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Baussart B, Hudelist B, Reina V, Villa C, Bertherat J, Assié G, Gaillard S. Diaphragm reconstruction using a TachoSil patch as alternative to intrasellar packing for small focal diaphragm defects in pituitary surgery: a cohort study. Acta Neurochir (Wien) 2024; 166:258. [PMID: 38853198 DOI: 10.1007/s00701-024-06152-5] [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: 02/22/2024] [Accepted: 05/31/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND During pituitary surgery, CSF leaks are often treated by intrasellar packing, using muscle or fat grafts. However, this strategy may interfere with the interpretation of postoperative MRI and may impact the quality of resection in cases of second surgery, due to the existence of additional fibrous tissue. We present an alternative technique, using a diaphragm reconstruction with a heterologous sponge combining fibrinogen and thrombin (TachoSil), applied in selected patients with low-flow CSF leaks. This study investigates the surgical outcome of patients treated with this strategy. METHODS From a cohort of 2231 patients treated from June 2011 to June 2023 by endoscopic endonasal approach for pituitary surgery, the surgical technique of diaphragm repair with TachoSil patch performed in 55 patients (2.6%) was detailed, and the rate of closure failure was analyzed at 6 months postoperatively. No intrasellar packing was used and sellar floor reconstruction was performed whenever possible. The rate of postoperative CSF leak was compared with that reported in three previous publications that also used the TachoSil patch technique. RESULTS Patients were mostly women (F/M ratio: 1.2) with a median age of 53.6 years. Surgery was indicated for non-functioning adenomas, Cushing's disease, acromegaly, and Rathke's cleft cysts in 38/55 (69.1%), 6/55 (10.9%), 5/55 (9.1%) and 6/55 (10.9%) patients respectively. The rate of postoperative CSF leak was 1.8% (n = 1/55), which was not significantly different from that reported in the three cohorts from the literature (2.8%, p > 0.05). No postoperative meningitis was recorded. CONCLUSIONS In highly selected patients with low-flow CSF leaks related to small focal diaphragm defects, diaphragm reconstruction using a TachoSil patch can be a safe and valuable alternative to intrasellar packing.
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Affiliation(s)
- Bertrand Baussart
- Department of Neurosurgery, Assistance Publique-Hôpitaux de Paris, La Pitié-Salpêtrière University Hospital, Assistance Publique Hôpitaux de Paris, 47-83 Boulevard de L'Hôpital, 75013, Paris, France.
- Université Paris Cité, CNRS, INSERM, Institut Cochin, 75014, Paris, France.
| | - Benoit Hudelist
- Department of Neurosurgery, Assistance Publique-Hôpitaux de Paris, La Pitié-Salpêtrière University Hospital, Assistance Publique Hôpitaux de Paris, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Vincent Reina
- Department of Neurosurgery, Assistance Publique-Hôpitaux de Paris, La Pitié-Salpêtrière University Hospital, Assistance Publique Hôpitaux de Paris, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Chiara Villa
- Department of Neuropathology, Assistance Publique-Hôpitaux de Paris, La Pitié-Salpêtrière University Hospital, Paris, France
| | - Jérôme Bertherat
- Université Paris Cité, CNRS, INSERM, Institut Cochin, 75014, Paris, France
- Department of Endocrinology, Center for Rare Adrenal Diseases, Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Guillaume Assié
- Université Paris Cité, CNRS, INSERM, Institut Cochin, 75014, Paris, France
- Department of Endocrinology, Center for Rare Adrenal Diseases, Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Stephan Gaillard
- Department of Neurosurgery, Assistance Publique-Hôpitaux de Paris, La Pitié-Salpêtrière University Hospital, Assistance Publique Hôpitaux de Paris, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
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Lu B, Zhang Y, Liu C, Ma X, Liu G, Bie Z, Yang Z, Liu P. Intraoperative cerebrospinal fluid leakage and residual tumors in endoscopic transsphenoidal surgery for pituitary adenoma: risk analysis and nomogram development. Acta Neurochir (Wien) 2023; 165:4131-4142. [PMID: 37966528 DOI: 10.1007/s00701-023-05830-0] [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: 05/07/2023] [Accepted: 09/19/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Endoscopic transsphenoidal surgery is the primary method used to treat pituitary adenomas (PAs) at present; however, this technique is associated with certain risks, including cerebrospinal fluid leakage (CFL) and residual tumors (RTs). In this study, we aimed to identify specific risk factors for intraoperative CFL (ioCFL) and postoperative RT in patients with pituitary adenoma and construct a corresponding nomogram for risk assessment. METHODS We collected a range of information from 782 patients who underwent endoscopic transsphenoidal PA resection in the Department of Neurosurgery at Beijing Tiantan Hospital between 2019 and 2021. Patients were then randomly assigned to training and validation groups (in a 8:2 ratio) with R software. Univariate and multivariable logistic regression models were then used to screen variables related to ioCFL and RT. These variables were then used to construct a predictive nomogram. Finally, the accuracy of the nomogram was validated by receiver operating characteristic curve (ROC) analysis, calibration plots, and decision curve analysis (DCA). RESULTS Univariate and multivariable logistic regression models identified four risk factors for ioCFL (Hardy grade, tumor size, position, and consistency) and five risk factors for RT (operation time, tumor size, consistency, Knosp grade, and primary/recurrence type). The area under the ROC curve (AUC) for the ioCFL risk model was 0.666 and 0.697 for the training and validation groups, respectively. For RT, the AUCs for the two groups were 0.788 and 0.754, respectively. The calibration plots for the ioCFL and RT models showed high calibration quality and DCA analysis yielded excellent efficiency with regards to clinical decision making. CONCLUSION Tumor size, growth characteristics, and invasion location were identified as the main factors affecting intraoperative CFL and RT. With our novel nomogram, surgeons can identify high-risk patients according to preoperative and intraoperative tumor performance and reduce the probability of complications.
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Affiliation(s)
- Bin Lu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yu Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Chenan Liu
- Department of Gastrointestinal Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xin Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Gemingtian Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Zhixu Bie
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Zhijun Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Pinan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.
- Department of Neural Reconstruction, Beijing Key Laboratory of Central Nervous System Injury, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China.
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Yamamoto M, Aiyama H, Koiso T, Watanabe S, Kawabe T, Sato Y, Higuchi Y, Barfod BE, Kasuya H. Postsurgical Salvage Radiosurgery for Nonfunctioning Pituitary Adenomas Touching/Compressing the Optic Chiasm: Median 13-Year Postirradiation Imaging Follow-up Results. Neurosurgery 2020; 85:476-485. [PMID: 30169702 DOI: 10.1093/neuros/nyy357] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/11/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND There is little information on long-term outcomes after salvage treatment by either surgery or stereotactic radiosurgery (SRS) for patients with recurrent/residual nonfunctioning pituitary adenomas (NFPAs). OBJECTIVE To reappraise the efficacy and safety of SRS for patients with NFPAs touching/compressing the optic apparatus (OA). METHODS We studied 27 patients (14 females, 13 males; mean age: 61 [range, 19-85] yr) who underwent SRS between 1998 and 2008 for NFPAs with such condition. The median tumor volume was 4.9 (range, 1.8-50.8) cc. To avoid excess irradiation to the OA, the lower part of the tumor was covered with a 50% or a 60% isodose gradient, ie 49% to 98% (mean, 84%; median, 88%) of the entire tumor received the selected doses. Median doses at the tumor periphery/OA were 7.6/11.0 (interquartile range [IQR], 5.8-9.1/10.1-11.8) Gy. RESULTS Seven patients (26%) were confirmed to be deceased due to unrelated diseases at a median post-SRS period of 149 (IQR, 83-158) mo. Follow-up magnetic resonance imaging (MRI) showed tumor growth in 2 patients (7%) at the 11th and 134th post-SRS month; the former underwent surgery and the other SRS. Excluding these 2 patients, the latest follow-up MRI examinations, performed 13 to 238 (median: 168, IQR: 120-180) mo after SRS, showed no size changes in 5 (19%) and shrinkage in 20 (74%) patients. Cumulative incidences of tumor growth control were 96.3% and 91.8% at the 120th and 180th post-SRS month. None of our patients developed subjective symptoms suggesting SRS-induced optic neuropathy or endocrinological impairment. CONCLUSION In patients with NFPAs touching/compressing the OA, SRS achieves good long-term results.
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Affiliation(s)
- Masaaki Yamamoto
- Katsuta Hospital Mito GammaHouse, Hitachi-naka, Ibaraki, Japan.,Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Hitoshi Aiyama
- Katsuta Hospital Mito GammaHouse, Hitachi-naka, Ibaraki, Japan.,Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Takao Koiso
- Katsuta Hospital Mito GammaHouse, Hitachi-naka, Ibaraki, Japan.,Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Shinya Watanabe
- Katsuta Hospital Mito GammaHouse, Hitachi-naka, Ibaraki, Japan.,Tsukuba Clinical Research and Development Organization, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Takuya Kawabe
- Katsuta Hospital Mito GammaHouse, Hitachi-naka, Ibaraki, Japan.,Department of Neurosurgery, Rakusai Shimizu Hospital, Kyoto, Japan
| | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Yoshinori Higuchi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Bierta E Barfod
- Katsuta Hospital Mito GammaHouse, Hitachi-naka, Ibaraki, Japan
| | - Hidetoshi Kasuya
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
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Jiao W, Huang Y, Sun W, Lei T. Microscopic Transnasal Transsphenoidal Surgery for Pediatric Pituitary Adenomas. J Craniofac Surg 2018; 28:1010-1012. [PMID: 28230605 DOI: 10.1097/scs.0000000000003632] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Microscopic transnasal transsphenoidal surgery (MTTS) has been a time-confirmed effective treatment for pituitary adenomas; however, the data supporting its use in pediatric patients is limited. In this study, the authors summarize the authors' 5-year experience of pituitary adenomectomy via MTTS in a pediatric population. The authors retrospectively reviewed the medical records of 35 patients aged ≤18 years who underwent microscopic transnasal transsphenoidal approach for pituitary adenomas between January 2011 and December 2015. Age, sex, symptoms, tumor size, extent of tumor resection, surgical outcomes, and complications were reviewed. All patients underwent MTTS 39 times. Total resection was obtained in 31 (88.6%) patients, while subtotal resection was achieved in 4 (11.4%) and no patient had partial resection. For the 21 patients with preoperative visual impairment, 18 (85.7%) resolved and 3 (14.3%) obtained subjective improvement. Of the 33 patients with preoperative hyperhormonal levels, endocrine function reduced to normal reference range in 28 (84.8%), decreased in 3 (9.1%) and 2 (6.1%) patients had no change. Diabetes insipidus occurred in 4 (11.4%) patients, of whom 1 patient (2.9%) developed persistent diabetes insipidus that was treated with Minirin. One patient incurred postoperative cerebrospinal fluid leakage that was resolved by lumbar drainage. Hypopituitarism occurred in 3 patients, of whom 1 patient developed permanent hypopituitarism that required hormone replacement therapy. There were no patients of death, intracranial hematoma, or meningitis. In conclusion, MTTS is a safe and effective surgical option for pediatric pituitary adenomas with minimal morbidity and excellent outcomes.
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Affiliation(s)
- Wei Jiao
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Negm HM, Al-Mahfoudh R, Pai M, Singh H, Cohen S, Dhandapani S, Anand VK, Schwartz TH. Reoperative endoscopic endonasal surgery for residual or recurrent pituitary adenomas. J Neurosurg 2017; 127:397-408. [DOI: 10.3171/2016.8.jns152709] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVERegrowth of the lesion after surgical removal of pituitary adenomas is uncommon unless subtotal resection was originally achieved in the first surgery. Treatment for recurrent tumor can involve surgery or radiotherapy. Locations of residual tumor may vary based on the original approach. The authors evaluated the specific sites of residual or recurrent tumor after different transsphenoidal approaches and describe the surgical outcome of endoscopic endonasal transsphenoidal reoperation.METHODSThe authors analyzed a prospectively collected database of a consecutive series of patients who had undergone endoscopic endonasal surgeries for residual or recurrent pituitary adenomas after an original transsphenoidal microscopic or endoscopic surgery. The site of the recurrent tumor and outcome after reoperation were noted and correlated with the primary surgical approach. The chi-square or Fisher exact test was used to compare categorical variables, and the Mann-Whitney U-test was used to compare continuous variables between surgical groups.RESULTSForty-one patients underwent surgery for residual/recurrent pituitary adenoma from 2004 to 2015 at Weill Cornell Medical College. The previous treatment was a transsphenoidal microscopic (n = 22) and endoscopic endonasal (n = 19) surgery. In 83.3% patients (n = 30/36) there was postoperative residual tumor after the initial surgery. A residual tumor following endonasal endoscopic surgery was less common in the sphenoid sinus (10.5%; 2/19) than it was after microscopic transsphenoidal surgery (72.7%; n =16/22; p = 0.004). Gross-total resection (GTR) was achieved in 58.5%, and either GTR or near-total resection was achieved in 92.7%. Across all cases, the average extent of resection was 93.7%. The rate of GTR was lower in patients with Knosp-Steiner Grade 3–4 invasion (p < 0.0005). Postoperative CSF leak was seen in only one case (2.4%), which stopped with lumbar drainage. Visual fields improved in 52.9% (n = 9/17) of patients and were stable in 47% (n = 8/17). Endocrine remission was achieved in 77.8% (n = 14/18) of cases, 12 by surgery alone and 2 by adjuvant medical (n = 1) and radiation (n = 1) therapy. New diabetes insipidus occurred in 4.9% (n = 2/41) of patients—in one of whom an additional single anterior hormonal axis was compromised—and 9.7% (n = 4/41) of patients had a new anterior pituitary hormonal insufficiency.CONCLUSIONSEndonasal endoscopic reoperation is extremely effective at removing recurrent or residual pituitary adenomas that remain after a prior surgery, and it may be preferable to radiation therapy particularly in symptomatic patients. Achievement of GTR is less common when lateral cavernous sinus invasion is present. The locations of residual/recurrent tumor were more likely sphenoidal and parasellar following a prior microscopic transsphenoidal surgery and sellar following a prior endonasal endoscopic surgery.
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Affiliation(s)
- Hazem M. Negm
- Departments of 1Neurological Surgery,
- 4Department of Neurosurgery, Menoufia University, Menoufia, Egypt
| | - Rafid Al-Mahfoudh
- Departments of 1Neurological Surgery,
- 5South East Neurosurgery and Spinal Surgery, Brighton and Sussex University Hospitals NHS Trust, East Sussex, United Kingdom
| | - Manish Pai
- Departments of 1Neurological Surgery,
- 6Tata Main Hospital, Jamshedpur, India
| | - Harminder Singh
- Departments of 1Neurological Surgery,
- 9Stanford University School of Medicine, Stanford, California
| | - Salomon Cohen
- Departments of 1Neurological Surgery,
- 7Department of Neurosurgery, National Institute of Neurology and Neurosurgery, “Manuel Velasco Suarez,” Mexico City, Mexico
| | - Sivashanmugam Dhandapani
- Departments of 1Neurological Surgery,
- 8Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India; and
| | | | - Theodore H. Schwartz
- Departments of 1Neurological Surgery,
- 2Otolaryngology, and
- 3Neuroscience, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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Outcomes and Complications of Endoscopic Versus Microscopic Transsphenoidal Surgery in Pituitary Adenoma. J Craniofac Surg 2016; 27:1015-20. [DOI: 10.1097/scs.0000000000002684] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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