Results of the lateral rhinotomy approach in transsphenoidal microsurgery for growth hormone-secreting pituitary adenoma

Surgery induced hypopituitarism in acromegalic patients: a systematic review and meta-analysis of the results

PURPOSE

Hypopituitarism is a possible complication of the surgical treatment of acromegaly. However, there is a wide variability in the incidence rates of surgery-induced hypopituitarism. The purpose of this study was the systematic collection and synthesis of information on the incidence rates of hypopituitarism, panhypopituitarism, specific axis deficiencies and diabetes insipidus after surgery for acromegaly treatment.

METHODS

We systematically reviewed all the papers that have reported pituitary deficits after surgery for acromegaly published up until December 2014, in the PubMed database. We identified 92 studies enrolling 6988 patients. A meta-analysis was performed to evaluate the incidence rates. We also performed several subgroup analyses to evaluate the impact of both surgical technique, and treatment prior to surgery, on the results.

RESULTS

The weighted incidence rates were 12.79 % for hypopituitarism (95 % CI 9.88-16.00 %), 2.50 % for panhypopituitarism (95 % CI 1.24-4.15 %), 6.50 % for ACTH deficiency (95 % CI 4.07-9.44 %), 4.39 % for TSH deficiency (95 % CI 2.99-6.04 %), 6.70 % for FSH/LH deficiency (95 % CI 3.89-10.17 %), 14.95 % for GH deficiency (95 % CI 7.25-24.64 %), 10.05 % for transient (95 % CI 7.18-13.33 %) and 2.42 % for permanent diabetes insipidus (95 % CI 1.70-3.27 %).

CONCLUSION

Our study provides new data on the incidence rates of hypopituitarism, specific pituitary axis deficiencies and diabetes insipidus after surgical treatment of acromegaly. Somatotroph function appears to be more prone to deficit than the other axes. However, there is a high heterogeneity between studies and several factors may influence the incidence of hypopituitarism.

Extended transsphenoidal approach with submucosal posterior ethmoidectomy for parasellar tumors. Technical note

The authors have developed an extended transsphenoidal approach with submucosal posterior ethmoidectomy for resection of tumors located in the cavernous sinus or the suprasellar region that are difficult to remove via the conventional transsphenoidal approach. Surgery was performed using this approach in 14 patients with large pituitary adenomas, three patients with craniopharyngiomas, and one patient with a meningioma of the tuberculum sellae. The submucosal dissection of the nasal septum used in the conventional transsphenoidal approach was extended to the superior lateral wall of the nasal cavity to expose the bony surface of the superior turbinate lying under the nasal mucosa. Submucosal posterior ethmoidectomy widened the area visualized through the conventional transsphenoidal approach both superiorly and laterally. This provided a safer and less invasive access to lesions in the cavernous sinus or the suprasellar region through the sphenoid sinus. Using this approach the authors encountered no postoperative complications, such as olfactory disturbance, cranial nerve palsy, or arterial injury. In this article the authors present the surgical methods used in this approach.

Early postoperative growth hormone levels: high predictive value for long-term outcome after surgery for acromegaly

OBJECTIVES

To explore the prognostic value of early - within 1 week - postoperative growth hormone (GH) measurements with regard to outcome after surgery for acromegaly in a short- and a long-term perspective.

DESIGN

Retrospective study of patients operated on between 1987 and 1998, including follow-up for up to 60 months.

SETTING

University hospital.

SUBJECTS

Sixty-eight patients with acromegaly.

INTERVENTION

Pituitary surgery aiming at adenomectomy with preservation of pituitary function.

MAIN OUTCOME MEASURES

The effect of the operation was evaluated after 3 months, mostly by means of an oral glucose load or by insulin-like growth factor 1 (IGF-1). The specificity, sensitivity and the predictive values of an early postoperative mean GH concentration </= 4.8 mU L-1, as well as of the GH response to thyrotropin-releasing hormone (TRH) 3 months after surgery, were calculated with regard to outcome of the operation in both 3-month and long-term perspectives.

RESULTS

Fifty patients (73.5%) showed a satisfactory effect at the evaluation 3 months postoperatively; 45 of these were followed between 12 and 60 months. Relapse was registered in five cases: 12, 12, 24, 24 and 48 months after surgery. In the long-term perspective, the predictive value of an early mean GH </= 4.8 mU L-1 was 93.6% with regard to a satisfactory effect of surgery, compared with 90.2% for a normalized somatomedin C (SmC)/IGF-1 and 90.0% for an absent GH response after TRH. An early mean GH > 4.8 mU L-1 had a 77.8% predictive value for persistent or recurrent disease, compared with 85.7% for persistently increased SmC/IGF-1 and 68.8% for an abnormal GH release after TRH 3 months after surgery. In the short-term perspective, the specificity and the predictive value of an early GH </= 4.8 mU L-1 were 77.3 and 97.1%, respectively. Early GH > 4.8 mU L-1 had a 94.4% sensitivity but a predicative value of only 63.0% for an unsatisfactory effect.

CONCLUSION

Measurement of GH within 1 week after surgery is highly predictive for outcome of surgery for acromegaly. Specifically, an early mean GH </= 4.8 mU L-1 is as predictive for a satisfactory effect of treatment as a normalized IGF-1 3 months after surgery. Early postoperative GH values > 4.8 mU L-1 have a high sensitivity for persistent or recurrent disease in both the short- and long-term perspectives, but lower predictive value. The usefulness of the TRH test can be questioned.