Endoscopic Transsphenoidal Surgery is typically performed through the nose & is designed to remove tumors from pituitary gland & the base of the skull. This is a minimally invasive surgery wherein the surgeon works through the nostrils with help of a tiny endoscope camera & light in order to remove tumors using long instruments. Having pituitary tumors can be dreadful as they can cause hormone problems & loss of vision. However, removal of these tumors will often reverse problems with vision & also restore the normal balance of hormones.
What is Transsphenoidal Surgery?
Literal meaning of transsphenoidal is ‘through the sphenoid sinuses’. This is a surgical intervention which is performed through nose & sphenoid sinus for removal of pituitary tumors. Moreover, transsphenoidal surgery can generally be performed with help of an endoscope, a microscope or both. This surgical intervention is most often a team effort between ENT (ear, nose & throat) surgeons & neurosurgeons. The traditional microscopic technique generally uses an incision in the skin under the lip along with the removal of large portions of the nasal septum in order to allow surgeons to directly see the area of operation. The minimally invasive technique which is called the endoscopic endonasal surgery utilizes a small incision located at the back of the nasal cavity. Eventually, this minimally invasive technique, in fact, causes very little disruption of nasal tissues. With help of a tiny camera & light known as an endoscope, ENT surgeons will work through the nostrils. Bony openings are made within the nasal septum, sphenoid sinus & sell in both these techniques, in order to reach the pituitary gland. Once an approach is made & pituitary gland is exposed, the neurosurgeon will take over & remove the tumor.
Good Candidates for Transsphenoidal Surgery
People having the following conditions are good candidates for transsphenoidal surgery.
- Pituitary Adenoma – This is a tumor which grows from pituitary gland. It can either be hormone-secreting or non-hormone secreting.
- Craniopharyngioma – These are benign (noncancerous) tumors which grow from cells located near the pituitary stalk. At times they may also invade the third ventricle.
- Rathke’s Cleft Cyst – This is generally a benign (non-cancerous) cyst or a fluid-filled sac located between the anterior & posterior lobes of the pituitary gland.
- Meningioma – These are tumors which grow from dura (meninges). Meninges are membranes which surround the brain & spinal cord.
- Chordoma – This is a malignant (cancerous) bone tumor which grows from the embryonic notochord remnants which are located at the base of the skull.
However, surgery may not be necessary for people having a prolactinoma or small (<10 mm) non-secretory tumors. Moreover, these types of tumors are found to respond very well to medications or may be periodically observed with MRI scans in order to watch for tumor growth. Some of these tumors are also found to extend beyond limits of transsphenoidal approach. Therefore, for these types of tumors, a more extensive operation is required which utilizes craniotomy procedure combined with skull base approaches.
Specialist Surgeons Team for Transsphenoidal Surgeries
Generally, neurosurgeons perform transsphenoidal surgery as a team including ENT (ear, nose & throat) surgeons who have undergone specialized training in endoscopic sinus surgery procedures. This team approach effectively allows comprehensive care of both sinus & brain related issues, before & after transsphenoidal surgery. It would, therefore, be sensible of patients to ask surgeons about their training & experience.
Transsphenoidal Surgery Procedure
Most patients would, however, begin by an initial appointment with the neurosurgeon, ENT surgeon & an endocrinologist prior to undergoing transsphenoidal surgery. Consulting an ophthalmologist may also be necessary in case the patient is having problems with vision. Surgeons will generally explain the procedure including risks & benefits & answer questions asked by patients during the initial appointment.
- Transsphenoidal Pre-surgery Formalities – Following this, when patients decide to undergo the procedure, they may have to sign consent forms in order to complete the paper work. Transsphenoidal surgery patients will now need to inform the surgeon about their medical history which includes the kind of allergies they have, medications & vitamins they are presently taking, history of bleeding, reactions to anesthesia & if they have undergone any previous surgeries. Patients must, however, discuss with the surgeon all medications they are taking, including herbal supplements, prescription & over-the-counter drugs they are taking, since some medications may be required to be stopped or continued on the day of surgery. Patients may also be scheduled for pre-surgical tests which include CT scans, chest X-Rays, electrocardiogram & blood tests several days prior to undergoing transsphenoidal surgery. Surgeons would also normally ask patients to stop taking all NSAIDs (Aleve, Nuprin, Motrin, Advil, Naprosyn) & blood thinners (aspirin, Plavix, Coumadin) at least 7 days before the day of surgery. Additionally, transsphenoidal surgery patients are also asked to refrain from smoking or chewing tobacco 10 – 15 days prior to undergoing surgery as nicotine is found to cause bleeding problems.
- On the Day of Transsphenoidal Surgery – Transsphenoidal patients should start the day in the following manner.
- Ideal for patients to shower using antibacterial soap. They should also dress in freshly washed loose-fitting garments.
- Patients should wear flat-heeled shoes which also have closed backs.
- When patients are given instructions to take regular medicines in the morning of surgery, they should do so with small sips of water.
- Ideal for patients to remove all kinds of make-up including nail polish, body piercings, contacts & hairpins.
- Patients should leave all valuables including wedding bands & jewelry at home.
- Ideal to bring along a list of medications which include prescription & over-the-counter drugs & herbal supplements along with dosages & the time of the day they are usually taken.
- Patients should also bring along a list of allergies they are having to food & medications.
It would be proper for transsphenoidal surgery patients to arrive at the hospital at least 2 hours prior to the time they are scheduled for surgery in order to complete the necessary paperwork which is involved along with pre-surgery work-ups. The patient will generally meet a nurse first who will ask for their name, date of birth & the kind of procedure they have come to undergo. The nurse will then explain the preoperative procedure & discuss any questions which patients may have. Subsequently, an anesthesiologist with talk to the patient & explain effects & risks of anesthesia.
- During Transsphenoidal Surgery Procedure – There are 6 steps to this surgical operation which normally take about 2 – 3 hours of time.
- Step 1: Preparing the Patient – Patients will have to lie on their back upon the operating table. The intravenous (IV) line will be placed on the arm of the patient & general anesthesia will be administered. The nasal cavity will then be prepped with an antiseptic & antibiotic solution. An image-guidance system will then be placed on the head of the patient. This device is akin to GPS (global positioning system) & will eventually help the surgeon navigate through the nose with help of 3D ‘map’ created with help of MRI or CT scans.
- Step 2: Making an Incision – During a minimally invasive endoscopic procedure, ENT surgeon will insert the endoscope into one nostril & advance the endoscope to the back of the nasal cavity. Endoscope basically is a thin, tube-like instrument which holds a light & a camera. Video from this camera will be viewed upon a monitor by the surgeon. Along with this arrangement, the surgeon will also pass a long operating instrument through the nostril while watching the monitor. A small portion of the nasal septum which divides the right & left nostril is now removed. Subsequently, with help of bone-biting instruments, the front wall of sphenoid sinus is opened.
- Step 3: Opening the Sella – The bone overlying the pituitary gland is called sell & is located on the back wall of the sphenoid sinus. This is a thin bone which is now removed in order to expose the tough lining of the skull called dura. Dura is then opened to expose the pituitary gland & tumor.
- Step 4: Removing the Tumor – The tumor is now removed by a neurosurgeon in pieces with help of special instruments known as curettes through a small hole in sell. Center of the tumor is subsequently cored out while allowing tumor margins to fall inwards so that the surgeon can reach them. After the entire visible tumor is removed, surgeons will advance the endoscope into sella in order to look & inspect for hidden tumors. In some cases, some tumors are found to grow sideways into cavernous sinus, which is basically a collection of veins. It is extremely difficult to completely remove this part of the tumor without causing injury to blood vessels & nerves. Any part of the tumor which is left behind will later be treated with radiation. Transsphenoidal surgery in some hospitals can be performed in special operating rooms which are equipped with intraoperative MRI scanners. This will enable the patient to undergo MRI during the surgical procedure. MRI will provide real-time images of the patient’s brain to surgeons & enable them to know as to exactly how much of the tumor has been successfully removed before closing the procedure. This technology is designed to enable surgeons remove tumors more completely & may eventually reduce need for another operation.
- Step 5: Obtaining Fat Graft (optional) – After removal of the tumor, surgeons will prepare to close the sella opening. A small 2 cm incision in the skin is sometimes made in the abdomen so as to obtain a small piece of fat when required. This fat graft is then used to fill the empty space which is left behind after tumor removal. The abdominal incision is then closed with sutures.
- Step 6: Closing the Sella Opening – Hole in sella floor is now replaced with a bone graft from the septum. Synthetic graft materials are also sometimes used when a suitable piece of the septum is not to be found, especially when the patient has undergone previous surgery. Biologic glue is generally applied over graft within sphenoid sinus. This glue is meant to allow healing & also to prevent leaking of CSF (cerebrospinal fluid) from the brain into sinus & nasal cavity as well. Soft & flexible splints are then placed inside nose along septum so as to prevent swelling & control bleeding. These splints are also helpful in preventing forming of adhesions which can often lead to chronic nasal congestion.
Transsphenoidal Surgery Aftercare
Transsphenoidal surgery patients will usually awaken in postoperative recovery area which is called the PACU. They will, however, be monitored for heart rate, blood pressure & respiration. Any pain which the patient is experiencing will be addressed. Once properly awake, patients are shifted to their regular rooms where they will increase their level of activity by walking or sitting in a chair. Some patients may also have to spend their night in an NICU (neuroscience intensive care unit) for close monitoring. Some patients experience a headache, nausea or nasal congestion following surgery. However, medications are provided & which will be able to control these symptoms. Endocrinologists will usually see the patient on the day following surgery so as to check whether the pituitary gland is producing normal levels of hormones. In case the pituitary gland is not producing sufficient levels of hormones, hormone-replacement medications are given to the patient. MRI imaging of brain will also be obtained on the day following surgery. Nevertheless, transsphenoidal surgery patients will be released from the hospital with discharge instruction in 1 – 2 days of time.
Discharge Instructions Following Transsphenoidal Surgery
- Discomfort – Pain is generally managed with narcotic medications following transsphenoidal surgery. But then, since narcotic pain medications are addictive, they are only used for a limited period normally lasting between 2 – 4 weeks. Moreover, as regular use of these medications also causes constipation, it would be ideal if patients consume high fiber foods & drink lots of water. Laxatives like Milk of Magnesia, Senokot & Dulcolax can also be bought without prescription & which will help patients deal with constipation. Thereafter, pain can be conveniently managed with acetaminophen (Tylenol). Patients must, however, check with the surgeon before taking NSAIDs like aspirin, ibuprofen & naproxen sodium since these may cause bleeding in some cases. Following transsphenoidal surgery, medicines are also generally prescribed so as to regulate hormonal levels. Side effects caused by these medications include mood swings, body swelling & hunger. As a remedy to these side effects, blood samples are taken from patients in order to monitor drug levels & manage side effects.
- Restrictions – In order to prevent injury to the surgical site, transsphenoidal surgery patients must avoid sneezing, coughing, blowing the nose, drinking with a straw, bending over or straining on the toilet for about 4 weeks following surgery. Patients should not also indulge in driving activity for about 15 days time after surgery unless they have been instructed otherwise.
- Activity – Fatigue is most common after transsphenoidal surgery. Patients must however gradually return to normal activity. Walking is normally encouraged, but patients must generally start with short distances & gradually increase to 1 or 2 miles every day.
- Bathing / Incision Care – Patients can generally shower on the day following surgery unless they have been instructed otherwise. Patients are usually given two sprays for the nose, a salt water spray & nasal decongestant, which will help them prevent bleeding, relieve nasal congestion & promote nasal healing. Patients who have undergone an abdominal incision so as to obtain fat graft should leave the wound open to air without any bandage. However, direct contact of water on the incision site should be avoided & vitamin E liquid should be applied on the wound every day.
Patients Must Call the Neurosurgeon or the ENT Surgeon When They Experience the Following Problems.
- Continuous nasal drainage, postnasal drip or excessive swallowing. These problems usually signal cerebrospinal fluid leakage.
- Uncontrolled nasal congestion or nosebleeds with difficulty in breathing.
- Increased headache, decreased alertness, a temperature exceeding 101 degrees Fahrenheit or severe neck pain which is preventing lowering of chin towards the chest.
- Increased urine output, weight loss or excessive thirst.
Recovery Following Transsphenoidal Surgery
Patients will need to set up an appointment for a follow-up visit with the ENT surgeon 7 days following surgery in order to remove nasal splints & evaluation of the surgical site. Patients will then have to see the ENT specialist every 3 weeks thereafter until the nasal cavities are completely healed. The entire process typically requires 2 – 4 visits. Small crusts are often formed in nose & which can also at times cause nasal congestion. ENT surgeons will, therefore, spray the nose in order to provide local anesthesia to nasal cavities, after which crusts can be comfortably removed. The patient will also be instructed to use nasal saline rinse after 4 weeks following surgery. This rinse is meant to decrease the need to remove crusts & eventually hasten nasal healing. Appointments for follow-up visits with neurosurgeons will be scheduled between 2 – 4 weeks after transsphenoidal surgery. Follow-up with endocrinologists may also be recommended in order to determine whether hormone replacement medications are required.
Risks & Complications Associated with Transsphenoidal Surgery
There is no surgery which does not pose risks. General complications associated with all types of surgeries include infections, blood clots, bleeding & reactions to anesthesia. Specific complications which are related to transsphenoidal surgery for pituitary tumors include the following.
- Loss of Vision – There is a possibility that optic chiasm can be damaged during transsphenoidal surgery. In case vision problems were already present prior to surgery, decompression may not be able to restore normal function of vision. Sometimes, the nerve may also have been permanently damaged by the pituitary tumor.
- Damage to Healthy Pituitary Gland – This is found to occur in about 5 – 10 percent of the cases for macroadenomas. In such a scenario, hormone therapies for testosterone, estrogen, growth hormone, thyroid hormone or cortisol may be required after transsphenoidal surgery.
- DI – Diabetes Insipidus – This is usually caused by damage to the posterior lobe of the pituitary gland. DI usually leads to excessive thirst & frequent urination, because kidneys are unable to adequately concentrate urine. Most often, this effect is temporary & will only last for 1 – 3 days. Moreover, DI can be effectively controlled with medications known as desmopressin acetate (DDAVP) & which come in pill form or nasal sprays. Permanent DI is, however, rare & can also be controlled with medication.
- Cerebrospinal Fluid or CSF Leakage – This fluid which surrounds the brain can escape through a hole in dura which is lining the skull. Happening in about one percent of transsphenoidal surgery cases, CSF is a clear watery-type of discharge which is coming from the nose, or as a postnasal drip causing excessive swallowing. Sometimes this may also require surgery to patch the leak.
- Meningitis – This is an infection of meninges which is often caused by CSF leakage.
- Sinus Congestion – Small adhesions can often stick together & form scars which block air flowing through the nose.
- Nasal Deformity – This is caused by adhesions or bone removal. However, it can be successfully corrected by surgery.
- Nasal Bleeding – Continual bleeding from the nose after transsphenoidal surgery only occurs among less than one percent of the patients. This complication may also require another surgery for correction.
- Stroke – Cavernous sinuses & carotid arteries are located on either side of the pituitary gland & may sometimes be damaged during transsphenoidal surgery. This may, therefore, cause an interruption in the supply of blood to the brain so as to cause strokes.
Transsphenoidal Surgery Outcomes
When the pituitary tumor is prolactinoma, acromegaly or Cushing’s & is secreting hormones, endocrinologists will follow hormone levels of the patient after surgery in order to determine if the patient has cured. Patients with Cushing’s disease generally have microadenomas, which are small tumors & are successfully cured about 90 percent of the time with surgery. Patients with acromegaly are found to have larger & more intensive tumors. The success rate of transsphenoidal surgery with growth-hormone secreting macroadenomas is about 60 percent. However, some pituitary tumors often remain surgically incurable when they have invaded cavernous sinuses & other surrounding important structures. In such cases, stereotactic radiosurgery can be used for the treatment of unresectable tumor remnants following surgery for prolactinomas, acromegaly & Cushing’s disease. Moreover, medical treatments are also available alongside in order to control excessive hormone secretions. Periodic monitoring using MRI scans are required for keeping watch on changes or re-growth since it is almost impossible to predict whether or when pituitary tumors may recur.
Affordable Neurosurgery for Pituitary Tumors in India
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