Interactive image-guided pituitary surgery - An experience of 101 procedures

This paper reports on a series of 101 pituitary region operations performed using image guidance technology in the Department of Neurosurgery, Frencha y hospital, Bristol, UK between 1992-1997. The cases form part of an overal l series of image guided surgery of 1 112 cases performed during that time. The systems used were the ISG/Elekta Viewing Wand and the Sofamor Danek St ealthStation. Thirty-five tumors had a diameter of >2.5 cm and 12 >5 cm. Th e clinical indications for surgery were: visual failure (n = 47), acromegal y (n = 22), Gushing syn drome (n = 6), hyperprolactinemia (n = I), hyposecr etion syndromes (n = 8), raised intracranial pressure/CSF leak (n = 13). Th ree cases were operated on because of radiological evidence of tumor progre ssion without symptoms. Eighty-five patients had skull base procedures (56 transnasal routes, 16 transsphenoidal approaches, 13 sphenoid fenestrations ), 16 underwent craniotomy. Operating times and postoperative bed stay were shortest the more minimally invasive the procedure. Sixty-eight percent of patients presenting with visual failure improved postoperatively. Surgery produced biochemical << cure >> in 41 % of patients with hypersecretion syn dromes. Fifty percent of patients with hypopituitary syndromes improved end ocrinologically postoperatively. Twenty five complications were noted: 9 rh inorrheas, 5 diabetes insipidus, 3 postoperative epilepsies, 3 induced visu al deteriorations and pituitary insufficiency. There were 2 deaths. Image g uidance technology is applicable to pituitary surgery, particularly in four situations: i) orientation in difficult skull base approaches e.g. reopera tions, paediatric cases, non pneumatised sphenoid, microadenomas, carotid a rteries medially placed, ii) in craniotomies to customise the surgical appr oach, locate different parts of a tumor and identify critical anatomy relat ed to the tumor, iii) in the planning and execution of minimally invasive a pproaches to the pituitary fossa (sphenoid fenestration, transnasal approac h), iiii) endoscopy.