10/23/2010. Excludes Single Surgeon Pituitary (N=~140) Skull Base Volume 12 Month UC SF. Patients. Anterior/Midline. Pituitary CSF Leak.

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1 Advances in Pituitary Surgery Ivan El-Sayed MD, FACS Director- Otolaryngology Minimally Invasive Skull Base Surgery Program Otolaryngology-Head and Neck Surgery University of California-San Francisco Minimally Invasive Skull Base Team at UCSF OHNS Ivan El-Sayed, M.D. Andrew Goldberg, M.D. Steve Pletcher, M.D. Neurosurgery Manish Aghi, M.D. Michael McDermott, M.D. Andrew Parsa, M.D. Neurospine Christopher Ames Praveen Mummaneni UC SF UCSF Endoscopic Skull Base Surgery 2008 Skull Base Volume 12 Month Pituitary Surgery Treat Hormonally Active Tumors Patients Anterior/Midline 43 Lateral Craniocervical Junction Pituitary CSF Leak Malignant Tumors Treat mass effect Cranial nerves in cavernous sinus Optic nerve decompression Excludes Single Surgeon Pituitary (N=~140) 1

2 History of Pituitary Surgical Therapy History Transcranial approach 1893 Caton & Paul first pituitary surgery 1914 Cushing describes gingivolabial submucosal- septal approach Transfrontal/Subcranial 1910 Horsley 1914 Von Eiselberg Transnasal 1907 Schloffer 1909 Cushing Von Eiselberg s Subcranial approach via lateral rhinotomy. Cushing abandoned approach due to bleeding 1971 Hardy reintroduces transeptal approach in U.S. Charlie Wilson (UCSF) Performed over 3500 TS pituitary resections Artwork Mayoclinic.org website Used by Von Eislenberg 1910: Image from PJ Donald, 1998 Cushing H. Surgical experiences with pituitary disorders. JAMA. 1914;63: Hardy J. Transsphenoidal hypophysectomy. J Neurosurg. Apr 1971;34(4): Modern Pituitary Surgery 1987 Grifftith and Verrapen introduce direct transnasal approach to sphenoid sinus Direct Endonasal Transphenoidal Surgery 1996 Jho and Carrau: Kunwar Results 50 Patients EBL <100cc No submucosal septal incision Displace Middle Turbinate Mucosal incision through rostrum of sphenoid Artwork drjho.com/pituitary_surgery.htm 2006: Kunwar 698 Patients (UCSF) Complications CSF 2% DI 2% Mortality 0% Used with Nasal Speculum and Microscope for microdissection Mean Hospital Stay 84% 1 days 96% DC by POD2 Kunwar UCSF CME Kunwar UCSF Experience 2006 Jho HD, Carrau RL: Endoscopic endonasal transsphenoidal surgery: Experience with 50 patients. Neurosurgical focus 1(1): article 2,

3 Is Endoscopic Pituitary Surgery Worthwhile? Meta-analysis analysis review Gross Total tumor of literature removal 78% Endoscopic Pituitary Surgery Hormone Resolution Adrenocorticotrophic hormone tumors 81% 9 Articles 821 patients Pooled Complication rate 2% CSF Leak 1% Diabetes Insipidus 0.24% mortality Growth hormone tumors 84% Prolactin secreting tumors 81% Tabee et al. J Neurosurgy 2009 Tabee et al. J Neurosurgy 2099 Direct Endoscopic Approach Appears Safe Effective Room for improvement Room for Improvement? Only 78% surgeries have gross total resection Mattozo Found 30/30 revision surgeries had inadequate opening made on first attempt. Need to address lesions that extend outside of the sella? Inadequate exposure in Prior Operation. Mattozo et al. Neurosurgery May

4 Expanded Endonasal Surgery What s New Corridor Concept Two Surgeon Endoscopic Dissection Improved Wound Closure Techniques Expanded Endonasal Surgery Important Anatomy Address lesions of the entire skull base Examine how this applies to pituitary surgery. Pituitary Gland Pituitary Vasculature Dural Relations Carotid Artery Optic Nerve Cavernous Sinus Sphenoid Anatomy ANTERIOR POST Kassam et al Neurosurg Focus

5 Sella Supra Sella Infra Sella Extend into sphenoid Extend posterioly toward 3 rd Ventricle Extend laterally to Infratemporal Fossa Pituitary Lesions Pituitary Gland Boundaries Superior pituitary stalk (deviates away from tumors) optic chiasm (pushed up by macroadenomas) Inferior sphenoid sinus, sellar bone Right/left cavernous sinus carotid arteries Proposed Advantages of EEA for Pituitary Surgery Improved Access for Better Dissection Improve 78% gross total resection? Overcome limitation of inadequate access Address Supra and Infra Sellar Lesions Two Surgeon Corridor Surgery Improved View over Microscope Better Lighting Light is carried through scope to tip Can see around corners Magnified 5

6 Total Ethmoidectomy Middle Turbinate Resection Open up maxillary sinus Define orbit to orbit in sphenoid. Posterior septectomy Allows working room for instruments. Create Corridor ) Allows Surgical Control Maneuver 4 instruments Reach targets Maintain View Why Corridor? Close Large Dural Defects with Local Pedicled Flap Corridors: Trans-sellarsellar B. Hahn El-Sayed et al, Skull Base Journal,

7 Corridors: Trans-planum Corridors: Trans-cribiform Corridors: Trans-clival Cranio Cervical Junction Endo-Nasal Endo-Oral El-Sayed et al. J Craniovert Jun Spine, Vol. 1, No. 1. (1 January 2010), pp

8 Lateral Corridor Maxillary Sinus & Infratemporal Fossa Sphenoid Central Skull Base Sella/Pituitary Clivus Odontoid El-Sayed et Al. Accepted Laryngoscope 2010 Sella Surpa sella= transplanum Division of Sella Lesions Infrasella= transclival Pitiutary Macroadenoma Dura with CSF Anterior To Tumor 8

9 Pitiutary Macroadenoma 2 prior drainage attempts single surgeon Failed Medical management for 2mo Complete pituitary hypofunction Pituitary Abscess Tumor Debulked to Posterior Dura Expanding cyst causing vision loss Pituitary Abscess Remove Cyst Lining Pituitary Abscess Preop MRI Postop MRI Only 2mm cyst left on MRI 9

10 Sella Lesion: Rathke s Cyst View After Removal of Cyst Rathke s Cyst Cause Visual Loss with expansion Drain Cyst Supra Sellar Lesions Meningioma Supra Sellar Lesions Need to remove Planum of sphenoid to access Creates large defect 10

11 Open Planum Dura Surgical Resection SupraSella Lesion Meningioma Infrasella Lesions Beware False Sense of Security Flow Void Chordoma Extravasated Gad on MRA 11

12 Macroadenoma with Carotid Aneurysm Massive Macroadenoma: An Argument Against Alternative Medicines Thank You 12