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Tang OY, Chen JS, Monje S, Kumarapuram S, Eloy JA, Liu JK. Comparison of Surgical Modalities for Giant Pituitary Adenoma: A Systematic Review and Meta-Analysis of 1413 Patients. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01238. [PMID: 38967434 DOI: 10.1227/ons.0000000000001238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 04/22/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Giant pituitary adenomas (GPAs) are a challenging clinical entity, composing 5% to 15% of all pituitary adenomas. While the endoscopic endonasal transsphenoidal (EET) approach has surpassed the microsurgical transsphenoidal (MT) and transcranial (TC) approaches as the first-line surgical modality in most institutions, a systematic review comparing the 3 approaches has not been undertaken since 2012. Given growing adoption of EET and development of novel operative techniques over the past decade, an updated comparison of GPA surgical modalities is warranted. METHODS We identified all studies related to the surgical management of GPAs in PubMed, Embase, and Web of Science from inception to December 31, 2021. End points assessed included gross total resection (GTR) rates, postoperative visual improvement, mortality, and perioperative complications. RESULTS After screening of 1701 studies, we identified 45 studies on the surgical management of GPAs for meta-analysis. Thirty-one used the EET approach (n = 1413), 11 studies used the MT approach (n = 601), and 10 used the TC approach (n = 416). The cumulative number of patients treated by EET did not exceed that of patients treated by the TC or MT approaches until 2014 and 2015, respectively. Despite patients undergoing EET having the highest average tumor diameter, pooled rates for GTR were significantly higher for EET (42%) than MT (33%, P < .001) and TC (8%, P < .001) and EET similarly exhibited superior rates of visual improvement (85%) than MT (73%, P < .001) and TC (56%, P < .001). Mortality rates were comparable between EET (0.6%) and MT (1.6%), but EET had significantly lower mortality than TC (2.7%, P < .001). Compared with MT, EET had lower rates of hypopituitarism (8.5% vs 14.9%, P = .012) but higher rates of diabetes insipidus (3.1% vs 0.5%, P = .001). CONCLUSION In an updated meta-analysis of 1413 patients with GPA, EET resection conferred significantly higher rates of visual improvement and GTR, when compared with the MT and TC approaches.
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Affiliation(s)
- Oliver Y Tang
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jia-Shu Chen
- Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Silas Monje
- Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Siddhant Kumarapuram
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Jean Anderson Eloy
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Otolaryngology and Facial Plastic Surgery, Cooperman Barnabas Medical Center, RWJ Barnabas Health, Livingston, New Jersey, USA
- Department of Neurosurgery, Cooperman Barnabas Medical Center, RWJ Barnabas Health, Livingston, New Jersey, USA
| | - James K Liu
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Otolaryngology and Facial Plastic Surgery, Cooperman Barnabas Medical Center, RWJ Barnabas Health, Livingston, New Jersey, USA
- Department of Neurosurgery, Cooperman Barnabas Medical Center, RWJ Barnabas Health, Livingston, New Jersey, USA
- Department of Neurosurgery, Skull Base Institute of New Jersey, Neurosurgeons of New Jersey, NYU Langone Neurosurgery Network, Livingston, New Jersey, USA
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Eguiluz-Melendez A, Sangrador-Deitos MV, Calderón-Yrigoyen PJ, Rodríguez-Hernández AL, Guinto-Nishimura YG, Alcazar-Felix JR, Caballero-Delgado S, Portocarrero-Ortiz AL, Valencia-Ramos C, Gómez-Amador LJ. Clinical and Surgical Outcomes of Endoscopic Endonasal Approach for Giant Pituitary Adenomas: Analysis of Predictive Factors. World Neurosurg 2024; 184:e659-e673. [PMID: 38342172 DOI: 10.1016/j.wneu.2024.02.009] [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: 12/27/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND Giant pituitary adenomas (GPAs) are defined as tumors with ≥40 mm in any maximum diameter, and these tend to invade multiple intracranial compartments. Hence, treatment remains a surgical challenge. OBJECTIVE To describe the clinical and surgical outcomes of the endoscopic endonasal approach (EEA) for GPA in a pituitary referral center in Latin America and to analyze associated predictive factors. METHODS 37 patients with histologically-confirmed GPA treated solely through the EEA between a 2-year period were included. Preoperative and postoperative clinical and neuroimaging findings; surgical morbidity and mortality; and binary logistic regression analysis to assess predictive factors were analyzed. RESULTS Preoperative visual impairment prevalence was 97.3%. Mean tumor volume was 32 cc and gross total resection rate was 40.5%. Favorable visual acuity and visual fields outcome rate was 75% and 82.9%, respectively. In the multivariate analysis, bilateral cavernous sinus invasion (P = 0.018) and postoperative cerebrospinal fluid (CSF) leak (P = 0.036) were associated with an unfavorable visual acuity outcome, while radiation therapy (P = 0.035) was for visual fields. Similarly, intraoperative CSF leak was a predictive factor for postoperative CSF leak (10.8%) (P = 0.042) and vascular injury (13.5%) (P = 0.048). CONCLUSIONS In this first Mexican clinical series, we demonstrated that the EEA is a safe and effective technique for GPA, although early diagnosis and prompt intervention may promote further visual function preservation without significant endocrine morbidity.
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Affiliation(s)
- Aldo Eguiluz-Melendez
- Department of Neurological Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | | | - P Juan Calderón-Yrigoyen
- Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - A Luis Rodríguez-Hernández
- Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Y Gerardo Guinto-Nishimura
- Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | | | - Silvia Caballero-Delgado
- Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - A Lesly Portocarrero-Ortiz
- Department of Neuroendocrinology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Cristopher Valencia-Ramos
- Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - L Juan Gómez-Amador
- Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
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3
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Pilonieta M, Pérez P, Prevedello DM. The Clinical Relevance of the Thalamogeniculate Arteries in Endoscopic Endonasal Surgery for Giant Pituitary Adenomas in the Interpeduncular Fossa. J Neurol Surg A Cent Eur Neurosurg 2024; 85:100-104. [PMID: 35760289 DOI: 10.1055/s-0042-1748773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Bilateral thalamic stroke is usually due to compromised artery of Percheron, an anatomical variation of the vascular supply of the thalamus. The stroke in this area is very uncommon, and is mainly due to top of the basilar syndrome. Other causes are extremely rare. We describe the case of a patient with a pituitary adenoma who underwent surgery and later presented with a bilateral thalamic infarct, suggesting compromise of the artery of Percheron. This would be the third case published in the literature about this complication. We present a literature review about the vascular supply of the thalamus, the artery of Percheron, and its involvement in pituitary surgery.
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Affiliation(s)
- Martin Pilonieta
- CALDAS, Santa Sofia de Caldas Academic State Hospital, Manizales, Colombia
| | - Paula Pérez
- CALDAS, Santa Sofia de Caldas Academic State Hospital, Manizales, Colombia
| | - Daniel M Prevedello
- Department of Neurosurgery, The Ohio State University, Columbus, Ohio, United States
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4
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Yang JY, Byun YH, Kim MS, Kim JH, Park CK, Kim YH, Kang H. Factors Limiting Complete Resection in the Subarachnoid Space in Endoscopic Surgery for Giant Pituitary Adenoma. World Neurosurg 2024; 181:e222-e233. [PMID: 37821027 DOI: 10.1016/j.wneu.2023.10.018] [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: 09/19/2023] [Accepted: 10/04/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVES Giant pituitary adenomas (>4 cm, GPAs) have presented great challenges to surgeons because the residual tumor in the subarachnoid space can cause hemorrhage or vessel injury following apoplexy. This study aimed to investigate the factors limiting surgical success in endoscopic skull base surgery (ESS) for GPAs. METHODS ESS was performed on 67 consecutive patients with GPAs from 2010 to 2020. We retrospectively analyzed the clinical and radiologic features and surgical outcomes. Correlations between the tumor characteristics and extent of resection were statistically presented with odds ratios (ORs). RESULTS Preoperative visual and hormonal impairments were present in 59 (88.1%) and 55 patients (82.1%), respectively. Gross total resection (GTR) was achieved in 58.2% of patients, and the tumor remained on the lateral side of the subarachnoid space or the cavernous sinus when complete resection failed. The tumor volume, maximal diameter, multilobulated shape, cavernous sinus invasion, posterior fossa extension, and extent of suprasellar lateral extension of tumors were significantly correlated with incomplete resection. In tumors with subarachnoid lateral extension, greater distances from the medial wall of the proximal cavernous internal carotid artery to the most lateral tumor significantly increased the risk of incomplete resection for the suprasellar lateral portion of the tumor, with an OR of 1.21. CONCLUSIONS Considerable surgical planning in ESS for GPAs is crucial for complete resection and patient safety. We elucidated that lateral extension of tumors in the subarachnoid space hindered the surgical success of the suprasellar portion of the tumor.
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Affiliation(s)
- Jung Yeop Yang
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yoon Hwan Byun
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Min-Sung Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jung Hee Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Pituitary Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chul-Kee Park
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yong Hwy Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea; Pituitary Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ho Kang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea.
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5
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Joshi KC, Kolb B, Khalili BF, Munich SA, Byrne RW. Surgical Strategies in the Treatment of Giant Pituitary Adenomas. Oper Neurosurg (Hagerstown) 2024; 26:4-15. [PMID: 37655871 DOI: 10.1227/ons.0000000000000896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 07/12/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The management of giant pituitary adenomas (GPAs) is challenging due to associated endocrinopathies and the close proximity of these tumors to critical structures, such as the optic nerves, structures of the cavernous sinus, and hypothalamus. The objective of this review article was to summarize the current management strategies for giant pituitary adenomas, including the role of open and endoscopic surgical approaches and the role of medical and radiation therapy in conjunction with surgery. METHODS We conducted a retrospective review of GPAs operated at our institute between January 2010 and March 2023. Surgical approaches, extent of resection, and associated complications were documented. Furthermore, we conducted a thorough literature review to identify relevant studies published in the past decade, which were incorporated along with insights gained from our institutional case series of GPAs to analyze and integrate both the existing knowledge base and our institution's firsthand experience in the management of GPAs. RESULTS A total of 46 giant pituitary adenomas (GPAs) were operated on, using various surgical approaches. Transsphenoidal approach was used in 25 cases and a staged approach using transsphenoidal and pterional was used in 15 cases. Other approaches included transcortical-transventricular, transcallosal, pterional/orbitozygomatic, and subfrontal approaches. Complications and technical nuances were reported. CONCLUSION The management of giant pituitary adenomas remains complex, often involving several modalities-open or endoscopic resection, radiosurgery, and medical management of both the tumor and associated endocrinopathies. Surgical resections are often challenging procedures that require careful consideration of several factors, including patient characteristics, tumor location, and size, and the experience and skill of the surgical team.
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Affiliation(s)
- Krishna C Joshi
- Department of Neurosurgery, Rush University Medical Center, Chicago , Illinois , USA
| | - Bradley Kolb
- Department of Neurosurgery, Rush University Medical Center, Chicago , Illinois , USA
| | | | - Stephan A Munich
- Department of Neurosurgery, Rush University Medical Center, Chicago , Illinois , USA
| | - Richard W Byrne
- Department of Neurosurgery, Rush University Medical Center, Chicago , Illinois , USA
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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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Nie D, Fang Q, Wong W, Gui S, Zhao P, Li C, Zhang Y. The effect of endoscopic transsphenoidal somatotroph tumors resection on pituitary hormones: systematic review and meta-analysis. World J Surg Oncol 2023; 21:71. [PMID: 36859291 PMCID: PMC9976528 DOI: 10.1186/s12957-023-02958-2] [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: 10/06/2022] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
PURPOSE Currently, endoscopic transsphenoidal surgery is the main treatment for pituitary neuroendocrine tumors (PitNETs). Excision of the tumor may have positive or negative effects on pituitary endocrine function, and the pituitary function of somatotroph tumors is a point of particular concern after the operation. This study aimed to conduct a meta-analysis on the effect of endoscopic transsphenoidal somatotroph tumor resection on pituitary function. METHODS A systematic literature search was conducted for articles that included the evaluation of pituitary target gland before and after endoscopic transsphenoidal pituitary tumor resection and were published between 1992 and 2022 in PubMed, Cochrane, and Ovid MEDLINE. RESULTS Sixty-eight studies that included biochemical remission rates in 4524 somatotroph tumors were concluded. According to the 2000 consensus, the biochemical remission rate after transsphenoidal endoscopic surgery was 66.4% (95% CI, 0.622-0.703; P = 0.000), the biochemical remission rate was 56.2% according to the 2010 consensus (95% CI, 0.503-0.620; P = 0.041), and with the rate of biochemical remission ranging from 30.0 to 91.7% with investigator's definition. After endoscopic resection, adrenal axis dysfunction was slightly higher than that before surgery, but the difference was not statistically significant. Hypothyroidism was 0.712 times higher risk than that before surgery (OR = 0.712; 95% CI, 0.527-0.961; P = 0.027). Hypogonadism was 0.541 times higher risk than that before surgery (OR = 0.541; 95% CI, 0.393-0.746; P = 0.000). Hyperprolactinemia was 0.131 times higher risk than that before surgery (OR = 0.131; 95% CI, 0.022-0.783; P = 0.026). The incidence of pituitary insufficiency was 1.344 times the risk before surgery after endoscopic resection of somatotroph tumors, but the difference was not statistically significant. CONCLUSIONS In patients with somatotroph tumors after undergoing endoscopic surgery, the risk of dysfunction and pituitary insufficiency tend to increase, while preoperative thyroid insufficiency, gonadal insufficiency, and hyperprolactinemia will be partially relieved.
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Affiliation(s)
- Ding Nie
- grid.24696.3f0000 0004 0369 153XBeijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Qiuyue Fang
- grid.24696.3f0000 0004 0369 153XBeijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Wakam Wong
- grid.24696.3f0000 0004 0369 153XBeijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Songbai Gui
- grid.24696.3f0000 0004 0369 153XDepartment of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peng Zhao
- grid.24696.3f0000 0004 0369 153XDepartment of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chuzhong Li
- grid.24696.3f0000 0004 0369 153XBeijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Yazhuo Zhang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.
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Iwamura H, Nonaka M, Li Y, Ueno K, Takeda J, Hashiba T, Asai A. A case of acute hydrocephalus due to a giant prolactinoma rescued by transventricular neuroendoscopic tumorectomy. Surg Neurol Int 2023; 14:30. [PMID: 36895233 PMCID: PMC9990795 DOI: 10.25259/sni_1060_2022] [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: 11/21/2022] [Accepted: 01/10/2023] [Indexed: 01/28/2023] Open
Abstract
Background A giant prolactinoma extending to the suprasellar area and causing hydrocephalus may be life-threatening and should be treated promptly. A case of a giant prolactinoma with acute hydrocephalus that underwent transventricular neuroendoscopic tumor resection followed by cabergoline administration is presented. Case Description A 21-year-old man had a headache lasting for about a month. He gradually developed nausea and disturbance of consciousness. Magnetic resonance imaging showed a contrast-enhanced lesion that extended from the intrasellar space to the suprasellar space and into the third ventricle. The tumor obstructed the foramen of Monro and caused hydrocephalus. A blood test showed marked elevation of prolactin (16,790 ng/mL). The tumor was diagnosed as a prolactinoma. The tumor in the third ventricle had formed a cyst, and the cyst wall blocked the right foramen of Monro. The cystic component of the tumor was resected using an Olympus VEF-V flexible neuroendoscope. The histological diagnosis was pituitary adenoma. The hydrocephalus improved rapidly and his consciousness became clear. After the operation, he was started on cabergoline. The tumor size subsequently decreased. Conclusion Prompt partial resection of the giant prolactinoma by transventricular neuroendoscopy resulted in early improvement of hydrocephalus with less invasiveness, allowing subsequent treatment with cabergoline.
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Affiliation(s)
- Haruka Iwamura
- Department of Neurosurgery, Kansai Medical University, Hirakata, Japan
| | - Masahiro Nonaka
- Department of Neurosurgery, Kansai Medical University, Hirakata, Japan
| | - Yi Li
- Department of Neurosurgery, Kansai Medical University, Hirakata, Japan
| | - Katsuya Ueno
- Department of Neurosurgery, Kansai Medical University, Hirakata, Japan
| | - Junichi Takeda
- Department of Neurosurgery, Kansai Medical University, Hirakata, Japan
| | - Tetsuo Hashiba
- Department of Neurosurgery, Kansai Medical University, Hirakata, Japan
| | - Akio Asai
- Department of Neurosurgery, Kansai Medical University, Hirakata, Japan
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Patel BK, Binu A, Stanley A, Shah SK, H R D, George T, H V E, Nair P. Large Pituitary Adenoma: Strategies to Maximize Volumetric Resection Using Endoscopic Endonasal Approaches and an Analysis of Factors Limiting Resection. World Neurosurg 2022; 167:e694-e704. [PMID: 35998810 DOI: 10.1016/j.wneu.2022.08.070] [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: 07/10/2022] [Revised: 08/15/2022] [Accepted: 08/16/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Large pituitary adenomas (LPAs), which constitute ∼5%-14% of all pituitary adenomas, are considered challenging tumors owing to their locally aggressive behavior, low gross total resection rate, and high prevalence of visual deficits and hypopituitarism. We evaluated the utility of various extended endoscopic endonasal approaches in maximizing the resection of LPAs and studied the factors affecting the extent of surgical resection. METHODS A retrospective study of all LPAs (defined as a minimum diameter >3 cm and tumor volume >10 cm3) treated via an endoscopic endonasal approach between January 2015 and December 2020 was performed. The volumetric extent of resection (3-dimensional volumetric analysis software) was correlated with various demographic, tumor-related, pathologic, and immunohistochemical factors and its effects on the clinical outcomes studied. RESULTS The present study included 106 patients with LPAs. The mean extent of the resection volume was 79.18 ± 21.75 cm3. The factors that affected the extent of resection included the preoperative tumor volume (P = 0.03) and Knosp grade (P = 0.03). The percentage increase in the extent of resection with the use of 2 endonasal corridors was 10.6% and with 3 corridors was 14%. Visual improvement occurred in 82% of patients, and new-onset persistent hormonal insufficiency occurred in 2.9% of patients. Mortality directly related to surgery occurred in 1.8% of cases. CONCLUSIONS Extended endoscopic endonasal approaches can safely and effectively be used for gross total resection of LPAs. However, we found that the preoperative tumor volume and Knosp grade were significant factors affecting the extent of tumor resection. The use of multiple endoscopic endonasal corridors can increase the volumetric extent of resection for LPAs.
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Affiliation(s)
- Biren Khimji Patel
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Anand Binu
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Antony Stanley
- Regional Technical Resource Centre for Health Technology Assessment, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Shrey Kumar Shah
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Darshan H R
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Tobin George
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Easwer H V
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Prakash Nair
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India.
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Chhabra R, Kumar A, Virk RS, Dutta P, Ahuja C, Mohanty M, Dhandapani S. Outcomes in pituitary adenoma causing acromegaly following endoscopic endonasal transsphenoidal surgery. J Neurosci Rural Pract 2022; 13:696-704. [PMID: 36743751 PMCID: PMC9894003 DOI: 10.25259/jnrp-2022-3-28-r1-(2453)] [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: 09/16/2022] [Accepted: 09/20/2022] [Indexed: 12/10/2022] Open
Abstract
Objectives The objectives of the study were to study the analysis of outcomes after endoscopic endonasal transsphenoidal surgery (EETSS) in acromegaly in terms of surgical complications, clinical improvement, endocrinological remission, achievement of prognostically critical growth hormone (GH) level, and requirement of additional treatment. Materials and Methods The study included 28 acromegaly patients, who underwent EETSS. A 2010 consensus criterion was used for defining remission. Assessment of prognostically critical GH level (random value <2.5 ng/ml), the extent of resection and additional treatment, was done at post-operative week (POW) 12. Results All adenomas were macroadenomas; with a mean volume of 16.34 cm3 (range, 0.4-99 cm3). Most adenomas had high-grade extensions. Most common suprasellar, infrasellar, anterior, and posterior extension grades were 3 (n = 13), 1 (n = 16), 1 (n = 14), and 0 (n = 20), respectively. Knosp Grade 3 was common on both sides (right, n = 9 and left, n = 8). One patient had already been operated on with EETSS, 1.5 years back from current surgery. Sixteen patients were on hormonal support, preoperatively. Four patients died during follow-up. Post-operative common complications were diabetes insipidus (DI, n = 18), cerebrospinal fluid rhinorrhea (n = 10), surgical site hematoma (n = 3), meningitis (n = 3), hydrocephalus (n = 2), and syndrome of inappropriate antidiuretic hormone (n = 1). The mean hospital stay was 11.62 days and 12.17 months were the mean follow-up period. At 12 POW, no improvement was seen in body enlargement and visual complaints, but all other complaints improved significantly except perspiration. Adenomas were decreased in all extensions except posterior and mean adenoma volume was reduced from 16.34 cm3 to 2.92 cm3 after surgery. Sub-total resection (STR, n = 10), near-total resection (NTR, n = 7), gross-total resection (GTR, n = 5), and partial resection (PR, n = 2) were achieved. Endocrinological remission and prognostically critical GH levels were attained in 29.17% (n = 7) and 66.67% (n = 16), respectively. NTR, GTR, STR, and PR were associated with 57.14%, 40%, 10%, and 0% endocrinological remission, respectively. Additional treatment was required in a total of 17 patients, three in GTR, nine in STR, three in NTR, and two in PR. Ten were treated with Gamma Knife radiosurgery along with medical treatment and seven with medical treatment alone. Conclusion A successful EETSS can reduce adenoma volume to achieve clinical improvement, endocrinologic remission, and prognostically critical GH level with some complications related to surgery. Pre-operative larger volume and higher extension grades affect these outcomes adversely.
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Affiliation(s)
- Rajesh Chhabra
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashwani Kumar
- Department of Neurosurgery, Government Medical College and Hospital, Chandigarh, India
| | - R. S. Virk
- Department of Otorhinolaryngology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pinaki Dutta
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Chirag Ahuja
- Department of Neuroradiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manju Mohanty
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sivashanmugam Dhandapani
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Chhabra R, Kumar A, Virk RS, Dutta P, Ahuja C, Mohanty M, Dhandapani S. Outcomes in Pituitary Adenoma Causing Acromegaly Following Endoscopic Endonasal Transsphenoidal Surgery. J Neurosci Rural Pract 2022. [DOI: 10.1055/s-0042-1751226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
Abstract
Objectives The objective of this study was the analysis of outcomes after endoscopic endonasal transsphenoidal surgery (EETSS) in acromegaly in terms of surgical complications, clinical improvement, endocrinological remission, achievement of prognostically critical growth hormone (GH) level, and requirement of additional treatment.
Materials and Methods The study included 28 acromegaly patients, who underwent EETSS. 2010 consensus criterion was used for defining remission. Assessment of prognostically critical GH level (random value less than 2.5 ng/mL), the extent of resection, and additional treatment was done at postoperative week (POW) 12.
Results All adenomas were macroadenomas, with the mean volume of 16.34 cm3 (range, 0.4–99 cm3). Most adenomas had high-grade extensions. Most common suprasellar, infrasellar, anterior, and posterior extension grades were 3 (n = 13), 1(n = 16), 1(n = 14), and 0 (n = 20), respectively. Knosp grade 3 was common on both sides (right, n = 9 and left, n = 8). One patient had already been operated on with EETSS, 1.5 years back from current surgery. Sixteen patients were on hormonal support, preoperatively. Four patients died during follow-up. Postoperative common complications were diabetes insipidus (n = 18), cerebrospinal fluid rhinorrhea (n = 10), surgical site hematoma (n = 3), meningitis (n = 3), hydrocephalus (n = 2), and syndrome of inappropriate antidiuretic hormone (n = 1). The mean hospital stay was 11.62 days, and 12.17 months was the mean follow-up period. At 12 POW, no improvement was seen in body enlargement and visual complaints, but all other complaints improved significantly except perspiration. Adenomas were decreased in all extensions except posterior, and mean adenoma volume was reduced from 16.34 to 2.92 cm3 after surgery. Subtotal resection (STR, n = 10), near-total resection (NTR, n = 7), gross-total resection (GTR, n = 5), and partial resection (PR, n = 2) were achieved. Endocrinological remission and prognostically critical GH levels were attained in 29.17% (n = 7) and 66.67% (n = 16), respectively. NTR, GTR, STR, and PR were associated with 57.14, 40, 10, and 0% endocrinological remission, respectively. Additional treatment was required in a total of 17 patients: 3 GTR, 9 STR, 3 NTR, and 2 PR patients. Ten patients were treated with gamma knife radiosurgery along with medical treatment and seven with medical treatment alone.
Conclusion A successful EETSS can reduce adenoma volume to achieve clinical improvement, endocrinological remission, and prognostically critical GH level with some complications related to surgery. Preoperative larger volume and higher extension grades affect these outcomes adversely.
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Affiliation(s)
- Rajesh Chhabra
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashwani Kumar
- Department of Neurosurgery, Government Medical College and Hospital, Chandigarh, India
| | - R S Virk
- Department of Otorhinolaryngology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pinaki Dutta
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Chirag Ahuja
- Department of Neuroradiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manju Mohanty
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sivashanmugam Dhandapani
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Butterfield JT, Araki T, Guillaume D, Tummala R, Caicedo-Granados E, Tyler MA, Venteicher AS. Estimating Risk of Pituitary Apoplexy after Resection of Giant Pituitary Adenomas. Skull Base Surg 2022; 83:e152-e159. [DOI: 10.1055/s-0041-1722993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Background Pituitary apoplexy after resection of giant pituitary adenomas is a rare but often cited morbidity associated with devastating outcomes. It presents as hemorrhage and/or infarction of residual tumor in the postoperative period. Because of its rarity, its incidence and consequences remain ill defined.
Objective The aim of this study is to estimate the rate of postoperative pituitary apoplexy after resection of giant pituitary adenomas and assess the morbidity and mortality associated with apoplexy.
Methods A systematic review of literature was performed to examine extent of resection in giant pituitary adenomas based on surgical approach, rate of postoperative apoplexy, morbidities, and mortality. Advantages and disadvantages of each approach were compared.
Results Seventeen studies were included in quantitative analysis describing 1,031 cases of resection of giant pituitary adenomas. The overall rate of subtotal resection (<90%) for all surgical approaches combined was 35.6% (95% confidence interval: 28.0–43.1). Postoperative pituitary apoplexy developed in 5.65% (n = 19) of subtotal resections, often within 24 hours and with a mortality of 42.1% (n = 8). Resulting morbidities included visual deficits, altered consciousness, cranial nerve palsies, and convulsions.
Conclusion Postoperative pituitary apoplexy is uncommon but is associated with high rates of morbidity and mortality in subtotal resection cases. These findings highlight the importance in achieving a maximal resection in a time sensitive fashion to mitigate the severe consequences of postoperative apoplexy.
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Affiliation(s)
- John T. Butterfield
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, United States
| | - Takako Araki
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, University of Minnesota, Minneapolis, Minnesota, United States
- Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, United States
| | - Daniel Guillaume
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, United States
- Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, United States
| | - Ramachandra Tummala
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, United States
- Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, United States
| | - Emiro Caicedo-Granados
- Department of Otolaryngology, University of Minnesota, Minneapolis, Minnesota, United States
- Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, United States
| | - Matthew A. Tyler
- Department of Otolaryngology, University of Minnesota, Minneapolis, Minnesota, United States
- Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, United States
| | - Andrew S. Venteicher
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, United States
- Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, United States
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Tang OY, Hsueh WD, Eloy JA, Liu JK. Giant Pituitary Adenoma – Special Considerations. Otolaryngol Clin North Am 2022; 55:351-379. [DOI: 10.1016/j.otc.2021.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Chen Y, Xu X, Cao J, Jie Y, Wang L, Cai F, Chen S, Yan W, Hong Y, Zhang J, Wu Q. Transsphenoidal Surgery of Giant Pituitary Adenoma: Results and Experience of 239 Cases in A Single Center. Front Endocrinol (Lausanne) 2022; 13:879702. [PMID: 35600598 PMCID: PMC9120954 DOI: 10.3389/fendo.2022.879702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 04/08/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Transsphenoidal surgery (TSS) is first-line treatment for giant pituitary adenomas (PAs). Although PA is a benign neuroendocrine tumor that originates from adenohypophysial cells, the surgical outcomes and prognosis of giant PAs differ significantly due to multiple factors such as tumor morphology, invasion site, pathological characteristics and so on. The aim of this study was to evaluate surgical outcomes of giant PAs in a single-center cohort. METHODS The clinical features and outcomes of 239 patients with giant PA who underwent sphenoidal surgery at the Second Affiliated Hospital of Zhejiang University School of Medicine from January 2015 to October 2021 were collected from medical records. The basic clinical information (age, gender, function etc.), surgical procedure, imaging features (maximum diameter, invasion characteristics, tumor shape etc.) and histopathological characteristics (pathological results, Ki-67, P53 etc.) were retrospectively reviewed. SPSS 25.0 and Stata 12.0 software were used for statistical analysis. RESULTS A total of 239 patients with giant PAs underwent TSS, of which 168 surgeries (70.29%) were endoscopic endonasal transsphenoidal (EETS) and 71 (29.71%) were microscopic transsphenoidal (MTS). The mean preoperative maximum diameter in the cohort was 45.64 mm. Gross-total resection was achieved in 46 patients (19.25%), near-total in 56 (23.43%), subtotal in 68 (28.45%), and partial in 69 (28.87%) patients. The maximum tumor diameter and Knosp grade were the significant factors that limited the extent of the resection of giant PAs. A total of 193 patients (80.75%) experienced surgical complications, and the most common complications were postoperative diabetes insipidus (DI) (91, 38.08%), intracranial infection (36, 15.06%) and cerebrospinal fluid (CSF) leaks (37, 15.48%). In addition, there was a significant difference in the incidence of CSF leaks between the neuroendoscopy group and the microscopic group (P < 0.05). CONCLUSION The management of giant PAs remains a therapeutic challenge due to their large size and postoperative complications. The maximum diameter and Knosp grade of giant PAs significantly limited the extent of resection, which warrants a reasonable surgical plan.
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Affiliation(s)
- Yike Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaohui Xu
- Department of Neurosurgery, The Fourth Affiliated Hospital, School of Medicine, Zhejiang University, Yiwu, China
| | - Jing Cao
- Department of Statistical Office, The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South, Changsha, China
| | - Yuanqing Jie
- Department of Neurosurgery, The Affiliated Quzhou People’s Hospital of Wenzhou Medical University, Quzhou, China
| | - Linkai Wang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Feng Cai
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wei Yan
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yuan Hong
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jianmin Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- *Correspondence: Qun Wu, ; Jianmin Zhang,
| | - Qun Wu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- *Correspondence: Qun Wu, ; Jianmin Zhang,
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Ashraf M, Kamboh UA, Raza MA, Haq NU, Choudhary N, Sultan KA, Hussain SS, Ashraf N. Usefulness of Intraoperative Computed Tomography on Extent of Resection of Large and Giant Pituitary Adenomas. Experience from a Developing Country. World Neurosurg 2021; 157:13-20. [PMID: 34619403 DOI: 10.1016/j.wneu.2021.09.114] [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: 08/18/2021] [Revised: 09/25/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVE The literature on the use of intraoperative computed tomography (iCT) is sparse. We provide our experience of the usefulness of iCT in extent of resection in large and giant pituitary adenomas. METHODS A retrospective review was performed of cases using the endonasal endoscopic technique in which iCT was used. Demographic factors, number of scans, and impact on the extent of resection are reported, with visual acuity and field changes. Tumors were graded according to the Hardy classification. Patients with cavernous sinus invasion were excluded. RESULTS All patients received a perioperative computed tomography scan with our iCT scanner. Thirty patients are reported, including 14 large and 16 giant pituitary adenomas, including 14 nonfunctional and 16 growth hormone-secreting tumors. The overall gross total resection (GTR), near-total resection, and subtotal resection rates were 83.3%, 16.7%, and 3.3%, respectively. iCT scanning detected residual in 13 of 30 patients, including 4 with 14 large (29%) and 9 with 16 (56.3%) giant adenomas promoting further surgery. iCT use improved GTR from 43.8% to 81.3% in giant adenomas and from 71% to 86% in large adenomas. Of the 13 patients in whom iCT detected residual disease, none required >2 iCT scans. No intraoperative complications were observed. CONCLUSIONS iCT can improve extent of resection in large and giant pituitary adenomas and facilitate maximum safe resection such as GTR or near-total resection in patients where such should be attempted. iCT use may reduce iatrogenic complications and has select financial benefits in our patients' socioeconomic demographics. However, further prospective controlled studies are required to affirm our conclusions.
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Affiliation(s)
- Mohammad Ashraf
- Wolfson School of Medicine, University of Glasgow, Glasgow, United Kingdom; Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan.
| | - Usman Ahmad Kamboh
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Muhammad Asif Raza
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Naseer Ul Haq
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Nabeel Choudhary
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Kashif Ali Sultan
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Syed Shahzad Hussain
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Naveed Ashraf
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
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Ceylan S, Sen HE, Ozsoy B, Ceylan EC, Ergen A, Selek A, Anik Y, Balci S, Cabuk B, Anik I. Endoscopic approach for giant pituitary adenoma: clinical outcomes of 205 patients and comparison of two proposed classification systems for preoperative prediction of extent of resection. J Neurosurg 2021; 136:786-800. [PMID: 34534953 DOI: 10.3171/2021.3.jns204116] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/15/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Giant pituitary adenoma is considered a challenging pathology for surgery owing to its complications and low resection rate. In this study, the authors present their experience of using the endoscopic endonasal approach to treat patients with giant pituitary adenoma, and they aimed to develop a classification system for prediction of extent of resection. METHODS The institutional medical records of patients diagnosed with giant pituitary adenoma who underwent endoscopic endonasal transsphenoidal surgery between August 1997 and December 2019 were retrospectively reviewed. Surgical and clinical outcomes were evaluated in detail. The effects of tumor characteristics on extent of resection were analyzed. The findings were used to develop two classification systems that could preoperatively predict extent of resection. Morphological score was based on tumor characteristics, and landmark-based classification was defined according to surgical zones based on neurovascular landmarks. The effects of change in surgical strategy, which aimed to maximize tumor resection and capsule dissection, on rates of resection and complications were evaluated before and after 2017. RESULTS This study included 205 patients, with a mean patient age of 46.95 years and mean preoperative tumor diameter of 46.56 mm. Gross-total resection (GTR) was achieved in 35.12% of patients, near-total resection (NTR) in 39.51%, and subtotal resection (STR) in 25.36%. Extent of resection differed significantly between the grades and zones of the classification systems (p < 0.001 for both). Among patients with grade 3 tumor, 75.75% of patients achieved STR, 21.21% achieved NTR, and 3.03% achieved GTR. Among patients with zone 3 tumor, 65.75% achieved STR, 32.87% achieved NTR, and 1.36% achieved GTR. Both grade 3 and zone 3 indicated limited extent of resection. The mean (range) follow-up duration was 50.16 (9-247) months. Postoperative recovery of at least one hormone axis was seen in 15.24% of patients with pituitary deficiency, and development of new hormonal deficiency was observed in 22.43% of patients. Complications included permanent diabetes insipidus (7.80%), cerebrospinal fluid leakage (3.90%), postoperative apoplexy (3.90%), meningitis (3.41%), and epistaxis (3.41%). The surgical mortality rate was 1.46%. Among 85 patients treated before 2017, 27.05% of patients achieved GTR, 37.64% achieved NTR, and 35.29% achieved STR; among 120 patients treated after 2017, 40.83% achieved GTR, 40.83% achieved NTR, and 18.33% achieved STR. Seven patients in the pre-2017 cohort had postoperative apoplexy versus only 1 patient in the post-2017 cohort. There were no statistically significant differences between the two periods in terms of the incidence rates of other complications. CONCLUSIONS Capsule dissection and GTR are valuable for preventing serious complications and reducing recurrence of giant adenoma. Treatment of giant pituitary adenoma may be better managed with the help of a classification system that provides information about extent of resection that can be achieved with an endoscopic approach.
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Affiliation(s)
- Savas Ceylan
- Departments of1Neurosurgery and Pituitary Research Center
| | - Harun Emre Sen
- Departments of1Neurosurgery and Pituitary Research Center
| | | | | | - Anil Ergen
- Departments of1Neurosurgery and Pituitary Research Center
| | | | | | - Sibel Balci
- 4Biostatistics and Medical Informatics, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Burak Cabuk
- Departments of1Neurosurgery and Pituitary Research Center
| | - Ihsan Anik
- Departments of1Neurosurgery and Pituitary Research Center
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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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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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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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20
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Assessing the association of tumor consistency and gland manipulation on hormonal outcomes and delayed hyponatremia in pituitary macroadenoma surgery. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2020. [DOI: 10.1016/j.inat.2019.100628] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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21
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Li K, Zhang J, Wang XS, Ye X, Zhao YL. A systematic review of effects and complications after transsphenoidal pituitary surgery: endoscopic versus microscopic approach. MINIM INVASIV THER 2019; 29:317-325. [PMID: 31495241 DOI: 10.1080/13645706.2019.1660369] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Microscopic transsphenoidal surgery (MTS) has been considered as the gold standard for transsphenoidal pituitary surgery, but nowadays endoscopic transsphenoidal surgery (ETS) has become popular due to its wide view and improved lighting.Material and methods: The electronic databases were systematically searched, and the meta-analyses of the eligible studies that evaluated endoscopic versus microscopic methods in patients with pituitary surgery were conducted with Review Manager 5.0. The primary outcomes included visual improvement, gross tumor removal (GTR), cerebrospinal fluid (CFS) leak, diabetes insipidus (DI), other complications, and length of hospital stay. The Egger's test was conducted to estimate possible publication bias.Results: In total, 13 articles eventually met the inclusion criteria. The meta-analyses suggested that the differences with regard to visual improvement, overall complication rate, GTR, CSF leak, diabetes insipidus (DI), meningitis, visual impairment, syndrome of inappropriate antidiuretic hormone secretion (SIADH), new onset hypopituitarism, and hypothyroidism between the endoscopic and microscopic groups were not statistically significant. The length of hospital stay was much longer with the microscopic approach when compared with the endoscopic method.Conclusion: The endoscopic and microscopic approaches show similar effects and complication rates. The endoscopic technique could be adopted as a reasonable alternative in pituitary surgery.
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Affiliation(s)
- Kai Li
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Jun Zhang
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Xin-Sheng Wang
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Xun Ye
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Yuan-Li Zhao
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
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22
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Lekgwara P, Kelly A, Younus A. Surgical considerations in the endoscopic endonasal transphenoidal approach for giant pituitary adenomas: A single surgeons' experience over a decade. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2019. [DOI: 10.1016/j.inat.2019.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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23
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Fallah N, Taghvaei M, Sadaghiani S, Sadrhosseini SM, Esfahanian F, Zeinalizadeh M. Surgical Outcome of Endoscopic Endonasal Surgery of Large and Giant Pituitary Adenomas: An Institutional Experience from the Middle East. World Neurosurg 2019; 132:e802-e811. [PMID: 31404693 DOI: 10.1016/j.wneu.2019.08.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Surgical treatment of large and giant pituitary adenomas is challenging and associated with higher risk of complications and lower rate of gross total resection. We present our experience with surgical management of large and giant adenomas using the extended endoscopic transsphenoidal approach (EETA). METHODS A total of 80 patients with large (30-39 mm) and giant (≥40 mm) pituitary adenomas who underwent tumor resection using EETA were studied. Radiologic data, hormonal and visual status, surgical outcomes, complications, and factors affecting the extent of resection were evaluated. RESULTS Forty-five tumors (56.3%) were classified as large and 35 (43.8%) as giant adenomas. Gross total resection was achieved in 66 patients (82.5%), near-total resection in 10 (12.5%), and subtotal resection in 4 (5%). Preoperative factors including larger tumor size, multilobular shape of tumor, and higher Knosp scores significantly decrease the likelihood of gross total resection. Of patients with preoperative visual acuity impairment and visual field deficit, 76.8% and 74.1%, respectively, experienced improvement after surgery. The most common complications include new pituitary insufficiency (16.4%), permanent diabetes insipidus (7.5%), and cerebrospinal fluid leakage (5%). Two cases of meningitis (2.5%) and 3 deaths (3.8%) occurred in this cohort of patients. Mean follow-up duration was 24.2 months. CONCLUSIONS EETA can be a safe and efficient approach as the first-line treatment of patients with large and giant pituitary adenomas and is associated with high rates of gross total resection or near-total resection, visual function improvement, and a relatively low rate of complications.
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Affiliation(s)
- Nahid Fallah
- Brain and Spinal Injury Research Center (BASIR), Pituitary Clinic, Neuroscience Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran; Department of Neurological Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Taghvaei
- Brain and Spinal Injury Research Center (BASIR), Pituitary Clinic, Neuroscience Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran; Department of Neurological Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Shokufeh Sadaghiani
- MS Research Center, Neuroscience Institute, 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
| | - Fatemeh Esfahanian
- Department of Endocrinology and Metabolism, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Zeinalizadeh
- Brain and Spinal Injury Research Center (BASIR), Pituitary Clinic, Neuroscience Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran; Department of Neurological Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.
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24
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Soneru CP, Riley CA, Hoffman K, Tabaee A, Schwartz TH. Intra-operative MRI vs endoscopy in achieving gross total resection of pituitary adenomas: a systematic review. Acta Neurochir (Wien) 2019; 161:1683-1698. [PMID: 31139934 DOI: 10.1007/s00701-019-03955-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 05/16/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intraoperative magnetic resonance imaging (iMRI) is a technology that may improve rates of gross total resection (GTR) for pituitary adenomas. The endoscope is another less expensive technology, which also may maximize resection rates. A direct comparison of these approaches and their additive benefit has never been performed. METHODS A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) standard. PubMed and Embase databases were searched for studies that examined GTR for pituitary adenoma resection with either endoscopic transsphenoidal surgery (eTSS), microscopic transsphenoidal surgery with iMRI (mTSS + iMRI), or endoscopic transsphenoidal surgery with iMRI (eTSS + iMRI). RESULTS Eighty-five studies that reported GTR rates in 7124 pituitary adenoma patients were identified. For all pituitary adenomas, eTSS had a pooled proportion of GTR of 68.9% (95% CI 64.7-73.0%) which was similar to that of mTSS + iMRI (GTR 68.3%; 95% CI = 59.4-76.5%) and eTSS + iMRI (GTR 70.7%; 95% CI = 56.9-89.6%). For the subgroup of pituitary macroadenomas, pooled proportions for GTR were similar between eTSS and mTSS + iMRI (eTSS: GTR 59.4%; 95% CI = 49.6-68.7% vs mTSS + iMRI: GTR 68.8%; 95% CI = 57.3-79.3%), and higher for eTSS + iMRI (81.1%; 95% CI = 75.5-86.2%). The post-operative CSF leak proportion for eTSS (4.7%; 95% CI = 3.6-5.9%) was similar to that for eTSS + iMRI (3.7%; 95% CI = 1.6-6.5%) and mTSS + iMRI (4.6%; 95% CI = 2.0-8.3%). No direct statistical comparisons could be performed. CONCLUSION Final GTR proportions are similar whether the surgeon uses a microscope supplemented with iMRI or endoscope with or without iMRI. The benefit of the two technologies may be complementary for macroadenomas. These findings are important to consider when comparing the efficacy of different technical strategies in the management of pituitary adenomas.
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25
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Marigil Sanchez M, Karekezi C, Almeida JP, Kalyvas A, Castro V, Velasquez C, Gentili F. Management of Giant Pituitary Adenomas: Role and Outcome of the Endoscopic Endonasal Surgical Approach. Neurosurg Clin N Am 2019; 30:433-444. [PMID: 31471050 DOI: 10.1016/j.nec.2019.05.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Giant adenomas represent a significant surgical challenge. Although traditionally several transcranial and transsphenoidal microscopic approaches have had a central role in their management, in the last 2 decades here have been increasing reports of the endoscopic endonasal approach for giant adenomas, citing its improved resection rates and lower complication profile. However, its role as the preferred approach has not been fully established and there is currently a paucity of evidence-based recommendations available in the literature. This article reviews the current literature and attempts to define the role and outcomes of the endoscopic endonasal surgical approach for giant pituitary adenomas.
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Affiliation(s)
- Miguel Marigil Sanchez
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Neurosurgery, Skull Base Research Unit, Lariboisière University Hospital, 2 Rue Ambroise Paré, Paris Cedex 10 75475, France.
| | - Claire Karekezi
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Neurosurgery, Rwanda Military Hospital, Kigali, Rwanda
| | - Joao Paulo Almeida
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Aristotelis Kalyvas
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Vitor Castro
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Carlos Velasquez
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Neurological Surgery, Hospital Universitario Marques de Valdecilla and Instituto de Investigacion Marques de Valdecilla (IDIVAL), Santander, Spain
| | - Fred Gentili
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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26
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Mikhaylov NI, Kalinin PL, Savin IA. [Complications after endoscopic endonasal transsphenoidal removal of pituitary adenomas]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2019; 82:105-113. [PMID: 30721224 DOI: 10.17116/neiro201882061105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The use of endoscopic technique has significantly extended the indications for surgery using the transsphenoidal approach. Currently, more than 90% of pituitary adenomas are operated on transsphenoidally. Transnasal removal of giant pituitary adenomas has become possible. Transition to the endoscopic endonasal approach in removal of pituitary adenomas changed the rate and structure of postoperative complications. We analyzed potential complications after endoscopic endonasal transsphenoidal removal of pituitary adenomas. These include complications of the approach itself (nasal bleeding, perforation of the nasal septum, impaired olfactory function, atrophic rhinitis, synechiae, mucoperiosteal flap necrosis, and external nasal deformities), infectious complications (meningitis, intracranial abscesses), cerebral circulation disorder (subarachnoid hemorrhage, cerebral vasospasm, injury to large vessels, intracranial hematomas), neuro-ophthalmological complications (visual and oculomotor disorders), endocrine (hypopituitarism, diabetes insipidus, hyponatremia) and somatic complications, and nasal liquorrhea. In conclusion, it should be noted that despite continuous improvement of the technique for endoscopic endonasal removal of pituitary adenomas, there is a risk of serious complications, which necessitates the development of techniques for prevention of these complications.
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Affiliation(s)
| | - P L Kalinin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - I A Savin
- Burdenko Neurosurgical Institute, Moscow, Russia
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27
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Nayak P, Montaser AS, Hu J, Prevedello DM, Kirschner LS, Ghalib L. Predictors of Postoperative Diabetes Insipidus Following Endoscopic Resection of Pituitary Adenomas. J Endocr Soc 2018; 2:1010-1019. [PMID: 30140786 PMCID: PMC6101506 DOI: 10.1210/js.2018-00121] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 07/24/2018] [Indexed: 12/12/2022] Open
Abstract
Context The development of diabetes insipidus (DI) following transsphenoidal resection of pituitary adenomas has been associated with higher postsurgical morbidity and longer hospitalizations. Identifying these patients promptly and efficiently can lead to improved health care outcomes. Objective We evaluated our institution’s incidence of DI following pituitary adenoma resection and assessed for preoperative risk factors that were associated with postoperative DI. Design A retrospective review of 271 patients who underwent endoscopic endonasal resection of a pituitary adenoma between July 2010 and December 2016 by a single neurosurgical provider was completed. Setting All cases were from a single-center, academic institution. Patients Patients with a pituitary adenoma diagnosis confirmed on histology were included in the study. Those with previous surgery by a different provider were excluded. Results The incidence of DI at our institution was 16.6% (45 of 271 patients), with only 4% (11 patients) having permanent DI. The presence of visual abnormalities (CI 1.29 to 4.75), suprasellar extension (CI 1.36 to 6.88), and maximal tumor diameter (1.02 to 1.08) was significantly associated with an increased incidence of postoperative DI (P < 0.05). Hyperprolactinemia, tumor functionality, and cerebrospinal fluid exposure were not associated with higher rates of postoperative DI (P > 0.05). Conclusion Pituitary adenoma patients presenting with visual abnormalities, suprasellar extension, or large tumors are at higher risk of developing DI postoperatively. These patients warrant closer postoperative monitoring as well as adequate preoperative counseling to decrease their postsurgical morbidity.
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Affiliation(s)
- Pratima Nayak
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Alaa S Montaser
- Department of Neurologic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.,Department of Neurologic Surgery, Ain Shams University, Cairo, Egypt
| | - Jie Hu
- College of Nursing, The Ohio State University, Columbus, Ohio
| | - Daniel M Prevedello
- Department of Neurologic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.,Department of Otolaryngology - Head and Neck Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio
| | - Lawrence S Kirschner
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio.,Department of Cancer Biology and Genetics, The Ohio State University, Columbus, Ohio
| | - Luma Ghalib
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Almutairi RD, Muskens IS, Cote DJ, Dijkman MD, Kavouridis VK, Crocker E, Ghazawi K, Broekman MLD, Smith TR, Mekary RA, Zaidi HA. Gross total resection of pituitary adenomas after endoscopic vs. microscopic transsphenoidal surgery: a meta-analysis. Acta Neurochir (Wien) 2018; 160:1005-1021. [PMID: 29307020 DOI: 10.1007/s00701-017-3438-z] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 12/14/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Microscopic transsphenoidal surgery (mTSS) is a well-established method to address adenomas of the pituitary gland. Endoscopic transsphenoidal surgery (eTSS) has become a viable alternative, however. Advocates suggest that the greater illumination, panoramic visualization, and angled endoscopic views afforded by eTSS may allow for higher rates of gross total tumor resection (GTR). The aim of this meta-analysis was to determine the rate of GTR using mTSS and eTSS. METHODS A meta-analysis of the literature was conducted using PubMed, EMBASE, and Cochrane databases through July 2017 in accordance with PRISMA guidelines. RESULTS Seventy case series that reported GTR rate in 8257 pituitary adenoma patients were identified. For all pituitary adenomas, eTSS (GTR=74.0%; I2 = 92.1%) was associated with higher GTR as compared to mTSS (GTR=66.4%; I2 = 84.0%) in a fixed-effect model (P-interaction < 0.01). For functioning pituitary adenomas (FPAs) (n = 1170 patients), there was no significant difference in GTR rate between eTSS (GTR=75.8%; I2 = 63.9%) and mTSS (GTR=75.5%; I2 = 79.0%); (P-interaction = 0.92). For nonfunctioning pituitary adenomas (NFPAs) (n = 2655 patients), eTSS (GTR=71.0%; I2 = 86.4%) was associated with higher GTR as compared to mTSS (GTR=60.7%; I2 = 87.5%) in a fixed-effect model (P-interaction < 0.01). None of the associations were significant in a random-effect model (all P-interaction > 0.05). No significant publication bias was identified for any of the outcomes. CONCLUSION Among patients who were not randomly allocated to either approach, eTSS resulted in a higher rate of GTR as compared to mTSS for all patients and for NFPA patients alone, but only in a fixed-effect model. For FPA, however, eTSS did not seem to offer a significantly higher rate of GTR. These conclusions should be interpreted with caution because of the nature of the included non-comparative studies.
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Affiliation(s)
- Reem D Almutairi
- Department of Pharmaceutical Business and Administrative Sciences, MCPHS University, Boston, MA, USA
- School of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Ivo S Muskens
- Brain Center Rudolf Magnus, Utrecht University Medical Center, Utrecht, The Netherlands
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - David J Cote
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.
| | - Mark D Dijkman
- Brain Center Rudolf Magnus, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Vasileios K Kavouridis
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Erin Crocker
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Kholoud Ghazawi
- Department of Pharmaceutical Business and Administrative Sciences, MCPHS University, Boston, MA, USA
| | - Marike L D Broekman
- Brain Center Rudolf Magnus, Utrecht University Medical Center, Utrecht, The Netherlands
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Timothy R Smith
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Rania A Mekary
- Department of Pharmaceutical Business and Administrative Sciences, MCPHS University, Boston, MA, USA
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Hasan A Zaidi
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
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Akbari H, Malek M, Ghorbani M, Ramak Hashemi SM, Khamseh ME, Zare Mehrjardi A, Emami Z, Ebrahim Valojerdi A. Clinical outcomes of endoscopic versus microscopic trans-sphenoidal surgery for large pituitary adenoma. Br J Neurosurg 2018; 32:206-209. [PMID: 29417847 DOI: 10.1080/02688697.2018.1429569] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To compare clinical outcomes of large pituitary adenomas (≥3 cm in maximum diameter), operated on by Endoscopic Transsphenoidal Surgery (ETS), versus Microscopic Transsphenoidal Surgery (MTS). METHODS Medical records and MRI Scans of patients with a diagnosis of pituitary adenoma for whom transphenoidal surgery was done were reviewed. Complete pre and post-operative data were available for 121 patients. Thirty five patients had large pituitary adenoma and were enrolled in this study. ETS was done in 16 patients, and 19 underwent MTS. All patients were followed for at least six months. Clinical and imaging characteristics were reported in details. Post-operative clinical outcomes were defined as clinical outcomes persisted 6 months after surgery. RESULTS The average tumor size was 36.3 ± 4.4 mm in ETS group, and 34.0 ± 4.6 mm in MTS group, (p = .46). Six months after surgery, tumor size was 4.6 ± 6.6 mm in ETS and 17.7 ± 12.2 mm in MTS group, (p = .002). Gross total resection (GTR) was observed in the 81.2% of the patient in the ETS group. In the MTS group, GTR was observed in 15.8%. Post-operative clinical outcomes including new onset hypopituitarism, visual impairment, and permanent diabetes insipidus (DI) were comparable between the two groups. CONCLUSION ETS is superior to MTS in treatment of large pituitary adenomas with comparable post-operative complications.
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Affiliation(s)
- Hamideh Akbari
- a Endocrine Research Center , Institute of Endocrinology and Metabolism, Iran University of Medical Sciences , Tehran , Iran
| | - Mojtaba Malek
- b Research Center for Prevention of Cardiovascular Disease , Institute of Endocrinology and Metabolism, Iran University of Medical Sciences , Tehran , Iran
| | - Mohammad Ghorbani
- c Department of Neurosurgery and Neuro-Intervention , Firouzgar Hospital, Iran University of Medical Sciences , Tehran , Iran
| | - Seyed Mahmoud Ramak Hashemi
- c Department of Neurosurgery and Neuro-Intervention , Firouzgar Hospital, Iran University of Medical Sciences , Tehran , Iran
| | - Mohammad Ebrahim Khamseh
- a Endocrine Research Center , Institute of Endocrinology and Metabolism, Iran University of Medical Sciences , Tehran , Iran
| | - Ali Zare Mehrjardi
- d Department of Pathology, Firouzgar Hospital, Iran University of Medical Sciences , Tehran , Iran
| | - Zahra Emami
- a Endocrine Research Center , Institute of Endocrinology and Metabolism, Iran University of Medical Sciences , Tehran , Iran
| | - Ameneh Ebrahim Valojerdi
- a Endocrine Research Center , Institute of Endocrinology and Metabolism, Iran University of Medical Sciences , Tehran , Iran
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30
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Muskens IS, Zamanipoor Najafabadi AH, Briceno V, Lamba N, Senders JT, van Furth WR, Verstegen MJT, Smith TRS, Mekary RA, Eenhorst CAE, Broekman MLD. Visual outcomes after endoscopic endonasal pituitary adenoma resection: a systematic review and meta-analysis. Pituitary 2017; 20. [PMID: 28643208 PMCID: PMC5606952 DOI: 10.1007/s11102-017-0815-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE Patients with pituitary adenomas often present with visual deficits. While the aim of endoscopic endonasal transsphenoidal surgery (EETS) is to improve these deficits, permanent worsening is a possible outcome. The aim of this meta-analysis was to evaluate the effect of EETS for pituitary adenomas on visual outcomes. METHODS A meta-analysis was conducted according to the PRISMA guidelines. Pooled prevalence was calculated for complete recovery, improvement, and deterioration of visual field deficits, visual acuity and unspecified visual function in fixed- and random-effect models, including assessment of heterogeneity (I2) and publication bias (Begg's test). RESULTS Out of 2636 articles, 35 case series were included in the meta-analysis. Results are described for fixed-effect models. For patients with impaired visual acuity, only one study reported complete recovery (27.2%). Pooled prevalence for improvement was 67.5% (95% CI = 59.1-75.0%), but with considerable heterogeneity (I2: 86.0%), and 4.50% (95% CI = 1.80-10.8%) for patients experiencing deterioration. For patients with visual field deficits, the prevalence was 40.4% (95% CI = 34.8-46.3%) for complete recovery, 80.8% (95% CI = 77.7-83.6%) for improvement, and 2.3% (95% CI = 1.1-4.7%) for deterioration. For the unspecified visual outcomes, pooled prevalence of complete recovery was 32.9% (95% CI: 28.5-37.7%), but with considerable heterogeneity (I2 = 84.2%). The prevalence was 80.9% (95% CI = 77.9-83.6) for improvement and 2.00% (95% CI = 1.10-3.40%) for deterioration. Random-effect models yielded similar results. Publication bias was non-significant for all the outcomes. CONCLUSION While visual deficits improved after EETS in the majority of patients, complete recovery was only achieved in less than half of the patients and some patients even suffered from visual deterioration.
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Affiliation(s)
- Ivo S Muskens
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Department of Neurosurgery, Cushing Neurosurgery Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA, 02115, USA
| | | | | | - Nayan Lamba
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Joeky T Senders
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Department of Neurosurgery, Cushing Neurosurgery Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA, 02115, USA
| | - Wouter R van Furth
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Marco J T Verstegen
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Timothy R S Smith
- Department of Neurosurgery, Cushing Neurosurgery Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA, 02115, USA
| | - Rania A Mekary
- Department of Neurosurgery, Cushing Neurosurgery Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA, 02115, USA
- MCPHS University, Boston, USA
| | - Christine A E Eenhorst
- Department of Ophthalmology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Marike L D Broekman
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
- Department of Neurosurgery, Cushing Neurosurgery Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA, 02115, USA.
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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31
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You L, Li W, Chen T, Tang D, You J, Zhang X. A retrospective analysis of postoperative hypokalemia in pituitary adenomas after transsphenoidal surgery. PeerJ 2017; 5:e3337. [PMID: 28560099 PMCID: PMC5444367 DOI: 10.7717/peerj.3337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 04/20/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Pituitary adenoma is one of the most common intracranial neoplasms, and its primary treatment is endoscopic endonasal transsphenoidal tumorectomy. Postoperative hypokalemia in these patients is a common complication, and is associated with morbidity and mortality. This study aimed to analyze the etiopathology of postoperative hypokalemia in pituitary adenomas after endoscopic transsphenoidal surgery. METHODS AND MATERIALS This retrospective study included 181 pituitary adenomas confirmed by histopathology. Unconditional logistic regression analysis was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). Repeated measures ANOVA was used to analyze change in serum potassium levels at different time points. RESULTS Multiple Logistic regression analysis revealed that only ACTH-pituitary adenoma (OR = 4.92, 95% CI [1.18-20.48], P = 0.029) had a significant association with postoperative hypokalemia. Moreover, the overall mean serum potassium concentration was significantly lower in the ACTH versus the non-ACTH group (3.34 mmol/L vs. 3.79 mmol/L, P = 0.001). Postoperative hypokalemia was predominantly found in patients with ACTH-pituitary adenoma (P = 0.033). CONCLUSIONS ACTH-pituitary adenomas may be an independent factor related postoperative hypokalemia in patients despite conventional potassium supplementation in the immediate postoperative period.
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Affiliation(s)
- Lili You
- Department of Clinical Epidemiology, First Hospital of Jilin University, Changchun, China
| | - Wenpeng Li
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
| | - Tang Chen
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
| | - Dongfang Tang
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
| | - Jinliang You
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
| | - Xianfeng Zhang
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
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Cheng Y, Xue F, Wang TY, Ji JF, Chen W, Wang ZY, Xu L, Hang CH, Liu XF. Analyses and treatments of postoperative nasal complications after endonasal transsphenoidal resection of pituitary neoplasms. Medicine (Baltimore) 2017; 96:e6614. [PMID: 28403108 PMCID: PMC5403105 DOI: 10.1097/md.0000000000006614] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
In this study, we analyze and discuss the treatments of postoperative nasal complications after endonasal transsphenoidal resection of pituitary neoplasms (PNs). We performed 129 endonasal transsphenoidal resections of PNs and analyzed and treated cases with nasal complications. After endonasal transsphenoidal resection of PNs, there were 26 cases of postoperative nasal complications (20.1%), including nasal hemorrhage (4.8%), cerebrospinal fluid rhinorrhea (6.9%), sphenoid sinusitis (2.3%), atrophic rhinitis (1.6%), olfactory disorder (1.6%), perforation of nasal septum (0.8%), and nasal adhesion (2.3%). All patients clinically recovered after therapy, which included treatment of the cavity through nasal endoscopy, intranasal corticosteroids, and nasal irrigation. We propose that regular nasal endoscopic review, specific nasal medications, and regular nasal irrigation can effectively clear nasal mucosal hyperemia-induced edema and nasal/nasoantral secretions, as well as promote regeneration of nasal mucosa, prevent nasal adhesion, maintain the sinus cavity drainage, and accelerate the recovery of the physiological function of the paranasal sinus. Timely treatment of patients with nasal complications after endonasal transsphenoidal resections of PNs could greatly relieve the clinical symptoms. Nasal cleaning is very beneficial to patients after surgery recovery.
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Affiliation(s)
- You Cheng
- Department of Otolaryngology-Head and Neck Surgery
| | - Fei Xue
- Department of Otolaryngology-Head and Neck Surgery
| | | | - Jun-Feng Ji
- Department of Otolaryngology-Head and Neck Surgery
| | - Wei Chen
- Department of Otolaryngology-Head and Neck Surgery
| | - Zhi-Yi Wang
- Department of Otolaryngology-Head and Neck Surgery
| | - Li Xu
- Department of Otolaryngology-Head and Neck Surgery
| | | | - Xin-Feng Liu
- Department of Neurology, Jinling Hospital, Nanjing, Jiangsu, China
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Double nasoseptal flap technique for endonasal pituitary surgery. Eur Arch Otorhinolaryngol 2016; 274:897-900. [PMID: 27683301 DOI: 10.1007/s00405-016-4314-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 09/19/2016] [Indexed: 10/20/2022]
Abstract
Endoscopic endonasal approach has been successfully used for the management of pituitary tumors; however, the loss of septal mucosa especially around sphenoethmoidal recess and posterior nasal septum might be a disadvantage of this technique. The aim of this study is to describe a variation of the endonasal approach, "double nasoseptal flap" technique in endoscopic transsphenoidal pituitary surgery, and to evaluate its outcomes. The technique depends on fully harvested bigger nasoseptal flap on one side and smaller on the other. Thirty patients were included. Functional results were assessed by preoperative and postoperative first month visual analogue scale (VAS), and morphology was evaluated by achieving intact septum from the sphenoid ostium to the columella. Sphenoid sinusitis, the presence of synechia and crusting in the sphenoethmoidal recess was also assessed. Mean VAS was 71 and 67 mm preoperatively and postoperatively, respectively (p > 0.01). There were no septal perforations, synechia, and sphenoid sinusitis postoperatively. Three patients had (10 %) crusts on sphenoethmoidal recess on first month postoperatively. Double nasoseptal flap technique has advantages, such as wider exposure during surgery; prepared flaps could be used if needed, better morphological and functional outcomes postoperatively. The technique is safe without any perforations and minimal crusting.
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