Adenomas gigantes de hipófisis: análisis de variables relacionadas con resultados visuales, endocrinológicos y de resección en cirugía endoscópica transesfenoidal / GIANT PITUITARY ADENOMAS: ANALYSIS OF VARIABLES RELATED TO VISUAL, ENDOCRINOLOGICAL AND RESECTION RESULTS IN TRANSSPHENOIDAL ENDOSCOPIC SURGERY

Introducción. Los adenomas gigantes de hipófisis (AGHs) son aquellos tumores con un diámetro máximo ≥4 cm en cualquier dirección, representando del 5% al 14% del total de los adenomas que se tratan quirúrgicamente. Su manejo terapéutico es desafiante ya que, debido a su extensión hacia otras estructuras cerebrales,está asociado a un riesgo mayor de complicaciones quirúrgicas, con una menor tasa de resección total. El objetivo de este trabajo fue evaluar el impacto de la cirugía endoscópica transesfenoidal en AGHs, analizando las variables asociadas a resultados visuales, endocrinológicos y según el grado de resección. Pacientes y Métodos. Se evaluó en 44 pacientes con AGHs(diámetro ≥4 cm y/o volumen ≥10 ml) la presentación visual, endocrinológica e imágenes. Se analizaron estadísticamente resultados visuales, endocrinológicos, grado de resección y complicaciones quirúrgicas. Resultados. Edad promedio de 48.8 años, 24 mujeres y 20 hombres. Presentación: déficit del campo visual (93.1%), hipopituitarismo (61.3%), cefalea (54.5%). Diámetro, volumen y extensión supraselar promedios: 4.8 cm, 20.3 ml, 1.8 cm, respectivamente. Campo visual: mejoría: 83.3%, sin cambios: 9.5%, mayormente en síntomas bilaterales (p<0.0001). Desmejoríavisual: 0%. En resección total: mayor posibilidad de mejoría visual (p=0.040). Buenos resultados endocrinológicos: 85.7%. Tasa de resección total: 52.3%. Resección subtotal: más frecuente con invasión del seno cavernoso (p=0.014). Sin diferencias en el grado de resección según diámetro, volumen, extensión supraselar, forma ni aspecto. Hipopituitarismo: 4.2%. Diabetes insípida: 9.5%, asociada a mayor diámetro (p=0.038) o extensión supraselar (p=0.010) y aspecto sólido (p=0.023). Fístula de LCR: 7.1%. Conclusión. La resección total puede lograrse en la mitad de los casos, siendo la limitante principal el grado de invasión del seno cavernoso y no el aspecto morfológico del AGH per se. Aun así, los resultados visuales y endocrinológicos son muy buenos. En resecciones incompletas se logra el control de la enfermedad mediante tratamientos complementarios

Introduction. Giant pituitary adenomas (sGAs) are those tumors with a maximum diame- ter ≥4 cm in any direction, representing 5% to 14% of all adenomas that are treated surgi- cally. Its therapeutic management is challenging since, due to its extension to other brain structures, it is associated with a higher risk of surgical complications, with a lower rate of total resection. Te objective of this work was to evaluate the impact of transsphenoidal endoscopic surgery on AGHs, analyzing the variables associated with visual and endocri- nological results and according to the degree of resection. Patients and Methods. Visual, endocrinological and imaging presentation were evaluated in 44 patients with sHAA (dia- meter ≥4 cm and/or volume ≥10 ml). Visual and endocrinological results, degree of resection and surgical complications were statistically analyzed. Results. Average age of 48.8 years, 24 women and 20 men. Presentation: visual field deficit (93.1%), hypopituitarism (61.3%), headache (54.5%). Average diameter, volume and suprasellar extension: 4.8 cm, 20.3 ml, 1.8 cm, respectively. Visual field: improvement: 83.3%, no changes: 9.5%, mostly in bilate- ral symptoms (p<0.0001). Visual impairment: 0%. In total resection: greater possibility of visual improvement (p=0.040). Good endocrinological results: 85.7%. Total resection rate: 52.3%. Subtotal resection: more frequent with invasion of the cavernous sinus (p=0.014). No differences in the degree of resection according to diameter, volume, suprasellar exten- sion, shape or appearance. Hypopituitarism: 4.2%. Diabetes insipidus: 9.5%, associated with greater diameter (p=0.038) or suprasellar extension (p=0.010) and solid appearance (p=0.023). CSF fistula: 7.1%. Conclusion. Total resection can be achieved in half of the cases, the main limitation being the degree of invasion of the cavernous sinus and not the morphological appearance of the HGA per se. Even so, the visual and endocrinological results are very good. In incomplete resections, disease control is achieved through com- plementary treatments

Osteomielitis por Yokenella regensburgei después de una craneotomía en una paciente inmunocompetente / Osteomyelitis due to Yokenella regensburgei following craniotomy in an immunocompetent patient

Yokenella regensburgei es un bacilo Gram negativo de la familia Enterobacteriaceae, que puede encontrarse en agua de pozos, alimentos y en el tubo digestivo de insectos y reptiles. Aunque se ha aislado de muestras provenientes de seres humanos, pocas veces se ha reportado como causante de infección y, en tales casos, especialmente en pacientes inmunosuprimidos. Se presenta aquí el primer caso de osteomielitis secundaria a una infección por Y. regensburgei en una paciente inmunocompetente después de un procedimiento quirúrgico.

The gram-negative bacillus Yokenella regensburgei (of the Enterobacteriaceae family) can be found in groundwater and foodstuffs, as well as the digestive tracts of insects and reptiles. Although it has been isolated from humans since its original description, it has rarely been reported as a cause of infection, and then, only in immunosuppressed patients. We report the first case of post-surgical secondary osteomyelitis due to Y. regensburgei in an immunocompetent woman who had undergone a craniotomy.

Descripción de variantes del acceso transeptoesfenoidal para el abordaje de la patología selar / Description of transseptosphenoidal access variants to sellar pathology approach

El abordaje quirúrgico de la patología selar ha sufrido importantes cambios desde sus primeras descripciones. Inicialmente de manejo neuroquirúrgico, hoy en día el abordaje hipofisiario transeptoesfenoidal se ha transformado en una de las vías de acceso más utilizadas por el otorrinolaringólogo para lesiones a nivel de silla turca. Esta publicación describe un tipo de acceso transeptoesfenoidal utilizado por el otorrinolaringólogo en el Instituto de Neurocirugía Dr. Alfonso Asenjo (INCA) en el abordaje de lesiones selares, tanto en cirugía primaria de hipófisis, cirugía secundaria o en casos con alteraciones anatómicas del septum nasal posterior.

The surgical approach to the sellar pathology has undergone significant changes since its first descriptions. Initially addressed by neurosurgical management, today the transseptosphenoidal pituitary approach has become one of the most used pathways by the otolaryngologist to reach sellar lesions. This publication describes one of the transseptosphenoidal approach used by the otolaryngologist at the Instituto de Neurocirugía Dr. Alfonso Asenjo (INCA) in addressing sellar lesions and its variations in primary pituitary surgery, secondary surgery, multiple interventions and in cases of anatomical variations of the posterior nasal septum.

Long-term follow-up on Cushing disease patient after transsphenoidal surgery

Cushing disease is caused by excessive adrenocorticotropic hormone (ACTH) production by the pituitary adenoma. Transsphenoidal surgery is its first-line treatment. The incidence of Cushing disease in children and adolescents is so rare that long-term prognoses have yet to be made in most cases. We followed-up on a 16-year-old male Cushing disease patient who presented with rapid weight gain and growth retardation. The laboratory findings showed increased 24-hour urine free cortisol and lack of overnight cortisol suppression by low-dose dexamethasone test. The serum cortisol and 24-hour urine free cortisol, by high-dose dexamethasone test, also showed a lack of suppression, and a bilateral inferior petrosal sinus sampling suggested lateralization of ACTH secretion from the right-side pituitary gland. However, after a right hemihypophysectomy by the transsphenoidal approach, the 24-hour urine free cortisol levels were persistently high. Thus the patient underwent a total hypophysectomy, since which time he has been treated with hydrocortisone, levothyroxine, recombinant human growth hormone, and testosterone enanthate. Intravenous bisphosphonate for osteoporosis had been administered for three years. At his current age of 26 years, his final height had attained the target level range; his bone mineral density was normal, and his pubic hair was Tanner stage 4. This report describes the long-term treatment course of a Cushing disease patient according to growth profile, pubertal status, and responses to hormone replacement therapy. The clinical results serve to emphasize the importance of growth optimization, puberty, and bone health in the treatment management of Cushing disease patients who have undergone transsphenoidal surgery.

Acessos endoscópicos para lesões hipofisárias / Endoscopic approach of the pituitary lesions

Ao longo dos anos, a cirurgia minimamente invasiva avançou com a contribuição importante dos neurocirurgiões sobre a melhor opção para a abordagem terapêutica de tumores da região selar, partindo-se de uma cirurgia extremamente prejudicial, com alta morbidade e mortalidade, até a evolução de técnicas mais modernas, as quais dispõem de materiais mais adequados, que permitem ressecções completas com menor agressão às estruturas neurovasculares. Para praticá-las, é necessário um grupo de trabalho que envolva diferentes especialidades, como endocrinologia, oftalmologia, otorrinolaringologia, neurocirurgia e radioterapia, a fim de oferecer aos pacientes as melhores opções, garantindo atendimento individualizado, resolutivo e pouco agressivo. Há necessidade de um planejamento pré-operatório cuidadoso, com o uso de exames complementares avançados como ressonância magnética, tomografia computadorizada dos seios da face, dosagem sérica dos hormônios hipofisários e campimetria visual. Ainda, durante o procedimento cirúrgico, pode-se dispor de neuronavegação, tornando a cirurgia mais segura, especialmente nas reoperações. Por essas vantagens, a cirurgia transesfenoidal por microscopia convencional e por endoscopia é o procedimento atual de escolha para tratar tumores selares e fornecer adequada descompressão de estruturas neurais, com recuperação favorável mais rápida no pós-operatório em comparação com a abordagem transcraniana convencional.

Over the years, minimally invasive surgery has advanced with the important contribution of neurosurgeons for the best option for the therapeutic approach of sellar tumors. Starting from an extremely harmful surgery with high morbidity and mortality until the evolution of techniques modern, which have the most suitable materials, which allow complete resections with less aggression to the neurovascular structures. To do them, is necessary a working group involving different specialities, such as endocrinology, ophthalmology, otolaryngology, neurosurgery and radiotherapy in order to offer patients the best options, ensuring individualized care, resolute and less aggressive. It?s necessary a careful preoperative planning, using advanced exams such as MRI, CT scan of the sinuses, serum levels of pituitary hormones and visual perimetry. Still, the surgical procedure can be increased with the neuronavigation, making surgery more safer, especially in reoperations. Thus, because of these advantages, transphenoidal surgery for conventional microscopy and for endoscopy is the current procedure of choice for treating parasellar tumors, and provide adequate decompression of the neural structures with a favorable and faster recovery after surgery compared to the approach transcranial conventional.

Controle hormonal dos adenomas hipofisários pela cirurgia transesfenoidal: evolução dos resultados nos primeiros cinco anos de experiência / Hormonal control of pituitary adenomas by transsphenoidal surgery: results of the first five years of experience

OBJETIVO: Avaliar os resultados iniciais de uma equipe cirúrgica no controle hormonal dos adenomas hipofisários secretores. MATERIAIS E MÉTODOS: Em cinco anos, foram operados 51 adenomas secretores (31 GH, 14 ACTH, 5 prolactina, 1 TSH). O controle hormonal foi GH basal < 2,5 ng/dL, cortisol livre urinário normal, redução dos níveis de prolactina, e T3 e T4 livre normais. RESULTADOS: As taxas de controle foram 36 por cento na acromegalia e 57 por cento no Cushing. Dois prolactinomas (40 por cento) normalizaram a prolactina. Os hormônios tiroidianos normalizaram no adenoma secretor de TSH. O controle do hipercortisolismo correlacionou-se com o tempo de experiência da equipe (p = 0,01). CONCLUSÃO: Nossos resultados, limitados aos primeiros anos de experiência cirúrgica, situam-se abaixo da variação reportada em grandes casuísticas com maior tempo de experiência. Ao longo do tempo, observou-se melhora progressiva nos níveis de cortisol urinário no pós-operatório inicial da doença de Cushing em função da experiência cirúrgica.

OBJECTIVE: To evaluate the initial results of a surgical team in the hormonal control of secreting pituitary adenomas. MATERIALS AND METHODS: In five years 51 functioning adenomas were operated (31 GH-secreting, 14 ACTH-secreting, 5 PRL-secreting and 1 TSH-secreting). Hormonal control was defined as GH < 2,5 ng/mL, normal free-urinary cortisol, lower prolactin and normal T3 and FT4. RESULTS: Control rates were 36 percent in acromegaly, and 57 percent in Cushing's disease. Two prolactinomas normalized prolactin levels. Thyroid hormone levels were normalized in the TSH-secreting adenoma. Control of hypercortisolism was positively correlated with years of experience (p = 0.01). CONCLUSION: Our results, although restricted to the beginning of our experience, lie below the reported range of other surgical series with much longer experience. During these years, there was a significant improvement in initial post surgery urinary cortisol levels in Cushing's disease as a function of surgical experience.

Effect of growth hormone combined with Radix Dipsaci on the body growth and the bone metabolism of hypophysectomized rats / 中国中西医结合杂志

<p><b>OBJECTIVE</b>To study the effect of growth hormone (GH) combined with Radix Dipsaci on the body growth and the bone mineral content (BMC) of hypophysectomized rats.</p><p><b>METHODS</b>The GH deficiency rats model was established using the hypophysectomized operation through the skull and the throat. Qualified rats were divided into the sham-operation group (n = 15), the negative control group (n = 13), the GH intervention group (n = 13), and the GH combined with Radix Dipsaci group(n = 12). GH (0.25 mg/kg) was subcutaneously injected from the cervical part in the GH intervention group and the GH combined with Radix Dipsaci group at the same time, while equal volume of normal saline was injected to the rest groups. 0.7 mL/100 kg Radix Dipsaci was given by gastrogavage to the GH combined with Radix Dipsaci group at the same time, while equal volume of normal saline was given by gastrogave to the rest groups. The body weight, the tail length, and the body length were measured during the intervention period. Blood was withdrawn after 14-day intervention. The femoral bone and the tibial bone were taken out. The levels of GH, insulin-like growth factor 1 (IGF-1), alkaline phosphatase (ALP), and osteocalcin (OC) were measured. The width of the tibial epiphyseal plate was measured. The bilateral femur bone mineral density (BMD) and BMC were measured using the dual energy X-ray absorptiometry.</p><p><b>RESULTS</b>The body weight, the body length, the length of the femoral bone, the length of the tibial bone, the width of the epiphyseal plate, the levels of the GH, IGF-1, ALP, and OC increased in the GH intervention group and the GH combined with Radix Dipsaci group after 2-week intervention, showing statistical difference when compared with the model group (P < 0.01). But there was no statistical difference in the tail length though it also increased (P > 0.05). There was insignificant difference in the aforesaid indices between the two groups (P > 0.05). Compared with the model group, the BMD of the GH combined with Radix Dipsaci group increased with statistical difference (P < 0.01). Compared with the model group, the BMC of the GH intervention group and the GH combined with Radix Dipsaci group increased with statistical difference (P < 0.01). It was highest in the GH combined with Radix Dipsaci group (P < 0.01).</p><p><b>CONCLUSIONS</b>GH combined with Radix Dipsaci showed unobvious effect on promoting the growth. But it could elevate BMD and BMC, and improve the bone metabolism.</p>

Clinical Results of Endoscopic Endonasal Transsphenoidal Hypophysectomy during an Acceleration Phase of Learning Curve / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The aim of this study was to compare endoscopic endonasal transsphenoidal hypophysectomy (EETSA) with microscopic transseptal transsphenoidal hypophysectomy (MTTSA) in terms of clinical results during an acceleration of learning curve. SUBJECTS AND METHOD: A retrospective chart review was performed of the first 14 cases of EETSA and previous 14 cases of MTTSA. Resection results, endocrinologic outcomes, complication rates, operating time, and duration of hospital stay were investigated. A non-parametric analysis was performed to determine the significance of differences between groups. RESULTS: EETSA was performed, achieving gross total removal, based on postoperative MRI, for 12 of the 14 patients (86%) and hormonal remission for 4 of the 5 patients (80%); on the other hand, MTTSA was performed, achieving gross total removal for 9 of the 14 patients (64%) and hormonal remission for 1 of the 5 patients (20%). We found better resection results in patients who underwent EETSA than in those who did MTTSA with respect to tumors extending into suprasellar area (p<0.05). Visual improvement was achieved in all the cases with visual defect (n=5) after EETSA, whereas 4 of 6 cases (66%) were improved after MTTSA. Significant differences in complication rates, operating time and hospital stay could not be determined. All cases with CSF leakage in EETSA were successfully managed by using the nasoseptal flap. CONCLUSION: EETSA provided better resection results than MTTSA did, especially in cases extending into the suprasellar area, showing good hormonal cure and visual improvement rates. Two approaches were comparable with respect to complications during the learning curve.

Surgical management of pediatric Cushing's disease: an analysis of 15 consecutive cases at a specialized neurosurgical center / Estratégia cirúrgica na doença de Cushing em pacientes pediátricos: análise de 15 casos consecutivos operados em centro neurocirúrgico especializado

OBJECTIVE: The aim of this study was to review the results of surgery for pediatric patients with Cushing's disease who were less than 18 years old and underwent transsphenoidal surgery in a specialized center during a 25-year period. SUBJECTS AND METHODS: Retrospective study, in which the medical records, histology and pituitary imaging of 15 consecutive pediatric patients with Cushing's disease (mean age: 13 years) were evaluated by the same team of endocrinologists and a neurosurgeon from 1982 to 2006. Patients were considered cured when there was clinical adrenal insufficiency and serum cortisol levels were below 1. 8 µg/dL or 50 nmol/L after one, two, three, or seven days following surgery; they therefore required cortisone replacement therapy. Follow-up was for a median time of 11.5 years (range: 2 to 25 years). RESULTS: Clinical and biochemical cure was achieved in 9/15 patients (60 percent) exclusively after transsphenoidal surgery. Hypopituitarism was observed in four patients; growth hormone deficiency, in two; permanent diabetes insipidus, in one case. CONCLUSIONS: Cushing's disease is rare in children and adolescents. Transsphenoidal surgery is an effective and safe treatment in most of these patients. Plasma cortisol level < 1. 8 µg/dL following surgery is the treatment goal and is a good predictive factor for long-term cure of Cushing's disease.

OBJETIVO: O objetivo deste estudo foi avaliar os resultados cirúrgicos em pacientes pediátricos com doença de Cushing com idade inferior a 18 anos, submetidos à cirurgia transfenoidal num centro especializado, durante um período de acompanhamento de 25 anos. SUJEITOS E MÉTODOS: Estudo retrospectivo dos prontuários médicos de 15 pacientes pediátricos com doença de Cushing (idade média de 13 anos), sendo avaliados aspectos clínicos, laboratoriais, histológicos e radiológicos. Todos os pacientes foram avaliados pela mesma equipe de endocrinologistas e operados por um mesmo neurocirurgião, entre 1982 e 2006. O tempo médio de seguimento foi 11,5 anos (2 a 25 anos). Os pacientes foram considerados curados quando houve insuficiência adrenal e níveis de cortisol plasmático inferiores a 1,8 µg/dL ou 50 nmol/L no pós-operatório um, dois, três ou sete dias após a cirurgia; estes pacientes necessitaram de reposição de corticosteroide. RESULTADOS: Cura clínica e bioquímica foi alcançada em 9/15 pacientes (60 por cento) após a cirurgia transfenoidal. Hipopituitarismo foi observado em quatro pacientes; déficit de hormônio de crescimento, em dois; diabetes insípido permanente, em um. CONCLUSÕES: A doença de Cushing é rara na infância e na adolescência. A cirurgia transfenoidal é um tratamento efetivo e seguro para a maioria dos pacientes. Uma concentração de cortisol plasmático < 1,8 µg/dL nos primeiros dias pós-cirurgia transfenoidal é o objetivo do tratamento e um fator preditivo tardio para a cura da doença de Cushing.

Prevention and cure sinusitis complicated by endoscopic transnasal approach in surgical treatment of pituitary adenoma / 临床耳鼻咽喉头颈外科杂志

OBJECTIVE@#To recognize the causes, methods of prevention and cure of sinusitis complicated by endoscopic transnasal approach in surgical treatment of pituitary adenomas.@*METHOD@#The data of 187 patients who underwent surgical treatments of pituitary adenomas through endoscopic transnasal approach were collected, and the surgical complications were analyzed.@*RESULT@#Endoscopic transnasal transsphenoidal approach were used successfully in 187 cases, twelve cases (6.4%) were suffered from sinusitis complication after surgery. The most frequent sinusitis complication was sphenoiditis, 9 cases (4.8%) were suffered, 2 cases (1.1%) were suffered from ethmoidal sinusitis, 1 case (0.5%) was suffered from maxillary sinusitis. Ten cases were treated with correspond medication in clinic. Two cases were ineffective with expectant treatment, and cured by second endoscopic sinusitis operation at last.@*CONCLUSION@#Endoscopic transnasal transsphenoidal approach offered a simple and rapid access to the sella, and also, it is a safe, valuable and efficient procedure for removing pituitary adenomas. It was obviously that timely accurate diagnosis for the sinusitis complication and comprehensive perioperative management may lead to less incidence of postoperative sinusitis complication in surgical treatment of pituitary adenomas through endoscopic transnasal approach, increase the achievement rate and improve survival quality obviously.

Pure endoscopic endonasal transsphenoidal approach for 375 pituitary adenomas / 中华外科杂志

<p><b>OBJECTIVE</b>To describe the experience with surgical treatment of pituitary adenomas via a fully transnasal endoscopic approach.</p><p><b>METHODS</b>Clinical records of 375 cases with pituitary adenomas underwent pure endoscopic operations between December 2006 and December 2009 were carefully assembled. Among 375 pure endoscopic operations of pituitary adenomas, 201 cases were nonfunctional adenomas and 174 cases were functional adenomas. There were 27 giant pituitary adenomas (7.2%) and 41 pituitary adenoma invaded cavernous sinus (10.9%). Intraoperative 1.5 T MRI and neuro-navigation system were used during some operations. The postoperative and follow-up data of patients were analyzed.</p><p><b>RESULTS</b>There were 234 (79.3%) cases of total resection, 56 (19.0%) cases of subtotal resection, 5 (1.7%) cases of partial resection. Sixty-eight patients had vision improved in 73 patients with vision decreasing before operation. Sixty-eight (77.3%) patients got normal endocrine in 88 hyper-prolactin patient. Fifty-five (84.1%) patients got normal growth hormone in 63 patients with somatotrophinomas. Eighteen (78.2%) patients got normal in 23 patients with corticotrophinoma. These was no death case in this group. One case (0.3%) suffered post-operative coma. Transient decreasing of vision occurred in 2 cases (0.5%). Transient palsy of oculomotor nerve or abducens nerve occurred in 7 cases of operations involved cavernous sinus. Three (0.8%) patients had cerebral meningitis. Two patients (0.5%) suffered from cerebrospinal fluid leak but none underwent operation to repair. Fourteen patients (3.7%) had transient diabetes insipidus. Six patients (1.6%) had nose bleeding.</p><p><b>CONCLUSIONS</b>Trans-nasal endoscopy provides a new device for operation of pituitary adenomas which is effective and safe. Comparing with microscope, endoscopic visual field is clearer, closer and wider.</p>

Oronasal complications in patients after transsphenoidal hypophyseal surgery / Complicações oronasais em pacientes pós-abordagem hipofisária via transesfenoidal

Transsphenoidal surgery is the most commonly used surgical procedure to handle the hypophyseal region, sometimes associated with oronasal complications. MATERIAL AND METHODS/AIM: To evaluate prospectively (specific questionnaire, clinical evaluation) undiagnosed chronic oronasal complications in patients submitted to conventional transsphenoidal adenomectomy surgery, operated at different neurosurgery services more than 6 months ago. RESULTS: 49 patients were evaluated, 37/45 presented macroadenoma. 28,5 percent were submitted to more than one intervention, 2/5 transsphenoidally. Transsphenoidal approach 92.8 percent through sublabial route. No patient had spontaneous complaint. With the specific questionnaire 63.2 percent presented complaints. One patient presented an oronasal fistula, 1 stenosis of the nasal valve area with external nasal deformity. Rhinoscopy detected alterations in 77.5 percent, nasal endoscopy in 87.7 percent. Septal perforation was present in 10/12 patients with scabs and 2 with purulent secretion. All 4 patients submitted to 2 transsphenoidal approaches presented septal perforation and nasal synechiae. In the endonasal, synechiae (2), alteration in medium meatus (1) and stenosis of the nasal valve area (1) were observed. Only two patients presented normal evaluation. CONCLUSION: A high incidence of nasal complications after conventional transsphenoidal surgery observed through examination and not reported spontaneously point to the need of otorhinolaryngological investigation complemented by nasal endoscopy in patients submitted to procedures through this route.

A cirurgia transesfenoidal é o procedimento cirúrgico mais utilizado para abordagem da região hipofisária, sendo por vezes associada a complicações oronasais. MATERIAL E MÉTODOS/OBJETIVO: Estudo prospectivo, através de questionário específico e avaliação clínica complicações oronasais crônicas não-diagnosticadas, em pacientes submetidos à cirurgia transesfenoidal convencional em diferentes serviços de neurocirurgia há mais de 6 meses. RESULTADOS: 49 pacientes, 37/45 com macroadenoma. 14/49 submetidos a mais de uma intervenção, em 2/5 por via transesfenoidal. Abordagem transesfenoidal 92,8 por cento via sublabial. Nenhum apresentava queixa espontânea. Com o questionário específico, 63,2 por cento apresentaram queixas. Um apresentava fístula oronasal, outro, estenose da área de válvula nasal com deformidade nasal externa. A rinoscopia detectou alterações em 77,5 por cento e a endoscopia nasal em 87,7 por cento. Perfuração septal presente em 10/12 pacientes com crostas e 2 com secreção purulenta. Todos 4 pacientes submetidos a 2 abordagens transesfenoidais apresentaram perfuração do septo e sinéquias nasais. Nos casos com abordagem endonasal observaram-se sinéquias2, alteração em meato médio1 e estenose em área de válvula nasal1. Apenas 2 pacientes apresentaram avaliação normal. CONCLUSÃO: Alta incidência de complicações nasais após abordagem transesfenoidal convencional, observadas (exame) e não referidas espontaneamente indicam a necessidad de investigação otorrinolaringológica complementada com endoscopia nasal sistemática nestes pacientes.

Comparative Study of the Effects of Different Growth Hormone Doses on Growth and Spatial Performance of Hypophysectomized Rats

This study was designed to examine the effects of recombinant human growth hormone replacement on somatic growth and cognitive function in hypophysectomized (HYPOX) female Sprague-Dawley rats. Rats (5 per group) were randomized by weight to 3 experimental groups: group 1, administered 200 microgram/kg of GH once daily for 9 days; group 2, administered 200 microgram/kg of GH twice daily; and group 3, administered saline daily. Somatic growth was evaluated by measurement of body weight daily and of the width of the proximal tibial growth plate of the HYPOX rats. Cognitive function was evaluated using the Morris water maze (MWM) test. The results indicated that GH replacement therapy in HYPOX rats promoted an increase in the body weight and the width of the tibial growth plate in a dose-dependent manner. On the third day of the MWM test, the escape latency in the GH-treated groups 1 and 2 was significantly shorter than that in the control rats (P<0.001 and P=0.032, respectively), suggesting that rhGH improved spatial memory acquisition in the MWM test. Therefore it is concluded that rhGH replacement therapy in HYPOX rats stimulates an increase in somatic growth in a dose-dependent manner and also has beneficial effects on cognitive functions.

Edema pulmonar por pressão negativa após hipofisectomia transesfenoidal: relato de caso / Negative-pressure pulmonary edema after transsphenoidal hypophysectomy: case report / Edema pulmonar por presión negativa después de la hipofisectomía transesfenoidal: relato de caso

JUSTIFICATIVA E OBJETIVOS: O edema pulmonar por pressão negativa (EPPN) é uma complicação incomum que evolui rapidamente após quadro agudo ou crônico de obstrução de vias aéreas. O objetivo deste relato foi apresentar um caso de EPPN após obstrução de vias aéreas superiores em paciente com acromegalia que foi submetido à hipofisectomia transesfenoidal. RELATO DO CASO: Paciente do sexo masculino, 48 anos, 80 kg, estado físico ASA III, portador de tumor de hipófise, hipertensão arterial e acromegalia, foi submetido à hipofisectomia transesfenoidal sob anestesia geral balanceada. O procedimento cirúrgico evoluiu sem intercorrências. A extubação traqueal foi realizada com o paciente em plano anestésico superficial. Evoluiu com esforço ventilatório, retração da parede abdominal, hipoxemia grave (SpO2 30 por cento), inconsciência e disritmia cardíaca (extra-sístole ventricular e bradicardia). A ventilação com pressão positiva sob máscara facial e cânula orofaríngea foi ineficaz. O paciente foi intubado e, nesse momento, havia estertores pulmonares bilaterais com a presença de secreção rósea aerada dentro da cânula traqueal compatível com quadro de EPPN. O paciente foi encaminhado ao CTI, onde permaneceu sob ventilação mecânica por 96 horas. Recebeu alta para a enfermaria no quinto dia pós-operatório sem seqüela neurológica. CONCLUSÃO: O EPPN pode ocorrer no período pós-anestésico imediato de hipofisectomia transesfenoidal. O diagnóstico e tratamento rápidos são essenciais para uma resolução precoce e diminuição da morbidade.

BACKGROUND AND OBJECTIVES: Negative-pressure pulmonary edema (NPPE) is a rare complication that evolves rapidly after acute or chronic obstruction of the airways. The objective of this report was to present a case of NPPE after upper airways obstruction in a patient with acromegaly who underwent transsphenoidal hypophysectomy. CASE REPORT: A 48 years old male patient, weighing 80 kg, physical status ASA III, with a tumor in the hypophysis, hypertension, and acromegaly, underwent transsphenoidal hypophysectomy under general balanced anesthesia. The surgery proceeded without intercurrences. The patient was extubated while in a superficial anesthetic plane. He developed difficulty breathing, retraction of the abdominal wall, severe hypoxemia (SpO2 30 percent), unconsciousness, and cardiac arrhythmia (PVCs and bradycardia). Positive-pressure ventilation with a face mask and oropharyngeal cannula was ineffective. The patient was intubated and, at this moment, there were bilateral pulmonary rales and frothy pinkish secretion inside the tracheal tube, compatible with NPPE. The patient was transferred to the ICU and remained on mechanical ventilation for 96 hours. He was discharged to the regular ward on the 5th postoperative day without neurological sequelae. CONCLUSION: Negative-pressure pulmonary edema may occur in the immediate postoperative period of transsphenoidal hypophysectomy. Immediate diagnosis and treatment are essential for early resolution of the process and to decrease morbidity.

JUSTIFICATIVA Y OBJETIVOS: El edema pulmonar por presión negativa (EPPN) es una complicación poco común que evoluciona rápidamente después de un cuadro agudo o crónico de obstrucción de las vías aéreas. El objetivo de este relato fue presentar un caso de EPPN después de la obstrucción de las vías aéreas superiores en paciente con acromegalia que fue sometido a la hipofisectomía transesfenoidal. RELATO DEL CASO: Paciente del sexo masculino, 48 años, 80 kg, estado físico ASA III, portador de tumor de hipófisis, hipertensión arterial y acromegalia, fue sometido a la hipofisectomía transesfenoidal bajo anestesia general balanceada. El procedimiento quirúrgico evoluciona sin intercurrencias. La extubación traqueal fue realizada con el paciente en plano anestésico superficial. Evoluciona con esfuerzo ventilatorio, retracción de la pared abdominal, hipoxemia grave (SpO2 30 por ciento), inconsciencia y arritmia cardíaca (extrasístolis ventricular y bradicardia). La ventilación con presión positiva bajo máscara facial y cánula orofaríngea fue ineficaz. El paciente fue intubado y en ese momento, había estertores pulmonares bilaterales con la presencia de secreción rósea ventilada dentro de la cánula traqueal compatible con el cuadro de EPPN. El paciente fue llevado al CTI, donde permaneció bajo ventilación mecánica por 96 horas. Recibió alta para enfermaría en el quinto día del postoperatorio sin secuela neurológica. CONCLUSIÓN: El EPPN puede ocurrir en el período postanestésico inmediato de hipofisectomía transesfenoidal. El diagnóstico y tratamiento rápidos son esenciales para una resolución precoz y para la disminución de la morbidez.

Endoscopic trans-sphenoid approach to pituitary tumors Kasr El-Eini Cairo University hospitals experience

Over the last decades pituitary surgery has been one of the models of the minimally invasive surgeries. Horsley performed the first reported pituitary operation in 1889 through a trans-cranial approach. Schloffer was the first to introduce the trans-sphenoid approach in 1907. Gushing popularized the sublabial trans-septal approach in 1910 and with the introduction of the operating microscope and intra-operative fluoroscopy in the 1950s and 1960s, the trans-septal approach became the gold standard for pituitary surgery. In the 1980s and 1990s, the nasal endoscope became the standard of care in surgery of the nose and PNS. Trans-sphenoidal hypophysectomy is becoming progressively less invasive. Recent endoscopic techniques avoid nasal or intraoral incisions, use of nasal specula and nasal packing for some operators. To present the endoscopic trans-sphenoidal approach for surgical treatment of pituitary adenomas and to evaluate its results and complications. From 1996 to 2006 in the Departments of Otorhinohryngology and Neurosurgery in Cairo University Hospital, 310 patients with pituitary adenomas were operated using the trans-sphenoidal endoscopic approach, among which 197 patients had giant adenomas with supra or para sellar extensions. Complete tumor removal was accomplished in 284 patients [91.6%]. Mortality rate was 3 patients [0.97%]. Morbidity rate was 68 patients [21.9%] in the form of transient diabetes insipidus in 64 patients [20.6%], intraoperative CSF leak in 2 patients [0.6%], bilateral visual loss in 1 patient [0.3%] and tension pneumocephalus in 1 patient [0.3%]. The endoscopic trans-sphenoid approach is the management of choice for pituitary adenomas including invasive type. The surgery can be done with minimal morbidity and more radically than classic transsphenoidal surgery. Invasion of the cavernous sinus is no longer a taboo and could he attempted in 68.2% of the cases with a parasellar extension

Transsphenoidal microsurgical results of non-invasive prolactinomas / 中华外科杂志

<p><b>OBJECTIVE</b>To analyze the transsphenoidal microsurgical results of non-invasive prolactinomas, in order to provide reference for their treatment choice.</p><p><b>METHODS</b>To review the transsphenoidal microsurgical results of 234 non-invasive prolactinomas treated in our department in recent 10 years, and to analyze the prognostic factors. There were 18 males and 216 females, aged between 13 and 58 years, averaged (31.1 +/- 8.5) years. The course ranged from half a month to 20 years, averaged (47.3 +/- 44.9) months. The preoperative serum PRL level ranged between 41 and 8406 ng/ml, averaged (400.5 +/- 888.0) ng/ml, with a median of 164.1 ng/ml. The primary symptoms were amenorrhea, galactorrhea and/or infertility in 211 cases. The tumor size was small (< 1 cm) in 100, large (> or = 1 cm) in 116 and giant (> or = 3 cm) in 18 cases. All the patients received transsphenoidal microsurgery and were followed-up for 12 to 132 months, averaged (43.8 +/- 35.0) months.</p><p><b>RESULTS</b>There was no mortality. One hundred and twenty-seven (54.3%) cases had transient postoperative imbalance of water and electrolytes. One hundred and eighty-eight cases (80.3%) were cured, 12 (5.1%) experienced clinical remission, 20 (8.5%) were improved, and 14 (6.0%) were ineffective. The male patient, the giant prolactinomas and those with higher preoperative serum PRL level had a relative poor postoperative prognosis. While the other factors had no influence on prognosis, including the course, preoperative bromocriptine intake, tumor texture, tumor apoplexy and intraoperative descending extent of the diaphragm of sella. The overall operative expense for transsphenoidal microsurgery ranged from 8323.8 to 22898.5 yuan, averaged (12912.0 +/- 2361.2) yuan.</p><p><b>CONCLUSIONS</b>Transsphenoidal microsurgery may be chosen as the primary therapy for non-invasive prolactinomas, with the purposes of therapeutical efficacy, facilitating the patients, re-establishing the patients' self-confidence and reducing the overall expense.</p>

Rathke's cleft cyst--an uncommon cause of headache in a young boy.

Developmental disorders of the pituitary can present like a mass lesion in the region of the pituitary and produce pressure effects. Rathke's cleft cyst is one such developmental disorder of the pituitary which presents in early life producing pressure effects namely visual disturbances due to its proximity to optic chiasma, headache, and hormonal imbalance due to pituitary malfunction. In this case report a 19 years boy presented with symptoms of headache and gradual loss of vision over one year period. Neuro-imaging study demonstrated a cystic lesion in the region of the pituitary. Trans-sphenoidal hypophysectomy was performed. Histopathology of the biopsied material was suggestive of Rathke's cleft cyst. Following surgery the boy had a good visual recovery. So early diagnosis and removal of a Rathke's cleft cyst has a good prognosis as compared to a craniopharyngioma which is a very close differential diagnosis.

Prospective evaluation of transsphenoidal pituitary surgery in 108 patients with Cushing's disease

Transsphenoidal pituitary surgery (TSS) remains the treatment of choice for Cushing's disease (CD). Despite the widespread acceptance of this procedure as the first line treatment in CD, the indication of a second TSS in not cured or relapsed DC patients is not consensus. We report the results of TSS in 108 patients with CD (a total of 117 surgeries). The mean postoperative follow-up period was 6 years. Remission was defined as clinical and laboratorial signs of adrenal insufficiency, period of glucocorticoid dependence, serum cortisol suppression on oral 1-mg dexamethasone overnight suppression test and clinical remission of hypercortisolism. We evaluated 103 patients with CD by the time of the first TSS. Fourteen patients underwent second TSS (5 had already been operated in others centers; in 5 patients the first surgery was not curative; in 4 patients CD relapsed). Remission rates were 85.4 percent and 28.6 percent (p < 0.001) after first and second TSS, respectively. In microadenomas, remission rates were higher than macroadenomas (94.9 percent vs. 73.9 percent; p = 0.006). In patients with negative pituitary imaging remission rates were 71.4 percent (p = 0.003; vs. microadenomas). Postoperative complications were: transient diabetes insipidus, definitive diabetes insipidus, hypopituitarism, stroke and one death. Only hypopituitarism was more frequent after second TSS (p = 0.015). In conclusion, TSS for CD is an effective and safe treatment. The best remission rates were observed at the first surgery and in microadenomas. The low remission rates after a second TSS suggest that this approach could not be a good therapeutic choice when the first one was not curative.

O tratamento de escolha para a doença de Cushing (DC) ainda é a cirurgia transesfenoidal (CTE) para ressecção do adenoma hipofisário produtor de ACTH. Porém, a indicação de uma segunda CTE representa uma questão controversa, tanto nos pacientes não curados após a primeira cirurgia quanto nos casos de recidiva. Neste trabalho, relatamos os resultados da CTE em 108 pacientes com DC (totalizando 117 cirurgias). O tempo médio de seguimento foi de 6 anos. Critérios de cura: ocorrência de insuficiência adrenal (clínica ou laboratorial), período de dependência ao glicocorticóide, supressão do cortisol sérico pós-1 mg de dexametasona overnight e remissão clínica do hipercortisolismo. Foram avaliados 103 pacientes com DC submetidos à primeira CTE. Quatorze pacientes foram submetidos a uma segunda CTE (5 já tinham sido operados em outros centros; a primeira cirurgia não fora curativa em 5; 4 pacientes com recidiva da DC). Índices de cura: 85,4 por cento e 28,6 por cento (p < 0,001) após a primeira e segunda CTE, respectivamente. Nos microadenomas, remissão maior que nos macroadenomas (94,9 por cento vs. 73,9 por cento; p = 0,006). Nos pacientes com imagem hipofisária negativa, cura foi de 71,4 por cento (p = 0,003; vs. micro). Complicações pós-operatórias: diabetes insipidus transitório e definitivo, hipopituitarismo, acidente vascular cerebral e um óbito. Apenas a ocorrência de hipopituitarismo foi mais freqüente após a segunda CTE (p = 0,015). Assim sendo, a CTE para a DC representa uma terapêutica efetiva e segura. Os melhores índices de cura foram obtidos na primeira cirurgia e em microadenomas. O baixo índice de cura após a segunda CTE sugere que esta abordagem não deve ser considerada uma boa opção terapêutica quando a primeira cirurgia não for curativa.

Criteria of cure and remission in Cushing's disease: an update: [review]

We review the clinical and biochemical criteria used for evaluation of the transsphenoidal pituitary surgery results in the treatment of Cushing's disease (CD). Firstly, we discuss the pathophysiology of the hypothalamic-pituitary-adrenal axis in normal subjects and patients with CD. Considering the series published in the last 25 years, we observed a significant variation in the remission or cure criteria, including the choice of biochemical tests, timing, threshold values to define remission, and the interference of glucocorticoid replacement or previous treatment. In this context we emphasize serum cortisol levels obtained early (from hours to 12 days) in the postoperative period without any glucocorticoid replacement or treatment. Our experience demonstrates that: (i) early cortisol < 5 to 7 µg/dl, (ii) a period of glucocorticoid dependence > 6 mo, (iii) absence of response of cortisol/ACTH to CRH or DDAVP, (iv) return of dexamethasone suppression, and circadian rhythm of cortisol are appropriate indices of remission of CD. In patients with undetectable cortisol levels early after surgery, recurrence seems to be low. Finally, although certain biochemical patterns are more suggestive of remission or surgical failure, none has been proven to be completely accurate, with recurrence observed in approximately 10 to 15 percent of the patients in long-term follow-up. We recommended that patients with CD should have long-term monitoring of the CRH-ACTH-cortisol axis and associated co-morbidities, especially hypopituitarism, diabetes mellitus, hypertension, cardiovascular disturbances, and osteoporosis.

Neste artigo, são revisados os principais critérios clínicos e hormonais utilizados para avaliação do tratamento cirúrgico da Doença de Cushing (DC). Inicialmente são comentados aspectos fisiopatológicos que orientam a avaliação hormonal e os principais fatores clínicos, laboratoriais, cirúrgicos e histológicos associados com melhores resultados, observados nas principais séries da literatura e em pacientes acompanhados prospectivamente pelos autores. Foram revisados, também, critérios adotados nas principais séries da literatura, nos últimos 25 anos, chamando-se atenção para as dosagens hormonais, o momento em que foram realizadas, a possibilidade de interferência de tratamentos prévios e da reposição glicocorticóide. À seguir, essas dosagens são discutidas salientando-se a importância do cortisol obtido seqüencialmente no pós-operatório e sem a interferência de reposição glicocorticóide. A experiência prospectiva dos autores, recentemente referendada na literatura, demonstra que valores de cortisol < 5 a 7 µg/dl associados com um período de dependência aos glicocorticóides > 6 meses, ausência de resposta do ACTH/cortisol ao DDAVP e/ou CRH, retorno da supressão à dexametasona e do ritmo circadiano, estão associados com remissão da DC. Em pacientes com cortisol indetectável após cirurgia transesfenoidal, a chance de recidiva parece ser menor do que naqueles em que se observa cortisol detectável. Finalmente, chamamos a atenção para que, mesmo adotando critérios rígidos de avaliação, a recidiva da DC pode ocorrer a longo prazo em até 15 por cento dos casos, recomendando-se, portanto, que esses pacientes sejam acompanhados por tempo indeterminado, com monitorização cuidadosa do eixo CRH-ACTH-cortisol e de suas co-morbidades, especialmente hipopituitarismo, diabete melito, hipertensão arterial, alterações cardiovasculares e osteoporose.