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transsphenoidal_approach

Transsphenoidal approach

The transsphenoidal approach is the gold standard for pituitary adenoma resection. However, despite advances in microsurgical and endoscopic techniques, some pituitary adenomas can be challenging to cure.

Traditionally performed with a microscope and a sublabial incision, the implementation of the endoscopic visualization and endonasal access has rendered the transsphenoidal approach less invasive and provided improved visualization into and around the sella.

see Endoscopic transsphenoidal approach

The standard endonasal approach has been expanded to provide access to other, parasellar lesions. With the addition of the endoscope, this expansion carries significant potential for the resection of skull base lesions.

see Extended endoscopic transsphenoidal approach

Although there is limited and low quality evidence available, the use of intraoperative ultrasound appears to be a safe and effective technological adjunct to transsphenoidal surgery for pituitary adenoma. Advances in ultrasound technology may allow for more widespread use of such devices 1).

History

As an alternative to the transcranial route the transsphenoidal approach was developed simultaneously in the first decade of the 20th century in the United States and in Europe, in particular in the Austrian monarchy. One reason that Vienna became the cradle for minimally invasive approach to pituitary tumours using an endonasal transsphenoidal approach was among others due to the basic and detailed anatomical studies of the paranasal sinuses performed in Vienna by the Austrian anatomist and Violin virtuoso Emil Zuckerkandl (1849–1910). His main work “On normal and pathological anatomy of the paranasal sinus and its pneumatic adnexes” in 1882 was the anatomical presupposition for the Viennese ENT surgeons to successfully develop minimally invasive endonasal approaches to pituitary tumours 2).

Initially described by Hans Schloffer 3) and Cushing 4) and subsequently popularized by Guiot 5) and Hardy and Wigser 6), the transsphenoidal approach to the sella now represents the preferred approach for removing pituitary adenomas. Traditionally performed with a microscope and a sublabial incision, the implementation of the endoscope and endonasal access has rendered the transsphenoidal approach less invasive and provided improved visualization into and around the sella.

Suprasellar extension is regarded a drawback for complete removal of these tumors through this approach.

Is very important to evaluate the correlation between the preoperative radiologic craniocaudal extension on MRI of pituitary adenomas and the extent of tumor removal. A retrospective study. Tertiary care hospital. 560 patients underwent transsphenoidal removal of pituitary adenomas. The degree of removal of pituitary tumor in the follow-up imaging of the patients was correlated with the preoperative extension in mid-Coronal T1 W Gd. Tumors with suprasellar extension can be classified into: Type I tumors with extension confined to the sellar boundaries, resulted in complete removal in all cases (100%), type II tumors with suprasellar extension reaching the floor of the 3rd ventricle, resulted in complete removal in 70.2% of the cases, type III tumors with suprasellar extension above the 3rd ventricle, had only 13.5% of complete removal. Integration of radiologic findings into a scheme for the preoperative determination of possibility of total removal of the tumor through transsphenoidal approach, can give better correlation to the surgical outcome of pituitary tumors 7).

Transsphenoidal surgery can safely be performed in the setting of chronic rhinosinusitis (CRS) without increased risk of intracranial complications 8).

Difficulties

Difficulties achieving radical resection with this method are encountered in patients with pituitary adenomas (PA) invading the cavernous sinus (CS), due to the inability of the standard transsphenoidal approach to expose all tumors adequately.

Complications

Case series

2016

Thirty patients with pituitary adenoma were recruited from Huashan Hospital between September 2010 and January 2014. The examination included pupil examination, anterior and posterior segment examination, standard automated perimetry (SAP), retinal nerve fiber layer (RNFL) and multifocal VEP (mfVEP). At three months and nine months after transsphenoidal approach, follow-up measurements were conducted in twenty-three patients, and at 18 months after surgery, the same examinations were performed in seven patients.

The average age of patients was 42.6±12.1years, with 23 males and 7 females. The mean score of SAP improved significantly: 1.75 before surgery; 0.62 at three months after surgery (p=0.00) and 0.50 at nine months after surgery (p=0.00). No significant improvement in RNFL thickness was observed at three months or nine months after surgery. The mean score of mfVEP also improved significantly: 0.85 before surgery; 0.53 at three months (p=0.00) and 0.38 at nine months after surgery (P=0.00). No statistical difference was observed in the outcome of patients at nine months of follow-up and 18 months of follow-up.

Visual field and mfVEP recovery with unchanged RNFL thickness was observed in patients after transsphenoid pituitary adenoma resection 9).


Eighteen patients with pituitary macroadenomas underwent transsphenoidal surgery during 2013-2014 under low-field iMRI control (PoleStar N20, 0.15 T). Intrasellar balloons were used in all of them to assess the presence of tumoral remnants. They compared the findings in iMRI and postoperative high-field MRI control scans and also analyzed the number of intermediate imaging controls needed during surgery using this technique.

In total, of the 18 patients, 14 underwent a complete resection. In the remaining four patients, a safe maximal resection was performed, leaving a remnant because of cavernous sinus invasion. In all cases, the balloons were a major help in distinguishing the anatomical structures from the tumoral remnants. Fewer imaging controls were required, and there were no false-positives or negative intraoperative findings. No complications related to the technique were registered.

The “intrasellar balloon technique” is a useful tool that facilitates surgeons' intraoperative decision making. It is an important contribution to overcome the limitations of low-field iMRI as it provides a precise delineation of the resection margins, reduces false-positives and -negatives, and decreases the number of intermediate imaging controls required 10).

1)
Marcus HJ, Vercauteren T, Ourselin S, Dorward NL. Intraoperative Ultrasound in Patients Undergoing Transsphoidal Surgery for Pituitary Adenoma: A Systematic Review. World Neurosurg. 2017 Jul 20. pii: S1878-8750(17)31154-3. doi: 10.1016/j.wneu.2017.07.054. [Epub ahead of print] Review. PubMed PMID: 28736351.
2)
Zuckerkandl E. Normale und pathologische Anatomie der Nasenhöhlen und ihrer pneumatisierten Anhänge. Vienna, Austria: Braumüller; 1882.
3)
Schloffer H: Erfolgreiche Operation eines Hypophysentumors auf nasalem Wege [Successful operation of a hypophyseal tumor through the nasal pas- sage]. Wien Klin Wochnschr 20:621–624, 1907.
4)
Cushing H: III. Partial hypophysectomy for acromegaly: With remarks on the function of the hypophysis. Ann Surg 50:1002–1017, 1909.
5)
Guiot G: Transsphenoidal approach in the surgical treatment of pituitary adenomas: General principles and indications in non-functioning adenomas, in Kohler PO, Ross GT (eds): Diagnosis and Treatment of Pituitary Tumors. New York, American Elsevier, 1973, pp 159–178.
6)
Hardy J, Wigser SM: Trans-sphenoidal surgery of pituitary fossa tumors with televised radiofluoroscopic control. J Neurosurg 23:612–619, 1965.
7)
Hamid O, El Hakim A, El Husseiny H, El Fiky L, Kamel S. Craniocaudal extension as an indication of surgical outcome in transsphenoidal surgery for pituitary adenomas. Indian J Otolaryngol Head Neck Surg. 2013 Aug;65(Suppl 2):231-5. doi: 10.1007/s12070-011-0350-3. Epub 2011 Nov 27. PubMed PMID: 24427652.
8)
Schaberg MR, Shah GB, Evans JJ, Rosen MR. Concomitant transsphenoidal approach to the anterior skull base and endoscopic sinus surgery in patients with chronic rhinosinusitis. J Neurol Surg B Skull Base. 2013 Aug;74(4):241-6. doi: 10.1055/s-0033-1342916. Epub 2013 Apr 3. PubMed PMID: 24436919.
9)
Qiao N, Ye Z, Shou X, Wang Y, Li S, Wang M, Zhao Y. Discrepancy between structural and functional visual recovery in patients after trans-sphenoidal pituitary adenoma resection. Clin Neurol Neurosurg. 2016 Sep 6;151:9-17. doi: 10.1016/j.clineuro.2016.09.005. PubMed PMID: 27728836.
10)
Jiménez P, Brell M, Sarriá-Echegaray P, Roldán P, Tomás-Barberán M, Ibáñez J. “Intrasellar Balloon Technique” in intraoperative MRI guided transsphenoidal endoscopic surgery for sellar region tumors. Usefulness on image interpretation and extent of resection evaluation. Technical note. Acta Neurochir (Wien). 2016 Mar;158(3):445-9. doi: 10.1007/s00701-015-2697-9. Epub 2016 Jan 9. PubMed PMID: 26748503.
transsphenoidal_approach.txt · Last modified: 2017/07/25 11:51 by administrador