Neurosurgical forum Letters to the editor
Endoscopic pituitary surgery To The Editor: We read with great interest the metaanalysis published by Tabaee et al.6 (Tabaee A, Anand VK, Barrón Y, et al: Endoscopic pituitary surgery: a systematic review and meta-analysis. Clinical article. J Neurosurg 111:545–554, September 2009). These authors documented the safety and the short-term efficacy of endoscopic pituitary surgery by reviewing the literature and applying meta-analytic methods. However, reading this article has raised questions. Indeed, in their inclusion criteria, Tabaee et al. indicated that they only focused on “purely endoscopic approaches to the pituitary gland,” but they included the article by Jho et al.5 in which the results of endoscopic surgery in a series of 160 patients (128 pituitary adenomas, 9 anterior fossa meningiomas, 7 clival chordomas, and 16 others pathologies) were reported. Owing to the fact that their series did not exclusively contain pituitary adenomas, only the complications of the pituitary adenoma surgeries should be reported in the meta-analysis to obtain strong results. It seems that the authors included only those complications associated with pituitary adenomas. Indeed, they indicated that Jho et al.5 reported a CSF leakage rate of 8%, indicating that there were 10 CSF leaks in 128 endoscopic pituitary surgeries (128 is the number of pituitary adenomas that Jho et al.5 reported). However, by carefully reading the article of Jho et al., 5 we realized that they actually reported 10 CSF leaks, but these 10 CSF leaks were reported for the entire series (160 operations). Therefore, we are right to question the veracity of the reported percentage and the final results of the meta-analysis. Maybe the authors asked Jho et al. if the 10 CSF leaks reported only involved the pituitary adenomas. Unfortunately, if so, this information is missing from their article. Moreover, other skull base surgeries may induce more CSF leaks than pituitary adenoma surgeries because they require extended approaches.1–3 For example, in a series of 35 anterior cranial base meningiomas, Gardner et al.4 reported a CSF leakage rate of 40%. Furthermore Tabaee et al. indicated that Jho et al. 5 reported a 4% rate (5 of 128 cases) of permanent diabetes insipidus, while in fact they reported this rate to be 3%, which represents around 5 of 160 cases. Most surprising is the fact that Tabaee et al. indicated that Jho et al.5 reported a death in their series of pituitary
J Neurosurg / Volume 121 / December 2014
adenomas, while the authors clearly indicated that the death involved a patient with a fibrosarcoma. Regarding endoscopic pituitary surgery, such analysis could be very useful to improve our knowledge on this subject, but can we trust the results of Tabaee et al.?
Mahmoud Messerer, M.D. Hôpital Neurologique Pierre Wertheimer Claude Bernard University Centre Hospitalier Universitaire Lyon Bron, France Julie Dubourg, M.D. Centre d’Investigation Clinique Hôpital Louis Pradel Centre Hospitalier Universitaire Lyon Lyon, France Disclosure
The authors report no conflict of interest. References 1. Couldwell WT, Weiss MH, Rabb C, Liu JK, Apfelbaum RI, Fukushima T: Variations on the standard transsphenoidal approach to the sellar region, with emphasis on the extended approaches and parasellar approaches: surgical experience in 105 cases. Neurosurgery 55:539–550, 2004 2. Dehdashti AR, Ganna A, Witterick I, Gentili F: Expanded endoscopic endonasal approach for anterior cranial base and suprasellar lesions: indications and limitations. Neurosurgery 64:677–689, 2009 3. Fatemi N, Dusick JR, de Paiva Neto MA, Malkasian D, Kelly DF: Endonasal versus supraorbital keyhole removal of craniopharyngiomas and tuberculum sellae meningiomas. Neurosurgery 64:269–286, 2009 4. Gardner PA, Kassam AB, Thomas A, Snyderman CH, Carrau RL, Mintz AH, et al: Endoscopic endonasal resection of anterior cranial base meningiomas. Neurosurgery 63:36–54, 2008 5. Jho HD: Endoscopic transsphenoidal surgery. J Neurooncol 54:187–195, 2001 6. Tabaee A, Anand VK, Barrón Y, Hiltzik DH, Brown SM, Kacker A, et al: Endoscopic pituitary surgery: a systematic review and meta-analysis. Clinical article. J Neurosurg 111: 545–554, 2009
Response: No response was received from the authors of the original article. Please include this information when citing this paper: published online October 3, 2014; DOI: 10.3171/2010.5.JNS10627. ©AANS, 2014
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Endoscopic pituitary surgery To The Editor: We read with great interest the metaanalysis published by Tabaee et al.6 (Tabaee A, Anand VK, Barrón Y, et al: Endoscopic pituitary surgery: a systematic review and meta-analysis. Clinical article. J Neurosurg 111:545–554, September 2009). These authors documented the safety and the short-term efficacy of endoscopic pituitary surgery by reviewing the literature and applying meta-analytic methods. However, reading this article has raised questions. Indeed, in their inclusion criteria, Tabaee et al. indicated that they only focused on “purely endoscopic approaches to the pituitary gland,” but they included the article by Jho et al.5 in which the results of endoscopic surgery in a series of 160 patients (128 pituitary adenomas, 9 anterior fossa meningiomas, 7 clival chordomas, and 16 others pathologies) were reported. Owing to the fact that their series did not exclusively contain pituitary adenomas, only the complications of the pituitary adenoma surgeries should be reported in the meta-analysis to obtain strong results. It seems that the authors included only those complications associated with pituitary adenomas. Indeed, they indicated that Jho et al.5 reported a CSF leakage rate of 8%, indicating that there were 10 CSF leaks in 128 endoscopic pituitary surgeries (128 is the number of pituitary adenomas that Jho et al.5 reported). However, by carefully reading the article of Jho et al., 5 we realized that they actually reported 10 CSF leaks, but these 10 CSF leaks were reported for the entire series (160 operations). Therefore, we are right to question the veracity of the reported percentage and the final results of the meta-analysis. Maybe the authors asked Jho et al. if the 10 CSF leaks reported only involved the pituitary adenomas. Unfortunately, if so, this information is missing from their article. Moreover, other skull base surgeries may induce more CSF leaks than pituitary adenoma surgeries because they require extended approaches.1–3 For example, in a series of 35 anterior cranial base meningiomas, Gardner et al.4 reported a CSF leakage rate of 40%. Furthermore Tabaee et al. indicated that Jho et al. 5 reported a 4% rate (5 of 128 cases) of permanent diabetes insipidus, while in fact they reported this rate to be 3%, which represents around 5 of 160 cases. Most surprising is the fact that Tabaee et al. indicated that Jho et al.5 reported a death in their series of pituitary
J Neurosurg / Volume 121 / December 2014
adenomas, while the authors clearly indicated that the death involved a patient with a fibrosarcoma. Regarding endoscopic pituitary surgery, such analysis could be very useful to improve our knowledge on this subject, but can we trust the results of Tabaee et al.?
Mahmoud Messerer, M.D. Hôpital Neurologique Pierre Wertheimer Claude Bernard University Centre Hospitalier Universitaire Lyon Bron, France Julie Dubourg, M.D. Centre d’Investigation Clinique Hôpital Louis Pradel Centre Hospitalier Universitaire Lyon Lyon, France Disclosure
The authors report no conflict of interest. References 1. Couldwell WT, Weiss MH, Rabb C, Liu JK, Apfelbaum RI, Fukushima T: Variations on the standard transsphenoidal approach to the sellar region, with emphasis on the extended approaches and parasellar approaches: surgical experience in 105 cases. Neurosurgery 55:539–550, 2004 2. Dehdashti AR, Ganna A, Witterick I, Gentili F: Expanded endoscopic endonasal approach for anterior cranial base and suprasellar lesions: indications and limitations. Neurosurgery 64:677–689, 2009 3. Fatemi N, Dusick JR, de Paiva Neto MA, Malkasian D, Kelly DF: Endonasal versus supraorbital keyhole removal of craniopharyngiomas and tuberculum sellae meningiomas. Neurosurgery 64:269–286, 2009 4. Gardner PA, Kassam AB, Thomas A, Snyderman CH, Carrau RL, Mintz AH, et al: Endoscopic endonasal resection of anterior cranial base meningiomas. Neurosurgery 63:36–54, 2008 5. Jho HD: Endoscopic transsphenoidal surgery. J Neurooncol 54:187–195, 2001 6. Tabaee A, Anand VK, Barrón Y, Hiltzik DH, Brown SM, Kacker A, et al: Endoscopic pituitary surgery: a systematic review and meta-analysis. Clinical article. J Neurosurg 111: 545–554, 2009
Response: No response was received from the authors of the original article. Please include this information when citing this paper: published online October 3, 2014; DOI: 10.3171/2010.5.JNS10627. ©AANS, 2014
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