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Pituitary

, Volume 16, Issue 3, pp 393–401 | Cite as

Single-surgeon fully endoscopic endonasal transsphenoidal surgery: outcomes in three-hundred consecutive cases

  • Adam N. Mamelak
  • John Carmichael
  • Vivien H. Bonert
  • Odelia Cooper
  • Shlomo Melmed
Article

Abstract

The objective of this study was to evaluate outcomes of endoscopic transsphenoidal surgery using a single-surgeon technique as an alternative to the more commonly employed two-surgeon, three-hand method. Three hundred consecutive endoscopic transsphenoidal procedures performed over a 5 year period from 2006 to 2011 were reviewed. All procedures were performed via a binasal approach utilizing a single surgeon two handed technique with a pneumatic endoscope holder. Expanded enodnansal cases were excluded. Surgical technique, biochemical and surgical outcomes, and complications were analyzed. 276 patients underwent 300 consecutive surgeries with a mean follow-up period of 37 ± 22 months. Non-functioning pituitary adenoma (NFPA) was the most common pathology (n = 152), followed by growth hormone secreting tumors (n = 41) and Rathke’s cleft cysts (n = 30). Initial gross total cyst drainage based on radiologic criteria was obtained in 28 cases of Rathke’s cleft cyst, with 5 recurrences. For NFPA and other pathologies (n = 173) gross total resection was obtained in 137 cases, with a 92 % concordance rate between observed and expected extent of resection. For functional adenoma, remission rates were 30/41 (73 %) for GH-secreting, 12/12 (100 %) for ACTH-secreting, and 8/17 (47 %) for prolactin-secreting tumors. Post-operative complications included transient (11 %) and permanent (1.4 %) diabetes insipidus, hyponatremia (13 %), and new anterior pituitary hormonal deficits (1.4 %). CSF leak occurred in 42 cases (15 %), and four patients required surgical repair. Two carotid artery injuries occurred, both early in the series. Epistaxis and other rhinological complications were noted in 10 % of patients, most of which were minor and diminished as surgical experience increased. Fully endoscopic single surgeon transsphenoidal surgery utilizing a binasal approach and a pneumatic endoscope holder yields outcomes comparable to those reported with a two-surgeon method. Endoscopic outcomes appear to be better than those reported in microscope-based series, regardless of a one or two surgeon technique.

Keywords

Endoscopic Pituitary Adenoma Surgery Outcomes 

Notes

Acknowledgments

The authors would like to thank William Gellipis, Lori Korsakoff, RN, and Ilana Litwin for assistance in gathering the data presented.

Conflict of interest

None of the authors have a perceived or real conflict of interest with any of the products or medical devices described in this manuscript.

References

  1. 1.
    de Divitiis E, Cappabianca P, Cavallo LM (2002) Endoscopic transsphenoidal approach: adaptability of the procedure to different sellar lesions. Neurosurgery 51:699–705 (discussion 705–697)PubMedGoogle Scholar
  2. 2.
    Jho HD (1999) Endoscopic pituitary surgery. Pituitary 2:139–154CrossRefPubMedGoogle Scholar
  3. 3.
    Spencer WR, Das K, Nwagu C, Wenk E, Schaefer SD, Moscatello A et al (1999) Approaches to the sellar and parasellar region: anatomic comparison of the microscope versus endoscope. Laryngoscope 109:791–794CrossRefPubMedGoogle Scholar
  4. 4.
    Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL (2005) Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus 19:E3PubMedGoogle Scholar
  5. 5.
    Catapano D, Sloffer CA, Frank G, Pasquini E, D’Angelo VA, Lanzino G (2006) Comparison between the microscope and endoscope in the direct endonasal extended transsphenoidal approach: anatomical study. J Neurosurg 104:419–425CrossRefPubMedGoogle Scholar
  6. 6.
    de Divitiis E, Cavallo LM, Cappabianca P, Esposito F (2007) Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors: part 2. Neurosurgery 60:46–58 (discussion 58–49)CrossRefPubMedGoogle Scholar
  7. 7.
    de Divitiis E, Cavallo LM, Esposito F, Stella L, Messina A (2008) Extended endoscopic transsphenoidal approach for tuberculum sellae meningiomas. Neurosurgery 62:1192–1201PubMedGoogle Scholar
  8. 8.
    Frank G, Pasquini E, Doglietto F, Mazzatenta D, Sciarretta V, Farneti G et al (2006) The endoscopic extended transsphenoidal approach for craniopharyngiomas. Neurosurgery 59:ONS75–ONS83PubMedGoogle Scholar
  9. 9.
    Frank G, Pasquini E, Farneti G, Mazzatenta D, Sciarretta V, Grasso V et al (2006) The endoscopic versus the traditional approach in pituitary surgery. Neuroendocrinology 83:240–248CrossRefPubMedGoogle Scholar
  10. 10.
    Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL (2005) Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum. Neurosurg Focus 19:E4PubMedGoogle Scholar
  11. 11.
    Netea-Maier RT, van Lindert EJ, den Heijer M, van der Eerden A, Pieters GF, Sweep CG et al (2006) Transsphenoidal pituitary surgery via the endoscopic technique: results in 35 consecutive patients with Cushing’s disease. Eur J Endocrinol 154:675–684CrossRefPubMedGoogle Scholar
  12. 12.
    Yano S, Kawano T, Kudo M, Makino K, Nakamura H, Kai Y et al (2009) Endoscopic endonasal transsphenoidal approach through the bilateral nostrils for pituitary adenomas. Neurol Med Chir (Tokyo) 49:1–7CrossRefGoogle Scholar
  13. 13.
    Cappabianca P, Cavallo LM, Colao A (2002) Del Basso De Caro M, Esposito F, Cirillo S, et al. Endoscopic endonasal transsphenoidal approach: outcome analysis of 100 consecutive procedures. Minim Invasive Neurosurg 45:193–200CrossRefPubMedGoogle Scholar
  14. 14.
    Carrau RL, Jho HD, Ko Y (1996) Transnasal-transsphenoidal endoscopic surgery of the pituitary gland. Laryngoscope 106:914–918CrossRefPubMedGoogle Scholar
  15. 15.
    Cusimano MD, Fenton RS (1996) The technique for endoscopic pituitary tumor removal. Neurosurg Focus 1:e1 (discussion 1p following e3)CrossRefPubMedGoogle Scholar
  16. 16.
    de Divitiis E, Cavallo LM, Esposito F, Stella L, Messina A (2007) Extended endoscopic transsphenoidal approach for tuberculum sellae meningiomas. Neurosurgery 61:229–237 (discussion 237–228)CrossRefPubMedGoogle Scholar
  17. 17.
    Gardner PA, Kassam AB, Snyderman CH, Carrau RL, Mintz AH, Grahovac S et al (2008) Outcomes following endoscopic, expanded endonasal resection of suprasellar craniopharyngiomas: a case series. J Neurosurg 109:6–16CrossRefPubMedGoogle Scholar
  18. 18.
    Kassam A, Carrau RL, Snyderman CH, Gardner P, Mintz A (2005) Evolution of reconstructive techniques following endoscopic expanded endonasal approaches. Neurosurg Focus 19:E8PubMedGoogle Scholar
  19. 19.
    Raymond J, Hardy J, Czepko R, Roy D (1997) Arterial injuries in transsphenoidal surgery for pituitary adenoma; the role of angiography and endovascular treatment. AJNR Am J Neuroradiol 18:655–665PubMedGoogle Scholar
  20. 20.
    Zanation AM, Snyderman CH, Carrau RL, Gardner PA, Prevedello DM, Kassam AB (2009) Endoscopic endonasal surgery for petrous apex lesions. Laryngoscope 119:19–25CrossRefPubMedGoogle Scholar
  21. 21.
    Castelnuova P, Locatelli D (2007) The endoscopic surgical technique: “two nostrils-four hands”. Endo-Press, TuttlingenGoogle Scholar
  22. 22.
    Fortes FS, Carrau RL, Snyderman CH, Prevedello D, Vescan A, Mintz A et al (2007) The posterior pedicle inferior turbinate flap: a new vascularized flap for skull base reconstruction. Laryngoscope 117:1329–1332CrossRefPubMedGoogle Scholar
  23. 23.
    Fortes FS, Carrau RL, Snyderman CH, Kassam A, Prevedello D, Vescan A et al (2007) Transpterygoid transposition of a temporoparietal fascia flap: a new method for skull base reconstruction after endoscopic expanded endonasal approaches. Laryngoscope 117:970–976CrossRefPubMedGoogle Scholar
  24. 24.
    Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH et al (2006) A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 116:1882–1886CrossRefPubMedGoogle Scholar
  25. 25.
    Cavallo LM, Prevedello DM, Solari D, Gardner PA, Esposito F, Snyderman CH et al (2009) Extended endoscopic endonasal transsphenoidal approach for residual or recurrent craniopharyngiomas. J Neurosurg 111:578–589CrossRefPubMedGoogle Scholar
  26. 26.
    Eskandari R, Amini A, Yonemura KS, Couldwell WT (2008) The use of the Olympus EndoArm for spinal and skull-based transsphenoidal neurosurgery. Minim Invasive Neurosurg 51:370–372CrossRefPubMedGoogle Scholar
  27. 27.
    Jane JA Jr, Starke RM, Elzoghby MA, Reames DL, Payne SC, Thorner MO et al (2011) Endoscopic transsphenoidal surgery for acromegaly: remission using modern criteria, complications, and predictors of outcome. J Clin Endocrinol Metab 96:2732–2740Google Scholar
  28. 28.
    Cappabianca P, Cavallo LM, Colao A, de Divitiis E (2002) Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg 97:293–298CrossRefPubMedGoogle Scholar
  29. 29.
    Charalampaki P, Ayyad A, Kockro RA, Perneczky A (2009) Surgical complications after endoscopic transsphenoidal pituitary surgery. J Clin Neurosci 16:786–789CrossRefPubMedGoogle Scholar
  30. 30.
    Choe JH, Lee KS, Jeun SS, Cho JH, Hong YK (2008) Endocrine outcome of endoscopic endonasal transsphenoidal surgery in functioning pituitary adenomas. J Korean Neurosurg Soc 44:151–155CrossRefPubMedGoogle Scholar
  31. 31.
    Dehdashti AR, Ganna A, Karabatsou K, Gentili F (2008) Pure endoscopic endonasal approach for pituitary adenomas: early surgical results in 200 patients and comparison with previous microsurgical series. Neurosurgery 62:1006–1015 (discussion 1015–1007)CrossRefPubMedGoogle Scholar
  32. 32.
    Frank G, Sciarretta V, Mazzatenta D, Farneti G, Modugno GC, Pasquini E (2005) Transsphenoidal endoscopic approach in the treatment of Rathke’s cleft cyst. Neurosurgery 56:124–128 (discussion 129)PubMedGoogle Scholar
  33. 33.
    Gondim JA, Almeida JP, de Albuquerque LA, Gomes E, Schops M, Ferraz T (2011) Pure endoscopic transsphenoidal surgery for treatment of acromegaly: results of 67 cases treated in a pituitary center. Neurosurg Focus 29:E7Google Scholar
  34. 34.
    Jho HD, Carrau RL (1997) Endoscopic endonasal transsphenoidal surgery: experience with 50 patients. J Neurosurg 87:44–51CrossRefPubMedGoogle Scholar
  35. 35.
    Rudnik A, Kos-Kudla B, Larysz D, Zawadzki T, Bazowski P (2007) Endoscopic transsphenoidal treatment of hormonally active pituitary adenomas. Neuro Endocrinol Lett 28:438–444PubMedGoogle Scholar
  36. 36.
    Rudnik A, Zawadzki T, Galuszka-Ignasiak B, Bazowski P, Duda I, Wojtacha M et al (2006) Endoscopic transsphenoidal treatment in recurrent and residual pituitary adenomas–first experience. Minim Invasive Neurosurg 49:10–14CrossRefPubMedGoogle Scholar
  37. 37.
    Shah S, Har-El G (2001) Diabetes insipidus after pituitary surgery: incidence after traditional versus endoscopic transsphenoidal approaches. Am J Rhinol 15:377–379PubMedGoogle Scholar
  38. 38.
    Ahmed S, Elsheikh M, Stratton IM, Page RC, Adams CB, Wass JA (1999) Outcome of transphenoidal surgery for acromegaly and its relationship to surgical experience. Clin Endocrinol (Oxf) 50:561–567CrossRefGoogle Scholar
  39. 39.
    Barker FG 2nd, Klibanski A, Swearingen B (2003) Transsphenoidal surgery for pituitary tumors in the United States, 1996–2000: mortality, morbidity, and the effects of hospital and surgeon volume. J Clin Endocrinol Metab 88:4709–4719CrossRefPubMedGoogle Scholar
  40. 40.
    Gittoes NJ, Sheppard MC, Johnson AP, Stewart PM (1999) Outcome of surgery for acromegaly—the experience of a dedicated pituitary surgeon. QJM 92:741–745CrossRefPubMedGoogle Scholar
  41. 41.
    Lissett CA, Peacey SR, Laing I, Tetlow L, Davis JR, Shalet SM (1998) The outcome of surgery for acromegaly: the need for a specialist pituitary surgeon for all types of growth hormone (GH) secreting adenoma. Clin Endocrinol (Oxf) 49:653–657CrossRefGoogle Scholar
  42. 42.
    Rees DA, Hanna FW, Davies JS, Mills RG, Vafidis J, Scanlon MF (2002) Long-term follow-up results of transsphenoidal surgery for Cushing’s disease in a single centre using strict criteria for remission. Clin Endocrinol (Oxf) 56:541–551CrossRefGoogle Scholar
  43. 43.
    Ciric I, Ragin A, Baumgartner C, Pierce D (1997) Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 40:225–236 (discussion 236–227)CrossRefPubMedGoogle Scholar
  44. 44.
    Cooke RS, Jones RA (1994) Experience with the direct transnasal transsphenoidal approach to the pituitary fossa. Br J Neurosurg 8:193–196CrossRefPubMedGoogle Scholar
  45. 45.
    De P, Rees DA, Davies N, John R, Neal J, Mills RG et al (2003) Transsphenoidal surgery for acromegaly in wales: results based on stringent criteria of remission. J Clin Endocrinol Metab 88:3567–3572CrossRefPubMedGoogle Scholar
  46. 46.
    D’Haens J, Van Rompaey K, Stadnik T, Haentjens P, Poppe K, Velkeniers B (2009) Fully endoscopic transsphenoidal surgery for functioning pituitary adenomas: a retrospective comparison with traditional transsphenoidal microsurgery in the same institution. Surg Neurol 72:336–340CrossRefPubMedGoogle Scholar
  47. 47.
    Koren I, Hadar T, Rappaport ZH, Yaniv E (1999) Endoscopic transnasal transsphenoidal microsurgery versus the sublabial approach for the treatment of pituitary tumors: endonasal complications. Laryngoscope 109:1838–1840CrossRefPubMedGoogle Scholar
  48. 48.
    Landolt AM, Zachmann M (1991) Results of transsphenoidal extirpation of craniopharyngiomas and Rathke’s cysts. Neurosurgery 28:410–415CrossRefPubMedGoogle Scholar
  49. 49.
    Laws ER, Vance ML, Thapar K (2000) Pituitary surgery for the management of acromegaly. Horm Res 53(Suppl 3):71–75CrossRefPubMedGoogle Scholar
  50. 50.
    Mampalam TJ, Tyrrell JB, Wilson CB (1988) Transsphenoidal microsurgery for Cushing disease. A report of 216 cases. Ann Intern Med 109:487–493CrossRefPubMedGoogle Scholar
  51. 51.
    Atkinson JL, Young WF Jr, Meyer FB, Davis DH, Nippoldt TB, Erickson D et al (2008) Sublabial transseptal vs transnasal combined endoscopic microsurgery in patients with Cushing disease and MRI-depicted microadenomas. Mayo Clin Proc 83:550–553PubMedGoogle Scholar
  52. 52.
    Harris PE, Afshar F, Coates P, Doniach I, Wass JA, Besser GM et al (1989) The effects of transsphenoidal surgery on endocrine function and visual fields in patients with functionless pituitary tumours. Q J Med 71:417–427PubMedGoogle Scholar
  53. 53.
    Kennedy DW, Cohn ES, Papel ID, Holliday MJ (1984) Transsphenoidal approach to the sella: the Johns Hopkins experience. Laryngoscope 94:1066–1074CrossRefPubMedGoogle Scholar
  54. 54.
    Ross DA, Wilson CB (1988) Results of transsphenoidal microsurgery for growth hormone-secreting pituitary adenoma in a series of 214 patients. J Neurosurg 68:854–867CrossRefPubMedGoogle Scholar
  55. 55.
    Wilson CB, Dempsey LC (1978) Transsphenoidal microsurgical removal of 250 pituitary adenomas. J Neurosurg 48:13–22CrossRefPubMedGoogle Scholar
  56. 56.
    Lasio G, Ferroli P, Felisati G, Broggi G (2002) Image-guided endoscopic transnasal removal of recurrent pituitary adenomas. Neurosurgery 51:132–136 (discussion 136–137)CrossRefPubMedGoogle Scholar
  57. 57.
    White DR, Sonnenburg RE, Ewend MG, Senior BA (2004) Safety of minimally invasive pituitary surgery (MIPS) compared with a traditional approach. Laryngoscope 114:1945–1948CrossRefPubMedGoogle Scholar
  58. 58.
    de Divitiis E, Cappabianca P, Cavallo LM, Esposito F, de Divitiis O, Messina A (2007) Extended endoscopic transsphenoidal approach for extrasellar craniopharyngiomas. Neurosurgery 61:219–227 (discussion 228)CrossRefPubMedGoogle Scholar
  59. 59.
    de Divitiis E, Cappabianca P, Gangemi M, Cavallo LM (2000) The role of the endoscopic transsphenoidal approach in pediatric neurosurgery. Childs Nerv Syst 16:692–696CrossRefPubMedGoogle Scholar
  60. 60.
    Laufer I, Anand VK, Schwartz TH (2007) Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. J Neurosurg 106:400–406CrossRefPubMedGoogle Scholar
  61. 61.
    Mamelak AN, King W, Mukherjee D (eds) (2011) Survery of surgical preferences for trasnssphenoidal surgery among members of the International Society of Pituitary Surgeons. International Society of Pituitary Surgeons Bi-Annual Meeting, 2010 October 9–10, NapaGoogle Scholar
  62. 62.
    Jarrahy R, Berci G, Shahinian HK (2000) Assessment of the efficacy of endoscopy in pituitary adenoma resection. Arch Otolaryngol Head Neck Surg 126:1487–1490CrossRefPubMedGoogle Scholar
  63. 63.
    Koc K, Anik I, Ozdamar D, Cabuk B, Keskin G, Ceylan S (2006) The learning curve in endoscopic pituitary surgery and our experience. Neurosurg Rev 29:298–305 (discussion 305)CrossRefPubMedGoogle Scholar
  64. 64.
    Leach P, Abou-Zeid AH, Kearney T, Davis J, Trainer PJ, Gnanalingham KK (2010) Endoscopic transsphenoidal pituitary surgery: evidence of an operative learning curve. Neurosurgery 67:1205–1212Google Scholar
  65. 65.
    Kassam AB, Mintz AH, Gardner PA, Horowitz MB, Carrau RL, Snyderman CH (2006) The expanded endonasal approach for an endoscopic transnasal clipping and aneurysmorrhaphy of a large vertebral artery aneurysm: technical case report. Neurosurgery 59:ONSE162–ONSE165CrossRefPubMedGoogle Scholar
  66. 66.
    Peter M, De Tribolet N (1995) Visual outcome after transsphenoidal surgery for pituitary adenomas. Br J Neurosurg 9:151–157CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Adam N. Mamelak
    • 1
  • John Carmichael
    • 2
  • Vivien H. Bonert
    • 2
  • Odelia Cooper
    • 2
  • Shlomo Melmed
    • 2
  1. 1.Department of NeurosurgeryCedars-Sinai Medical CenterLos AngelesUSA
  2. 2.Division of Endocrinology and MetabolismCedars-Sinai Medical CenterLos AngelesUSA

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