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Endoscopic surgery is performed through the nose to remove tumors from the pituitary gland and skull base. In this minimally invasive surgery, the surgeon works through the nostrils with a tiny endoscope camera and light to remove tumors with long instruments. Pituitary tumors can cause hormone problems and vision loss. Tumor removal often reverses vision problems and restores normal hormone balance. What is transsphenoidal pituitary surgery?Transsphenoidal literally means “through the sphenoid sinus.” It is a surgery performed through the nose and sphenoid sinus to remove pituitary tumors (Fig. 1). Transsphenoidal surgery can be performed with an endoscope, microscope, or both. It is often a team effort between neurosurgeons and ear, nose, and throat (ENT) surgeons. Figure 1. A. Endoscopic transsphenoidal surgery is performed with less disruption to the nose to reach the sphenoid sinus and pituitary. B. The microscope technique removes a large portion of the septum to insert a retractor so that the surgeon can see to the sphenoid sinus and pituitary. A traditional microscope technique uses a skin incision under the upper lip and removal of a large portion of the nasal septum so that the surgeon can directly see the sphenoid sinus area. A minimally invasive technique, called endoscopic endonasal surgery, uses a small incision at the back of the nasal cavity and causes little disruption of the nasal tissues. The ENT surgeon works through the nostrils with a tiny camera and light called an endoscope. In both techniques, bony openings are made in the nasal septum, sphenoid sinus, and sella to reach the pituitary. Once the pituitary is exposed, the neurosurgeon removes the tumor. Who is a candidate?You may be a candidate for transsphenoidal surgery if you have a:
If you have a prolactinoma or a small (<10mm) non-secretory tumor, surgery may not be required. These types of tumors respond well to medication or may be observed with periodic MRIs to watch for tumor growth. Some tumors extend beyond the limits of the transsphenoidal approach. For these tumors, a more extensive craniotomy combined with skull base approaches may be needed. Who performs the procedure?A neurosurgeon performs transsphenoidal surgery often as a team with an ENT (ear, nose, and throat) surgeon who has specialized training in endoscopic sinus surgery. A team approach allows comprehensive care of both brain- and sinus-related issues before, during, and after surgery. Ask your surgeons about their training and experience. What happens before surgery?You will have an office visit with a neurosurgeon, ENT surgeon, and endocrinologist before surgery. A consult with an ophthalmologist may be necessary if you have vision problems. During the office visit, the surgeon will explain the procedure, its risks and benefits, and answer any questions. Next, you will sign consent forms and complete paperwork to inform the surgeon about your medical history (i.e., allergies, medicines, bleeding history, anesthesia reactions, previous surgeries). Discuss all medications (prescription, over-the-counter, and herbal supplements) you are taking with your health care provider. Some medications need to be continued or stopped the day of surgery. Presurgical tests (e.g., blood test, electrocardiogram) may need to be done several days before surgery. Consult your primary care physician about stopping certain medications and ensure you are cleared for surgery. Stop taking all non-steroidal anti-inflammatory medicines (ibuprofen, naproxen, etc.) and blood thinners (Coumadin, Plavix, aspirin, etc.) 7 days before surgery. Stop using nicotine and drinking alcohol 1 week before and 2 weeks after surgery to avoid bleeding and healing problems. You may be asked to wash your skin with Hibiclens (CHG) or Dial soap before surgery. It kills bacteria and reduces surgical site infections. (Avoid getting CHG in eyes, ears, nose or genital areas.) Morning of surgery
Patients are admitted to the hospital the morning of surgery. The nurse will explain the preoperative process and discuss any questions you may have. An anesthesiologist will talk with you to explain the effects of anesthesia and its risks. What happens during surgery?There are 6 steps of the procedure, which generally takes 2 to 3 hours. Step 1: prepare the patient An image-guidance system may be placed on your head (Fig. 2). This device is like a global positioning system (GPS) and helps the surgeon navigate through the nose using a 3D “map” created from your CT or MRI scans. Figure 2. An image-guidance system helps the surgeon navigate through the nose. Skull landmarks and infrared cameras correlate the “real patient” to the 3D computer model generated from the patient’s CT or MRI scans. Instruments are detected by the cameras and displayed on the computer as the surgeon removes the tumor. Step 2: make an incision Step 3: open the sella Step 4: remove the tumor The center of the tumor is cored out, allowing the tumor margins to fall inward so the surgeon can reach it. After all visible tumor is removed, the surgeon advances the endoscope into the sella to look and inspect for hidden tumor. Some tumors grow sideways into the cavernous sinus, a collection of veins. It may be difficult to completely remove this portion of the tumor without causing injury to the nerves and vessels. Any tumor left behind may be treated later with radiation. At some hospitals, surgery can be performed in a special OR room equipped with an intraoperative MRI scanner. The patient can undergo an MRI during surgery. This gives the surgeon real-time images of the patient’s brain to know exactly how much tumor has been removed before ending the procedure. This technology enables more complete tumor removal and may reduce the need for a second operation [1]. Step 5: obtain fat graft (optional) Step 6: close the sella opening Soft, flexible splints may be placed in the nose along the septum to control bleeding and prevent swelling. The splints also prevent adhesions from forming that may lead to chronic nasal congestion. What happens after surgery?After surgery you will be taken to the recovery room, where vital signs are monitored as you awake from anesthesia. Then you'll be transferred to a regular room or the intensive care unit (ICU) for observation and monitoring. You will be encouraged to get out of bed as soon as you are able (sitting in a chair, walking). After surgery you may experience nasal congestion, nausea, and headache. Medication can control these symptoms. An endocrinologist may see you the day after surgery to check that the pituitary gland is producing appropriate levels of hormones. If it is not, hormone-replacement medications may be given. An MRI of the brain will be obtained the day after surgery. In 1 to 2 days, you'll be released from the hospital and given discharge instructions. Follow the surgeon’s home care instructions for 2 weeks after surgery or until your follow-up appointment. In general, you can expect: Restrictions
Incision care
Medications
Activity
When to call your doctor
Recovery and preventionAn appointment for a follow-up visit with your ENT surgeon is typically scheduled 1 week after surgery to remove any nasal splints and to check the surgical site. The ENT will see you as needed until the nasal cavities are healed. Typically, this requires 2 to 4 visits. Small crusts often form in the nose that can cause nasal congestion. The ENT surgeon will spray the nose to provide local anesthesia to the nasal cavities. Crusts can then be removed comfortably. Four weeks after surgery, the patient will be instructed to use a nasal saline rinse. The rinse will decrease the need to remove crusts and hasten nasal healing. An appointment for a follow-up visit with your neurosurgeon will be scheduled for 2 to 4 weeks after surgery. An endocrine follow-up may be recommended to determine if hormone replacement medications are needed. What are the results?If the tumor is hormone secreting (prolactinoma, Cushing’s, or acromegaly), the endocrinologist will follow your hormone levels after surgery to determine whether you are cured. Patients with Cushing’s disease usually have small tumors (microadenomas) and are surgically cured about 90% of the time [2]. Patients with acromegaly often have larger, more invasive tumors. The success rate is about 60% with growth-hormone secreting macroadenomas [2]. Some pituitary tumors remain surgically incurable due to invasion of the cavernous sinuses and other important structures. Radiosurgery can be used to treat unresectable tumor remnants with very good long-term control rates (Fig. 6). If there is residual tumor after surgery for acromegaly, Cushing’s disease, or prolactinomas, medical treatments are available to control the excess hormone secretion. Figure 6. Radiation may be used after surgery to control remaining tumor that has invaded the cavernous sinuses.Since it is impossible to predict whether or when a tumor may recur, periodic monitoring with MRI scans is needed to watch for changes or regrowth. What are the risks?No surgery is without risks. General complications of any surgery include bleeding, infection, blood clots, and reactions to anesthesia. Specific complications related to pituitary surgery include:
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