Endoscopic Transsphenoidal Treatment in Recurrent and Residual Pituitary Adenomas - First Experience

Abstract

Aim of the Study: The aim of the study has been the assessment of the endoscopic method in the surgical management of recurrent and residual pituitary adenomas, as concerns treatment efficiency, substantial complications, and its possible advantages for the operating surgeon and patient. Material and Methods: In Department of Neurosurgery, Silesian University School of Medicine in Katowice, between October 2001 and June 2004, 125 patients underwent endoscopic surgery due to pituitary adenoma. The analysis comprised 20 patients, who were operated on due to recurrent adenomas or residual tumour not completely removed during the first surgical procedure. The group of patients was composed of 9 women and 11 men. The youngest patient was 32 years of age, the oldest 79. The average age was 53.9 years. The analysed group had 14 non-functioning adenomas, 4 GH-secreting adenomas, 1 PRL-secreting adenoma and 1 ACTH-secreting adenoma. 19 of them were macroadenomas while 1 was a microadenoma. 11 of the 20 adenomas infiltrated the cavernous sinuses. The surgical procedures were performed by a stable team, composed of 2 neurosurgeons, a laryngologist and an anaesthesiologist. The surgery method was based upon the technique developed by Jho and Carrau, with own modifications of the operators. A rigid neuroendoscope having the diameter of 4 mm with 0 ° and 30 ° optics by Storz was used. The follow-up period after surgery was between 12 and 42 months, 24.2 months on average. Results: Of the 20 cases, complete recovery was achieved in 40 % of patients undergoing secondary surgical procedures. In the group of 11 patients with adenomas not infiltrating the cavernous sinuses, recovery was reported for 8 of them, that is 73 %. No fatalities occurred. 7 cases of liquorrhoea occurred during operation, requiring reconstruction and sealing of the sella by means of tissue glue and artificial dura or freeze-dried human dura. In 1 case, despite the application of post-operative lumbar drainage, rhinorrhoea occurred one month after the procedure, which required endoscopic reconstructive treatment. In the same patient, a pneumoencephalocele was observed. The average time of the repeat surgical procedure using endoscopic techniques was shorter by 18 minutes than the repeat procedure using microscopic techniques. Conclusions: The endoscopic method is a safe, hardly invasive and efficient surgical technique in the treatment of recurrent and residual pituitary adenomas. Advantages which add to its attractiveness are also reduction of the procedure duration, very good visualisation of the operative field, absence of serious complications, less pain experienced after the surgery.

Key words

Recurrent adenoma - secondary surgery - endoscopic method - transsphenoidal approach

References

• 1 Hardy J. Transsphenoidal approach to the pituitary gland. In: Wilkins RH, Rengachary SS (eds). Neurosurgery. New York: McGraw-Hill Book Co 1983: 889-898
• 2 Ciric I, Mikhael M, Stafford T, Lawson L, Garces R. Transsphenoidal microsurgery of pituitary macroadenomas with long-term follow-up results.  J Neurosurg. 1983;  59 395-401
• 3 Ciccarelli E, Ghigo E, Miola C, Gandini G, Muller E E, Camanni F. Long-term follow-up of “cured” prolactinoma patients after successful adenomectomy.  Clin Endocrinol. 1990;  32 583-592
• 4 Friedman R B, Oldfield E H, Nieman L K, Chrousos G P, Doppman J L, Cutler Jr G B, Loriaux D L. Repeat transsphenoidal surgery for Cushing's disease.  J Neurosurg. 1989;  71 520-527
• 5 Abosch A, Tyrrell J B, Lamborn K R, Hannegan L T, Applebury C B, Wilson C B. Transsphenoidal microsurgery for growth hormone-secreting pituitary adenomas: initial outcome and long-term results.  J Clin Endocrinol Metab. 1998;  83 3411-3418
• 6 Jho H D, Carrau R L. Endoscopic endonasal transsphenoidal surgery: Experience with 50 patients.  J Neurosurg. 1997;  87 44-51
• 7 Jho H D. Endoscopic transsphenoidal surgery.  J Neurooncol. 2001;  54 187-195
• 8 Cappabianca P, Cavallo L M, Colao A, Del Basso De Caro M, Esposito F, Cirillo S, Lombardi G, Divitiis E de. Endoscopic endonasal transsphenoidal approach: outcome analysis of 100 consecutive procedures.  Minim Invas Neurosurg. 2002;  45 193-200
• 9 Cappabianca P, Alfieri A, Colao A, Cavallo L M, Fusco M, Peca C, Lombardi G, Divitiis E de. Endoscopic endonasal transsphenoidal surgery in recurrent and residual pituitary adenomas: technical note.  Minim Invas Neurosurg. 2000;  43 38-43
• 10 Rudnik A, Zawadzki T, Wojtacha M, Bażowski P, Gamrot J, Gałuszka-Ignasiak B, Duda I. Endoscopic transnasal transsphenoidal treatment of pathology of the sellar region.  Minim Invas Neurosurg. 2005;  48 101-107
• 11 Landolt A M. Surgical management of recurrent pituitary tumors. In: Schmidek HH (ed), Schmidek & Sweet Operative Neurosurgical Techniques: Indications, Methods, and Results, 4th edn. Vol. 1. Philadelphia: WM Saunders 2000: 455-466
• 12 Griffith H B, Veerapen R. A direct transnasal approach to the sphenoid sinus. Technical note.  J Neurosurg. 1987;  66 140-142
• 13 Cooke R S, Jones R AC. Experience with the direct transnasal transsphenoidal approach to the pituitary fossa.  Br J Neurosurg. 1994;  8 193-196
• 14 Visot A, Gaillard S, Derome P J. Surgical management of endocrinologically silent pituitary tumors. In: Schmidek HH (ed), Schmidek & Sweet Operative Neurosurgical Techniques: Indications, Methods, and Results, 4th edn. Vol. 1. Philadelphia: WM Saunders 2000: 424-437
• 15 Abe T, Ludecke D K. Recent results of secondary transnasal surgery for residual or recurring acromegaly.  Neurosurgery. 1998;  42 1013-1021
• 16 Kurosaki M, Ludecke D K, Abe T. Effectiveness of secondary transnasal surgery in GH-secreting pituitary macroadenomas.  Endocr J. 2003;  50 635-642
• 17 Alfieri A, Jho H D. Endoscopic endonasal approaches to the cavernous sinus: surgical approaches.  Neurosurgery. 2001;  49 354-360
• 18 Jho H D, Ha H G. Endoscopic endonasal skull base surgery: Part 2.The cavernous sinus.  Minim Invas Neurosurg. 2004;  47 9-15
• 19 Koren I, Hadar T, Rappaport Z H, Yaniv E. Endoscopic transnasal transsphenoidal microsurgery versus the sublabial approach for the treatment of pituitary tumors: endonasal complications.  Laryngoscope. 1999;  109 1838-1840
• 20 Cho D Y, Liau W R. Comparison of endonasal endoscopic surgery and sublabial microsurgery for prolactinomas.  Surg Neurol. 2002;  58 371-375