巨大垂体腺瘤的显微手术治疗

为提高巨大垂体腺瘤显微手术的疗效 ,回顾性分析 5 6例巨大垂体腺瘤患者的临床资料及治疗方法。依据肿瘤的生长方向及部位将 5 6例分为四型 ,据此分别采用经蝶、经额下、额下经蝶、扩大经蝶、扩大额下硬膜外、额下 -翼点等 10种入路进行显微手术。5 6例巨大垂体腺瘤全切 2 9例 ,近全切 2 0例 ,大部切除 7例。无死亡者。提示依据巨大垂体腺瘤的不同位置及生长方向选择适当的手术入路是提高全切率、降低死亡率及复发率的重要手段     

Complications of endoscopic surgery of the pituitary adenomas: analysis of 570 patients and review of the literature

Endoscopic transsphenoidal surgery is emerging as a minimally invasive and maximally effective procedure for pituitary adenomas. In this report we analyzed the complications in 624 procedures of endonasal transsphenoidal endoscopic surgery in the treatment of 570 patients with pituitary adenomas. The leading author (MB) operated pituitary adenomas via pure endoscopic endonasal transsphenoidal surgery between January 2006 and August 2011 at the Hacettepe University, Department of Neurosurgery in Ankara. Complications were assessed in 624 surgical procedures under five groups; rhinological, CSF leaks, infection, vascular and endocrinologic complications. We observed a total of 76 complications (12.1%). Rhinological complications occurred in 8 patients (1.3%): 4 epistaxis (0.6%) and 4 hyposmia (0.6%). Postoperative CSF leaks occurred in 8 patients (1.3%), and infectious complications occurred in 8 patients: 3 cases of sphenoidal sinusitis (0.4%), 5 cases of meningitis (0.8%). Only 1 case of internal carotid aneurysm rupture during the opening of sellar floor (0.16%) was observed. Endocrinologic complications occurred in 51 (8.1%) patients: Anterior pituitary deficiency in 12 (1.9%), transient diabetes insipidus (DI) in 29 (4.6%), permanent DI in 3 (0.4%) and inappropriate antidiuretic hormone secretion syndrome occurred in 7 (1.1%). There was no mortality directly related to the surgical procedure. The complication rates observed in our study suggests that the endoscopic pituitary surgery is at least as safe as microscopic transphenoidal surgery. These rates were obtained with due experience and well-coordinated teamwork. To further improve these rates, new technological developments will be helpful.     

Transcranial surgery for pituitary adenomas

Following a century of evolution and refinements in standard surgical techniques, the vast majority of operations for pituitary adenoma to date are performed utilizing transsphenoidal approaches. From current large series one obtains the impression that certainly less than 10% of these tumors require craniotomies. However, still several tumors, which’s volume is mainly localized outside of the sella require transcranial approaches, of which the pterional and subfrontal routes are the most widely used. The goal of surgical treatment is rapid eradication of the tumor mass, decompression of visual pathways and elimination of hormonal oversecretion whilst preserving the normal gland and avoiding potential surgical complications. Even with microsurgical techniques and standardized approaches, there is still some mortality associated with transcranial approaches and morbidity is undoubtly higher than with transsphenoidal operations. However, a selection bias must be considered, which shifts tumors with a larger size, less favourable prognosis and higher complication rate into the transcranial series. Moreover, with extended transsphenoidal approaches, lesions have become accessible for transsphenoidal surgery, which previously have been considered as contraindications. In this article current indications and limitations for transcranial surgery of pituitary adenomas, the preoperative workup, surgical techniques, results, and complications are briefly reviewed.     

Hypophysen- und Nebennierenoperationen

Laparoscopic adrenalectomy and transsphenoidal pituitary surgery are currently established as the surgical procedures of choice with a low complication rate. Beyond potential surgical complications, one has to consider endocrine sequelae such as adrenal insufficiency and hypopituitarism. Without adequate endocrine treatment patients are prone to develop potentially lethal complications such as Addisonian crises or pituitary coma. Therefore, all patients should be seen by an endocrinologist before and after surgery. Patients with bilateral adrenalectomy require lifelong substitution of glucocorticoids and mineralocorticoids. Cushing's syndrome patients with unilateral adrenalectomy need temporary substitution. After pituitary surgery, all patients require functional assessment of their pituitary function, and, if necessary, adequate replacement therapy.     

Endoscopic pituitary surgery

Pituitary surgery is a continuous evolving speciality of the neurosurgeons’ armamentarium, which requires precise anatomical knowledge, technical skills and integrated appreciation of the pituitary pathophysiology. What we consider “pure” endoscopic transsphenoidal surgery is a procedure performed through the nose and the sphenoid bone, with the endoscope alone throughout the whole approach to visualize the surgical target area and without the use of any transsphenoidal retractor. It offers some advantages due to the endoscope itself: a superior close-up view of the relevant anatomy and an enlarged working angle are provided with an increased panoramic vision inside the surgical area. Concerning results in terms of mass removal, relief of clinical symptoms, cure of the underlying disease and complication rate, they are, at least, similar to those reported in the major microsurgical series, but patient compliance is by far better. Furthermore transsphenoidal endoscopy brings advantages to the patient (less nasal traumatism, no nasal packing, less post-op pain and usually quick recovery), to the surgeon (wider and closer view of the surgical target area, increase of the scientific activity as from the peer-reviewed literature on the topic in the last 10 years, smoothing of interdisciplinary cooperation), to the institution (shorter post-op hospital stay, increase of the case load). Besides, further progress and technological advance are expected from the close cooperation between different technologies and industries. Continuing works in such field of “minimalism” will offer further possibilities to provide the surgeon with even more effectiveness and safety, and, on the other hand, the patient with improvement of results.     

Sphenoid sinus pyocele after transsphenoidal approach for pituitary adenoma

Transsphenoidal pituitary adenoma surgery is related to a low morbidity rate. The complications that can occur are classified as intra- and extracranial. The aim of the study is to discuss one group of these complications involving the sphenoid sinus: mucocele and its possible transformation into pyocele. We evaluate clinical presentation, management strategy and the outcome after long-term follow-up presenting an explicative case and a review of the literature. A patient presented to our outpatient clinic 8?months after transsphenoidal surgery for selective removal of a pituitary adenoma because of an acute onset of frontal headache during an airplane travel, fever and pulsating sensation in left eye and ear. MRI revealed a contrast-enhancing lesion in the left inferior portion of the sphenoid sinus. An endonasal endoscopic revision of the sphenoid sinus was performed. After opening of the scar to enter in the left sinus a pyocele was found and treated with drainage and marsupialisation. Development of sphenoid sinus pyocele is an extremely rare postoperative complication of transsphenoidal surgery. This lesion should be taken in consideration in patients presenting with retroorbital headache of acute onset and fever after pituitary surgery. Diagnosis can be suspected on the MRI studies and confirmed by a targeted flexible endoscope examination. Endoscopic drainage with wide opening of the sphenoid sinus and marsupialisation is the treatment of choice to avoid recurrences.     

Endoscopic Pituitary Surgery

Endoscopy has been adopted for transsphenoidal pituitary surgery. A rigid rod-lens endoscope, 4-mm in diameter and 17-cm in length, is used in replacement of the operating microscope. This endoscopic technique utilizes the patient's natural nasal air passage as a surgical corridor without a sublabial or nasal mucosal incision. The use of a transsphenoidal retractor is not necessary. Postoperative nasal packing is not required. The average length of a patient's hospital stay is overnight. Postoperative discomfort is minimal. An angled lens endoscope enables the surgeon to operate on tumors located in the suprasellar region under direct visualization. When the adoption of endoscopy in transsphenoidal pituitary surgery had demonstrated obvious advantages over conventional microscopic surgery, the use of this endoscopic endonasal technique has been expanded to include other skull base lesions at the anterior fossa skull base, cavernous sinus, clivus and clival posterior fossa. In this chapter, the author describes the evolution of this endoscopic transsphenoidal surgery, the pertinent sinonasal anatomy related to transsphenoidal endoscopy, the details of endoscopic endonasal transsphenoidal pituitary surgery, surgical approaches to the other skull base lesions, surgical results, and potential complications and their avoidance.     

Endoscopic endonasal transsphenoidal surgery: surgical results of 228 pituitary adenomas treated in a pituitary center

Pituitary tumors are challenging tumors in the sellar region. Surgical approaches to the pituitary have undergone numerous refinements over the last 100 years. The introduction of the endoscope have revolutionized pituitary surgery. The aim of this study is to report the results of a consecutive series of patients undergoing pituitary surgery using a pure endoscopic endonasal approach and to evaluate the efficacy and safety of this procedure. We reviewed the data of 228 consecutive patients who underwent endonasal transsphenoidal adenoma removal over an 10-year period. Pre- and post-operative hormonal status (at least 3 months after surgery) were analyzed and compared with clinical parameters presented by the patients. Tumor removal rate, endocrinological outcomes, and complications were retrospectively assessed in 228 patients with pituitary adenomas who underwent 251 procedures between December 1998 and December 2007. There were 93 nonfunctioning adenomas, 58 growth hormone-secreting, 41 prolactin-secreting, 28 adrenocorticotropin hormone secreting, 7 FSH-LH secreting and 1 thyroid-stimulating hormone-secreting adenomas. Gross total removal was achieved in 79.3% of the cases after a median follow-up of 61.5 months. The remission results for patients with nonfunctioning adenomas was 83% and for functioning adenomas were 76.3% (70.6% for GH hormone-secreting, 85.3% for prolactin hormone-secreting, 71.4% for ACTH hormone-secreting, 85.7% for FSH-LH hormone-secreting and 100% for TSH hormone-secreting), with no recurrence at the time of the last follow-up. Post-operative complications were present in 35 (13.9%) cases. The most frequent complications were temporary and permanent diabetes insipidus (six and two cases, respectively), syndrome of inappropriate antidiuretic hormone secretion (two cases) and CSF leaks (eight cases). There was no death related to the procedure in this series. The endoscopic endonasal approach for resection of pituitary adenomas, provides acceptable results representing a safe alternative procedure to the microscopic approach. This less invasive method, associated with a small number of complications, provides excellent tumor removal rates and represents an important tool for the achievement of good results in the pituitary surgery, mainly for the complete removal of large adenomas.     

Transsphenoidal pituitary surgery via the endoscopic technique: results in 35 consecutive patients with Cushing's disease

OBJECTIVE AND DESIGN: The endoscopic technique has been recently introduced in the field of transsphenoidal pituitary surgery. This technique allows inspection of sellar, supra- and parasellar structures and removal of the tumor under direct visualization, is minimally traumatic and permits easier reoperations. This is the first report on the results of endoscopic surgery for patients with Cushing's disease. Our aim was to retrospectively analyze the results of pituitary surgery in 35 consecutive patients with Cushing's disease operated in our hospital after the introduction of the endoscopic technique (1998-2004). METHODS: Remission was defined as suppression of plasma cortisol (< or =50 nmol/L) after 1 mg dexamethasone overnight determined in the first 3 months after surgery and disappearance of clinical signs and symptoms of hypercortisolism. The patients were followed for an average of 27 months (range 4 to 81 months, median 20 months). RESULTS: Pituitary MRI showed a macroadenoma in 6 patients, a microadenoma in 17 patients and no adenoma in 12 patients. After the initial surgery 27 patients (77%) were in remission. None of the patients had a relapse during follow-up. In the remaining 8 patients hypercortisolemia persisted after surgery. Three of them had a second endoscopic pituitary surgery resulting in remission in two patients. In one patient a second endoscopic pituitary surgery will soon follow. The remaining four patients were treated with radiotherapy postoperatively. Two of them were at the time of data collection in remission. One patient from the remission group had a serious epistaxis and three patients had cerebrospinal fluid leakage, one requiring an external lumbar drain, shortly after surgery. No complications were recorded in the failure group. Postoperatively 34% of all patients required substitution with levothyroxine, 40% required substitution with glucocorticoids, 17% received estrogens or testosterone and 6% still required desmopressin. CONCLUSIONS: Endoscopic transsphenoidal pituitary surgery resulted in our series of patients with Cushings disease in an excellent postoperative remission rate. A randomized clinical trial, comparing endoscopic and conventional pituitary surgery in patients with Cushings disease, is needed to determine the pros and cons of both techniques.     

Endoscopic endonasal approach for pituitary adenoma: surgical complications in 301 patients

The authors investigate the complications of transnasal transsphenoidal endoscopic surgery in the treatment of 301 patients with pituitary adenomas. A retrospective analysis of complications in 301 patients submitted to transsphenoidal transnasal endoscopic surgery at the General Hospital of Fortaleza, Brazil between January 1998 and December 2009. The complications were divided in two groups: anatomical (oronasofacial, sphenoid sinus, intrasellar, suprasellar and parasellar) and endocrinological complications (anterior and posterior pituitary dysfunctions). We observed a total of 81 complications (26.9%) in our series. Anatomical complications occurred in 8.97% (27 cases): 8 CSF postoperative leaks (2.6%), 6 cases (1.9%) of delayed nasal bleeding, 5 cases (1.6%) of sphenoidal sinusitis, 3 cases (0.9%) of carotid artery lesion, 2 cases of meningitis (0.6%) and one case (0.3%) of each of the uncommon following complications: intrasella-suprasella hematoma, pontine hematoma and chiasmaplexy. Endocrinological complications occurred in 17.9% (54 cases): additional postoperative anterior lobe insufficiency in 35 cases (11.6%), and postoperative diabetes insipidus in 19 cases (6.3%). In our series, 3 cases of deaths (not directly related to the procedure) were also observed. Endoscopic transsphenoidal surgery represents an effective option for the treatment of patients with pituitary tumor. Complications still occur and must be reduced as much as possible. Successful endoscopic pituitary surgery requires extensive training in the use of an endoscope and careful planning of the surgery. Additional improvement can be expected with greater experience and new technical developments.     

Endoscopic Decompression of Tension Pneumosella Following Transsphenoidal Pituitary Tumor Resection

Objective and importance: Tension pneumosella is an extremely rare complication of transsphenoidal surgery, having been reported only three times previously. Patients who develop this expanding pneumocele confined to the sella present with visual field changes consistent with optic chiasm compression. If left untreated, this condition can lead to permanent visual deficits. We report a case of tension pneumosella after transsphenoidal resection of a benign pituitary adenoma that was successfully treated endoscopically. Clinical presentation: Six months after transsphenoidal resection of a pituitary tumor, a 70-year-old man presented with subjective vision loss and was found on formal testing to have bitemporal hemianopsia. A diagnosis of tension pneumosella was made with a head CT after tumor recurrence was ruled out with MRI. The expanding pneumocele developed after vigorous nose blowing in the setting of a surgical sellar floor defect and an intact diaphragma sellae. Intervention: The pneumocele was endoscopically decompressed using a transnasal approach guided by frameless stereotaxy. An immediate decrease in the amount of air was confirmed with intraoperative fluoroscopy. The defect was subsequently repaired with a hemostatic agent and fibrin glue. The patient rapidly recovered his vision and went home on postoperative day one with no further visual complications. Conclusion: Tension pneumosella should be considered as a possible diagnosis in patients presenting with subacute visual field deficits after transsphenoidal pituitary region surgery. Endoscopy may play a valuable role in the diagnosis and management of this rare phenomenon, as well as other more common complications of transsphenoidal surgery.     

Treatment of pituitary tumors: surgery

Following a century of technical developments and refinements, a variety of standard operation techniques to date are available for the surgical treatment of pituitary tumors. The vast majority of the lesions can be dealt with satisfactorily utilizing transsphenoidal approaches. The goal of surgical treatment is rapid eradication of the tumor mass, decompression of visual pathways, and elimination of hormonal oversecretion while preserving the normal gland and avoiding potential surgical complications. The tumor's size, extension, and configuration and the magnitude of hormonal oversecretion, are the essential factors that decide whether all the goals can be reached. Another important factor is the individual skill and experience of the surgeon. Still, several lesions that are mainly developed outside of the sella require transcranial approaches, of which the pterional and subfrontal routes are the most widely used. With microsurgical techniques and standard approaches, mortality is far below 1% and morbidity is remarkably low. The most favorable surgical results are obtained with microadenomas, which in the MR image are depicted as distinct low intensity lesions. Only recently has the recovery of pituitary function following surgery been convincingly demonstrated. With the extended transsphenoidal approaches, lesions become accessible that previously have been considered contraindications for transsphenoidal surgery. The introduction of new technical gadgets such as neuronavigation, endoscopy, and intraoperative imaging open new avenues and, even more, widen the spectrum of accessible lesions. Indications for surgery, the preoperative workup, surgical techniques, results, limitations, and new technical developments are briefly reviewed in this article.     

Metastatic tumors of the sella turcica masquerading as primary pituitary tumors

Tumors metastatic to the pituitary gland are uncommon, but may mimic a typical pituitary adenoma and are an important part of the differential diagnosis of sellar mass lesions. Pituitary metastases were treated by transsphenoidal microsurgical removal in 14 patients. Most tumors appeared in men in the sixth and seventh decades of life. Half of the patients presented with visual loss, 6 had anterior hypopituitarism, and 4 had diabetes insipidus. Primary cancer had been diagnosed and treated previously in 5 patients. In the remaining 9 patients, the transsphenoidal operation provided the initial diagnosis of cancer, and primary lesions subsequently were detected in all but 2. Transsphenoidal surgery also provided satisfactory decompression of the mass effect related to the tumors, improving the presenting symptoms in the majority of patients, and the surgery was free of mortality or serious complications.     

Surgical management of pituicytomas: case series and comprehensive literature review

Objective

Pituicytomas are rare neoplasms that typically present as solid, noninfiltrative tumors occupying the sella and/or suprasellar space for which there is no consensus on optimal surgical management. We aimed to define a preferred surgical strategy for these tumors based on our clinical experience and comprehensive review of the world literature.

Design

Case series and review of the literature.

Methods

We documented the clinical, radiographic, and surgical findings of three patients with pituicytoma treated at our institution, as well as complications and long-term outcomes. A comprehensive review of the medical literature identified all cases of pituicytoma for which data regarding surgical approach, outcome and complications could be extracted. We compared our results with published data.

Results

All three cases at our institution achieved gross total removal. Two patients underwent an expanded endoscopic endonasal transsphenoidal and transplanum (EETS-TP) approach, while one tumor was removed via craniotomy. Post-operatively all patients developed pan-hypopitutarism. The patient undergoing craniotomy suffered profound visual loss but no other neurological complications were noted. A literature review identified 67 reported cases of pituicytoma. Surgical data was available in 60 cases. Surgical approach was documented in 57 patients. Sixty-three surgeries were performed in which approach and extent of resection was available. Gross total removal was obtained in 33 % of craniotomies, 42 % of transsphenoidal procedures, and 100 % of expanded transsphenoidal procedures. Neurological complications including visual loss, hemiparesis and cranial nerve palsies were reported after craniotomy, but not after transsphenoidal approaches. Overall EETS-TP approaches were associated with the highest rate of gross total removal and no visual or neurological complications.

Conclusions

EETS-TP surgery is the preferred strategy for surgical removal of pituicytoma. EETS-TP and transsphenoidal approaches are associated with higher rates of gross total removal and lower rates of neurological complications than craniotomy. Gross total removal should be the intended goal of surgery.     

Repeated transsphenoidal pituitary surgery (TS) via the endoscopic technique: a good therapeutic option for recurrent or persistent Cushing's disease (CD)

Background  No data on results of repeated transsphenoidal surgery via the endoscopic technique for patients with persistent or recurrent Cushing's disease are available.
Design and patients  We retrospectively evaluated the remission rates and complications of repeated transsphenoidal surgery via the endoscopic technique in 14 patients with persistent ( N  = 6) or recurrent ( N  = 8) Cushing's disease treated in our centre between 1999 and 2007.
Main outcomes  Remission was defined as the disappearance of symptoms of hypercortisolism with basal plasma cortisol level ≤ 50 nmol/l 24–48 h after glucocorticoid withdrawal and/or suppression of plasma cortisol level ≤ 50 nmol/l after 1 mg dexamethasone overnight within the first 3 months after transsphenoidal surgery.
Results  With repeated endoscopic transsphenoidal surgery a remission rate of 10/14 (71%) was achieved. No patient had a relapse during a median follow-up of 24 months. Cerebrospinal fluid leakage was the most frequent complication (6 patients) and 11 patients required hormonal substitution after surgery. The success of repeated transsphenoidal surgery could not be predicted by visualization of an adenoma on MRI before first or second surgery, histopathological confirmation of an ACTH secreting adenoma after first or second surgery, treatment with cortisol lowering agents before first or second surgery, the operation technique used during the first surgery, persistent vs. recurrent disease after the first surgery, age, gender and interval between the two surgeries.
Conclusion  Repeated transsphenoidal surgery via the endoscopic technique is a good treatment option for selected patients with recurrent or persistent Cushing's disease following primary pituitary surgery.     

Progress in transsphenoidal hypophysectomy for treatment of pituitary-dependent hyperadrenocorticism in dogs and cats

Cushing's disease or pituitary-dependent hyperadrenocorticism (PDH) is common in dogs and rare in cats. PDH is caused by a pituitary tumor producing adrenocorticotropin (ACTH). Pituitary imaging with computed tomography (CT) or magnetic resonance imaging (MRI) is required to assess the size and location of the pituitary adenoma in relation to the surgical landmarks. In a specialized veterinary institution, microsurgical transsphenoidal hypophysectomy has proven to be a safe and effective treatment for dogs (n=84) and cats (n=7) with Cushing's disease. Pituitary surgery requires a team approach and the neurosurgeon performing hypophysectomies must master a learning curve. The surgical results compared favorably with those for dogs with PDH treated medically with mitotane at the same institution. The recurrence rate after initially successful surgery increases with longer follow up-times. Pituitary function testing in 39 dogs with PDH treated with hypophysectomy revealed that, much more so than the other adenohypophyseal cell types, residual corticotropes present in the sella turcica after surgery are functional. Such normal ACTH secreting cells may maintain normocorticism whereas residual adenoma cells may lead to mild recurrence after relatively long periods of remission. Microsurgical transsphenoidal hypophysectomy is an effective treatment for canine and feline Cushing's disease.     

An endoscopic modification of the simultaneous ‘above and below’ approach to large pituitary adenomas

Surgical resections of large-to-giant pituitary adenomas (PA) are technically challenging procedures. Tumors with a fibrous consistency or ??hour-glass?? configurations are particularly difficult to remove completely and safely through the transsphenoidal route alone. Although the transcranial approach can facilitate the removal of a large suprasellar mass, it may be associated with significant bleeding within the intradural space. A simultaneous microscopic transcranial and transsphenoidal approach has been described as an alternative surgical strategy. We have further modified this ??above and below?? approach by adopting endoscopic techniques for the transsphenoidal part of the procedure. This modified approach has the advantages of requiring only one operating microscope, and permitting freer maneuvers and easier orientation for both surgical teams. We present two patients successfully treated with this approach. Complete tumor removal was achieved and both patients achieved satisfactory functional recovery.     

Pituitary tumor apoplexy in patients with Cushing’s disease: endocrinologic and visual outcomes after transsphenoidal surgery

Pituitary apoplexy in patients with adrenocorticotropic hormone (ACTH) producing tumors is a rare occurrence. We report four patients with Cushing's disease harboring ACTH-secreting macroadenomas who presented with pituitary apoplexy. We report the endocrinologic and visual outcomes of these patients after emergent transsphenoidal surgery. A retrospective chart review was performed in 4 patients who presented with pituitary apoplexy from hemorrhage into an ACTH-secreting pituitary adenoma. The patient charts were reviewed for clinical presentation, neuroimaging findings, intraoperative surgical findings, pathologic findings, and postoperative endocrinologic and visual outcomes. All patients presented with acute headaches, nausea, vomiting, and visual loss from optic compression. MR imaging demonstrated a hemorrhagic macroadenoma that was confirmed at surgery. All patients underwent emergent transsphenoidal decompression (within 24 h of presentation). One of these underwent an additional craniotomy to resect residual tumor. Postoperatively, all patients showed significant improvement in visual acuity and visual fields with biochemical remission confirmed on laboratory testing. Significant weight loss as well as resolution of diabetes and hypertension was noted in all cases. All four patients remained in biochemical remission at their most recent follow-up visit (mean 40 months, range: 24-72 months). Excellent endocrine and visual outcomes can be achieved after emergent transsphenoidal surgery in patients with Cushing's disease presenting with pituitary apoplexy. Although the cure rates of non-apoplectic ACTH macroadenomas are generally poor, higher rates of remission can be achieved in cases of pituitary apoplexy. This may be partly due to the effects of tumor infarction.     

Adrenocorticotropin levels do not change during early recovery of transsphenoidal surgery for ACTH-secreting pituitary tumors

In patients with ACTH-secreting pituitary tumor the peri-tumoral normal corticotrophs were supposed to be suppressed by cronic hypercortisolemia since frequently they develop transient secondary adrenal insufficiency after pituitary tumor resection and during early postoperative days. We evaluated the ACTH dynamics during transsphenoidal surgery in 16 patients with ACTH-secreting pituitary tumors (6 cured by surgery, 8 not cured Cushing's disease patients and 1 cured by surgery and 1 not cured Nelson's syndrome patients) and tested the hypothesis that in these patients, ACTH secretion from the peri-tumoral normal corticotrophs is inhibited and hence removal of the entire tumor should result in subtle postoperative reduction in plasma ACTH. Blood samples for ACTH determination were obtained from 14 Cushing's disease patients immediately before pituitary gland manipulation and 10, 30, 60, 90, 120, 150 and 300 min after pituitary tumor resection and on postoperative day one. In Nelson's syndrome patients the blood sample was obtained only after tumor removal. All patients received intravenous hydrocortisone during surgery and on the first postoperative day. Patients were considered cured by surgery if they presented adrenal insufficiency after hydrocortisone withdrawal. Mechanical pituitary manipulation induced increase in ACTH level. In all 14 Cushing's disease patients (cured and not cured), mean plasma ACTH levels were significantly greater 10 min after pituitary tumor resection (54.4+/-12.8 pmol/l) than in the premanipulation period (ACTH=26.3+/-5.3 pmol/l) (p=0.005). In Cushing's disease patients, the ACTH levels did not change significantly until 300 min after pituitary tumor resection either in those 6 patients cured by surgery (at 10 min after pituitary tumor resection ACTH was 54.4+/-12.8 pmol/l for all 14 Cushing's disease patients and at 300 min after tumor removal ACTH was 39.0+/-12.6 pmol/l for cured and 41.3+/-15.7 pmol/l for not cured Cushing's disease patients). The ACTH level also persisted high until 300 min after complete pituitary tumor resection in one cured patient with Nelson's syndrome. ACTH level does not change in the early recovery period after ACTH-secreting pituitary tumor, even in those cured patients, and probably peri-tumoral normal corticotrophs are not completely suppressed by cronic hypercortisolemia (and acute glucocorticoid administration) when these patients are under intense stress, like transsphenoidal surgery. Mechanical pituitary manipulation may induce ACTH release in patients with ACTH-secreting pituitary tumors but probably does not interfere in the maintenance of high ACTH-levels during the early postoperative period, since ACTH half-life is only 8-15 min. In patients with ACTH-secreting pituitary tumors, the behavior of the human hypothalamic-pituitary-adrenal system during transsphenoidal surgery does not conform to the specifications of a negative feedback mechanism.     

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

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.