DISCLOSURES Benvenue (consultant/royalty) Spineology - PDF document

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 Co-Director, Gamma Knife Program, Washington Hospital 1 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. 2 1

1/25/20 PITUITARY GLAND THE MASTER GLAND 3 • March 1907 Hermann Schloffer reported the first successful removal of a pituitary tumor (transnasal, TS) • 1909 Theodor Kocher modification (transnasal, HISTORY OF transeptal/submucosal) TRANSSPHENOIDAL • 1910 Albert Halstead proposed a sublabial gingival incision SURGERY • June 1910 Harvey Cushing performs the first sublabial, transeptal TS • June 1910 Oskar Hirsch performs the first endonasal, transeptal TS 4 2

1/25/20 Harvey Cushing performed 231 TS with 5.6% mortality 1910–1925 1929–1965 Transcranial approach dominated in North America HISTORY OF TRANSSPHENOIDAL SURGERY 5 NORMAN NO 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) 6 3

1/25/20 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 7 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 8 4

1/25/20 CHARLES B. WILSON • performed over 3500 TS • Curative resection possible with preservation of gland • Minimize need for radiotherapy • Improved safety of surgery 9 • Since 2001 • The endonasal transsphenoidal surgery was developed and exclusively used for resection of pituitary lesions HISTORY OF • Anterior mucosal incision was eliminated TRANSSPHENOIDAL • Nasal Packings were eliminated SURGERY • Endoscope was utilized for complicated cases • Over 3000 endonasal transsphenoidal surgeries have been performed • High cure rates and even lower morbidity were achieved 10 5

1/25/20 Transphenoidal corrider 11 SUBLABIAL, TRANSEPTAL TRANSSPHENOID AL APPROACH 12 6

1/25/20 FIRST MODIFICATION: ENDONASAL TRANSSPHENOIDAL APPROACH 13 14 7

1/25/20 15 SECOND MODIFICATION: ENDOSCOPIC ENDONASAL TRANSSPHENOIDAL 16 8

1/25/20 Resection of a microadenoma 17 FACTORS THAT INFLUENCE SURGICAL OUTCOME SURGEON/PATIENT SURGEON TRAINING SURGEON RELATIONSHIP EXPERIENCE 18 9

1/25/20 Best Surgical Outcomes MAXIMIZE TUMOR RESECTION MINIMIZE COMPLICATIONS • MOST TUMORS CAN BE CURED SURGICALLY IF AN ATTEMPT TO REMOVE 100% OF THE TUMOR IS FOR BENIGN TUMORS, MINIMIZING • MADE COMPLICATIONS IS CRITICAL • SOME TUMORS CAN NEVER BE CURED BY PRESERVE/IMPROVE VISION • PRESERVE/IMPROVE THE PITUITARY GLAND SURGERY ALONE, REGARDLESS OF EXPERIENCE • FUNCTION IF THE GLAND IS WORKING, KEEP THE • GLAND WORKING MINIMIZE RISK OF SPINAL FLUID LEAK • MINIMIZE RISK OF ARTERIAL INJURY • 19 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 20 10

1/25/20 THE GOOD Should be curable by most surgeons 21 THE BAD Difficult to treat, but still can be cured 22 11

1/25/20 THE UGLY Gross invasion into the cavernous sinus, can not be cured by surgery alone 23 COMPLICATION RATES CORRELATE WITH EXPERIENCE Ciric Ivan, Ragin Ann, Baumgartner Craig, Pierce Debi, Complications of Transsphenoidal Surgery: Results of a National Survey, Review of the Literature, and Personal Experience, Neurosurgery , Volume 40, Issue 2, February 1997, Pages 225–237 24 12

1/25/20 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. 25 TECHNIQUE IS IMPORTANT IN MAXIMIZING RESECTION/MINIMIZING COMPLICATIONS 26 13

1/25/20 GIANT ADENOMA (5.5 CM) 72 yo male with bitemporal vision loss, headache, panhypopituitarism 27 POSTOP – EETS 28 14

1/25/20 69 yo with a tuberculum sella meningioma 29 30 15

1/25/20 CLINICAL VIGNETTE (INVASIVE ADENOMA/ACROMEGALY) 31 SINGLE SURGEON, UCSF EXPERIENCE 2016-2017 272 ENDONASAL TRANSSPHENOIDAL SURGERIES Length of Stay 250 200 150 100 50 0 1 2 3 4 5 7 Patients with pituitary adenoma/Rathke’s Cleft Cyst 84% of patients discharge on POD#1 96% of patients discharged by POD#2 32 16

1/25/20 SINGLE SURGEON, UCSF EXPERIENCE 2016-2017 272 ENDONASAL TRANSSPHENOIDAL SURGERIES Complications: 33 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 34 17

1/25/20 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 • 35 ACKNOWLEDGEMENTS - CCPD Department of Neurosurgery Division of Neuropathology Manish Aghi Andrew Bollen Philip Theodosopolous Tarik Tihan James Sardelis Arie Perry NeuroEndocrinology Lewis Blevins Blake Tyrell Radiation Oncology Division of Neuroradiology William Dillon Penny Sneed Christopher Hess Steve Braunstein Christine Glastonbury Jean Nakamura 36 18