Endoscopic Transsphenoidal Pituitary Surgery: Evidence of an Operative Learning Curve

Leach, Philip; AbouZeid, Amr Abdelhamid; Kearney, Tara; Davis, John R.; Trainer, Peter J; Gnanalingham, Kanna

doi:10.1227/neu.0b013e3181ef25c5

Cited by 136 publications

(118 citation statements)

References 36 publications

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“…8, 25 The current literature focuses on 2 major techniques for the endoscopic transnasal approach to the sella, with or without use of a speculum. With help of a nasal speculum, which is used to dilate the working channel, the neurosurgeon reaches the sphenoid sinus through 1 nostril, the mononostril or monoportal approach.…”

Section: Discussionmentioning

confidence: 99%

Binostril versus mononostril approaches in endoscopic transsphenoidal pituitary surgery: clinical evaluation and cadaver study

Conrad

Ayyad

Wüster³

et al. 2016

JNS

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S urgical approaches to the pituitary gland have undergone numerous refinements over the last 100 years. Successful application of the transseptal transsphenoidal approach to the pituitary gland was first described by Hermann Schloffer in 1906. This procedure became the most commonly used approach for resection of pituitary adenomas and is associated with a low rate of morbidity.29 In 1910, Hirsch described a direct endonasal approach to the sphenoid sinus and to the sella, but this technique included resection of the middle turbinate and parts of the nasal septum.19 Halstead published the sublabial gingival approach in the same year.17 In the 1960s and after introduction of the operating microscope, Hardy combined lateral fluoroscopy with microsurgical techniques. This significantly improved magnification and illumination, reduced the risk of brain injury, und increased abbreviatioNs ACTH = adrenocorticotrophic hormone; ENT = ear, nose, and throat; FSH = follicle-stimulating hormone; GH = growth hormone; IGF-1 = insulin-like growth factor-1; LH = luteinizing hormone; TSH = thyroid-stimulating hormone. obJective Over the past 2 decades, endoscopy has become an integral part of the surgical repertoire for skull base procedures. The present clinical evaluation and cadaver study compare binostril and mononostril endoscopic transnasal approaches and the surgical techniques involved. methods Forty patients with pituitary adenomas were treated with either binostril or mononostril endoscopic surgery. Neurosurgical, endocrinological, ophthalmological, and neuroradiological examinations were performed. Ten cadaver specimens were prepared, and surgical aspects of the preparation and neuroradiological examination were documented. results In the clinical evaluation, 0° optics were optimal in the nasal and sphenoidal phase of surgery for both techniques. For detection of tumor remnants, 30° optics were superior. The binostril approach was significantly more time consuming than the mononostril technique. The nasal retractor limited maneuverability of instruments during mononostril approaches in 5 of 20 patients. Endocrinological pituitary function, control of excessive hormone secretion, ophthalmological outcome, residual tumor, and rates of adverse events, such as CSF leaks and diabetes insipidus, were similar in both groups. In the cadaver study, there was no significant difference in the time required for dissection via the binostril or mononostril technique. The panoramic view was superior in the binostril group; this was due to the possibility of wider opening of the sella in the craniocaudal and horizontal directions, but the need for removal of more of the nasal septum was disadvantageous. coNclusioNs Because of maneuverability of instruments and a wider view in the sphenoid sinus, the binostril technique is superior for resection of large tumors with parasellar and suprasellar expansion and tumors requiring extended approaches. The mononostril technique is preferable for tumors with limited extension in the intra- and...

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Section: Discussionmentioning

confidence: 99%

Binostril versus mononostril approaches in endoscopic transsphenoidal pituitary surgery: clinical evaluation and cadaver study

Conrad

Ayyad

Wüster³

et al. 2016

JNS

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“…Sonnenburg et al evaluated their results with pi- 30 Another study demonstrated significant improvement in visual outcome and operating time after 50 endoscopic endonasal pituitary cases. 18 It would seem self-evident that there would be a learning curve in expanded endonasal cranial base procedures in which the depth of surgical field is increased and the lesions are more intimately associated with critical neurovascular structures. 31,32 However, there is a paucity of evidence to demonstrate this learning curve and provide appropriate recommendations.…”

Section: Learning Curve In Craniopharyngioma Surgerymentioning

confidence: 99%

“…In fact, very little published documentation exists regarding the learning curve associated with endonasal cranial base cases in general. 17,18,24,30,33 The purpose of the present study was to determine if, and to what extent, a learning curve exists for the endoscopic transnasal resection of craniopharyngiomas.…”

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confidence: 99%

The learning curve in endoscopic endonasal resection of craniopharyngiomas

Kshettry

Do²,

Elshazly

et al. 2016

FOC

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OBJECTIVE There is a paucity of literature regarding the learning curve associated with performing endoscopic endonasal cranial base surgery. The purpose of this study was to determine to what extent a learning curve might exist for endoscopic endonasal resection in cases of craniopharyngiomas. METHODS A retrospective review was performed for all endoscopic endonasal craniopharyngioma resections performed at Thomas Jefferson University from 2005 to 2015. To assess for a learning curve effect, patients were divided into an early cohort (2005–2009, n = 20) and a late cohort (2010–2015, n = 23). Preoperative demographics, clinical presentation, imaging characteristics, extent of resection, complications, tumor control, and visual and endocrine outcomes were obtained. Categorical variables and continuous variables were compared using a 2-sided Fisher's exact test and t-test, respectively. RESULTS Only the index operation performed at the authors' institution was included. There were no statistically significant differences between early and late cohorts in terms of patient age, sex, presenting symptoms, history of surgical or radiation treatment, tumor size or consistency, hypothalamic involvement, or histological subtype. The rate of gross-total resection (GTR) increased over time from 20% to 65% (p = 0.005), and the rate of subtotal resection decreased over time from 40% to 13% (p = 0.078). Major neurological complications, including new hydrocephalus, meningitis, carotid artery injury, or stroke, occurred in 6 patients (15%) (8 complications) in the early cohort compared with only 1 (4%) in the late cohort (p = 0.037). CSF leak decreased from 40% to 4% (p = 0.007). Discharge to home increased from 64% to 95% (p = 0.024). Visual improvement was high in both cohorts (88% [early cohort] and 81% [late cohort]). Rate of postoperative panhypopituitarism and permanent diabetes insipidus both increased from 50% to 91% (p = 0.005) and 32% to 78% (p = 0.004), which correlated with a significant increase in intentional stalk sacrifice in the late cohort (from 0% to 70%, p < 0.001). CONCLUSIONS High rates of near- or total resection and visual improvement can be achieved using an endoscopic endonasal approach for craniopharyngiomas. However, the authors did find evidence for a learning curve. After 20 cases, they found a significant decrease in major neurological complications and significant increases in the rates of GTR rate and discharge to home. Although there was a large decrease in the rate of postoperative CSF leak over time, this was largely attributable to the inclusion of very early cases prior to the routine use of vascularized nasoseptal flaps. There was a significant increase in new panhypopituitarism and diabetes insipidus, which is attributable to increase rates of intentional stalk sacrifice.

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“…15 Specifically, nasal preparation was performed with topical application of preoperative decongestants (cophenylcaine, Aurum Ltd.) into both nostrils. No antiseptic wash or injection of vasoconstrictors was used.…”

Section: Operative Techniquementioning

confidence: 99%

Nasal symptoms following endoscopic transsphenoidal pituitary surgery: assessment using the General Nasal Patient Inventory

Wang¹,

Srirathan²,

Tirr³

et al. 2011

FOC

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Object The endoscopic approach for pituitary tumors is a recent innovation and is said to reduce the nasal trauma associated with transnasal transsphenoidal surgery. The authors assessed the temporal changes in the rhinological symptoms following endoscopic transsphenoidal surgery for pituitary lesions, using the General Nasal Patient Inventory (GNPI). Methods The GNPI was administered to 88 consecutive patients undergoing endoscopic transsphenoidal surgery at 3 time points (presurgery, 3–6 months postsurgery, and at final follow-up). The total GNPI score and the scores for the individual GNPI questions were calculated and differences between groups were assessed once before surgery, several months after surgery, and at final follow-up. Results Of a maximum possible score of 135, the mean GNPI score at 3–6 months postsurgery was only 12.9 ± 12 and was not significantly different from the preoperative score (10.4 ± 13) or final follow-up score (10.3 ± 10). Patients with functioning tumors had higher GNPI scores than those with nonfunctioning tumors for each of these time points (p < 0.05). Individually, a mild increase in symptom severity was seen for symptoms attributable to the nasal trauma of surgery, with partial recovery (nasal sores and bleeding) or complete recovery (nasal blockage, painful sinuses, and unpleasant nasal smell) by final follow-up (p < 0.05). Progressive improvements in symptom severity were seen for symptoms more attributable to tumor mass preoperatively (for example, headaches and painkiller use [p < 0.05]). In total, by final follow-up 8 patients (9%) required further treatment or advice for ongoing nasal symptoms. Conclusions Endoscopic transsphenoidal surgery is a well-tolerated minimally invasive procedure for pituitary fossa lesions. Overall patient-assessed nasal symptoms do not change, but some individual symptoms may show a mild worsening or overall improvement.

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Endoscopic Transsphenoidal Pituitary Surgery: Evidence of an Operative Learning Curve

Abstract: The improvements in the duration of surgery and visual outcome noted after about 50 endoscopic procedures would favor the existence of an operative learning curve for these parameters. This further highlights the benefits of subspecialization in pituitary surgery.

Cited by 136 publications

References 36 publications

Binostril versus mononostril approaches in endoscopic transsphenoidal pituitary surgery: clinical evaluation and cadaver study

Binostril versus mononostril approaches in endoscopic transsphenoidal pituitary surgery: clinical evaluation and cadaver study

The learning curve in endoscopic endonasal resection of craniopharyngiomas

Nasal symptoms following endoscopic transsphenoidal pituitary surgery: assessment using the General Nasal Patient Inventory

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