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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
Pituitary Adenoma Resection

Microscopic Transseptal-transsphenoidal
Approach

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
Pituitary 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.


Endoscopic Transnasal-Transsphenoidal
Pituitary Adenoma Resection

Combined Micro-endoscopic Approach

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


Pituitary Adenoma Resection

Fully Endoscopic Transnasal-Transsphenoida


Pituitary 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

Number

Total number of Patients

512

Age (years)
Mean
Range

46
16-75

Sex: F:M

1.6:1

Prior Pituitary Surgery

79

LOS (days)
Mean
Range

1.6

Follow-up period (months)


Mean
Range

1-5
9
1-26

Early Post-operative Remission Rates


Endoscopic vs. Microscopic Results

Endoscopic Series
Microscopic Series a
a

Hormonally Active Non-functioning


Adenomas
Adenomas
ACTH PRL
GH
84%
78% 88%
93%
81%

66%

77%

82%

Calculated from several published microscopic series

Complication Rates (percent)


Endoscopic vs. Microscopic
Ant. Pit.
Insuf.

DI

Loss of
Vision

Carotid
Injury

CNS
Injury

Intrasellar
Hemor.

CSF
Leak

Meningitis

Endoscopic

2.7

1.4

2.7

1.9

Microscopic a

19.4

17.8

1.8

1.1

1.3

2.9

3.9

1.5

Calculated from several published microscopic series

Fully Endoscopic Transnasal-Transsphenoidal


Pituitary 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


Pituitary 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


Pituitary 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