Int J Clin Exp Med 2015;8(4):5137-5143 www.ijcem.com /ISSN:1940-5901/IJCEM0006543
Original Article Endoscopic endonasal transsphenoidal surgery for treating pituitary adenoma via a sub-septum mucosa approach Sheng Nie1,2, Keqin Li1,2, Yi Huang1,2, Jikuang Zhao1,2, Xiang Gao1,2, Jie Sun1,2 Department of Neurosurgery, Ningbo First Hospital, Ningbo Hospital, Zhejiang University, Ningbo 315010, Zhejiang, China; 2Zhou Liangfu Academician Workstation, Neurosurgery Ningbo branch of Shanghai Huashan Hospital, Ningbo 315010, Zhejiang, China 1
Received January 31, 2015; Accepted April 2, 2015; Epub April 15, 2015; Published April 30, 2015 Abstract: A novel sub-suptum mucusa approach was used to investigate the surgical method via an endonasal sub-septum-mucosa approach to pituitary adenoma under endoscopy. In this work, we aim to ensure the quality of operation and to reduce the operation trauma and complications. By endoscopy, the nasal mucosa was incised in the nasal septum, and all mucosal flaps were retained, a sub-septum-mucosa surgical corridor was made where the endoscope was used in the mucosa cavity for operation and to remove the pituitary adenoma. 52 patients (28 women, mean age 46.76 years) underwent endoscopic endonasal transsphenoidal sub-septum-mucosa approach for treating pituitary adenoma. 46 patients (88.5%) underwent gross total removal (GTR) for the tumor; 6 patients (11.5%) went through partial tumor removal (PTR). After operation, all nasal mucosa was retained, no complications such as nasal bleeding, loss of sense of smell or cerebrospinal fluid rhinorrhea. Our results showed that treating pituitary adenoma using endonasal transsphenoidal surgeries by keeping nasal mucosa under neuroendoscopy tend to have smaller trauma. This novel method more advanced since it provides a clear operation field, a flexible transformation of operation modes and leads to less postoperative complications. Keywords: Endonasal, endoscopy, pituitary adenoma, transsphenoidal surgery, nasal flap
Introduction The endoscopic endonasal transsphenoidal approach (EETA) is rapidly becoming as the preferred minimally invasive approach for treatment of patients with pituitary adenoma, and the method is also being used for treatment of patients with various skull base lesions [1, 2]. This technique has been considered to be a milestone of modern and contemporary neurosurgery in the treatment of pituitary tumors and related lesions of the sellar area [3]. Previous approaches [4, 5] may damage the mucosa around the nasal septum and sphenoid ostium. However, using the sub-septum-mucosa approach we can operate in the double nostril operation by four hands and keep the nasal mucosa intact. Thus, it provides a potential ideal mucosa paddle for cases with unplanned CSF leak. In this study, we aim to present our experience in the 52 patients with pituitary adenoma treated by endoscopic endonasal
transsphenoidal via a sub-septum-mucosa approach. Materials and methods General information 52 cases of patients with pituitary adenoma accepted endoscopic endonasal transsphenoidal surgical treatment by a sub-septum-mucosa approach in our department between January 2012 and December 2012. Each patient underwent thoroughly pre-operative multi- disciplinary work-up, including neuroradiological, endocrinological, general physical and ophthalmological assessments. Neuroradiology Each patient underwent a pre-operative magnetic resonance imaging (MRI) of the brain, including pre- and post-contrast series. These scans were repeated 3 months and 12 months
Surgical treatment of pituitary adenoma
Figure 1. Use electric knife to cut the mucosa in the position of nasal septum (NS) just rostral to the anterior head of the inferior turbinate (IT).
Figure 2. Elevation of the mucoperichondrium, by use of a dissector, proceeds in an anterior to posterior direction to the anterior face of the sphenoid sinus and sphenoid ostium to produce a submucosal operation space.
postoperatively. All patients received CT scans in prior to the operation to further delineate the anatomical relationship of the cranial base and the tumor. Adenomas were classified as microadenoma (diameter < 1 cm), macroadenoma (diameter > 1 cm). The series included 7 cases microadenoma, 45 cases macroadenoma. The degree of tumor resection was judged on the basis of the 3 month post-operative MRI:
5138
Figure 3. A view of Sphenoid sinus cavity (SS).
Figure 4. After the tumor was removed, the nasal mucosa on the operation side was pushed back.
gross total removal (GTR) indicated the absence of residuum on MRI; whereas partial tumor removal (PTR) correlated with the presence of tumor on MRI. Endocrine All patients underwent a complete endocrinological assessment 1 month and 3 months postoperatively. Follow-up was scheduled as required, mostly on an annual basis. Cure in secreting adenomas was established following the strictest modern criteria [6, 7]: in GH adenomas, remission was defined by nor-
Int J Clin Exp Med 2015;8(4):5137-5143
Surgical treatment of pituitary adenoma Ophthalmological tests All patients underwent full visual assessment pre-operatively in the ophthalmology department of our hospital or in the referring hospital. Visual field and visual acuity assessments were performed up to one month pre-operatively (unless there had been a recent deterioration), and these were repeated three months postoperatively, unless required more urgently. Ophthalmological results were categorized as normalized, improved, unchanged and worsened. Surgical method Figure 5. In the case of obvious CSF leak from large arachnoid and dural defects, the right septum mucosal would be shaped as a vascularized septal mucosal flap (MF).
Figure 6. Use the vascularized septal mucosal flap to reconstruct the skull base.
mal sex- and age-adjusted IGF-level and GH nadir < 1 ng/ml after oral glucose tolerance test; In PRL-secreting adenomas, remission was defined as having normal serum PRL levels (< 30 ng/ml in females, < 15 ng/ml in males) without previously having had dopaminergic therapy for at least 2 months; Hypopituitarism was evaluated by baseline hormonal assessment and dynamic test, where required. The most common used dynamic test was the Synacthen test, and this was performed within 6-8 weeks after surgery to evaluate a secondary hypoadrenalism.
5139
After general anesthesia and orotracheal intubation, the patient is placed supine, while his head is secured in a three-pin head holder for neuronavigation. With head back 15°, the patient’s head is rotated 20° towards the operator. Iodine was used to disinfect the face and nasal cavity. The 0° endoscope was used in the right nostril to allow the recognition of the inferior and middle turbinate laterally and the identification of the nasal septum and sphenoid ostium. The unipolar electric knife was used to cut the mucosa in the position when nasal septum just rostral to the anterior head of the inferior turbinate (Figure 1), 2-2.5 cm in length. Elevation of the mucoperichondrium, by use of a dissector, proceeded in an anterior to posterior direction to the anterior face of the sphenoid sinus and sphenoid ostium to produce a submucosal operation space (Figure 2). The abrasive drill was used to remove the posterior portion of nasal septum, to expose the contralateral sphenoid ostium and the contralateral nasal septum mucosa (Figure 3). The bone of the sphenoid sinus anterior wall and sphenoid septum were removed by a rongeur. The sellar osteotomy with a range of 1-1.5 cm in diameter is performed with bone rongeurs. The sellar dura is then opened with a micro-blade. After the tumor was removed, the nasal mucosa on the operation side was pushed back (Figure 4). For the large pituitary adenoma, which needed double nostrils-four-hand operation, an incision of 5 mm long was made open on the contralateral nasal septum mucosa, where the surgical instrument could be imported. Early in this series of patients, the endoscopic part of the case was performed with single nostrils approach. In the latter half of the series, double nostrils 3-hand technique was typically used,
Int J Clin Exp Med 2015;8(4):5137-5143
Surgical treatment of pituitary adenoma Table 1. Summary of clinical details of 52 patients used for analysis Clinical details
N
Total 52 Sex male 24 female 28 Age range, years 25-76 Endocrine-active adenoma 35 Endocrine-inactive adenoma 17 Prolactinomas 26 GH-secreting adenomas 8 PRL + GH secreting adenomas 1 Size Microadenomas (< 10 mm) 7 Macroadenomas (> 10 mm) 45 10-19 mm 11 20-39 mm 30 ≥ 40 mm 4 Visual disturbance 29 Headache 10 Clinical follow-up months 6-24 Radiological follow-up months 3-24
Percentage, % 100.0% 46.2% 53.8% 67.3% 32.7% 50.0% 15.4% 2.0% 13.5% 86.5% 24.4% 66.7% 8.9% 55.8% 19.2%
an incision of 5 mm long was made open on the contralateral nasal septum mucosa, where the surgical instrument could be inserted. In the case of obvious CSF leak from large arachnoid and dural defects, the right septum mucosal would be shaped as a vascularized septal mucosal flap (Figure 5), just as that Kassam et al. [8] described to reconstruct the skull base (Figure 6). Wherein, one patient of our cases had relatively severe intraoperative cerebrospinal fluid leakage. After the completion of tumor resection, the mucosal incision was clipped into the pedicle mucosal flap; the operation was based on the description of Amin B. Kassam, covered at the bottom of the saddle, to form a good repair substrate for the skull base. Results As shown in Table 1, there were 24 males and 28 females. Age was from 25 to 76, with an average age of 46.8. Overall, 35 patients had an endocrine-active adenoma and 17 had endocrine-inactive adenoma (45 macroadenomas and 7 microadenomas). Among the 35 endocrine-active adenomas, there were 26 pro5140
lactinomas, 8 GH-secreting adenomas and 1 PRL + GH secreting adenomas. Clinical and imaging evidence of pituitary apoplexy was present in 19.2% (10/52) of patients including 20% (7/35) of those with endocrine-active adenomas and 23.5% (4/17) of those with endocrine-inactive tumors. Cavernous sinus invasion was visualized on preoperative images and confirmed intraoperatively in 26.9% 14/52) of patients, including 28.6% (10/35) of those with functional adenomas and 23.5% (4/17) of those with nonfunctional tumors. Among the 45 macroadenomas, 11 (24.4%) were 10-19 mm in diameter, 30 (66.7%) were 20-39 mm in diameter and 4 (8.9%) were giant, that is, ≥ 40 mm in maximal diameter. Decreased visual acuity or a visual field defect was the presenting complaint in 29 patients (55.8%) and headache in 10 patients (19.2%). The median clinical follow-up was 16 months, ranged from 6 to 24 months, and the median radiological follow-up was 14 months, ranging from 3 to 24 months. Surgical results As shown in Table 2, there were 46 cases (88.5%) of total resection of tumor, 6 cases (11.5%) of partial resection. 9 cases (90.0%) of headache patients were obviously relieved. Ophthalmological results Of the 29 patients who presented with visual disturbance, 89.7% improved post-operatively while in the remaining 10.3% the vision remained unchanged. Endocrinological results Early remission was achieved in 68.6% (24/35) of endocrine-active adenomas according to standard early remission criteria. Specifically, remission was achieved in 69.2% (18/26) of patients with a prolactinoma and in 62.5% (5/8) of those with GH-secreting adenomas, all these 5 with an OGTT confirming the remission status. Patients with PRL + GH-secreting adenomas had early remission. Complications 6 cases of diabetes insipidus after surgery were all recovered with normal urine output in 3-7 days after the administration of pituitrin; headache symptoms in 3 patients were all Int J Clin Exp Med 2015;8(4):5137-5143
Surgical treatment of pituitary adenoma Table 2. Surgical results for the 52 patients Surgical results Total Gross total removal (GTR) Partial tumor removal (PTR) Headache relieved Vision recovered Endocrinological results endocrine-active adenomas remission prolactinoma remission GH-secreting adenomas remission OGTT PRL + GH-secreting adenomas Complications diabetes insipidus recovered with normal urine output in 3-7 days headache symptoms relieved in 5-10 days recovered 3 months
relieved in 5-10 days after treatment with symptomatic support. Due to tumor invasion of cavernous sinus, 1 patient with oculomotor nerve paralysis recovered 3 months after surgery, in which a large number of gelatin sponge was used to oppress the intraoperative cavernous sinus hemorrhage. There were no postoperative complications such as nasal bleeding, sense of smell diminishing, cerebrospinal fluid rhinorrhea, intracranial infection or intracranial bleeding. Discussions Endoscopic endonasal surgery, supported by recent technological advancements, has been increasingly used over the last decade for the treatment of pituitary adenoma [9]. In this article we described the surgical technique and subseptum mucosa approach as applied to pituitary tumors. This approach is simpler and less invasive than the previously advocated medial transnasal approach, while the novel method leads to comparable results in terms of safety and extent in tumor removal. In most of previous approaches [10], the mucosa overlying the anterior wall of the sphenoid, which locates between the sphenoid osteum and approximately 1 cm above the choanae, is usually diathermied and stripped laterally. It will not only cause damage to the normal anatomical structure, but also cause injury to the sphenopalatine artery [11]. In our approach, the mucosa around both nasal septums, middle 5141
N 52 46 6 9 26
Percentage, % 100.0% 88.5% 11.5% 90.0% 89.7%
24/35 18/26 5/8 5/5
68.6% 69.2% 62.5% 100.0%
6 3 1
turbinate and sphenoid ostium was kept intact, which makes the operation less invasive. This approach helps neurosurgeons to avoid lacerating the nasal mucosa such as middle and inferior turbinate mucosa when endoscopy and other equipment are applied. This is very helpful for patients who have small noses. It also reduces the clouding of the endoscope lens by blood, so as to make the vision of operation clearer as well as reducing the time of intraoperative endoscopic lenses cleaning. Meanwhile, the mucosa contains the posterior septal branches of the sphenopalatine artery is elevated from the sphenoid rostrum and the arteries are thereby protected. In this group, the early 24 patients underwent operation through a uninostril endoscopic approach. Due to the small room, the instruments may hinder each other and passing the instruments along the endoscope may be cumbersome. There is a recent shift towards the binostril approach by an increasing number of neurosurgeons. In the latter 28 patients of the series, we adapted the double nostril approach, in which a mucosal incision was made on the contralateral nasal septum mucosa during the operation, thus the doctors could insert the instruments from both nostrils. The binostril approach allows easier movement and insertion of instruments. 88.5% of the cases archived total removal, which is similar to the results of other reports. There was no more complication when compared to the previous results. Int J Clin Exp Med 2015;8(4):5137-5143
Surgical treatment of pituitary adenoma The most common complication of EETA was postoperative CSF leak (16.7%) necessitating reoperation and/or lumbar drain placement [12, 13]. In our group, 1 patient had intraoperative cerebrospinal fluid leakage after tumor resection due to large arachnoidal/dural defect. The right septum mucosa was shaped as a vascularised naso-septal mucosal flap for the reconstruction of skull base. There was no postoperative CSF leak. Some authors advocated an early pedicled mucoperiosteal/mucoperichondrial flap at the beginning of the surgery, for the possible CSF leak. However, if there was no intraoperative CSF leak, the preparation of flap would cause unnecessary injury to patients. On the other hand, it might be disheartening at the end of a long skull base procedure to discover that the flap has been inadvertently devascularized by injury to the pedicle. During our operation, the decision of a pedicle could be made at any time, depending on the finding of the operation. It should be noticed that our cases were consisted of pituitary adenomas only. We are not sure if this approach is suitable for the other skull base lesions, such as mingimoas or chordomas. In summary, treating pituitary adenoma using endonasal transsphenoidal surgeries by keeping nasal mucosa under neuroendoscopy tend to have smaller trauma. We found this novel method more advanced since it provides a clear operation field, a flexible transformation of operation modes and leads to less postoperative complications. Further progress is obviously expected in endoscopic endonasal transsphenoidal surgery because of technological developments and scientific contributions. Disclosure of conflict of interest None. Address correspondence to: Dr. Xiang Gao or Dr. Jie Sun, Department of Neurosurgery, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo 315010, Zhejiang, China. Tel: 86-57487085517; Fax: 86-574-87085517; E-mail: [email protected] (XG); [email protected] (JS)
References [1]
Kalinin PL, Sharipov OI, Shkarubo AN, Fomichev DV, Kutin MA, Alekseev SN, Kadashev BA, Iakovlev SB, Dorokhov PS, Bukharin E, Kurn-
5142
osov AB and Popugaev KA. [Damage to the cavernous segment of internal carotid artery in transsphenoidal endoscopic removal of pituitary adenomas (report of 4 cases)]. Zh Vopr Neirokhir Im N N Burdenko 2013; 77: 28-37; discussion 38. [2] Saeki N, Horiguchi K, Murai H, Hasegawa Y, Hanazawa T and Okamoto Y. Endoscopic endonasal pituitary and skull base surgery. Neurol Med Chir (Tokyo) 2010; 50: 756-764. [3] Ceylan S, Koc K and Anik I. Extended endoscopic approaches for midline skull-base lesions. Neurosurg Rev 2009; 32: 309-319; discussion 318-309. [4] Yano S, Kawano T, Kudo M, Makino K, Nakamura H, Kai Y, Morioka M and Kuratsu J. Endoscopic endonasal transsphenoidal approach through the bilateral nostrils for pituitary adenomas. Neurol Med Chir (Tokyo) 2009; 49: 1-7. [5] Dehdashti AR, Ganna A, Karabatsou K and Gentili F. Pure endoscopic endonasal approach for pituitary adenomas: early surgical results in 200 patients and comparison with previous microsurgical series. Neurosurgery 2008; 62: 1006-1015; discussion 1015-1007. [6] Fatemi N, Dusick JR, de Paiva Neto MA and Kelly DF. The endonasal microscopic approach for pituitary adenomas and other parasellar tumors: a 10-year experience. Neurosurgery 2008; 63: 244-256; discussion 256. [7] Giustina A, Chanson P, Bronstein MD, Klibanski A, Lamberts S, Casanueva FF, Trainer P, Ghigo E, Ho K and Melmed S. A consensus on criteria for cure of acromegaly. J Clin Endocrinol Metab 2010; 95: 3141-3148. [8] Kassam AB, Thomas A, Carrau RL, Snyderman CH, Vescan A, Prevedello D, Mintz A and Gardner P. Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 2008; 63: ONS44-52; discussion ONS52-43. [9] Torales J, Halperin I, Hanzu F, Mora M, Alobid I, De Notaris M, Ferrer E and Ensenat J. Endoscopic endonasal surgery for pituitary tumors. Results in a series of 121 patients operated at the same center and by the same neurosurgeon. Endocrinol Nutr 2014; 61: 410-6. [10] Cavallo LM, Messina A, Cappabianca P, Esposito F, de Divitiis E, Gardner P and Tschabitscher M. Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations. Neurosurg Focus 2005; 19: e2. [11] Gandomi B, Arzaghi MH, Khademi B and Rafatbakhsh M. Endoscopic cauterization of the sphenopalatine artery to control severe and recurrent posterior epistaxis. Iran J Otorhinolaryngol 2013; 25: 147-154.
Int J Clin Exp Med 2015;8(4):5137-5143
Surgical treatment of pituitary adenoma [12] Gondim JA, Schops M, de Almeida JP, de Albuquerque LA, Gomes E, Ferraz T and Barroso FA. Endoscopic endonasal transsphenoidal surgery: surgical results of 228 pituitary adenomas treated in a pituitary center. Pituitary 2010; 13: 68-77.
5143
[13] Laws ER Jr, de Los Reyes K and Rincon-Torroella J. Lumbar drains in transsphenoidal surgery. J Neurosurg 2013; 118: 480-481.
Int J Clin Exp Med 2015;8(4):5137-5143
Original Article Endoscopic endonasal transsphenoidal surgery for treating pituitary adenoma via a sub-septum mucosa approach Sheng Nie1,2, Keqin Li1,2, Yi Huang1,2, Jikuang Zhao1,2, Xiang Gao1,2, Jie Sun1,2 Department of Neurosurgery, Ningbo First Hospital, Ningbo Hospital, Zhejiang University, Ningbo 315010, Zhejiang, China; 2Zhou Liangfu Academician Workstation, Neurosurgery Ningbo branch of Shanghai Huashan Hospital, Ningbo 315010, Zhejiang, China 1
Received January 31, 2015; Accepted April 2, 2015; Epub April 15, 2015; Published April 30, 2015 Abstract: A novel sub-suptum mucusa approach was used to investigate the surgical method via an endonasal sub-septum-mucosa approach to pituitary adenoma under endoscopy. In this work, we aim to ensure the quality of operation and to reduce the operation trauma and complications. By endoscopy, the nasal mucosa was incised in the nasal septum, and all mucosal flaps were retained, a sub-septum-mucosa surgical corridor was made where the endoscope was used in the mucosa cavity for operation and to remove the pituitary adenoma. 52 patients (28 women, mean age 46.76 years) underwent endoscopic endonasal transsphenoidal sub-septum-mucosa approach for treating pituitary adenoma. 46 patients (88.5%) underwent gross total removal (GTR) for the tumor; 6 patients (11.5%) went through partial tumor removal (PTR). After operation, all nasal mucosa was retained, no complications such as nasal bleeding, loss of sense of smell or cerebrospinal fluid rhinorrhea. Our results showed that treating pituitary adenoma using endonasal transsphenoidal surgeries by keeping nasal mucosa under neuroendoscopy tend to have smaller trauma. This novel method more advanced since it provides a clear operation field, a flexible transformation of operation modes and leads to less postoperative complications. Keywords: Endonasal, endoscopy, pituitary adenoma, transsphenoidal surgery, nasal flap
Introduction The endoscopic endonasal transsphenoidal approach (EETA) is rapidly becoming as the preferred minimally invasive approach for treatment of patients with pituitary adenoma, and the method is also being used for treatment of patients with various skull base lesions [1, 2]. This technique has been considered to be a milestone of modern and contemporary neurosurgery in the treatment of pituitary tumors and related lesions of the sellar area [3]. Previous approaches [4, 5] may damage the mucosa around the nasal septum and sphenoid ostium. However, using the sub-septum-mucosa approach we can operate in the double nostril operation by four hands and keep the nasal mucosa intact. Thus, it provides a potential ideal mucosa paddle for cases with unplanned CSF leak. In this study, we aim to present our experience in the 52 patients with pituitary adenoma treated by endoscopic endonasal
transsphenoidal via a sub-septum-mucosa approach. Materials and methods General information 52 cases of patients with pituitary adenoma accepted endoscopic endonasal transsphenoidal surgical treatment by a sub-septum-mucosa approach in our department between January 2012 and December 2012. Each patient underwent thoroughly pre-operative multi- disciplinary work-up, including neuroradiological, endocrinological, general physical and ophthalmological assessments. Neuroradiology Each patient underwent a pre-operative magnetic resonance imaging (MRI) of the brain, including pre- and post-contrast series. These scans were repeated 3 months and 12 months
Surgical treatment of pituitary adenoma
Figure 1. Use electric knife to cut the mucosa in the position of nasal septum (NS) just rostral to the anterior head of the inferior turbinate (IT).
Figure 2. Elevation of the mucoperichondrium, by use of a dissector, proceeds in an anterior to posterior direction to the anterior face of the sphenoid sinus and sphenoid ostium to produce a submucosal operation space.
postoperatively. All patients received CT scans in prior to the operation to further delineate the anatomical relationship of the cranial base and the tumor. Adenomas were classified as microadenoma (diameter < 1 cm), macroadenoma (diameter > 1 cm). The series included 7 cases microadenoma, 45 cases macroadenoma. The degree of tumor resection was judged on the basis of the 3 month post-operative MRI:
5138
Figure 3. A view of Sphenoid sinus cavity (SS).
Figure 4. After the tumor was removed, the nasal mucosa on the operation side was pushed back.
gross total removal (GTR) indicated the absence of residuum on MRI; whereas partial tumor removal (PTR) correlated with the presence of tumor on MRI. Endocrine All patients underwent a complete endocrinological assessment 1 month and 3 months postoperatively. Follow-up was scheduled as required, mostly on an annual basis. Cure in secreting adenomas was established following the strictest modern criteria [6, 7]: in GH adenomas, remission was defined by nor-
Int J Clin Exp Med 2015;8(4):5137-5143
Surgical treatment of pituitary adenoma Ophthalmological tests All patients underwent full visual assessment pre-operatively in the ophthalmology department of our hospital or in the referring hospital. Visual field and visual acuity assessments were performed up to one month pre-operatively (unless there had been a recent deterioration), and these were repeated three months postoperatively, unless required more urgently. Ophthalmological results were categorized as normalized, improved, unchanged and worsened. Surgical method Figure 5. In the case of obvious CSF leak from large arachnoid and dural defects, the right septum mucosal would be shaped as a vascularized septal mucosal flap (MF).
Figure 6. Use the vascularized septal mucosal flap to reconstruct the skull base.
mal sex- and age-adjusted IGF-level and GH nadir < 1 ng/ml after oral glucose tolerance test; In PRL-secreting adenomas, remission was defined as having normal serum PRL levels (< 30 ng/ml in females, < 15 ng/ml in males) without previously having had dopaminergic therapy for at least 2 months; Hypopituitarism was evaluated by baseline hormonal assessment and dynamic test, where required. The most common used dynamic test was the Synacthen test, and this was performed within 6-8 weeks after surgery to evaluate a secondary hypoadrenalism.
5139
After general anesthesia and orotracheal intubation, the patient is placed supine, while his head is secured in a three-pin head holder for neuronavigation. With head back 15°, the patient’s head is rotated 20° towards the operator. Iodine was used to disinfect the face and nasal cavity. The 0° endoscope was used in the right nostril to allow the recognition of the inferior and middle turbinate laterally and the identification of the nasal septum and sphenoid ostium. The unipolar electric knife was used to cut the mucosa in the position when nasal septum just rostral to the anterior head of the inferior turbinate (Figure 1), 2-2.5 cm in length. Elevation of the mucoperichondrium, by use of a dissector, proceeded in an anterior to posterior direction to the anterior face of the sphenoid sinus and sphenoid ostium to produce a submucosal operation space (Figure 2). The abrasive drill was used to remove the posterior portion of nasal septum, to expose the contralateral sphenoid ostium and the contralateral nasal septum mucosa (Figure 3). The bone of the sphenoid sinus anterior wall and sphenoid septum were removed by a rongeur. The sellar osteotomy with a range of 1-1.5 cm in diameter is performed with bone rongeurs. The sellar dura is then opened with a micro-blade. After the tumor was removed, the nasal mucosa on the operation side was pushed back (Figure 4). For the large pituitary adenoma, which needed double nostrils-four-hand operation, an incision of 5 mm long was made open on the contralateral nasal septum mucosa, where the surgical instrument could be imported. Early in this series of patients, the endoscopic part of the case was performed with single nostrils approach. In the latter half of the series, double nostrils 3-hand technique was typically used,
Int J Clin Exp Med 2015;8(4):5137-5143
Surgical treatment of pituitary adenoma Table 1. Summary of clinical details of 52 patients used for analysis Clinical details
N
Total 52 Sex male 24 female 28 Age range, years 25-76 Endocrine-active adenoma 35 Endocrine-inactive adenoma 17 Prolactinomas 26 GH-secreting adenomas 8 PRL + GH secreting adenomas 1 Size Microadenomas (< 10 mm) 7 Macroadenomas (> 10 mm) 45 10-19 mm 11 20-39 mm 30 ≥ 40 mm 4 Visual disturbance 29 Headache 10 Clinical follow-up months 6-24 Radiological follow-up months 3-24
Percentage, % 100.0% 46.2% 53.8% 67.3% 32.7% 50.0% 15.4% 2.0% 13.5% 86.5% 24.4% 66.7% 8.9% 55.8% 19.2%
an incision of 5 mm long was made open on the contralateral nasal septum mucosa, where the surgical instrument could be inserted. In the case of obvious CSF leak from large arachnoid and dural defects, the right septum mucosal would be shaped as a vascularized septal mucosal flap (Figure 5), just as that Kassam et al. [8] described to reconstruct the skull base (Figure 6). Wherein, one patient of our cases had relatively severe intraoperative cerebrospinal fluid leakage. After the completion of tumor resection, the mucosal incision was clipped into the pedicle mucosal flap; the operation was based on the description of Amin B. Kassam, covered at the bottom of the saddle, to form a good repair substrate for the skull base. Results As shown in Table 1, there were 24 males and 28 females. Age was from 25 to 76, with an average age of 46.8. Overall, 35 patients had an endocrine-active adenoma and 17 had endocrine-inactive adenoma (45 macroadenomas and 7 microadenomas). Among the 35 endocrine-active adenomas, there were 26 pro5140
lactinomas, 8 GH-secreting adenomas and 1 PRL + GH secreting adenomas. Clinical and imaging evidence of pituitary apoplexy was present in 19.2% (10/52) of patients including 20% (7/35) of those with endocrine-active adenomas and 23.5% (4/17) of those with endocrine-inactive tumors. Cavernous sinus invasion was visualized on preoperative images and confirmed intraoperatively in 26.9% 14/52) of patients, including 28.6% (10/35) of those with functional adenomas and 23.5% (4/17) of those with nonfunctional tumors. Among the 45 macroadenomas, 11 (24.4%) were 10-19 mm in diameter, 30 (66.7%) were 20-39 mm in diameter and 4 (8.9%) were giant, that is, ≥ 40 mm in maximal diameter. Decreased visual acuity or a visual field defect was the presenting complaint in 29 patients (55.8%) and headache in 10 patients (19.2%). The median clinical follow-up was 16 months, ranged from 6 to 24 months, and the median radiological follow-up was 14 months, ranging from 3 to 24 months. Surgical results As shown in Table 2, there were 46 cases (88.5%) of total resection of tumor, 6 cases (11.5%) of partial resection. 9 cases (90.0%) of headache patients were obviously relieved. Ophthalmological results Of the 29 patients who presented with visual disturbance, 89.7% improved post-operatively while in the remaining 10.3% the vision remained unchanged. Endocrinological results Early remission was achieved in 68.6% (24/35) of endocrine-active adenomas according to standard early remission criteria. Specifically, remission was achieved in 69.2% (18/26) of patients with a prolactinoma and in 62.5% (5/8) of those with GH-secreting adenomas, all these 5 with an OGTT confirming the remission status. Patients with PRL + GH-secreting adenomas had early remission. Complications 6 cases of diabetes insipidus after surgery were all recovered with normal urine output in 3-7 days after the administration of pituitrin; headache symptoms in 3 patients were all Int J Clin Exp Med 2015;8(4):5137-5143
Surgical treatment of pituitary adenoma Table 2. Surgical results for the 52 patients Surgical results Total Gross total removal (GTR) Partial tumor removal (PTR) Headache relieved Vision recovered Endocrinological results endocrine-active adenomas remission prolactinoma remission GH-secreting adenomas remission OGTT PRL + GH-secreting adenomas Complications diabetes insipidus recovered with normal urine output in 3-7 days headache symptoms relieved in 5-10 days recovered 3 months
relieved in 5-10 days after treatment with symptomatic support. Due to tumor invasion of cavernous sinus, 1 patient with oculomotor nerve paralysis recovered 3 months after surgery, in which a large number of gelatin sponge was used to oppress the intraoperative cavernous sinus hemorrhage. There were no postoperative complications such as nasal bleeding, sense of smell diminishing, cerebrospinal fluid rhinorrhea, intracranial infection or intracranial bleeding. Discussions Endoscopic endonasal surgery, supported by recent technological advancements, has been increasingly used over the last decade for the treatment of pituitary adenoma [9]. In this article we described the surgical technique and subseptum mucosa approach as applied to pituitary tumors. This approach is simpler and less invasive than the previously advocated medial transnasal approach, while the novel method leads to comparable results in terms of safety and extent in tumor removal. In most of previous approaches [10], the mucosa overlying the anterior wall of the sphenoid, which locates between the sphenoid osteum and approximately 1 cm above the choanae, is usually diathermied and stripped laterally. It will not only cause damage to the normal anatomical structure, but also cause injury to the sphenopalatine artery [11]. In our approach, the mucosa around both nasal septums, middle 5141
N 52 46 6 9 26
Percentage, % 100.0% 88.5% 11.5% 90.0% 89.7%
24/35 18/26 5/8 5/5
68.6% 69.2% 62.5% 100.0%
6 3 1
turbinate and sphenoid ostium was kept intact, which makes the operation less invasive. This approach helps neurosurgeons to avoid lacerating the nasal mucosa such as middle and inferior turbinate mucosa when endoscopy and other equipment are applied. This is very helpful for patients who have small noses. It also reduces the clouding of the endoscope lens by blood, so as to make the vision of operation clearer as well as reducing the time of intraoperative endoscopic lenses cleaning. Meanwhile, the mucosa contains the posterior septal branches of the sphenopalatine artery is elevated from the sphenoid rostrum and the arteries are thereby protected. In this group, the early 24 patients underwent operation through a uninostril endoscopic approach. Due to the small room, the instruments may hinder each other and passing the instruments along the endoscope may be cumbersome. There is a recent shift towards the binostril approach by an increasing number of neurosurgeons. In the latter 28 patients of the series, we adapted the double nostril approach, in which a mucosal incision was made on the contralateral nasal septum mucosa during the operation, thus the doctors could insert the instruments from both nostrils. The binostril approach allows easier movement and insertion of instruments. 88.5% of the cases archived total removal, which is similar to the results of other reports. There was no more complication when compared to the previous results. Int J Clin Exp Med 2015;8(4):5137-5143
Surgical treatment of pituitary adenoma The most common complication of EETA was postoperative CSF leak (16.7%) necessitating reoperation and/or lumbar drain placement [12, 13]. In our group, 1 patient had intraoperative cerebrospinal fluid leakage after tumor resection due to large arachnoidal/dural defect. The right septum mucosa was shaped as a vascularised naso-septal mucosal flap for the reconstruction of skull base. There was no postoperative CSF leak. Some authors advocated an early pedicled mucoperiosteal/mucoperichondrial flap at the beginning of the surgery, for the possible CSF leak. However, if there was no intraoperative CSF leak, the preparation of flap would cause unnecessary injury to patients. On the other hand, it might be disheartening at the end of a long skull base procedure to discover that the flap has been inadvertently devascularized by injury to the pedicle. During our operation, the decision of a pedicle could be made at any time, depending on the finding of the operation. It should be noticed that our cases were consisted of pituitary adenomas only. We are not sure if this approach is suitable for the other skull base lesions, such as mingimoas or chordomas. In summary, treating pituitary adenoma using endonasal transsphenoidal surgeries by keeping nasal mucosa under neuroendoscopy tend to have smaller trauma. We found this novel method more advanced since it provides a clear operation field, a flexible transformation of operation modes and leads to less postoperative complications. Further progress is obviously expected in endoscopic endonasal transsphenoidal surgery because of technological developments and scientific contributions. Disclosure of conflict of interest None. Address correspondence to: Dr. Xiang Gao or Dr. Jie Sun, Department of Neurosurgery, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo 315010, Zhejiang, China. Tel: 86-57487085517; Fax: 86-574-87085517; E-mail: [email protected] (XG); [email protected] (JS)
References [1]
Kalinin PL, Sharipov OI, Shkarubo AN, Fomichev DV, Kutin MA, Alekseev SN, Kadashev BA, Iakovlev SB, Dorokhov PS, Bukharin E, Kurn-
5142
osov AB and Popugaev KA. [Damage to the cavernous segment of internal carotid artery in transsphenoidal endoscopic removal of pituitary adenomas (report of 4 cases)]. Zh Vopr Neirokhir Im N N Burdenko 2013; 77: 28-37; discussion 38. [2] Saeki N, Horiguchi K, Murai H, Hasegawa Y, Hanazawa T and Okamoto Y. Endoscopic endonasal pituitary and skull base surgery. Neurol Med Chir (Tokyo) 2010; 50: 756-764. [3] Ceylan S, Koc K and Anik I. Extended endoscopic approaches for midline skull-base lesions. Neurosurg Rev 2009; 32: 309-319; discussion 318-309. [4] Yano S, Kawano T, Kudo M, Makino K, Nakamura H, Kai Y, Morioka M and Kuratsu J. Endoscopic endonasal transsphenoidal approach through the bilateral nostrils for pituitary adenomas. Neurol Med Chir (Tokyo) 2009; 49: 1-7. [5] Dehdashti AR, Ganna A, Karabatsou K and Gentili F. Pure endoscopic endonasal approach for pituitary adenomas: early surgical results in 200 patients and comparison with previous microsurgical series. Neurosurgery 2008; 62: 1006-1015; discussion 1015-1007. [6] Fatemi N, Dusick JR, de Paiva Neto MA and Kelly DF. The endonasal microscopic approach for pituitary adenomas and other parasellar tumors: a 10-year experience. Neurosurgery 2008; 63: 244-256; discussion 256. [7] Giustina A, Chanson P, Bronstein MD, Klibanski A, Lamberts S, Casanueva FF, Trainer P, Ghigo E, Ho K and Melmed S. A consensus on criteria for cure of acromegaly. J Clin Endocrinol Metab 2010; 95: 3141-3148. [8] Kassam AB, Thomas A, Carrau RL, Snyderman CH, Vescan A, Prevedello D, Mintz A and Gardner P. Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 2008; 63: ONS44-52; discussion ONS52-43. [9] Torales J, Halperin I, Hanzu F, Mora M, Alobid I, De Notaris M, Ferrer E and Ensenat J. Endoscopic endonasal surgery for pituitary tumors. Results in a series of 121 patients operated at the same center and by the same neurosurgeon. Endocrinol Nutr 2014; 61: 410-6. [10] Cavallo LM, Messina A, Cappabianca P, Esposito F, de Divitiis E, Gardner P and Tschabitscher M. Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations. Neurosurg Focus 2005; 19: e2. [11] Gandomi B, Arzaghi MH, Khademi B and Rafatbakhsh M. Endoscopic cauterization of the sphenopalatine artery to control severe and recurrent posterior epistaxis. Iran J Otorhinolaryngol 2013; 25: 147-154.
Int J Clin Exp Med 2015;8(4):5137-5143
Surgical treatment of pituitary adenoma [12] Gondim JA, Schops M, de Almeida JP, de Albuquerque LA, Gomes E, Ferraz T and Barroso FA. Endoscopic endonasal transsphenoidal surgery: surgical results of 228 pituitary adenomas treated in a pituitary center. Pituitary 2010; 13: 68-77.
5143
[13] Laws ER Jr, de Los Reyes K and Rincon-Torroella J. Lumbar drains in transsphenoidal surgery. J Neurosurg 2013; 118: 480-481.
Int J Clin Exp Med 2015;8(4):5137-5143
