Complications's prophylaxis in neuroendoscopic endonasal transsphenoidal surgery for pituitary adenomas

Objective To discuss the complicatiaons’s prophylaxis of removing pituitary adenomas by neuroendoscopy in tranasphenoidal surgery. Methods Clinical data of 253 cases treated by endoscopic endanasal transsphenoidal surgery were analysed. Results The total tumor removal was done in 216 (85.38%) cases,subtotal in

Comparative Study between Microscopic and Endoscopic Trans-Sphenoidal Surgery for Growth Hormone-Secreting Pituitary Adenomas with Super-Sellar Extension

Background: Advances in the era of modern micro-neurosurgery enabled a reduction of surgical invasiveness and brain retraction which has been defined as minimally invasive or keyhole surgery. Sinonasal endoscopy has brought radical changes in the concepts of pathophysiology and treatment of sinonasal aliments as well as surgical techniques. Aim of the Study: To compare between the use of endoscopic and microscopic trans-sphenoidal approach in resection of growth hormone-secreting pituitary adenomas with Suprasellar Extension. Patients and Methods: This is a prospective study. It had been conducted upon 20 patients having growth hormone secreting pituitary adenoma admitted to Neurosurgery department in Alzar University hospitals and Nasr City Insurance hospital from 2015 to 2018, divided into 2 groups;group A (10 cases) underwent endoscopic endonasal trans-sphenoidal pituitary adenoma resection, while group B (10 cases) operated upon using the standard microscopic trans-sphenoidal pituitary adenoma resection. The inclusion criteria were included: All patients with growth hormone secreting pituitary adenomas showing manifestations of acromegaly, mass effect or hormonal disturbance. Results: This study showed that improvement in outcome was higher in endoscopic group opposed to microscopic group (100% vs. 71% improved headache, 80% vs. 60% visual improvement, 75% vs. 20% fundus improvement and 60% vs. 30% field improvement). Conclusion: We concluded that fully endoscopic procedure result in improved rates of complete tumor removal and a reduced incidence of complications, when compared to the microscopic approach.

Endoscopic Transsphenoidal Surgery for Pituitary Adenoma. Early Experience in Sohag University Hospitals

Objective: To report the results of our first series of patients undergoing a purely endoscopic endonasal approach for pituitary surgery in Sohag University Hospitals. Patients and Methods: We reviewed 20 consecutive patients during the period from January 2017 to January 2020 with pituitary adenoma who underwent purely endoscopic transsphenoidal resection of their lesions. The patients’ clinical outcomes, degrees of tumor removal, and complications were reported. Results: There were 18 primary and 2 recurrent adenomas (19 nonfunctioning and 1 functioning GH secreting adenoma). The average degree of gross total removal for tumors was 70%, C.S.F leak occurred in 20%, diabetes insipidus in 10% and sellar hemorrhage in 5%. There was no post-operative mortality, vascular injury, sphenoiditis, septal perforation, epistaxis or general complication. Conclusion: A purely endoscopic approach for pituitary adenoma treatment is a safe and effective alternative to the traditional microscopic procedure.

Analysis of complications of transsphenoidal surgery for pituitary adenomas

Objective To analyze the complications of transsphenoidal operation for pituitary adenomas. Methods Postoperative complications of 323 patients underwent transphenoidal surgery for pituitary adenoma between January 2001 and December 2009 in our department were retrospectively reviewed. Results Insipidus was the most common complication after

The causes and prevention and treatment of cerebrospinal fluid leak during transsphenoidal pituitary adenomas surgery

Objective To analyze the causes and prevention and treatment of cerebrospinal fluid leak during transsphenoidal pituitary adenoma surgery. Methods Retrospective study of 260 cases of microscopic transsphenoidal surgery and 274 cases of endoscopic surgery for resection of the pituitary adenomas was performed. CSF leak occurred

Transsphenoidal microsurgical operation for pituitary adenomas with suprasellar extensions

Objective: To evaluate the feasibility and therapeutic effectiveness of the transsphenoidal microsurgical removal of pituitary adenomas with suprasellar extensions. MethodS: We reviewed the diagnosticmodes, surgical technique, and outcomes of 152 patients suffering from pituitary adenomas with suprasellarextensions who were treated by transsphenoidal microsurgery in our department. Diagnosis was confirmed byCT or MRI scanning. All tumours with diameter >10 mm were characterized by suprasellar extensions. Op.erations were performed via either sublabio-septo-sphenoidal approach or naso-vestibulo-sphenoidal approachunder microscope. A subarachnoid catheter was preoperatively inserted in the lumbar cistern, through whichsaline was slowly injected during operation to increase the intracranial pressure (ICP) so as to deliver thesuprasellar tumour into the operative field to aid the removal. Result: Of the 152 cases, the gross total removal of adenoma in 106 cases (69. 7% ) and subtotal removal in 37 cases (24. 4% ) were achieved, and partial removal was carried out in the remaining 9 cases (5. 9 % ) of fibrous or dumbbell-shaped adenomas. Therewere no deaths after operation in this group. Follow-up review (median 3. 5 years) in 137 patients revealedgood recovery in 97 patients (70. 8% ), and late recurrence in 40 patients (29. 2% ) who need reoperativemanagement, drug therapy, radiotherapy, or radiosurgery used either alone or combined. Conclusion: Microsurgical technique via transsphenoidal approach is a safe and effective way to remove the pitoitary adenomas with suprasellar extensions but not for fibrous or dumbbell-shaped ones.

EFFECT OF PREOPERATIVE USE OF LONG-ACTING OCTREOTIDE ON GROWTH HORMONE SECRETING PITUITARY ADENOMA AND TRANSSPHENOIDAL SURGERY

Objective To investigate whether somatostatin analog octreotide long acting release (LAR) shrinks growth hormone (GH) secreting adenomas, and improves the results of subsequent transsphenoidal surgery. Methods Seventeen previously untreated active acromegalic patients with pituitary adenomas were treated with LAR (30 mg intramuscular injection every 28 days) for 3 months prior to transsphenoidal surgery. Clinical reaction, mean GH secretion, and tumor volume were measured under basal conditions and after LAR treatment. Results Presurgical treatment improved acromegaly symptoms and induced a significant reduction of GH under the 5 ng/mL limit in microadenoma (P < 0.05), while only 18.2% (2/11) in macroadenoma. Meanwhile, tumor shrinkage occurred in 58.8% (10/17) patients, with 1 case in the microadenoma group. All marked shrinkage (> 25%) occurred in the macroadenoma group. Statistical analysis showed tumor shrinkage caused by LAR was greater in macroadenoma group than that in microadenoma group (P < 0.05). During operation, adenoma was soft in 15 cases, with the exception of 2 cases in which the soft tumor was divided by fibrous septa, but all tumor removal was smooth. Conclusions A short term administration of preoperative LAR may induce a significant decrease in GH-secretion level and adenoma volume. Presurgical use of octreotide LAR improves surgical results especially in macroadenomas.

The Use of Neuronavigation with Vasular Microdoppler in Transsphenoidal Pituitary Surgery

Object: To evaluate the use of neuronavigation with vascular micro-doppler in transsphenoidal pituitary surgery. Methods: 141 cases having done transsphenoidal pituitary surgery are evaluated from 2005 to 2014. Fluoroscopy was used in 69 cases and vascular micro-doppler with neuronavigation were used in 72 cases. Results: Transsphenoidal surgery has a lot of risks due to sella’s deep location, and position of the carotid artery and the optic nerve. Clasically the fluoroscopy and microscopic anatomical markers were used in order to minimize the risk of carotid artery and optic nerve damage. Additional devices such as neuronavigation and vascular micro-doppler are needed to decrease the morbidity and mortality arising from these injuries. Conclusion: Neurovascular complications such as carotid artery and optic nerve injuries owing to disorientation in transsphenoidal surgery will reduce the use of neuronavigation with vascular micro-doppler.

Surgical Technique and Efficacy Analysis of Extra-pseudocapsular Transnasal Transsphenoidal Surgery for Pituitary Microprolactinoma

Objective To elucidate the role of transsphenoidal surgery in the treatment of pituitary microprolactinoma.Methods The clinical data of 107 prolactinoma cases treated by extra-pseudocapsular transnasal transsphenoidal surgery(ETTS)for different indications in our department since 2011 was retrospectively analyzed.Results The most common indication was the ineffectiveness of oral medication(41.1%),followed by the personal willingness of the patient(35.5%),and 20.6%of the patients were young women with clear tumor boundaries.The pseudocapsule was not observed in 63 cases(58.9%),incomplete pseudocapsule was observed in 26 cases(24.3%),and complete pseudocapsule in 18 cases(16.8%).A total of 97 patients(90.7%)obtained 1-year post-operation remission.According to the relative location of the adenoma and pituitary gland on the MRI scan,46 patients were classified into a central type,59 a lateral type,and 2 a supra-pituitary type.Two patients developed hypogonadism,one patient developed hypocortisolism,and one patient developed post-operative hypothyroidism.Two patients were administrated with hormone replacement treatment,and the treatment was stopped within one week.There was no permanent hypopituitarism.Further investigation demonstrated that the adenoma types could affect the remission rates of hyperprolactinemia and gross total resection rate in microprolactinoma.Conclusion ETTS was an effective treatment for pituitary microprolactinomas.This could be the first choice for patients who presented enclosed adenoma on the MRI and were potentially curable in a preoperative evaluation.Maximal safe removal of the adenoma by ETTS with the aim to increase the sensitivity of the drugs was also recommended for patients with invasive dopamine agonist resistant prolactinomas and patients with difficulty in childbirth.

Predictors and dynamic online nomogram for postoperative delayed hyponatremia after endoscopic transsphenoidal surgery for pituitary adenomas:a single-center,retrospective,observational cohort study with external validation

Background Postoperative delayed hyponatremia(PDH)is a major cause of readmission after endoscopic transsphenoidal surgery(eTSS)for pituitary adenomas(PAs).However,the risk factors associated with PDH have not been well established,and the development of a dynamic online nomogram for predicting PDH is yet to be realized.We aimed to investigate the predictive factors for PDH and construct a dynamic online nomogram to aid in its prediction.Methods We analyzed the data of 226 consecutive patients who underwent eTSS for PAs at the Department of Neurosurgery in Jinling Hospital between January 2018 and October 2020.An additional 97 external patients were included for external validation.PDH was defined as a serum sodium level below 137 mmol/L,occurring on the third postoperative day(POD)or later.Results Hyponatremia on POD 1-2(OR=2.64,P=0.033),prothrombin time(PT)(OR=1.78,P=0.008),and percentage of monocytes(OR=1.22,P=0.047)were identified as predictive factors for PDH via multivariable logistic regression analysis.Based on these predictors,a nomogram was constructed with great discrimination in internal validation(adjusted AUC:0.613-0.688)and external validation(AUC:0.594-0.617).Furthermore,the nomogram demonstrated good performance in calibration plot,Brier Score,and decision curve analysis.Subgroup analysis revealed robust predictive performance in patients with various clinical subtypes and mild to moderate PDH.Conclusions Preoperative PT and the percentage of monocytes were,for the first time,identified as predictive factors for PDH.The dynamic nomogram proved to be a valuable tool for predicting PDH after eTSS for PAs and demonstrated good generalizability.Patients could benefit from early identification of PDH and optimized treatment decisions.

HYPONATREMIA AFTER TRANSSPHENIODAL SURGERY OF PITUITARY ADENOMA

Objective. To clarify the frequency, presentation, associated factors, treatment and outcome of hy-ponatremia after transsphenoidal surgery of pituitary adenomas.Methods. Retrospectively reviewed the database of 183 patients who underwent transsphenoidal surgeryof pituitary adenomas between January 1999 and June 2000 in our department.Result.s. 38.8% (71/183) had postoperative hyponatremia. Among them, 59.2% (42/71) appeared onthe 4th to 7th day postoperatively. 59.2% (42/71) presented with nausea, vomiting, headache, dizzi-ness, confusion and weakness. Hyponatremia was related to age, tumor size and adenoma type, but notrelated to sex and degree of resection. Treatment consisted of salt replacement and mild fluid restrictionin 4 patients and salt and fluid replacement in 67 patients. Hyponatremia resolved within 16 days in allthe patients.Conclusions. Hyponatremia often appeared about 7 days after transsphenoidal surgery of pituitary ade-nomas, especially in elderly and patients with macroadenomas and huge pituitary adenomas. The principleof treatment was salt and fluid replacement.

Endoscopic Skull Base Surgery in Assiut University, Single Center Early Experience

Background: Endoscopic transnasal skull base surgery had started long time ago in different centers around the world for excision of skull base lesions with good results and more cost effectiveness. The aim of this study is to discuss our early results in endoscopic skull base surgery and the development of the learning curve. Patients and Methods: We analyzed our experience regarding 25 patients presented to us in Neurosurgery Department, Assiut University Hospital, Assiut University, Assiut, Egypt in a period of 3 years (2015, 2016, 2017) and operated by endoscopic transnasal approach. All patients signed an informed consent. Results: With the highest percentage was pituitary adenoma 56%, pituitary apoplexy 12%, craniopharyngioma 12%, CSF rhinorrhea 12%, Planum sphenoidal meningioma 4% and suprasellar granuloma 4%. 88% of patients were operated without complications, 8% mortality rate postoperative, 12% complication rate and 76% complete improvement postoperative. Conclusion: Endoscopic skull base surgery is a safe approach to the skull base that needs a good experience, practice and good anatomical knowledge. Teamwork between a Neurosurgeon and ENT surgeon is a must for patient safety.

Relationship Between Histopathology and Clinical Prognosis of Invasive Pituitary Adenoma

Objective: To study the relationship between histopathology and clinical prognosis of invasive pituitary adenoma subjected to transsphenoidal surgery. Methods: The enrolled were 82 patients with invasive pituitary adenomas undergoing transsphenoidal surgery during Jan. 2000 - May 2003 in our department with full MR imaging findings, pathology data and follow-up information. The follow-up duration was 5-30 months. Results: MR imaging findings of invasive pituitary adenoma included: depression of the sellar floor, involvement of sphenoid sinus and cavernous sinus, breakthrough of diaphragma sellae, encasement of internal carotid artery, etc. Pathological examination revealed that the invasion rate of dura in sella turcica was the highest among the structures around tumor. Pituitary adenoma apoplexy was found in 20 cases (24.4%). The total removal rate for PRL-secreting adenomas was significantly lower than that for non-secreting adenomas (P<0.01), but non-, GH-, ACTH-secreting adenomas had no significant differences. The recurrence rate of PRL-secreting adenomas was higher than that of non- and GH-secreting adenomas (P<0.05). Conclusion: Among invasive pituitary adenomas, the therapeutic effects of non-and GH-secreting pituitary adenomas are better than that of PRL-secreting adenomas. Invasive biological behaviors of invasive pituitary adenomas result in radical operation failure and postoperative recurrence.

Sudden Sensorineural Hearing Loss after Pituitary Adenoma Resection-A Case Series with Literature Review

Objective Complications after transsphenoidal surgery for pituitary adenoma have been well documented in the literatures,but the occurrence of delved sudden sensorineural hearing loss(SNHL)after pituitary adenoma resection is extremely rare.In this study three cases who developed sudden SNHL 3 to 7 days after pituitary adenoma surgery without experiencing cerebrospinal fluid leak or meningitis were presented,and the possible causes of SNHL were discussed.Methods Three cases with sudden hearing loss after transsphenoidal surgery for pituitary adenoma were reviewed.The past medical history,onset of sudden hearing loss,accompanying symptoms such as headache,tinnitus,dizziness and aural fullness,and the post-operative MRI images,therapy and hearing results were reported.Results Three cases developed profound sudden SNHL on the 3rd to 7th post-operative day,all accompanied by prior headache,tinnitus and dizziness.One patient developed episodic vertigo,ear fullness accompanying with fluctuating hearing loss in the first post-operative month.Two patients had past medical history of arteriosclerosis and coronary heart disease or cerebral infarction.Two of three demonstrated obstructive hydrocephalus on MRI on the first post-operative day.Under treatment with prednisone orally,dexamethasone intratympanic mjection,neurotrophic and vasodilatation drugs for 3 to 8 months,hearing of all three improved partially.Obstructive hydrocephalus and ischemia might be responsible for the hearing loss.Conclusion Post-operative obstructive hydrocephalus and ischemia of labyrinthine arteries might lead to the delayed SNHL after transsphenoidal surgery for pituitary adenoma.

Bilateral inferior petrosal sinus sampling for the treatment of Cushing's disease Data from 52 cases from one institute over an eight-year period

The present study analyzed data from 108 Cushing＇s disease patients, who underwent transsphenoidal surgery in one hospital between January 2003 and April 2010, to investigate the performance value of bilateral inferior petrosal sinus sampling （BIPSS）. Of the 108 patients 52 underwent BIPSS prior to surgery and 56 did not. Results showed that BIPSS accuracy for the diagnosis of Cushing＇s disease was 86.5% （45/52）, and accuracy for adenoma lateralization during surgery was 76.9% （40/52）. In addition, early remission rate was significantly greater compared to patients without BIPSS. Results demonstrated that BIPSS facilitated localization and diagnosis of Cushing＇s disease and helped to predict adenoma lateralization.

Predictive value of pituitary tumor morphology on outcomes and complications in endoscopic transsphenoidal surgery

Purpose:Endoscopic transsphenoidal surgery(ETSS)is an increasingly utilized approach for resection of pituitary tumors.Prior studies have evaluated preoperative tumor size,location,and extent as prognostic factors for surgical resection.There is little data on the relationship between preoperative pituitary tumor radiographic morphology and surgical outcomes.Study Design:Retrospective longitudinal study.Setting:Single tertiary care institution.Subjects and Methods:Preoperative magnetic resonance imaging and computed tomography scans from patients undergoing ETSS for pituitary tumor resections from 2007 to 2017 were retrospectively evaluated.A neuroradiologist classified these pituitary tumors into six morphologic groups,each defined by volume,dimensions,extension,and shape.Surgical difficulty,rates of incomplete resection,and postoperative complications were then stratified in relation to the morphologic groups.Results:Pituitary tumors from 131 patients were classified from preoperative imaging into six characteristic morphologies:(1)microtumor,(2)round,(3)transverse oblong,(4)superior-inferior oblong,(5)bilobed,and(6)large lobulated.Tumors that were characterized with the large lobulated,bilobed,and transverse oblong morphologies correlated with higher rates of postoperative evidence of residual tumor(70%,36%,and 47%,respectively,all P<0.002).Likewise,large lobulated,bilobed,and transverse oblong morphologies were also associated with intraoperative cerebrospinal fluid leaks(70%,31%,and 35%,respectively,all P<0.05).Conclusions:We describe a novel descriptive system for the morphology of pituitary tumors that can be determined from preoperative imaging.Different tumor morphologic groups are associated with varying degrees of gross tumor resection,complications,and surgical difficulty.Utilizing pituitary tumor morphology may aid surgeons in planning the extent of resection,need for complex closure,and patient counseling.

Rathke Cleft Cyst with a Coexisting Gonadotropin Producing Pituitary Adenoma

Rathke cleft cyst is thought to arise from incomplete obliteration of the lumen of Rathke pouch. The cells of the anterior pituitary lobe, from which pituitary adenomas develop, are also derived from the cells of Rathke pouch. Although Rathke cleft cyst and pituitary adenoma have a shared ancestry, they rarely occur coincidentally. Rathke cleft cysts have been found incidentally in 11% - 33% of post-mortem examinations, and were associated with 1.7% - 2.1% of the pituitary adenoma cases. These coexisting lesions are difficult to diagnose pre-operatively due to the variable signal intensity and position of the Rathke cleft cysts. Treatment of these lesions involves surgical resection to decrease mass effect and medical management to normalize hormonal imbalances. To our best knowledge, only 42 cases of Rathke cleft cyst with a coexisting pituitary adenoma have been reported in the English or Japanese literatures, but none of the coexisting pituitary adenoma is gonadotropin producing. We would like to report a case of Rathke cleft cyst with a coexisting gonadotropin producing adenoma that was successfully treated by endoscopic endonasal transsphenoidal approach with the removal of the sellar lesion and temporary hormone replacement.

Obstructive Hydrocephalus Caused by Pituitary Adenoma: A Case Report

Among pituitary tumors, prolactin (PRL)-secreting pituitary adenomas are by far the most frequent ones. The development of symptomatic hydrocephalus due to a pituitary adenoma is an exceptional event. The authors describe a 37-year-old man who had a pituitary adenoma associated with obstructive hydrocephalus that was managed by endoscopic transnasal transsphenoidal surgery. Postoperative CT and MRI scans showed resolution of the obstructive hydrocephalus and the foramen of Monro was open. Postoperatively, the patient had visual and headache improvement. Subsequently, the patient is a candidate for cranial surgery or medical therapy to complete the treatment. The present case highlights the fact that pituitary adenomas with obstructive hydrocephalus should be distinguished from other tumors especially colloid cysts.

术中MRI指导下经鼻蝶入路神经内镜手术治疗巨大无功能垂体腺瘤的疗效分析

目的探讨术中MRI指导下经鼻蝶入路神经内镜手术治疗巨大(最大径>4 cm)无功能垂体腺瘤的疗效。方法回顾性分析2009年2月至2015年6月经鼻蝶入路神经内镜手术治疗的24例巨大无功能垂体腺瘤的临床资料。术中使用MRI指导手术切除肿瘤。结果肿瘤最大直径4~5 cm有18例,>5 cm有6例。术中MRI扫描1次15例,2次6例,3次2例,4次1例;平均(1.5±0.8)次/例。肿瘤全切除18例,次全切除6例。术中发现脑脊液鼻漏2例,术后出现脑脊液鼻漏1例、一过性尿崩6例;未出现颅内感染、颅内血肿。术后随访3~60个月,平均45个月;术后视力及视野改善19例,头痛缓解11例;新发垂体功能低下3例,嗅觉功能障碍4例,肿瘤复发2例。结论术中MRI指导下经鼻蝶入路神经内镜手术是治疗巨大无功能垂体腺瘤安全有效的方式,能获得比较满意的疗效,手术安全性高、并发症少。

垂体腺瘤经鼻蝶入路术后并发DSH的危险因素

经鼻蝶入路神经内镜手术是治疗垂体腺瘤的手术方式之一,迟发性低钠血症(DSH)是术后常见并发症,发生率在3.6%~19.8%。尽管可以通过检测血清钠离子浓度明确诊断,但病人通常缺乏典型的临床症状,难以预测起病时间,易误诊、漏诊,从而增加病人的死亡风险。近年来,很多研究分析DSH的危险因素并进行归纳、总结,以改善DSH对垂体腺瘤病人术后预后的影响。本文就垂体腺瘤经鼻蝶入路神经内镜术后DSH的危险因素的研究进展进行综述,为临床提供参考。