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Pang JC, Bitner BF, Nottoli MM, Abiri A, Bui AT, Nguyen CH, Hsu TI, Nguyen TV, Hsu FPK, Kuan EC. Tissue Sealant Impact on Skull Base Reconstruction Outcomes: A Systematic Review and Meta-Analysis. Laryngoscope 2024; 134:3425-3436. [PMID: 38470297 DOI: 10.1002/lary.31390] [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] [Received: 10/17/2023] [Revised: 01/29/2024] [Accepted: 02/22/2024] [Indexed: 03/13/2024]
Abstract
OBJECTIVE Despite significant advances in understanding of skull base reconstruction principles, the role of tissue sealants in modifying postoperative cerebrospinal fluid (CSF) leak outcomes remains controversial. We evaluate postoperative CSF leak incidence associated with tissue sealant use in skull base defect repair during endoscopic skull base surgery (ESBS). DATA SOURCES Web of Science, PubMed/MEDLINE, Scopus, and Cochrane Library. REVIEW METHODS Systematic review and meta-analysis of risk differences (RD). A search strategy identified original studies reporting CSF leakage following ESBS with disaggregation by tissue sealant use and/or type. RESULTS 27 non-randomized studies (n = 2,403) were included for qualitative and meta-analysis. Reconstruction with a tissue sealant did not significantly reduce postoperative CSF leak risk compared with reconstruction without sealant (RD[95% CI] = 0.02[-0.01, 0.05]). Sub-analyses of dural sealant (-0.02[-0.11, 0.07]) and fibrin glue (0.00[-0.07, 0.07]) compared with no sealant were similarly unremarkable. Postoperative CSF leakage was not significantly modulated in further sub-analyses of DuraSeal (0.02[-0.02, 0.05]), Adherus (-0.03[-0.08, 0.03]), or Bioglue (-0.06[-0.23, 0.12]) versus no dural sealant use, or Tisseel/Tissucol versus fibrin glue nonuse (0.00[-0.05, 0.05]). No significant association was seen comparing dural sealant use versus fibrin glue use on pairwise (0.01[-0.03, 0.05]) or network meta-analysis (-0.01[-0.05, 0.04]). Limitations in source literature prevented sub-analyses stratified by leak characteristics, defect size and location, and accompanying reconstruction materials. CONCLUSION Tissue sealant use did not appear to impact postoperative CSF leak incidence when compared with nonuse. Higher quality studies are warranted to thoroughly elucidate the clinical value of adjunct sealant use in endoscopic skull base reconstruction. LEVEL OF EVIDENCE N/A Laryngoscope, 134:3425-3436, 2024.
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Affiliation(s)
- Jonathan C Pang
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Benjamin F Bitner
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Madeline M Nottoli
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Arash Abiri
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Anh-Tram Bui
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Cecilia H Nguyen
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Timothy I Hsu
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Theodore V Nguyen
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Frank P K Hsu
- Department of Neurological Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
- Department of Neurological Surgery, University of California, Irvine, Orange, California, U.S.A
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Gu J, Chen X, Cheng X, Zou Y, Deng Z, Li D, Zhou Z, Jiang X. Headache alleviation with nasal irrigation following endoscopic endonasal surgery for pituitary adenomas. BMC Endocr Disord 2024; 24:45. [PMID: 38622616 PMCID: PMC11017480 DOI: 10.1186/s12902-024-01573-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 03/28/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND Headache is a common occurrence after endoscopic endonasal surgery (EES) for pituitary adenomas and significantly impacts the quality of life of patients. This study aims to investigate the effectiveness of nasal irrigation in relieving postoperative headache after EES. METHODS A retrospective analysis was conducted on a cohort of 101 patients (Cohort I) who underwent EES for pituitary adenomas to explore the risk factors associated with postoperative headache. Another cohort of 72 patients (Cohort II) who received adjuvant nasal irrigation following surgery was enrolled for further analysis. The Headache Impact Test (HIT-6) was used to score the severity of headache, and patients with a HIT score > 55 were classified as having headache. RESULTS In Cohort I, 21.78% of patients experienced headache one month after EES, which decreased to 5.94% at the three-month follow-up. Multivariate analysis revealed that postoperative nasal sinusitis (OR = 3.88, 95%CI 1.16-13.03, p = 0.028) and Hardy's grade C-D (OR = 10.53, 95%CI 1.02-109.19, p = 0.049) independently predicted the presence of postoperative headache at one month. At the three-month follow-up, patients with sinusitis had higher HIT-6 scores compared to those without sinusitis (44.43 ± 9.78 vs. 39.72 ± 5.25, p = 0.017). In Cohort II, the incidence of sinusitis at three months was significantly lower than that in Cohort I (p = 0.028). Importantly, both the incidence of headache and HIT-6 scores in Cohort II were significantly lower than those in Cohort I at the one- and three-month follow-ups. CONCLUSIONS Postoperative sinusitis is an independent risk factor for the development of headache following EES for pituitary adenomas. Prophylactic nasal irrigation helps relieve postoperative headache, possibly by preventing the occurrence of sinusitis.
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Affiliation(s)
- Jiayu Gu
- Department of Neurosurgery/Neuro-Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Xiaoqun Chen
- Department of Neurosurgery/Neuro-Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Xiaoman Cheng
- Department of Neurosurgery/Neuro-Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Yunzhi Zou
- Department of Neurosurgery/Neuro-Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Zekun Deng
- Department of Neurosurgery/Neuro-Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Depei Li
- Department of Neurosurgery/Neuro-Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Zhihuan Zhou
- Department of Neurosurgery/Neuro-Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.
| | - Xiaobing Jiang
- Department of Neurosurgery/Neuro-Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.
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Jolly K, Gupta KK, Egbuji O, Naik PP, Ahmed SK. Endoscopic transsphenoidal surgery reconstruction using the fibrin sealant patch Tachosil ®. Br J Neurosurg 2024; 38:498-502. [PMID: 33769186 DOI: 10.1080/02688697.2021.1905771] [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] [Received: 11/29/2020] [Revised: 03/25/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The incidence of CSF leak following endoscopic transsphenoidal surgery remains the most important measure in the success of any repair. The nasoseptal flap (NSF) has played a pivotal role in reconstructing defects. However, morbidity associated with the NSF includes bleeding, septal injury, altered smell and crusting. Tachosil® is an absorbable fibrin sealant patch that promotes haemostasis and wound healing. The purpose of this study was to evaluate the effectiveness of Tachosil® to repair intraoperative defects during an endoscopic transsphenoidal approach. MATERIALS AND METHODS All patients who underwent an endoscopic transsphenoidal approach with the use of Tachosil® at the Queen Elizabeth Hospital Birmingham, between January 2013 and June 2020 were retrospectively analysed. Tachosil® was used as an overlay patch over of the bony defect, in a multi-layered repair depending on the defect and grade of CSF leak. The primary outcome measure was post-operative CSF leak. RESULTS A total of 52 primary procedures where Tachosil® was used as the overlay were analysed. There were 23 (44.2%) intraoperative CSF leaks. The overall post-operative CSF leak rate was 7.8% (n = 4), with all cases having had a Tachosil® overlay reconstruction with no NSF. A formal NSF was harvested in only five cases alongside the Tachosil® patch, where a grade 2 or more leak was identified at the time of the primary procedure, none of which developed a post-operative leak. No patient had any post-operative adverse outcomes that were attributed to Tachosil®. CONCLUSIONS We believe this to be the largest case series evaluating the endoscopic use of Tachosil® in skull base reconstruction. Our data show that in endoscopic transsphenoidal approach, Tachosil® may be used safely in a multi-layered approach as an effective alternative to the NSF in low flow CSF leak cases, or alongside a NSF in higher flow leaks.
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Affiliation(s)
- Karan Jolly
- Department of Otolaryngology, New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Keshav Kumar Gupta
- Department of Otolaryngology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ofuchi Egbuji
- Department of Otolaryngology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paresh Pramod Naik
- Department of Otolaryngology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Shahzada Khuram Ahmed
- Department of Otolaryngology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Park J, Golub D, White TG, Ruelle M, Quach ET, Yang K, Shah HA, Fastenberg JH, Eisenberg MB, Dehdashti AR. Anterior-posterior diameter is a key driver of resectability and complications for pituitary adenomas with suprasellar extension in endoscopic transsphenoidal surgery. Pituitary 2023; 26:629-641. [PMID: 37713155 DOI: 10.1007/s11102-023-01354-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND As endoscopic transsphenoidal approaches are more routinely selected for progressively larger pituitary adenomas with parasellar extension, understanding potential anatomical factors that limit resection and contribute to complications is becoming increasingly important for tailoring a surgical approach. This study aimed to reevaluate existing predictive tools for resectability in pituitary adenomas specifically with suprasellar extension, and furthermore identify any additional measurable features that may be more useful in preoperative planning. METHODS A single-center retrospective chart review of adult patients who underwent endoscopic transsphenoidal surgery for pituitary adenomas with suprasellar extension from 2015 to 2020 was performed. Preoperative MRIs were systematically assessed to assign a Knosp classification, a Zurich Pituitary Score (ZPS), and for dimensional measurements of the suprasellar aspect of the lesions. Univariate comparisons and multivariate regression models were employed to assess the influence of these factors on extent of resection and postoperative complications. RESULTS Of the 96 patients with suprasellar pituitary adenomas who underwent endoscopic transsphenoidal surgery, 74 patients (77%) had a gross total resection (GTR). Neither Knosp grade nor ZPS score, even when dichotomized, demonstrated an association with GTR (Knosp 3A-4 versus Knosp 0-2, p = 0.069; ZPS III-IV versus ZPS I-II, p = 0.079). Multivariate regression analysis identified suprasellar anterior-posterior tumor diameter (SSAP) as the only significant predictor of extent of resection in this cohort (OR 0.951, 95% CI 0.905-1.000, p = 0.048*). A higher SSAP also had the strongest association with intraoperative CSF leaks (p = 0.0012*) and an increased overall rate of postoperative complications (p = 0.002*). Further analysis of the regression model for GTR suggested an optimal cut point value for SSAP of 23.7 mm, above which predictability for failing to achieve GTR carried a sensitivity of 89% and a specificity of 41%. CONCLUSIONS This study is unique in its examination of endoscopic transsphenoidal surgical outcomes for pituitary adenomas with suprasellar extension. Our findings suggest that previously established grading systems based on lateral extension into the cavernous sinus lose their predictive value in lesions with suprasellar extension and, more specifically, with increasing suprasellar anterior-posterior diameter.
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Affiliation(s)
- Jung Park
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Danielle Golub
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA.
| | - Timothy G White
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Marianne Ruelle
- Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY, USA
| | - Eric T Quach
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Kaiyun Yang
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Harshal A Shah
- Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY, USA
| | - Judd H Fastenberg
- Department of Otolaryngology-Head and Neck Surgery, Northwell Health, Manhasset, NY, USA
| | - Mark B Eisenberg
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
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Gstrein NA, Zwicky S, Serra C, Hugelshofer M, Regli L, Soyka MB, Holzmann D, Meerwein CM. Rhinologic outcome of endoscopic transnasal-transsphenoidal pituitary surgery: an institutional series, systematic review, and meta-analysis. Eur Arch Otorhinolaryngol 2023; 280:4091-4099. [PMID: 36988686 PMCID: PMC10382340 DOI: 10.1007/s00405-023-07934-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 03/17/2023] [Indexed: 03/30/2023]
Abstract
PURPOSE We aimed to summarize the available data on the objective rhinologic outcome after endoscopic transnasal-transsphenoidal (ETT) surgery. METHODS Retrospective study on a consecutive cohort of treatment-naïve patients undergoing ETT pituitary gland surgery. Additionally, a systematic review and meta-analysis with focus on the rhinologic outcome, including postoperative smell function was performed. RESULTS The institutional series incorporated 168 patients. A concomitant endoscopic septoplasty was performed in 29/168 patients (17.3%). A nasoseptal flap was used for reconstruction of large skull-base defects or high-flow CSF leaks in 4/168 (2.4%) patients. Early postoperative rhinologic complications (< 4 weeks) included epistaxis (3%), acute rhinosinusitis (1.2%) and late postoperative complications (≥ 8 weeks) comprised prolonged crusting (15.6%), symptomatic synechiae (11.9%) and septal perforation (0.6%). Postoperative smell function was not impaired (Fisher's exact test, p = 1.0). The systematic review included 19 studies on 1533 patients with a median postoperative epistaxis rate of 1.4% (IQR 1.0-2.2), a postoperative acute rhinosinusitis rate of 2.3% (IQR 2.1-3.0), a postoperative synechiae rate of 7.5% (IQR 1.8-19.1) and a postoperative septal perforation rate of 2.2% (IQR 0.5-5.4). Seven studies including a total of 206 patients reported adequate outcome measures for smell function before and after ETT surgery. Only 2/7 studies reported an impairment of smell function postoperatively, especially in patients with nasoseptal flap harvesting. CONCLUSION Early and late postoperative rhinologic complication rates after ETT surgery for pituitary lesions seem to be low. A thorough evaluation of smell function, in particular in patients at risk for nasoseptal flap harvesting, may be an important factor in optimal postoperative care.
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Affiliation(s)
- Nathalie A Gstrein
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 24, 8091, Zurich, Switzerland
| | - Sebastian Zwicky
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 24, 8091, Zurich, Switzerland
| | - Carlo Serra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Michael Hugelshofer
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Michael B Soyka
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 24, 8091, Zurich, Switzerland
| | - David Holzmann
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 24, 8091, Zurich, Switzerland
| | - Christian M Meerwein
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 24, 8091, Zurich, Switzerland.
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Chang H, Zhao K, Qiu J, Ji XJ, Chen WG, Li BY, Lv C, Xiong ZC, Chen SB, Shu XJ. Prediction of intraoperative cerebrospinal fluid leaks in endoscopic endonasal transsphenoidal pituitary surgery based on a deep neural network model trained with MRI images: a pilot study. Front Neurosci 2023; 17:1203698. [PMID: 37575298 PMCID: PMC10413098 DOI: 10.3389/fnins.2023.1203698] [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: 04/11/2023] [Accepted: 07/13/2023] [Indexed: 08/15/2023] Open
Abstract
Objective This study aimed to investigate the reliability of a deep neural network (DNN) model trained only on contrast-enhanced T1 (T1CE) images for predicting intraoperative cerebrospinal fluid (ioCSF) leaks in endoscopic transsphenoidal surgery (EETS). Methods 396 pituitary adenoma (PA) cases were reviewed, only primary PAs with Hardy suprasellar Stages A, B, and C were included in this study. The T1CE images of these patients were collected, and sagittal and coronal T1CE slices were selected for training the DNN model. The model performance was evaluated and tested, and its interpretability was explored. Results A total of 102 PA cases were enrolled in this study, 51 from the ioCSF leakage group, and 51 from the non-ioCSF leakage group. 306 sagittal and 306 coronal T1CE slices were collected as the original dataset, and data augmentation was applied before model training and testing. In the test dataset, the DNN model provided a single-slice prediction accuracy of 97.29%, a sensitivity of 98.25%, and a specificity of 96.35%. In clinical test, the accuracy of the DNN model in predicting ioCSF leaks in patients reached 84.6%. The feature maps of the model were visualized and the regions of interest for prediction were the tumor roof and suprasellar region. Conclusion In this study, the DNN model could predict ioCSF leaks based on preoperative T1CE images, especially in PAs in Hardy Stages A, B, and C. The region of interest in the model prediction-making process is similar to that of humans. DNN models trained with preoperative MRI images may provide a novel tool for predicting ioCSF leak risk for PA patients.
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Affiliation(s)
- Hui Chang
- School of Computer and Information Engineering and Henan Engineering Research Center of Intelligent Technology and Application, Henan University, Kaifeng, Henan Province, China
| | - Kai Zhao
- The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jun Qiu
- Department of Critical Care Medicine, The Second People’s Hospital of Yibin, Yibin, Sichuan Province, China
| | - Xiang-Jun Ji
- Department of Neurosurgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Wu-Gang Chen
- School of Computer and Information Engineering and Henan Engineering Research Center of Intelligent Technology and Application, Henan University, Kaifeng, Henan Province, China
| | - Bo-Yuan Li
- School of Computer and Information Engineering and Henan Engineering Research Center of Intelligent Technology and Application, Henan University, Kaifeng, Henan Province, China
| | - Cheng Lv
- School of Mathematics and Computer Sciences, Nanchang University, Nanchang, Jiangxi Province, China
| | - Zi-Cheng Xiong
- School of Computer and Information Engineering and Henan Engineering Research Center of Intelligent Technology and Application, Henan University, Kaifeng, Henan Province, China
| | - Sheng-Bo Chen
- School of Computer and Information Engineering and Henan Engineering Research Center of Intelligent Technology and Application, Henan University, Kaifeng, Henan Province, China
| | - Xu-Jun Shu
- Department of Neurosurgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
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Loeschner D, Enciu A, Kellner G, Meyer A, Wallaschofski H, McLean ACL, Gerlach R. Two- and three-dimensional endoscopic endonasal surgery of large and giant pituitary adenomas-outcome analysis of a series of 62 patients from a single pituitary center. Neurosurg Rev 2023; 46:150. [PMID: 37358696 DOI: 10.1007/s10143-023-02050-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 06/08/2023] [Accepted: 06/10/2023] [Indexed: 06/27/2023]
Abstract
To analyze the perioperative course and clinical outcome of patients with large (lPA) and giant (gPA) pituitary adenoma who underwent endoscopic endonasal transsphenoidal surgery (EETS) using either two-dimensional (2D-E) or three-dimensional (3D-E) endoscopic systems. Single-center retrospective study of consecutive patients with lPA and gPA who underwent EETS between November 2008 and January 2023. LPA were defined as ≥ 3 cm and < 4 cm in diameter in at least one dimension and a volume of ≥ 10ccm; gPA were defined as larger than 4 cm in diameter and with a greater volume than 10ccm. Patient data (age, sex, endocrinological and ophthalmological status) and tumor data (histology, tumor volume, size, shape, cavernous sinus invasion according to the Knosp classification) were analyzed. 62 patients underwent EETS. 43 patients were treated for lPA (69.4%) and 19 patients for gPA (30.6%). 46 patients (74.2%) underwent surgical resection using 3D-E and 16 patients 2D endoscopy (25.8%). Statistical results are referred to the comparison between 3D-E and 2D-E. Patients' age ranged from 23-88 years (median 57), 16 patients were female (25.8%), 46 male (74.2%). Complete tumor resection was possible in 43.5% (27/62), partial resection in 56.5% (35/62). Resection rates did not differ between 3D-E (27 patients [43.5%]) and 2D-E (7 patients [43.8%], (p = 0.985). Visual acuity improved in 30 of 46 patients with preoperative deficit (65.2%). In the 3D-E group 21 of 32 patients (65.7%) improved, compared to 9 of 14 patients in the 2D-E group (64.3%). Improvement of visual field was achieved in 31 of 50 patients (62.0%; 22 of 37 patients in the 3D-E group [59.4%] and 9 of 13 patients in the 2D-E group [69.2%]). CSF leak was the most frequent complication and occurred in 9 patients (14.5%, [8 patients 17.4% 3D-E]) without statistical significance. Other surgical complications like postoperative bleeding, infection (meningitis) and deterioration of visual acuity and field were detected without statistical difference. New pituitary anterior lobe dysfunction was observed in 30 of 62 patients (48.4%, 8 patients [50.0%] in the 2D-E group and 22 patients [47.8%] in the 3D-E group). A transient deficit of posterior lobe was detected in 22.6% (14/62). No patient died within 30 days of surgery. Although 3D-E may improve surgical dexterity, in this series of lPA and gPA it was not associated with higher resection rates compared to 2D-E. However, 3D-E visualization during resection of large and giant PA is safe and feasible and patient's clinical outcome is not different compared to 2D-E.
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Affiliation(s)
- Denise Loeschner
- Department of Neurosurgery, Helios Klinikum Erfurt, Nordhaeuser Str. 74, 99089, Erfurt, Germany
| | - Andrei Enciu
- Department of Neurosurgery, Helios Klinikum Erfurt, Nordhaeuser Str. 74, 99089, Erfurt, Germany
| | - Geralf Kellner
- Department of ENT surgery, Helios Klinikum Erfurt, Nordhaueser Str. 74, 99089, Erfurt, Germany
| | - Almuth Meyer
- Department of Medicine, Helios Klinikum Erfurt, Nordhaeuser Str. 74, 99089, Erfurt, Germany
| | | | | | - Ruediger Gerlach
- Department of Neurosurgery, Helios Klinikum Erfurt, Nordhaeuser Str. 74, 99089, Erfurt, Germany.
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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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9
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Cong Z, Zhu J, Sun H, Tang C, Yang J, Ma C. Endoscopic 1½-transseptal approach for pituitary surgery. Front Oncol 2023; 12:1116408. [PMID: 36713529 PMCID: PMC9877324 DOI: 10.3389/fonc.2022.1116408] [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: 12/05/2022] [Accepted: 12/28/2022] [Indexed: 01/14/2023] Open
Abstract
Background We previously introduced the one-and-a-half (1½) nostril endoscopic transsphenoidal approach (OETA) to reduce the damage to the nasal structures. Here, we reported the modified approach which is called the endoscopic 1½-transseptal approach (EOTA) for pituitary surgery by combining the OETA and the microscopic transseptal approach to simplify intranasal procedures and protect nasal mucosa. In EOTA, we removed the sellar lesions in a corridor that is composed of the right submucosal space and the anterior left ½ nasal cavity. Methods We introduced EOTA with a detailed technical description and preliminary clinical outcomes. A total of 128 patients who underwent EOTA for pituitary surgery from July 2018 to September 2020 were reviewed for evaluation of the safety and efficacy of this approach. Results EOTA had a high gross total resection (GTR) rate and a 1ow complication rate. GTR was achieved in 106 (82.8%) patients, with 81.4% for pituitary adenomas and 93.3% for other non-adenomatous lesions. Post-operative complications included 3 patients (2.3%) with postoperative cerebrospinal fluid leak, 3 patients (2.3%) with diabetes insipidus, 5 patients (3.9%) with anterior pituitary insufficiency and 2 patients (1.6%) with meningitis. In addition, EOTA simplified the intranasal procedures, which led to shortened operation time (67.8 minutes). The results of ASK nasal-12, the Lund-Kennedy score, and the odor identification test showed that patients who underwent EOTA recovered quickly after surgery and the nasal cavity returned to the preoperative condition both apparently and physiologically one month after surgery. Conclusions EOTA is a simple, safe and effective approach for pituitary lesions, which provides not only a sufficient surgical corridor for 2-surgeon/4- or 3-hands technique but also minimally invasive access to the sellar region.
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Affiliation(s)
- Zixiang Cong
- Department of Neurosurgery, Affiliated Jinling Hospital, Medicine School of Nanjing University, Nanjing, Jiangsu, China
| | - Junhao Zhu
- Department of Neurosurgery, Affiliated Jinling Hospital, Medicine School of Nanjing University, Nanjing, Jiangsu, China
| | - Huaiyu Sun
- Department of Neurosurgery, Tiemei General Hospital of Liaoning Province Healthy Industrial Group, Tieling, Liaoning, China
| | - Chao Tang
- Department of Neurosurgery, Affiliated Jinling Hospital, Medicine School of Nanjing University, Nanjing, Jiangsu, China
| | - Jin Yang
- Department of Neurosurgery, Affiliated Jinling Hospital, Medicine School of Nanjing University, Nanjing, Jiangsu, China
| | - Chiyuan Ma
- Department of Neurosurgery, Affiliated Jinling Hospital, Medicine School of Nanjing University, Nanjing, Jiangsu, China,*Correspondence: Chiyuan Ma,
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10
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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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11
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Charleux T, Vendrely V, Huchet A, Trouette R, Ferrière A, Tabarin A, Jecko V, Loiseau H, Dupin C. Management after initial surgery of nonfunctioning pituitary adenoma: surveillance, radiotherapy or surgery? Radiat Oncol 2022; 17:165. [PMID: 36229880 PMCID: PMC9559766 DOI: 10.1186/s13014-022-02133-z] [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: 05/29/2022] [Accepted: 09/22/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction The first line of treatment for nonfunctioning pituitary adenoma (NFPA) is surgery. Adjuvant radiotherapy or surveillance and new treatment (second surgical operation or salvage radiotherapy) in case of recurrence are options discussed at the multidisciplinary tumor board. The purpose of this study was to evaluate the therapeutic outcome for each option. Methods The records of 256 patients followed with NFPA between 2007 and 2018 were retrospectively reviewed. Mean age at initial surgery was 55 years [18–86]. Post-operative MRI found a residual tumor in 87% of patients. Mean follow-up was 12.1 years [0.8–42.7]. Results After initial surgery, 40 patients had adjuvant radiotherapy. At 5, 10 and 15 years progression-free survival (PFS) was significantly different after surgery alone (77%, 58% and 40%) compared to surgery and adjuvant radiotherapy (84%, 78% and 78%) (HR = 0.24 [0–0.53] p < 0.0005). Overall, after first, second or third surgical operation, 69 patients had adjuvant radiotherapy and 41 salvage radiotherapy. Five-year PFS was similar for adjuvant (90%) and salvage radiotherapy (97%) (p = 0.62). After a second surgical operation, 62% and 71% of patients were irradiated after 2 and 5 years respectively. The risk of corticotropic and thyrotropic deficiency rates were 38% and 59% after second or third surgical operation and 40% and 73% after radiotherapy. Brain tumors occurred in 4 patients: 1 meningioma present at initial surgery, and after radiotherapy, 1 neurinoma which appeared at 5 years, 1 glioblastoma at 13 years and 1 meningioma at 20 years. Conclusion Among patients treated by surgery for NFPA, a “wait-and-see” attitude should be an option since adjuvant radiotherapy is not superior to salvage radiotherapy. However, in case of recurrence or progression, the authors recommended delivery of salvage radiotherapy to avoid a second surgical operation. Supplementary Information The online version contains supplementary material available at 10.1186/s13014-022-02133-z.
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Affiliation(s)
- Thomas Charleux
- Radiotherapy Department, CHU Bordeaux, 33000, Bordeaux, France
| | - Véronique Vendrely
- Radiotherapy Department, CHU Bordeaux, 33000, Bordeaux, France.,BRIC (BoRdeaux Institute of onCology), UMR1312, INSERM, University of Bordeaux, 33000, Bordeaux, France
| | - Aymeri Huchet
- Radiotherapy Department, CHU Bordeaux, 33000, Bordeaux, France
| | - Renaud Trouette
- Radiotherapy Department, CHU Bordeaux, 33000, Bordeaux, France
| | | | - Antoine Tabarin
- Endocrinology Department, CHU Bordeaux, 33000, Bordeaux, France
| | - Vincent Jecko
- Neurosurgery Department, CHU Bordeaux, 33000, Bordeaux, France
| | - Hugues Loiseau
- Neurosurgery Department, CHU Bordeaux, 33000, Bordeaux, France
| | - Charles Dupin
- Radiotherapy Department, CHU Bordeaux, 33000, Bordeaux, France. .,BRIC (BoRdeaux Institute of onCology), UMR1312, INSERM, University of Bordeaux, 33000, Bordeaux, France.
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12
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Li B, Zhao S, Fang Q, Nie D, Cheng J, Zhu H, Li C, Gui S, Zhang Y, Zhao P. Risk factors and management associated with postoperative cerebrospinal fluid leak after endoscopic endonasal surgery for pituitary adenoma. Front Surg 2022; 9:973834. [PMID: 36157406 PMCID: PMC9489931 DOI: 10.3389/fsurg.2022.973834] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/22/2022] [Indexed: 11/20/2022] Open
Abstract
Objective To determine risk factors and management for the development of a postoperative cerebrospinal fluid (CSF) leak after an endoscopic endonasal surgery (EES) for pituitary adenomas. Methods The clinical data of 400 patients who underwent EES for resection of pituitary adenomas from December 2018 to November 2019 in the Department of Neurosurgery of Beijing Tiantan Hospital were retrospectively reviewed. Age, gender, body mass index (BMI), tumor size, Knosp grade, suprasellar extension grade, sellar floor erosion grade, repeated transsphenoidal surgery, intraoperative CSF leak, use of pedicled nasoseptal flap and lumbar drain were collected and analyzed. Results Postoperative CSF leak occurred in 14 of 400 patients (3.5%). Age, gender, BMI, tumor size, Knosp grade and repeated transsphenoidal surgery were not risk factors for CSF leak. Suprasellar extension grade (≥B 6.0% vs. <B 1.4%; p = 0.024), sellar floor erosion grade (≥III 5.7% vs. <III 0.6%; p = 0.020) and intraoperative CSF leak (Yes 7.5% vs. No 2.0%; p = 0.009) were factors associated with an increased postoperative CSF leak rate. Conclusions Higher suprasellar extension grade, higher sellar floor erosion grade and intraoperative CSF leak were risk factors for postoperative CSF leak after endoscopic treatment of pituitary adenoma. Strict skull base reconstruction including use of a pedicled nasoseptal flap and perioperative lumbar drainage may avoid postoperative CSF leak.
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Affiliation(s)
- Bin Li
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Sida Zhao
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Qiuyue Fang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Ding Nie
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Jianhua Cheng
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Haibo Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chuzhong Li
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Songbai Gui
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yazhuo Zhang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Correspondence: Yazhuo zhang Peng Zhao
| | - Peng Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Correspondence: Yazhuo zhang Peng Zhao
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13
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Boetto J, Joitescu I, Raingeard I, Ng S, Le Corre M, Lonjon N, Crampette L, Favier V. Endoscopic transsphenoidal surgery for non-functioning pituitary adenoma: Learning curve and surgical results in a prospective series during initial experience. Front Surg 2022; 9:959440. [PMID: 35983556 PMCID: PMC9379140 DOI: 10.3389/fsurg.2022.959440] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background To report the initial experience of surgery for non-functioning pituitary adenoma (NFPA) from a neurosurgeon in a dedicated residency training endoscopic transsphenoidal (ETS) program, and detail the surgical and clinical outcomes during this period. Methods A prospective series of all patients operated for NFPA, using an ETS approach, during the three first years of experience of a newly board-certified neurosurgeon was analysed. Clinical, radiological and peri-operative data were collected. Extent of resection (EOR) was determined by formal volumetric analysis. Impact of the learning curve and predictive factors of gross total resection (GTR) were determined. Results Fifty-three patients with NFPA were included in this prospective cohort which was divided in two periods of time (“First period”: 30 first cases, and “second period”: 23 following cases). Baseline characteristics of the patients in the two periods were similar. Overall occurrence of complication was 22% and was not significantly different in the two periods of time. No patient had severe neurological complication. Gross total resection was achieved in 70% of patients. Mean Extent of resection was 96%. In a multiple linear regression model, a higher EOR was positively correlated with experience (p = 0.018) and negatively correlated with Knosp Score equal to 4 (p < 0.001). Predictive factors for GTR were Higher Knosp grade (p = 0,01), higher pre-operative volume (p = 0.03), and second period of time (p = 0.01). Conclusion NFPA surgery can be safe and efficient during the learning period. Dedicated intensive learning, careful patient selection and multidisciplinary work are key to shorten the learning curve and achieve satisfactory results.
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Affiliation(s)
- Julien Boetto
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- IGF, Université de Montpellier, CNRS, INSERM, Montpellier, France
- Correspondence: Julien Boetto
| | - Irina Joitescu
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Isabelle Raingeard
- Department of Endocrinology, Lapeyronie Hospital, Montpellier University Medical Center, Montpellier, France
| | - Sam Ng
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- IGF, Université de Montpellier, CNRS, INSERM, Montpellier, France
| | - Marine Le Corre
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Nicolas Lonjon
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Louis Crampette
- Department of ENT Surgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Valentin Favier
- Department of ENT Surgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
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14
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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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15
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Carnevale JA, Babu CS, Goldberg JL, Fong R, Schwartz TH. Visual deterioration after endonasal endoscopic skull base surgery: causes, treatments, and outcomes. J Neurosurg 2022; 136:1103-1113. [PMID: 34598134 DOI: 10.3171/2021.3.jns204378] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/23/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Visual deterioration after endoscopic endonasal transsphenoidal surgery (EETS) for sellar and parasellar masses is a rare but serious complication caused by either compressive or ischemic mechanisms. Timely diagnosis and intervention may restore vision if instituted appropriately. The associated risk factors and their relation to the success of intervention are not well understood. METHODS The authors examined a series of 1200 consecutive EETS cases performed by the senior author at Weill Cornell/NewYork-Presbyterian Hospital from 2010 to 2020. Cases with postoperative visual deterioration were identified. Pre- and postoperative clinical data, mechanism of visual decline, latency to intervention, and long-term visual outcome were retrospectively collected and analyzed with appropriate statistical methods. RESULTS Twenty-one patients (1.75%) complained of early postoperative visual deterioration. The most common pathology associated with postoperative visual loss was craniopharyngioma (7.69%), followed by meningioma (5.43%) and then pituitary adenoma (1.94%). Timely intervention restored vision in 81% of patients for a 0.33% rate of permanent visual deterioration. Average time to visual deterioration was 28.8 hours, and over 70% of patients experienced vision loss within the first 13 hours. Compressive etiology (n = 11), consisting of either hematoma (n = 8) or graft displacement (n = 3), occurred 7.3 hours and 70.3 hours after surgery, respectively, and was more common in adenomas. Acute postoperative visual deterioration was more common in firm closures (4.78%) compared with soft closures (1.03%; p = 0.0006). Ischemic etiology (n = 10) occurred 10.3 hours after surgery and was more common with craniopharyngiomas and meningiomas (p = 0.08). Sixteen patients (76.2%) underwent early reoperation to explore and decompress the optic apparatus. Vision was restored to baseline after reoperation in all 11 compressive cases, whereas 6/10 ischemic cases improved with supplemental oxygen and hypervolemic hypertensive therapy (p = 0.02). Fluid expansion from 8 to 16 hours (p = 0.034) and systolic blood pressure elevation from 32 to 48 hours (p = 0.05) after surgery were significantly higher in those ischemic patients who recovered some vision compared with those with persistent visual deficits. CONCLUSIONS Visual deterioration after EETS is a rare event but can be effectively treated if acted upon appropriately and in a timely fashion. Compressive etiology is reversible with early reoperation. Ischemic etiology can be successfully treated in roughly half of cases with supplemental oxygen and hypertensive hypervolemic therapy but may result in permanent visual deterioration if not instituted appropriately or if delayed with unnecessary exploratory surgery.
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Affiliation(s)
| | | | | | | | - Theodore H Schwartz
- Departments of1Neurological Surgery
- 3Neuroscience, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York
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16
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Complications in Endoscopic Pituitary Surgery. Otolaryngol Clin North Am 2022; 55:431-448. [DOI: 10.1016/j.otc.2021.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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17
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d'Artigues J, Graillon T, Boissonneau S, Farah K, Amodru V, Brue T, Fuentes S, Dufour H. Fully endoscopic endonasal approach for the treatment of intrasellar arachnoid cysts. Pituitary 2022; 25:191-200. [PMID: 34609694 DOI: 10.1007/s11102-021-01187-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To report our experience of endoscopic endonasal obliteration of symptomatic sellar arachnoid cyst (SAC). METHODS From 2002 to 2019, we retrospectively reported the data of 17 cases of SAC operated in Timone University Hospital, Marseille, France. Preoperative clinical findings were collected including main symptoms, visual function and endocrinological assessment. Surgical procedure was homogeneous and consisted in endonasal fully endoscopic surgical obliteration of the cyst cavity with fat graft. Post-operative outcomes, complication and follow-up was reported. RESULTS Visual disorders and/or headaches were the main symptoms. Our technique provided improvement for 83.3% of the patients suffering from visual disturbance and for 87.5% of those suffering from headaches. We reported 2 cases of cerebrospinal fluid (CSF) leakage (11.8%), but no meningitis. One case of definitive diabetes insipidus occurred and one case of postoperative syndrome of inappropriate antidiuretic hormone secretion was temporary. There was one case of recurrence reported. The mean follow-up was 39 months. CONCLUSION Patients with symptomatic SAC can be treated successfully by endoscopic endonasal obliteration of the cyst. This simple technique offers true benefits for the patients without craniotomy, but the complication rate remains high especially with the risk of CSF leakage. Special attention to skull base opening and closing could reduce this risk.
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Affiliation(s)
- Jean d'Artigues
- Department of Neurosurgery, Hôpital de La Timone, Marseille, France.
| | - Thomas Graillon
- Department of Neurosurgery, Hôpital de La Timone, Marseille, France
| | | | - Kaissar Farah
- Department of Neurosurgery, Hôpital de La Timone, Marseille, France
| | - Vincent Amodru
- Department of Endocrinology, Hôpital de La Conception, Marseille, France
| | - Thierry Brue
- Department of Endocrinology, Hôpital de La Conception, Marseille, France
| | - Stéphane Fuentes
- Department of Neurosurgery, Hôpital de La Timone, Marseille, France
| | - Henry Dufour
- Department of Neurosurgery, Hôpital de La Timone, Marseille, France
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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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Guan X, Wang Y, Zhang C, Ma S, Zhou W, Jia G, Jia W. Surgical Experience of Transcranial Approaches to Large-to-Giant Pituitary Adenomas in Knosp Grade 4. Front Endocrinol (Lausanne) 2022; 13:857314. [PMID: 35634502 PMCID: PMC9133328 DOI: 10.3389/fendo.2022.857314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/04/2022] [Indexed: 11/15/2022] Open
Abstract
Pituitary adenomas in Knosp grade 4 are difficult to resect completely and are generally involved in poor prognosis, because of the close relationship between the tumor and internal carotid. In this study, the authors retrospectively reviewed the outcome of different transcranial approaches in the management of large-to-giant pituitary adenomas in Knosp grade 4. A total of 42 patients with large-to-giant pituitary adenomas in Knosp grade 4, who underwent craniotomy in the Pituitary Disease Subdivision, Department of Neurosurgery, Beijing Tiantan Hospital, between March 2012 and March 2015 were included in this study. Clinical characteristics, surgical methods, complications, and outcomes were evaluated. The median age was 45 years (range, 19-73 years old), and 42.9% of the enrolled cases were men. The mean tumor diameter was 43.6 mm, and the mean volume was 30.9 cm3. 26 patients underwent the frontolateral approach, while 16 cases accepted the frontotemporal approach. Gross total resection was achieved in 11 patients (26.2%), near total in 26 (61.9%), and subtotal in 5 (11.9%). The adenomas were larger, and the distance of the tumor extending to the lateral skull base was also further in the frontotemporal approach cases. The surgical time was shorter, and the bleeding volume was less in the frontolateral approach cases. Subsellar extension was associated with incomplete resection in pituitary macroadenomas of Knosp grade 4. The craniotomy is still an effective treatment for pituitary macroadenomas in Knosp grade 4.
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Affiliation(s)
- Xiudong Guan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yangyang Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chengkai Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | | | - Wenjianlong Zhou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guijun Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wang Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing, China
- *Correspondence: Wang Jia,
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20
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Sharipov OI, Ershova ON, Kurdyumova NV, Kalinin PL. [Nosocomial meningitis in endoscopic transsphenoidal surgery]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:89-95. [PMID: 35942842 DOI: 10.17116/neiro20228604189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
One of the main problems of transsphenoidal surgery is the risk of infectious complications. Nosocomial meningitis (NCM) can lead to increased length of hospital stay and financial costs, poor treatment outcomes and even mortality. This complication is an indicator of the quality of medical care for patients with neurosurgical diseases. The purpose of the review was to study the main risk factors of NCM, modern schemes for antibiotic prophylaxis and treatment of this complication after endoscopic transsphenoidal surgery. The main risk factors of meningitis are intra- and postoperative CSF leakage, overweight, diabetes mellitus, previous transsphenoidal surgeries and radiotherapy. To date, there are no generally accepted periods for antibiotic prophylaxis in nasal CSF leakage, installed external ventricular / lumbar drains or tampons in nasal cavity. Antibiotic prophylaxis should not exceed 3 postoperative days due to the risk of cultivating the drug-resistant organisms. If NCM is detected, treatment should be initiated immediately with a broad spectrum of antibiotics.
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Affiliation(s)
| | - O N Ershova
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - P L Kalinin
- Burdenko Neurosurgical Center, Moscow, Russia
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21
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Kahilogullari G, Bahadır B, Bozkurt M, Akcalar S, Balci S, Arat A. Carotid Artery-Cavernous Segment Injury during an Endoscopic Endonasal Surgery: A Case Report and Literature Review of the Overlooked Option for Surgical Trapping in the Hyperacute Phase. J Neurol Surg Rep 2021; 82:e53-e62. [PMID: 34917447 PMCID: PMC8670996 DOI: 10.1055/s-0041-1740511] [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: 05/14/2021] [Accepted: 09/20/2021] [Indexed: 10/26/2022] Open
Abstract
Internal carotid artery (ICA) injury is a catastrophic complication of endoscopic endonasal surgery (EES). However, its standard management, emergent endovascular treatment, may not always be available, and the transnasal approach may be insufficient to achieve hemostasis. A 44-year-old woman with pituitary adenoma underwent EES complicated with the ICA cavernous segment injury (CSI). In urgent intraoperative angiogram, a good collateral flow from the contralateral carotid circulation was observed. Due to the unavailability of intraoperative embolization, emergent surgical trapping was performed by combined transcranial and cervical approach. The patient recovered but later developed a giant cavernous pseudoaneurysm. During the pseudoaneurysm embolization, ICA was directly accessed via a 1.7-F puncture hole using a bare microcatheter technique. Then, both the aneurysm and parent artery were obliterated with coils. At the 4-year follow-up, the patient was asymptomatic without a residual tumor. To our knowledge, this is the first case of ICA-CSI during EES successfully treated with ICA trapping as a lifesaving urgent surgery that achieved a complete recovery after a pseudoaneurysm embolization. Although several studies reported that EES-related ICA-CSIs with percutaneous carotid artery access, neither our surgical salvage technique nor our carotid access and tract embolization techniques were previously described.
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Affiliation(s)
| | - Burak Bahadır
- Department of Neurosurgery, Ankara University, Ankara, Turkey
| | - Melih Bozkurt
- Department of Neurosurgery, Ankara University, Ankara, Turkey
| | - Seray Akcalar
- Department of Radiology, Ankara University, Ankara, Turkey
| | - Sinan Balci
- Department of Radiology, Hacettepe University, Ankara, Turkey
| | - Anil Arat
- Department of Radiology, Hacettepe University, Ankara, Turkey
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22
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Wang M, Cai Y, Jiang Y, Peng Y. Risk factors impacting intra- and postoperative cerebrospinal fluid rhinorrhea on the endoscopic treatment of pituitary adenomas: A retrospective study of 250 patients. Medicine (Baltimore) 2021; 100:e27781. [PMID: 34889229 PMCID: PMC8663863 DOI: 10.1097/md.0000000000027781] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 10/28/2021] [Indexed: 01/05/2023] Open
Abstract
We aimed to identify the risk factors associated with intra- and postoperative cerebrospinal fluid (CSF) leakage in pituitary adenomas treated with endoscopic transsphenoidal surgery.This study is a retrospective analysis of 250 pituitary adenoma cases from January 2017 to December 2019 at our hospital. All patients underwent endoscopic endonasal transsphenoidal surgeries. Univariate and multivariate analyses were performed to investigate the risk factors associated with intra- and postoperative CSF rhinorrhea.Eighty (32.0%) and nine (3.6%) patients had intra- and postoperative CSF leakage, respectively. Tumor size was an independent risk factor for intraoperative CSF leakage (odds ratio [OR], 1.229; 95% confidence interval [CI], 1.133-1.334; P < .001); intraoperative CSF leakage was an independent risk factor for postoperative CSF leakage (OR, 7.707; 95% CI, 1.336-44.455; P = .022). Chronic respiratory disease (OR, 57.500; 95% CI, 8.031-411.682; P < .001) was also an independent risk factor for postoperative CSF leakage. Vascularized septal mucosal flap was a protective factor (OR, 0.107; 95% CI, 0.013-0.894; P = .039).Intraoperative CSF leakage is more likely to occur in large pituitary adenomas. In the presence of intraoperative CSF leakage, postoperative CSF rhinorrhea is very likely to occur. Patients with chronic respiratory disease are also more likely to develop postoperative CSF leakage. The sellar base reconstructed using vascularized nasal septal flaps can significantly decrease the risk. The Knosp grade, degree of tumor resection, and postoperative use of a lumbar subarachnoid drain did not have any effects on postoperative CSF rhinorrhea.
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23
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Thakur JD, Corlin A, Mallari RJ, Yawitz S, Eisenberg A, Sivakumar W, Griffiths C, Carrau RL, Rettinger S, Cohan P, Krauss H, Araque KA, Barkhoudarian G, Kelly DF. Complication avoidance protocols in endoscopic pituitary adenoma surgery: a retrospective cohort study in 514 patients. Pituitary 2021; 24:930-942. [PMID: 34215990 PMCID: PMC8252985 DOI: 10.1007/s11102-021-01167-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2021] [Indexed: 12/02/2022]
Abstract
PURPOSE To evaluate the impact of using consistent complication-avoidance protocols in patients undergoing endoscopic pituitary adenoma surgery including techniques for avoiding anosmia, epistaxis, carotid artery injury, hypopituitarism, cerebrospinal fluid leaks and meningitis. METHODS All patients undergoing endoscopic adenoma resection from 2010 to 2020 were included. Primary outcomes included 90-day complication rates, gland function outcomes, reoperations, readmissions and length of stay. Secondary outcomes were extent of resection, short-term endocrine remission, vision recovery. RESULTS Of 514 patients, (mean age 51 ± 16 years; 78% macroadenomas, 19% prior surgery) major complications occurred in 18(3.5%) patients, most commonly CSF leak (9, 1.7%) and meningitis (4, 0.8%). In 14 of 18 patients, complications were deemed preventable. Four (0.8%) had complications with permanent sequelae (3 before 2016): one unexplained mortality, one stroke, one oculomotor nerve palsy, one oculoparesis. There were no internal carotid artery injuries, permanent visual worsening or permanent anosmia. New hypopituitarism occurred in 23/485(4.7%). Partial or complete hypopituitarism resolution occurred in 102/193(52.8%) patients. Median LOS was 2 days; 98.3% of patients were discharged home. Comparing 18 patients with major complications versus 496 without, median LOS was 7 versus 2 days, respectively p < 0.001. Readmissions occurred in 6%(31/535), mostly for hyponatremia (18/31). Gross total resection was achieved in 214/312(69%) endocrine-inactive adenomas; biochemical remission was achieved in 148/209(71%) endocrine-active adenomas. Visual field or acuity defects improved in 126/138(91.3%) patients. CONCLUSION This study suggests that conformance to established protocols for endoscopic pituitary surgery may minimize complications, re-admissions and LOS while enhancing the likelihood of preserving gland function, although there remains opportunity for further improvements.
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Affiliation(s)
| | - Alex Corlin
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Regin Jay Mallari
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Samantha Yawitz
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Amalia Eisenberg
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Walavan Sivakumar
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Chester Griffiths
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA
| | | | - Sarah Rettinger
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Pejman Cohan
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Howard Krauss
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Katherine A Araque
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA.
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA.
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24
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Chanson P, Wolf P. Clinically non-functioning pituitary adenomas. Presse Med 2021; 50:104086. [PMID: 34718111 DOI: 10.1016/j.lpm.2021.104086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 10/20/2021] [Indexed: 12/30/2022] Open
Abstract
Clinically non functioning pituitary adenomas (NFPAs) include all pituitary adenomas that are not hormonally active. They are not associated with clinical syndromes such as amenorrhea-galactorrhea (prolactinomas), acromegaly, Cushing's disease or hyperthyroidism (TSH-secreting adenomas) and are therefore usually diagnosed by signs and symptoms related to a mass effect (headache, visual impairment, sometimes pituitary apoplexy), but also incidentally. Biochemical work up often documents several pituitary insufficiencies. In histopathology, the majority of NFPAs are gonadotroph. In the absence of an established medical therapy, surgery is the mainstay of treatment, unless contraindicated or in particular situations (e.g. small incidentalomas, distance from optic pathways). Resection, generally via a trans-sphenoidal approach (with the help of an endoscope), should be performed by a neurosurgeon with extensive experience in pituitary surgery, in order to maximize the chances of complete resection and to minimize complications. If a tumor remnant persists, watchful waiting is preferred to routine radiotherapy, as long as the tumor residue does not grow and is distant from the optic pathways. NFPA can sometimes recur even after complete resection, but predicting the individual risk of tumor remnant progression is difficult. Postoperative irradiation is only considered in case of residual tumor growth or relapse, due to its potential side effects.
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Affiliation(s)
- Philippe Chanson
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France.
| | - Peter Wolf
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France; Medical University of Vienna, Department of Internal Medicine III, Division of Endocrinology and Metabolism, 1090 Vienna, Austria
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25
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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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26
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Evaluation of the Gross Total Resection Rate of Suprasellar Pituitary Macroadenomas with and without the Removal of the Tuberculum Sellae Bone. World Neurosurg 2021; 156:e291-e299. [PMID: 34547527 DOI: 10.1016/j.wneu.2021.09.049] [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: 07/13/2021] [Revised: 09/10/2021] [Accepted: 09/11/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Improving the gross total resection (GTR) rate of suprasellar pituitary macroadenomas (SPMAs) using the pure endoscopic endonasal transsphenoidal approach (EETA) has been a long-standing focus of neurosurgeons. This study was aimed at evaluating the influences of the removal of the tuberculum sellae bone (TSB) without opening the dura of the tuberculum sellae on the GTR rate of SPMAs via the EETA. METHODS We retrospectively analyzed medical reports of patients with SPMAs who underwent EETA between February 2015 and November 2020. Data on clinical manifestations, endocrinologic types, imaging features (Hardy classification, morphology, and texture), clinical outcomes, and TSB removal status were collected. All patients were followed up for 6 months postoperatively. RESULTS Seventy-eight patients were enrolled in our study. The GTR rates of the TSB removal group (45/78, 57.7%) and nonremoval group (33/78, 42.3%) were 80.0% (36/45) and 57.6% (19/33), respectively. Univariate logistic regression analysis found that the removal of TSB, rounded morphology, and low Hardy classification were correlated with higher GTR rates. Multiple logistic regression analysis indicated that even after adjusting for tumor types and imaging features, the removal of TSB had an independent effect on the GTR rate (odds ratio, 7.6; 95% confidence interval, 1.8-31.6; P = 0.005). The incidence rates of postoperative cerebrospinal fluid leakage and diabetes insipidus were not significantly different between the TSB removal group and TSB nonremoval group. CONCLUSIONS TSB removal using EETA without opening the tuberculum sellae dura improves the GTR rate of SPMAs without increasing the incidence of postoperative complications.
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27
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Ahn S, Park JS, Kim DH, Kim SW, Jeun SS. Surgical Experience in Prevention of Postoperative CSF Leaks Using Abdominal Fat Grafts in Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Adenomas. J Neurol Surg B Skull Base 2021; 82:522-527. [PMID: 34513557 DOI: 10.1055/s-0040-1712179] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 03/19/2020] [Indexed: 10/23/2022] Open
Abstract
Objective Cerebrospinal fluid (CSF) leaks are the most common complication during endonasal endoscopic transsphenoidal approach (EETSA) and prevention of postoperative CSF leaks is critical. In this study, we report a single surgeon's experience of sellar floor reconstruction using abdominal fat grafts for prevention of postoperative CSF leaks in EETSA for pituitary adenomas. Study Design This study is presented as case series with retrospective chart review. Setting Present study was conducted at tertiary referral center. Participants A total of 216 patients who underwent surgery via EETSA for pituitary adenomas between 2008 and 2018 at our institution were evaluated. When an intraoperative CSF leak occurred, sellar floor reconstruction was performed using a fat graft harvested from the abdomen via a 2-cm skin incision. Main Outcome Measures Primary outcome and measures of this study was postoperative CSF leaks. Results A total of 53 patients showed intraoperative CSF leaks (24.5%) and 2 patients showed postoperative CSF leaks (0.93%). There were no postoperative CSF leaks in any patients who showed intraoperative CSF leaks and received sellar floor reconstruction using fat grafts. There were also no postoperative CSF leaks in 12 patients who received preventative sellar floor reconstruction using fat grafts due to extensive arachnoid herniation without intraoperative CSF leaks. However, there were two postoperative CSF leaks in patients who did not show intraoperative CSF leaks and did not receive sellar floor reconstruction. Conclusion The effectiveness of sellar floor reconstruction using abdominal fat grafts in patients receiving EETSA for pituitary adenoma was reported. We suggest that identification of intraoperative CSF leaks is important and preventive sellar floor reconstruction without evidence of intraoperative CSF leaks can also be beneficial.
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Affiliation(s)
- Stephen Ahn
- Department of Neurosurgery, The Catholic University of Korea, Seoul St. Mary's Hospital, College of Medicine, Seoul, Republic of Korea
| | - Jae-Sung Park
- Department of Neurosurgery, The Catholic University of Korea, Seoul St. Mary's Hospital, College of Medicine, Seoul, Republic of Korea
| | - Do H Kim
- Department of Otolaryngology-Head and Neck Surgery, The Catholic University of Korea, Seoul St. Mary's Hospital, College of Medicine, Seoul, Republic of Korea
| | - Sung W Kim
- Department of Otolaryngology-Head and Neck Surgery, The Catholic University of Korea, Seoul St. Mary's Hospital, College of Medicine, Seoul, Republic of Korea
| | - Sin-Soo Jeun
- Department of Neurosurgery, The Catholic University of Korea, Seoul St. Mary's Hospital, College of Medicine, Seoul, Republic of Korea
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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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29
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Abdali A, Astafeva LI, Trunin YY, Chernov IV, Sidneva YG, Abdilatipov AA, Kalinin PL. [Modern aspects of surgery for cushing's disease]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:111-117. [PMID: 34463458 DOI: 10.17116/neiro202185041111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cushing's disease is a severe neuroendocrine disorder caused by chronic hypersecretion of ACTH by pituitary adenoma (corticotropinoma). Surgical resection is a gold standard for this disease resulting stable remission in about 65-95% of cases. Despite benign nature of corticotropinoma, recurrence rate is still higher (25-35%) even in specialized neurosurgical centers. Modifications in surgical strategy can prolong recurrence-free period.
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Affiliation(s)
- A Abdali
- Peoples' Friendship University of Russia, Moscow, Russia
| | | | | | - I V Chernov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | | | - P L Kalinin
- Burdenko Neurosurgical Center, Moscow, Russia
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30
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Subramanian V, Lee RSM, Howell S, Gregson S, Lahart IM, Kaushal K, Pappachan JM. Non-functioning pituitary macroadenomas: factors affecting postoperative recurrence, and pre- and post-surgical endocrine and visual function. Endocrine 2021; 73:407-415. [PMID: 33822319 DOI: 10.1007/s12020-021-02713-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/23/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Non-functioning pituitary macroadenomas (NFPAs) with visual field defects are ideally managed by transsphenoidal tumour resection to improve vision, and long-term postsurgical follow up is necessary to monitor for tumour recurrence. Regular updates from global data are necessary for developing optimal management strategies of these tumours. METHODS Pre- and postoperative visual and endocrine profile, imaging characteristics and details of surgical interventions among patients with NFPAs managed between 2008 and 2019 in a UK regional centre were assessed. The radiological and surgical outcomes including postoperative complications, recurrence risk and the factors influencing outcomes also were assessed. RESULTS 105 cases with mean (SD) age 60.1 (14.3) years and follow-up duration 60 (37) months were studied. 67 (64%) patients were male. Five-year recurrence-free survival rate was 71.5% (95% confidence interval [CI] 62.7% to 81.6%) with 33 (31%) tumour recurrences of whom 20 (60%) received radiotherapy and 9 (27%) underwent further surgery. Younger age, tumour volume, and bilateral cavernous sinus extension were the predictors of recurrence on univariate analysis, while younger age was the only factor on multivariate analysis (Hazard ratio 0.95; 95% CI: 0.92, 0.97). 72/78 patients (92%) with preoperative visual field defects improved after surgery, of whom 27 (35%) had full recovery. 20 (24%) patients had recovery of an abnormal hormone axis. 15 patients (16%) developed perioperative complications such as cerebrospinal fluid leak (12 cases), meningitis (2 cases), and bleeding (2 cases). CONCLUSIONS Five-year recurrence-free survival after transsphenoidal resection for NFPAs was 71.5% with older age at surgery conferring lower risk of recurrence. Visual recovery/ improvement occurred in 92% of cases with preoperative visual defects following surgery.
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Affiliation(s)
- Venkatram Subramanian
- Department of Endocrinology & Metabolism, Royal Preston Hospital, The Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | | | - Simon Howell
- Department of Endocrinology & Metabolism, Royal Preston Hospital, The Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Samuel Gregson
- Department of Neuroradiology, Royal Preston Hospital, The Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Ian M Lahart
- Faculty of Education, Health and Wellbeing, University of Wolverhampton, Walsall, UK
| | - Kalpana Kaushal
- Department of Endocrinology & Metabolism, Royal Preston Hospital, The Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
- The University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Joseph M Pappachan
- Department of Endocrinology & Metabolism, Royal Preston Hospital, The Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK.
- The University of Manchester, Oxford Road, Manchester, M13 9PL, UK.
- Manchester Metropolitan University, All Saints Building, Manchester, M15 6BH, UK.
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Experience of Endoscopic Endonasal Approach for 803 Pituitary Tumors With Cavernous Sinus Invasion. J Craniofac Surg 2021; 33:e118-e122. [PMID: 34334752 DOI: 10.1097/scs.0000000000008049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE The aim of this study was to investigate the effectiveness, safety, complications, and prognosis of endoscopic endonasal surgery for pituitary adenomas with cavernous sinus invasion (CSI). METHODS The clinical data of 803 pituitary adenomas with CSI surgeries performed in our single ward between January 1, 2006 and December 31, 2018 were retrospectively reviewed. The resection degree, bone invasion, endocrine examination, complications, and outcome were retrospectively summarized. RESULTS Gross total resection was achieved in 394 patients (49.1%) subtotal resection in 171 patients (21.3%) and partial resection in 238 patients (29.6%). Clinically variable analyses showed that there was a significant correlation between CSI and female, older age, operation history, and non-gross total resection (NGTR). Among the pituitary adenomas with CSI, there was a significant correlation between bone invasive and NGTR, Knosp classification, recurrence. K-M curves showed that young age, larger tumors, bilateral invasion, Grade 4 of Knosp classification, NGTR, and bone invasion were associated with pituitary adenomas regrowth. Multivariate analysis revealed that bone invasion, NGTR, and Grade 4 of Knosp classification were independent risk factors for pituitary adenomas regrowth. There was a significant correlation between CSI and female, older age, operation history, and tumor resection degree. CONCLUSIONS There was a significant correlation between CSI and female, older age, operation history, and tumor resection degree. The patients with CSI and bone invasion were likely to recurrent. Non-gross total resection, bone invasion, and Grade 4 of Knosp classification were independent risk factors for pituitary adenomas regrowth. Endoscopic endonasal surgery is an excellent choice for pituitary adenomas with CSI.
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Salehpoor F, Kamalifar A, Mirzaii F, Aghazadeh J, Mousavi Aghdas M, Kamalifar S, Bagheri A, Hamadani H. Surgical outcome of trans-sphenoidal approach to pituitary adenoma in adult patients: 10 years experience in northwest of Iran. Med J Islam Repub Iran 2021; 35:88. [PMID: 34291012 PMCID: PMC8285561 DOI: 10.47176/mjiri.35.88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Indexed: 11/09/2022] Open
Abstract
Background: Pituitary adenoma (PA) is a frequent intracranial lesion, that needs surgical evacuation. In this study, we evaluated the surgical outcome of PA treated via endoscopic and microscopic trans-sphenoidal approach. Methods: In this retrospective cross-sectional study, we evaluate ten years of PA surgery experience in the northwest of Iran. 721 patients underwent trans sphenoidal surgery of PA. Complication of the surgery, extension of tumors resection, demographic and clinical findings (gender, age, tumor type,..) were reviewed in this study. SPSS version 25 and statistical tests including chi square and T-test were used. P-value ˂0.5 was considered as statistically significant. Results: 483 males (58.9%) and 336 females (41.02%) were included in this study. Mean age of patients was 47.3±1.96 years.The most common initial complaints were deterioration of vision (n=528, 64.4%) and headache (n=343, 41.88%), followed by accelerated development (n=254, 31.01%), amenorrhea and galactorrhea (n=253, 30.8%). 57 (6.95%) patients had symptoms of Cushing's disease. 105 (12.8%) patients had acromegaly. TR was achieved in 87.5% of cases and sub-TR in 103 (12.5%) cases and no patient had a partial or insufficient resection. After surgery, the endocrine function was normalized in 76 (31.7%) patients who had preoperative hyper hormonal levels. 36 (4.3%) patients developed postoperative CSF leakage; of which, 4 (0.48 %) patients did not improve by lumbar drainage and other conservative treatments and needed reoperation for reconstruction of the skull base. Conclusion: The combination of microscopic and endoscopic trans-sphenoidal approach in PA surgery can be lead to total resection of tumors.
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Affiliation(s)
- Firouz Salehpoor
- Department of Neurosurgery, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amir Kamalifar
- Department of Neurosurgery, Faculty of Medicine, Urumia University of Medical Sciences, Urumia, Iran
| | - Farhad Mirzaii
- Department of Neurosurgery, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Javad Aghazadeh
- Department of Neurosurgery, Faculty of Medicine, Urumia University of Medical Sciences, Urumia, Iran
| | | | - Samar Kamalifar
- Student Research Committee, Faculty of Medicine, Arak University of Medical Sciences, Markazi, Arak, Iran
| | - Asgar Bagheri
- Department of Neurosurgery, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hosein Hamadani
- Department of Neurosurgery, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
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Alexopoulou O, Everard V, Etoa M, Fomekong E, Gaillard S, Parker F, Raftopoulos C, Chanson P, Maiter D. Outcome of pituitary hormone deficits after surgical treatment of nonfunctioning pituitary macroadenomas. Endocrine 2021; 73:166-176. [PMID: 33852154 DOI: 10.1007/s12020-021-02701-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/16/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Nonfunctionning pituitary macroadenomas (NFPMA) are benign tumors that cause symptoms of mass effects including hypopituitarism. Their primary treatment is transsphenoidal surgery. We aimed to determine the outcome of pituitary hormone deficits after surgical treatment of NFPMA and to identify factors predicting hormonal recovery. DESIGN We retrospectively included 246 patients with NFPMA diagnosed and operated in one of the two participating centers. All hormonal axes were evaluated except growth hormone (GH). Postoperative improvement of pituitary endocrine function was considered if at least one hormonal deficit had recovered and a lower total number of deficits was observed 1 year after surgery. RESULTS 80% (n = 197) of patients had one or more pituitary deficits and 28% had complete anterior hypopituitarism. Besides GH, the gonadotropic and thyrotropic axes were the most commonly affected (68% and 62%, respectively). The number of hypopituitary patients dropped significantly to 61% at 1 year (p < 0.001) and a significant improvement was observed for all hormonal axes, except central diabetes insipidus. Among patients with preoperative hypopituitarism, 88/175 (50%) showed improved pituitary function at 1 year. Both hyperprolactinemia at diagnosis and a lower tumor diameter independently predicted favorable endocrine outcome. CONCLUSIONS Hypopituitarism is present in 80% of patients with NFPMA and nearly half of them will benefit from sustained improvement after surgery. Hyperprolactinaemia at diagnosis and lower tumor dimensions are associated with favorable endocrine prognosis. This supports the option of early surgery in NFPMA patients with pituitary deficits independent of the presence of visual disturbances.
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Affiliation(s)
- Orsalia Alexopoulou
- Department of Endocrinology and Nutrition, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
| | - Valérie Everard
- Department of Endocrinology and Nutrition, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Martine Etoa
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Le Kremlin-Bicêtre, France
| | - Edward Fomekong
- Department of Neurosurgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | | | - Fabrice Parker
- Assistance Publique-Hôpitaux de Paris, Service de Neurochirurgie, Hopital Bicêtre, Le Kremlin-Bicêtre, France
| | - Christian Raftopoulos
- Department of Neurosurgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Philippe Chanson
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Le Kremlin-Bicêtre, France
- Inserm, Physiologie et Physiopathologie Endocriniennes, Université Paris-Saclay, Le Kremlin- Bicêtre, France
| | - Dominique Maiter
- Department of Endocrinology and Nutrition, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
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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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Utility of intraoperative ultrasonography for resection of pituitary adenomas: a comparative retrospective study. Acta Neurochir (Wien) 2021; 163:1725-1734. [PMID: 33403430 DOI: 10.1007/s00701-020-04674-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/04/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The evolution of pituitary surgery has made it a safe and effective form of treatment; however, risks of inadequate tumor resection, cerebrospinal fluid (CSF) leak, pituitary dysfunction, and vascular injury still exist. The use of intraoperative ultrasonography (IOUS) in pituitary surgery has been well described. Recent advancements in ultrasound technology have allowed for expanded utility as described here. METHODS A retrospective review was performed between January 2016 and December 2019. One hundred thirty-eight patients (mean age 53.7 years, 47% females) were identified undergoing transsphenoidal surgery for pituitary tumors. Thirty-four patients had IOUS performed using a side-firing ultrasound probe, while 104 did not. Data was analyzed for preoperative (demographics, clinical, and radiographic features), perioperative (blood loss, operative time), and postoperative (complications, length of stay, hormone remission, and extent of resection) outcomes. RESULTS There were no significant differences in patient age, gender, tumor volume, Knosp grade, and hormone-secreting status between the two groups. Patients treated using IOUS had significantly higher rates of gross total resection (79% vs. 44%, p = 0.0008), shorter operative times (74 vs. 146 min, p < 0.0001), lower blood loss (119 vs. 284 cc, p < 0.0001), and hospital stays (2.9 vs. 4.2 days, p = 0.001). Overall complication rates were lower in the IOUS group compared to standard pituitary surgery but did not reach significance. CONCLUSIONS Recent improvements in ultrasound technology have allowed for miniaturization of probes capable of delivering high-resolution images. The use of IOUS in transsphenoidal pituitary surgery may significantly increase rates of gross total resection, while decreasing blood loss, hospital LOS, and operative time.
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Goyal-Honavar A, Sarkar S, Asha HS, Kapoor N, Thomas R, Balakrishnan R, Chacko G, Chacko AG. Impact of Experience on Outcomes After Endoscopic Transsphenoidal Surgery for Acromegaly. World Neurosurg 2021; 151:e1007-e1015. [PMID: 34023462 DOI: 10.1016/j.wneu.2021.05.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Acromegaly is a syndrome of metabolic alterations secondary to increased growth hormone levels from a somatotroph pituitary adenoma. A multidisciplinary approach beginning with surgery, followed by adjuvant radiation or medical therapy for residual disease, is considered standard of care. Several factors affect the likelihood of remission after surgery, but the impact of surgical experience on remission rates has not been adequately assessed. METHODS Retrospective review of 203 patients, divided into 2 eras (era 1, 102 patients; era 2, 101 patients) of patients who underwent transsphenoidal surgery for acromegaly by a single surgeon over 11 years, was performed, determining the effect of surgical experience on rates of remission and various complications. Remission was defined according to the 2014 Endocrine Society Clinical Practice Guideline. RESULTS The rate of surgical remission was 40.6% (62.9% among noninvasive adenomas). Rates of surgical remission significantly improved in the latter half of this cohort (31.2% in the first half vs. 50% in the second half), despite other factors being comparable. On multivariate analysis, surgeon experience, cavernous sinus invasion, and preoperative growth hormone levels affected the rates of surgical remission. Rates of cerebrospinal fluid leak and hypopituitarism were lower in the second half, whereas resolution of acromegaly-associated comorbidities was increased. CONCLUSIONS We report, in this large single-surgeon review of endoscopically operated acromegaly cases, increased rates of surgical remission and reduced complications with increasing surgeon experience. The overall experience of the treating team in dealing with perioperative and intraoperative factors also contributes to improved outcomes.
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Affiliation(s)
| | - Sauradeep Sarkar
- Department of Neurosurgery, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Nitin Kapoor
- Department of Endocrinology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Regi Thomas
- Department of Otorhinolaryngology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Rajesh Balakrishnan
- Department of Radiation Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Geeta Chacko
- Department of Pathology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ari G Chacko
- Department of Neurosurgery, Christian Medical College, Vellore, Tamil Nadu, India. ]
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Van Gerven L, Qian Z, Starovoyt A, Jorissen M, Meulemans J, van Loon J, De Vleeschouwer S, Lambert J, Bex M, Vander Poorten V. Endoscopic, Endonasal Transsphenoidal Surgery for Tumors of the Sellar and Suprasellar Region: A Monocentric Historical Cohort Study of 369 Patients. Front Oncol 2021; 11:643550. [PMID: 34026618 PMCID: PMC8138557 DOI: 10.3389/fonc.2021.643550] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/06/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The endoscopic endonasal transsphenoidal approach (EETA) is an established technique for the resection of a large variety of benign sellar and suprasellar lesions, mostly pituitary adenomas. It has clear advantages over the microscopic approach, like a superior close-up view of the relevant anatomy and the tumor-gland interface, an enlarged working angle, as well as an increased panoramic vision inside the surgical area. We have been performing the EETA for over a decade, and this study will focus on perioperative and postoperative outcomes and complications and their association with the learning curve. MATERIAL AND METHODS All patients in our tertiary referral center (n = 369) undergoing an EETA for a lesion of the sellar and suprasellar region between January 1st 2008 and December 31st 2018 were included, and data were retrospectively retrieved from the electronic patient records. RESULTS Median follow-up after surgery was 55 months. Pituitary adenomas (n = 322) were the most frequent pathology. Headache (43.4%) and loss of vision (29.3%) were the most common presenting symptoms. Median procedure duration was significantly longer during the initial 5 years (106 versus 79 minutes; p <0.0001), but incidence of peri- and postoperative CSF leaks in the early years was not significantly higher. Knosp grade >2 was associated with perioperative CSF leak (p =0.002), and perioperative CSF leak was associated with postoperative CSF leak (p <0.001). Almost all cases of meningitis were preceded by a postoperative CSF leak. In 22.4% of patients, tumor recurrence required additional therapy. Perioperative (iatrogenic) mortality was 0.8%. The overall hospital stay decreased over time from an average of 7 to 5 days, and the case load increased yearly (p =0.015). CONCLUSION The EETA is an excellent technique with complication rates comparable to or even lower than those in large microsurgical series in the literature. EETA has a significant learning curve affecting the procedure duration. Throughout the first 10 years following the transition from the microscopic approach to the EETA in our cohort, the caseload increased and hospital stay was reduced, while no increase in peri- and postoperative complications was observed.
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Affiliation(s)
- Laura Van Gerven
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Otorhinolaryngology, KU Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and transplantation, Allergy and Clinical Immunology Research Unit, KU Leuven, Leuven, Belgium
| | - Zhen Qian
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Anastasiya Starovoyt
- Department of Neurosciences, Experimental Otorhinolaryngology, KU Leuven, Leuven, Belgium
| | - Mark Jorissen
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Jeroen Meulemans
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, Section Head and Neck Oncology, KU Leuven, Leuven, Belgium
| | - Johannes van Loon
- Neurosciences, Research Group Experimental Neurosurgery and Neuroanatomy and Leuven Brain Institute, Leuven, Belgium
| | - Steven De Vleeschouwer
- Neurosciences, Research Group Experimental Neurosurgery and Neuroanatomy and Leuven Brain Institute, Leuven, Belgium
| | - Julie Lambert
- Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Marie Bex
- Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Vincent Vander Poorten
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, Section Head and Neck Oncology, KU Leuven, Leuven, Belgium
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Graillon T, Passeri T, Boucekine M, Meyer M, Abritti R, Bernat AL, Labidi M, Dufour H, Froelich S. Chiasmapexy for secondary empty sella syndrome: diagnostic and therapeutic considerations. Pituitary 2021; 24:292-301. [PMID: 33136230 DOI: 10.1007/s11102-020-01104-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Secondary empty sella syndrome (SESS) following pituitary surgery remains a diagnostic and therapeutic challenge. The aim of this study was to specify the diagnostic criteria, surgical indications and results of chiasmapexy in the SESS. METHODS Three cases from two experienced neurosurgical centers were collected and the available literature was reviewed. RESULTS The 3 patients were operated for a giant non-functioning pituitary adenoma, a cystic macroprolactinoma, and an arachnoid cyst respectively. Postoperative visual outcome was initially improved, and then worsened progressively. At the time of SESS diagnosis, visual field defect was severe in all cases with optic nerve (ON) atrophy in 2 cases. Patients were operated via an endoscopic endonasal extradural approach. One patient was re-operated because of early fat reabsorption. Visual outcome improved in 1 case and stabilized in 2 cases. Statistical analyses performed on 24 cases from the literature review highlighted that patient age and severity of the preoperative visual defect were respectively significant and nearly significant prognostic factors for visual outcome, unlike the surgical technique. CONCLUSION T2-weighted or CISS/FIESTA sequence MRI is mandatory to visualize adhesions, ON kinking and neurovascular conflict. TS approach is the most commonly used approach. The literature review could not conclude on the need for an intra or extradural approach suggesting case by case adapted strategy. Intrasellar packing with non-absorbable material such as bone should be considered. Severity of the visual loss clearly decreases the visual outcome suggesting early chiasmapexy. In case of severe and long standing symptoms before surgery, benefits and surgical risks should be carefully balanced.
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Affiliation(s)
- Thomas Graillon
- Neurosurgery Department, Aix-Marseille Univ, APHM, CHU Timone, Marseille, France.
| | - Thibault Passeri
- Neurosurgery Department, Hôpital Lariboisiere, APHP, Université Paris Diderot, Paris, France
| | - Mohamed Boucekine
- EA 3279 CEReSS - Health Service Research and Quality of Life Center, Aix-Marseille Univ, School of Medicine - La Timone Medical Campus, |27 bd Jean Moulin Cedex 05, 13385, Marseille, France
| | - Mikael Meyer
- Neurosurgery Department, Aix-Marseille Univ, APHM, CHU Timone, Marseille, France
| | - Rosaria Abritti
- Neurosurgery Department, Hôpital Lariboisiere, APHP, Université Paris Diderot, Paris, France
| | - Anne-Laure Bernat
- Neurosurgery Department, Hôpital Lariboisiere, APHP, Université Paris Diderot, Paris, France
| | - Moujahed Labidi
- Neurosurgery Department, Hôpital Lariboisiere, APHP, Université Paris Diderot, Paris, France
| | - Henry Dufour
- Neurosurgery Department, Aix-Marseille Univ, APHM, CHU Timone, Marseille, France
| | - Sébastien Froelich
- Neurosurgery Department, Hôpital Lariboisiere, APHP, Université Paris Diderot, Paris, France
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Brady Z, Garrahy A, Carthy C, O'Reilly MW, Thompson CJ, Sherlock M, Agha A, Javadpour M. Outcomes of endoscopic transsphenoidal surgery for Cushing's disease. BMC Endocr Disord 2021; 21:36. [PMID: 33658018 PMCID: PMC7931517 DOI: 10.1186/s12902-021-00679-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 01/02/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Transsphenoidal surgery (TSS) to resect an adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma is the first-line treatment for Cushing's disease (CD), with increasing usage of endoscopic transsphenoidal (ETSS) technique. The aim of this study was to assess remission rates and postoperative complications following ETSS for CD. METHODS A retrospective analysis of a prospective single-surgeon database of consecutive patients with CD who underwent ETSS between January 2012-February 2020. Post-operative remission was defined, according to Endocrine Society Guidelines, as a morning serum cortisol < 138 nmol/L within 7 days of surgery, with improvement in clinical features of hypercortisolism. A strict cut-off of < 50 nmol/L at day 3 post-op was also applied, to allow early identification of remission. RESULTS A single surgeon (MJ) performed 43 ETSS in 39 patients. Pre-operative MRI localised an adenoma in 22 (56%) patients; 18 microadenoma and 4 macroadenoma (2 with cavernous sinus invasion). IPSS was carried out in 33 (85%) patients. The remission rates for initial surgery were 87% using standard criteria, 58% using the strict criteria (day 3 cortisol < 50 nmol/L). Three patients had an early repeat ETSS for persistent disease (day 3 cortisol 306-555 nmol/L). When the outcome of repeat early ETSS was included, the remission rate was 92% (36/39) overall. Remission rate was 94% (33/35) when patients with macroadenomas were excluded. There were no cases of CSF leakage, meningitis, vascular injury or visual deterioration. Transient and permanent diabetes insipidus occurred in 33 and 23% following first ETSS, respectively. There was one case of recurrence of CD during the follow-up period of 24 (4-79) months. CONCLUSION Endoscopic transsphenoidal surgery produces satisfactory remission rates for the primary treatment of CD, with higher remission rates for microadenomas. A longer follow-up period is required to assess recurrence rates. Patients should be counselled regarding risk of postoperative diabetes insipidus.
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Affiliation(s)
- Zarina Brady
- Medical University of Varna, Varna, Bulgaria
- Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
| | - Aoife Garrahy
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland.
- Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Claire Carthy
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Michael W O'Reilly
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Christopher J Thompson
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mark Sherlock
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Amar Agha
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mohsen Javadpour
- Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
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Redjal N, Venteicher AS, Dang D, Sloan A, Kessler RA, Baron RR, Hadjipanayis CG, Chen CC, Ziu M, Olson JJ, Nahed BV. Guidelines in the management of CNS tumors. J Neurooncol 2021; 151:345-359. [PMID: 33611702 DOI: 10.1007/s11060-020-03530-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 05/05/2020] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Evidence-based, clinical practice guidelines in the management of central nervous system tumors (CNS) continue to be developed and updated through the work of the Joint Section on Tumors of the Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS). METHODS The guidelines are created using the most current and clinically relevant evidence using systematic methodologies, which classify available data and provide recommendations for clinical practice. CONCLUSION This update summarizes the Tumor Section Guidelines developed over the last five years for non-functioning pituitary adenomas, low grade gliomas, vestibular schwannomas, and metastatic brain tumors.
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Affiliation(s)
- Navid Redjal
- Department of Neurosurgery, Capital Institute for Neurosciences, Two Capital Way, Pennington, NJ, 08534, USA.
| | - Andrew S Venteicher
- Center for Pituitary and Skull Base Surgery, Department of Neurosurgery, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Danielle Dang
- Inova Neuroscience and Spine Institute, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Andrew Sloan
- Department of Neurosurgery, Case Western Reserve University, Cleveland, OH, USA
| | - Remi A Kessler
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rebecca R Baron
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Clark C Chen
- Center for Pituitary and Skull Base Surgery, Department of Neurosurgery, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Mateo Ziu
- Inova Neuroscience and Spine Institute, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University, Atlanta, GA, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
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Konan ML, Haidara A, Meuga WM, Djondé G, Gbazi SM, Okamon M, Derou LK, Oka DN. Early Experience of Endoscopic Endonasal Transphenoidal Surgery for Pituitary Adenoma: Preliminary Report of 56 Cases Operated in a West African Institution. World Neurosurg 2021; 149:e329-e335. [PMID: 33609765 DOI: 10.1016/j.wneu.2021.02.028] [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: 11/24/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although endoscopic endonasal approach (EEA) has been popularized worldwide for pituitary adenoma surgery, in sub-Saharan Africa, neurosurgeons are still only starting their experience with it. This study was designed to assess the early results of EEA for pituitary adenoma from an under-equipped environment, namely, the Department of Neurosurgery of the Teaching Hospital of Yopougon Abidjan and Bouaké in Ivory Coast. METHODS The data of 56 cases of EEA for pituitary adenoma surgery performed between 2016 and March 2019 at the Teaching Hospital of Yopougon-Abidjan and Bouaké were retrospectively assessed. Pre- and postoperative neuro-ophthalmologic and hormonal status were analyzed. Moreover, the quality of tumor removal, and pre- and postoperative complications were also evaluated. RESULTS In this study, there were nonfunctional adenomas (20), prolactinoma (18), Cushing disease (9), and acromegaly (3). A reduced visual acuity and/or visual field defect was observed in 49 cases. The mean operation time was 225 ± 94.7 minutes. The tumor removals were complete in 57.14%, subtotal in 35.71%, and partial in 7.14%. These led to a visual improvement in 69.64%. Postoperative complications were cerebrospinal fluid leaks (19.64%), diabetes insipidus (12.50%), visual worsening (7.14%), meningitis (3.57%), and carotid injury (3.57%) that led to death. CONCLUSIONS This study represents the early surgical experience using EEA for treating pituitary adenoma in an under-equipped environment. Although the postoperative complication rate was relatively high, refinements of local surgeons' technique would lead to a better patient outcome.
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Affiliation(s)
- Meleine Landry Konan
- Department of Neurosurgery, Teaching Hospital of Yopougon, University Felix Houphouet Boigny, Abidjan, Cote d'Ivoire.
| | - Aderehime Haidara
- Department of Neurosurgery, Teaching Hospital of Bouaké, University Alassane Ouattara, Bouaké, Cote d'Ivoire
| | - Wilfried M Meuga
- Department of Neurosurgery, Teaching Hospital of Yopougon, University Felix Houphouet Boigny, Abidjan, Cote d'Ivoire
| | - Grace Djondé
- Department of Neurosurgery, Teaching Hospital of Yopougon, University Felix Houphouet Boigny, Abidjan, Cote d'Ivoire
| | - Sidoine M Gbazi
- Department of Neurosurgery, Teaching Hospital of Yopougon, University Felix Houphouet Boigny, Abidjan, Cote d'Ivoire
| | - Marcel Okamon
- Department of Neurosurgery, Teaching Hospital of Yopougon, University Felix Houphouet Boigny, Abidjan, Cote d'Ivoire
| | - Louis K Derou
- Department of Neurosurgery, Teaching Hospital of Bouaké, University Alassane Ouattara, Bouaké, Cote d'Ivoire
| | - Dominique Ndri Oka
- Department of Neurosurgery, Teaching Hospital of Yopougon, University Felix Houphouet Boigny, Abidjan, Cote d'Ivoire
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Cai X, Yang J, Zhu J, Tang C, Cong Z, Liu Y, Ma C. Reconstruction strategies for intraoperative CSF leak in endoscopic endonasal skull base surgery: systematic review and meta-analysis. Br J Neurosurg 2021; 36:436-446. [PMID: 33475004 DOI: 10.1080/02688697.2020.1849548] [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: 02/07/2023]
Abstract
BACKGROUND Endoscopic endonasal surgery (EES) is one of the preferred options for skull base pathologies. Cerebrospinal fluid (CSF) leak is a significant complication of EES and neurosurgeons have proposed various reconstructive strategies to decrease this morbidity. We describe and compare the efficacy of these strategies. METHODS We searched PubMed, Cochrane Library, and Web of Science for publications between 1990 and November 2019. We defined a reconstruction hierarchy of seven levels from inside to outside: fat graft, intracranial intradural layer (inlay), intracranial extradural layer (onlay), buttress, mucosal flap, nasal packing and lumbar drainage. A single-arm analysis was performed for the primary outcome of CSF leak rate. RESULTS Of 3641 records identified, 48 studies met the inclusion criteria. Pituitary tumors had lower postoperative CSF leak rate than other diseases (1.8% vs. 6.5%, RD = -4.7% [-7.1%, -2.1%]). In high CSF flow group, the post-operative leak rate was reduced by application of mucosal flap (4.3% vs. without mucosal flap at 12.8%, RD = -8.5% [-15.1%, -1.9%]). The use of inlay showed potential of decreasing the post-operative leak rate (5.0% vs. 7.2%, RD = -2.2% [-7.7%, 3.3%]). In low CSF flow group, tampon was better than balloon for nasal packing (1.0% vs. 10.5%, RD = -9.5% [-16.5%, -2.4%]). CONCLUSIONS Mucosal flap and inlay for high-flow intraoperative CSF leak and tampon (compared with balloon) for low-flow intraoperative CSF leak, improved the postoperative CSF leak rate. Further studies are required to establish more robust evidence.
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Affiliation(s)
- Xiangming Cai
- School of Medicine, Southeast University, Nanjing, China
| | - Jin Yang
- Department of Neurosurgery, Jinling Hospital, Nanjing, China
| | - Junhao Zhu
- School of Medicine, Nanjing Medical University, Nanjing, China
| | - Chao Tang
- Department of Neurosurgery, Jinling Hospital, Nanjing, China
| | - Zixiang Cong
- Department of Neurosurgery, Jinling Hospital, Nanjing, China
| | - Yuxiu Liu
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, China.,Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Chiyuan Ma
- Department of Neurosurgery, Jinling Hospital, Nanjing, China.,School of Medicine, Nanjing University, Nanjing, China
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Pérez-López C, Palpán AJ, Saez-Alegre M, Zamarrón Á, Alfonso C, Álvarez-Escola C, Isla A. Volumetric Study of Nonfunctioning Pituitary Adenomas: Predictors of Gross Total Resection. World Neurosurg 2020; 147:e206-e214. [PMID: 33309892 DOI: 10.1016/j.wneu.2020.12.020] [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] [Received: 07/06/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Despite the efforts made to determine the achieved resection grade after pituitary adenoma surgery, there is a high level of disagreement among all the available classifications and measurement methods used. Our objective is to identify the factors that preoperatively could predict a gross total resection (GTR) of a clinically nonfunctioning pituitary adenoma through an endoscopic endonasal approach. METHODS Across 100 surgeries, we analyzed epidemiologic and clinical data, radiologic relevant data, extent of resection (EOR), and postoperative outcomes. The EOR was measured objectively through an accurate volumetric analysis. RESULTS The median presurgical volume was 8.58 cm3 (range, 0.5-58 cm3), the median maximum diameter was 27.3 mm (range, 7-67 mm), and the Knosp grade was 0 in 1 patient, 1 in 23%, 2 in 31%, 3 in 23% and 4 in 22% of patients. In the multivariate logistic regression analysis, we found 3 factors that significantly predicted the chances of a successful GTR: previous sellar surgery, Knosp grade, and tumor signal in the T2-weighted magnetic resonance imaging scan. Another 10 radiologic variables were analyzed and had no effect on the EOR. CONCLUSIONS Knosp grade (P < 0.001; odds ratio [OR], 25.65; 95% confidence interval, 7.19-91.52) is the most predictive factor for performing a GTR of nonfunctioning pituitary adenoma. Previous pituitary surgery (P = 0.023; OR, 5.81) and an isointense T2-weighted signal (P = 0.034; OR, 3.75) also negatively influenced the chances of GTR. We highlight the influence of T2-weighted signal in the chances of GTR.
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Affiliation(s)
- Carlos Pérez-López
- Department of Neurosurgery, Hospital Universitario La Paz, Madrid, Spain.
| | - Alexis J Palpán
- Department of Neurosurgery, Hospital Universitario La Paz, Madrid, Spain
| | - Miguel Saez-Alegre
- Department of Neurosurgery, Hospital Universitario La Paz, Madrid, Spain
| | - Álvaro Zamarrón
- Department of Neurosurgery, Hospital Universitario La Paz, Madrid, Spain
| | - Carolina Alfonso
- Department of Otorhinolaryngology, Hospital Universitario La Paz, Madrid, Spain
| | | | - Alberto Isla
- Department of Neurosurgery, Hospital Universitario La Paz, Madrid, Spain
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Li C, Zhu H, Zong X, Wang X, Gui S, Zhao P, Bai J, Liu C, Cao L, Li Z, Zhang Y. Experience of trans-nasal endoscopic surgery for pituitary tumors in a single center in China: Surgical results in a cohort of 2032 patients, operated between 2006 and 2018. Clin Neurol Neurosurg 2020; 197:106176. [PMID: 32905978 DOI: 10.1016/j.clineuro.2020.106176] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 07/06/2020] [Accepted: 08/20/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES This study was conducted to investigate complications and outcome by endonasal endoscopic approach in our single center. PATIENTS AND METHODS The clinical data of 2032 pituitary adenoma surgeries performed in our ward between January 2006 and December 2018 were retrospectively reviewed. The GTR (gross total resection) rate, hormonal control, complications, and tumor recurrence rate were retrospectively analyzed. RESULTS There were 628 (83.5 %) preoperative headache patients, 513 (68.9 %) visual acuity and visual field impaired patients, 218 (66.4 %) endocrine symptom patients and 26 (53.1 %) SIADH (syndrome of inappropriate secretion of antidiuretic hormone) patients experienced improvement after surgery. GTR was achieved in 1627 patients (80.1 %) and NGTR (non-gross total resection) in 405 patients (19.9 %). Clinically variable analyses revealed a significant correlation between GTR and Knosp's grades, large tumor volume, bone-invasive and recurrent tumors. Postoperative complications mainly included 34 (1.7 %) CSF (cerebral spinal fluid) leak, 72 (3.5 %) pituitary insufficiency, 30 (1.5 %) meningitis, 20 (0.98 %) cranial nerve deficits, 5 (0.25 %) hematoma, 5 (0.25 %) patients with internal carotid artery injury, and other complications mainly included nasal complications occurred in 168 patients (8.6 %). Overall, there were 3 deaths (0.15 %) occurred in our series. Univariate analysis showed that larger tumors, invasion, bone invasive, recurrent tumors and NGTR were associated with tumor regrowth. Multivariate analysis showed that NGTR and invasion were independent risk factors for tumor regrowth. CONCLUSIONS NGTR and invasion were independent risk factors for tumor regrowth. Endoscopic surgery is an excellent choice for pituitary adenomas. It has the advantages of being minimally invasive, safe, and efficacious.
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Affiliation(s)
- Chuzhong Li
- Beijing Neurosurgical Institute, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China; Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China; Beijing Institute for Brain Disorders Brain Tumor Center, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China; China National Clinical Research Center for Neurological Diseases, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Haibo Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Xuyi Zong
- Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Xinsheng Wang
- Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Songbai Gui
- Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Peng Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Jiwei Bai
- Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Chunhui Liu
- Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Lei Cao
- Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Zhenye Li
- Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Yazhuo Zhang
- Beijing Neurosurgical Institute, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China; Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China; Beijing Institute for Brain Disorders Brain Tumor Center, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China; China National Clinical Research Center for Neurological Diseases, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China.
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Aydin S, Ozoner B, Sahin S, Alizada O, Comunoglu N, Oz B, Gazioglu N, Kadioglu P, Tanriover N. A follow-up study on outcomes of endoscopic transsphenoidal approach for acromegaly. Clin Neurol Neurosurg 2020; 198:106201. [PMID: 32927330 DOI: 10.1016/j.clineuro.2020.106201] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/16/2020] [Accepted: 08/30/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE A thorough follow-up study in which the same clinic presents the change in the surgical outcomes of acromegaly over the years, is still lacking in the endoscopic era. In this study, we intended to evaluate the clinical characteristics, radiological features, surgical and late remission rates of newly diagnosed acromegaly patients treated in our clinic between 2014 and 2019 in order to delineate the surgical remission status according to radiological, microscopic, and hormonal features. As a follow-up to our initial report, we also aimed to display the change of surgical remission rates over time in a tertiary center. METHODS A total of newly diagnosed 106 patients with acromegaly, who underwent endoscopic endonasal trans-sphenoidal approach (EETSA) in the last five years were retrospectively analyzed and presented in this study. Medical records were reviewed in clinical, biochemical, pathological, and radiological aspects to assess the relationship of preoperative patient characteristics with surgical remissions. RESULTS The percentages of the giant pituitary adenomas (≥4 cm), adenomas with suprasellar extension and adenomas with surgically proven invasion of the cavernous sinus in the present series were 13%, 34%, and 20%, respectively. Gross total resection was achieved in 80% of the patients. Surgical remission and late remission rates were 66% and 86%, respectively. Nine (9.4%) patients in our current report had postoperative transient diabetes insipidus. The mean follow-up period in this series was 36.1 ± 18.1 (range 12-59) months. CONCLUSION The presented surgical results are considerably better than our published initial series of acromegaly patients operated in the same clinic between 2007 and 2014. The improvement in surgical remission rate support a positive surgical volume - remission rate relationship for acromegaly in the era of endoscopic endonasal skull base approaches. One possible factor for better results may be the increasing surgical experience in EETSA, which follows a trend toward gradual improvement of long-term late remissions via a multidisciplinary approach.
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Affiliation(s)
- Seckin Aydin
- Department of Neurosurgery, Okmeydani Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Baris Ozoner
- Department of Neurosurgery, Bahcesehir University Faculty of Medicine, Istanbul, Turkey
| | - Serdar Sahin
- Department of Endocrinology and Metabolism, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Orkhan Alizada
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Nil Comunoglu
- Department of Pathology, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Buge Oz
- Department of Pathology, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Nurperi Gazioglu
- Department of Neurosurgery, Demiroglu Bilim University School of Medicine, Istanbul, Turkey
| | - Pinar Kadioglu
- Department of Endocrinology and Metabolism, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Necmettin Tanriover
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey.
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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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Pelsma ICM, Verstegen MJT, de Vries F, Notting IC, Broekman MLD, van Furth WR, Biermasz NR, Pereira AM. Quality of care evaluation in non-functioning pituitary adenoma with chiasm compression: visual outcomes and timing of intervention clinical recommendations based on a systematic literature review and cohort study. Pituitary 2020; 23:417-429. [PMID: 32419072 PMCID: PMC7316692 DOI: 10.1007/s11102-020-01044-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE Surgery in patients with non-functioning pituitary macroadenomas (NFMA) is effective in ameliorating visual function. The urgency for decompression, and preferred timing of surgery related to the preoperative severity of dysfunction is unknown. METHODS Systematic review for evidence to provide clinical guidance for timing of surgical decompression of the optic chiasm, and a cohort study of 30 NFMA patients, in whom mean deviation (MD), and severity of visual dysfunction was assessed. RESULTS Systematic review 44 studies were included with a total of 4789 patients. Postoperatively, visual field defects improved in 87.0% of patients, stabilized in 12.8% and worsened in 1.0%. Specific protocols regarding timing of surgery were not reported. Only seven studies (16.7%) reported on either the duration of visual symptoms, or diagnostic, or treatment delay. Cohort study 30 NFMA patients (50% female, 60 eyes, mean age 58.5 ± 14.8 years), had a median MD of - 5.3 decibel (IQR - 3.1 to - 10.1). MD was strongly correlated with clinical severity (r = - 0.94, P < 0.0001), and were used for severity of defects cut-off values: (1) normal > - 2 dB, (2) mild - 2 dB to - 4 dB, (3) moderate - 4 to - 8 dB, (4) severe - 8 to - 17 dB, (5) very severe < - 17 dB. CONCLUSION Surgical decompression is highly effective in improving visual function. Uniform, quantitative grading of visual dysfunction was lacking. MD is a promising quantitative outcome measure. We provide recommendations for the evaluation of timing of surgery, considering severity of visual impairment, which will need further validation based on expert clinical practice.
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Affiliation(s)
- Iris C M Pelsma
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
- Center for Endocrine Tumors Leiden, Leiden University Medical Center, Leiden, The Netherlands.
| | - Marco J T Verstegen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
- Center for Endocrine Tumors Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Friso de Vries
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Center for Endocrine Tumors Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Irene C Notting
- Department of Ophthalmology, Leiden University Medical Center, Leiden, The Netherlands
- Center for Endocrine Tumors Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Marike L D Broekman
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurosurgery, Haaglanden Medical Center, Den Haag, The Netherlands
| | - Wouter R van Furth
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
- Center for Endocrine Tumors Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Nienke R Biermasz
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Center for Endocrine Tumors Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Alberto M Pereira
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Center for Endocrine Tumors Leiden, Leiden University Medical Center, Leiden, The Netherlands
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Soliman MAR, Eaton S, Quint E, Alkhamees AF, Shahab S, O'Connor A, Haberfellner E, Im J, Elashaal AA, Ling F, Elbreki M, Dang T, Morassutti DJ, Shamisa A. Challenges, Learning Curve, and Safety of Endoscopic Endonasal Surgery of Sellar-Suprasellar Lesions in a Community Hospital. World Neurosurg 2020; 138:e940-e954. [PMID: 32298827 PMCID: PMC7195030 DOI: 10.1016/j.wneu.2020.04.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/04/2020] [Indexed: 11/21/2022]
Abstract
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.
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Affiliation(s)
- Mohamed A R Soliman
- Neurosurgery Department, Cairo University, Cairo, Egypt; Schulich School of Medicine and Density, Western University, London.
| | - Sydney Eaton
- Schulich School of Medicine and Density, Western University, London
| | - Elise Quint
- Schulich School of Medicine and Density, Western University, London
| | - Abdullah F Alkhamees
- Schulich School of Medicine and Density, Western University, London; Neurosurgery Department, Qassim University, Qassim, Kingdom of Saudi Arabia
| | - Saba Shahab
- Schulich School of Medicine and Density, Western University, London
| | - Avalon O'Connor
- Schulich School of Medicine and Density, Western University, London
| | | | - Jacob Im
- Schulich School of Medicine and Density, Western University, London
| | | | - Francis Ling
- Ear, Nose and Throat Department, Windsor Regional Hospital, Western University, ON, Canada
| | - Mustafa Elbreki
- Ear, Nose and Throat Department, Windsor Regional Hospital, Western University, ON, Canada
| | - Tommy Dang
- Neurosurgery Department, Windsor Regional Hospital, Western University, ON, Canada
| | - Dante J Morassutti
- Neurosurgery Department, Windsor Regional Hospital, Western University, ON, Canada
| | - Abdalla Shamisa
- Neurosurgery Department, Windsor Regional Hospital, Western University, ON, Canada
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Hlaváč M, Knoll A, Mayer B, Braun M, Karpel-Massler G, Etzrodt-Walter G, Coburger J, Wirtz CR, Paľa A. Ten years’ experience with intraoperative MRI-assisted transsphenoidal pituitary surgery. Neurosurg Focus 2020; 48:E14. [DOI: 10.3171/2020.3.focus2072] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 03/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEMany innovations have been introduced into pituitary surgery in the quest to maximize the extent of tumor resection. Because of the deep and narrow surgical corridor as well as the heterogeneity of confronted pathologies, anatomical orientation and identification of the target tissue can become difficult. Intraoperative MRI (iMRI) may have the potential to increase extent of resection (EOR) in transsphenoidal pituitary surgery. Furthermore, it may simplify anatomical orientation and risk assessment in difficult cases. Here, the authors evaluated the additional value of iMRI for the resection of pituitary adenomas performed in the past 10 years in their department.METHODSThey performed a retrospective single-center analysis of patients treated for pituitary adenoma in their department after the introduction of iMRI between 2008 and 2018. Of 495 transsphenoidal approaches, 300 consecutive MRI-assisted surgeries for pituitary adenomas encompassing 294 patients were selected for further analysis. Microscopic, endoscopic, or endoscope-assisted microscopic transsphenoidal approaches were distinguished. EOR as well as additional resection following iMRI was evaluated via detailed volumetric analysis. Patients were stratified according to the Knosp adenoma classification. Furthermore, demographic data, clinical symptoms, endocrine outcome, and complications were evaluated. Univariable and multivariable Cox regression analyses of progression-free survival (PFS) were performed.RESULTSPituitary adenomas classified as Knosp grades 0–2 were found in 60.3% of cases (n = 181). The most common tumors were nonfunctioning adenomas (75%). Continued resection following iMRI significantly increased EOR (7.5%, p < 0.001) and the proportion of gross-total resections (GTRs) in transsphenoidal pituitary surgery (54% vs 68.3%, p < 0.001). Additional resection after iMRI was performed in 37% of cases. Only in the subgroup of patients with Knosp grades 0–2 adenomas treated with the microsurgical technique was additional resection significantly more common than in the endoscopic group (p = 0.039). Residual tumor volume, Knosp grade, and age were confirmed as independent predictors of PFS (p < 0.001, p = 0.021, and p = 0.029, respectively) in a multivariable Cox regression analysis. Improvement of visual field deficits was documented in 78.6% of patients whose optic apparatus had been affected preoperatively. Revision surgery was done in 7.3% of cases; in 5.6% of cases, it was performed for cerebrospinal fluid fistula.CONCLUSIONSIn this series, iMRI led to the detection of a resectable tumor remnant in a high proportion of patients, resulting in a greater EOR and higher proportion of GTRs after continued resection in microsurgical and endoscopic transsphenoidal resection of pituitary adenomas. The volume of residual tumor was the most important predictor of PFS. Given the study data, the authors postulated that every bit of removed tumor serves the patient and increases their chances of a favorable outcome.
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Affiliation(s)
- Michal Hlaváč
- 1Department of Neurosurgery, University of Ulm, Günzburg
| | - Andreas Knoll
- 1Department of Neurosurgery, University of Ulm, Günzburg
| | - Benjamin Mayer
- 3Institute of Epidemiology and Medical Biometry, University of Ulm
| | - Michael Braun
- 4Department of Neuroradiology, University of Ulm, Günzburg, Germany
| | | | | | - Jan Coburger
- 1Department of Neurosurgery, University of Ulm, Günzburg
| | | | - Andrej Paľa
- 1Department of Neurosurgery, University of Ulm, Günzburg
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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: 72] [Impact Index Per Article: 18.0] [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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