How to deal with giant pituitary adenomas: transsphenoidal or transcranial, simultaneous or two-staged?

Giant pituitary adenomas (diameter >4 cm) are a challenge to treat, and there is no consensus on the optimal surgical strategy. We report here our experience in surgical management of these lesions. Adult patients with giant pituitary adenomas (n = 62; 54 non-functioning and eight hormone-secreting adenomas) who underwent surgical resection at our hospital from 2009 to 2015 were retrospectively reviewed. Surgical and clinical outcomes were analyzed. Single transsphenoidal and transcranial approaches were used in 43 (69.4%) and four (6.5%) patients, respectively. A combined transsphenoidal and transcranial approach was used in 13 patients (20.9%) and in two patients (3.2%), a transcranial procedure was followed 3 months later by a transsphenoidal approach. Greater than 90% resection was achieved in 47 cases (75.8%). During a mean follow-up period of 46.9 months, 49 patients (79%) showed improved visual impairment scores, while none experienced visual deterioration. There was no post-operative hemorrhage or mortality. A total of 27 patients (43.5%) received adjuvant medical and/or radiation therapy. At last follow-up, eight patients (12.9%) had recurrence. For giant pituitary adenoma, the transsphenoidal and transcranial approaches should be combined flexibly based on the characteristics of the tumor. In certain cases, a simultaneous combined approach can maximize tumor extirpation and lower the risk of swelling and bleeding of the residual tumor.

Sub arachnoid block for emergency cesarean section in a pituitary dwarf.

Anaesthesia for parturient patients with dwarfism is an uncommon problem faced by anaesthesiologists. There is an ongoing debate regarding general versus regional anaesthesia in these cases. In many centers there is lack of facilities for epidural or continuous epidural anaesthesia. A primiparous dwarf woman of 27 years old having 124 cm height and 37 kg weight was admitted in Mymensingh Medical College Hospital for elective cesarean section due to cephalopelvic disproportion. She was diagnosed as a case of pituitary dwarf previously on antenatal checkup depending on both clinical and endocrine ground. After admission she suddenly developed respiratory distress with less foetal movement and presented in our department for emergency cesarean section. We have managed the case by sub-arachnoid block (SAB) using 7.5 mg (1.5 ml) of 0.5% heavy bupivacaine at a level of L3-L4 interspace having adequate level of block and analgesia. The case was managed successfully and uneventfully. In this presentation, the role of SAB and a management guideline has been highlighted.

[Bilateral lengthening of short lower limbs. 26 cases treated with the Ilizarov method]. / Allongement bilatéral des membres inférieurs pour petite taille. 26 cas traités par la méthode d'Ilizarov.

Gradual distraction with the Ilizarov external fixator was used on 26 patients for short stature. 19 patients complete their program (G1, 64 fixators): average pain is 12 cm for an initial stature of 133 cm; 3 patients stopped their program before end for psychological problems. Surgical procedures included: section of tensor fascia lata (9 cases), lengthening of Achilleus tendon (16 cases), skin debridement around pins (3 cases), modification of apparatus under general anesthesia (53 cases), iterative corticotomy (4 cases in G1) or peroneus section (4 in G1). Healing index was 23 D/cm for femur and 29 D/cm for tibia. Events occurred during the program: 1) mechanicals: 1 pin rupture; 2) bony: 1 delayed healing needing graftng, 3 bone impactions and 11 fractures after fixator removal, 1 axial deviation needing callotasy at fixator removal; 3) nervous and musculary: 12 transitory peroneal nerve lesions, 3 compartment syndromes, 2 proximal sciatic lesion, recovered, and 2 motor palsies; 4) joint lesions: 1 knee stiffness needing an extensive quadriceps release; 5) vascular: 1 deep venous thrombosis; 6) infectious: 10 superficial infections around pins, 4 osteitis and 1 arthritis; 7) cutaneous: 7 scar removals. Lengthening of people with short stature concerns motivated people fully aware of events occurring during a lengthening program which will decrease the initial handicap.

[Beneficial effects of pituitary grafts under the renal capsule on behavior of dwarf mutant mice]. / Effets bénéfiques des greffes hypophysaires sous capsule rénale sur le comportement de la Souris mutante "dwarf".

The effects of pituitary grafts under the kidney capsule were studied in "dwarf" mutant mice which because of anterohypophyseal deficiency, exhibit dwarfism, sterility and important behavioral deficits. One month after grafting, the body weight was 120% in the grafted mutants while only 11 and 8% respectively in normal and sham-grafted controls. At the behavioral level, the animals were examined on 2 tasks: spontaneous alteration in a T maze and passive avoidance (step-through). Grafted mutant mice, as well as sham-grafted normal controls, were able to alternate successfully, while the sham-grafted "dwarf" mice persevered. In the step-through task, grafted animals as well as sham-grafted normal mice, avoided, entering the dark compartment, 24 h after the shock trial. On contrast, sham-grafted dwarf mice did not show passive avoidance of the shock. According to the literature, pituitary grafts under the kidney capsule secrete high levels of prolactin and very little, if any, of other pituitary hormones. It is not yet clear how the presence of only prolactin can explain the body weight and the maintenance of the behaviors we investigated.