Preservation of hormonal function by identifying pituitary gland at endoscopic surgery

Endonasal endoscopic or endoscopic-assisted transcranial surgery of Rathke's cleft cysts: does the approach and surgical technique influence the radicality and recurrence rate?

OBJECTIVE

Resections of symptomatic Rathke's cleft cysts (RCCs) are mainly performed via an endonasal transsphenoidal approach. However, there is a lack of equivalent data in current literature concerning transcranial keyhole approach in the treatment of RCCs. In order to find general recommendations for the surgical treatment of RCCs also with regard to recurrence, the object of this study is the analysis and comparison of both techniques.

METHODS

Twenty-nine patients having been surgically treated between January 2004 and August 2019 were retrospectively analysed. The transsphenoidal approach was chosen in 16 cases and the transcranial keyhole approach in 13 cases. Both surgical techniques were analyzed and compared concerning preoperative symptoms and cyst characteristics, complications, surgical radicality, endocrinological and ophthalmological outcome and recurrences in patients´ follow up.

RESULTS

The postoperative outcome of both techniques was identic and showed highly satisfying success rates with 92% for neurological deficits, 82% for endocrinological dysfunctions and 86% for visual deficits. In contrast, momentous postoperative complications were significantly more likely after transsphenoidal operations. After a mean follow-up time of 5.7 years, the recurrence rates of both cohorts were the same with 0% each.

CONCLUSIONS

Regarding its equal outcome with its lower complication rate, the authors suggest using the supraorbital keyhole approach for RCCs whose anatomical configuration allow both techniques. Yet, the decision should always consider the surgeon's personal experience and other individual patient characteristics. Further studies with higher numbers of cases and longer follow-up periods are necessary to analyse the effect of the selected approach on recurrence.

Central diabetes insipidus (vasopressin deficiency) after surgery for pituitary tumours: a systematic review and meta-analysis

OBJECTIVE

Central diabetes insipidus or vasopressin deficiency (AVP-D) is the most frequent water balance disorder after transsphenoidal surgery (TSS) with variable prevalence amongst studies. We aimed to determine rates of newly developed transient or permanent AVP-D in patients with pituitary tumours treated with TSS.

DESIGN AND METHODS

We performed systematic review of Medline, Embase, and Cochrane Library between January 1, 2000 and January 31, 2021 for studies reporting on outcomes for pituitary adenoma, craniopharyngioma, and Rathke's cleft cyst (RCC) after TSS and providing definition of post-operative AVP-D. We pooled the results as proportions with 95% confidence intervals (CIs) using Freeman-Tukey transformation random effects meta-analysis.

RESULTS

From 11 694 studies, 51 were included. Rates of transient or permanent AVP-D were: 17% (95% CI, 13-21) and 3% (95% CI, 2-5) in total group, 16% (95% CI, 12-21) and 2% (95% CI, 2-3) in pituitary adenomas, 31% (95% CI, 24-39) and 30% (95% CI, 22-39) in craniopharyngiomas, and 35% (95% CI, 16-57) and 14% (95% CI, 6-23) in RCCs, respectively. Based on diagnostic criteria, rates of transient or permanent AVP-D were: For hypotonic polyuria, 14% (95% CI, 8-22) and 3% (95% CI, 1-4), for hypotonic polyuria and hypernatraemia, 21% (95% CI, 13-29) and 5% (95% CI, 2-11), and for desmopressin administration, 22% (95% CI, 15-29) and 9% (95% CI, 0-30), respectively.

CONCLUSIONS

Following TSS, a small proportion of patients with pituitary adenoma have permanent AVP-D (2%), but prevalence reaches 30% in ones with craniopharyngioma and 14% in those with RCC. Diagnostic criteria for post-operative AVP-D remain variable affecting reported rates of this condition.

Sellar metastasis: A rare intraoperative finding - surgical treatment, strategies and outcome

OBJECTIVE

The sellar region, though uncommon for metastatic spread, may become more prevalent due to longer survival of patients with metastatic malignancies. Compression of adjacent vital anatomy can cause disabling symptoms and endocrine disturbances, leading to significant morbidity METHODS: This study analyzed sellar pathologies treated via endonasal approach from January 2011 to December 2021 to assess the incidence of sellar metastases. Patient demographics, presenting symptoms, radiological and histological findings, management, and outcomes were evaluated RESULTS: Among 334 patients treated during the study period, eight (2.3 %) had metastases confirmed histopathologically, with one having a known malignant tumor history. Preoperative imaging suspected malignancy or metastasis in two cases. Diagnosis was unexpectedly confirmed in 57 % of cases. Subtotal resection was achieved in three cases, near-total resection in one. Mean follow-up was 2.4 years, with 71 % mortality CONCLUSIONS: The sellar region can manifest metastatic disease, with sellar symptoms potentially indicating neoplastic disease onset. Rapid hormonal dysfunction or ophthalmoplegia suggests metastasis, even without a known primary. Further meta analysis of reported cases is necessary to determine the incidence and optimal treatment of these rare metastases.

Comparison of the Novel Two-Hand Technique Using the Saraj Endocath with the Traditional Three-Hand Technique in Transnasal Endoscopic Pituitary Surgery: An Innovation for the Future

BACKGROUND

Endoscopic surgery has become the preferred treatment of sellar lesions because of its minimally invasive nature. Visualization is frequently obscured as a result of the frequent contact of the lens with blood and tissue debris. We seek to alleviate these problems and increase the efficiency and safety of neuroendoscopic surgery by introducing a new device (Saraj Endocath) combining the major function of suction with the endoscope.

METHODS

A total of 75 patients with pituitary macroadenoma who were eligible for transnasal transsphenoidal endoscopic excision were included in the study between January 2020 and January 2023. Forty-one patients were operated on by the traditional 3-hand technique and 34 patients were operated on using the Saraj Endocath. The duration of surgery, in-out frequency of the endoscope, number of wipes needed to clean the endoscopic lens, and outcomes were assessed. A questionnaire regarding assistance, ergonomics, and instrument handling compared the Saraj Endocath procedure with the traditional technique.

RESULTS

The 3-hand technique was converted into the 2-hand technique. The mean operative time using the novel technique with the Saraj Endocath was reduced significantly compared with the traditional technique. The mean number of in-out movements of the endoscope and the number of wipes per hour decreased significantly using the Saraj Endocath. There was no dependency on the assistant's expertise and skills.

CONCLUSIONS

The use of the Saraj Endocath can effectively reduce the mean operative time by decreasing the frequency of in-out movement and wiping off the lens of the endoscope. It reduces fatigue, avoids clustering of instruments and hands, and minimizes the dependency on assistants.

Endoscopic Extended Transsphenoidal Approach for Sellar and Suprasellar Xanthogranuloma: Potential Implications for Surgical Strategies in Adult Craniopharyngioma

OBJECTIVE

Differentiation of suprasellar xanthogranuloma (XG) from adult craniopharyngioma (CP) can be problematic in endoscopic extended transsphenoidal surgery.

METHODS

We reviewed the clinical data, preoperative imaging, intraoperative endoscopic findings, and intraoperative frozen section pathology in newly diagnosed adult CPs (19 patients) and XGs (6 patients).

RESULTS

Intracystic signal intensity was often high on T1-weighted magnetic resonance images in the XGs but low in the CPs (P = 0.015). Capsular intensity was low on T2-weighted imaging in XGs but iso to high in CPs (P < 0.001). Capsular gadolinium enhancement was often seen in CPs and not in XGs (P < 0.001). CPs often had a solid component with contrast enhancement but none in XGs (P < 0.001). Intraoperative endoscopic observations frequently found a whitish solid component in the CPs but yellow to brown fibrous granulomatous lesions in XGs (P < 0.001). The tumor capsule was dark grayish and soft in CPs, whereas it was fibrously hard in XGs (P = 0.002). Yellowish hemosiderin deposits were seen in all XGs (P = 0.003). Intraoperative pathologic diagnosis of CP was all verified whereas no evidence of tumor was found in XGs (P < 0.001). Partial removal was performed in 4 patients with XGs. No recurrence was observed in these patients during the follow-up period (1.5-8 years).

CONCLUSIONS

Careful interpretation of preoperative magnetic resonance imaging, intraoperative endoscopic findings, and intraoperative frozen section diagnosis may be important for the differential diagnosis between XG and CP. In endoscopic-extended transsphenoidal surgery, intentional partial removal can be effective for XG after careful diagnosis.

A new comprehensive grading for giant pituitary adenomas: SLAP grading

AimGiant pituitary adenomas are difficult to resect due to multicompartmental extension. We developed a new grading system for giant pituitary adenomas (GPAs) considering possible extension in superior, lateral, anterior, and posterior (SLAP) directions. We also related the degree of resection to the SLAP grading.MethodsA review of case files and radiological images of patients with the GPAs defined as pituitary adenomas with a size of more than 4 cm in any dimension was done. The extent of the tumour was noted and scored as per the SLAP system. The maximum total score is 10 and represents a large tumour with maximum extensions in all directions. The subtotal resection (STR) was defined as a residual tumour volume of more than 10%. The association between individual and total score on the degree of resection was determined.ResultsA total of 103 cases of GPAs were analyzed. All patients had a suprasellar (S) extension. The lateral (L) extension was seen in 97.3% of cases. The anterior (A) extension was seen in 28 (27.2%) cases. The posterior (P) extension was seen in 45 (43.7%). Forty-eight (46.6%) had a total score of 5 or more. The STR was achieved in 64 (62.2%) cases. On regression analysis, a total score of ≥5 was associated with odds of 5.02 (1.69-14.93), p-value 0.004 for STR.ConclusionThe SLAP grading is a comprehensive grading system that can be applied easily to the GPAs and gives a complete picture of the extension of the tumour.

Endoscopic Endonasal Transsphenoidal Approach for the Surgical Treatment of Pituitary Apoplexy and Clinical Outcomes

Purpose: This study investigated the clinical manifestations, surgical method, and treatment outcomes of patients with pituitary apoplexy and evaluated the safety and effectiveness of the endoscopic endonasal transsphenoidal approach in the treatment of pituitary adenomas. Patients and methods: In this retrospective study, were analyzed the data of patients with symptomatic pituitary apoplexy who received surgical treatment by endoscopic endonasal transsphenoidal approach from January 2017 to June 2020 at the Department of Neurosurgery of the First Affiliated Hospital of Bengbu Medical College. Patients were followed up through outpatient visits and telephone interviews. Results: Data for 24 patients including 13 males and 11 females with an average age of 46.46 years were analyzed. Headache (83.33%) and visual disturbances (75.00%) were the most common preoperative manifestations. In the 24 patients, 21 (87.50%) tumors were completely removed and 3 (12.50%) were partly removed. Intractable headache improved in all patients over a mean follow-up time of 25.16 months, and postoperative improvement in visual acuity was achieved in 17 of 18 patients (94.44%) with vision defects. Four patients (16.67%) experienced transient urinary collapse after the operation. No intracranial infection, carotid artery injury, or death occurred. Conclusion: The endoscopic endonasal transsphenoidal approach is a safe and effective method for the treatment of pituitary apoplexy.

Transcranial approach as surgical treatment for giant pituitary adenoma during COVID 19 pandemic - What can we learn?: A case report

Introduction

In the COVID 19 pandemic, pituitary surgery is one of challenging surgical treatment, especially the involving transsphenoid approach. It was reported that the aerosolisation and mucosal involvement increase the risk of viral transmission during operation. Therefore, transcranial is a safer surgical approach during COVID-19 pandemic. This study aimed to reported transcranial approach to treat giant pituitary adenoma with aggressive visual disturbance which require urgent surgical management.

Case presentation

We reported a 21-year old male, who required urgent surgery because of progressive visual disturbance due to giant pituitary adenoma. On brain MRI with contrast, it was revealed an extraaxial tumor extending anteriorly over plannum sphenoidal with the greatest diameter was 5.34 cm. Transcranial approach was chosen to resect the tumor. Near total removal of the tumor was achieved without damaging vital neurovascular structure. The visual acuity was improved and no significant postoperative complication. Pathology examination revealed pituitary adenoma.

Conclusion

Transcranial surgery for pituitary adenoma is still an armamentarium in neurosurgical practice, especially in the COVID 19 pandemic to provide safer surgical approach.

Comparative study of complications after primary and revision transsphenoidal endoscopic surgeries

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.

Challenges, Learning Curve, and Safety of Endoscopic Endonasal Surgery of Sellar-Suprasellar Lesions in a Community Hospital

BACKGROUND AND OBJECTIVE

Endoscopic endonasal surgery (EES) for the management of sellar, suprasellar, and anterior skull base lesions is gaining popularity. Our aim was to analyze and present the clinical outcomes of EES for the management of these lesions in a community hospital setting.

METHODS

We retrospectively reviewed the charts of 56 patients with sellar, suprasellar, and anterior skull base lesions who underwent EES between 2010 and 2018.

RESULTS

There was male predominance (53.6%) with a mean age of 54.9 ± 13.7 years. Lesions were 45 pituitary adenomas, 5 meningiomas, 3 metastatic, 1 craniopharyngioma, 1 Rathke cyst, and 1 mucocele. Gross total excision was achieved in 57.1%, subtotal excision occurred in 37.5%, and decompression and biopsy were achieved in 5.4% patients. Postoperative vision normalized or improved in 27 patients (86.1%) and was stable in 4 patients (13.9%). Recovery of a preexisting hormonal deficit occurred in 13 (23.2%) patients, and a new hormonal deficit occurred in 9 patients (16.1%). The mean hospital stay was 6.1 ± 4.9 days. Postoperative complications included cerebrospinal fluid leak in 8 patients (14.3%). Four patients (7.1%) had meningitis. Diabetes insipidus was present in 19 patients (33.9%), and postoperative intracranial hematoma requiring evacuation was necessary in 2 patients (3.6%). The mean follow-up duration was 47.5 ± 25.8 months. Lesion progression or recurrence requiring redo surgery occurred in 5 patients (8.9%). Regarding the learning curve, the postoperative cerebrospinal fluid leak, meningitis, new hormonal deficits, and diabetes insipidus decreased in the second half of the patients.

CONCLUSIONS

EES provides an effective and safe surgical option with low morbidity and mortality for the treatment of sellar, suprasellar, and anterior skull base lesions in a community hospital setting.

Cyclooxygenase enzyme and PGE2 expression in patients with functional and non-functional pituitary adenomas

BACKGROUND

Pituitary adenomas as multifactorial intracranial neoplasms impose a massive burden of morbidity on patients and characterizing the molecular mechanism underlying their pathogenesis has received considerable attention. Despite the appealing role of cyclooxygenase enzymes and their bioactive lipid products in cancer pathogenesis, their relevance to pituitary adenoma pathogenesis is debated and yet to be determined. Thus, the current study perused this relevance.

METHODS

The expression level of the isoforms of cyclooxygenase (COX-1 and COX-2) was evaluated in hormone-secreting and in-active pituitary adenoma tumors and normal pituitary tissues through Real-Time PCR. The level of PGE2, as the main product of enzymes, was assessed using enzyme immunoassay kits in patients and healthy subjects.

RESULTS

The results of the current study demonstrated that COX-1 and COX-2 expression levels were increased in pituitary tumors including non-functional pituitary adenoma (NFPA), acromegaly, Cushing's disease and prolactinoma compared with normal pituitary tissues. A significant expression level of COX-2 was observed in NFPA compared with the other pituitary tumors. Furthermore, the COX-2 expression level was significantly increased in macroadenoma and invasive tumors. The level of PGE2 was consistent with COX enzymes enhanced in pituitary adenoma tumors compared with healthy pituitary tissue. A significant elevation in the PGE2 level was detected in NFPA compared with hormone-secreting pituitary tumors. Additionally, the PGE2 level was increased in macroadenoma compared with microadenoma and in invasive compared with non-invasive pituitary tumors. The diagnostic values of cyclooxygenase isoforms and PGE2 were considerable between patients and healthy groups; however, COX-2 revealed more value in distinguishing endocrinologically active and non-active pituitary tumors.

CONCLUSIONS

Data from the current study provides expression patterns of COX-1, COX-2 and PGE2 in prevalent pituitary tumors and their association with patients' clinical features which may open up new molecular targets for early diagnosis/follow up of pituitary tumor growth.

Difference in the incidence of cerebrospinal fluid leakage and residual tumors between functional and nonfunctional pituitary adenomas treated by endoscopic transsphenoidal pituitary adenomectomy

Objective

This study compared the incidence of cerebrospinal fluid (CSF) leakage and residual tumors between functional and nonfunctional pituitary adenomas treated with the endoscopic endonasal transsphenoidal approach (EETA).

Methods

All patients underwent endocrine examinations and brain magnetic resonance imaging before and after surgery. The length of admission, incidence of central diabetes insipidus, incidence of CSF leakage, symptom relief, and presence of residual tumors were compared between patients with functional and nonfunctional pituitary adenomas.

Results

Thirty-eight patients were enrolled, among whom 12 and 26 had functional and nonfunctional pituitary adenomas, respectively. The incidence of CSF leakage was significantly higher in patients with nonfunctional adenomas; a hard or elastic tumor character accounted for the difference. A large tumor size and cavernous sinus invasion were risk factors for residual tumors. No significant differences were found in sex, length of admission, operative times, incidence of diabetes insipidus, or number of residual tumors between the two groups. The hormone levels were lower postoperatively than preoperatively in patients with nonfunctional adenomas.

Conclusion

Nonfunctional pituitary macroadenomas resulted in more CSF leakage. Use of the rescue nasoseptal flap reduced unnecessary nasal destruction. Cooperation between a neurosurgeon and otolaryngologist was safer and more effective when using the EETA.

The extended endoscopic approach to perisellar and skull base lesions: is one nostril enough?

The extended endonasal endoscopic approach to the skull base is still under investigation. The main advantage of using this technique is to approach lesions in a minimally invasive manner resulting without brain retraction. Here, the authors present the results of extended endonasal endoscopic surgery via one nostril. All skull base procedures performed via an endonasal approach at the author's Department between January 2011 and May 2017 were analysed prospectively. Special attention was paid to complications, radicality, advantages and disadvantages of the endoscopic technique. Additionally, the application of various telescopes and the technique of dural closure were analysed. Sixty-two patients were operated on various pathologies of the skull base via an extended endonasal approach. Seven pathologies were resected via binostril technique. All other pathologies could be exposed by the mononostril technique. In 2 of 62 cases, the authors had to switch to binostril technique. MRI revealed radical gross total resection in 93% of all cases when intended. Overall complication rate was 16% (9/55) in the mononostril and 57% (4/7) in the binostril cohort. Seven patients in the mononostril cohort (13%) versus three patients in the binostril cohort (43%) complained of postoperative nasal congestion. This clinical report shows that many extended skull base lesions can be treated by a mononostril endonasal approach. In selected cases, this technique might represent an alternative to the binostril approach. Nevertheless, the binostril technique offers a better range of manipulation and exposure and should be preferred in difficult and very extended cases.

Visualization and Identification of the Pituitary Gland Tissue in Endonasal Pituitary Surgery: Is There a Difference Between High-Definition Endoscopy and Microscopy?

OBJECTIVE

Neurosurgical techniques for the treatment of sellar pathologies have been evolving continuously over recent decades. In addition to the innovation of approaches and surgical techniques, this progress yielded to the application of modern operative technologies. The introduction of high-definition (HD) cameras for endoscopic systems has shown good results in endonasal pituitary surgery. The aim of this study was to assess endoscopic HD image quality in comparison with microscopic visualization.

METHODS

All pituitary surgeries were performed via an endonasal approach in the endoscopic technique. For each comparison, pituitary gland tissue was predefined intraoperatively. A resident was randomly required to identify this tissue either using HD endoscopic or microscopic visualization through the endonasal approach. Subjective image quality was requested with a questionnaire. Furthermore, the illuminance level of the endoscope and microscope was measured in the sellar region in an experimental setup.

RESULTS

Thirty-five procedures were performed and included in this comparison. Of the 35 procedures, 74% of gland tissue cases were identified correctly under endoscopic visualization, whereas it was identified correctly under microscopic visualization in 8% (P < 0.05). There was no significant correlation of experience and intraoperative results in cases of the microscopic (r = -0.15) or endoscopic visualization (r = 0.22). The identification of tissue in the depth of the surgical field via endoscopic HD visualization was thought to be superior to the microscope in 86.8%. Both modalities were assessed equal in 10.4%. Microscopic visualization was rated superior in 2.8% of all cases. There was a significant superiority of endoscopic visualization (P < 0.05). The mean lux level for endoscopic visualization of the sellar region was 221,000. The mean lux level decreased significantly by 66% to 241,000 lx with 350-mm distance and by 60% to 141,000 lx with 450-mm distance because of the positioning of the microscope in front of the head form to visualize the surgical field at the sellar region.

CONCLUSIONS

HD endoscopic visualization accounted for significantly more reliable identifications of pituitary gland tissue in comparison with the microscope in the presented setting. The subjective impression of image quality is better with HD endoscopes. The goal of further studies should be to identify if these findings would also result in improved surgical outcome in short-term and long-term follow-up.

Sinonasal outcome after endoscopic mononostril transsphenoidal surgery: A single center cohort study

OBJECTIVE

The endoscopic endonasal approach has been well established for skull base surgery. However, there are only few studies pointing out nasal complaints after surgery. In this study, the authors evaluated postoperative nasal complaints and complications after mononostril endoscopic procedures.

METHODS

All patients operated on parasellar and sellar pathologies at our department via an endoscopic mononostril transnasal transsphenoidal approach from January 2011 to May 2015 were analyzed. To assess specific postoperative nasal pathological conditions and complaints, a questionnaire was established. Applicable data of 79 patients with additional ENT follow-up could be included. Endpoints were the quantitative evaluation of complications and correlation of these data.

RESULTS

There was no vascular injury or worsening of visual function. Two patients had persisting CSF fistula and one of them meningitis. There was a significant decrease of nasal complaints during follow up after 2 years (p < 0.001). Further surgical treatment by ENT physician was necessary in 11.4%. Resurgery significantly increased the risk of postsurgical complaints (p < 0.005). The use of a tamponade significantly reduced the risk of postsurgical reduced nasal airflow (p = 0.026) and sinusitis (p = 0.002).

CONCLUSIONS

Endoscopic endonasal procedures to skull base lesions achieve high radicality with low complication rates. However, they induce temporary and permanent nasal complaints and complications. Thereby, resurgeries increase the risk of nasal complaints and the use of nasal tamponades might increase the sinonasal outcome. Further prospective studies are necessary to objectify the evaluation of postsurgical nasal complications.

The endoscopic surgical resection of intrasellar lesions conserves the hormonal function: a negative correlation to the microsurgical technique

BACKGROUND

The endonasal endoscopic approach is still currently under investigation for sellar tumor surgery: a higher resection rate is to be expected and complications should be minimized. The authors report their surgical results of endonasal endoscopic neurosurgery with special focus on postoperative hypopituitarism in comparison to microsurgical procedures.

METHODS

Sixty patients received endoscopic endonasal transsphenoidal procedures for sellar pathologies. All patients were followed up prospectively. A second group of 60 patients received microsurgical transsphenoidal procedures for sellar pathologies in our neurosurgical department before and were prospectively followed until now. Special attention was paid to hormonal insufficiency and medical substitution.

RESULTS

Sixty-eight percent (41 of 60) of the patients who underwent microsurgical procedures showed a new persisting pituitary insufficiency postoperatively. Twenty-three patients (55.5%) were substituted with thyroxine, hydrocortisone and sexual hormones and one patient (2.5%) also with ADH cause of global pituitary insufficiency. In 19 cases without any hormonal insufficiency after microsurgical procedures nine patients (47%) showed remnant tumor in follow-up MRI. The patients who underwent endoscopic procedures for pituitary adenomas revealed significant (P<0.01) less new persistent hormonal insufficiency with 13% of all cases (8/60). Five patients (62.5%) were substituted with thyroxine and hydrocortisone, two patients (25%) substituted with thyroxine, hydrocortisone and sexual hormones and one patient also with ADH because of global pituitary insufficiency. Thereby, in follow-up MRI and hormonal testing, radical tumor resection was detected in 92% in the endoscopic group.

CONCLUSIONS

This study seems to indicate that a better intraoperative identification and preservation of pituitary gland is possible in endoscopic transsphenoidal surgery with consecutive lower postoperative hypopituitarism rate.

Reaching the sellar region endonasally - One or both nostrils? A pilot study in body donors

INTRODUCTION

The purpose of this study was to evaluate the effect of posterior septectomy size on surgical exposure and surgical freedom during the endoscopic transsphenoidal approach to the sellar and parasellar region.

METHODS

A mononostril and binostril approach to the sellar region was performed on 4 formalin-fixed cadaveric heads. Predefined anatomical structures were identified. Additionally, a millimeter gauge was introduced into the surgical site and the extent of dorsal septectomy was analyzed for both approaches. Surgical freedom was defined as the distance between the ipsilateral and contralateral limit of opening of the sphenoid sinus.

RESULTS

The mean extent of dorsal septectomy was 15.7±5.7mm using a binostril approach to achieve adequate visualization of all relevant anatomical structures. Superior results were obtained via binostril technique with respect to the ability to identify the contralateral internal carotid artery or opticocarotid recessus. No such advantage was found for all other landmarks. Surgical freedom between the ipsilateral and contralateral limit of exposure of the sphenoid sinus was measured with 15±0.8mm in the mononostril and 19.2±0.9mm in the binostril group.

CONCLUSIONS

The surgical exposure increased significantly with progressively larger posterior septectomy in binostril approaches until a 20-mm posterior septectomy. Bilateral lateral opticocarotid recesses were accessible with a mean of 15mm for posterior septectomy. In the mononostril group no dorsal septectomy was necessary. Thus, the nasal mucosa is more preserved by this technique. However, the lateral exposure is partially limited and the use of angled endoscopes is recommended when adopting a mononostril approach to the sellar region.