Peer-Review Reports
Contemporary Indications for Transsphenoidal Pituitary Surgery Brandon A. Miller, Adriana G. Ioachimescu, Nelson M. Oyesiku
Key words Pituitary adenoma - Pituitary surgery -
Abbreviations and Acronyms ACTH: Adrenocorticotropic hormone CSF: Cerebrospinal fluid GH: Growth hormone MRI: Magnetic resonance imaging Department of Neurosurgery, Emory University, Atlanta, Georgia, USA To whom correspondence should be addressed: Nelson M. Oyesiku, M.D., Ph.D. [E-mail: [email protected]] Citation: World Neurosurg. (2014) 82, 6S:S147-S151. http://dx.doi.org/10.1016/j.wneu.2014.07.037 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com
- OBJECTIVE:
To analyze current indications for transsphenoidal pituitary
surgery. - METHODS:
The current literature regarding transsphenoidal surgery for all subtypes of pituitary adenomas and other sellar lesions was examined. Alternate approaches for pituitary surgery were also reviewed.
- RESULTS:
Transsphenoidal surgery continues to be the mainstay of surgical treatment for pituitary tumors, and has good outcomes in experienced hands. Pre- and postoperative management of pituitary tumors remains an important part of the treatment of patients with pituitary tumors.
- CONCLUSIONS:
Even as medical and surgical treatment for pituitary tumors evolves, transsphenoidal surgery remains a mainstay of treatment. Outcomes after transshenoidal surgery have improved over time. Neurosurgeons must be aware of the indications, risks and alternatives to transsphenoidal pituitary surgery.
1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved.
INTRODUCTION The indications for transsphenoidal surgery have expanded considerably since the advent of this approach in the early 1900s. The most common indication for the transsphenoidal approach is resection of pituitary adenomas; however, it can be used for resection of craniopharyngiomas, Rathke cleft cysts, chordomas, meningiomas, and skull base reconstruction. Although a transcranial approach can also be used to access the sella, a transsphenoidal approach is preferred unless special circumstances, such as extensive cavernous sinus invasion, apply. Before surgery, other surgical and nonsurgical options must be properly considered. An appropriate endocrine work-up must be completed because certain pituitary tumors may be amenable to medical therapy. The neurosurgeon should take into account all surgical options available when approaching a pituitary lesion and use the optimal transsphenoidal or transcranial technique. HISTORICAL AND RECENT DEVELOPMENTS IN TRANSSPHENOIDAL SURGERY The first transsphenoidal operation is credited to Schloffer in 1907 (15). Cushing
performed his first transsphenoidal operation in 1909 with the successful treatment of a patient with acromegaly (17). Cushing performed almost 300 transsphenoidal operations with a commendable mortality rate for the time of 5.6%, but subsequently he favored the transcranial approach because of high tumor recurrence rates and improvements in instrumentation for transcranial neurosurgery (15, 17, 25). In parallel with Cushing’s loss of enthusiasm for the technique, transsphenoidal surgery fell out of favor until the 1960s, when Dott, Guiot, and Hardy popularized the procedure again (15, 17). Hardy was the first to perform a selective microadenectomy via a microscopic transsphenoidal approach (35). At the present time, a transsphenoidal approach is the method of choice for resection of pituitary adenomas. Although microscopic techniques are used, the endoscopic technique is gaining favor as the preferred approach in experienced hands (13, 40). New three-dimensional endoscopes are gaining popularity as a solution to the limitations of the twodimensional view provided by traditional endoscopes. Complications after endoscopic surgery are generally low, with transient diabetes insipidus being the most common and still
Contemporary Indications for Transsphenoidal Pituitary Surgery Brandon A. Miller, Adriana G. Ioachimescu, Nelson M. Oyesiku
Key words Pituitary adenoma - Pituitary surgery -
Abbreviations and Acronyms ACTH: Adrenocorticotropic hormone CSF: Cerebrospinal fluid GH: Growth hormone MRI: Magnetic resonance imaging Department of Neurosurgery, Emory University, Atlanta, Georgia, USA To whom correspondence should be addressed: Nelson M. Oyesiku, M.D., Ph.D. [E-mail: [email protected]] Citation: World Neurosurg. (2014) 82, 6S:S147-S151. http://dx.doi.org/10.1016/j.wneu.2014.07.037 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com
- OBJECTIVE:
To analyze current indications for transsphenoidal pituitary
surgery. - METHODS:
The current literature regarding transsphenoidal surgery for all subtypes of pituitary adenomas and other sellar lesions was examined. Alternate approaches for pituitary surgery were also reviewed.
- RESULTS:
Transsphenoidal surgery continues to be the mainstay of surgical treatment for pituitary tumors, and has good outcomes in experienced hands. Pre- and postoperative management of pituitary tumors remains an important part of the treatment of patients with pituitary tumors.
- CONCLUSIONS:
Even as medical and surgical treatment for pituitary tumors evolves, transsphenoidal surgery remains a mainstay of treatment. Outcomes after transshenoidal surgery have improved over time. Neurosurgeons must be aware of the indications, risks and alternatives to transsphenoidal pituitary surgery.
1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved.
INTRODUCTION The indications for transsphenoidal surgery have expanded considerably since the advent of this approach in the early 1900s. The most common indication for the transsphenoidal approach is resection of pituitary adenomas; however, it can be used for resection of craniopharyngiomas, Rathke cleft cysts, chordomas, meningiomas, and skull base reconstruction. Although a transcranial approach can also be used to access the sella, a transsphenoidal approach is preferred unless special circumstances, such as extensive cavernous sinus invasion, apply. Before surgery, other surgical and nonsurgical options must be properly considered. An appropriate endocrine work-up must be completed because certain pituitary tumors may be amenable to medical therapy. The neurosurgeon should take into account all surgical options available when approaching a pituitary lesion and use the optimal transsphenoidal or transcranial technique. HISTORICAL AND RECENT DEVELOPMENTS IN TRANSSPHENOIDAL SURGERY The first transsphenoidal operation is credited to Schloffer in 1907 (15). Cushing
performed his first transsphenoidal operation in 1909 with the successful treatment of a patient with acromegaly (17). Cushing performed almost 300 transsphenoidal operations with a commendable mortality rate for the time of 5.6%, but subsequently he favored the transcranial approach because of high tumor recurrence rates and improvements in instrumentation for transcranial neurosurgery (15, 17, 25). In parallel with Cushing’s loss of enthusiasm for the technique, transsphenoidal surgery fell out of favor until the 1960s, when Dott, Guiot, and Hardy popularized the procedure again (15, 17). Hardy was the first to perform a selective microadenectomy via a microscopic transsphenoidal approach (35). At the present time, a transsphenoidal approach is the method of choice for resection of pituitary adenomas. Although microscopic techniques are used, the endoscopic technique is gaining favor as the preferred approach in experienced hands (13, 40). New three-dimensional endoscopes are gaining popularity as a solution to the limitations of the twodimensional view provided by traditional endoscopes. Complications after endoscopic surgery are generally low, with transient diabetes insipidus being the most common and still
