Endoscopic transsphenoidal pituitary surgery: evidence of an operative learning curve.

BACKGROUND: The use of the fiberoptic endoscope is a recent innovation in pituitary surgery. OBJECTIVE: To investigate the evidence of an operative learning curve after the introduction of endoscopic transsphenoidal surgery in our unit. METHODS: The first 125 patients who underwent endoscopic transnasal transsphenoidal surgery for pituitary fossa lesions between 2005 and 2007 performed by 1 surgeon were studied. Changes in a number of parameters were assessed between 2 equal 15-month time periods: period 1 (53 patients) and period 2 (72 patients). RESULTS: There were 67 patients (54%) with nonfunctioning adenomas, 22 (18%) with acromegaly, and 10 (8%) with Cushing's disease. Between study periods 1 and 2, there was a decrease in the mean duration of surgery for nonfunctioning adenomas (from 120 minutes to 91 minutes; P < .01). This learning effect was not apparent for functioning adenomas, the surgery for which also took longer to perform. The proportion of patients with an improvement in their preoperative visual field deficits increased over the study period (from 80% to 93%; P < .05). There were nonsignificant trends toward improved endocrine remission rates for patients with Cushing's disease (from 50% to 83%), but operative complications, notably the rates of hypopituitarism, did not change. Overall length of hospital stay decreased between time periods 1 and 2 (from 7 to 4 days median; P < .01). CONCLUSION: The improvements in the duration of surgery and visual outcome noted after about 50 endoscopic procedures would favor the existence of an operative learning curve for these parameters. This further highlights the benefits of subspecialization in pituitary surgery.

Isolated extradural Rosai-Dorfman disease of the thoracic spine: a rare cause of spinal cord compression: case report.

OBJECTIVE: Rosai-Dorfman disease is a rare benign histiocytic disease of unknown origin that arises predominantly in lymph nodes with generalized fever and malaise but can affect a variety of organs. We describe a case of isolated Rosai-Dorfman disease causing thoracic cord compression. CLINICAL PRESENTATION: A 24-year-old man presented with progressive spastic paraparesis. A magnetic resonance scan revealed an anteriorly placed extradural lesion of the T4-T7 thoracic spine causing cord compression. He was systemically well with no other disease. INTERVENTION: The patient made a complete recovery after a limited T4-T7 laminectomy and biopsy of the lesion. Repeat magnetic resonance scan at 6 months revealed a further posteriorly placed lesion at the T8/9 level. More extensive posterior surgery was carried out with subtotal resection of the lesion with pedicle screw fixation. Histologically, all specimens revealed fibrous connective tissue infiltrated by histiocytic cells with CD68 and S100 positivity, confirming a diagnosis of Rosai-Dorfman disease. CONCLUSIONS: This is a rare case of isolated Rosai-Dorfman disease causing thoracic cord compression. It should be considered among the differential diagnoses of extradural cord compression. Radiological features and treatment options are discussed.

Transient asystole during endoscopic transsphenoidal surgery for acromegaly: an example of trigeminocardiac reflex.

Cardiac arrhythmias are rare during transsphenoidal surgery and is often secondary to stimulation of the trigeminal nerve endings that supply the nasal passages and cavernous sinus walls. Authors report a patient with Acromegaly, who developed transient asystole, during the dissection of the adenoma extending into the left cavernous sinus wall. In such cases, the use of prophylactic atropine may help to avoid such a complication.