The endoscopic hemi-transseptal approach to the sella turcica: operative technique and case-control study

A randomized prospective comparative study on sinonasal morbidity and quality of life of transsphenoidal endoscopic surgery for pituitary adenomas: endonasal versus trans-septal approach

PURPOSE

Endoscopic endonasal transsphenoidal approach (Endonasal approach) is commonly used to treat pituitary adenomas. The extent of dissection possibly changes the anatomy and the physiology of the nasal cavities and could give rise to post-operative morbidity and the quality of life (QoL). The purpose of this study was to investigate sinonasal morbidity and general QoL in patients who underwent surgery for treatment of pituitary adenoma, comparing Endonasal and endoscopic trans-septal transsphenoidal approach (Trans-septal approach).

METHODS

A prospective observational study, recruiting 40 patients undergoing surgery for pituitary adenoma, 20 via Endonasal approach and 20 via Trans-septal approach at our institution. Surveys with Sinonasal Outcome Test-22 (SNOT-22), Chronic Sinusitis Survey (CSS), and Short Form Health Survey 36 version 2 (SF-36v2) were obtained to collect QoL data pre- and postoperatively.

RESULTS

All the 40 patients completed the questionnaires. At 6 months postoperatively, the SNOT-22 and CSS score shows significant improvements both in Endonasal approach (p = 0.01) and in Trans-septal approach (p = 0.02). No significant difference in sinonasal morbidity is observed between the two groups for SNOT-22 (p = 0.13) and CSS scores, except for sinus headache (p = 0.49), with a better score in Endonasal approach. The mean SF-36v2 scores remain the same in pre- and post-operative periods, but an improvement in time is seen in general health (p = 0.027), and general health compared to one year ago (p < 0.001).

CONCLUSIONS

Endoscopic transsphenoidal surgery has negligible morbidity and does not negatively affect the nasal function in the long term. Endonasal approach and Trans-septal approach are comparable in terms of morbidity outcomes and general QoL, leaving the choice of the approach to the surgeon preference.

Endoscopic 1½-transseptal approach for pituitary surgery

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.

Heterogeneity in Outcome Reporting in Endoscopic Endonasal Skull Base Reconstruction: A Systematic Review

Objective  Presently, there are no standards for reporting outcomes of endoscopic endonasal skull base reconstruction (ESBR). This is problematic as a lack of consistent reporting makes synthesizing findings in systematic reviews and meta-analysis challenging. Thus, the aim of this study was to systematically review and describe the patterns of reporting outcomes in ESBR as a foundation for developing reporting guidelines. Study Design  Present study is a systematic review. Methods  Embase, PubMed, CINAHL, Cochrane Library, and Web of Science were searched for all publications with ≥25 patients and a focus on ESBR. The reporting patterns of each study's variables and outcomes were assessed. Results  A total of 112 studies were included in the review. The most commonly reported demographic variables were the number of included patients ( n  = 112, 100%) and types of pathologies treated ( n  = 104, 92.9%). Meanwhile, the most routinely described preoperative variable was history of prior treatment ( n  = 48, 42.9%). Type of reconstruction was a commonly reported intraoperative variable ( n  = 110, 98.2%), though the rate of intraoperative cerebrospinal fluid (CSF) leak was noted in only 76 studies (67.9%). With regard to postoperative outcomes, postoperative CSF leak rate was routinely provided ( n  = 101, 90.2%), but reporting of other surgical complications was more inconsistent. Ultimately, of the 43 variables and outcomes reviewed, a median of 12 (range: 4-22) was reported in each study. Conclusion  There is significant heterogeneity in the outcomes reported in studies relating to ESBR. This highlights the need for the development of standard reporting guidelines to minimize bias and improve interstudy comparability.

Nasal Morbidity and Quality of Life After Endoscopic Transsphenoidal Surgery: A Single-Center Prospective Study

OBJECTIVE

The aim of this study was to assess nasal morbidity of endoscopic transsphenoidal approaches (ETAs) for treatment of sellar and parasellar diseases through evaluation of quality of life (QoL) and nasal function. The impact of different ETAs, according to extent and reconstruction technique, was also studied.

METHODS

Patients undergoing ETA for treatment of sellar or parasellar lesions were prospectively recruited and examined preoperatively and at 6 months after surgery according to the following workup: nasal endoscopy, rhinomanometry, acoustic rhinometry, University of Pennsylvania Smell Identification Test, Anterior Skull Base Nasal Inventory-12, Sino-nasal Outcome Test-22, and Short-Form Health Survey-36 (SF-36).

RESULTS

Of 34 patients initially recruited, 29 completed follow-up examinations. Seven patients (24.14%) developed turbinoseptal synechiae; anterior septal perforations were observed in 3 patients (10.35%). More extended surgical dissection was associated with the presence of postoperative septal perforation and synechiae. No significant difference was noted between preoperative and postoperative results on the University of Pennsylvania Smell Identification Test, acoustic rhinometry, Sino-nasal Outcome Test-22, or Anterior Skull Base Nasal Inventory-12. There was a significant increase in nasal airflow after surgery and improvement of the Short-Form Health Survey-36 score in 4 of 8 domains.

CONCLUSIONS

The modular ETA technique is associated with minimal morbidity and preserves nasal patency, airflow, and olfactory function. Quality of life is not affected and although small septal perforations and synechiae can be observed, nasal physiology is not compromised. Nonetheless, careful manipulation of sinonasal structures is recommended to minimize postoperative sequelae.

Extent of Surgery in Endoscopic Transsphenoidal Skull Base Approaches and the Effects on Sinonasal Morbidity

Background

Endoscopic transsphenoidal skull base surgery (ETSS) is now considered the criterion standard approach for resection of pituitary adenomas and other midline anterior skull base lesions. Normal sinonasal structures are resected during ETSS, which raises concerns for nasal morbidity and patient-based outcome.

Objective

To perform a surgical outcome assessment by examining whether the extent of ETSS approaches affected patient-specific sinonasal quality of life as measured by the 22-item Sino-Nasal Outcome Test (SNOT-22).

Methods

A single-center prospective cohort study of patients operated on by the same skull base team between 2012 and 2016. Patients with completed pre- and postoperative SNOT-22 were included. The primary outcome was SNOT-22 scores at preoperative, 0–1 month, 2–4 months, >5 months follow-up. Age, sex, tumor pathology, surgical procedure, and intraoperative cerebral spinal fluid leak repair were also obtained.

Results

Of the 249 ETSS performed, 148 patients (59%) had at least one completed SNOT-22; 45 (18%) met the inclusion criteria. Sinonasal quality of life based on SNOT-22 at the 0–1-month follow-up was significantly worse than the presurgical levels (p < 0.05). However, there was a return of SNOT-22 scores to preoperative levels at 2–4 months (p > 0.05), which was sustained at >5 months (p > 0.05). Factors such as the extent of ETSS, a previous nasal surgery, repair of an intraoperative cerebral spinal fluid leak, and the tumor pathology did not affect SNOT-22 scores at any follow-up intervals (p > 0.05).

Conclusion

Sinonasal quality of life worsened after ETSS at 0–1 month follow-up but returned to preoperative levels at 2–4 months and remained at postoperative levels >5 months. Analysis of these data will allow us to educate our patients that the anticipated nasal morbidity after ETSS is usually only transient and should be expected to recover to preoperative levels.

Hemi-transseptal Approach for Pituitary Surgery: A Follow-Up Study

Objectives The hemi-transseptal (Hemi-T) approach was developed to overcome the potential drawbacks of the nasoseptal flap (NSF) in endoscopic endonasal transsphenoidal skull base surgery. In this study, we describe further refinements on the Hemi-T approach, and report long-term outcomes as compared with traditional methods of skull base reconstruction. Design A retrospective case-control study. Setting Montreal Neurological Institute and Jewish General Hospital, Montreal, Canada. Participants Patients who underwent endoscopic endonasal transsphenoidal approach to skull base pathology. Main Outcome Measures Operative time, CSF rhinorrhea, and postoperative nasal morbidity. Results A total of 105 patients underwent the Hemi-T approach versus 40 controls. Operative time was shorter using the Hemi-T technique (180.51 ± 56.9 vs. 202.9 ± 62 minutes; p = 0.048). The rates of nasal morbidity (septal perforation [5/102 vs. 6/37; p = 0.029] and mucosal adhesion [11/102 vs. 10/39 p = 0.027]), fascia lata harvest (21/100 vs. 18/39; p = 0.0028), and postoperative CSF leak rates (7/100 vs. 9/38; p = 0.006) were lower in the Hemi-T group. Conclusion Advantages of the Hemi-T approach over traditional exposure techniques include preservation of the nasal vascular pedicle, shorter operative time, reduced fascia lata harvest rates, and decreased nasal morbidity.