Transnasal endoscopic surgery of the pituitary: modifications and results over 10 years.

[staticnrg]

Article pasted below (readable, although format isn't great). I have the PDF, also. Much easier to read. Dr. J. is listed multiple times in bibliography. This is his technique.

 

Transnasal Endoscopic Surgery of the Pituitary: Modifications and Results Over 10 Years

[Triological Society Papers]

 

Kelley, Richard T. MD; Smith, Joseph L. II MD; Rodzewicz, Gerald M. MD

From the Departments of Otolaryngology and Communication Sciences (r.t.k., j.l.s.) and Neurosurgery (g.m.r.), Upstate Medical University, Syracuse, New York, U.S.A.

Editor?s Note: This Manuscript was accepted for publication May 10, 2006.

Podium presentation at the Triologic Society Southern Section Meeting, Naples, Florida, U.S.A., January 19-21, 2006.

Send correspondence to Dr. Richard T. Kelley, Department of Otolaryngology and Communication Sciences, Upstate Medical University, 750 East Adams Street, Syracuse, New York, 13210. E-mail: kelleyr@upstate.edu.

Abstract

 

Objective: A 10-year retrospective review of three endoscopic approaches used by the authors for pituitary gland surgery is presented. We review our results and complications and outline the advantages and disadvantages of each. The variations in nasal anatomy that factor in the endoscopic approach are tabulated and discussed.

 

Methods: A chart review and examination of computed tomography and magnetic resonance imaging scans of patients who have had endoscopic pituitary surgery by the authors was performed. We gathered specific details of the operative approach, nasal-sinus anatomy, tumor location, required ancillary nasal procedures, and postoperative complications.

 

Results: Ninety patients had endoscopic pituitary surgery. Operative reports and review of radiographic studies were possible for 75 patients. The surgical approach progressed over 10 years from endoscopic transseptal (42) to bilateral transostial (13) to unilateral transostial (20). Adequate exposure for the degree of resection was achieved in all patients. Complications included hemorrhage requiring return to the operating room (1), transient visual field loss (2), and transient diabetes insipidus (7). Four patients subsequently had craniotomy to resect suprasellar tumor extension. The average follow-up was 6 years. One patient required revision endoscopic resection 3 years later for tumor recurrence. Anatomic findings included nasal septal deflections in 36 (48%) of the patients, abnormalities of the turbinates in 42 (56%), and variances of the sphenoid sinus septum in 59 (79%) of the patients. In the unilateral transostial approach, the operative side was often determined by anatomic factors.

 

Conclusion: The authors have exclusively used endoscopic surgery of pituitary gland tumors for over 10 years. Modifications to the approach have occurred as a result of increased surgeon experience and improved technology. The unilateral transostial approach is safe, effective, and recommended.

 

INTRODUCTION

 

Endoscopic techniques are considered state of the art in many areas of surgery because there has been a trend toward minimally invasive procedures. It has been over 12 years since pituitary surgery using endoscopes initially was reported.1?3 Endoscopic pituitary surgery is seen as an effective, less-invasive way to adequately remove or debulk tumors. The early concern of lack of three-dimensional viewing has not lessened the apparent adoption of the endoscope. Several reports demonstrate the advantages of decreased nasal morbidity, improved visualization of the sella, decreased operative time, and possibly decreased hospitalization time, thus implying medical cost savings.4?8

 

Newer instrumentation allows for more efficient and less traumatic endoscopic surgery. Narrower endoscopes provide more room for other instrumentation. Microdebrider instruments are now widely used by endoscopic surgeons, and a variety of blades and burs are available.

 

Unlike the open, retractor-placed transseptal approach, however, the endoscopic technique requires the surgeon negotiate through and around intranasal structures. Nasal and sphenoid sinus anatomy has a wide range of variability, which may affect the ease of performing endoscopic pituitary surgery.9,10 Familiarity with the types and incidence of intranasal deformities that are encountered and determining when to avoid structures and when to remove obstructions to facilitate the tumor removal is beneficial.

 

We reviewed our endoscopic pituitary surgery cases over the past 10 years and report modifications based on increased experience and technological advances; we also reviewed our complications. We list advantages and disadvantages to approach. We present salient radiographic and intranasal findings that influence the sidedness of our recommended unilateral endoscopic technique.

METHODS

 

A chart review and examination of computed tomography (CT) and magnetic resonance imaging scans of patients who have had endoscopic pituitary surgery by the senior authors from December 1994 until June 2005 was performed. Specific details of the nasal anatomy, tumor location, operative approach, required ancillary nasal procedures, and postoperative complications were reviewed.

 

In evaluation of the anatomic radiographic findings, we reviewed the films of each patient and tabulated the findings. Septal deflections were divided into anterior, mid-septum, and posterior. Middle turbinate abnormalities were defined as presence of concha bullosa, marked hypertrophy, or paradoxic curvature. Sphenoid sinus septal configurations were listed as right or left predominant, multiple, or absent. Any other findings (e.g., polyps) were also noted. The anatomic findings in cases with use of the current technique of unilateral transostial endoscopic approach were tabulated.

RESULTS

 

Ninety patients underwent endoscopic pituitary surgery. Detailed operative reports dictated by the same surgeon and radiographic studies were found for 75. Several of the earlier patients in the review had films that had been destroyed. The average age of the patients was 51 and ranged from 23 to 83 years old. In the 75 patients included, there was a fairly even distribution of men and women (40 and 35, respectively). The pathology was primarily pituitary nonhormone secreting small cell adenoma (62) but other pathology included hormone-secreting adenoma (6), pituitary apoplexy (4), Rathke cyst (2), and craniopharyngioma (1).

 

There was a progression from an endoscopic transseptal (42 patients) to a bilateral transostia (13) to a unilateral transostium (20) approach during the study period (Table I). In the first 5 years, transseptal was routinely used except for four patients who had previously undergone an open, nonendoscopic transseptal approach and subsequently required a second pituitary surgery because of tumor regrowth. These were all performed endoscopically by way of a transostial approach (3 bilateral and 1 unilateral). In the last 3 years, the transseptal approach was used only for two patients with significant bilateral septal and turbinate abnormalities and massive tumor filling the sphenoid sinus. The unilateral transostial approach was used for 84% (16/19) of the cases in the last 3 years.

 

Graphic

TABLE I. Distribution of Surgical Approaches to Pituitary Gland Used.

 

Complications are reported in Table II. Four patients were readmitted to the hospital for persistent headache with a concern of a cerebrospinal fluid (CSF) leak. No CSF leaks were identified. One postoperative hemorrhage occurred, which resulted in a new visual field loss and required emergent evacuation of an operative bed hematoma. Two other patients had new, temporary postoperative visual field cuts that also completely resolved. Seven (9%) patients experienced transient diabetes insipidus (DI). Of the 75 procedures performed, 4 (5%) required further craniotomies secondary to inability to adequately resect suprasellar tumor extension. In the subpopulation of patients who had previously undergone an open transseptal approach (before 1994) and subsequently required a second pituitary surgery, all indicated less discomfort and quicker recovery with the endoscopic approach.

 

Graphic

TABLE II. Complications and Limitations.

 

The average follow-up duration was 8 years (transseptal), 4.5 years (bilateral), and 2.5 years (unilateral). The degree of resection (usually subtotal) and need for subsequent radiation therapy (

 

Anatomic variations are listed in Table III. Radiographic findings included septal deflections and abnormal turbinates (concha bullosa, paradoxic curvature, or hypertrophy). Thirty-six (48%) patients had deviations of one or more regions of their septum, whereas 39 (52%) had no deflection. Mid-septal deflections were most common. A majority of patients, 42 (56%), also had variable middle turbinate anatomy. Asymmetric sphenoid sinus configurations were identified in 59 (79%) of the patients. Several other patients had polyps, inferior turbinate hypertrophy, or a marked bulla ethmoidalis.

 

Graphic

TABLE III. Anatomic Variations.

 

On reviewing the operative reports in cases using the unilateral transostium approach, however, intranasal anatomy was clinically important (Table IV). The left-sided approach was used when the sphenoid septum was right predominant (8/11), and the tumor was left-sided (3/11). The right-sided approach was used when the sphenoid septum was on the opposite side (5/9). Middle turbinate partial resection was performed in each case of an abnormality to allow for wider access to the sphenoid. In cases of bilateral anatomic findings, the posterior abnormality dictated the sidedness of the approach.

 

Graphic

TABLE IV. Sidedness of Unilateral Ostium Approach and Anatomical Variability.

DISCUSSION

 

Over 10 years ago, we began using endoscopes for pituitary tumor surgery. During this period, there have been changes to our initial technical description.11 Sonnenberg et al.12 determined that there was not a statistical difference in complications using the same endoscopic technique and concluded a surgeon learning curve was not present. There has been, however, a learning curve in modifying the approach by deciding what works and what does not. At first, we sought to primarily replace the open sublabial approach with use of endoscopes through a smaller transseptal route. This exposure allowed for access to and obliteration of the sphenoid sinus with fat, and the sinus could then be sealed, with re-approximation of the septal mucosa.

 

The advantages to this approach were the ability to place a retractor in the nasal septal incision for easy introduction of instruments and endoscopes, avoid turbinate or mucosal abnormalities, correct any septal deflection, convert to an open approach quickly if needed, avoid the sublabial incision, nasal spine removal and possible postoperative nasal tip droop, and identify and work in the midline. The disadvantages included additional operative time, oozing from the larger septal flaps obscuring the lens, patient discomfort, and need for septal splints or packing.

 

In revision cases from previous ?open? transseptal surgeries, in which the septum was midline but scarred or perforated and did not allow for a transseptal approach, we opted to perform the more direct bilateral transostial approach. This had the advantage of placing the endoscope in one side, sometimes in a scope holder, while instruments were passed though the other nasal cavity. Use of an endoscope holder was not favored because it required additional set-up time and use of an endosheath to flush the scope clean in situ. The bilateral approach had problems with ?blind? passage of instruments and the need for straight access on both sides, necessitating correction of bilateral septal curvatures and all obstructing turbinates. After several cases, we believed that there was no compelling reason to use the bilateral approach except for tumor filling the sphenoid sinus.

 

Last, we began using a unilateral transostial approach and continue to use this technique. Advantages include easy visualization of instruments as they are passed through the nasal cavity, decreased operative time, and minimal patient discomfort because no packing is required. Favorable anatomy is only required on one side, and a preferred side was chosen to maximize the exposure to the tumor with the least amount of nasal sinus mucosal disruption. The left side was chosen when there was a right posterior septum, left turbinate abnormality, right-sided sphenoid septum, or left tumor location. The right side was chosen when there was right turbinate abnormality or left sphenoid septum or equivocal anatomy by surgeon preference.

 

Severe anterior deflections require that the opposite side be used or the deflection be endoscopically corrected. Middle turbinate abnormalities (concha bullosa, hypertrophy, and paradoxical curvature) may represent an obstruction in trying to reach the natural ostium of the sphenoid sinus. Seithi et al.10 found that 77% of sphenoid ostia could be visualized without middle turbinate removal. They did not comment on lateralization of the turbinates or on treatment of the superior turbinate. Carrau et al.13 describe never needing to resect the middle turbinate. Partial middle turbinate resection, however, can improve exposure of the posterior nasal cavity. Because concha bullosa often accompany a septal deflection to the opposite side, a partial sagittal middle turbinectomy not only increases exposure but also increases the intranasal workspace. We found partial middle turbinectomy to be useful 33% of the time.

 

A transostial approach is off the midline. However, routine use of a high-speed angled burr and microdebrider to enlarge the ostial opening medially to include the posterior midline septum and sphenoidal crest allows a near-midline orientation of the endoscope and instruments. Otori et al.14 used a navigation system in 40 endoscopic pituitary cases but did not perform a comparative study to determine the value using it. We used a three-dimensional navigation system for three cases but found it added additional time, and at posterior wall of the sphenoid, there was often 2 mm or greater difference comparing the CT with endoscopic bony landmarks, which was unacceptable. Fluoroscopy was used for determination of sagittal extent of curette location with tumor removal.

 

The sphenoid anatomy we encountered is detailed in Table III. The 79% variability agrees with Renn and Rhoton 9 and Seithi et al.,10 who studied sphenoid anatomy and the variations in extent of pneumatization, dehiscence of optic nerve and the internal carotid artery, and sphenoid septum. In the 30 cases studied by Seithi et al., the sphenoid septum was found to be singular (70%) or multiple (30%), midline (40%) or asymmetric, (right dominant 27%, left 33%) complete, or partial extending to the midline sella or laterally to the carotid.

 

The overall complication rate in our retrospective review was low. There were no alar or septal injuries. Four patients were readmitted for concern of CSF leak, but none were identified. The rate of CSF leak is reported as 2% to 3.8%.15 We used autologous fat and fibrin sealant for each case and found it to be universally effective. If an intraoperative CSF leak was apparent, the lumbar drain inserted at the beginning of the case was left in place. Short-term and transient DI has also been reported to occur in 5.5% to 20% of patients.5,15 Shah and Har-El 5 reported a higher incidence of immediate and short-term DI in patients undergoing the traditional open approach compared with the endoscopic approach. In our review, all seven patients with transient DI had surgery with the transseptal, endoscopic approach. No patients operated with a transostial technique developed DI.

 

Determination of degree of resection and need for additional treatment with radiation was made by the neurosurgeon. Although angled endoscopic lenses are routinely used to help with visualization and tumor resection, 5% of our cases had suprasellar tumor and had craniotomies to complete resection. In the future, more aggressive endoscopic resections may allow for adequate removal of suprasellar tumor. Only one patient in our review required subsequent surgery for recurrence.

CONCLUSION

 

The endoscopic approach to the pituitary gland has been used for over 10 years by the authors. Conversion to an open approach has never been needed. There have been modifications to the originally described technique primarily because of operator experience. There have been few instrument improvements such as the angled burr, which allow for safe and more rapid exposure of the sphenoid sinus. A unilateral transostial approach is currently favored. A majority of patients had nasal anatomic variations that influenced the sidedness of the surgery, and there was often a need for septal or turbinate correction. Complication rates were low. Patients generally reported minimal nasal discomfort after surgery, and for those who had already undergone an open approach, they uniformly preferred the endoscopic approach.

BIBLIOGRAPHY

 

1. Jankowski R, Auque J, Simon C, et al. Endoscopic pituitary surgery. Laryngoscope 1992;102:198?202. [Context Link]

 

2. Wurster CF, Smith DE. The endoscopic approach to the pituitary gland [Letter]. Arch Otolaryngol Head Neck Surg 1994;120:674. [Context Link]

 

3. Shikani AH, Kelly JH. Endoscopic debulking of a pituitary tumor. Am J Otolaryngol 1993;14:254?256. [Context Link]

 

4. J. HD, Alfieri A. Endoscopic transsphenoidal pituitary surgery: various surgical techniques and recommended steps for procedural transition. Br J Neurosurg 2000;14:432?440. [Context Link]

 

5. Shah S, Har-El G. Diabetes insipidus after pituitary surgery: incidence after traditional versus endoscopic transsphenoidal approaches. Am J Rhinol 2001;15:377?379. [Context Link]

 

6. Jame JA, Thapar K, Kaptain GJ, et al. Pituitary surgery: transsphenoidal approach. Neurosurgery 2002;51:435?442. Ovid Full Text Bibliographic Links [Context Link]

 

7. Cappabianca P, Cavallo LM, Colao A, et al. Endoscopic endonasal transsphenoidal approach: outcome analysis of 100 consecutive procedures. Minim Invas Neurosurg 2002;45:193?200. [Context Link]

 

8. J. HD, Alfieri A. Endoscopic endonasal pituitary surgery: evolution of surgical technique and equipment in 150 operations. Minim Invas Neurosurg 2001;44:1?12. [Context Link]

 

9. Renn WH, Rhoton AL. Microsurgical anatomy of the sellar region. J of Neuroscience 1975;43:288?298. [Context Link]

 

10. Sethi DS, Stanley RE, Pillay PK. Endoscopic anatomy of the sphenoid sinus and sella turcica. J Laryngol Otol 1995;109:951?955. Bibliographic Links [Context Link]

 

11. Rodziewicz GS, Kelley RT, Kellman RM, Smith MV. Transnasal endoscopic surgery of the pituitary gland: technical note. Neurosurgery 1996;39:189?193. Ovid Full Text Bibliographic Links [Context Link]

 

12. Sonnenburg RE, White D, Ewend MG, Senior B. The learning curve in minimally invasive pituitary surgery. Am J Rhinol 2004;18:259?263. [Context Link]

 

13. Carrau RL, J. HD, Ko Y. Transnasal-transsphenoidal endoscopic surgery of the pituitary gland. Laryngoscope 1996;106:914?918. Ovid Full Text [Context Link]

 

14. Otori N, Haruna S, Kamio M, et al. Endoscopic transethmosphenoidal approach for pituitary tumors with image guidance. Am J Rhinol 2001;15:381?386. [Context Link]

 

15. Cappabianca P, Cavallo LM, Colao AM, deDivitus E. Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg 2002;97:293?298. Bibliographic Links [Context Link]

[nycsmile]

Thanks for posting some of these and thanks to MaryO for making the New Item / Research section for you to put them in.

 

That whole PubMed cite makes me bonkers. Everytime I do a google search on a medical issue I want to research I get this teaser I can not read. That being said I am PMing you two I would be interested in reading if you are still avoiding your to-do list and would not mind looking them up!

[staticnrg]

Some things are available via Medscape (free account). Some of these I get through VCU's online library (using daughters' accounts). Some I still can't get, either, without paying. Eventually I can. But at first, they cost. In a few months they won't. I know...it's aggravating.

 

Hugs!

Robin