DISCLOSURES Benvenue (consultant/royalty) Spineology - - PDF document

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DISCLOSURES Benvenue (consultant/royalty) Spineology - - PDF document

Jan 09, 2024 377 likes •581 views

1/25/20 Goals and Complications of Pituitary Surgery: How to Ensure the Best Outcomes for Patients Sandeep Kunwar, M.D. Surgical Director, California Center for Pituitary Disorders Associate Professor, University of California, San Francisco

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Goals and Complications of Pituitary Surgery: How to Ensure the Best Outcomes for Patients

Sandeep Kunwar, M.D. Surgical Director, California Center for Pituitary Disorders Associate Professor, University of California, San Francisco Co-Director, Gamma Knife Program, Washington Hospital

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DISCLOSURES

  • Benvenue (consultant/royalty)
  • Spineology (consultant/royalty)
  • SpineWave (royalty)
  • Nuvasive (royalty)
  • I have no relevant financial relationships with any companies related to the

content of this talk.

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PITUITARY GLAND

THE MASTER GLAND

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HISTORY OF TRANSSPHENOIDAL SURGERY

  • March 1907 Hermann Schloffer reported the first

successful removal of a pituitary tumor (transnasal, TS)

  • 1909 Theodor Kocher modification (transnasal,

transeptal/submucosal)

  • 1910 Albert Halstead proposed a sublabial gingival

incision

  • June 1910 Harvey Cushing performs the first

sublabial, transeptal TS

  • June 1910 Oskar Hirsch performs the first endonasal,

transeptal TS

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HISTORY OF TRANSSPHENOIDAL SURGERY

1910–1925

Harvey Cushing performed 231 TS with 5.6% mortality

1929–1965

Transcranial approach dominated in North America

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NO NORMAN N DO DOTT

  • Rockefeller Fellow, 1923-1924
  • Neurosurgeon at the Royal Infirmary of

Edinburgh

  • Continued performing TS surgery until 1962
  • Improved illumination with a modified

speculum with lights

  • (0 mortality in 80 patients)

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GE GERARD GU GUIOT

  • Neurosurgeon at the Hospital Foch
  • Performed TS surgery from 1956-

1981 (over 1000 cases)

  • Introduced televised fluoroscopy
  • Changed the position to semisitting
  • Combined surgery with

postoperative radiation therapy

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JULES HARDY

  • Worked as a fellow with Guiot
  • Continued to use fluoroscopy but added

preoperative angiography and intraoperative pneumoencephalography

  • Introduced the use of the operating microscope

and developed specialized instruments

  • 1968, he introduced the concept of

microadenomas

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CHARLES B. WILSON

  • performed over 3500 TS
  • Curative resection possible with preservation
  • f gland
  • Minimize need for radiotherapy
  • Improved safety of surgery

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HISTORY OF TRANSSPHENOIDAL SURGERY

  • Since 2001
  • The endonasal transsphenoidal surgery

was developed and exclusively used for resection of pituitary lesions

  • Anterior mucosal incision was eliminated
  • Nasal Packings were eliminated
  • Endoscope was utilized for complicated cases
  • Over 3000 endonasal transsphenoidal surgeries

have been performed

  • High cure rates and even lower morbidity were

achieved 10

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Transphenoidal corrider

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SUBLABIAL, TRANSEPTAL TRANSSPHENOID AL APPROACH

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FIRST MODIFICATION: ENDONASAL TRANSSPHENOIDAL APPROACH

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SECOND MODIFICATION: ENDOSCOPIC ENDONASAL TRANSSPHENOIDAL

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Resection of a microadenoma

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FACTORS THAT INFLUENCE SURGICAL OUTCOME

SURGEON/PATIENT RELATIONSHIP SURGEON TRAINING SURGEON EXPERIENCE

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MAXIMIZE TUMOR RESECTION

  • MOST TUMORS CAN BE CURED SURGICALLY IF AN

ATTEMPT TO REMOVE 100% OF THE TUMOR IS MADE

  • SOME TUMORS CAN NEVER BE CURED BY

SURGERY ALONE, REGARDLESS OF EXPERIENCE

MINIMIZE COMPLICATIONS

  • FOR BENIGN TUMORS, MINIMIZING

COMPLICATIONS IS CRITICAL

  • PRESERVE/IMPROVE VISION
  • PRESERVE/IMPROVE THE PITUITARY GLAND

FUNCTION

  • IF THE GLAND IS WORKING, KEEP THE

GLAND WORKING

  • MINIMIZE RISK OF SPINAL FLUID LEAK
  • MINIMIZE RISK OF ARTERIAL INJURY

Best Surgical Outcomes

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WHY ARE NOT ALL PITUTIARY TUMORS CURABLE BY SURGERY

  • Not all tumors are the same
  • Invasion into the cavernous sinus
  • Firmness of the tumor
  • Vascularity of the tumor
  • Biology of the tumor

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THE GOOD

Should be curable by most surgeons

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THE BAD

Difficult to treat, but still can be cured

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THE UGLY

Gross invasion into the cavernous sinus, can not be cured by surgery alone

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COMPLICATION RATES CORRELATE WITH EXPERIENCE

Ciric Ivan, Ragin Ann, Baumgartner Craig, Pierce Debi, Complications of Transsphenoidal Surgery: Results

  • f a National Survey, Review of the Literature, and Personal Experience, Neurosurgery, Volume 40, Issue 2,

February 1997, Pages 225–237

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THE TOOL DOES NOT CORRELATE WITH OUTCOME

CO COMPARISON OF VOLUMETRIC EXTENT OF TUMOR RESECTION FROM A PROSPECT CTIVE MU MULTICENTER CONTROLLED STUDY OF FULLY ENDOSCOPIC VERSUS MI MICROSCOPIC PIC TRA TRANSSPHENOIDAL S SUR URGERY F Y FOR N R NONFUN UNCTI TIONING P PITUI TUITARY A Y ADENOMAS: T THE HE TRAN ANSSPHE PHER ST STUDY

ANDREW S. LITTLE, MD; DANIEL F. KELLY MD; WILLIAM L. WHITE, MD; PAUL A. GARDNER, MD; JUAN C. FERNANDEZ- MIRANDA, MD; MICHAEL R. CHICOINE, MD; GARNI BARKHOUDARIAN, MD; JAMES P. CHANDLER MD; DANIEL M. PREVEDELLO, MD; BRANDON D. LIEBELT, MD, BS; JOHN SFONDOURIS, MD; MARC R. MAYBERG, BA, MD

  • CONCLUSION: This unadjusted analysis does not support the hypothesis that endoscopic

visualization improves extent of tumor resection over microscopic surgery for nonfunctioning

  • adenomas. A multivariate analysis of independent predictors of extent of resection is

forthcoming.

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TECHNIQUE IS IMPORTANT IN MAXIMIZING RESECTION/MINIMIZING COMPLICATIONS

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GIANT ADENOMA (5.5 CM)

72 yo male with bitemporal vision loss, headache, panhypopituitarism

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POSTOP – EETS

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69 yo with a tuberculum sella meningioma

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CLINICAL VIGNETTE (INVASIVE ADENOMA/ACROMEGALY)

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SINGLE SURGEON, UCSF EXPERIENCE 2016-2017 272 ENDONASAL TRANSSPHENOIDAL SURGERIES

50 100 150 200 250 1 2 3 4 5 7

Length of Stay

Patients with pituitary adenoma/Rathke’s Cleft Cyst 84% of patients discharge on POD#1 96% of patients discharged by POD#2

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SINGLE SURGEON, UCSF EXPERIENCE 2016-2017 272 ENDONASAL TRANSSPHENOIDAL SURGERIES

Complications:

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LESSONS LEARNED

  • 1000 consecutive endonasal transsphenoidal surgeries
  • Diagnosis
  • Pituitary Adenoma – 778
  • Rathke’s Cleft Cyst – 124
  • Craniopharyngioma – 28
  • Chordoma – 11
  • CSF leak repair – 11
  • Meningioma – 6
  • Langerhans – 4
  • Arachnoid Cyst – 4

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LESSONS LEARNED

  • Diagnosis (cont’d)
  • Epidermoid Cyst – 4
  • Optic nerve tumor – 4
  • Metastatic tumors - 4
  • Lymphocytic hypophysitis – 5
  • Germ cell tumor - 3
  • Colloid Cyst – 2
  • Hypothalamic mass – 2
  • Plasmacytoma – 1
  • Cholesterol granuloma – 1
  • Hemangioblastoma – 1

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ACKNOWLEDGEMENTS - CCPD

Department of Neurosurgery Manish Aghi Philip Theodosopolous James Sardelis NeuroEndocrinology Lewis Blevins Blake Tyrell Division of Neuroradiology William Dillon Christopher Hess Christine Glastonbury Division of Neuropathology Andrew Bollen Tarik Tihan Arie Perry Radiation Oncology Penny Sneed Steve Braunstein Jean Nakamura

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