Fully endoscopic endonasal vs. transseptal transsphenoidal pituitary surgery.

A long-term retrospective study of 300 patients who underwent fully endoscopic endonasal pituitary adenoma resection between November 1998 and October 2004. The patients' records as well as the data obtained from postoperative follow-up visits was used to determine outcomes. Additionally, the data were then compared to mean values calculated from several transseptal-transsphenoidal reports. From a total of 300 pituitary adenomas, 139 (46 %) were hormonally active, while 161 (54 %) were non-functioning. Mean follow-up period was 38.2 months. The average length of hospital stay (LOS) was 1.4 days. All patients had postoperative magnetic resonance imaging (MRI) studies to assess residual or recurrent disease; all patients with hormonally active tumors had additional postoperative hormonal studies. Remission, being defined as no hormonal or radiological evidence of recurrence within the time-frame of the follow-up, was demonstrated in 127/134 (95 %) of enclosed and 144/166 (87 %) of invasive adenomas. A comparison of fully endoscopic endonasal vs. transseptal-transsphenoidal remission results revealed an improved outcome using the fully endoscopic endonasal technique: ACTH (86 % vs. 81 %), PRL (89 % vs. 66 %) and GH (85 % vs. 77 %). The remission rate for non-functioning adenomas was 149/161 (93 %). Additionally, we noted a marked reduction in complications related to the endoscopic procedure. Our results conclude that the fully endoscopic endonasal technique is a safe and effective method for removal of pituitary adenomas providing more complete tumor removal and reducing complications.     

A rare vascular complication of transsphenoidal surgery

We report a rare case of anterior cerebral artery (ACA) thrombosis following transsphenoidal surgery in a case of growth hormone secreting pituitary macroadenoma. During the surgery, there was arachnoid breach with cerebrospinal fluid (CSF) leak. Post operatively, she became blind in both eyes for which re-exploration was done. A computed tomographic (CT) scan 16 hours after surgery showed a large tumor bed haematoma which was explored transcranially. During surgery, the right A1 was thrombosed while the ICA and middle cerebral artery (MCA) were patent as confirmed by post-operative magnetic resonance imaging (MRI). However, she died on the second post-operative day. ACA thrombosis following transsphenoidal surgery has not been reported before. A review of literature and possible mechanism of this complication has been discussed.     

Hemorrhagic complications resulting in reoperation after peripheral vascular surgery: a fourteen-year experience

Eighty-nine patients who underwent reoperation because of hemorrhagic complications after peripheral arterial surgery were studied and compared with 103 patients without such complications. Elevation of erythrocyte sedimentation rate, serum creatinine values, and blood pressure before anesthesia was found more often in patients with hemorrhage. The frequency of reoperation due to control hemorrhage was 2.8%; femorodistal and carotid reconstructions were complicated by hemorrhage requiring reoperation significantly more often than other types of vascular surgery, 3.2% and 4.2%, respectively. The use of vacuum drains apparently did not contribute to the diagnosis of bleeding requiring reoperation. Amputation was a more frequent outcome in femorodistal reconstructions complicated by hemorrhage than in similar operations without this complication. After reoperations performed within 48 hours of the primary operation, the clinical course mostly was uncomplicated, whereas in reoperations performed later the bleeding usually was associated with infection of the reconstruction, resulting in a higher frequency of amputation. Most of the late hemorrhages occurred in groin incisions.     

Rare fatal vascular complication of transsphenoidal surgery

Summary We report the case of a 61-year-old man, who underwent transsphenoidal surgery for a pituitary macroadenoma. The presence of tough fibrous septa dividing the tumour permitted only a partial resection. Progressive loss of consciousness soon after surgery occurred, an emergency CT scan showed no evidence of haemorrhage. Twenty hours later, MRI revealed compression of both internal carotid arteries with arrest of arterial flow resulting in stroke by an enlarged haemorrhagic mass consistent with a pituitary apoplexy. On the second postoperative day, the patient died as a result of this extensive stroke. The mechanisms of this rare complication after transsphenoidal surgery are theorized and the sensitivity of imaging methods is discussed.     

Comparative study of complications after primary and revision transsphenoidal endoscopic surgeries

Neurosurgical Review - A preferred treatment for residual/recurrent pituitary adenomas has not been established. The existence of higher complication rates for revision surgeries remains under...     

Surgical complications after transsphenoidal microscopic and endoscopic surgery for pituitary adenoma: a consecutive series of 506 procedures

Background

This single-institution, consecutive series of transsphenoidal procedures included all patients in a defined population of 2.6 million inhabitants who underwent surgery during a specific time period.

Objective

We sought to determine the surgical complication rate and overall survival rate after transsphenoidal surgery for pituitary adenoma.

Methods

All transsphenoidal procedures for histologically verified pituitary adenomas performed between September 2002 and February 2011 at our institution were included in this study. The data were obtained from a prospectively collected database and from reviewing medical records. No patients were lost to follow-up, and the median follow-up time was 28 months.

Results

A total of 506 transsphenoidal procedures were performed on 446 patients. There were 268 microscopic and 238 endoscopic procedures involving 352 non-functioning and 154 hormone-secreting adenomas. A total of 73 % of the procedures were primary surgeries, and 27 % were repeat surgeries for tumor recurrence. The overall complication rate was 9.1 %. The three most frequent complications were cerebrospinal fluid (CSF) leakage (4.7 %), meningitis (2 %), and visual deterioration (2 %). Multivariate analyses showed that the overall risk for complications increased with older age, surgery for recurrent tumors, and surgery performed by a low-volume surgeon. There was no significant difference in the overall complication rate between the microsurgical and endoscopic techniques. The rate of surgical mortality was 0.6 %, and the overall survival rates at 1 and 5 years were 95 % and 90 %, respectively. The only negative predictor of survival was older age.

Conclusions

Transsphenoidal surgery for pituitary adenomas has a low complication rate and a low rate of mortality. We did not find a significant difference in the complication rate between endoscopic and microscopic techniques.     

Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas

OBJECT: To assess postoperative complications related to the surgical procedure, a retrospective analysis was conducted in a series of 146 consecutively treated patients who underwent an endoscopic endonasal transsphenoidal approach to the sellar region for resection of pituitary adenomas between January 1997 and July 2001. METHODS: Complications were divided into groups (nasofacial, sphenoid sinus, sella turcica, supra or parasellar, and endocrine complications) according to the anatomical structures and the systems involved. Overall, a decreased incidence of complications has been observed, compared with large historical series of the traditional microsurgical transsphenoidal approach, likely because of the overview inside the anatomy facilitated by the endoscope, and the decreased surgical trauma. CONCLUSIONS: Transsphenoidal surgery, either microscopic or endoscopic, is a safe procedure in experienced hands, but serious complications still occur and must be reduced as much as possible. Additional improvement can be expected with greater experience and new technical developments. A coordinated team effort with other dedicated colleagues from different specialties is advised.     

A novel transnasal transsphenoidal speculum: a design for both microscopic and endoscopic transsphenoidal pituitary surgery

Over the last several years minimally invasive surgical approaches to the sella turcica and parasellar regions have undergone significant change. The transsphenoidal approach to this region has evolved from a sublabial transnasal, to transnasal, to pure endonasal approaches with the increasing popularity of endoscopic over microscopic techniques. Endoscopic and microscopic techniques individually or in combination have their own unique advantages, and the preference of one over the other awaits further technological refinements and surgical experience. In parallel with this evolution in techniques for transsphenoidal surgery, the authors designed an adaptable versatile speculum for the endonasal/transnasal transsphenoidal approach to the sella turcica and parasellar regions that can be used equally effectively with a microscope or an endoscope. The development of this instrument and its unique features are described, and its initial clinical use is summarized. This transnasal transsphenoidal speculum has interchangeable blades, unique blade angulations, and independent blade opening mechanisms and allows safe, optimal exposure in all patients regardless of the size and anatomical aberrations of individual nasal and endonasal regions. An attached endoscope carrier further allows it to be used interchangeably with microscopic or endoscopic techniques without having to remove the speculum; likewise, a single surgeon can use both hands without need of an assistant. A forehead headrest component adds further stabilization. This device has been used successfully in 90 transsphenoidal procedures.     

Quality of life and complications following image-guided endoscopic sinus surgery.

OBJECTIVES: To compare the quality of life (QOL) outcome and incidence of complications following image-guided versus non-image-guided endoscopic sinus surgery (ESS). STUDY DESIGN: The operative, office, and hospital charts of patients who underwent primary ESS for chronic sinusitis by a single surgeon with (2002-2005) or without (1997-2002) image guidance were reviewed for patient demographics, incidence of complications, and revision procedures. A telephone survey was used to administer the QOL survey to both cohorts. RESULTS: In comparing patients who underwent image-guided (60) versus non-image-guided surgery (179), respectively, there was no statistically significant difference in the incidence of major intraoperative complications (6.6% vs 5.6%), major postoperative complications (5% vs 3.9%), revision procedures (6.6% vs 7.3%), and postoperative SNOT-20 symptom scores (23.6 vs 23.4). A higher incidence of intraoperative cerebrospinal fluid leak was noted in the non-image-guided group (0% vs 2.2%). CONCLUSIONS: Our study does not demonstrate an improvement in the incidence of complications, need for revision procedures, or quality-of-life outcome for patients undergoing primary ESS for chronic sinusitis. The use of image guidance may result in a lower incidence of skull base trauma and cerebrospinal fluid leak. EBM rating: B-2b.     

Sellar repair in endoscopic endonasal transsphenoidal surgery: results of 170 cases

OBJECTIVE: To describe techniques and materials used in sellar repair after an endoscopic endonasal transsphenoidal approach. METHODS: Different techniques of sellar closure and indications for each specific condition are reviewed in a series of 170 consecutive patients. RESULTS: Only 47 (27.6%) of 170 patients were considered candidates for sellar reconstruction after the endoscopic operation, mainly because of intraoperative cerebrospinal fluid leaks (14.1%). The overall rate of postoperative cerebrospinal fluid leakage was 2.3%, which was cured by means of an early reoperation in three cases and with lumbar drainage in the fourth case. CONCLUSION: Reconstruction of the sella was considered necessary in only one-third of the patients who underwent operations via an endoscopic transsphenoidal procedure. Some minor expedients can be useful for the reconstruction, and the ideal material for the repair should be chosen.     

Postoperative complications in abdominal vascular surgery

Two hundred patients who consecutively underwent abdominal vascular surgery were retrospectively studied with regard to early (less than 30 days) postoperative complications. The mortality was 4% after elective surgery and 30% after emergency surgery, which was chiefly for aortic aneurysm. The main causes of death were cardiac and renal diseases. Postoperative morbidity was mainly of cardiopulmonary or renal origin. Quantitatively, however (length of hospital stay), the foremost complications were local--haematoma, lymph fistula and necrosis in the incisions, especially in the groins. Against this background, the importance of scrupulous technique in vascular surgery is stressed.     

内镜下大隐静脉交通支离断术术后并发症防治

目的探讨内镜下大隐静脉交通支离断术术后并发症的防治方法。方法回顾分析我院2002年1月至2005年12月收治下肢慢性静脉功能不全患者136例临床资料,共172条肢体均行内镜下大隐静脉交通支离断术(subfascialendoscopicperforatorsurgery,SEPS),155条肢体随访,随访率90.1%,随访时间1~36个月。结果SEPS术后出现筋膜下出血12条肢体(7.1%),皮下气肿18条肢体(10.5%),小腿前内侧及足踝区感觉麻木33条肢体(19.2%)。结论术前下肢静脉造影及结合Pratt试验定位交通支,术中膝关节上上止血带,术后应用弹力绷带能较好预防SEPS术后筋膜下出血及皮下气肿的发生。     

Training in endoscopic endonasal transsphenoidal surgery using a skull model and eggs

Background  

Recently, endoscopic pituitary surgery is increasingly being used in pituitary surgery. Compared to conventional microscopic pituitary surgery, outcomes have been non-inferior, so endoscopic pituitary surgery has become an established surgical technique. However, this is a highly specialized surgery and sophisticated surgical techniques are required. We report our development of a training model for endoscopic endonasal transsphenoidal surgery.