Nancy McLaughlin

Value of endoscopy for maximizing tumor removal in endonasal transsphenoidal pituitary adenoma surgery

OBJECT Endoscopy as a visual aid (endoscope assisted) or as the sole visual method (fully endoscopic) is increasingly used in pituitary adenoma surgery. Authors of this study assessed the value of endoscopic visualization for finding and removing residual adenoma after initial microscopic removal. METHODS Consecutive patients who underwent endoscope-assisted microsurgical removal of pituitary adenoma were included in this study. The utility of the endoscope in finding and removing residual adenoma not visualized by the microscope was noted intraoperatively. After maximal tumor removal under microscopic visualization, surgeries were categorized as to whether additional tumor was removed via endoscopy. Tumor removal and remission rates were also noted. Patients undergoing fully endoscopic tumor removal during this same period were excluded from the study. RESULTS Over 3 years, 140 patients (41% women, mean age 50 years) underwent endoscope-assisted adenoma removal of 30 endocrine-active microadenomas and 110 macroadenomas (39 endocrine-active, 71 endocrine-inactive); 16% (23/140) of patients had prior surgery. After initial microscopic removal, endoscopy revealed residual tumor in 40% (56/140) of cases and the additional tumor was removed in 36% (50 cases) of these cases. Endoscopy facilitated additional tumor removal in 54% (36/67) of the adenomas measuring ≥ 2 cm in diameter and in 19% (14/73) of the adenomas smaller than 2 cm in diameter (p < 0.0001); additional tumor removal was achieved in 20% (6/30) of the microadenomas. Residual tumor was typically removed from the suprasellar extension and folds of the collapsed diaphragma sellae or along or within the medial cavernous sinus. Overall, 91% of endocrine-inactive tumors were gross-totally or near-totally removed, and 70% of endocrine-active adenomas had early remission. CONCLUSIONS After microscope-based tumor removal, endoscopic visualization led to additional adenoma removal in over one-third of patients. The panoramic visualization of the endoscope appears to facilitate more complete tumor removal than is possible with the microscope alone. These findings further emphasize the utility of endoscopic visualization in pituitary adenoma surgery. Longer follow-ups and additional case series are needed to determine if endoscopic adenomectomy translates into higher long-term remission rates.

Endoscopic endonasal transpterygoid nasopharyngectomy

Describe our technique for endoscopic transpterygoid nasopharyngectomy and support its feasibility with our early clinical outcomes.

Use of stent-assisted coil embolization for the treatment of wide-necked aneurysms: A systematic review

Background: The use of stent-assisted coiling (SAC) has been shown to be a treatment option for complex aneurysms. We reviewed systematically the immediate and mid-term angiographic results following treatment of wide-necked aneurysms with self-expanding stents and coils, as well as the peri- and postprocedural rate of complications. Methods: A computerized database search was conducted from 01/2000 to 04/2011 using appropriate indexed terms on Pubmed. Inclusion criteria were: (1) homogeneous populations of ≥10 patients with wide-necked aneurysms; (2) use of a self-expandable neurovascular stent and coils for aneurysm treatment; (3) immediate and follow-up angiographic results; and (4) periprocedural and delayed thrombotic complications. Results: Seventeen studies were included, containing retrospectively collected data on 656 patients/702 aneurysms. The target aneurysm was located on the anterior circulation in 78.4% of patients. The immediate rate of complete occlusion was 46.3%, (19.3-98.1%). The intra- and postprocedural rate of intrastent thrombosis or thromboembolic event was 4.6% and 4.3%, respectively. Complete occlusion was documented in 71.9% at last angiographic follow-up. The rate of recanalization was 13.2% of aneurysms (0-28.8%). Delayed in-stent stenosis occurred in 5.3% cases (0-20.6%). Conclusion: SAC has been considered a treatment option for selected wide-necked aneurysms in some institutions. The use of intracranial stents should take into consideration the risk of ischemic complications, recanalization, delayed in-stent stenosis; and the currently unknown lifetime risks for stenosis, vascular injury, device failure, and aneurysm recurrence related to intracranial stenting. There is an evident need for a prospective multicenter registry for all treated patients with SAC.

Time-driven activity-based costing: a driver for provider engagement in costing activities and redesign initiatives

OBJECT To date, health care providers have devoted significant efforts to improve performance regarding patient safety and quality of care. To address the lagging involvement of health care providers in the cost component of the value equation, UCLA Health piloted the implementation of time-driven activity-based costing (TDABC). Here, the authors describe the implementation experiment, share lessons learned across the care continuum, and report how TDABC has actively engaged health care providers in costing activities and care redesign. METHODS After the selection of pilots in neurosurgery and urology and the creation of the TDABC team, multidisciplinary process mapping sessions, capacity-cost calculations, and model integration were coordinated and offered to engage care providers at each phase. RESULTS Reviewing the maps for the entire episode of care, varying types of personnel involved in the delivery of care were noted: 63 for the neurosurgery pilot and 61 for the urology pilot. The average cost capacities for care coordinators, nurses, residents, and faculty were

Surgical Management of Blood Blister–like Aneurysms of the Internal Carotid Artery

0.70 (range

Pulmonary edema and cardiac dysfunction following subarachnoid hemorrhage

0.63-

Endoneurosurgical Resection of Intraventricular and Intraparenchymal Lesions Using the Port Technique

0.75),

Teamwork in skull base surgery: An avenue for improvement in patient care.

1.55 (range

Effectiveness of Burr Holes for Indirect Revascularization in Patients with Moyamoya Disease—A Review of the Literature

1.28-

The supraorbital approach for recurrent or residual suprasellar tumors.

2.04),