Ten years' experience with intraoperative MRI-assisted transsphenoidal pituitary surgery.

OBJECTIVE: Many innovations have been introduced into pituitary surgery in the quest to maximize the extent of tumor resection. Because of the deep and narrow surgical corridor as well as the heterogeneity of confronted pathologies, anatomical orientation and identification of the target tissue can become difficult. Intraoperative MRI (iMRI) may have the potential to increase extent of resection (EOR) in transsphenoidal pituitary surgery. Furthermore, it may simplify anatomical orientation and risk assessment in difficult cases. Here, the authors evaluated the additional value of iMRI for the resection of pituitary adenomas performed in the past 10 years in their department. METHODS: They performed a retrospective single-center analysis of patients treated for pituitary adenoma in their department after the introduction of iMRI between 2008 and 2018. Of 495 transsphenoidal approaches, 300 consecutive MRI-assisted surgeries for pituitary adenomas encompassing 294 patients were selected for further analysis. Microscopic, endoscopic, or endoscope-assisted microscopic transsphenoidal approaches were distinguished. EOR as well as additional resection following iMRI was evaluated via detailed volumetric analysis. Patients were stratified according to the Knosp adenoma classification. Furthermore, demographic data, clinical symptoms, endocrine outcome, and complications were evaluated. Univariable and multivariable Cox regression analyses of progression-free survival (PFS) were performed. RESULTS: Pituitary adenomas classified as Knosp grades 0-2 were found in 60.3% of cases (n = 181). The most common tumors were nonfunctioning adenomas (75%). Continued resection following iMRI significantly increased EOR (7.5%, p < 0.001) and the proportion of gross-total resections (GTRs) in transsphenoidal pituitary surgery (54% vs 68.3%, p < 0.001). Additional resection after iMRI was performed in 37% of cases. Only in the subgroup of patients with Knosp grades 0-2 adenomas treated with the microsurgical technique was additional resection significantly more common than in the endoscopic group (p = 0.039). Residual tumor volume, Knosp grade, and age were confirmed as independent predictors of PFS (p < 0.001, p = 0.021, and p = 0.029, respectively) in a multivariable Cox regression analysis. Improvement of visual field deficits was documented in 78.6% of patients whose optic apparatus had been affected preoperatively. Revision surgery was done in 7.3% of cases; in 5.6% of cases, it was performed for cerebrospinal fluid fistula. CONCLUSIONS: In this series, iMRI led to the detection of a resectable tumor remnant in a high proportion of patients, resulting in a greater EOR and higher proportion of GTRs after continued resection in microsurgical and endoscopic transsphenoidal resection of pituitary adenomas. The volume of residual tumor was the most important predictor of PFS. Given the study data, the authors postulated that every bit of removed tumor serves the patient and increases their chances of a favorable outcome.

Current management of Cushing's disease.

Cushing's disease (CD) is caused by a pituitary tumour that secretes adrenocorticotropin (ACTH) autonomously, leading to excess cortisol secretion from the adrenal glands. The condition is associated with increased morbidity and mortality that can be mitigated by treatments that result in sustained endocrine remission. Transsphenoidal pituitary surgery (TSS) remains the mainstay of treatment for CD but requires considerable neurosurgical expertise and experience in order to optimize patient outcomes. Up to 90% of patients with microadenomas (tumour below 1 cm in largest diameter) and 65% of patients with macroadenomas (tumour at or above 1 cm in greatest diameter) achieve endocrine remission after TSS by an experienced surgeon. Patients who are not in remission postoperatively or those who relapse may benefit from undergoing a second pituitary operation. Alternatively, radiation therapy to the sella with interim medical therapy, or bilateral adrenalectomy, can be effective as definitive treatments of CD. Medical therapy is currently adjunctive in most patients with CD and is generally prescribed to patients who are about to receive radiation therapy and will be awaiting its salutary effects to occur. Available treatment options include steroidogenesis inhibitors, centrally acting agents and glucocorticoid receptor antagonists. Several novel agents are in clinical trials and may eventually constitute additional treatment options for this serious condition.

NextLens-The Next Generation of Surgical Navigation: Proof of Concept of an Augmented Reality System for Surgical Navigation.

Objective The aim of this work was the development of an augmented reality system including the functionality of conventional surgical navigation systems. Methods An application software for the Augmented Reality System HoloLens 2 from Microsoft was developed. It detects the position of the patient as well as position of surgical instruments in real time and displays it within the two-dimensional (2D) magnetic resonance imaging or computed tomography (CT) images. The surgical pointer instrument, including a pattern that is recognized by the HoloLens 2 sensors, was created with three-dimensional (3D) printing. The technical concept was demonstrated at a cadaver skull to identify anatomical landmarks. Results With the help of the HoloLens 2 and its sensors, the real-time position of the surgical pointer instrument could be shown. The position of the 3D-printed pointer with colored pattern could be recognized within 2D-CT images when stationary and in motion at a cadaver skull. Feasibility could be demonstrated for the clinical application of transsphenoidal pituitary surgery. Conclusion The HoloLens 2 has a high potential for use as a surgical navigation system. With subsequent studies, a further accuracy evaluation will be performed receiving valid data for comparison with conventional surgical navigation systems. In addition to transsphenoidal pituitary surgery, it could be also applied for other surgical disciplines.

Evaluation of Retrospective Patient Preference on Extent of Resection of Nonfunctioning Pituitary Adenomas.

BACKGROUND: Neurosurgeons treat nonfunctioning pituitary adenomas by surgical resection. Based on the adherence of the tumor to the normal pituitary gland, operative risks may include hormone replacement therapy for postoperative hypopituitarism with gross total resection that injures the gland or recurrent tumor with subtotal resection and purposeful avoidance of gland manipulation. None of the patients presented in this article had a preoperative preference regarding extent of resection. This study aimed to evaluate postoperative patient preferences regarding extent of resection. METHODS: Adult patients who underwent resection of adenomas between 2015 and 2023 were retrospectively reviewed and surveyed. After surgery, participating patients were asked for their preference regarding 100% tumor resection with lifelong daily hormone replacement therapy versus 90% tumor resection with a chance of recurrence in the hypothetical situation where the neurosurgeon encounters tumor adherent to the normal gland. RESULTS: Of the 73 patients included, 54 (74.0%) responded to the survey, with the majority (36 [66.7%]) preferring 90% resection with the chance of tumor recurrence. Tumor recurrence (odds ratio 2.3, 95% confidence interval 2.1-2.5, P = 0.03) and steroid avoidance (odds ratio 2.2, 95% confidence interval 2.0-2.4, P = 0.04) were the 2 variables that were significant predictors of patient preference in multivariate regression analysis. CONCLUSIONS: Although patients may not have the preoperative insight or experience to have a strong conviction regarding the extent of adenoma resection, the consequences following surgery clearly influence their preference. Most patients in our study, including patients with gross total resection and especially patients who experienced side effects of steroid therapy, preferred subtotal resection with the chance of tumor recurrence over hormone replacement therapy.

Impact of metabolic syndrome on postoperative outcomes of transsphenoidal pituitary surgery: analysis of U.S. nationwide inpatient sample data 2005-2018.

Introduction: Transsphenoidal surgery (TSS) is the preferred surgical method for most pituitary adenomas owing to high efficacy and low mortality. This study aimed to evaluate the influence of metabolic syndrome (MetS) on postoperative outcomes of TSS for pituitary adenoma. Methods: This population-based, retrospective observational study extracted data of adults 20-79 y receiving TSS for pituitary adenoma from the US Nationwide Inpatient Sample (NIS) between 2005-2018. Primary outcomes were pituitary-related complications, poor outcomes (i.e., in-hospital mortality or unfavorable discharge), prolonged length of stay (LOS), and patient safety indicators (PSIs). Univariate and multivariate regressions were performed to determine the associations between study variables and outcomes. Results: 19,076 patients (representing a 93,185 US in-patient population) were included, among which 2,109 (11.1%) patients had MetS. After adjustment, pre-existing MetS was not significantly associated with presence of pituitary-related complications and poor outcomes. In contrast, MetS was significantly associated with an increased risk for prolonged LOS (adjusted OR (aOR) = 1.19; 95% CI: 1.05-1.34), PSIs (aOR = 1.31; 95% CI: 1.07-1.59) and greater hospital costs (adjusted ß = 8.63 thousand USD; 95% CI: 4.98-12.29). Among pituitary-related complications, MetS was independently associated with increased risk of cerebrospinal fluid (CSF) rhinorrhea (aOR = 1.22, 95% CI: 1.01, 1.47) but lowered diabetes insipidus (aOR = 0.83, 95% CI: 0.71, 0.97). Discussion: MetS does not pose excessive risk of in-hospital mortality or unfavorable discharge. However, MetS independently predicted having PSIs, prolonged LOS, greater hospital costs, and CSF rhinorrhea. Study findings may help clinicians achieve better risk stratification before TSS.

Impact of Facility Volume on Patient Safety Indicator Events After Transsphenoidal Pituitary Surgery.

OBJECTIVES: To investigate the impact of facility volume on Patient Safety Indicator (PSI) events following transsphenoidal pituitary surgery (TSPS). STUDY DESIGN: Retrospective database review. SETTING: National Inpatient Sample database (2003-2011). METHODS: The National Inpatient Sample was queried for TSPS cases from 2003 to 2011. Facility volume was defined by tertile of average annual number of TSPS procedures performed. PSIs, based on in-hospital complications identified by the Agency of Healthcare Research and Quality, and poor outcomes, such as mortality and tracheostomy, were analyzed. RESULTS: An overall 16,039 cases were included: 804 had ≥1 PSI and 15,235 had none. A greater proportion of male to female (5.8% vs 4.3%) and Black to White (7.0% vs 4.5%) patients experienced PSIs. There was an increased likelihood of poor outcome (odds ratio [OR], 3.1 [95% CI, 2.5-3.7]; P < .001) and mortality (OR, 30.1 [95% CI, 18.5-48.8]; P < .001) with a PSI. The incidence rates of PSIs at low-, intermediate-, and high-volume facilities were 5.7%, 5.1%, and 4.2%, respectively. Odds of poor outcome with PSIs were greater at low-volume facilities (OR, 3.3 [95% CI, 2.4-4.4]; P < .001) vs intermediate (OR, 3.1 [95% CI, 2.1-4.2]; P < .001) and high (OR, 2.5 [95% CI, 1.7-3.8]; P < .001). Odds of mortality with PSIs were greater at high-volume facilities (OR, 43.0 [95% CI, 14.3-129.4]; P < .001) vs intermediate (OR, 40.0 [95% CI, 18.5-86.4]; P < .001) and low (OR, 17.3 [95% CI, 8.0-37.7]; P < .001). CONCLUSION: PSIs were associated with a higher likelihood of poor outcome and mortality following TSPS. Patients who experienced PSIs had a lower risk of poor outcome but increased mortality at higher-volume facilities.

Effects of acromegaly treatment on left ventricular systolic function assessed by speckle tracking echocardiography in relation to sex differences: results from a prospective single center study.

Background: Despite the preserved LVEF, patients with acromegaly are characterized by subclinical systolic dysfunction i.e., abnormal global longitudinal strain (GLS) assessed by speckle tracking echocardiography (STE). The effect of acromegaly treatment on LV systolic function assessed by STE, has not been evaluated so far. Patients and methods: Thirty-two naïve acromegalic patients without detectable heart disease were enrolled in a prospective, single-center study. 2D-Echocardiography and STE were performed at diagnosis, 3&6 months on preoperative somatostatin receptor ligand (SRL) treatment and 3 months after transsphenoidal surgery (TSS). Results: Treatment with SRL resulted in reduction in median (IQR) GH&IGF-1 levels after 3 months, from 9.1(3.2-21.9) to 1.8(0.9-5.2) ng/mL (p<0.001) and from 3.2(2.3-4.3) to 1.5(1.1-2.5) xULN (p<0.001), respectively. Biochemical control on SRL was achieved in 25.8% of patients after 6 months and complete surgical remission was achieved in 41.7% of patients. TSS resulted in decrease in median (IQR) IGF-1 compared to IGF-1 levels on SRL treatment: from 1.5(1.2-2.5) to 1.3(1.0-1.6) xULN (p=0.003). Females had lower IGF-1 levels at baseline, on SRL and after TSS compared to males. The median end diastolic and end systolic left ventricle volumes were normal. Almost half of the patients (46.9%) had increased LVMi, however the median value of LVMi was normal in both sex groups: 99g/m2 in males and 94g/m2 in females. Most patients (78.1%) had increased LAVi and the median value was 41.8mL/m2. At baseline 50% of patients, mostly men (62.5% vs. 37.5%) had GLS values higher than -20%. There was a positive correlation between baseline GLS and BMI r=0.446 (p=0.011) and BSA r=0.411 (p=0.019). The median GLS significantly improved after 3 months of SRL treatment compared to baseline: -20.4% vs. -20.0% (p=0.045). The median GLS was lower in patients with surgical remission compared to patients with elevated GH&IGF-1 levels: -22.5% vs. -19.8% (p=0.029). There was a positive correlation between GLS and IGF-1 levels after TSS r=0.570 (p=0.007). Conclusion: The greatest beneficial effect of acromegaly treatment on LV systolic function is visible already after 3 months of preoperative SRL treatment, especially in women. Patients with surgical remission have better GLS compared to patients with persistent acromegaly.

Reconstruction of the Anterior Skull Base Using the Nasoseptal Flap: A Review.

The nasoseptal flap is a workhorse reconstructive option for anterior skull base defects during endonasal surgery. This paper highlights the versatility of the nasoseptal flap. After providing a brief historical perspective, this review will focus on the relevant primary literature published in the last ten years. We will touch upon new applications of the flap, how the flap has been modified to expand its reach and robustness, and some of the current limitations. We will conclude by discussing what the future holds for improving upon the design and use of the nasoseptal flap in anterior skull base reconstruction.

Multidisciplinary Postoperative Care Pathway to Reduce Readmissions following Endoscopic Transsphenoidal Pituitary Surgery: Improving Quality of Patient Care.

Background Thirty-day unplanned readmission following endoscopic transsphenoidal pituitary surgery (ETPS) occurs in up to 14% of patients. Delayed hyponatremia is one of the most common causes, accounting for 30% of readmissions and often occurs within 1 week of surgery. The authors' prior retrospective review identified endocrinology follow-up as protective factor. Objectives Implementation of a multidisciplinary postoperative care (POC) pathway: (1) to reduce 30-day hospital readmissions following ETPS and (2) improve inpatient and outpatient coordination of care with endocrinologist. Methods This study is a single institution temporal cohort study of patients prior to (control cohort) and after implementation of the POC pathway (intervention cohort). The POC pathway utilized postdischarge 1 to 1.5 L/d fluid restriction, postoperative days 5 to 7 serum sodium, and endocrinology follow-up within 1 week of discharge to stratify patients into tiered hyponatremia regimens. Results A total of 542 patients were included in the study, 409 (75%) in the control cohort and 133 (25%) in the intervention cohort. All-cause readmission was significantly reduced following implementation of the POC pathway (14 vs. 6%, p = 0.015). Coordination with endocrinologist significantly increased in the inpatient (96 vs. 83%, p < 0.001) and outpatient (77 vs. 68%, p = 0.042) settings. Patients who were not in the POC pathway had the highest risk of readmission (odds ratio: 2.5; 95% confidence interval: 1.1-5.5). Conclusion A multidisciplinary POC pathway incorporating endocrinologist in conjunction with postdischarge weight-based fluid restriction and postoperative serum sodium levels can safely be used to reduce 30-day readmissions following ETPS.

Pediatric Cushing's disease: Case reports and retrospective review.

BACKGROUND: We report four pediatric subjects with Cushing's disease (CD) diagnosed in the Czech Republic. We focus on initial symptoms of Cushing's syndrome (CS) which can lead to early diagnosis, on typical symptoms of CS in children, their age and sex distribution, the mean length of symptoms prior to diagnosis, indication for examination, post-cure growth, sexual development and pituitary function in our four CD patients after transsphenoidal pituitary surgery (TSS). We describe the diagnostic process leading to confirmation of CD and we emphasize the biochemical and radiological diagnostic difficulties. CONCLUSIONS: Pediatric CD has a number of features distinct from adult CD. Our retrospective analysis confirmed the presence of growth retardation and change in facial appearance with development of moon face as the first symptoms of CS. According to our observation, growth retardation is prior to development of moon face. The other typical symptoms frequently seen in pediatric patients are pseudo-precocious puberty in both sexes, hirsutism in pubertal girls due to excessive adrenal androgen secretion and pubertal delay. A corticotropin-releasing hormone (CRH) test and especially bilateral inferior petrosal sinus sampling for ACTH (BIPSS) contribute to confirming the diagnosis of CD and excluding ectopic ACTH syndrome in children with unvisible adenoma on pituitary magnetic resonance imaging (MRI).

Diagnosis, Manifestations, Laboratory Investigations, and Prognosis in Pediatric and Adult Cushing's Disease in a Large Center in China.

Purpose: Cushing's disease (CD) is a rare disease that contributes to 70-80% hypercortisolemia, which presents similarities and differences between pediatric and adult patients, and even between male and female patients. However, the comparative study of CD between different age groups and different genders is still insufficient. The aim of the study is to make a systematic comparison to reveal the gender differences in children and adult patients of CD, helping clinicians to provide optimal treatment for different groups of patients. Methods: We conducted a retrospective research consisting of 30 pediatric and 392 adult CD patients in a single center in Peking Union Medical College Hospital. All 422 patients showed symptoms related to hypercortisolism and received adenoma excision surgery in the department of neurosurgery between 2014 and 2020. Results: For the accuracy of diagnosis, the sensitivity of BIPSS at baseline in pediatric patients was lower than in adults (75 vs. 91%, P = 0.054) but increased greatly after desmopressin stimulation (94 vs. 95%). However, the accuracy of lateralization for BIPSS was not preferred for prediction. As for clinical manifestations, growth retardation, weight gain, hirsutism, and acne were more prevalent for children, while for adults, hypertension, osteopenia, glucometabolic disorder, easy bruising, hair loss, and weight loss were more frequently seen. As previously reported, we observed a significant difference between the male prevalence of pediatric and adult patients (50 vs. 17%, P < 0.001), which was possibly caused by the more severe and earlier onset of a series of symptoms. Gender-related comparison showed greater morbidity of nephrolithiasis, hypokalemia, hypertension, easy bruising, osteopenia, and striae for male patients, while irregular menses, hirsutism, and hair loss were more common for female patients. Further analysis showed that the secretory activity of the PA axis was higher for males, presenting as the more remarkable alteration of laboratory parameters and contributing to the more severe clinical manifestations. For patients treated with transsphenoidal pituitary surgery (TSS), the immediate prognosis could be predicted by operation history, invasiveness, Ki-67, and information provided by MRI, including tumor size and Knosp grading. However, we still lack methods to predict long-term prognosis. Conclusions: Our study is the first detailed and systematic comparison between pediatric and adult CD patients. Further exploration of the impact of CD on different genders reveals a more severe and probably an earlier-onset pattern of CD for male patients.

Geographic Variation in Costs of Transsphenoidal Pituitary Surgery in the United States.

BACKGROUND: Geographic variations in health care costs have been reported for many surgical specialties. OBJECTIVE: In this study, we sought to describe national and regional costs associated with transsphenoidal pituitary surgery (TPS). METHODS: Data from the Truven-MarketScan 2010-2014 were analyzed. We examined overall total, hospital/facility, physician, and out-of-pocket payments in patients undergoing TPS including technique-specific costs. Mean payments were obtained after risk adjustment for patient-level and system-level confounders and estimated differences across regions. RESULTS: The estimated overall annual burden was $43 million/year in our cohort. The average overall total payment associated with TPS was $35,602.30, hospital/facility payment was $26,980.45, physician payment was $4685.95, and out-of-pocket payment was $2330.78. Overall total and hospital/facility costs were highest in the West and lowest in the South (both P < 0.001), whereas physician reimbursements were highest in the North-east and lowest in the South (P < 0.001). There were no differences in out-of-pocket expenses across regions. On a national level, there were significantly higher overall total and hospital/facility payments associated with endoscopic compared with microscopic procedures (both P < 0.001); there were no significant differences in physician payments or out-of-pocket expenses between techniques. There were also significant within-region cost differences in overall total, hospital/facility, and physician payments in both techniques as well as in out-of-pocket expenses associated with microsurgery. There were no significant regional differences in out-of-pocket expenses associated with endoscopic surgery. CONCLUSIONS: Our results show significant geographic cost disparities associated with TPS. Understanding factors behind disparate costs is important for developing cost containment strategies.

Effect of intravenous lignocaine infusion on the quality of emergence in patients undergoing transsphenoidal resection of pituitary tumors - A prospective, randomized controlled trial.

BACKGROUND: Emergence from anesthesia is a critical step in patients undergoing transsphenoidal pituitary surgery (TSS). The cough suppressant and anesthetic sparing properties of lignocaine makes it a favorable option for smooth extubation and maintaining stable hemodynamics intraoperatively. We aimed to evaluate the effect of lignocaine infusion on the quality of emergence (QOE) and intraoperative hemodynamics in patients undergoing transsphenoidal resection of pituitary tumors. METHODS: Fifty patients scheduled to undergo TSS were randomly divided into ligocaine group (n = 25), receiving 1.5 mg/kg bolus dose of lignocaine followed by continuous infusion of 1.5 mg/kg/h and saline group (n = 25). Patients assigned to the control group received equal volume of saline receiving equal volume of saline. The four emergence parameters (mean arterial pressure [MAP], heart rate (HR), cough, and agitation) were abbreviated into an aggregated score for QOE. Time to emergence and intraoperative hemodynamics were also recorded. RESULTS: The QOE was not found to be different between the two groups (P = 0.294). Lignocaine did not increase the time to emergence (P = 0.166). The intraoperative HR and MAP were comparable between the two groups. A lower minimum alveolar concentration of desflurane was required in lignocaine group during insertion of nasal speculum (P = 0.018) and at the time of seller ridge dissection (P = 0.043) compared to the saline group. CONCLUSION: Intraoperative lignocaine infusion of 1.5 mg/kg/h did not significantly improve the QOE with respect to hemodynamics, cough, and emergence agitation in patients undergoing transsphenoidal resection of pituitary tumors.

Predictive factors for the recurrence of Cushing's disease after surgical treatment in childhood.

INTRODUCTION: Cushing's disease (CD) is a rare cause of hypercortisolaemia caused by excessive adrenocorticotropic hormone (ACTH) excretion by a pituitary adenoma. Data on the predictive factors for the recurrence of the disease are limited in comparison with those for the adult population. The identification of the predictive factors for CD recurrence in patients after surgical treatment in childhood was the aim of the presented study. MATERIAL AND METHODS: A retrospective analysis of 26 CD patients, mean age at the time of diagnosis 13.46 years, treated at the Children's Memorial Health Institute (CMHI) in the years 1994-2018. Two time points were set at which the follow-up (FU) of patients was finished. The first time point (shorter FU, 24 patients) was set when the patients completed their treatment at the CMHI. The second time point (longer FU, 26 patients) was determined on the basis on the time when adult patients (previous CMHI patients) completed the author's questionnaire. In the case of the other patients (current CMHI paediatric patients and patients who did not respond to the questionnaire), the latest FU in this second time point was made during the last visit to the CMHI. The predictors of disease recurrence were evaluated by the construction of a logistic regression model and receiver operating characteristics. RESULTS: The average FU after transsphenoidal pituitary surgery (TSS) of 26 patients was 10.23 years (0.67-24.50). Recurrence of CD occurred in four out of 26 patients (15.4%) after an average time of 3.6 years (0.92-8.08) following definitive treatment. The results of the statistical analysis of potential predictive factors for CD recurrence were not conclusive, with no variables confirmed above the statistical significance threshold of p < 0.05. As regards the longer FU, two potential predictors: mean cortisol level at night (p = 0.10) and max. ACTH level after ovine corticotropin-releasing hormone (oCRH) test (p = 0.10), were the closest to meeting the assumed threshold of statistical significance. CONCLUSION: Recurrence of CD may be diagnosed even a long time after its effective treatment. It is possible that cortisol levels at night and ACTH values in oCRH test before TSS may be helpful to predict which patients may experience a recurrence after successful initial treatment. However, further studies on a larger sample are needed to confirm this hypothesis.

The manufacturing procedure of 3D printed models for endoscopic endonasal transsphenoidal pituitary surgery.

BACKGROUND: Endoscopic endonasal transsphenoidal pituitary surgery is usually difficult and risky. With limited sources of cadaveric skulls, traditional methods of using virtual images to study the surgery are difficult for neurosurgeons and students because the surgery requires spatial imagination and good understanding of the patient's conditions as well as practical experience. The three-dimensional (3D) printing technique has played an important role in clinical medicine due to its advantages of low cost, high-efficiency and customization. OBJECTIVE: CT images are used as the source data of 3D printing. The data obtained directly from the CT machine has limited accuracy, which cannot be printed without processing. Some commercial platforms can help build an accurate model but the cost and customization are not satisfactory. In this situation, a tactile, precise and low-cost 3D model is highly desirable. METHODS: Five kinds of computer software are used in the manufacturing of medical 3D models and the processing procedure is easy to understand and operate. RESULTS: This study proposes a practical and cost-effective method to obtain the corrected digital model and produce the 3D printed skull with complete structures of nasal cavity, sellar region and different levels of pituitary tumors. The model is used for the endoscopic endonasal transsphenoidal pituitary surgery preparation. CONCLUSION: The 3D printed medical model can directly help neurosurgeons and medical students to practice their surgery skills on both general and special cases with customized structures and different levels of tumors.

Impact of frailty on short-term outcomes in patients undergoing transsphenoidal pituitary surgery.

OBJECTIVE: Frailty, a state of decreased physiological reserve, has been shown to significantly impact outcomes of surgery. The authors sought to examine the impact of frailty on the short-term outcomes of patients undergoing transsphenoidal pituitary surgery. METHODS: Weighted data from the 2000-2014 National (Nationwide) Inpatient Sample were studied. Patients diagnosed with pituitary tumors or disorders who had undergone transsphenoidal pituitary surgery were identified. Frailty was determined using the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnoses indicator. Standard descriptive techniques and matched propensity score analyses were used to explore the odds ratios of postoperative complications, discharge dispositions, and costs. RESULTS: A total of 115,317 cases were included in the analysis. Frailty was present in 1.48% of cases. The mean age of frail versus non-frail patients was 57.14 ± 16.96 years (mean ± standard deviation) versus 51.91 ± 15.88 years, respectively (p < 0.001). A greater proportion of frail compared to non-frail patients had an age ≥ 65 years (37.08% vs 24.08%, respectively, p < 0.001). Frail patients were more likely to be black or Hispanic (p < 0.001), possess Medicare or Medicaid insurance (p < 0.001), belong to lower-median-income groups (p < 0.001), and have greater comorbidity (p < 0.001). Results of propensity score-matched multivariate analysis revealed that frail patients were more likely to develop fluid and electrolyte disorders (OR 1.61, 95% CI 1.07-2.43, p = 0.02), intracranial vascular complications (OR 2.73, 95% CI 1.01-7.49, p = 0.04), mental status changes (OR 3.60, 95% CI 1.65-7.82, p < 0.001), and medical complications including pulmonary insufficiency (OR 2.01, 95% CI 1.13-4.05, p = 0.02) and acute kidney failure (OR 4.70, 95% CI 1.88-11.74, p = 0.01). The mortality rate was higher among frail patients (1.46% vs 0.37%, p < 0.001). Frail patients also demonstrated a greater likelihood for nonroutine discharges (p < 0.001), higher mean total charges ($109,614.33 [95% CI $92,756.09-$126,472.50] vs $56,370.35 [95% CI $55,595.72-$57,144.98], p < 0.001), and longer hospitalizations (9.27 days [95% CI 7.79-10.75] vs 4.46 days [95% CI 4.39-4.53], p < 0.001). CONCLUSIONS: Frailty in patients undergoing transsphenoidal pituitary surgery is associated with worse postoperative outcomes and higher costs, indicating that state's potential role in routine preoperative risk stratification.

Perioperative Course of Transsphenoidal Pituitary Surgery through Endoscopic versus Microscopic Approach: Interim Concerns for Neurosurgical Anesthesiology.

BACKGROUND: Endonasal endoscopic approach for transsphenoidal excision of pituitary adenoma has undergone remarkable evolution in the last two decades. It is considered less invasive and less stressful, with results comparable to the previous "gold standard" technique of microscopic transsphenoidal excision of pituitary adenoma. The aim of this study was to compare the various perioperative anesthetic and surgical factors which differ in the two approaches (endoscopic vs. microscopic) for pituitary adenoma excision, during the period when surgeons increasingly started using endoscope at our center. MATERIALS AND METHODS: Data of 307 patients from January 2011 to December 2013 were reviewed in this retrospective study. Various parameters were divided and compared on the basis of the type of approach for pituitary tumor resection vis-à-vis microscope-assisted sublabial transsphenoidal (MSLTS) resection or microscope-assisted transnasal transsphenoidal (MTNTS) resection or endoscope-assisted endonasal transsphenoidal (ETSS) resection. RESULTS: Demographic variables (except age); tumor type, dimensions, and invasiveness; patients' comorbidities; postoperative nausea/vomiting, electrolyte imbalance, respiratory, and cardiovascular problems were comparable among three groups. Duration of surgery and anesthesia were shortest for MTNTS group and longest for ETSS group (P < 0.001). Blood loss was higher in ETSS technique (median 300 mL) and least in MTNTS (median 100 mL), and the difference was significant across all three groups (P = 0.0003). Postoperative cerebrospinal fluid rhinorrhea was 17% in the MSLTS group compared to 6.5% in MTNTS and 7.9% in ETSS (P = 0.047). CONCLUSION: ETSS with the expected advantage of being less invasive offers a better chance for complete resection of adenoma. Neuroanesthesiologist must be prepared for longer surgical time and more blood loss as compared to previous microscopic approach, at least till the surgeons expertise in this newer technique.

The Impact of Resident and Fellow Participation in Transsphenoidal Pituitary Surgery.

OBJECTIVES/HYPOTHESIS: Postoperative complications is an important marker of healthcare quality. The aim of this study was to analyze the impact of resident and fellow participation on postoperative complications in transsphenoidal pituitary surgery in a multi-institutional setting. STUDY DESIGN: Retrospective analysis of population-based surgical registry. SETTING: Academic medical center. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was utilized to generate transsphenoidal pituitary surgery patient cohorts. The attending with resident and/or fellow group was compared to the attending alone based on demographics and preoperative and postoperative variables. RESULTS: A total of 469 cases were included in the analysis, with 315 performed with resident participation and 154 by attendings alone. The attending group had higher rates of diabetics (20.1% vs. 11.7%, P = 0.015) and patients with a history of previous percutaneous coronary intervention (6.0 vs. 1.6%, P = 0.009). Although the attending group demonstrated higher rates of surgical complications, and the resident/fellow group showed increased incidence in medical and overall complication rates, there was no statistical difference between the two groups. Multivariate analysis further demonstrated lack of significance in complication rates between attendings and residents/fellows. CONCLUSION: Resident and fellow participation in transsphenoidal surgery is not associated with significant differences in surgical complications, medical complications, mortality, operating time, reoperation rates, or readmission rates when compared to attendings. LEVEL OF EVIDENCE: 4 Laryngoscope, 128:2707-2713, 2018.

Physiologic Mechanisms of Water and Electrolyte Disturbances After Transsphenoidal Pituitary Surgery.

BACKGROUND: Disturbances in water and electrolyte homeostasis are common after transsphenoidal surgery. These disorders are variable and unpredictable, increasing patient risk and complicating postsurgical treatment. Clinically, it is generally accepted that damage to the pituitary is the cause, but the mechanisms behind the response variability and underlying pathophysiology remain unknown. OBJECTIVE: To test the hypothesis that changing the degree of damage to the pituitary stalk produces a spectrum of water and electrolyte disturbance along which all presentations of postsurgical water and electrolyte disturbances can be identified. METHODS: We used HumMod, a large mathematical model of physiology, to simulate pituitary stalk damage at differing fractions: 20%, 40%, 60%, and 80%. The damaged neurons were modeled to undergo a 5-day countdown to degeneration and release stored antidiuretic hormone as they die, as is proposed to occur. RESULTS: Lower pituitary damage (20%) resulted in transient polyuria and intermediate damage (40%) was associated with delayed polyuria and diabetes insipidus. Higher levels of damage (60% and 80%) showed a triphasic pattern of diabetes insipidus. CONCLUSIONS: We postulate that our model provides a plausible mechanistic explanation for some varieties of postsurgical water and electrolyte disturbances, in which increasing damage to the pituitary potentiates the likelihood of a full triphasic response. However, our simulation shows that merely modifying the level of damage does not produce every presentation of water and electrolyte imbalance. This theory suggests that other mechanisms, which are still unclear and not a part of this model, may be responsible for postoperative hyponatremia and require further investigation.