otorhinolaryngology – Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, United States
- Department of Otorhinolaryngology – Head and Neck Surgery, Montefiore Medical Center, Bronx, New York, United States
| | - Vijay Agarwal
- Department of Neurological Surgery, Albert Einstein College of Medicine, Bronx, New York, United States
- Department of Neurological Surgery, Montefiore Medical Center, Bronx, New York, United States
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Vasan V, Dullea JT, Devarajan A, Vasa D, Ali M, Nichols N, Henson P, Porras C, Lopez C, Luna D, Liou L, Iloreta AM, Govindaraj S, Bederson J, Shrivastava RK. Predictors of Prolonged Length of Stay After Pituitary Adenoma Resection: A Large Cohort Analysis Using the National Inpatient Sample (2016-2019). Am J Rhinol Allergy 2023; 37:758-765. [PMID: 37550993 DOI: 10.1177/19458924231193527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
OBJECTIVE In this nationwide retrospective study, the authors aimed to identify demographic, clinical, and baseline health risk factors predictive of a prolonged length of stay (PLOS) for patients with pituitary adenomas (PAs). METHODS The National Inpatient Sample dataset from 2016 to 2019 was utilized to identify all included hospitalizations for PA resection as identified by the appropriate diagnosis-related group code. Comorbidities were classified based on the Charlson Comorbidity Index mapping of ICD-10 codes, and PLOS was identified as any stay longer than 3 days. Univariable and multivariable logistic regression models, accounting for the sample design, were built to determine factors associated with PLOS and emergent surgery. RESULTS Overall, 30 945 patients were included in this study with 10 535 patients having PLOS. Female patients experienced an increased odds of PLOS (odds ratio [OR]: 1.29; P < .001). Black patients (OR: 1.49; P < .001) and Hispanic patients (OR: 1.30; P = .003) had 1.49 times and 1.30 times the odds of PLOS compared to White patients, respectively. Compared to patients insured by Medicare, patients insured by Medicaid had an increased odds of PLOS (OR: 1.36; P = .007) as well as emergent surgery (OR: 5.40; P < .001). When stratified by emergent surgeries, Black patients (OR: 1.89; P < .001), Hispanic patients, (OR: 2.14; P < .001), and patients on Medicaid insurance (OR: 1.71; P < .001) were at an increased risk of emergent procedures. However, female sex (OR: 0.65; P < .001), upper third quartile (OR: 0.73; P = .017), and fourth quartile (OR: 0.69; P = .014) of patients categorized by zip code income were at decreased odds of an emergent procedure. CONCLUSIONS Black and Hispanic patients, patients with Medicaid insurance, and patients of low socioeconomic status patients are at significantly higher risk of emergent PA resection and PLOS. Efforts to prevent emergent surgeries and shorten hospitalization after pituitary surgery may need to primarily focus on patient groups with select sociodemographic characteristics.
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Affiliation(s)
- Vikram Vasan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jonathan T Dullea
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alex Devarajan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Devarshi Vasa
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Noah Nichols
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Philip Henson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Christian Porras
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Christine Lopez
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Diego Luna
- Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Lathan Liou
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alfred Marc Iloreta
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Satish Govindaraj
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joshua Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Raj K Shrivastava
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
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Albaharna H, Alqurashi A, Alshareef M, Alromaih S, Alrasheed AS, Alroqi A, Ajlan A, Alsaleh S. Impact of Concurrent Chronic Rhinosinusitis on Complication Rates after Endonasal Endoscopic Skull Base Surgery: A Single-Center Experience. J Neurol Surg B Skull Base 2023; 84:507-512. [PMID: 37671295 PMCID: PMC10477013 DOI: 10.1055/s-0042-1755602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 06/20/2022] [Indexed: 10/15/2022] Open
Abstract
Objectives Preoperative planning of endoscopic skull base surgery (ESBS) is essential. The safety of performing surgery before managing sinus pathologies including concurrent chronic rhinosinusitis (CRS) in patients undergoing ESBS has been questioned. The current study aimed to evaluate and compare the complication rates between patients with and without CRS undergoing ESBS. Design This is a retrospective study. Setting Present study was conducted at tertiary referral center. Participants We included all patients who underwent ESBS between March 2015 and March 2021. However, patients who had surgical revision for remnant tumor, primary sinonasal tumor excision, and cerebrospinal fluid (CSF) leakage repair were excluded. The presence of concurrent CRS was determined according to the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS 2020) criteria by reviewing electronic charts about the preoperative clinical assessment and CT scan images of the paranasal sinuses. Then, the incidence rates of postoperative meningitis, CSF leakage, and surgical site infection were compared between patients with and without concurrent CRS undergoing ESBS. Main Outcome Measures Postoperative complication rates in patients underwent ESBS with and without CRS. Results From a total of 130 ESBS cases, 99 patients were included in this study. Among them, 24 had concurrent CRS. One patient presented with postoperative meningitis, one with CSF leakage, and two with surgical site infections. The incidence rate of postoperative meningitis, CSF leakage, and surgical site infection did not significantly differ between patients with and without concurrent CRS. Conclusion Concurrent CRS is not a contraindication for ESBS. Moreover, simultaneous endoscopic sinus surgery can safely be performed without additional morbidity in ESBS.
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Affiliation(s)
- Hussain Albaharna
- Department of Otolaryngology, Head and Neck Surgery, Qatif Central Hospital, Qatif City, Saudi Arabia
- Department of Otolaryngology, Head and Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ashwag Alqurashi
- Department of Neurosurgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohammad Alshareef
- Department of Otolaryngology, Head and Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Department of Otolaryngology, Head and Neck Surgery, Khamis Mushait General Hospital, Khamis Mushait City, Saudi Arabia
| | - Saud Alromaih
- Department of Otolaryngology, Head and Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz S. Alrasheed
- Department of Otolaryngology, Head and Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ahmad Alroqi
- Department of Otolaryngology, Head and Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulrazag Ajlan
- Department of Neurosurgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Saad Alsaleh
- Department of Otolaryngology, Head and Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Drexler R, Rotermund R, Smith TR, Kilgallon JL, Honegger J, Nasi-Kordhishti I, Gardner PA, Gersey ZC, Abdallah HM, Jane JA, Marino AC, Knappe UJ, Uksul N, Rzaev JA, Galushko EV, Gormolysova EV, Bervitskiy AV, Schroeder HWS, Eördögh M, Losa M, Mortini P, Gerlach R, Azab M, Budohoski KP, Rennert RC, Karsy M, Couldwell WT, Antunes ACM, Westphal M, Ricklefs FL, Flitsch J. Defining benchmark outcomes for transsphenoidal surgery of pituitary adenomas: a multicenter analysis. Eur J Endocrinol 2023; 189:379-386. [PMID: 37668325 DOI: 10.1093/ejendo/lvad124] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/14/2023] [Accepted: 08/01/2023] [Indexed: 09/06/2023]
Abstract
IMPORTANCE Benchmarks aid in improve outcomes for surgical procedures. However, best achievable results that have been validated internationally for transsphenoidal surgery (TS) are not available. OBJECTIVE We aimed to establish standardized outcome benchmarks for TS of pituitary adenomas. DESIGN A total of 2685 transsphenoidal tumor resections from 9 expert centers in 3 continents were analyzed. SETTING Patients were risk stratified, and the median values of each center's outcomes were established. The benchmark was defined as the 75th percentile of all median values for a particular outcome. The postoperative benchmark outcomes included surgical factors, endocrinology-specific values, and neurology-specific values. RESULTS Of 2685 patients, 1149 (42.8%) defined the low-risk benchmark cohort. Within these benchmark cases, 831 (72.3%) patients underwent microscopic TS, and 308 (26.8%) patients underwent endoscopic endonasal resection. Of all tumors, 799 (29.8%) cases invaded the cavernous sinus. The postoperative complication rate was 19.6% with mortality between 0.0% and 0.8%. Benchmark cutoffs were ≤2.9% for reoperation rate, ≤1.9% for cerebrospinal fluid leak requiring intervention, and ≤15.5% for transient diabetes insipidus. At 6 months, benchmark cutoffs were calculated as follows: readmission rate: ≤6.9%, new hypopituitarism ≤6.0%, and tumor remnant ≤19.2%. CONCLUSIONS This analysis defines benchmark values for TS targeting morbidity and mortality and represents the best outcomes in the best patients in expert centers. These cutoffs can be used to assess different centers, patient populations, and novel surgical techniques. It should be noted that the benchmark values may influence each other and must be evaluated in their own context.
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Affiliation(s)
- Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - John L Kilgallon
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Jürgen Honegger
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Isabella Nasi-Kordhishti
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Paul A Gardner
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Zachary C Gersey
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Hussein M Abdallah
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - John A Jane
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Alexandria C Marino
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Hospital Minden, Ruhr-University Bochum, Minden, Germany
| | - Nesrin Uksul
- Department of Neurosurgery, Johannes Wesling Hospital Minden, Ruhr-University Bochum, Minden, Germany
| | - Jamil A Rzaev
- Department of Neurosurgery, Federal Center of Neurosurgery, Novosibirsk, Russia
- Department of Neurosurgery, Novosibirsk State Medical University, Novosibirsk, Russia
| | - Evgeniy V Galushko
- Department of Neurosurgery, Federal Center of Neurosurgery, Novosibirsk, Russia
| | | | - Anatoliy V Bervitskiy
- Department of Neurosurgery, Federal Center of Neurosurgery, Novosibirsk, Russia
- Department of Neurosurgery, Novosibirsk State Medical University, Novosibirsk, Russia
| | - Henry W S Schroeder
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Márton Eördögh
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Rüdiger Gerlach
- Department of Neurosurgery, Helios Kliniken, Erfurt, Germany
| | - Mohammed Azab
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - Karol P Budohoski
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - Robert C Rennert
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - Michael Karsy
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - Apio C M Antunes
- Department of Neurosurgery, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Dumitriu-Stan RI, Burcea IF, Salmen T, Poiana C. Prognostic Models in Growth-Hormone- and Prolactin-Secreting Pituitary Neuroendocrine Tumors: A Systematic Review. Diagnostics (Basel) 2023; 13:2118. [PMID: 37371013 DOI: 10.3390/diagnostics13122118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/02/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
Growth-hormone (GH)- and prolactin (PRL)-secreting PitNETs (pituitary neuroendocrine tumors) are divided into multiple histological subtypes, which determine their clinical and biological variable behavior. Proliferation markers alone have a questionable degree of prediction, so we try to identify validated prognostic models as accurately as possible. (1) Background: The data available so far show that the use of staging and clinical-pathological classification of PitNETs, along with imaging, are useful in predicting the evolution of these tumors. So far, there is no consensus for certain markers that could predict tumor evolution. The application of the WHO (World Health Organisation) classification in practice needs to be further evaluated and validated. (2) Methods: We performed the CRD42023401959 protocol in Prospero with a systematic literature search in PubMed and Web of Science databases and included original full-text articles (randomized control trials and clinical trials) from the last 10 years, published in English, and the search used the following keywords: (i) pituitary adenoma AND (prognosis OR outcome OR prediction), (ii) growth hormone pituitary adenoma AND (prognosis OR outcome OR prediction), (iii) prolactin pituitary adenoma AND (prognosis OR outcome OR prediction); (iv) mammosomatotroph adenoma AND (prognosis OR outcome OR prediction). (3) Results: Two researchers extracted the articles of interest and if any disagreements occurred in the selection process, these were settled by a third reviewer. The articles were then assessed using the ROBIS bias assessment and 75 articles were included. (4) Conclusions: the clinical-pathological classification along with factors such as GH, IGF-1, prolactin levels both preoperatively and postoperatively offer valuable information.
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Affiliation(s)
- Roxana-Ioana Dumitriu-Stan
- Department of Endocrinology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Doctoral School of 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Iulia-Florentina Burcea
- Department of Endocrinology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
- 'C. I. Parhon' National Institute of Endocrinology, 011863 Bucharest, Romania
| | - Teodor Salmen
- Doctoral School of 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Catalina Poiana
- Department of Endocrinology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
- 'C. I. Parhon' National Institute of Endocrinology, 011863 Bucharest, Romania
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Baig Mirza A, Boardman T, Okasha M, El-Hariri HM, Al Banna Q, Syrris C, Baig Mirza K, Vastani A, Visagan R, Shapey J, Maratos E, Barazi S, Thomas N. Fat in the Fossa and the Sphenoid Sinus: A Simple and Effective Solution to CSF Leaks in Transsphenoidal Surgery. Cohort Study and Systematic Review. J Neurol Surg B Skull Base 2023; 84:143-156. [PMID: 36895808 PMCID: PMC9991530 DOI: 10.1055/a-1757-3069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 01/30/2022] [Indexed: 10/19/2022] Open
Abstract
Objectives Cerebrospinal fluid (CSF) leak following endoscopic transsphenoidal surgery (TSS) remains a challenge and is associated with high morbidity. We perform a primary repair with f at in the pituitary f ossa and further fat in the s phenoid sinus (FFS). We compare the efficacy of this FFS technique with other repair methods and perform a systematic review. Design, Patients, and Methods This is a retrospective analysis of patients undergoing standard TSS from 2009 to 2020, comparing the incidence of significant postoperative CSF rhinorrhea (requiring intervention) using the FFS technique compared with other intraoperative repair strategies. Systematic review of current repair methods described in the literature was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Results In all, there were 439 patients, with 276 patients undergoing multilayer repair, 68 patients FFS repair, and 95 patients no repair. No significant differences were observed in baseline demographics between the groups. Postoperative CSF leak requiring intervention was significantly lower in the FFS repair group (4.4%) compared with the multilayer (20.3%) and no repair groups (12.6%, p < 0.01). This translated to fewer reoperations (2.9% FFS vs. 13.4% multilayer vs. 8.4% no repair, p < 0.05), fewer lumbar drains (2.9% FFS vs. 15.6% multilayer vs. 5.3% no repair, p < 0.01), and shorter hospital stay (median days: 4 [3-7] FFS vs. 6 (5-10) multilayer vs. 5 (3-7) no repair, p < 0.01). Risk factors for postoperative leak included female gender, perioperative lumbar drain, and intraoperative leak. Conclusion Autologous fat on fat graft for standard endoscopic transsphenoidal approach effectively reduces the risk of significant postoperative CSF leak with reduced reoperation and shorter hospital stay.
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Affiliation(s)
- Asfand Baig Mirza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Timothy Boardman
- GKT School of Medical Education, King's College London, London, United Kingdom
| | - Mohamed Okasha
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Qusai Al Banna
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Christoforos Syrris
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Amisha Vastani
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Ravindran Visagan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Jonathan Shapey
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom.,Department of Surgical and Interventional Engineering, School of Biomedical Engineering and Imaging Science, King's College London, United Kingdom
| | - Eleni Maratos
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Sinan Barazi
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Nick Thomas
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
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8
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Endoscopic Endonasal Skull Base Surgery Complication Avoidance: A Contemporary Review. Brain Sci 2022; 12:brainsci12121685. [PMID: 36552145 PMCID: PMC9776068 DOI: 10.3390/brainsci12121685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/03/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
The endoscopic endonasal approach (EEA) provides a direct trajectory to ventral skull base lesions, avoidance of brain retraction, and clear visualization of cranial nerves as they exit skull base foramina. Despite these benefits, the EEA is not without complications. Here, we review published literature highlighting complications associated with the EEA including cerebrospinal fluid (CSF) leak, cranial nerve (CN) dysfunction, pituitary gland dysfunction, internal carotid artery (ICA) injury, infection, and others; we place special emphasis on discussing the prevention of these complications. As widespread adoption of the EEA continues, it becomes critical to educate surgeons regarding potential complications and their prevention while identifying gaps in the current literature to guide future research and advances in clinical care.
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9
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Villalonga JF, Solari D, Cuocolo R, De Lucia V, Ugga L, Gragnaniello C, Pailler JI, Cervio A, Campero A, Cavallo LM, Cappabianca P. Clinical application of the “sellar barrier’s concept” for predicting intraoperative CSF leak in endoscopic endonasal surgery for pituitary adenomas with a machine learning analysis. Front Surg 2022; 9:934721. [PMID: 36157423 PMCID: PMC9492953 DOI: 10.3389/fsurg.2022.934721] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Recently, it was defined that the sellar barrier entity could be identified as a predictor of cerebrospinal fluid (CSF) intraoperative leakage. The aim of this study is to validate the application of the sellar barrier concept for predicting intraoperative CSF leak in endoscopic endonasal surgery for pituitary adenomas with a machine learning approach. Methods We conducted a prospective cohort study, from June 2019 to September 2020: data from 155 patients with pituitary subdiaphragmatic adenoma operated through endoscopic approach at the Division of Neurosurgery, Università degli Studi di Napoli “Federico II,” were included. Preoperative magnetic resonance images (MRI) and intraoperative findings were analyzed. After processing patient data, the experiment was conducted as a novelty detection problem, splitting outliers (i.e., patients with intraoperative fistula, n = 11/155) and inliers into separate datasets, the latter further separated into training (n = 115/144) and inlier test (n = 29/144) datasets. The machine learning analysis was performed using different novelty detection algorithms [isolation forest, local outlier factor, one-class support vector machine (oSVM)], whose performance was assessed separately and as an ensemble on the inlier and outlier test sets. Results According to the type of sellar barrier, patients were classified into two groups, i.e., strong and weak barrier; a third category of mixed barrier was defined when a case was neither weak nor strong. Significant differences between the three datasets were found for Knosp classification score (p = 0.0015), MRI barrier: strong (p = 1.405 × 10−6), MRI barrier: weak (p = 4.487 × 10−8), intraoperative barrier: strong (p = 2.788 × 10−7), and intraoperative barrier: weak (p = 2.191 × 10−10). We recorded 11 cases of intraoperative leakage that occurred in the majority of patients presenting a weak sellar barrier (p = 4.487 × 10−8) at preoperative MRI. Accuracy, sensitivity, and specificity for outlier detection were 0.70, 0.64, and 0.72 for IF; 0.85, 0.45, and 1.00 for LOF; 0.83, 0.64, and 0.90 for oSVM; and 0.83, 0.55, and 0.93 for the ensemble, respectively. Conclusions There is a true correlation between the type of sellar barrier at MRI and its in vivo features as observed during endoscopic endonasal surgery. The novelty detection models highlighted differences between patients who developed an intraoperative CSF leak and those who did not.
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Affiliation(s)
- J. F. Villalonga
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina
- Correspondence: J. F. Villalonga
| | - D. Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
| | - R. Cuocolo
- Department of Advanced Biomedical Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
| | - V. De Lucia
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
| | - L. Ugga
- Department of Advanced Biomedical Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
| | - C. Gragnaniello
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
- Department of Neurological Surgery, Swedish Neuroscience Institute, Seattle, WA, United States
| | - J. I. Pailler
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina
| | - A. Cervio
- Departamento de Neurocirugía, FLENI, Buenos Aires, Argentina
| | - A. Campero
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina
| | - L. M. Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
| | - P. Cappabianca
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita’ degli Studi di Napoli Federico II, Naples, Italy
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10
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Al-Qurayshi Z, Bennion DM, Greenlee JDW, Graham SM. Endoscopic pituitary surgery: A national database review. Head Neck 2022; 44:2678-2685. [PMID: 36039744 DOI: 10.1002/hed.27179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 07/04/2022] [Accepted: 08/16/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pituitary tumors surgery is increasingly performed via endoscopic transsphenoidal approach (TSP). This study describes outcomes of TSP surgery in the United States. METHODS A retrospective cross-sectional analysis of adult patients with pituitary adenoma was performed using the Nationwide Readmissions Database, 2010-2015. RESULTS A total of 5891 patients were identified. The average age was 51.29 ± 0.29 years. The risk of postoperative epistaxis, diabetes insipidus, cerebrospinal fluid (CSF) leak, and other general postoperative complications was 0.71%, 10.20%, 8.35%, and 2.37%, respectively. Independent risk factors of CSF leak included: age <65-year, male, body mass index ≥25, and multiple comorbidities (p < 0.001 each). The prevalence of CSF leak was not associated with hospital TSP volume and teaching status. CONCLUSION This study provides a national epidemiological perspective on TSP in the United States. The risk of postoperative CSF leak appears to be associated with intrinsic patient factors rather than resource and expertise availability.
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Affiliation(s)
- Zaid Al-Qurayshi
- Department of Otolaryngology-Head & Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Douglas M Bennion
- Department of Otolaryngology-Head & Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Jeremy D W Greenlee
- Department of Otolaryngology-Head & Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Scott M Graham
- Department of Otolaryngology-Head & Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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11
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Yu S, Taghvaei M, Collopy S, Piper K, Karsy M, Lavergne P, Barton B, Chitguppi C, D'Souza G, Rosen MR, Nyquist GG, Rabinowitz M, Farrell CJ, Evans JJ. Evaluation of early postoperative day 1 discharge after endoscopic endonasal pituitary adenoma resection. J Neurosurg 2022; 136:1337-1346. [PMID: 34653980 DOI: 10.3171/2021.5.jns2185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/17/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE While multiple studies have evaluated the length of stay after endonasal transsphenoidal surgery (ETS) for pituitary adenoma, the potential for early discharge on postoperative day 1 (POD 1) remains unclear. The authors compared patients discharged on POD 1 with patients discharged on POD > 1 to better characterize factors that facilitate early discharge after ETS. METHODS A retrospective chart review was performed for patients undergoing ETS for pituitary adenoma at a single tertiary care academic center from February 2005 to February 2020. Discharge on POD 1 was defined as a discharge within 24 hours of surgery. RESULTS A total of 726 patients (mean age 55 years, 52% male) were identified, of whom 178 (24.5%) patients were discharged on POD 1. These patients were more likely to have pituitary incidentaloma (p = 0.001), require dural substitutes and DuraSeal (p = 0.0001), have fewer intraoperative CSF leaks (p = 0.02), and have lower postoperative complication rates (p = 0.006) compared with patients discharged on POD > 1. POD 1 patients also showed higher rates of macroadenomas (96.1% vs 91.4%, p = 0.03) and lower rates of functional tumors (p = 0.02). POD > 1 patients were more likely to have readmission within 30 days (p = 0.002), readmission after 30 days (p = 0.0001), nasal synechiae on follow-up (p = 0.003), diabetes insipidus (DI; 1.7% vs 9.8%, p = 0.0001), postoperative hypocortisolism (21.8% vs 12.1%, p = 0.01), and postoperative steroid usage (44.6% vs 59.7%, p = 0.003). The number of patients discharged on POD 1 significantly increased during each subsequent time epoch: 2005-2010, 2011-2015, and 2016-2020 (p = 0.0001). On multivariate analysis, DI (OR 7.02, 95% CI 2.01-24.57; p = 0.002) and intraoperative leak (OR 2.02, 95% CI 1.25-3.28; p = 0.004) were associated with increased risk for POD > 1 discharge, while operation epoch (OR 0.46, 95% CI 0.3-0.71; p = 0.0001) was associated with POD 1 discharge. CONCLUSIONS This study demonstrates that discharge on POD 1 after ETS for pituitary adenomas was safe and feasible and without increased risk of 30-day readmission. On multivariate analysis, surgical epoch was associated with decreased risk of prolonged length of stay, while factors associated with increased risk of prolonged length of stay included DI and intraoperative CSF leak. These findings may help in selecting patients who are deemed reasonable for safe, early discharge after pituitary adenoma resection.
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Affiliation(s)
- Siyuan Yu
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Mohammad Taghvaei
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Sarah Collopy
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Keenan Piper
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Michael Karsy
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Pascal Lavergne
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Blair Barton
- 2Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Chandala Chitguppi
- 2Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Glen D'Souza
- 2Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Marc R Rosen
- 2Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Gurston G Nyquist
- 2Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Mindy Rabinowitz
- 2Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Christopher J Farrell
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - James J Evans
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
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12
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Correlation Analysis of Magnetic Resonance Imaging Characteristics and Prognosis of Invasive Pituitary Adenomas in Neurosurgery Hospitals. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:8280540. [PMID: 35494529 PMCID: PMC9050260 DOI: 10.1155/2022/8280540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/27/2022] [Accepted: 04/06/2022] [Indexed: 11/18/2022]
Abstract
The incidence of pituitary adenoma is second only to glioma and meningioma, and its incidence ranks third among intracranial tumors. Most pituitary adenomas are benign and noninvasive tumors, but invasive pituitary adenomas pose a great threat to human health. In order to explore the risk factors that affect the clinical aggressive behavior of patients with pituitary adenoma, analyze the correlation between different classification methods and clinical aggressive behavior, and lay the foundation for early judgment and individualized treatment of clinical aggressive behavior of patients with pituitary adenoma. We conducted statistical research on patients who were treated for pituitary adenomas in the city's Yangzhou Hongquan Hospital. The results of the study showed that six patients in this study showed aggressiveness in the clinical symptomatic outcome, six patients showed aggressiveness in the serological outcome, and seven patients showed aggressiveness in imaging. In the multimodal classification, the clinical aggressiveness of pituitary adenomas in the invasion + atypical group was significantly higher than that in other groups, and the difference was statistically significant (P < 0.05). The correlation analysis of magnetic resonance imaging features and prognosis of invasive pituitary adenomas were verified to be feasible for the treatment of patients.
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13
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Taghvaei M, Fallah S, Sadaghiani S, Sadrhosseini SM, Tabari A, Fathi M, Zeinalizadeh M. Surgical complications of endoscopic approach to skull base: analysis of 584 consecutive patients. Eur Arch Otorhinolaryngol 2022; 279:3189-3199. [PMID: 35102476 DOI: 10.1007/s00405-022-07256-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/03/2022] [Indexed: 02/08/2023]
Abstract
PURPOSE Endoscopic techniques have been widely applied for challenging cranial base surgeries in recent years. In this study, we evaluated the safety and efficacy of using the endoscopic endo-nasal route for various skull base pathologies in terms of postoperative complications. METHODS A total of 584 consecutive patients who underwent endoscopic skull base surgery were studied. Peri- and post-operative complications and risk factors affecting the occurrence of these complications were evaluated. RESULTS 648 endoscopic skull base surgical procedures were performed on 584 patients (47.8% females and 52.2% males) with the mean age of 41.2 years. Pituitary adenoma (69.3%) was the most common pathology. Post-operative mortality was 2.0%. The rates of post-operative permanent neurological deficit (one case of 6th nerve injury, two 12th nerve injuries and one hemiparesis) and visual deterioration were 0.6% and 1.5%, respectively. Ten patients (1.7%) were complicated with meningitis and it was the cause of death in 3. Systemic complications not directly attributable to skull base surgical access occurred in 2% (11 patients) with 5 mortalities. The rate of intra-operative vascular injury was 1% and among them one patient died due to PCA injury. The most common post-operative complications were diabetes insipidus (12.5%), anterior pituitary dysfunction (10.6%) and CSF leak (3.6%), respectively. In general, reoperation, malignant lesions, and level IV of surgical complexity were associated with a higher incidence of complications. CONCLUSION Endoscopic endo-nasal approach can be a safe and less-morbid first-line treatment of patients with various skull base lesions.
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Affiliation(s)
- Mohammad Taghvaei
- Brain and Spinal Injury Research Center (BASIR), Neuroscience Institute, Tehran University of Medical Sciences, Keshavarz Blvd, P. O. Box 1419733141, Tehran, Iran
- Department of Neurological Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Sara Fallah
- Brain and Spinal Injury Research Center (BASIR), Neuroscience Institute, Tehran University of Medical Sciences, Keshavarz Blvd, P. O. Box 1419733141, Tehran, Iran
- Department of Neurological Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Shokufeh Sadaghiani
- Department of Neurological Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mousa Sadrhosseini
- Department of Otolaryngology-Head and Neck Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Azin Tabari
- Department of Otolaryngology-Head and Neck Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Fathi
- Brain and Spinal Injury Research Center (BASIR), Neuroscience Institute, Tehran University of Medical Sciences, Keshavarz Blvd, P. O. Box 1419733141, Tehran, Iran
- Department of Neurological Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Zeinalizadeh
- Brain and Spinal Injury Research Center (BASIR), Neuroscience Institute, Tehran University of Medical Sciences, Keshavarz Blvd, P. O. Box 1419733141, Tehran, Iran.
- Department of Neurological Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.
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14
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Zhou Z, Zuo F, Chen X, Zhao Q, Luo M, Jiang X, Duan Y. Risk factors for postoperative cerebrospinal fluid leakage after transsphenoidal surgery for pituitary adenoma: a meta-analysis and systematic review. BMC Neurol 2021; 21:417. [PMID: 34706659 PMCID: PMC8555154 DOI: 10.1186/s12883-021-02440-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 10/12/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Postoperative cerebrospinal fluid (CSF) leakage represents a challenge even for experienced pituitary surgeons. We aimed to quantitatively synthesize data from studies regarding the risk factors for postoperative CSF leakage after transsphenoidal surgery (TSS) for pituitary adenoma (PA). METHODS PubMed, Web of Science, The Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), Wanfang database, and VIP database were searched for case-control and cohort studies, focusing on the risk factors associated with postoperative CSF leakage after TSS for PA. Pooled odds ratios (ORs) and 95% confidence intervals were calculated to determine the risk factors. RESULTS A total of 34 case-control and cohort studies involving a total of 9,144 patients with PA were included in this systematic review. The overall rate of postoperative CSF leakage after TSS for PA was 5.6%. Tumor size, adenoma consistency, revision surgery, and intraoperative CSF leakage were independent risk factors for postoperative CSF leakage (ORs, 3.18-6.33). By contrast, the endoscopic approach showed a slight protective benefit compared with the microscopic approach in TSS (OR, 0.69). CONCLUSIONS This review provides a comprehensive overview of the quality of the evidence base, informing clinical staff of the importance of screening risk factors for postoperative CSF leakage after TSS for PA. More attention should be paid to PA patients at high risk for CSF leakage after TSS to reduce complications and improve prognosis.
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Affiliation(s)
- Zhihuan Zhou
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
- Department of Neurosurgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
| | - Feifei Zuo
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
- Department of Neurosurgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
| | - Xiaoqun Chen
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
- Department of Neurosurgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
| | - Qinqin Zhao
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
- Department of Neurosurgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
| | - Mengna Luo
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, PR China
| | - Xiaobing Jiang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
- Department of Neurosurgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
| | - Yuyu Duan
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China.
- Department of Neurosurgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China.
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15
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Nys C, Versyck G, Buelens E, Engelborghs K, Cornips E, Van Leeuwen-Wintjens H, Vankelecom H, Weyns F, Peuskens D. Transnasal transsphenoidal pituitary surgery in a large tertiary hospital, a retrospective study. Acta Chir Belg 2021; 123:272-280. [PMID: 34590931 DOI: 10.1080/00015458.2021.1988231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Pituitary adenomas (PAs), although being small tumours, can have quite an impact on patients' lives causing hormonal and visual disturbances, for which surgery must be performed. As a large peripheral hospital with specialists in pituitary surgery, an assessment of the efficacy and safety of transnasal transsphenoidal pituitary surgery was made. METHODS A retrospective analysis of neurosurgical reports as well as pre and postoperative imaging was made to evaluate the presenting symptoms, tumoural variables, peri-operative morbidity, and long-term outcome. RESULTS This cohort included 105 patients who were operated for PAs over a 9-year period, with a slight male predominance. Adenomas had a mean maximum diameter of almost 25 mm, with one-third of tumours presenting with a Knosp-grade 3 or 4. As expected, most patients presented with either visual (32.4%) or hormonal (40.0%) disturbances. After surgery, 85.3% had complete resolution of visual deficits, and 97.1% had normalisation of hormonal hypersecretion. Postoperative hormonal insufficiency requiring substitution was observed in 43.1% and was significantly more frequent in males and in non-functioning pituitary adenomas (NFAs). Postoperative cerebrospinal fluid (CSF) leakage was observed in 2.9%, and merely one patient developed meningitis. Tumour recurrence was significantly more frequent in patients with partial resection as compared to complete resection (25.6 vs. 7.9%). CONCLUSIONS This study demonstrates that transnasal transsphenoidal pituitary surgery can be performed safely and effectively in a large non-university hospital, improving visual and/or hormonal disturbances as well as providing long-term tumour control. Patients with larger adenomas are at an increased risk to develop postoperative hypopituitarism.
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Affiliation(s)
- Charlotte Nys
- Department of Development and Regeneration, Laboratory of Tissue Plasticity in Health and Disease, Cluster of Stem Cell and Developmental Biology, KU Leuven (University of Leuven), Leuven, Belgium
| | - Georges Versyck
- Department of Neurosurgery, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Eveleen Buelens
- Department of Neurosurgery, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| | - Koen Engelborghs
- Department of Neurosurgery, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| | - Erwin Cornips
- Department of Neurosurgery, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| | | | - Hugo Vankelecom
- Department of Development and Regeneration, Laboratory of Tissue Plasticity in Health and Disease, Cluster of Stem Cell and Developmental Biology, KU Leuven (University of Leuven), Leuven, Belgium
| | - Frank Weyns
- Department of Neurosurgery, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| | - Diederik Peuskens
- Department of Neurosurgery, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
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16
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The incidence of postoperative cerebrospinal fluid leakage after elective cranial surgery: a systematic review. Neurosurg Rev 2021; 45:1827-1845. [PMID: 34499261 DOI: 10.1007/s10143-021-01641-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/12/2021] [Accepted: 09/02/2021] [Indexed: 10/20/2022]
Abstract
Cerebrospinal fluid (CSF) leakage is a major complication after elective neurosurgical procedures. The aim of this systematic literature review is to summarize the incidence rates of postoperative cerebrospinal fluid leakage for neurosurgical procedures, classified by surgical approach. The Pubmed, Cochrane, Embase, and Web of Science databases were searched for studies reporting the outcome of patients undergoing elective neurosurgical procedures. The number of patients, surgical approach, and indication for surgery were recorded for each study. Outcomes related to CSF leakage such as clinical manifestation and treatment were reported as well. One hundred and thirteen studies were included, reporting 94,695 cases. Overall, CSF leaks were present in 3.8% of cases. Skull base surgery had the highest rate of CSF leakage with 6.2%. CSF leakage occurred in 5.9% of anterior skull base procedures, 6.4% of middle fossa, and 5.2% of transpetrosal surgeries. 5.8% of reported infratentorial procedures were complicated by CSF leakage versus 2.9% of supratentorial surgeries. CSF leakage remains a common serious adverse event after cranial surgery. There exists a need for standardized procedures to reduce the incidence of postoperative CSF leakage, as this serious adverse event may lead to increased health care costs.
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17
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Kaya-Ugur B, Erkutlu I, Saracaloglu A, Geyik AM, Demiryürek S, Demiryürek AT. Comparison of serum dynamic thiol/disulphide homeostasis and nitric oxide levels of total intravenous vs inhaled anaesthesia in endoscopic transsphenoidal pituitary surgery. Int J Clin Pract 2021; 75:e14485. [PMID: 34107152 DOI: 10.1111/ijcp.14485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/24/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Transsphenoidal pituitary surgery (TPS) is traditionally performed under general anaesthesia. This study aimed to compare the effects of total intravenous anaesthesia (TIVA) or sevoflurane, an inhalation anaesthetic, on thiol-disulphide homeostasis in patients undergoing endoscopic endonasal TPS. METHODS In this study, 84 patients scheduled for TPS were randomly categorised into two groups: propofol (n = 42, the TIVA group) or sevoflurane (n = 42, the SEVO group). Blood samples were taken before induction of general anaesthesia and at the 30 minutes of postoperation. Serum native thiol and total thiol levels were detected, and the number of dynamic disulphide bonds and related ratios were calculated from these values. Serum nitric oxide (NO) levels were measured using a chemiluminescence method. RESULTS Although native thiol levels in TIVA postoperation group were markedly increased (P < .05), total thiol levels in SEVO postoperation group were significantly decreased (P < .01). Disulphide levels were declined in both groups (P < .05 for TIVA and P = .001 for SEVO groups). Disulphide/native thiol (P < .05 for both groups) and disulphide/total thiol ratios (P < .05 for TIVA and P < .01 for SEVO groups) were depressed in postoperation groups. We found a marked elevation in native thiol/total thiol ratio in both groups (P < .05 for TIVA and P < .01 for SEVO groups). There was significant augmentation in serum NO levels in the SEVO postoperation group (P < .05). CONCLUSION These results are the first to show that both TIVA and sevoflurane showed similar antioxidant effect with reduced disulphide levels, but sevoflurane may offer more robust oxidative stress protection and augmented NO production than TIVA during TPS. However, the clinical effect is needed to further investigate.
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Affiliation(s)
- Berna Kaya-Ugur
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Ibrahim Erkutlu
- Department of Neurosurgery, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Ahmet Saracaloglu
- Department of Medical Pharmacology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Abidin M Geyik
- Department of Neurosurgery, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Seniz Demiryürek
- Department of Physiology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Abdullah T Demiryürek
- Department of Medical Pharmacology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
- Vocational School of Health Services, Gaziantep University, Gaziantep, Turkey
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Zeden JP, Baldauf J, Schroeder HWS. Repair of the sellar floor using bioresorbable polydioxanone foils after endoscopic endonasal pituitary surgery. Neurosurg Focus 2021; 48:E16. [PMID: 32480371 DOI: 10.3171/2020.3.focus2064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Postoperative CSF leakage is the most common unwanted sequela of transnasal pituitary surgery. The individual anatomy, the extent of the sellar opening, and the occurrence of an intraoperative CSF leak add to the risk of postoperative rhinorrhea. Despite the current sophistication and recent developments in pituitary surgery, watertight closure of the sellar floor remains a matter of concern. Improvements and additions to the technical armamentarium of sellar reconstruction are therefore still desirable. METHODS The authors present a closure technique of the sellar floor using a bioresorbable polydioxanone foil, which is placed between the dura and the bony margins of the open sellar floor to keep the intrasellar implants in place and to withstand the pressure arising from the intracranial compartment. RESULTS The technique was used in a technical case series of 30 patients, and in all patients the floor could be sufficiently reconstructed. CSF flow intraoperatively was documented in 10 cases (33.3%). Postoperative CSF rhinorrhea was detected in one patient (3.3%). No complications could be attributed to the technique or the material during a mean follow-up period of 477 days. The foils can easily be identified on MR images and CT scans and therefore do not affect the postoperative radiological assessment. CONCLUSIONS The described technique is an easy, inexpensive, and reliable method for sellar floor reconstruction and has a low CSF leakage rate. It is recommended when the risk of a postoperative CSF leak is high and there is still enough bony margin of the sellar floor left that enables a sufficient fixation of the foil.
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Shahrestani S, Ballatori AM, Chen XT, Ton A, Strickland BA, Brunswick A, Zada G. Analysis of modifiable and nonmodifiable risk factors in patients undergoing pituitary surgery. J Neurosurg 2021; 134:1816-1823. [PMID: 32534499 DOI: 10.3171/2020.4.jns20417] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 04/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pituitary adenomas (PAs) are among the most common intracranial tumors. Understanding the clinical effects of various modifiable risk factors (MRFs) and nonmodifiable risk factors (NMRFs) is important in guiding proper treatment, yet there is limited evidence outlining the influence of MRFs and NMRFs on outcomes of PA resection. The aim of this study was to analyze MRFs and NMRFs in patients undergoing resection for PAs. METHODS Using the 2016 and 2017 National Readmission Database, the authors identified a cohort of 9472 patients undergoing microscopic or endoscopic resection of a PA. Patients with nonoverlapping MRFs and NMRFs were analyzed for length of stay (LOS), hospital cost, readmission rates, and postoperative complications. From the original cohort, a subset of 373 frail patients (as defined by the Johns Hopkins Frailty Index) were identified and propensity matched to nonfrail patients. Statistical analysis included 1-way ANOVA, Tukey multiple comparisons of means, odds ratios, Wald testing, and unpaired Welch 2-sample t-tests to compare complications, outcomes, and costs between each cohort. Perioperative outcomes and hospital readmission rates were tracked, and predictive algorithms were developed to establish precise relationships between relevant risk factors and neurosurgical outcomes. RESULTS Malnourished patients had significantly longer LOSs when compared to nonmalnourished patients (p < 0.001). There was a significant positive correlation between the number of MRFs and readmission at 90 days (p = 0.012) and 180 days (p = 0.020). Obese patients had higher rates of postoperative neurological injury at the 30-day follow-up (p = 0.048) compared to patients with normal BMI. Within this NMRF cohort, frail patients were found to have significantly increased hospital LOS (p < 0.001) and total inpatient costs compared to nonfrail patients (p < 0.001). Predictive analytics showed that frail patients had significantly higher readmission rates at both 90-day (p < 0.001) and 180-day follow-ups (p < 0.001). Lastly, rates of acute postsurgical infection were higher in frail patients compared to nonfrail patients (p < 0.001). CONCLUSIONS These findings suggest that both MRFs and NMRFs negatively affect the perioperative outcomes following PA resection. Notable risk factors including malnutrition, obesity, elevated lipid panels, and frailty make patients more prone to prolonged LOS, higher inpatient costs, and readmission. Further prospective research with longitudinal data is required to precisely pinpoint the effects of various risk factors on the outcomes of pituitary surgery.
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Yong M, Wu YQ, Su S, Hanna E, Prisman E, Thamboo A, Walgama E. The effect of prior radiation on the success of ventral skull base reconstruction: A systematic review and meta-analysis. Head Neck 2021; 43:2795-2806. [PMID: 33973680 DOI: 10.1002/hed.26709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 04/07/2021] [Indexed: 11/08/2022] Open
Abstract
The incidence of cerebrospinal fluid leak after ventral skull base reconstruction is a primary outcome of interest to skull base surgeons. Exposure to pre-operative radiation may put patients at an increased risk of skull base reconstructive failure. A systematic search identified studies which included patients receiving ventral skull base reconstruction in the setting of pre-operative radiation. A meta-analysis using a random effects model was conducted to estimate an odds ratio of cerebrospinal fluid (CSF) leak in patients exposed to pre-operative radiation. A meta-analysis of 13 studies demonstrated that the odds ratio of CSF leak was 1.73 (95% CI 0.98-3.05). The majority of studies (77%) used vascularized tissue grafts for reconstruction. We identified an increased incidence of CSF leak among patients undergoing ventral skull base reconstruction after prior radiation therapy, although not of statistical significance. Skull base surgeons should exercise caution when planning reconstruction in this population.
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Affiliation(s)
- Michael Yong
- Division of Otolaryngology - Head and Neck Surgery, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Yu Qi Wu
- Division of Otolaryngology - Head and Neck Surgery, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Shirley Su
- Department of Otolaryngology - Head & Neck Surgery, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Ehab Hanna
- Department of Otolaryngology - Head & Neck Surgery, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Eitan Prisman
- Division of Otolaryngology - Head and Neck Surgery, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Andrew Thamboo
- Division of Otolaryngology - Head and Neck Surgery, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Evan Walgama
- Department of Otolaryngology - Head & Neck Surgery, M. D. Anderson Cancer Center, Houston, Texas, USA
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Hunsaker J, Khan M, Makarenko S, Evans J, Couldwell W, Karsy M. Prediction of Readmission and Complications After Pituitary Adenoma Resection via the National Surgical Quality Improvement Program (NSQIP) Database. Cureus 2021; 13:e14809. [PMID: 34123604 PMCID: PMC8191857 DOI: 10.7759/cureus.14809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2021] [Indexed: 02/07/2023] Open
Abstract
Introduction Pituitary adenomas are common intracranial tumors (incidence 4:100,000 people) with good surgical outcomes; however, a subset of patients show higher rates of perioperative morbidity. Our goal was to identify risk factors for postoperative complications or readmission after pituitary adenoma resection. Methods We undertook a retrospective cohort study of patients who underwent surgery for pituitary adenoma in 2006-2018 by using the National Surgical Quality Improvement Program database. The main outcome measures were patient complications and the 30-day readmission rate. Results Among the 2,292 patients (mean age 53.3±15.9 years), there were 491 complications in 188 patients (8.2%). Complications and 30-day readmission have remained stable over time rather than declined. Unplanned readmission was seen in 141 patients (6.2%). Multivariable analysis demonstrated that hypertension (OR=1.6; 95% CI= 1.1, 2.1; p=0.005) and high white blood cell count (OR=1.08; 95% CI=1.03, 1.1; p=0.0001) were independent predictors of complications. Return to the operating room (OR=5.9, 95% CI=1.7, 20.2, p=0.0005); complications (OR=4.1, 95% CI=1.6, 10.6, p=0.004); and blood urea nitrogen (OR=1.08, 95% CI=1.02, 1.2, p=0.02) were independent predictors of 30-day readmission. Conclusion Using one of the largest datasets of pituitary adenoma patients, we identified perioperative factors most critical for patient outcome. One strength of this study is adjusting for cofactors that predict outcomes, which has not been done previously. Several patient biomarkers, namely white blood cell count and blood urea nitrogen, may serve as preoperative markers that might identify patients at higher risk. Control of blood pressure and renal disease may be perioperative management strategies that can impact the outcome.
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Affiliation(s)
- Joshua Hunsaker
- Neurological Surgery, University of Utah, Salt Lake City, USA
| | - Majid Khan
- Medicine, Reno School of Medicine, University of Nevada, Reno, USA
| | - Serge Makarenko
- Neurological Surgery, University of Utah, Salt Lake City, USA
| | - James Evans
- Neurosurgery, Thomas Jefferson Medical College, Philadelphia, USA
| | | | - Michael Karsy
- Neurological Surgery, University of Utah, Salt Lake City, USA
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Villalonga JF, Solari D, Cavallo LM, Cappabianca P, Prevedello DM, Carrau R, Martinez-Perez R, Hardesty D, Fuchssteiner C, Saenz A, Abbritti RV, Valencia-Ramos C, Kaen A, Bernat AL, Cardenas E, Hirtler L, Gomez-Amador JL, Liu J, Froelich S, Cervio A, Campero A. The sellar barrier on preoperative imaging predicts intraoperative cerebrospinal fluid leak: a prospective multicenter cohort study. Pituitary 2021; 24:27-37. [PMID: 32918661 DOI: 10.1007/s11102-020-01082-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The type of sellar barrier observed between a pituitary tumor and cerebrospinal fluid (CSF) on preoperative magnetic resonance imaging (MRI) may predict intraoperative CSF leak during endonasal pituitary surgery. This is the first multicentric prospective cohort trial to study the sellar barrier concept and CSF leak rate during endoscopic pituitary surgery. METHODS This multi-center, international study enrolled patients operated for pituitary adenomas via fully endoscopic endonasal surgery over a period of 4 months. The independent variable was the subtype of sellar barrier observed on preoperative MRI (strong, mixed or weak); the dependent variable was the presence of an intraoperative CSF leak. The primary goal was to determine the association between a particular type of sellar barrier and the risk of intraoperative CSF leak. Appropriate statistical methods were then applied for data analysis. RESULTS Over the study period, 310 patients underwent endoscopic endonasal surgery for pituitary tumor. Preoperative imaging revealed a weak sellar barrier in 73 (23.55%), a mixed sellar barrier in 75 (24.19%), and a strong sellar barrier in 162 (52.26%) patients. The overall rate of intraoperative CSF leak among all patients was 69 (22.26%). A strong sellar-type barrier was associated with significantly reduced rate of intraoperative CSF leak (RR = 0.08; 95% CI 0.03-0.19; p < 0.0001), while a weak sellar barrier associated with higher rates of CSF leak (RR = 8.54; 95% CI 5.4-13.5; p < 0.0001). CONCLUSIONS The preoperative MRI of pituitary patients can suggest intraoperative CSF leak rates, utilizing the concept of the sellar barrier. Patients with a weak sellar barrier carry a higher risk for an intraoperative CSF leak, whereas a strong sellar barrier on MRI seems to mitigate intraoperative CSF leak. We propose that preoperatively assessment of the sellar barrier can prepare surgeons for intraoperative CSF leak repair.
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Affiliation(s)
- Juan F Villalonga
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Lamadrid 875, San Miguel de Tucumán, Tucumán, Argentina.
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Luigi M Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Paolo Cappabianca
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Daniel M Prevedello
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Ricardo Carrau
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Rafael Martinez-Perez
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Douglas Hardesty
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Christoph Fuchssteiner
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Amparo Saenz
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Lamadrid 875, San Miguel de Tucumán, Tucumán, Argentina
| | | | | | - Ariel Kaen
- Hospital Virgen del Rocío, Sevilla, Spain
| | - Anne-Laure Bernat
- Lariboisière University Hospital - Assistance Publique, Paris, France
| | | | - Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | | | - James Liu
- Rutgers New Jersey Medical School, Newark, NY, USA
| | | | | | - Alvaro Campero
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Lamadrid 875, San Miguel de Tucumán, Tucumán, Argentina
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23
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do Amaral LC, Reis BL, Ribeiro-Oliveira A, da Silva Santos TM, Giannetti AV. Comparative study of complications after primary and revision transsphenoidal endoscopic surgeries. Neurosurg Rev 2020; 44:1687-1702. [PMID: 32783077 DOI: 10.1007/s10143-020-01360-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 06/21/2020] [Accepted: 07/27/2020] [Indexed: 12/11/2022]
Abstract
A preferred treatment for residual/recurrent pituitary adenomas has not been established. The existence of higher complication rates for revision surgeries remains under debate. This study aimed to compare complication rates of primary and revision transsphenoidal endoscopic surgeries and to identify risk factors for complications. Data from 144 primary and 39 revision surgeries were analysed. The surgical complications evaluated were intraoperative and postoperative cerebrospinal fluid (CSF) leaks; meningitis; permanent diabetes insipidus (DI) and hypopituitarism; worsening visual acuity; ophthalmoplegias; visual field defects; otorhinolaryngological, systemic and vascular complications; and death. The variables that were potentially associated with surgical complications were gender, age, comorbidities, lumbar drain use, duration of lumbar drain use, invasion of the sphenoid and cavernous sinuses, presence and degree of suprasellar expansion, preoperative identification of the pituitary, CSF leaks and intraoperative pituitary identification. Intraoperative CSF leaks, visual field losses and worsening visual acuity were more common for revision surgeries. There were no between-group differences in the occurrence of postoperative CSF leaks; systemic, vascular and otorhinolaryngological complications; meningitis; DI and hypopituitarism; ophthalmoplegias; or death. Intraoperative identification of the pituitary was associated with lower rates of permanent DI and hypopituitarism, systemic complications, intraoperative CSF leaks and worsening visual acuity. Suprasellar expansion increased the risk of intraoperative CSF leaks but not endocrinological deficits or visual impairment. Intraoperative CSF leaks were associated with postoperative CSF leaks, meningitis, anterior hypopituitarism, DI and worsening visual acuity. Intraoperative CSF leaks, worsening visual acuity and visual field losses were more common in reoperated patients.
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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Vimawala S, Chitguppi C, Reilly E, Fastenberg JH, Garzon-Muvdi T, Farrell C, Rabinowitz MR, Rosen MR, Evans J, Nyquist GG. Predicting prolonged length of stay after endoscopic transsphenoidal surgery for pituitary adenoma. Int Forum Allergy Rhinol 2020; 10:785-790. [PMID: 32362064 DOI: 10.1002/alr.22540] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/26/2019] [Accepted: 01/21/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic transsphenoidal surgery (ETS) for the resection of pituitary adenoma has become more common throughout the past decade. Although most patients have a short postoperative hospitalization, others require a more prolonged stay. We aimed to identify predictors for prolonged hospitalization in the setting of ETS for pituitary adenomas. METHODS A retrospective chart review as performed on 658 patients undergoing ETS for pituitary adenoma at a single tertiary care academic center from 2005 to 2019. Length of stay (LoS) was defined as date of surgery to date of discharge. Patients with LoS in the top 10th percentile (prolonged LoS [PLS] >4 days, N = 72) were compared with the remainder (standard LoS [SLS], N = 586). RESULTS The average age was 54 years and 52.5% were male. The mean LoS was 2.1 days vs 7.5 days (SLS vs PLS). On univariate analysis, atrial fibrillation (p = 0.002), hypertension (p = 0.033), partial tumor resection (p < 0.001), apoplexy (p = 0.020), intraoperative cerebrospinal fluid (ioCSF) leak (p = 0.001), nasoseptal flap (p = 0.049), postoperative diabetes insipidus (DI) (p = 0.010), and readmission within 30 days (p = 0.025) were significantly associated with PLS. Preoperative continuous positive airway pressure (CPAP) (odds ratio, 15.144; 95% confidence interval, 2.596-88.346; p = 0.003) and presence of an ioCSF leak (OR, 10.362; 95% CI, 2.143-50.104; p = 0.004) remained significant on multivariable analysis. CONCLUSION For patients undergoing ETS for pituitary adenomas, an ioCSF leak or preoperative use of CPAP predicted PLS. Additional common reasons for PLS included postoperative CSF leak (10 of 72), management of DI or hypopituitarism (15 of 72), or reoperation due to surgical or medical complications (14 of 72).
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Affiliation(s)
- Swar Vimawala
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Chandala Chitguppi
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Erin Reilly
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Judd H Fastenberg
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Tomas Garzon-Muvdi
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Christopher Farrell
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Mindy R Rabinowitz
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Marc R Rosen
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - James Evans
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Gurston G Nyquist
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
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Endonasal endoscopic surgery for pediatric anterior cranial fossa encephaloceles: A systematic review. Int J Pediatr Otorhinolaryngol 2020; 132:109919. [PMID: 32036168 DOI: 10.1016/j.ijporl.2020.109919] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic endonasal skull base surgery (ESBS) is a well-established management strategy for anterior cranial fossa (ACF) encephaloceles in adults. However, its application to the pediatric population has not been evaluated in large-scale studies. This study systematically reviews the safety of ESBS for pediatric ACF encephaloceles. METHODS Articles reporting on pediatric patients undergoing purely ESBS for encephaloceles were reviewed from three databases (PubMed, Scopus, and Cochrane Library). Main outcomes were post-operative cerebrospinal fluid (CSF) leak and other surgical complications. RESULTS Twenty-three articles provided data on 110 eligible patients with a mean age of 4.3 years (range birth - 18 years). Intraoperative CSF leaks occurred in 18.5% of children while post-operative CSF leaks developed in 6.0% of cases. Rates of meningitis and hydrocephalus were each 3.7%. Other complications included alar collapse, nasal stenosis, transient diabetes insipidus, pneumonia, and neurologic injury, collectively occurring in 7.0% of cases. The rate of death was 4.8%. The average duration of follow-up was 25.3 months. Encephaloceles recurred in 5.2% of patients. CONCLUSIONS ESBS for pediatric ACF encephaloceles provides a relatively favorable risk-benefit profile, with a low rate of post-operative CSF leak, other surgical complications, and disease recurrence.
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Lee JA, Cooper RL, Nguyen SA, Schlosser RJ, Gudis DA. Endonasal Endoscopic Surgery for Pediatric Sellar and Suprasellar Lesions: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2020; 163:284-292. [PMID: 32204653 DOI: 10.1177/0194599820913637] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The advent of endonasal endoscopic skull base surgery (ESBS) has redefined the management of pediatric sellar and suprasellar lesions. To date, the outcomes of these procedures have not been systematically reviewed. This study performed a systematic review with meta-analysis of surgical outcomes for pediatric patients undergoing ESBS for sellar and suprasellar lesions. DATA SOURCES PubMed (National Library of Medicine, National Institutes of Health), Scopus (Elsevier), and Cochrane Library (Wiley). REVIEW METHODS Articles reporting on pediatric patients undergoing ESBS for craniopharyngiomas, pituitary adenomas, and Rathke's cleft cysts were reviewed. The primary outcome was postoperative cerebrospinal fluid (CSF) leak. Secondary outcomes included endocrine, visual, and other complications. RESULTS Twenty-five articles reporting on 554 patients were included. Overall postoperative CSF leak rate was 8.6%, with tumor-specific rates of 10.6% in craniopharyngiomas, 6.5% in pituitary adenomas, and 7.2% in Rathke's cleft cysts (P > .05). Older studies demonstrate higher postoperative CSF leak rates as compared with more recent studies (12.5% vs 6.1%, P = .0082). Younger children (8.9-12.6 years old) experienced a higher rate of postoperative CSF leaks as compared with older children (13.0-16.6 years old; 12.9% vs 4.9%, P = .0016). Additional postoperative complications included diabetes insipidus (26.7%), hypopituitarism (46.6%), visual deficits (2.6%), meningitis (3.4%), and weight gain (3.4%). CONCLUSION ESBS for pediatric sellar and suprasellar lesions is overall an effective management approach with an increasingly favorable risk-benefit profile. Younger children may be more susceptible to postoperative CSF leak as compared with older pediatric patients. Tumor type does not appear to be an independent risk factor for postoperative CSF leak in this population.
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Affiliation(s)
- Joshua A Lee
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Rebecca L Cooper
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Rodney J Schlosser
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David A Gudis
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Irving Medical Center, New York, New York, USA
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Lee SJ, Cohen J, Chan J, Walgama E, Wu A, Mamelak AN. Infectious Complications of Expanded Endoscopic Transsphenoidal Surgery: A Retrospective Cohort Analysis of 100 Cases. J Neurol Surg B Skull Base 2019; 81:497-504. [PMID: 33134016 DOI: 10.1055/s-0039-1696999] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 08/08/2019] [Indexed: 12/14/2022] Open
Abstract
Objective To identify perioperative factors that may predict postoperative cerebrospinal fluid (CSF) leak and meningitis following expanded endoscopic transsphenoidal surgery (EETS). Study Design This is a retrospective study. This study was set at the Cedars-Sinai Medical Center, Los Angeles. A total of 78 patients who underwent EETS between January 2007 and November 2018 were participated. The main outcome measures were CSF leak and meningitis. Results A total of 78 patients underwent a total of 100 EETS procedures; 17.9 and 10.3% of patients developed postoperative CSF leaks and meningitis, respectively. Out of eight, three patients with meningitis did not develop an observable CSF leak. The risk of developing meningitis in patients with a CSF leak was significantly higher than those without a leak, with an odds ratio (OR) of 11.48 (95% confidence interval, 2.33-56.47; p = 0.004). Pituicytomas were significantly associated with meningitis compared with other pathologies. No other patient-specific factors were identified as risks for leak or meningitis, including method of skull base repair, sex, tumor volume, or body mass index, although there was a strong trend toward reduced CSF leak rates in patient with nasoseptal flaps used for skull base repair, compared with those without (9.5 vs. 25%). CSF protein was consistently elevated on the first CSF values obtained when meningitis was suspected. Conclusion CSF leak and meningitis are common complications of expanded endonasal surgery No statistically significant risk factors for developing a postoperative leak other than the pathology of pituicytoma were identified, including method of skull base repair, although the use of a vascularized nasoseptal flap did trend toward a reduced CSF leak rate. CSF protein is the most sensitive marker for the presumptive diagnosis and timely treatment of meningitis.
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Affiliation(s)
- Seung J Lee
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Justin Cohen
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Julie Chan
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Evan Walgama
- Department of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Arthur Wu
- Department of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Adam N Mamelak
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
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Parikh A, Adapa A, Sullivan SE, McKean EL. Predictive Factors, 30-Day Clinical Outcomes, and Costs Associated with Cerebrospinal Fluid Leak in Pituitary Adenoma Resection. J Neurol Surg B Skull Base 2019; 81:43-55. [PMID: 32021749 DOI: 10.1055/s-0039-1679896] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 01/11/2019] [Indexed: 10/27/2022] Open
Abstract
Cerebrospinal fluid (CSF) leak is a complication of endoscopic endonasal pituitary adenoma resection. Previous studies examining complications of pituitary adenoma resection have not examined associations of an exhaustive list of clinical and financial variables with CSF leak. We designed a retrospective analysis of 334 consecutive patients that underwent endoscopic endonasal pituitary adenoma resection at a single institution over 5 years, analyzing associations between CSF leak and demographic data, operative data, comorbidities, clinical complications and outcomes, costs, charges, and payments. Of the 20 preoperative variables studied, none were positively associated with CSF leak in between-groups comparison, although multivariate analysis revealed an association with a history of radiation to the skull base (odds ratio [OR], 8.67; 95% confidence interval [CI], 0.94-57.03; p < 0.05). CSF leak was associated with a significantly higher rate of postoperative diabetes insipidus (Δ = 33.4%, p = 0.040) and increased length of stay after operation in between-groups comparison. Multivariate analysis on postoperative variables revealed significant associations between CSF leak and intracerebral hemorrhage (OR, 17.44; 95% CI, 0.65-275.3; p < 0.05) and postoperative intracranial infection (OR, 28.73; 95% CI, 2.04-438.7; p < 0.05). Also, CSF leak was associated with significantly higher costs (Δ = $15,643, p < 0.05) and hospital charges (Δ = $46,026, p < 0.05). Operating room time, room and board, and supplies and implants were the strongest cost drivers. This study highlights the difficulty of utilizing preoperative variables to predict CSF leak, the clinical complications and outcomes of leak, and the financial subcategories that drive the costs, charges, and payments associated with this complication.
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Affiliation(s)
- Adish Parikh
- Department of Otolaryngology Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, United States
| | - Arjun Adapa
- Department of Otolaryngology Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, United States
| | - Stephen E Sullivan
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, United States
| | - Erin L McKean
- Department of Otolaryngology Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, United States.,Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, United States
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Gollapudy S, Poetker DM, Sidhu J, Riess ML. Total intravenous versus inhaled anesthesia in transsphenoidal tumor surgery. Am J Otolaryngol 2018; 39:567-569. [PMID: 30017373 PMCID: PMC6105509 DOI: 10.1016/j.amjoto.2018.06.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 06/22/2018] [Indexed: 01/10/2023]
Abstract
PURPOSE Visualization of the surgical field is essential for patient safety during endoscopic transsphenoidal tumor surgery. In this retrospective chart review and data analysis of patients undergoing endoscopic transsphenoidal resection of pituitary tumors under general anesthesia we sought to determine if total intravenous anesthesia with propofol and remifentanil leads to decreased bleeding, surgical duration, time to extubation and/or length of stay in the recovery room compared to inhaled anesthesia with sevoflurane or desflurane. METHODS After IRB approval, chart reviews of 193 American Society of Anesthesiologists class 1 to 3 patients were conducted who had undergone transsphenoidal, endonasal resections of pituitary tumors under total intravenous or inhaled anesthesia at an academic teaching hospital in the United States over a seven-year time period. One hundred four patients fulfilled the inclusion criteria and were further reviewed. Primary outcome was intraoperative blood loss; secondary outcomes were surgical duration, time to extubation and length of stay in the recovery room. RESULTS Gender, age, and Lund-Mackay-Scores were equally distributed between the two anesthetic groups. We found no significant effect of the anesthetic technique, age, gender, or Lund Mackay score on any of the primary or secondary outcomes. The only significant predictor for recovery room length of stay was intraoperative blood loss. CONCLUSION Our study shows no evidence that total intravenous anesthesia is superior to inhaled anesthesia or vice versa during endoscopic transsphenoidal sinus surgery with regard to relevant clinical outcome parameters.
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Affiliation(s)
- Suneeta Gollapudy
- Department of Anesthesiology, Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI 53226, USA
| | - David M Poetker
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI 53226, USA
| | - Jasmeet Sidhu
- Department of Anesthesiology, Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI 53226, USA
| | - Matthias L Riess
- Anesthesiology, TVHS VA Medical Center, 1310 24th Avenue South, Nashville, TN 37212, USA; Departments of Anesthesiology and Pharmacology, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN 37232, USA.
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Fam MD, Potash A, Potash M, Robinson R, Karnell L, O'Brien E, Greenlee JDW. Skull Base Dural Thickness and Relationship to Demographic Features: A Postmortem Study and Literature Review. J Neurol Surg B Skull Base 2018; 79:614-620. [PMID: 30456033 DOI: 10.1055/s-0038-1651501] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 03/31/2018] [Indexed: 02/02/2023] Open
Abstract
Dural membrane is an important anatomic structure that surrounds and protects the entire central nervous system. Physical properties of the dura have many pathophysiological and therapeutic implications in cranial surgery, especially skull base disorders. The aim of this study is to investigate variation in skull base dural thickness and correlation with different demographic parameters. At the time of autopsy, the petrous apex dura with the underlying bone of 20 cadavers was harvested. Dural thickness was independently measured by two pathologists at the thinnest and thickest segments in the specimen. Correlational analyses were then performed to compare dural thickness with gender, age, neck circumference, height, weight, and body mass index (BMI). Mean, minimum, and maximum skull base dural thickness in our study was 0.36, 0.27, and 0.46 mm, respectively. Age demonstrated a negative correlation with dural thickness with significantly thinner dura in the older subjects, p = 0.01. There was a trend toward thinner dura in females that approached statistical significance, p = 0.06. No strong correlation could be found with body weight, height, neck circumference, or BMI. Our findings show a considerable intersubject and intrasubject variability in skull base dural thickness. Some demographic parameters also seem to impact dural thickness. Additional histological studies are needed for better understanding of the pathophysiological mechanisms pertaining to the tensile properties of the dural membrane.
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Affiliation(s)
- Maged D Fam
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Andrea Potash
- Department of Otolaryngology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Martin Potash
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Robert Robinson
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Lucy Karnell
- Department of Otolaryngology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Erin O'Brien
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota, United States
| | - Jeremy D W Greenlee
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
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Lobatto DJ, de Vries F, Zamanipoor Najafabadi AH, Pereira AM, Peul WC, Vliet Vlieland TPM, Biermasz NR, van Furth WR. Preoperative risk factors for postoperative complications in endoscopic pituitary surgery: a systematic review. Pituitary 2018; 21:84-97. [PMID: 28916976 PMCID: PMC5767215 DOI: 10.1007/s11102-017-0839-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
BACKGROUND The ability to preoperatively predict postoperative complication risks is valuable for individual counseling and (post)operative planning, e.g. to select low-risk patients eligible for short stay surgery or those with higher risks requiring special attention. These risks however, are not well established in pituitary surgery. METHODS We conducted a systematic review of associations between preoperative characteristics and postoperative complications of endoscopic transsphenoidal surgery according to the PRISMA guidelines. Risk of bias was assessed through the QUIPS tool. RESULTS In total 23 articles were included, containing 5491 patients (96% pituitary adenoma). There was a wide variety regarding the nature and number of risk factors, definitions, measurement and statistics employed, and overall quality of mainly retrospective studies was low. Consistent significant associations were older age for complications in general, and intraventricular extension for cerebrospinal fluid (CSF) leaks. Associations identified in some but not all studies were younger age, increased BMI, female gender, and learning curve for CSF leaks; increased tumor size for complications in general; and Rathke's cleft cysts for diabetes insipidus. Mortality (incidence rate 1%) was not addressed as a risk factor. CONCLUSION Based on current literature, of low to medium quality, it is not possible to comprehensively quantify risk factors for complications. Nevertheless, older age and intraventricular extension were associated with increased postoperative complications. Future research should aim at prospective data collection, reporting of outcomes, and uniformity of definitions. Only then a proper risk analysis can be performed for endoscopic pituitary surgery.
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Affiliation(s)
- Daniel J Lobatto
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - Friso de Vries
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | | | - Alberto M Pereira
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Thea P M Vliet Vlieland
- Department of Orthopedic Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Nienke R Biermasz
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Wouter R van Furth
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
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Konuthula N, Khan MN, Del Signore A, Govindaraj S, Shrivastava R, Iloreta AM. A Systematic Review of Secondary Cerebrospinal Fluid Leaks. Am J Rhinol Allergy 2017; 31:48-56. [DOI: 10.2500/ajra.2017.31.4487] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Secondary cerebrospinal leaks (CSF) are leaks that recur after an initial endoscopic repair of CSF leaks. Identification of characteristics that could predict secondary leaks may allow surgeons to plan repairs with the knowledge that these defects are more likely to fail. Objective To identify characteristics that could predict secondary CSF leaks. Methods A search of all studies that reported outcomes after endoscopic repair of CSF leaks was conducted by using medical literature data bases. Studies with the following criteria were included: written in the English language, secondary CSF leaks after primary repair, and assessment of success of fistula repair. Data extracted included the etiology of the leak, site of the leak, reconstructive materials used, and success of the repair. Results Ninety-four studies, from 1988 to 2015, with a total of 3149 primary CSF leaks were included. Sixty-three studies (67%) had a success rate of ≥80%; 77 studies (82%) had secondary leak rates of <40%. For 88 of the 94 studies (94%), the success rate after secondary repair improved to 81.0–100%. Of 48 studies that included leaks of more than one site, the sphenoid was the most common site of leak in 26 studies (55%), the ethmoid was the most common site in 16 studies (34%), and the cribriform was the most common site in 11 studies (23%). Conclusion The rate of secondary CSF leaks was low due to advances in endoscopic repair techniques. Spontaneous and iatrogenic CSF leaks were more likely to recur, especially without adequate control of underlying factors, such as increased intracranial pressure and obesity. Further studies with consistent reporting are required for more definitive conclusions about secondary CSF leaks.
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Affiliation(s)
- Neeraja Konuthula
- Department of Otolaryngology—Head and Neck Surgery, Mount Sinai Medical Center, New York, New York
| | - Mohemmed N. Khan
- Department of Otolaryngology—Head and Neck Surgery, Mount Sinai Medical Center, New York, New York
| | - Anthony Del Signore
- Department of Otolaryngology—Head and Neck Surgery, Mount Sinai Beth Israel, New York, New York
| | - Satish Govindaraj
- Department of Otolaryngology—Head and Neck Surgery, Mount Sinai Medical Center, New York, New York
| | - Raj Shrivastava
- Department of Neurosurgery—Head and Neck Surgery, Mount Sinai Medical Center, New York, New York
| | - Alfred M. Iloreta
- Department of Otolaryngology—Head and Neck Surgery, Mount Sinai Medical Center, New York, New York
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Sefcik RK, Rasouli J, Bederson JB, Shrivastava RK. Three-Dimensional, computer simulated navigation in endoscopic neurosurgery. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2017; 8:17-22. [PMID: 28451520 DOI: 10.1016/j.inat.2017.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND In order to address the pre- and perioperative need for visualization and prediction of patient-specific anatomy for surgical planning, endoscopic neurosurgeons have increasingly relied on computerized navigation devices to guide their surgical approaches. OBJECTIVE This manuscript aims to review: 1) the use of neuronavigation in endoscopic neurosurgery for pre-operative planning, 2) the intraoperative advantages of neuronavigation in endoscopic neurosurgery, and 3) the effects of navigation guidance on operative time, registration accuracy, brain shift, and avoidance of complications. Limitations of the current neuroendoscopic navigation literature will be discussed. METHODS We conducted a search using PubMed-MEDLINE; the keywords "stereotactic navigation AND endoscopic surgery" and "simulation AND endoscopic neurosurgery". 36 studies were identified that addressed the use of neuronavigation in endoscopic neurosurgery. These studies were then further analyzed for topics relevant to computerized neuroendoscopy and reviewed for the purposes of this article. CONCLUSION Three-dimensional, frameless neuronavigation systems are useful in endoscopic neurosurgery to assist in the pre-operative planning of potential trajectories and to help localize the pathology of interest. Neuronavigation appears to be accurate to < 1-2 mm without issues related to brain shift. Further work is necessary in the investigation of the effect of neuronavigation on operative time, cost, and patient-centered outcomes.
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Affiliation(s)
- Roberta K Sefcik
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 7th Floor, 5 E 98th St New York, New York 10029, United States
| | - Jonathan Rasouli
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 7th Floor, 5 E 98th St New York, New York 10029, United States
| | - Joshua B Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 7th Floor, 5 E 98th St New York, New York 10029, United States
| | - Raj K Shrivastava
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 7th Floor, 5 E 98th St New York, New York 10029, United States
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Nishioka H. Recent Evolution of Endoscopic Endonasal Surgery for Treatment of Pituitary Adenomas. Neurol Med Chir (Tokyo) 2017; 57:151-158. [PMID: 28239067 PMCID: PMC5409268 DOI: 10.2176/nmc.ra.2016-0276] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
For the treatment of pituitary tumors, microscopic transsphenoidal surgery has been considered the "gold standard" since the late 1960s. Over the last two decades, however, a worldwide shift towards endoscopic endonasal surgery is in progress for many reasons. These include a wide panoramic view, improved illumination, an ability to look around anatomical corners using angled tip and, in addition, application to the extended approaches for parasellar tumors. Both endoscopic and microscopic approaches appear equally effective for nonfunctioning adenomas without significant suprasellar or lateral extensions, whereas the endoscopic approach may improve outcomes associated with the extent of resection and postoperative complications for larger tumors. Despite many theoretical benefits in the endoscopic surgery, remission rates of functioning adenomas do not substantially differ between the approaches in experienced hands. The endoscopic approach is a valid alternative to the microscopic approach for adenomas. The benefits will be more appreciated in the extended surgery for parasellar tumors.
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Affiliation(s)
- Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital.,Okinaka Memorial Institute for Medical Research
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Luk LJ, DelGaudio JM, Wise SK. Advancements in Skull Base Reconstruction. CURRENT OTORHINOLARYNGOLOGY REPORTS 2016. [DOI: 10.1007/s40136-016-0135-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Shahangian A, Soler ZM, Baker A, Wise SK, Rereddy SK, Patel ZM, Oyesiku NM, DelGaudio JM, Hadjipanayis CG, Woodworth BA, Riley KO, Lee J, Cusimano MD, Govindaraj S, Khan MN, Psaltis A, Wormald PJ, Santoreneos S, Sindwani R, Trosman S, Stokken JK, Woodard TD, Recinos PF, Vandergrift WA, Boling C, Schlosser RJ. Successful repair of intraoperative cerebrospinal fluid leaks improves outcomes in endoscopic skull base surgery. Int Forum Allergy Rhinol 2016; 7:80-86. [DOI: 10.1002/alr.21845] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 06/29/2016] [Accepted: 07/26/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Arash Shahangian
- Department of Otolaryngology-Head & Neck Surgery; Medical University of South Carolina; Charleston SC
| | - Zachary M. Soler
- Department of Otolaryngology-Head & Neck Surgery; Medical University of South Carolina; Charleston SC
| | - Andrew Baker
- Department of Otolaryngology-Head & Neck Surgery; Medical University of South Carolina; Charleston SC
| | - Sarah K. Wise
- Department of Otolaryngology-Head & Neck Surgery; Emory University; Atlanta GA
| | - Shruthi K. Rereddy
- Department of Otolaryngology-Head & Neck Surgery; Emory University; Atlanta GA
- Department of Otorhinolaryngology-Head & Neck Surgery; University of Pennsylvania; Philadelphia PA
| | - Zara M. Patel
- Department of Otolaryngology-Head & Neck Surgery; Stanford University; Stanford CA
| | | | - John M. DelGaudio
- Department of Otolaryngology-Head & Neck Surgery; Emory University; Atlanta GA
| | - Constantinos G. Hadjipanayis
- Department of Neurosurgery; Emory University; Atlanta GA
- Department of Otolaryngology-Head & Neck Surgery; Mount Sinai Beth Israel; New York City NY
| | - Bradford A. Woodworth
- Division of Otolaryngology-Head & Neck Surgery; University of Alabama at Birmingham; Birmingham AL
| | - Kristen O. Riley
- Department of Neurosurgery; University of Alabama at Birmingham; Birmingham AL
| | - John Lee
- Department of Otolaryngology-Head & Neck Surgery; University of Toronto; St. Michael's Hospital; Toronto ON Canada
| | - Michael D. Cusimano
- Department of Neurosurgery University of Toronto; St. Michael's Hospital; Toronto ON Canada
| | - Satish Govindaraj
- Department of Otolaryngology-Head & Neck Surgery; Mount Sinai Hospital; New York City NY
| | - Mohemmed N. Khan
- Department of Otolaryngology-Head & Neck Surgery; Mount Sinai Hospital; New York City NY
| | - Alkis Psaltis
- Department of Otolaryngology-Head & Neck Surgery; Royal Adelaide Hospital; Adelaide SA Australia
| | - Peter J. Wormald
- Department of Otolaryngology-Head & Neck Surgery; Royal Adelaide Hospital; Adelaide SA Australia
| | | | - Raj Sindwani
- Section of Rhinology; Head and Neck Institute and the Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center; Cleveland Clinic; Cleveland OH
| | - Samuel Trosman
- Section of Rhinology; Head and Neck Institute and the Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center; Cleveland Clinic; Cleveland OH
| | - Janalee K. Stokken
- Department of Otolaryngology-Head & Neck Surgery; Mayo Clinic; Rochester MN
| | - Troy D. Woodard
- Section of Rhinology; Head and Neck Institute and the Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center; Cleveland Clinic; Cleveland OH
| | - Pablo F. Recinos
- Section of Rhinology; Head and Neck Institute and the Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center; Cleveland Clinic; Cleveland OH
| | | | - Caitlin Boling
- Department of Otolaryngology-Head & Neck Surgery; Medical University of South Carolina; Charleston SC
| | - Rodney J. Schlosser
- Department of Otolaryngology-Head & Neck Surgery; Medical University of South Carolina; Charleston SC
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Incidence and Risk Factors for Prolonged Hospitalization and Readmission after Transsphenoidal Pituitary Surgery. Otolaryngol Head Neck Surg 2016; 155:688-94. [DOI: 10.1177/0194599816652379] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 05/10/2016] [Indexed: 12/18/2022]
Abstract
Objective To evaluate the incidence and factors associated with 30-day readmission and to analyze risk factors for prolonged hospital length of stay following transsphenoidal pituitary surgery. Study Design Retrospective longitudinal claims analysis. Setting American College of Surgeons National Surgical Quality Improvement Program. Subjects and Methods The database of the American College of Surgeons National Surgical Quality Improvement Program was queried for patients who underwent transsphenoidal pituitary surgery ( Current Procedural Terminology code 61548 or 62165) between 2005 and 2014. Patient demographic information, indications for surgery, and incidence of hospital readmission and length of stay were reviewed. Risk factors for readmission and prolonged length of stay, defined as >75th percentile for the cohort, were identified through logistic regression modeling. Results A total of 1006 patients were included for analysis. Mean hospital length of stay after surgery was 4.1 ± 0.2 days. Predictors of prolonged length of stay were operative time ( P < .001, odds ratio [OR] = 1.7, 95% confidence interval [95% CI] = 1.5-2.0), bleeding disorder ( P = .049, OR = 3.1, 95% CI = 1.0-9.5), insulin-dependent diabetes ( P = .007, OR = 2.4, 95% CI = 1.3-4.4), and reoperation ( P < .001, OR = 10.3, 95% CI = 4.7-23.9). In a subset analysis of 529 patients who had surgery between 2012 and 2014, 7.2% (n = 38) required hospital readmission. History of congestive heart failure (CHF) was a predictor of hospital readmission ( P = 0.03, OR = 12.7, 95% CI = 1.1-144.0). Conclusion This review of a large validated surgical database demonstrates that CHF is an independent predictor of hospital readmission after transsphenoidal surgery. Although CHF is a known risk factor for postoperative complications, it poses unique challenges to patients with potential postoperative pituitary dysfunction.
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Deipolyi A, Bailin A, Hirsch JA, Walker TG, Oklu R. Bilateral inferior petrosal sinus sampling: experience in 327 patients. J Neurointerv Surg 2016; 9:196-199. [DOI: 10.1136/neurintsurg-2015-012164] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 01/20/2016] [Accepted: 01/25/2016] [Indexed: 11/04/2022]
Abstract
ObjectiveTo describe findings and outcomes of 331 bilateral inferior petrosal sinus sampling (BIPSS) procedures performed in 327 patients evaluated for Cushing disease (CD).Materials and methodsThe radiology department's electronic database was searched to identify all BIPSS procedures (1990–2013). Electronic medical records were used to identify demographics, laboratory, procedural, surgical and pathologic findings.ResultsA total of 331 BIPSS procedures were performed in 327 patients (254 F, 73 M), mean age 41 (range 7–81) years. The overall technical success rate was 88% for bilateral cannulation, though nearly two-thirds of the technical failures had unilateral sampling that diagnosed CD. Of the 331 BIPSS procedures, 40 were performed without, and 291 with stimulation by Acthrel or desmopressin. Sensitivity was 89–94% for unstimulated BIPSS, 96% for stimulated BIPSS, and 77% for MRI. BIPSS lateralization was accurate in about half of patients, compared with 75% accuracy for MRI. Mean inferior petrosal sinus (IPS):peripheral adrenocorticotropic hormone ratio was 17.3 (SE 1.8) at baseline, and 99.2 (SE 14.8) at 3 min, with decreasing values over time. All patients with follow-up after surgical resection for centralizing BIPSS were reported to be cured, with cortisol levels significantly decreased from 19 to 4 μg/dL (p<0.0001). Complications from BIPSS were rare, including groin hematoma (2.5%), but no thromboembolic complications were seen.ConclusionsBIPSS remains the ‘gold standard’ for diagnosing CD. Stimulation with Acthrel or desmopressin is key to increasing specificity. When only one IPS can be successfully cannulated, results may still be diagnostic. BIPSS findings cannot be used to accurately lateralize lesions within the pituitary.
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Kern RC. EDITORIAL. Int Forum Allergy Rhinol 2016; 6:5-7. [PMID: 26749201 DOI: 10.1002/alr.21713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Robert C Kern
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
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