SKULL BASE INSTITUTE

The Evolution of Pituitary Surgery:

From an Open Transcranial to a Minimally Invasive Endoscopic Approach.

Hrayr K. Shahinian M.D.

Objectives

Describe pituitary anatomy and the various presentations of pituitary adenomas Discuss the the three standard surgical approaches to pituitary adenomas - Transcranial - Microscopic Transseptal-transsphenoidal - Endoscopic Transnasal-transsphenoidal

Objectives

Discuss results from our latest research comparing outcomes for patients undergoing Microscopic vs. Endoscopic Transsphenoidal Pituitary Adenoma Resection

Transcranial Approach

Transcranial Approach

Requires craniotomy and retraction of the frontal lobes of the brain. Sub-optimal exposure of inferior and posterior aspects of tumor. Difficult to distinguish normal gland from tumor from distal perspective.

Transcranial Approach

Forces surgeon to operate between CN I or over orbit risking injury to vision or sense of smell. Used for large invasive tumors or tumors with significant suprasellar extension. Often used as a combined second stage approach following a transsphenoidal resection.

Microscopic Transseptal-transsphenoidal TransseptalPituitary Adenoma Resection

Microscopic Transseptal-transsphenoidal TransseptalApproach

Current standard operation for most pituitary adenomas Has demonstrated equal outcomes for cure compared to open transcranial approach with less morbidity and mortality. Allows for more rapid recovery

Endoscopic Transnasal-Transsphenoidal TransnasalPituitary Adenoma Resection

Made possible by advances in endoscopic technology

Endoscopes Varying widths and angles of view Cameras Three chip, Digital, Three dimensional Light Sources Halogen, Metal Halide, Xenon Recorders/Processors Digital, Real Time Irrigation Sheaths Holding Arms

Endoscopic Procedures Developed Using Animal Models

Animal models developed at SBI have demonstrated the safety and revealed the advantages of the endoscopic approach. Endoscope allows for clear visualization of pituitary gland, hypophyseal stalk, cavernous sinuses, and optic nerves. Angled endoscopes enable visualization of lateral recesses and suprasellar areas.

Microscopic Transseptal-transsphenoidal vs. TransseptalEndoscopic Transnasal-Transsphenoidal TransnasalPituitary Adenoma Resection

Combined Micro-endoscopic Approach Micro

SBI began with combined approach in 1996 Early combined micro-endoscopic series, including one performed at SBI have demonstrated a 33 - 49% incidence of residual tumor, recognized only with the additional visualization provided by the endoscope.

Fully Endoscopic Transnasal-Transsphenoidal TransnasalPituitary Adenoma Resection

Fully Endoscopic Transnasal-Transsphenoidal TransnasalPituitary Adenoma Resection

In 1998 SBI converted to a fully endoscopic technique. Since then we have compiled results for all patients undergoing fully endoscopic pituitary adenoma resection. Submitted these endoscopic results for publication, comparing early outcomes and complication rates to published results using the standard microscopic transsphenoidal operation.

Endoscopic vs. Microscopic Surgical Approach to Pituitary Adenomas

Feature
Total number of Patients Age (years) Mean Range Sex: F:M Prior Pituitary Surgery LOS (days) Mean Range Follow-up period (months) Mean Range

Number
512 46 16-75 1.6:1 79 1.6 1-5 9 1-26

Early Post-operative Remission Rates PostEndoscopic vs. Microscopic Results

Hormonally Active Non-functioning Adenomas Adenomas ACTH PRL GH 84% 78% 88% 93% 81% 66% 77% 82%

Endoscopic Series Microscopic Series a

a

Calculated from several published microscopic series

Complication Rates (percent) Endoscopic vs. Microscopic

Ant. Pit. Insuf. DI 1.4 17.8 Loss of Vision 0 1.8 Carotid Injury 0 1.1 CNS Injury 0 1.3 Intrasellar Hemor. 2.7 2.9 CSF Leak 1.9 3.9 Meningitis 0 1.5

Endoscopic Microscopic a

2.7 19.4

Calculated from several published microscopic series

Fully Endoscopic Transnasal-Transsphenoidal TransnasalPituitary Adenoma Resection

A safer operation:
Improved visualization of surrounding optic bulbs, brainstem, and carotid prominences. Improved ability to differentiate tumor from normal pituitary tissue Completely transnasal approach avoids the risk of naso-oral fistulae, and lip numbness seen with the transseptal approach.

Fully Endoscopic Transnasal-Transsphenoidal TransnasalPituitary Adenoma Resection

A more complete operation: Improved visualization sellar and parasellar tumor extension, should result in a lower recurrence rate, as demonstrated by our early results.

Fully Endoscopic Transnasal-Transsphenoidal TransnasalPituitary Adenoma Resection

Minimally invasive approach allows for a more rapid recovery with less post-operative discomfort: Most patients discharged within 48 hours. Completely endonasal approach avoids the need for post-operative nasal packing.

The Evolution of Pituitary Surgery:

From an Open Transcranial to a Minimally Invasive Endoscopic Approach.
Continued research into improved medical and surgical treatment of pituitary adenomas:

New 3-dimensional endoscopes Animal models using fetal pituitary cell transplantation