The evolution of image guidance in transsphenoidal pituitary surgery

Outcomes in Pediatric Transsphenoidal Pituitary Surgery Stratified by the Use of Image Guidance: An Analysis of the Kids' Inpatient Database from 1997 to 2016

Background  To evaluate the utilization of image guidance technology for pediatric transsphenoidal pituitary resection (TSPR) and analyze the complication rates, length of stay (LOS), and total cost for such surgeries as function of time and utilization of image guidance. Methods  The Healthcare Cost and Utilization Project Kids' Inpatient Database (KID) was queried for all cases of TSPR between 1997 and 2016. Factors extracted included patient demographics, use of image guidance, LOS, total cost, and complications, including panhypopituitarism, diabetes insipidus (DI), cerebrospinal fluid (CSF) rhinorrhea, and cranial nerve (CN) III, IV, and VI palsies. Multivariate logistic regression was utilized to determine the odds ratio of developing panhypopituitarism, DI, CSF rhinorrhea, and CN palsies for image-guided versus nonimage-guided cases. A generalized linear model was used to determine the effect of image guidance on inflation-adjusted total cost and LOS. Results  A total of 1,297 cases of TSPR were included in the KID over this time period. The majority were female, Caucasian, and older than 15 years. Utilization of image guidance has rapidly increased since 2006. Complication rates were comparable, but when controlling for other factors, the use of image guidance showed a lower risk of postoperative DI ( p  = 0.05). The use of image guidance also resulted in a shorter LOS by 2.84 days ( p  < 0.001) with no associated increase in total cost ( p  = 0.663). Conclusion  The use of imaging guidance for pediatric TSPR has precipitously increased in recent years, as it is cost-effective, decreases LOS, and may lead to lower complication rates, such as DI.

Transsellar Ultrasound in Pituitary Surgery With a Designated Probe: Early Experiences

BACKGROUND

Anatomic orientation in transsphenoidal surgery can be difficult, and residual tumors are common. A major limitation of both direct microscopy and endoscopic visualization is the inability to see below the surface of the surgical field to confirm the location of vessels, nerves, tumor remnants, and normal pituitary tissue.

OBJECTIVE

To present our initial experience with a new forward-looking, custom-designed ultrasound probe for transsellar imaging.

METHODS

The center frequency of the prototype tightly curved linear array, bayonet-shaped probe is 12 MHz. Twenty-four patients with pituitary adenomas were included after informed consent.

RESULTS

With the use of transsellar ultrasound, we could confirm the location of important neurovascular structures and improve the extent of resection in 4 of 24 cases, as rated subjectively by the operating surgeons. Image quality was good. In 17 patients (71%), biochemical cures and/or complete resections were confirmed at 3 months.

CONCLUSION

We found the images from our custom-designed ultrasound probe to be clinically helpful for anatomic orientation during surgery, and the technology is potentially helpful for improving the extent of resection during transsphenoidal surgery. This quick and flexible form of intraoperative imaging in transsphenoidal surgery could be of great support for surgeons in both routine use and difficult cases. The concept of transsellar intraoperative ultrasound imaging can be further refined and developed.