Endoscopic endonasal approach for pituitary adenoma: surgical complications in 301 patients

The authors investigate the complications of transnasal transsphenoidal endoscopic surgery in the treatment of 301 patients with pituitary adenomas. A retrospective analysis of complications in 301 patients submitted to transsphenoidal transnasal endoscopic surgery at the General Hospital of Fortaleza, Brazil between January 1998 and December 2009. The complications were divided in two groups: anatomical (oronasofacial, sphenoid sinus, intrasellar, suprasellar and parasellar) and endocrinological complications (anterior and posterior pituitary dysfunctions). We observed a total of 81 complications (26.9%) in our series. Anatomical complications occurred in 8.97% (27 cases): 8 CSF postoperative leaks (2.6%), 6 cases (1.9%) of delayed nasal bleeding, 5 cases (1.6%) of sphenoidal sinusitis, 3 cases (0.9%) of carotid artery lesion, 2 cases of meningitis (0.6%) and one case (0.3%) of each of the uncommon following complications: intrasella-suprasella hematoma, pontine hematoma and chiasmaplexy. Endocrinological complications occurred in 17.9% (54 cases): additional postoperative anterior lobe insufficiency in 35 cases (11.6%), and postoperative diabetes insipidus in 19 cases (6.3%). In our series, 3 cases of deaths (not directly related to the procedure) were also observed. Endoscopic transsphenoidal surgery represents an effective option for the treatment of patients with pituitary tumor. Complications still occur and must be reduced as much as possible. Successful endoscopic pituitary surgery requires extensive training in the use of an endoscope and careful planning of the surgery. Additional improvement can be expected with greater experience and new technical developments.     

Endoscopic endonasal transsphenoidal surgery: surgical results of 228 pituitary adenomas treated in a pituitary center

Pituitary tumors are challenging tumors in the sellar region. Surgical approaches to the pituitary have undergone numerous refinements over the last 100 years. The introduction of the endoscope have revolutionized pituitary surgery. The aim of this study is to report the results of a consecutive series of patients undergoing pituitary surgery using a pure endoscopic endonasal approach and to evaluate the efficacy and safety of this procedure. We reviewed the data of 228 consecutive patients who underwent endonasal transsphenoidal adenoma removal over an 10-year period. Pre- and post-operative hormonal status (at least 3 months after surgery) were analyzed and compared with clinical parameters presented by the patients. Tumor removal rate, endocrinological outcomes, and complications were retrospectively assessed in 228 patients with pituitary adenomas who underwent 251 procedures between December 1998 and December 2007. There were 93 nonfunctioning adenomas, 58 growth hormone-secreting, 41 prolactin-secreting, 28 adrenocorticotropin hormone secreting, 7 FSH-LH secreting and 1 thyroid-stimulating hormone-secreting adenomas. Gross total removal was achieved in 79.3% of the cases after a median follow-up of 61.5 months. The remission results for patients with nonfunctioning adenomas was 83% and for functioning adenomas were 76.3% (70.6% for GH hormone-secreting, 85.3% for prolactin hormone-secreting, 71.4% for ACTH hormone-secreting, 85.7% for FSH-LH hormone-secreting and 100% for TSH hormone-secreting), with no recurrence at the time of the last follow-up. Post-operative complications were present in 35 (13.9%) cases. The most frequent complications were temporary and permanent diabetes insipidus (six and two cases, respectively), syndrome of inappropriate antidiuretic hormone secretion (two cases) and CSF leaks (eight cases). There was no death related to the procedure in this series. The endoscopic endonasal approach for resection of pituitary adenomas, provides acceptable results representing a safe alternative procedure to the microscopic approach. This less invasive method, associated with a small number of complications, provides excellent tumor removal rates and represents an important tool for the achievement of good results in the pituitary surgery, mainly for the complete removal of large adenomas.     

Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of giant pituitary adenomas

Giant (>4 cm) pituitary macroadenomas often require surgery to decompress the optic nerves. Compared with traditional open or transsphenoidal microscopic methods, the extended endoscopic endonasal transsphenoidal approach offers the potential for aggressive resection via a minimal access corridor. We conducted a systematic review of the literature to further our understanding of the role of endoscopy in the management of these challenging lesions. MEDLINE search of the modern literature (1995-2010) to identify surgical series for pediatric and adult pituitary adenomas >4 cm in maximal diameter. Patient and tumor characteristics, resection, morbidity and visual outcome were compared by approach. Chi-square and Fisher's exact tests with post-hoc Bonferroni analysis were used for statistical analyses. Sixteen studies (478 patients) were included. Compared with the open cohort, the endoscopic cohort had higher rates of gross total resection (47.2% vs. 9.6%; P < 0.003) and improved visual outcome (91.1% vs. 45.7%; P < 0.003). The microscopic transsphenoidal cohort had lower rate of total resection and worse visual outcomes than the endoscopic group. There were no instances of postoperative CSF leak reported in the endoscopic group. The transcranial group had a higher rate perioperative mortality compared to the transsphenoidal group (P = 0.004). In select cases, the endoscopic endonasal approach is safe and effective for the treatment of giant pituitary adenomas, with the potential for gross total resection and improved visual outcome. CSF leak, which is a major limitation of the endonasal approach, may be avoided using meticulous multi-layer closure and vascularised nasoseptal flaps.     

A panoramic view of the skull base: systematic review of open and endoscopic endonasal approaches to four tumors

Endoscopic endonasal surgery has been established as the safest approach to pituitary tumors, yet its role in other common skull base lesions has not been established. To answer this question, we carried out a systematic review of reported series of open and endoscopic endonasal approaches to four major skull base tumors: olfactory groove meningiomas (OGM), tuberculum sellae meningiomas (TSM), craniopharyngiomas (CRA), and clival chordomas (CHO). Data from 162 studies containing 5,701 patients were combined and compared for differences in perioperative mortality, gross total resection (GTR), cerebrospinal fluid (CSF) leak, neurological morbidity, post-operative visual function, post-operative anosmia, post-operative diabetes insipidus (DI), and post-operative obesity/hyperphagia. Weighted average rates for each outcome were calculated using relative study size. Our findings indicate similar rates of GTR and perioperative mortality between open and endoscopic approaches for all tumor types. CSF leak was increased after endoscopic surgery. Visual function symptoms were more likely to improve after endoscopic surgery for TSM, CRA, and CHO. Post-operative DI and obesity/hyperphagia were significantly increased after open resection in CRA. Recurrence rates per 1,000 patient-years of follow-up were higher in endoscopy for OGM, TSM, and CHO. Trends for open and endoscopic surgery suggested modest improvement in all outcomes over time. Our observations suggest that endonasal endoscopy is a safe alternative to craniotomy and may be preferred for certain tumor types. However, endoscopic surgery is associated with higher rates of CSF leak, and possibly increased recurrence rates. Prospective study with long-term follow-up is required to verify these preliminary observations.     

The trans-sphenoidal resection of pituitary adenomas in elderly patients and surgical risk

In western countries, the process of “ageing of the population” is increasingly forcing clinical medicine to find answers for pathologies affecting the elder segments of our community. In this respect, pituitary adenomas often raise difficult questions on surgical indications, since little is known about postoperative morbidity and mortality in elderly patients. The transsphenoidal endonasal approach (TNS), which is considered the gold standard for surgical resection of the majority of functioning and non-functioning pituitary adenomas, is supposed to be a low morbidity and mortality procedure in adult patients. However, only a few contradicting data are available in the literature about elderly patients. In this paper we retrospectively analyze a cohort of 43 consecutive patients aged more than 65 years, operated on for pituitary adenomas at our Institution in the years 1998–2007. These patients were treated by transsphenoidal endonasal approach (TNS) for resection of non-functioning pituitary adenomas (n = 31), GH-secreting adenomas (n = 4) and ACTH-secreting adenomas (n = 8). Clinical records reported a macroadenoma with tumour-related mass symptoms in about 80 % of patients; single or multiple pituitary deficits were present in 44 % of patients. Regarding comorbidities, cardiac disease was the most frequently observed (86 %); assessment of anaesthesiological risk indicated a moderate to severe ASA score in most patients, 11 % showing a 4–5 score. On the basis of current criteria, our retrospective analysis revealed that cure was achieved in 54 % of patients. The outcome was similar to that observed in the general population of patients undergoing transphenoidal surgery in our centre, without differences in the rate of surgical and endocrinological cure, minor and major surgical complications and hospitalization duration. In particular, no significant anaesthesiological complications were observed and no patient developed either permanent diabetes insipidus or cerebrospinal fluid rhinorrhea. In conclusion, in specialized centres the surgical treatment of pituitary adenomas via the transsphenoidal route can be a safe and effective procedure even in elderly patients.     

Volumetric classification of pituitary macroadenomas predicts outcome and morbidity following endoscopic endonasal transsphenoidal surgery

Endoscopy in combination with extended approaches allow for resection of large pituitary adenomas via a transsphenoidal route. The objective of the current study was to determine a volumetric threshold for lesions with high perioperative morbidity and high rate of subtotal resection following endonasal endoscopic surgery. Thus, we analyzed a prospectively collected database of 71 patients who underwent endoscopic transsphenoidal approaches for macroadenomas (diameter >1 cm). Extend of resection (EOR) was calculated based on volumetric analysis of pre-and post-operative contrast-enhanced MRI. Average EOR was 97.8% and a gross total resection (GTR) was achieved in 76.1% of all patients. GTR was accomplished in 92.0% versus 38.1% of adenomas either without or with CS invasion, respectively. Likewise, GTR was accomplished in 90.2% versus 40.0% of lesions less than or greater then 10 cm(3) respectively. However, even if only subtotal resection was achieved, 90.3% of tumor volume was removed. At 17 months follow-up, visual field defects improved in 80.8% of patients. Complications included permanent diabetes insipidus (5 patients), panhypopituitarism (4 patients), injury to the ophthalmic artery (1 patient) and CSF leak (1 patient). On multivariate logistic regression, two factors negatively predicted GTR: invasion of the CS and volume greater than 10 cm(3). A 10 cm(3) threshold was a stronger predictor of EOR and complication risk than diameter-based measurements. A volume greater than 10 cm(3) and CS invasion may help to identify pituitary lesions associated with a higher likelihood of subtotal resection and post-operative morbidity.     

Risk factors impacting intra- and postoperative cerebrospinal fluid rhinorrhea on the endoscopic treatment of pituitary adenomas: A retrospective study of 250 patients

We aimed to identify the risk factors associated with intra- and postoperative cerebrospinal fluid (CSF) leakage in pituitary adenomas treated with endoscopic transsphenoidal surgery.This study is a retrospective analysis of 250 pituitary adenoma cases from January 2017 to December 2019 at our hospital. All patients underwent endoscopic endonasal transsphenoidal surgeries. Univariate and multivariate analyses were performed to investigate the risk factors associated with intra- and postoperative CSF rhinorrhea.Eighty (32.0%) and nine (3.6%) patients had intra- and postoperative CSF leakage, respectively. Tumor size was an independent risk factor for intraoperative CSF leakage (odds ratio [OR], 1.229; 95% confidence interval [CI], 1.133–1.334; P < .001); intraoperative CSF leakage was an independent risk factor for postoperative CSF leakage (OR, 7.707; 95% CI, 1.336–44.455; P = .022). Chronic respiratory disease (OR, 57.500; 95% CI, 8.031–411.682; P < .001) was also an independent risk factor for postoperative CSF leakage. Vascularized septal mucosal flap was a protective factor (OR, 0.107; 95% CI, 0.013–0.894; P = .039).Intraoperative CSF leakage is more likely to occur in large pituitary adenomas. In the presence of intraoperative CSF leakage, postoperative CSF rhinorrhea is very likely to occur. Patients with chronic respiratory disease are also more likely to develop postoperative CSF leakage. The sellar base reconstructed using vascularized nasal septal flaps can significantly decrease the risk. The Knosp grade, degree of tumor resection, and postoperative use of a lumbar subarachnoid drain did not have any effects on postoperative CSF rhinorrhea.     

Olfactory Function and Quality of Life Following Microscopic Endonasal Transsphenoidal Pituitary Surgery

Olfactory outcomes as well as oronasal postoperative complications of transsphenoidal pituitary surgery have not been well studied. The objective of this study was to investigate nasal symptoms including olfactory function as well as quality of life following transsphenoidal pituitary surgery.The study is designed as a prospective cohort study set in a single tertiary hospital.A total of 53 patients with pituitary adenomas were included.All patients underwent pituitary surgery with the right-sided endonasal transsphenoidal approach.Outcomes were assessed with the Chinese version of the Medical Outcomes Study Short Form-36 (SF-36) to survey patient health, the Chinese version of the 22-item Sinonasal Outcome Test (SNOT-22), and a Toyota and Takagi (T&T) olfactometer. Assessments were carried out before surgery and at 1 week, and 1 and 4 months after surgery.The overall SF-36 scores were significantly lower, but the SNOT-22 scores were higher at 1 week and 1 month postoperatively compared with baseline (all P < 0.001). The results of T&T olfactometer testing showed that there was a significant decline in the ability to detect odors postoperatively, even at 4 months. Multivariate linear regression analysis showed that lower education level, partial tumor removal, and longer duration of surgery were independent risk factors for a higher SNOT-22 score at 1 week after surgery.The findings show that microscopic endonasal transsphenoidal pituitary surgery impairs olfactory function in most patients for at least 4 months after surgery.     

Endoscopic Pituitary Surgery

Endoscopy has been adopted for transsphenoidal pituitary surgery. A rigid rod-lens endoscope, 4-mm in diameter and 17-cm in length, is used in replacement of the operating microscope. This endoscopic technique utilizes the patient's natural nasal air passage as a surgical corridor without a sublabial or nasal mucosal incision. The use of a transsphenoidal retractor is not necessary. Postoperative nasal packing is not required. The average length of a patient's hospital stay is overnight. Postoperative discomfort is minimal. An angled lens endoscope enables the surgeon to operate on tumors located in the suprasellar region under direct visualization. When the adoption of endoscopy in transsphenoidal pituitary surgery had demonstrated obvious advantages over conventional microscopic surgery, the use of this endoscopic endonasal technique has been expanded to include other skull base lesions at the anterior fossa skull base, cavernous sinus, clivus and clival posterior fossa. In this chapter, the author describes the evolution of this endoscopic transsphenoidal surgery, the pertinent sinonasal anatomy related to transsphenoidal endoscopy, the details of endoscopic endonasal transsphenoidal pituitary surgery, surgical approaches to the other skull base lesions, surgical results, and potential complications and their avoidance.     

神经导航系统引导单鼻孔蝶窦入路垂体瘤切除术的应用

目的观察神经导航系统引导单鼻孔蝶窦入路垂体瘤切除术的应用效果。方法32例垂体瘤患者,术前行MRI或CT薄层扫描,将图像资料输入Brain LAB Vector Vision神经导航系统中进行三维重建,据此设计最佳手术入路,并对肿瘤及重要结构作标记;术中在神经导航系统的引导下寻找蝶窦前壁、鞍底、颈内动脉、海绵窦和斜坡等结构,切除肿瘤。结果32例均在神经导航引导下经鼻蝶入路顺利到达肿瘤部位,注册误差0．3～2．5mm;肿瘤全切除24例,次全切除6例,大部切除2例;术后26例症状有不同程度的改善,6例无变化,无严重并发症出现。结论神经导航引导单鼻孔蝶窦入路垂体瘤切除术定位准确、肿瘤全切除率高、并发症少。     

Diabetes insipidus after endoscopic transsphenoidal surgery: multicenter experience and development of the SALT score

Objective

To identify risk factors for the development of postoperative diabetes insipidus (DI) in a modern cohort of endoscopic endonasal transsphenoidal surgery.

Methods

Analysis of prospectively collected data of 449 consecutive patients operated on for anterior skull base pathology. DI was defined as a polyuria (>?250 ml/h for?≥?2 consecutive hours) polydipsia syndrome associated with hypotonic urine with or without hypernatraemia. Multivariate logistic regression was used to identify predictors of postoperative DI. A simple scoring system was then created.

Results

Postoperative DI occurred in 46 (10.2%) patients. The development of DI did not affect quality of life. Predictors of DI on multivariate analysis included suprasellar extension (OR 2.2; p?=?0.04), age?<?50 years (OR 2.8; p?=?0.003), craniopharyngioma histology (OR 6.7; p?=?0.002), and Kelly grade 3 intraoperative CSF leak (OR 2.1; p?=?0.04). The SALT score was created based on these characteristics, with one point awarded for each feature present, and predicted DI with fair to good predictive value in our cohort (AUROC 0.735 (95%CI 0.65–0.82)). The rates of postoperative DI were 4.0%, 6.5%, 15.0%. 36.8% and 85.7% for SALT scores of zero, one, two, three, and four, respectively.

Conclusions

The SALT score predicts postoperative DI with fair to good accuracy, and now requires prospective external validation. Improved prediction of DI could optimize resource allocation and facilitate individualised preoperative patient counselling. We also provide our algorithm for diagnosis and treatment of DI.

     

Single-surgeon fully endoscopic endonasal transsphenoidal surgery: outcomes in three-hundred consecutive cases

The objective of this study was to evaluate outcomes of endoscopic transsphenoidal surgery using a single-surgeon technique as an alternative to the more commonly employed two-surgeon, three-hand method. Three hundred consecutive endoscopic transsphenoidal procedures performed over a 5 year period from 2006 to 2011 were reviewed. All procedures were performed via a binasal approach utilizing a single surgeon two handed technique with a pneumatic endoscope holder. Expanded enodnansal cases were excluded. Surgical technique, biochemical and surgical outcomes, and complications were analyzed. 276 patients underwent 300 consecutive surgeries with a mean follow-up period of 37 ± 22 months. Non-functioning pituitary adenoma (NFPA) was the most common pathology (n = 152), followed by growth hormone secreting tumors (n = 41) and Rathke’s cleft cysts (n = 30). Initial gross total cyst drainage based on radiologic criteria was obtained in 28 cases of Rathke’s cleft cyst, with 5 recurrences. For NFPA and other pathologies (n = 173) gross total resection was obtained in 137 cases, with a 92 % concordance rate between observed and expected extent of resection. For functional adenoma, remission rates were 30/41 (73 %) for GH-secreting, 12/12 (100 %) for ACTH-secreting, and 8/17 (47 %) for prolactin-secreting tumors. Post-operative complications included transient (11 %) and permanent (1.4 %) diabetes insipidus, hyponatremia (13 %), and new anterior pituitary hormonal deficits (1.4 %). CSF leak occurred in 42 cases (15 %), and four patients required surgical repair. Two carotid artery injuries occurred, both early in the series. Epistaxis and other rhinological complications were noted in 10 % of patients, most of which were minor and diminished as surgical experience increased. Fully endoscopic single surgeon transsphenoidal surgery utilizing a binasal approach and a pneumatic endoscope holder yields outcomes comparable to those reported with a two-surgeon method. Endoscopic outcomes appear to be better than those reported in microscope-based series, regardless of a one or two surgeon technique.     

Repeat endoscopic transsphenoidal surgery for acromegaly: remission and complications

Reported biochemical remission rates following surgical intervention for acromegaly range from 38 to 83 %. In patients not achieving surgical remission, few options remain, mostly limited to medical management and radiation therapy. There is debate over whether or not to offer reoperation to patients in whom surgical remission is not achieved with initial resection. Retrospective chart review was undertaken to determine all patients having acromegaly with persistently elevated GH and/or IGF-1 levels after initial pituitary adenoma resection, and who underwent reoperation using endoscopic endonasal approach at a single institution. Biochemical remission was defined as a postoperative GH level <1 ng/mL and a normal postoperative IGF-1 level in the absence of any medical therapy. In total, 14 patients underwent repeat surgical intervention for acromegaly via endoscopic transsphenoidal approach. Of the 14 patients, 8 (57 %) achieved biochemical remission following repeat surgical intervention. Lower preoperative GH levels were associated with greater chance of biochemical remission (P = 0.048). New endocrinopathies were seen in 2 patients (14 %), and both were transient diabetes insipidus. Meningitis occurred in 2 patients (14 %); both were aseptic meningitis with no sequelae. No mortality was encountered. Repeat surgical intervention for acromegaly via endoscopic transsphenoidal approach appears safe and effective. With no mortality and minimal morbidity, repeat surgical intervention via endoscopic transsphenoidal approach appears a reasonable option for these hard-to-treat patients and should be considered for patients in whom surgical remission is not achieved with initial surgery.     

Serial MR Intensity Changes of the Posterior Pituitary in Patients with Diabetes Insipidus After Transsphenoidal Surgery for Pituitary Adenomas: Report of Two Cases

This is the first report describing magnetic resonance (MR) intensity changes of the posterior pituitary gland in the patients suffering from the classical "triphasic" diabetes insipidus (DI) after transsphenoidal surgery for pituitary adenomas. A 21-year-old female and a 54-year-old female were admitted to our hospital with the diagnosis of Cushing's disease and acromegaly due to pituitary microadenomas, respectively. No evidence of DI was found, and T1-weighted MR images exhibited "bright spot" corresponding to the posterior pituitary in both cases. Both experienced the classical "triphasic" pattern of water metabolism disturbance after successful transsphenoidal resection of pituitary adenomas, that is, polyuria-oliguria-polyuria. The MR signal hyperintensity in posterior pituitary was detected during the first polyuric phase, but the hyperintensity disappeared during the second polyuric phase. In addition, "bright spot" was restored along with the recovery from DI in the chronic phase. These findings of serial MR images supported that the first DI phase of the classical triphasic course of water metabolism disturbance was caused by secretional dysfunction of stored vasopressin from the posterior gland, whereas the second DI phase was due to impairment in the functional integrity producing vasopressin-containing granules after depletion of vasopressin in the oliguric phase.     

Surgical management of GH-secreting pituitary adenomas: an outcome study using modern remission criteria.

The results of transsphenoidal surgery as initial therapy for GH-secreting pituitary adenomas in 57 acromegalic patients were analyzed retrospectively. Patients with prior surgery or radiation therapy were excluded from the study. Three different criteria were used to define remission: glucose-suppressed (nadir) GH less than 1.0 microg/liter, a normal sex- and age-adjusted IGF-I level, and postoperative random GH levels of 2.5 microg/liter or less. Additionally, we analyzed the neuropathological data, including immunohistochemistry and ultrastructural categorization, and the surgical complications. The short-term remission rate (6-wk postoperative follow-up visit), as determined by a random GH measurement of 2.5 microg/liter or less, was 48.8%; the remission rate, as determined by nadir GH, was 51.4%. For 57 patients followed for 12 months or more after surgery (mean, 37.7 months), surgical remission was achieved in 70.2%, 66.7%, and 61.1%, respectively, for patients assessed by normal IGF-I, random GH, and nadir GH. One patient (1.1%) developed recurrence of active acromegaly 81 months after initially successful surgical therapy. Extrasellar growth of the tumor (P = 0.04) and dural invasion by the adenoma (P = 0.008) were significant univariate predictors of a poor outcome. Tumor size was significantly greater in patients with persistent or recurrent acromegaly (P = 0.02). Patients with tumors of the ultrastructural categories of mixed GH/PRL cell and mammosomatotroph adenomas had the lowest remission rates (50% and 42.9%, respectively). There were no perioperative deaths, and there was no serious morbidity. The permanent complication rate was 3.3% (1 permanent DI and 2 nasal septal perforations). Surgical management of acromegaly currently provides prompt, effective, and satisfactory initial treatment for the majority of patients. Using stringent criteria for remission, primary transsphenoidal surgery for GH-secreting pituitary adenomas is effective and often definitive therapy for acromegaly. These results provide a benchmark for the contemporary results of surgical management as assessed by modern outcome criteria.     

Pituitary adenomas in adolescence--ten-year experience and literature review

Pituitary adenomas account for less than 6% of all intracranial tumors in adolescence. Between November 1987 and October 1996, 8 patients were treated by transsphenoidal resection at Kaohsiung Medical College Hospital. This series included 4 girls and 4 boys with ages ranging from 14 to 19 years. Symptoms reflecting endocrine dysfunction such as scanty pubic hairs in males and amenorrhea in females, were more often found than neurological problems in all adolescents at presentation. Macroadenoma occurred in five of our eight cases (62%) of adolescent pituitary adenoma. In one case (12%), the tumor was plurihormonal tumor. Long-term follow-up (mean 4.5 +/- 2.7 years) revealed the majority of patients had good endocrine function. Significant operative morbidity included steroid-induced psychosis in one patient and transient diabetes insipidus in three, which resolved in all three within two weeks. Our study showed that 1) pituitary tumors in children were uncommon, and when they occurred they were frequently large and invasive; 2) the endocrine disturbance caused by pituitary adenomas alerted the patients to seek medical help more often than neurological deficit; 3) in adolescence, almost all pituitary adenomas were functioning; nonfunctioning pituitary adenomas were rare in adolescence; and 4) transsphenoidal surgery was feasible and safe in adolescence, even with poor pneumatization of the sphenoid sinus, which remains controversial in the literature.     

Preoperative risk factors for postoperative complications in endoscopic pituitary surgery: a systematic review

Background

The ability to preoperatively predict postoperative complication risks is valuable for individual counseling and (post)operative planning, e.g. to select low-risk patients eligible for short stay surgery or those with higher risks requiring special attention. These risks however, are not well established in pituitary surgery.

Methods

We conducted a systematic review of associations between preoperative characteristics and postoperative complications of endoscopic transsphenoidal surgery according to the PRISMA guidelines. Risk of bias was assessed through the QUIPS tool.

Results

In total 23 articles were included, containing 5491 patients (96% pituitary adenoma). There was a wide variety regarding the nature and number of risk factors, definitions, measurement and statistics employed, and overall quality of mainly retrospective studies was low. Consistent significant associations were older age for complications in general, and intraventricular extension for cerebrospinal fluid (CSF) leaks. Associations identified in some but not all studies were younger age, increased BMI, female gender, and learning curve for CSF leaks; increased tumor size for complications in general; and Rathke’s cleft cysts for diabetes insipidus. Mortality (incidence rate 1%) was not addressed as a risk factor.

Conclusion

Based on current literature, of low to medium quality, it is not possible to comprehensively quantify risk factors for complications. Nevertheless, older age and intraventricular extension were associated with increased postoperative complications. Future research should aim at prospective data collection, reporting of outcomes, and uniformity of definitions. Only then a proper risk analysis can be performed for endoscopic pituitary surgery.

     

The endoscopic versus the traditional approach in pituitary surgery

The transsphenoidal route is the most widely used technique for pituitary adenoma surgery due to its rapidity, good tolerance, effectiveness and low complication rate. These are the parameters we utilized in comparing endoscopic with microscopic transsphenoidal surgery. We reviewed the medical records of 418 patients affected by pituitary adenomas who underwent endoscopic transsphenoidal surgery between May 1998 and December 2004, and in this paper, we present the results of 381 patients who fulfilled the follow-up criteria after a minimum period of 15 months. Our experience confirms the previous data on the rapidity and satisfactory tolerance of the endoscopic procedure. We also confirm the low complication rate, specifying that complications characteristic of the approaching phase were certainly reduced; instead, complications characteristic of tumor removal still remained similar to those reported in the microsurgical literature. The results were comparable with those of the best microsurgical series regarding endosellar lesions, but tumor removal was notably superior when dealing with tumors having an extrasellar extension. The improvement may be explained by the excellent vision of the deep surgical fields due to the endoscope and by the extreme flexibility of the surgical trajectory, mainly due to the absence of the divaricator, giving access to the ramifications of the tumor, otherwise difficult to reach.     

Repeated transsphenoidal pituitary surgery (TS) via the endoscopic technique: a good therapeutic option for recurrent or persistent Cushing's disease (CD)

Background  No data on results of repeated transsphenoidal surgery via the endoscopic technique for patients with persistent or recurrent Cushing's disease are available.
Design and patients  We retrospectively evaluated the remission rates and complications of repeated transsphenoidal surgery via the endoscopic technique in 14 patients with persistent ( N  = 6) or recurrent ( N  = 8) Cushing's disease treated in our centre between 1999 and 2007.
Main outcomes  Remission was defined as the disappearance of symptoms of hypercortisolism with basal plasma cortisol level ≤ 50 nmol/l 24–48 h after glucocorticoid withdrawal and/or suppression of plasma cortisol level ≤ 50 nmol/l after 1 mg dexamethasone overnight within the first 3 months after transsphenoidal surgery.
Results  With repeated endoscopic transsphenoidal surgery a remission rate of 10/14 (71%) was achieved. No patient had a relapse during a median follow-up of 24 months. Cerebrospinal fluid leakage was the most frequent complication (6 patients) and 11 patients required hormonal substitution after surgery. The success of repeated transsphenoidal surgery could not be predicted by visualization of an adenoma on MRI before first or second surgery, histopathological confirmation of an ACTH secreting adenoma after first or second surgery, treatment with cortisol lowering agents before first or second surgery, the operation technique used during the first surgery, persistent vs. recurrent disease after the first surgery, age, gender and interval between the two surgeries.
Conclusion  Repeated transsphenoidal surgery via the endoscopic technique is a good treatment option for selected patients with recurrent or persistent Cushing's disease following primary pituitary surgery.