Endoscopic Transsphenoidal Pituitary Surgery

Endoscopic Transsphenoidal Pituitary Surgery

Hypophyseal(pituitary) tumours are skull base lesions that are treated by surgery using an endoscope and removing the lesion through the nose. The pituitary is a very important gland that is located in the centre of the skull base, whose function is to produce various hormones. It is a vital gland to maintain the body's endocrine (hormonal) balance. Tumours that most frequently appear in this gland are called pituitary adenomas, and are benign in nature.

When is the intervention indicated?

It is indicated in cases where the tumour produces hormonal disorders that are not controlled by medication or when neighbouring structures are damaged,such as the optic nerves. The aim of the operation would be to resect the anomalous tissue, if possible in its entirety, and obtain a sample for analysis.

What is the operation about?

The intervention consists of an approach through one or both nostrils with an endoscope (this is, our camera) and two other instruments (aspirator and dissector) until reaching the sella turcica (bony cover where the pituitary gland is lodged), with which the tumour is accessed in a very direct and safe way. After the approach the lesion is removed, trying to respect healthy pituitary tissue.

Removal of the tumour does not ensure that it will not grow back, regardless of whether it is benign or malignant, nor does it ensure that there are no endocrine disorders that require hormonal replacement therapyafter surgery.

You must know that all of these interventions are very delicate. The objective of the operation is to try to completely remove the lesion, obtain material for anatomopathological study that allows us to confirm the lesion, to give a prognosis including the need for additional treatment, and to improve the endocrinological symptomatology and the ophthalmologic clinic details if they exist.

What are the possible risks, complications and sequelae?

You should know that this sort of surgical procedure is complex and delicate. Anaesthesia and care in the ICU and ward are also complex.

There may be postoperative complications related to surgery (fistula of cerebrospinal fluid, i.e. leakage of fluid that covers the brain through the nose, haemorrhage, infection) and manipulation of the hypophysis or hypothalamus (hormonal changes), arteries (cerebral infarction) or cranial nerves (decreased vision, paralysis of the nerves that motion the eyes). Any of these complications may lead to transient or permanent neurological worsening of the patient's symptoms or to the appearance of other new symptoms. In many cases the so-called diabetes insipidus occurs, which means that the patient urinates profuse fluid due to the lack of a hormone secreted by the pituitary, called antidiuretic hormone (ADH).

This occurrence is usually transient but may require long-term pharmacological treatment. Other complications are not directly related to the intervention (pulmonary infection, venous thrombosis, embolism, lack of sodium in the blood, anemia, digestive haemorrhage, etc) although the end result and complications will depend on the patient's condition and the aggressiveness of the surgery performed.

For one cause or the other, postoperative mortality may in some cases reach 1%.

Endoscopic Pituitary Surgery Postoperative Course

The patient will leave the operating room with one or two blockages in the nose and must breathe through the mouth for a few days. In general, after surgery, the patient enters the Intensive Care Unit for at least the first 24 hours, for strict control of the immediate postoperative period. The next day after surgery, if there are no complications, the patient will be taken to a hospital room. Once there, the patient will begin to tolerate diet and, if there are no contraindications,the patient will start to get out of bed.

The patientwill be usually discharged in 4-5 days, and may be delayed or not depending on the condition of each patient. During admission time the usual constants of any postoperative period will be monitored and, in this particular case, daily diuresis will be controlled. This fact is highlighted because, during the postoperative period of a pituitary tumour, several of the hormones produced by the pituitary gland may not be secreted in their physiological doses due to the manipulation of the gland. Your doctor will temporarily medicate the corticoid shaft, and diuresis will be monitored because sometimes theantidiuretic hormone (ADH) is not produced in normal doses, by which the patient usually excretes excessive amounts of urinethat will need to be under monitoring.The patient will also be asked every day if there are nasal liquid secretions in excess.

Surgery performed through the nostrils often generates secretions mixed with blood running the nose during the first few days. If these secretions are too liquid and in a considerable amount, it can be inferred that there has not been any "cerebrospinal fluid leakage" (cerebrospinal fluid outflow through the nose) and it must be ruled out. The doctor will evaluate these secretions and explain if any kind of procedure is necessary. Once the days of recommended hospital monitoring have passed the patient will be able to leave the hospital. The discharge report will describe the intervention, and continued relative rest for at least one month, an endocrinological follow-up and painkillersprescription will be recommended.