Showkat Mirza

Comparison of endoscopic and microscopic trans-sphenoidal pituitary surgery: early results in a single centre

Abstract Introduction. Pituitary surgery has seen a recent shift from a microscopic to an endoscopic trans-sphenoidal approach. We present our early experience with endoscopic surgery and compare the outcome with our recent microscopic experience. Methods. From January 2008 until present time, 80 consecutive patients underwent trans-sphenoidal pituitary surgery in our institution. Until September 2009, all patients had a microscopic trans-septal approach. After this time, the patients underwent endoscopic trans-sphenoidal surgery. All patients underwent pre- and post-operative MRI and full endocrinological evaluation. Data was collected prospectively including tumour volume, endocrine function, visual function, length of stay and complications. Results. There were 40 patients in each group. In the microscopic group, there were 26 non-functioning tumours and 14 functioning tumours. In the endoscopic group, there were 24 non-functioning and 16 functioning tumours. There were significantly better results in terms of tumour resection (p = 0.002) and remission (p = 0.018) in the endoscopic group. In this group there was also a lower incidence of CSF leaks and a shorter length of stay for secreting tumours (p = 0.005). 1 patient in the endoscopic group died at day 43 post-operatively, having initially presented in a poor clinical state with pituitary apoplexy. Conclusion. Microscopic trans-sphenoidal surgery remains the benchmark for future surgical techniques. Our early results suggest that endoscopic trans-sphenoidal surgery provides favourable results in both tumour resection and control of secreting tumours in comparison with microscopic surgery. Further longer-term evaluation is required to ensure the outcome of endoscopic surgery.

Transnasal trans-sphenoidal endoscopic repair of CSF leak secondary to invasive pituitary tumours using a nasoseptal flap.

Cerebrospinal fluid (CSF) leak following initiation of Dopamine agonist therapy for macroprolactinomas, although uncommon, has been described previously in the literature. Traditional management includes primary repair of the defect using either fat or fascia lata in conjunction with lumbar drain insertion. In this case series we outline two cases of CSF leak secondary to invasive pituitary tumour that were repaired successfully using a nasoseptal flap. We believe that this form of repair is effective and associated with minimal morbidity.

Endoscopic endonasal resection of the odontoid peg for paediatric basilar invagination

Osteogenesis imperfecta (OI) is a genetic disorder whose primary manifestations are fractures, bone deformity and bone pain. Brainstem compression due to basilar invagination is a rare and potentially life-threatening complication of OI. Children with this condition often require significant medical input and multiple admissions to hospital. Traditionally, anterior decompression is carried out through an open trans-oral route. We describe an endoscopic endonasal approach for resection of the peg in a child with OI and basilar invagination. We believe this approach provides an excellent alternative with minimal morbidity and decreased length of stay especially in the paediatric population.

The use of the nasoseptal flap to reduce the rate of post-operative cerebrospinal fluid leaks following endoscopic trans-sphenoidal surgery for pituitary disease.

Abstract Introduction. Our aim was to evaluate the routine use of a pedicled nasoseptal flap (NSF) as a primary repair for intra-operative CSF leaks compared with fat/fascia lata graft and lumbar drain insertion by performing a retrospective review of elective patients undergoing primary trans-sphenoidal surgery from January 2008 to present. Materials and methods. A retrospective review of consecutive primary elective trans-sphenoidal cases for sellar pathology was undertaken. Prior to September 2009, microscopic trans-sphenoidal surgery (MTSS) was performed in 40 cases and since then endoscopic trans-sphenoidal surgery (ETSS) was performed in 100 cases. Results and analysis. In the MTSS group, intra-operative CSF leaks were repaired with fat graft, tisseal and lumbar drain insertion. Intra-operative leaks in the ETSS group were routinely repaired with a pedicled NSF. Post-operative CSF leak rates were 12.5% in the MTSS and 3% in the ETSS groups, respectively. Three patients in the ETSS group developed a post-op CSF leak. All of these patients underwent surgery for craniopharyngiomas. This group had subsequent endoscopic repairs and were managed with repositioning of the NSF. Conclusion. The advent of the pedicled NSF conveys a significant advantage in preventing post-operative CSF leak, decreasing the morbidity associated with lumbar drain insertion and reduces the length of hospital stay.

Endoscopic removal of a dermoid cyst via scalp incision.

Nasal dermoid sinus cysts are the most common congenital midline nasal lesions. We describe a novel technique for the excision of a nasal dermoid cyst in a 2-year-old boy using a four hand endoscopic approach via a small scalp incision behind the hairline. The technique, although somewhat challenging, avoids a facial scar. Laryngoscope, 123:1862–1864, 2013Nasal dermoid sinus cysts are the most common congenital midline nasal lesions. We describe a novel technique for the excision of a nasal dermoid cyst in a 2‐year‐old boy using a four hand endoscopic approach via a small scalp incision behind the hairline. The technique, although somewhat challenging, avoids a facial scar. Laryngoscope, 123:1862–1864, 2013

Radiological “Teddy Bear” Sign on CT Imaging to Aid Internal Carotid Artery Localization in Transsphenoidal Pituitary and Anterior Skull Base Surgery

Objectives Internal carotid artery (ICA) injury remains a rare but potentially fatal complication of transsphenoidal pituitary or anterior skull base surgery. Preoperative imaging must be scrutinized to minimize risk. On axial computed tomography (CT), the protrusions of the ICAs into the sphenoid resemble a “teddy bear.” This article aims to describe the sign, its grading system (0–2) and quantify its presence. Design Retrospective review of preoperative CT imaging. Setting Tertiary referral center in the United Kingdom. Participants One hundred patients who underwent endoscopic transsphenoidal surgery for pituitary disease were enrolled. Main Outcome Measure The presence and grading of the “teddy bear” sign were assessed on preoperative CT imaging. Results A grade 2 (strongly positive) “teddy bear” sign was identified in 40% at the level of the superior pituitary fossa, 78% at the inferior pituitary fossa, and 59% at the clivus. A grade 1 (intermediate) sign was seen in 23.5, 7.5, and 10% of cases, respectively. In 5% of cases, the sign was grade 0 at all levels—indicating poor intraoperative localization of the ICA. Conclusion The “teddy bear” sign is a useful preoperative tool for identification of anatomy predisposing patients to a higher risk of ICA injury. Those patients who have an absent or grade 0 “teddy bear” sign require extra care to ensure intraoperative localization of the ICAs which may include the use of neuronavigation or a Doppler probe. A grade 2 sign predicts good intraoperative localization of the ICA intraoperatively to inform the safe lateral limit of sellar bone resection.

The Pathophysiology of Early Hypotension Following Epinephrine-containing Local Anesthetic Infiltration of the Nasal Mucosa in Patients Undergoing Endoscopic Transsphenoidal Hypophysectomy: A Prospective, Observational Study.

In patients undergoing endoscopic transsphenoidal hypophysectomy, the nasal mucosa is often infiltrated with local anesthetic solutions that contain epinephrine to aid hemostasis. This may, however, result in hemodynamic changes, especially hypotension. We characterized the cardiovascular changes using a LiDCOrapid monitor in 13 patients after the infiltration of 4% articaine containing 1:200,000 epinephrine. Nine (69%) had a >20% decrease in mean arterial pressure at a median time of 116 seconds after the infiltration of articaine with epinephrine. Analysis of the cardiac output data revealed that this was caused by a sustained reduction in systemic vascular resistance. The arterial blood pressure normalized over a period of 60 to 90 seconds secondary to increases in stroke volume and heart rate producing an elevation in cardiac output. Transient hypotension following the infiltration of epinephrine-containing local anesthetics may be caused by epinephrine stimulation of &bgr;2-adrenoceptors producing vasodilation.

The novel use of coblation whilst undertaking a challenging tracheostomy in a patient with anaplastic thyroid cancer

Introduction: Coblation is a relatively new technique where tissue is ablated using radiofrequency energy. It has increasing applications in benign and malignant head and neck tumours. Case report: We present the case of a 63-year-old man with an anaplastic spindle cell thyroid carcinoma, presenting to the on-call ENT team with acute stridor. A recent MRI scan showed a 7 cm mass invading through the lateral wall of the trachea and extending superiorly into the supraglottic larynx. The history suggested previous radiotherapy treatment. A tracheostomy under local anaesthesia was performed. The tumour was large, hard and displacing the trachea and therefore coblation was utilised for this challenging case. Conclusion: The use of coblation was valuable in this setting as it allowed tumour debulking with haemostatic control over the thyroid cartilage and trachea. We report the first case, as far as we are aware, of the use of coblation in a surgical tracheostomy. Correspondence to: Ramkishan Balakumar, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK; Email: rambala86@doctors.org.uk

National clinical coding of trans-sphenoidal pituitary surgery

Further to our correspondence regarding clinical coding and optimising renumeration for pituitary surgery in our department, we now report on national data in this regard. The Payment by Results (PbR) system was introduced to the English National Health Service in 2003. After a patient undergoes treatment and is discharged, clinical coding of the admission is performed and a tariff is paid for each clinical activity. Information recorded in the patient’s notes; including any operations performed, diagnoses, complications and co-morbidities, is translated into clinical codes. For pituitary surgery, there are a number of procedure codes available with varying tariffs. We assessed how pituitary operations are coded nationally using Hospital Episode Statistics (HES) for April 2013 to March 2014, containing details of all admissions, outpatient appointments and A&E attendances at NHS hospitals in England. There were a total of 1288 pituitary operations over the 12-month period, coded by 11 different procedure codes. All codes for elective surgery in patients without co-morbidities earned a tariff of £6693 each, except B01.2 trans-sphenoidal hypophysectomy, which had a tariff of £5496 (£1197 less). Most procedures (8211⁄4 64%), were coded as B04.1 excision of lesion of pituitary gland. However, 329 procedures (26%) were coded as B01.2 trans-sphenoidal hypophysectomy, with the lower tariff. This represents £393,813 in lost tariffs nationally over 12 months. Given these findings, it is recommended that departments regularly review their pituitary coding to achieve appropriate renumeration for the costs of performing pituitary surgery. Ideally surgeons should work closely with colleagues in clinical coding to ensure that correct tariffs are achieved.

The “Mickey Mouse” Sign

Objective: In transnasal endoscopic pituitary surgery and transsellar approaches to anterior skull base lesions, a bony sella window is created with the lateral limits being the carotid arteries. Method: Coronal CT scan of the sphenoid sinuses were reviewed in a tertiary referral hospital and compared with intra operative findings. Results: Sphenoid anatomy is variable in terms of the degree of pneumatization and bony anatomy around the pituitary gland and internal carotid arteries. We describe a radiological sign ascertained from computerized tomography (CT) that when present indicates whether the carotid arteries can be readily identified endoscopically on entering the sphenoid sinus. On the axial CT the carotid arteries may produce protuberances either side of the sella which together with the bony sella and dorsum sella appear to form the outline of the head of Mickey Mouse or a teddy bear. Conclusion: When this sign is not present then the junction between the sella and carotids may not be clear and surgeons must be cautious or use neuronavigation.