Outcome of Purely Endoscopic Surgery for Pituitary Adenoma

Outcome of Purely Endoscopic Outcome of Purely Endoscopic Surgery for Pituitary AdenomaSurgery for Pituitary Adenoma

Orphee Makiese MD, Promod Pillai MD Orphee Makiese MD, Promod Pillai MD Venko Filipce MD, Mario Ammirati MD,MBAVenko Filipce MD, Mario Ammirati MD,MBA

Dept. of Neurological SurgeryDept. of Neurological SurgeryOhio State University Medical CenterOhio State University Medical Center

Columbus , OHColumbus , OH

NASBS-2008

A Systematic Literature A Systematic Literature ReviewReview

A Systematic Literature ReviewA Systematic Literature Review

I. INTRODUCTIONI. INTRODUCTION

Applying new technology: a challenging change to Applying new technology: a challenging change to surgical routinessurgical routines

After feasibility study, using technology to treat patients After feasibility study, using technology to treat patients requires strict follow-ups and comparisons with reference requires strict follow-ups and comparisons with reference (s) technique (s)(s) technique (s)

In order to fully and safely benefit patients In order to fully and safely benefit patients

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Over last decade, endoscopic used to assist Over last decade, endoscopic used to assist trans-sphenoidal approachestrans-sphenoidal approaches

Review of the literature outcome of pure Review of the literature outcome of pure endoscopic assisted pituitary surgery endoscopic assisted pituitary surgery


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I. INTRODUCTION (Cont’d)I. INTRODUCTION (Cont’d)


II. MATERIALS & METHODSII. MATERIALS & METHODS

Medline Pubmed (PM) data base (Medline Pubmed (PM) data base (English)English)

Publications ranging from early 1990’sPublications ranging from early 1990’s to 2007 to 2007

Eligible studies all included outcome Eligible studies all included outcome measurementsmeasurements

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A.A. MaterialsMaterials


Outcomes measurement ofOutcomes measurement ofMajor and Major and Minor complicationsMinor complications

Remission and recurrence rates evaluationRemission and recurrence rates evaluation Comparison to microscopic survey and Comparison to microscopic survey and

systematic literature reviewsystematic literature review

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B. Methods ObjectivesB. Methods Objectives


C.C. Inclusion CriteriaInclusion Criteria

Purely endoscopic studies for pituitary Purely endoscopic studies for pituitary adenoma (+10 patients)adenoma (+10 patients)

Adult pituitary surgeryAdult pituitary surgery Trans-sphenoidal surgery (sub labial or nostril) Trans-sphenoidal surgery (sub labial or nostril)

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Diagnosis confirmed by MRI and Diagnosis confirmed by MRI and endocrinology screeningendocrinology screening

Histopathology-definite diagnosis of pituitary Histopathology-definite diagnosis of pituitary adenomaadenoma

Studies including outcome measurementsStudies including outcome measurements Follow-up more than 6 monthsFollow-up more than 6 months First surgeryFirst surgery

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C. C. Inclusion Criteria (Cont’d)Inclusion Criteria (Cont’d)


D.D. Exclusion CriteriaExclusion Criteria

Following cases were disregarded…Following cases were disregarded…Recurrent pituitary tumorsRecurrent pituitary tumorsSubjects to previous endoscopic approachSubjects to previous endoscopic approachSubmitted to prior radiationSubmitted to prior radiation

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III.III. RESULTSRESULTS

16 Articles: 16 Articles: 2 Class II2 Class II 2 Class III2 Class III 12 Class IV 12 Class IV

From 105 articles “From 105 articles “Pituitary and Endoscope Pituitary and Endoscope Surgery’’, PM termsSurgery’’, PM terms

Selection from a pool of 26617 articles on Selection from a pool of 26617 articles on “Pituitary surgery” PM terms“Pituitary surgery” PM terms

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37.5% NA, 25% EU, 25% Asia, 12.5% ME37.5% NA, 25% EU, 25% Asia, 12.5% ME 974 patients: 974 patients:

444 non functioning444 non functioning480 functioning480 functioning709 macro adenoma709 macro adenoma265 micro adenoma265 micro adenoma

Mean age=46 yrs; 51% female Mean age=46 yrs; 51% female NASBS-2008

III.III. RESULTS (Cont’d)RESULTS (Cont’d)

Identical methodology for microscopic groupIdentical methodology for microscopic group Statistical comparison of groups based on Statistical comparison of groups based on

homogeneity and known epidemiologic homogeneity and known epidemiologic pathologypathology

Assuming different surgeons and distinct Assuming different surgeons and distinct populationpopulation

16 articles for endoscopic group 974 16 articles for endoscopic group 974 16 articles for microscopic group 197116 articles for microscopic group 1971

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III.III. RESULTS (Cont’d)RESULTS (Cont’d)

Authors Year Type of Study Study Population

Mean Age(Y) F H Duration of Study

Macro Micro

Jho H D and Carrau R L

1997 Clinical, R 44 38(14-88) 19 25 1993-1996 31 13

Sheehan MT et al 1998 Clinical, RC 26 59.2(25-80) 8 18 1995-1997 26 0

ILan K et al 1999 Clinical, RC 18 1996-1997 12 6

Badie B et al 1999 Clinical, PC 16 48 6 10 1996-1999 9 7

Ogawa T et al 2000 Clinical, RC 13 49.1(19-73) 6 7 1996-1999 11 2

Cappabianca P et al 2002 Clinical, R 146 46.1(16-74) 76 68 1997-2001 125 21

Cho D Y et al 2002 clinical, PC 22 45.3(22-60) 22 0 1996-2000 11 11

White D R et al 2004 Clinical, RC 50 41.1 26 24 2000-2002

Kabil M S et al 2005 Clinical, RC 300 46(16-75) 176 124 1998-2004 235 65

Netea-Maier R T et al 2006 Clinical, R 35 41(14-68) 25 10 1998-2004 6 29

Rudnik A et al 2006 Clinical, R 63 48.3(11-77) 34 29 2001-2002 52 11

Kenan K et al 2006 Clinical, R 78 44.7(11-67) 1997-2005 67 11

Jain A.K. et al 2007 Clinical, P 10 40.1 6 4 9 1

Dehdashiti AR et al 2007 Clinical, R 25 42 19 6 2004 -2007 7 18

Charalampaki P et al 2007 Clinical, R 50 56(28-84) 30 20 2004-2005 41 9

Zhang X et al 2007 Clinical, R 78 45.1(15-76) 42 36 1998-2005 67 11

Authors Year Type of Study Study Population

Mean Age(Y) F H Duration of Study

Macro Micro

Sheehan MT et al 1998 Clinical, RC 44 57.8(32-85) 13 31 1995-1997 44

Laws and Semple 1999 Clinical, R 105 38.5 (6-78) 83 22 1992-1997 13 92

Zhang X et al 1999 Clinical, R 208 47.5(16-71) 110 98 1982-1997 189 0

ILan K et al 1999 Clinical, RC 20 1993-1995 11 8

Badie B et al 1999 Clinical, PC 21 43 11 10 1996-1999 12 6

Ogawa T et al 2000 Clinical, RC 18 49.4(23-73) 8 10 1996-1999 16 2

Kaltsas et al 2001 Clinical, R 67 1993-1998 50 17

Kreutzer et al 2001 Clinical, R 57 43.9(16-71) 37 20 1992-1998 38 19

Rees D A et al 2001 Clinical, R 54 41.3(14-73) 42 12 1980-2000

Shimon I et al 2002 Clinical, R 74 39(8-72) 64 10 1990-2000 3 71

Cho D Y et al 2002 Clinical, PC 22 46.7(18-56) 21 1 1996-2000 10 12

DE P. et al 2003 Clinical, R 47 61(29-86) 24 23 1990-2001 35 12

Höybye C et al 2004 Clinical, R 34 40(13-74) 26 8 1990-1999 2 32

White D R et al 2004 Clinical, RC 50 43.5 17 33 1996-1999

Mortini P et al 2005 Clinical, R 1140 43(8-82) 681 459 1990-2002 788 72

Jain A.K. et al 2007 Clinical, PR 10 31.6 5 5 8 2


A.A. Comparability: Sex, Age and Comparability: Sex, Age and Adenoma SizeAdenoma Size

Endoscope Microscope P-value

Mean Age 46 44.6 0.6276

Sex 495F, 381M 1189F, 795M 0.0942

Macro adenoma 77% 78% 0.5168

Micro adenoma 23% 22% 0.51680.5168

Functioning 52% 77% 0.00010.0001

Nonfunctioning 48% 33% 0.00010.0001

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Endoscope Microscope Ciric National Survey 1997

Relative Risk

P-value

CSF 3.6% 2.6% 3.9% 1.45 0.0736

Meningitis 0.71% 0.2% 1.5% 3.48 0.0435

Sinusitis 1.9% 0.3% 8.5% 6.34 0.0027

Vascular injury 1.3% 0.57% 1.1% 2.38 0.0563

DI-Transient 5.6% 8.1% 0.68 0.0697

DI permanent 3.5% 3.6% 17.8% 0.99 0.9632

Visual loss 1.7% 0.36% 1.4% 4.88 0.0005

Major Complications 14.7% 10.7% 1.26 0.002

B.B. Major Complications and Major Complications and ComparisonsComparisons

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C.C. Minor Complications and Minor Complications and Comparisons Comparisons

Endoscope Microscope Ciric National survey 1997

Relative Risk P-value

Epistaxis 0.72% 0.26% 3.4% 2.72 0.1286Septum perf 0.62% 0.67% 6.7% 0.92 0.8583Nerves injury 0% 0.1% 1.3%Anosmia 0.31% 0%Crusting 0.62% 0.21% 3.0 0.1491Synechia 0.52% 0.36% 1.42 0.7689Saddle nose 0% 0.05%Minorcomplications

2.8% 2.3% 1.138 0.49550.4955

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D.D. Length of Stay in HospitalLength of Stay in Hospital

Endoscope Microscope P-value

Length of stay in hospital 3.34 days 6.1 days 0.09840.0984

too few too few values in values in micro gpmicro gp

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E.E. Death, Follow-up and Death, Follow-up and RemissionRemission

Endoscope Microscope Ciric National survey 1997 Relative Risk

P-value

Death 0.6% 0.4% 0.9% 1.44 0.73

Follow up 19.2 months

43.3 months

Remission 65.2% 65.3% 0.998 0.947726

Recurrence 0.1% 4.2% 0.024 1.78*10-10

too few values in endosc gp

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CONCLUSIONSCONCLUSIONS

Two accurate observations that:Two accurate observations that:

Statistics seem SIGNIFICANT for microscope Statistics seem SIGNIFICANT for microscope performed on major complications but…performed on major complications but…

NON SIGNIFICANT on minor complications NON SIGNIFICANT on minor complications

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A. A. Preliminary RemarksPreliminary Remarks

Study accuracy would require more …Study accuracy would require more … Report data about length of stay in hospital for Report data about length of stay in hospital for

microscopic group microscopic group Report data about recurrence and follow-up for Report data about recurrence and follow-up for

endoscopic group endoscopic group Comparative studies to further meta-analysis studyComparative studies to further meta-analysis study

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B.B. Research recommendationsResearch recommendations

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Outcome of Purely Endoscopic Surgery for Pituitary Adenoma