Transsphenoidal approach to pituitary adenomas with suprasellar extension

During the past six years, we have operated upon a total of 59 pituitary adenomas with suprasellar extension. Of 26 patients treated by transsphenoidal operations, 54% (19 of 35 eyes) recovered normal visual acuity; improvement was noted in another 37% (13 of 35 eyes). The visual field was corrected in 84% (41 of 49 eyes). In about 60% (31 of 51 eyes) of the patients who underwent frontal craniotomy, visual improvement occurred. Endocrinologic cure of hypersecreting adenomas with suprasellar extension was difficult, although visual impairment improved. We suggest that in most cases the transsphenoidal approach is the method of choice in pituitary adenomas with suprasellar extension. With this approach there has been excellent visual improvement and fewer operative complications.     

显微镜下蝶窦入路微创治疗垂体瘤的回顾性分析

目的回顾性观察显微镜下经单鼻孔蝶窦入路微创手术切除垂体瘤的临床效果。方法选取我院住院并接受显微镜下经单鼻孔蝶窦入路微创手术切除垂体瘤患者42例,回顾性分析其疗效。结果显微镜下经单鼻孔蝶窦入路垂体瘤部分切除3例,垂体瘤大部切除10例,垂体瘤近全切15例,垂体瘤全切14例,平均手术时间58min,术后症状和内分泌功能都得到明显改善,无死亡。结论显微镜下经单鼻孔蝶窦入路微创手术切除垂体瘤疗效彻底、创伤小、副作用少,值得临床推广应用。     

Complications of transsphenoidal surgery in patients with pituitary adenoma: experience at a single centre

Summary Objective. This paper reports the complications of transsphenoidal surgery for pituitary adenomas in a series of 1240 consecutive patients operated at our Institute between 1990 and 2004 (first operations) and indicate the clinical characteristics of patients which affected surgical morbidity and mortality. Methods. According to tumour type, there were 420 (33.9%) non-functioning pituitary adenomas (NFPA), 349 (28.1%) GH-secreting, 288 (23.2%) ACTH-secreting, 155 (12.5%) prolactin (PRL)-secreting, and 28 (2.3%) TSH-secreting adenomas. The mean age of patients was 43.7 ± 0.4 yr and 122 patients (9.9%) were 65 yr or older; the female/male ratio was 1.5/1. There were 370 (29.8%) microadenomas and 870 (70.2%) macroadenomas of which 54 (4.4%) were giant adenomas. Results. The series mortality was 0.2%, the medical morbidity 1.9%, and the surgical morbidity 3.5%. Medical complications were significantly more frequent in patients older than 65 yr (4.9 vs. 1.4%; p = 0.009) and in patients with giant adenomas (5.6 vs. 1.6%; p = 0.03). Multivariate analysis showed that both variables were independently associated with a higher morbidity rate. The surgical morbidity was increased in giant adenomas (15 vs. 3%; p = 0.0001), in NFPA (6.2 vs. 2.1% in secreting adenomas; p = 0.0002) and in patients older than 65 yr (6.6 vs. 3.1%; p = 0.05). Multivariate analysis showed that only giant size was independently associated with an increased surgical morbidity rate. Conclusions. In our experience, the size of the adenoma was a risk factor for medical and surgery related complications and age over 65 yr for medical complications alone.     

Management of pituitary apoplexy: clinical experience with 40 patients

Summary Background. Pituitary apoplexy is a rare major clinical event with neurological, neuro-ophthalmological, cardiovascular and hormonal consequences, resulting from an acute infarction of pituitary adenoma. We report our experience with a series of 40 patients presenting with pituitary apoplexy.Patients. Forty patients (27 males, 13 females; mean age, 51.2yr) were admitted to our medical center between years 1985–2002 with acute presentation of pituitary apoplexy. Visual field defects occurred in 61% and ocular paresis in 40% of subjects. Sixty-three percent of adenomas were nonfunctional, and prolactinomas comprised 31%.Results. Thirty-four patients underwent transsphenoidal pituitary decompression. Visual fields and ophthalmoplegia improved in 81% and 71%, respectively. During follow-up (4.5±5.4yr), 79% of patients developed hypogonadotrophic hypogonadism, central hypothyroidism appeared in 54% and hypocortisolism – in 40% of patients. Permanent diabetes insipidus was diagnosed in 8%. Serial sellar MRI showed disappearance of pituitary tumor in 63% of operated subjects. Six patients (3 with PRL-secreting and 3 nonfunctional adenomas) were treated medically (corticosteroids, dopamine agonists), two patients (out of three) with visual deficits improved, and tumor shrinkage was noted in four.Conclusions. We present a large series of patients with pituitary apoplexy. Most subjects were operated, but six were treated conservatively. Almost all patients improved clinically, including those who were not operated, but hormonal deficiencies are very common.     

DDAVP use in patients undergoing transsphenoidal surgery for pituitary adenomas

Summary Background. Disorders of fluid and sodium regulation, often termed “diabetes insipidus,” are a frequent occurrence following surgery for pituitary adenomas. The present study was undertaken to identify the incidence of diabetes insipidus after pituitary surgery and its associated factors. Methods. A retrospective review of the medical records 300 patients who underwent transsphenoidal surgery for pituitary adenoma was undertaken. Information regarding patient gender, perioperative serum sodium levels and urinary output volumes, tumor size, previous pituitary surgery, tumor subtype, and the use of DDAVP was gathered. A multivariate statistical analysis was performed. Findings. Follow-up data were available on 288 patients. During the inpatient postoperative hospital stay, DDAVP was administered to 19% of all patients and 16% of patients not taking DDAVP preoperatively. Of patients with normal fluid/sodium regulation preoperatively, DDAVP was prescribed for 9% at discharge and 4% at 6 weeks postoperatively. Only 1.4% of patients were taking vasopressing replacement at the time of last follow-up. Significant correlations were found between gender, previous surgery, serum sodium levels, and urine volumes at various time points. Immunohistochemical type of tumor and tumor size were not related to DDAVP requirement. Conclusions. Transient hypotonic polyuria is frequently encountered after pituitary surgery. However, only a small number of patients will develop a long-term requiring for ongoing medical treatment. Previous surgery, female gender, and elevated serum sodium and urine volumes in perioperative period were associated with DDAVP requirement.     

Magnetic resonance imaging after transsphenoidal surgery of clinically non-functional pituitary macroadenomas and its impact on detecting residual adenoma

Summary. Summary.   Background and Purpose: In clinically non-functional pituitary macroadenomas, prospective follow-up magnetic resonance imaging (MRI) was conducted after transsphenoidal surgery both to study the changes of the sellar contents at the post-operative site over time and to assess the amount of residual adenoma tissue.   Methods: A total of 50 patients with clinically non-functional pituitary macroadenomas were treated by transsphenoidal tumour resection and were examined by MRI before and directly after surgery (early MR) and 3 months (intermediate MR) and 1 year after surgery (late MR). Changes in the sellar contents over time and the degree of tumour excision were studied on T1-weighted enhanced and unenhanced scans. All patients underwent complete neuro-ophthalmological and endocrinological assessments before and 3 months after surgery. For the interpretation of the post-operative images the results of the endocrinological examinations after surgery were also taken into account.   Results: The maximum size of tumour extension on coronal T1-weighted images ranged from 1.2 cm to 5.0 cm (mean 2.3 cm). Despite tumour resection, early post-operative images still showed a persistent mass in the sella in 83% that was usually caused by post-operative haemorrhage, fluid collection and implanted fat material. However, rapid improvement in visual symptoms was noted in 89%. Changes in the sellar region at the early post-operative site markedly hindered the interpretation of MR images for detecting residual tumour tissue, which was suspected in half of the patients (1 intrasellar, 13 suprasellar, and 11 parasellar). Regression of the post-operative mass in the sella was present 3 months after surgery, resulting in a 50% change in the volume of the coronal sellar extension, which also improved the reliability in interpreting the post-operative MR images. On the intermediate MR images residual tumour tissue was detected in 30% of the patients (4 intrasellar, 2 suprasellar and 9 parasellar). Because the suprasellar mass descended over time, an increasing rate of tumour remnant within the sella was seen 3 months following surgery. Before surgery the pituitary gland was visible superiorly or posterosuperiorly to the macroadenomas in 35 patients. However, at the early post-operative site the remaining gland was only visible in 12 patients. Under the condition that endocrinological function tests confirmed adequate hormonal function, the remaining gland was detectable by MRI in 36 patients 3 months after surgery.   Conclusion: Delayed regression of the sellar contents after transsphenoidal surgery of pituitary macroadenomas was demonstrated by this prospective MR study. Owing to the changes at the post-operative site, it was difficult to interpret early post-operative images and detect residual adenoma tissue. With respect to the delayed regression of the sellar contents, the interpretation of post-operative images for detection of residual adenoma was improved 3 months after surgery. At this time, residual adenoma tissue was found in 30% of clinically non-functional macroadenomas, mostly at the parasellar and, after descent from the suprasellar space, at the intrasellar site.     

Transsphenoidal approach with low field MRI for pituitary adenoma

INTRODUCTION: Appropriate evaluation of resection remains one of the major difficulties of surgical treatment of pituitary adenoma. The transsphenoidal approach does not allow direct visual control. Endoscopy provides useful information but may no distinguish well residual adenoma from the pituitary gland. Intraoperative MRI offers new perspectives for assessing the quality of resection. We report our experience with low field intraoperative MRI in surgical treatment of pituitary adenoma. POPULATION: Intraoperative MRI (Polestar N10, 30 patients and Polestar N20, 17 patients) was performed in 45 consecutive patients undergoing surgery for pituitary adenoma. Thirty-seven patients had a macroadenoma. Patients were in the prone position with the head fixed with a three-pin MRI-compatible headholder. METHOD: Coronal T1 MRI scans with enhancement were acquired pre and per operatively. We compared scans and surgical filling (complete removal). If there was a difference, a surgical control was undertaken. RESULTS: Intraoperative images were unavailable for two patients due to small size of the neck and the pituitary glands which were not in the middle in the field of view. For the others, the pituitary glands were in the field of view and the intraoperative scans could be used for comparison. For four patients, there was a discrepancy between surgeon filling and the intraoperative MRI. A control showed no residual adenoma but hemostatic tissue. CONCLUSION: Low field intraoperative MRI is an excellent technique for controlling the size of pituitary adenoma resection.     

Transsphenoidal surgery for pituitary adenoma in elderly patients

Summary   Background. As the population continues to age, the number of elderly patients with symptomatic pituitary tumours will continue to increase. Little information exists as to the safety of pituitary surgery in this patient population. The current study was undertaken to evaluate the presentation and perioperative risk associated with transsphenoidal surgery in patients over the age of 70. Methods. A retrospective chart review was undertaken for patients over the age of 70 undergoing transsphenoidal surgery at the Penn State Hershey Medical Center between 1995 and 2005. Findings. Sixty-four patients over the age of 70 were identified with an average age of 73.4 years (range 70–84). The average follow-up period was 44 months (range 14–104). Symptoms of mass effect were the presenting complaint in 72% of patients while 9% had documentation of growth on imaging studies. Twelve percent presented with a history consistent with apoplexy. Three patients (5%) presented with acromegaly. Post-operative hospital stay averaged 2.6 days (range 2–7). Eight patients had new hormonal deficits post-operatively (1 ACTH, 3 TSH, 2 ACTH/TSH, 2 vasopressin). There were no cardiopulmonary complications and no deaths within 90 days of surgery. Conclusions. Transsphenoidal surgery can be performed in patients over the age of 70 without undo significant risks. Surgical removal of pituitary adenomas should be considered the mainstay of treatment in elderly patients in whom treatment is necessary. Patients who are medically suitable candidates should be offered surgical resection as would their younger counterparts. Correspondence: Jonas M. Sheehan, M.D., Hershey Medical Center, Department of Neurosurgery, Penn State College of Medicine, 500 University Drive, Hershey, 17033 Pennsylvania, USA.     

Rhinological complications of sublabial transseptal transsphenoidal surgery for sellar and suprasellar lesions: prevention and management

Transseptal transsphenoidal surgery is the most widely accepted operative procedure for sellar and suprasellar lesions. About 35% out of fifty-four cases operated by this procedure at our centre had rhinological complications. Possible mechanism involved and their prevention and management is discussed herewith.     

Concomitant Transsphenoidal Approach to the Anterior Skull Base and Endoscopic Sinus Surgery in Patients with Chronic Rhinosinusitis

Objectives To describe outcomes of endoscopic resection of sellar tumors with concomitant endoscopic sinus surgery for patients with chronic rhinosinusitis (CRS).Design Retrospective chart review.Setting Tertiary care medical center.Participants Patients who underwent endoscopic transsphenoidal surgery for excision of anterior skull base lesions and simultaneous functional endoscopic sinus surgery (FESS) for CRS between January 2006 and January 2011 by senior authors (MRR and JJE).Main Outcomes Measured Short- and long-term postoperative complications.Results Fourteen patients were identified. Average follow-up was 27 months. All patients had preoperative symptoms consistent with CRS. No patients were treated with preoperative antibiotics. Surgical pathology revealed chronic sinusitis in all specimens. Pathology of the intracranial lesions included 11 pituitary macroadenomas, one craniopharyngioma, one chondrosarcoma, and one cholesterol granuloma. Short-term postoperative morbidities included a sphenoid polyp, one adhesion, and one case of pharyngitis. Long-term outcomes included one frontoethmoidal mucocele, one recurrence of nasal polyps, and three cases of acute sinusitis. There were no intracranial complications for the entire follow-up period.Conclusions Transsphenoidal surgery can safely be performed in the setting of CRS without increased risk of intracranial complications.     

Endonasal endoscopic transsphenoidal approach robot prototype: A cadaveric trial

BackgroundThe Endonasal Endoscopic Transsphenoidal Surgery (EETS) is a minimally invasive procedure to approach and remove pituitary tumors and other sellar lesions. The process causes less pain, faster recovery, and provides further minimal invasive access in critical cases. However, a slight deviation of tools from the target area can be fatal to the patients. The aim of this study is to design and develop a prototype robot to demonstrate neurosurgical robot-assisted EET approach.MethodsThe effectiveness of a prototype robot in executing a minimally invasive EET surgery was studied in 6 cadavers. The robot was associated with a multi-information integrated technique for surgery including QR code tracking. The robot was controlled and driven by the neurosurgeon.ResultsThe standard procedure of EET was followed and the robot carried out the first stage of EET under the supervision of neurosurgeon. Finally, the sellar was reached by the neurosurgeon. The result was determined by qualitative analysis and was confirmed by the neurosurgeon. The time for the entire EET surgical procedure showed marked reduction compared to the traditional EET approach.ConclusionThe robot design was found to be technically feasible and hence can be used for assisting the EET procedure. The robot used was able to assist the neurosurgeon correctly to approach the sinus.     

Intra- and postoperative plasma ACTH concentrations in patients with Cushing's disease cured by transsphenoidal pituitary surgery

Summary.  Background: The optimal treatment of choice for ACTH-producing pituitary adenomas is their complete removal by the transsphenoidal surgical approach. ACTH-producing pituitary adrenomas are, however, often small in size not detectable with neuro-imaging techniques, which may result in difficulties during their surgical removal. With the advent of rapid methods for plasma ACTH measurement, a few neurosurgical centers introduced intra-operative plasma ACTH determinations in peripheral and central blood samples to help improve the outcome of pituitary surgery in patients with Cushing's disease.  Method: To evaluate the usefulness of this new method, we performed, under standardized conditions, intra-operative plasma ACTH measurements with a rapid immunochemiluminometric method at different stages of transsphenoidal pituitary surgery in 7 patients with Cushing's disease.  Findings: We found that from the beginning of anesthesia until the end of operation, ACTH concentrations in venous plasma were highly variable by both the rapid and the standard methods. In most cases the changes in venous plasma ACTH concentrations that occurred until the end of surgery failed to indicate the removal of the ACTH-producing pituitary adenoma. However, a more than 50% decrease of venous plasma ACTH concentrations by the rapid assay was observed 2 h after completion of the operation in all but one of the patients. As evidenced by a long-term hormonal and clinical remission, these changes in plasma ACTH levels in all patients were accompanied by a complete removal of the ACTH-producing pituitary adenoma.  Interpretation: These findings indicate a slow disappearance of ACTH from the circulation after a successful pituitary surgery in patients with Cushing's disease. Published online October 10, 2002 Correspondence: Dr. K. Rácz, 2nd Department of Medicine, Semmelweis University Medical School, 1088 Budapest, Hungary     

Endoscope-assisted microsurgery for tumors of the septum pellucidum: surgical considerations and benefits of the method in the treatment of four serial cases

Neoplasms that primarily originate from the septum pellucidum are extremely rare. Generally the septum pellucidum is involved in direct extension of tumors that arise from the neighboring structures, principally the corpus callosum. Endoscope-assisted techniques form a useful adjunct to common microsurgical procedures to completely remove intraventricular lesions. There are two main advantages of endoscope-assisted surgery over common microsurgical techniques: reduction of superficial brain retraction with less iatrogenic trauma to the neighboring structures and inspection of hidden corners depict simultaneously anatomical details which are not precisely visible in the zoomed and thus light-reduced beam of the microscope. Four patients with septum pellucidum tumors underwent surgery by a transcallosal approach. In all four patients the endoscope-assisted microsurgery technique was used to remove the tumor. In one of the four patients neuronavigation was additionally used for guidance. Complete tumor excision was achieved in all patients. The histological findings showed pilocytic astrocytoma in two cases, one subependymoma and one neurocytoma, respectively. There were no postoperative complications. Endoscope-assisted microsurgery provides maximum efficiency to remove the septum pellucidum tumors with minimum invasiveness.     

Transanal endoscopic microsurgery in 143 consecutive patients with rectal adenocarcinoma: results from a Danish multicenter study

Objective  The long-term results are presented on total survival, cancer-specific survival and recurrence in 143 consecutive patients treated with transanal endoscopic microsurgery (TEM) for adenocarcinoma of the rectum.
Method  Four Danish centres established in 1995 a database for registration of all TEM procedures. Data were supplemented from pathology reports and death certificates were checked in the Danish patient registry. Data were analysed with multivariance regression and survival analysis.
Results  The T stage was as follows: T1 50%, T2 33%, T3 14%, and stage unknown 3%. TEM was performed with curative intent in 43%, for compromise in 52% and for palliation in 5%. Five-year total survival was 66% and 5-year cancer-specific survival 87%. Cancer-specific survival for T1 was 94%. The significant predictors for total survival were age and tumour size. For cancer-specific survival T stage, radical resection, tumour size and recurrence were significant predictors. Eighteen per cent had recurrence and 15% had immediate reoperation.
Conclusion  The TEM provides good long-term results for pT1 cancers. In old patients and patients with co-morbidity TEM may provide acceptable long-term results for T2 cancers. Tumours larger than 3 cm should not be treated with TEM for cure.     

Feasibility of a novel extraperitoneal two‐port laparoendoscopic approach for radical prostatectomy: An initial study

The aim of this study was to describe the surgical technique and to report the early outcomes of an original extraperitoneal two‐port laparoendoscopic approach for radical prostatectomy. A total of 22 consecutive patients diagnosed with early‐stage prostate cancer (cT1c, cT2N0) were operated on and included in this analysis. A multichannel port with three 5‐mm trocars, providing easier instrument handling, was inserted extraperitoneally through a 2.5‐cm lower umbilical “U” incision. An additional 12‐mm port was inserted into the left fossa to allow an adequate working angle to facilitate the most critical steps of the surgical procedures. The operation was successfully completed in all patients; one patient required an additional 5‐mm port to control bleeding. The median operation time was 259 min (range 207–453 min), and the fluid loss, including urine and blood, was 946 mL (range 257–1821 mL). The median Foley catheter indwelling period was 6 days (range 3–11 days) after surgery. No intraoperative complications occurred. Judging from this initial trial, this procedure can be safely carried out if the surgeon is familiar with conventional five‐port laparoscopic radical prostatectomy.     

经单鼻孔-蝶窦入路垂体腺瘤显微手术治疗及其策略

目的 总结采用经单鼻孔-蝶窦入路显微手术治疗垂体腺瘤的临床疗效.方法 从2003年1月至2007年12月,经单鼻孔-蝶窦入路显微手术治疗垂体腺瘤241例,并对其临床表现、肿瘤病理、肿瘤切除率、术后并发症进行总结分析.结果 垂体腺瘤241例中,全切除171例(71%),次全切除28例(11.6%),大部分切除26例(10.7%),部分切除16例(6.6%).术后多饮、多尿38例(15.8%)、术后视力一过性下降12例(4.9%)、术后脑脊液漏4例(1.6%)、一侧动眼神经损伤2例(0.8%),无死亡病例.除动眼神经损伤的2例外,其余病例的术后并发症在出院时已治愈.随访1-36个月,所有病例的临床症状均有不同程度改善.结论 经单鼻孔-蝶窦人路显微切除垂体腺瘤手术时间缩短,创伤小,手术效果好.     

三切口食管癌根治术:胸腔镜与开放手术的回顾性研究

目的 比较胸腔镜和开胸三切口食管癌根治术的围手术期并发症及中期疗效.方法 回顾性分析2005年1月至2012年6月间复旦大学附属中山医院胸外科收治827例接受三切口食管癌根治术患者的临床资料,其中胸腔镜482例和常规开胸345例.比较两组的围手术期相关指标及中期生存情况.结果 与开胸组相比,胸腔镜手术组平均淋巴结清扫个数更多[(28.3±5.1)个对(27.4±5.6)个,P=0.017],术后住院时间短[(14.6±5.6)天对(16.9±9.3)天,P=0.000],再入ICU率低(5.6％对10.1％,P=0.014),围手术期病死率低(1.0％对3.2％,P=0.027),围手术期总体并发症少(37.6％对44.9％,P=0.033),呼吸系统并发症少(9.3％对13.9％,P=0.040).胸腔镜组术后1年、2年、3年生存率略优于开胸组,但组间差异均无统计学意义.结论 胸腔镜与开胸手术与三切口食管癌根治术相比,围手术期疗效优势比较明显,中期疗效的优势尚有待于进一步验证.