Complications and Learning Curve following Transition to Endoscopic Transsphenoidal Surgery

Background: Endoscopic transnasal approaches to the sella provide improved exposure with comparable oncological outcomes and complication. Previous experiences with transitioning to endoscopic techniques in an academic setting showed steep operative learning curves. Despite the promising future for endoscopic pituitary surgery the technique is still relatively novel and requires additional scrutiny to refine technique and decrease complications. The purpose of this study is to delineate an operative learning curve after transition to pituitary resection through an endoscopic transsphenoidal approach.

Methods: A retrospective chart review of all patients who underwent endoscopic pituitary surgery from April 2006 to August of 2008 was performed. Surgical cases were jointly performed by one Otolaryngologist and several neurosurgeons. Demographic data, tumor type, complication rates, need for revision surgery, and follow up periods were documented. The complications included were cerebrospinal leak, meningitis, epistaxis, nasal debridements, septal osteomyelitis, anosmia, nasal obstruction, and sinusitis. Analysis was performed on the first 100 patients in a sequential fashion to delineate a learning curve. Additional analysis was performed on all patients to evaluate overall experience.

Results: The mean age was 50.8 years, median age was 54.8 years with a range of 13.8–81 years. Fifty-four percent of patients were male and 46% were female. Of the first 100 of the total 432 patients studied, average OR time was 155.6 minutes with a range from 62–307 minutes. Three percent of patients had revision surgery for residual or recurrent tumors. The overall complication rate requiring extended hospitalization or surgery was 7%, 7 patients had an intraoperative CSF leak and 5 were delayed. Five intraoperative leaks resolved with sellar reconstruction with abdominal fat and cartilage alone at initial operation and 2 required the addition of a lumbar drain. Four delayed leaks required a lumbar drain and operative exploration with 1 resolving with a lumbar drain alone. Seven cases of post-operative epistaxis were reported with only 1 requiring operative intervention. During post-operative visits, nineteen patients did not require nasal debridement, 43 patients needed at least one debridement, 15 patients had two debridements and 9 patients required three or more debridements. There were no reported cases of nasal septal osteomyelitis or need for revision surgery in the first 100 patients. Only 1 patient had anosmia, 4% reported nasal obstruction, and 4% were treated for postoperative sinusitis. There were no reports of meningitis or mortality. In the learning curve analyses, epistaxis increased (odds ratio = 1.9, p = 0.02). All other complications showed no significant learning curves. There was a significant decrease in operative time with increasing experience (p = 0.0027).

Conclusion: This study reports an initial learning curve for the first 100 patients in terms of operative time; however there was no such relationship defined with complications rates except delayed epistaxis. These findings support the notion that collaboration between a specialized otolaryngologist and neurosurgeon can predict safe transition to endoscopic pituitary surgery in the academic setting.