Endoscopic pituitary tumor surgery is performed through nose so as to remove brain tumors from pituitary gland & skull base. This is a minimally invasive procedure where the neurosurgeon works through nostrils with a tiny endoscopic camera & lights so as to remove pituitary tumors with long instruments. Most often pituitary tumors cause hormone problems & loss of vision. Pituitary tumors usually cause vision loss & hormone problems. However, pituitary tumor removal most often reverses problems with vision while restoring normal balance of hormones.
Ideal Candidates for Transsphenoidal Pituitary Tumor Surgery
Ideal candidates for transsphenoidal pituitary tumor surgery include patients with the following brain tumors.
- Pituitary Adenomas – This is a brain tumor which grows from the pituitary gland. It may either be hormone-secreting or non-secreting pituitary tumor.
- Craniopharyngioma – This is a benign brain tumor which grows from cells located near the pituitary stalk. It is often found to invade the third ventricle.
- Rathke’s Cleft Cyst – This is usually a benign cyst or a fluid-filled sac located between the anterior & posterior lobes of pituitary gland.
- Meningioma – This brain tumor grows from dura & which is known as meninges. Dura is the membrane surrounding the brain & the spinal cord.
- Chordoma – This is a malignant bone tumor which grows from the embryonic notochord remnants which are located at the base of the skull.
When patients have prolactinomas or smaller than 10 mm non-secretory pituitary tumors, surgery may not at all be necessary. These types of pituitary tumors respond very well to medications or may also be observed over a period of time with periodical MRIs in order to watch for growth of tumors. However, some pituitary tumors are found to extend beyond limits of transsphenoidal approach. A more extensive operation is required for such pituitary tumors which utilizes craniotomy combined with other skull base approaches as required.
What happens during Endoscopic Transsphenoidal Pituitary Tumor Surgery?
Normally, there are 6 basic steps involved in the endoscopic transsphenoidal brain tumor surgery which typically takes 2 to 3 hours of time to complete.
- Step 1 – The beginning involves preparing the patient. They will be made to lie on their back on the operating table. An intravenous or IV line will be placed in the patient’s arm & general anesthesia will be administered to them. Nasal cavity will also be prepped with antiseptic & antibiotic solutions. An image guiding system will then be placed on the patient’s head. This device is meant to work like GPS (global positioning system) & which will eventually help the neurosurgeon navigate through the patient’s nose by creating a 3D map from MRI or CT scans.
- Step 2 – The 2nd step involves making an incision. In this minimally invasive endoscopic procedure, ENT surgeons insert the endoscope through a nostril & advance it to the back of nasal cavity. Endoscope usually is a thin, tube-like instrument fit with light & camera. Video relayed from this camera is viewed upon a monitor by the neurosurgeon. The neurosurgeon will pass these long instruments through the nostril & watch it progress on the monitor. A small portion of nasal septum dividing the right & the left nostril is removed for the purpose of operation. The front wall of the sphenoid sinus is now opened with the help of bone-biting instruments.
- Step 3 – This step involves opening the sella. Sella is located at the back of sphenoid sinus wall. It is the bony formation which is overlying the pituitary gland. Thin bone of sella is now removed so as to expose the tough lining of skull known as dura. Dura is next opened up in order to expose the brain tumor & pituitary gland.
- Step 4 – The 4th stage involves removing the brain tumor. This is usually done through a small hole in sella. The brain tumor is removed in pieces by the neurosurgeon with help of special instruments known as curettes. The center of the brain tumor is first cored out which allows tumor margins to fall inwards so that the neurosurgeon can then reach them. Following this all visible tumor is relieved & the neurosurgeon advances the endoscope into sella so as to look & inspect for hidden portions of the brain tumor. Some brain tumors are found to grow sideways into cavernous sinus which is a region enclosing a collection of veins. It would be quite difficult to completely remove this portion of brain tumor without causing any injury to nerves & blood vessels. Any portion of the brain tumor left behind in this area can subsequently be treated with radiation. Pituitary brain tumor surgery at some hospitals are performed in special operation theaters which are equipped with intraoperative MRI scanners where the brain tumor patient can undergo MRI during the surgical intervention. This provides the neurosurgeon with real-time MRI images of the patient’s brain in order to enable them know exactly how much of the brain tumor has been removed before closing the operation. This technology is incorporated to enable neurosurgeons remove the tumor more completely & thereby reduce the requirement of a second operation.
- Step 5 – After removal of the brain tumor, neurosurgeons will prepare to close the opening in sella. For this purpose & if needed, a small 2 cm incision is made in abdomen so as to obtain a small piece of fat. This fat graft is then used to fill the empty space left by the brain tumor removal. Following this the abdominal incision is closed with the help of sutures.
- Step 6 – The last & the final step involves closing the opening made in sella. A hole which was made in sella floor for the operation is now sealed with a bone graft from septum. Sometimes synthetic graft materials are also used when suitable piece of septum is unavailable or if the patient has undergone previous nasal surgery. Biologic glue is also applied over graft in sphenoid sinus. This glue is meant to allow healing while preventing leakage of (CSF) cerebrospinal fluid from brain into nasal cavity or sinuses. Soft & flexible splints are also placed inside nose along the septum in order to prevent swelling & control bleeding. These splints are also found to prevent adhesions from forming & which may in some cases lead to chronic nasal congestion.
What Happens After Endoscopic Transsphenoidal Pituitary Tumor Surgery?
Brain tumor surgery patient will awaken within the postoperative recovery area known as the PACU. Heart rate, blood pressure & respiration will be monitored. Any kind of pain will also be addressed by the healthcare team. Patients will be moved to a regular room once they are awake & where their activity will increase. They will be made to walk or sit in the chair. Brain tumor surgery patient may also have to spend a night in the NSICU or neuroscience intensive care unit for closer monitoring. Following surgery, pituitary tumor patients may experience nausea, headache & nasal congestion. However, medications are able to control these symptoms. Endocrinologist may visit the patient on the day after surgery in order to check if the pituitary gland is producing normal levels of hormones. Hormone replacement medications may be given to the patient in case pituitary is not producing appropriate levels. MRI of the brain is usually taken on the day following surgery. The patient will however be released from the hospital with discharge instructions in a day or two following surgery.
Recovery & Prevention Following Pituitary Tumor Surgery
Pituitary tumor surgery patients will need to set up appointments for follow up visits with ENT surgeons within the first week following operation in order to remove nasal splints & for checking surgical sites. ENT specialists will also see patients every 3 weeks after that until nasal cavities are completely healed. This usually requires 2 to 4 visits after an operation. Small crusts are also often found to form in nose which can cause nasal congestion after pituitary tumor operation. For this reason ENT surgeons often spray the nose so as to provide local anesthesia inside nasal cavities. These crusts can then be comfortably removed. Pituitary tumor surgery patient will be instructed to use a nasal saline rinse 4 weeks after surgical intervention. This rinse is meant to decrease need for removal of crusts & will also hasten nasal healing. Appointment of follow-up visits with the neurosurgeon will be scheduled after 2 to 4 weeks following pituitary tumor surgery. Endocrine follow-up is also recommended in order to determine if hormone replacement medications are required.
Endoscopic Pituitary Tumor Surgery Outcomes
When the pituitary tumor is Cushing’s, acromegaly or prolactinoma, they are hormone-secreting & the endocrinologist will follow the hormone levels of the pituitary gland after surgery in order to determine whether the patient has been cured. Pituitary tumor patients with Cushing’s disease usually have microadenomas or small tumors which are most often surgically cured in about 90 percent of the cases. However, pituitary tumor patients with acromegaly have larger & more invasive tumor growths. Success rate of pituitary tumor surgery is about 60 percent with macroadenomas that are growth-hormone secreting. Nevertheless some pituitary tumors remain surgically incurable mainly due to invasion of cavernous sinuses & other important brain structures. Radiosurgery can also be used for treatment of unresectable remnants of brain tumors with extremely positive rates of long term control. Whenever there are residual brain tumors following surgery for acromegaly, prolactinomas or Cushing’s disease, medical treatments are available for controlling excessive hormone secretions.
Affordable Endoscopic Transsphenoidal Pituitary Tumor Surgery in India
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