David H. Hiltzik

Endoscopic pituitary surgery: a systematic review and meta-analysis

OBJECTnSurgery on the pituitary gland is increasingly being performed through an endoscopic approach. However, there is little published data on its safety and relative advantages over traditional microscope-based approaches. Published reports are limited by small sample size and nonrandomized study design. A meta-analysis allows for a description of the impact of endoscopic surgery on short-term outcomes.nnnMETHODSnThe authors performed retrospective review of data from their institution as well as a systematic review of the literature. The pooled data were analyzed for descriptive statistics on short-term outcomes.nnnRESULTSnNine studies (821 patients) met inclusion criteria. Overall, the pooled rate of gross tumor removal was 78% (95% CI 67-89%). Hormone resolution was achieved in 81% (95% CI 71-91%) of adrenocorticotropic hormone secreting tumors, 84% (95% CI 76-92%) of growth hormone secreting tumors, and 82% (95% CI 70-94%) of prolactin secreting tumors. The pooled complication rates were 2% (95% CI 0-4%) for CSF leak and 1% (95% CI 0-2%) for permanent diabetes insipidus. There were 2 deaths reported in the literature that were both related to vascular injury, giving an overall mortality rate of 0.24%.nnnCONCLUSIONSnThe results of this meta-analysis support the safety and short-term efficacy of endoscopic pituitary surgery. Future studies with long-term follow-up are required to determine tumor control.

Safety of low-dose intrathecal fluorescein in endoscopic cranial base surgery.

OBJECTIVE Intraoperative identification of cerebrospinal fluid (CSF) leakage is critical in successful closure after endoscopic cranial base surgery. Intrathecal injection of fluorescein is quite useful in identifying CSF leaks. However, complications have been reported with various doses and the technique has fallen out of favor. We explored the safety of low-dose intrathecal fluorescein administered to patients undergoing endoscopic cranial base surgery. METHODS A retrospective chart review and postoperative patient survey were performed. The nature and incidence of complications and subjective complaints were recorded in 54 patients who underwent endoscopic, endonasal approaches to the anterior cranial base and received intrathecal fluorescein after premedication with dexamethasone and diphenhydramine. RESULTS Intraoperative CSF leak was identified with fluorescein in 46.3% of the patients and helped determine the reconstruction technique. Postoperative CSF leak occurred in 9.3% of the patients and resolved with lumbar drainage. There were no seizures. Most side effects were nonspecific, transient, and likely not caused by fluorescein including malaise (57.4%), headache (51.9%), dizziness (31.5%), or nausea/vomiting (24.1%). Three patients (5.6%) experienced persistent subjective lower extremity weakness (n = 2) and numbness (n = 2) postoperatively; however, two of them had undergone lumbar drainage. CONCLUSION Low-dose injection of intrathecal fluorescein after premedication with steroid and antihistamine agents is generally safe. Most symptoms are nonspecific and transient, likely caused by the surgery or lumbar drainage. However, fluorescein should be administered with some caution because it may be responsible for occasional lower extremity weakness and numbness.

Endoscopic transphenoidal pituitary surgery with real-time intraoperative magnetic resonance imaging.

Background The aim of this study was to report and show the technique, results, and complications of combined endoscopic and intraoperative magnetic resonance imaging (IMRI) surgical treatment of pituitary disease from both a technical and a surgical perspective. Methods We performed a retrospective chart review of 10 endoscopic, endonasal resections of 10 pituitary macroadenomas using the Polestar N-10 IMRI system in a tertiary health care facility. The patient demographics, tumor measurements, and postoperative symptoms and complications were assessed. The effect of the magnetic field on the video screen, the image quality of the IMRI images, and IMRI detection of residual tumor were evaluated also. Results IMRI images were obtained in all cases and were of sufficiently high quality to indicate adequate decompression of the optic chiasm and the removal of all suprasellar tumor. However, there was significant distortion of the video monitor regardless of the viewing angle. This was overcome with a wall-mounted plasma screen. Residual tumor was found with IMRI and resected endoscopically in three cases. In two other cases, suspected residual tumor on IMRI was examined endoscopically and found to be a normal postoperative change. In two cases no tumor was seen on the IMRI. Five patients who had preoperative progressive visual loss preoperatively improved postresection and two patients who had increased insulin growth factor 1 preoperatively normalized postoperatively. No delayed cerebrospinal fluid leaks or any other complications occurred. Conclusion Combining intraoperative endoscopy and IMRI is an effective surgical modality for pituitary surgery. Each technology provides complimentary information, which can assist the surgeon in safely maximizing the extent of resection.

Predictors of short-term outcomes following endoscopic pituitary surgery

OBJECTIVEnRefinement of endoscopic pituitary surgery requires an understanding of the impact of demographic and surgical variables on outcomes.nnnMETHODSnMultivariate logistic regression and ANOVA models were used to explore variables for association with outcomes in a consecutive series of 57 patients undergoing endoscopic pituitary surgery.nnnRESULTSnThe mean duration of surgery was 177 min and was longer in patients with larger tumor size (p=0.03) and presentation with visual symptoms (p=0.02) in univariate analyses. The median duration of hospitalization was 3 days and was longer in patients with larger tumors (p=0.0005). Gross tumor removal was achieved in 89%. Tumor size correlated with extent of tumor removal with an almost 3-fold decrease in complete tumor removal for every 1cm increase in tumor size (p=0.047). High rates of hormonal control (90%) and improvement in visual symptoms (92%) were noted.nnnCONCLUSIONSnHigh rates of gross tumor removal, hormonal cure and visual field improvement were noted in this series. Markers including tumor size and visual symptoms may be used to stratify patients.

Osteoplastic flap for frontal sinus obliteration in the era of image-guided endoscopic sinus surgery.

Background This study evaluates the management of frontal sinus disease using osteoplastic flap surgery (OPFS) in the current era of image-guided endoscopic sinus surgery (IGESS). Study Design: A retrospective chart review was performed of patients who underwent OPFS and imaged-guided endoscopic frontal sinus surgery in the past 10 years at a tertiary care teaching hospital. Methods Chart reviews of clinic patients and inpatients who underwent OPFS were performed. Indications for surgery, prior sinus surgeries, time to OPFS, post-OPFS sinus surgeries, and associated comorbid factors were reviewed. Results In the period under review, 710 IGESS cases were performed. Thirty patients, who were candidates for OPFS, underwent IGESS for frontoethmoid disease. Fourteen patients from this group failed IGESS and underwent OPFS. The indications for OPFS included mucocele in 10 cases, tumors in 2 cases, and trauma in 2 cases. Four patients underwent revision OPFS. The patients who failed IGESS had prior trauma, tumor resection, radiation, or large septate frontal sinus with lateral extension in which the mucocele could not be drained endoscopically. The average time to OPFS was 6.2 years (0–27 years). Nine patients had prior sinus surgery (1–7 prior surgeries) and five patients had subsequent endoscopic surgical procedures. Conclusion In all patients with frontal mucocele, surgery should be attempted endoscopically using IGESS because of the low morbidity of the procedure. Patients with risk factors for failure should be considered for OPFS if IGESS proves to be unsuccessful.

Microbiology and antibiotic resistance of chronic rhinosinusitisin patients undergoing primary vs. revision endoscopic sinus surgery

INTRODUCTION Chronic Rhinosinusitis (CRS) is an inflammatory process associated with several different pathogenic aerobic and anaerobic organisms. The microbiology of CRS has been studied extensively. As a result, probability guided antibiotics have been used. Endoscopic cultures of the middle meatus and sinuses have assisted in directing the choice of antibiotics and overall treatment. Reports of cultured organisms in medically treated patients as well those treated surgically by functional endoscopic sinus surgery (FESS) have demonstrated differences in the isolates. (1-6) Many patients that undergo FESS, however, often have recurrent and persistent CRS that requires additional surgical intervention after appropriate medical treatment. Studying the endoscopically guided cultures intraoperatively may demonstrate those microorganisms that persist in the nasal cavity and sinuses despite aggressive treatment. In this article, we describe the microbiology of patients undergoing primary FESS and those requiring revision FESS.