Skull Base Brain Tumor Research

Endoscopic Pituitary Surgery
By Hrayr Shahinian, M.D.

Patient presentation and preoperative assessment
This is the case of a 42 year-old Caucasian female with an eighteen month history of amenorrhea, galactorrhea, hypothyroidism, and hypocortisolism that was being treated by a multifaceted hormone replacement regimen prior to her presentation. She was referred to us and to Dr. Shlomo Melmed for joint surgical and endocrinological evaluation at the Skull Base Institute. Physical examination at the time of our initial consultation was unremarkable, with no overt manifestations of hormone deficiencies detectable. Review of the patient's M.R.I. scan revealed a 1.8 x 2.0 cm pituitary macroadenoma in the sella turcica without radiological evidence of optic chiasm compression or parasellar extension. Our collective conclusions based upon the patient's history and objective radiological findings were that she would be an ideal candidate for a minimally invasive endoscopic transnasal resection. Treatment options were discussed with the patient and her family, who all agreed to proceed with endoscopic surgery.

Operative technique and postop course
Anesthetized, in supine position, and with the head and neck draped to reveal only the nostrils, a 0-degree, 4- mm wide, 18-cm long endoscope was passed through the right nostril and fixed in a specially designed endoscope holder. The surgical anatomy of the right nasal cavity was identified, including the middle turbinate and the site of the sphenoid ostium at the confluence of the middle turbinate and nasal septum. The mucosa overlying the sphenoid ostium was electrocoagulated and resected and the bone of the anterior wall of the sphenoid sinus was removed using Kerrison rongeurs. Thus exposed, the cavity of the sphenoid sinus was explored by advancing the endoscope into it.

At this point, attention was turned to the posterior wall of the sphenoid sinus (the floor of the sella). Micro-osteotomes were used to fracture the bone and Kerrison rongeurs were again used to enlarge the osteotomy. The endoscope was advanced again further into the surgical field and the contents of the sella were exposed. The dura was incised, the adenoma was revealed, and resection was begun.

Both the 0-degree and 30-degree endo-scopes were used to define the anatomy of the sella and parasellar structures, including tumor, normal pituitary gland, the cavernous sinuses, and the carotid prominences bilaterally, enabling a complete gross resection. The patient tolerated the procedure well. She was transferred to a regular room after spending 18 hours in the intensive care unit and discharged home 36 hours after surgery. She demonstrated no signs of diabetes insipidus, CSF leak, or neurologic sequelae.

While long term data is not yet available, we anticipate that this will ultimately translate into lower rates of tumor recurrence, lower morbidity, lower costs and more importantly less discomfort.