Abstract
Background
Surgery is currently the first-line treatment of Cushing’s disease. Surgery for Cushing’s patients requires technical specificity, especially if no adenoma is identified on dedicated preoperative pituitary MRI.
Method
From 2006 to 2020, 683 patients with Cushing’s disease were operated on with a mononostril endoscopic endonasal approach by the same two senior neurosurgeons. Here, we report the particularities of this challenging surgery.
Conclusion
A rigorous and planned surgical strategy avoids the pitfalls of Cushing’s disease surgery and leads to a high rate of endocrine remission.
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References
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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
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Key Points
1. Current guidelines still consider pituitary surgery as the first-line treatment of Cushing’s disease.
2. No pituitary surgery should be decided until Cushing’s disease has been assessed by a referent endocrinologist.
3. A venous bleeding is usually observed, explained by the specific mucosal fragility and increased intracranial pressure due to obesity.
4. Optimal positioning with a more sitting position and anaesthetic protocol are crucial to limit mucosal venous bleeding.
5. The sphenoid rostrum is the most consistent median anatomical landmark.
6. In conchal-type sphenoid sinus, we recommend a centrifugal drilling of the sellar floor under neuronavigation.
7. Sellar and dural opening should expose the entire pituitary gland.
8. In case of an obvious lateralization on preoperative inferior petrosal or cavernous sinus samplings, the pituitary exploration starts on the suspect side.
9. Well-circumscribed adenomas are removed with a selective adenomectomy, poorly circumscribed adenomas are removed with an enlarged adenomectomy.
10. If no adenoma is identified, a partial anterior and posterior hypophysectomy including the inferior third of the pituitary gland is performed.
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Baussart, B., Gaillard, S. Pituitary surgery for Cushing’s disease. Acta Neurochir 163, 3155–3159 (2021). https://doi.org/10.1007/s00701-021-04995-w
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DOI: https://doi.org/10.1007/s00701-021-04995-w