Outcome of Purely Endoscopic Surgery for Pituitary Adenoma Orphee Makiese MD, Promod Pillai MD Venko Filipce MD, Mario Ammirati MD,MBA Dept. of Neurological Surgery Ohio State University Medical Center Columbus, OH NASBS-2008 A Systematic Literature Review

I. INTRODUCTION Applying new technology: a challenging change to surgical routines Applying new technology: a challenging change to surgical routines After feasibility study, using technology to treat patients requires strict follow-ups and comparisons with reference (s) technique (s) After feasibility study, using technology to treat patients requires strict follow-ups and comparisons with reference (s) technique (s) In order to fully and safely benefit patients In order to fully and safely benefit patients NASBS-2008

Over last decade, endoscopic used to assist trans-sphenoidal approaches Over last decade, endoscopic used to assist trans-sphenoidal approaches Review of the literature outcome of pure endoscopic assisted pituitary surgery Review of the literature outcome of pure endoscopic assisted pituitary surgery A Systematic Literature Review NASBS-2008 I. INTRODUCTION (Cont’d)

A Systematic Literature Review II. MATERIALS & METHODS Medline Pubmed (PM) data base (English) Medline Pubmed (PM) data base (English) Publications ranging from early 1990’s to 2007 Publications ranging from early 1990’s to 2007 Eligible studies all included outcome measurements Eligible studies all included outcome measurements NASBS-2008 A.Materials

A Systematic Literature Review Outcomes measurement of Outcomes measurement of Major and Major and Minor complications Minor complications Remission and recurrence rates evaluation Remission and recurrence rates evaluation Comparison to microscopic survey and systematic literature review Comparison to microscopic survey and systematic literature review NASBS-2008 B. Methods Objectives

A Systematic Literature Review C.Inclusion Criteria Purely endoscopic studies for pituitary adenoma (+10 patients) Purely endoscopic studies for pituitary adenoma (+10 patients) Adult pituitary surgery Adult pituitary surgery Trans-sphenoidal surgery (sub labial or nostril) Trans-sphenoidal surgery (sub labial or nostril) NASBS-2008

A Systematic Literature Review Diagnosis confirmed by MRI and endocrinology screening Diagnosis confirmed by MRI and endocrinology screening Histopathology-definite diagnosis of pituitary adenoma Histopathology-definite diagnosis of pituitary adenoma Studies including outcome measurements Studies including outcome measurements Follow-up more than 6 months Follow-up more than 6 months First surgery First surgery NASBS-2008 C. Inclusion Criteria (Cont’d)

A Systematic Literature Review D.Exclusion Criteria Following cases were disregarded… Following cases were disregarded… Recurrent pituitary tumors Recurrent pituitary tumors Subjects to previous endoscopic approach Subjects to previous endoscopic approach Submitted to prior radiation Submitted to prior radiation NASBS-2008

A Systematic Literature Review III.RESULTS 16 Articles: 16 Articles: 2 Class II 2 Class II 2 Class III 2 Class III 12 Class IV 12 Class IV From 105 articles “Pituitary and Endoscope Surgery’’, PM terms From 105 articles “Pituitary and Endoscope Surgery’’, PM terms Selection from a pool of articles on “Pituitary surgery” PM terms Selection from a pool of articles on “Pituitary surgery” PM terms NASBS-2008

A Systematic Literature Review 37.5% NA, 25% EU, 25% Asia, 12.5% ME 37.5% NA, 25% EU, 25% Asia, 12.5% ME 974 patients: 974 patients: 444 non functioning 444 non functioning 480 functioning 480 functioning 709 macro adenoma 709 macro adenoma 265 micro adenoma 265 micro adenoma Mean age=46 yrs; 51% female Mean age=46 yrs; 51% female NASBS-2008 III.RESULTS (Cont’d)

Identical methodology for microscopic group Identical methodology for microscopic group Statistical comparison of groups based on homogeneity and known epidemiologic pathology Statistical comparison of groups based on homogeneity and known epidemiologic pathology Assuming different surgeons and distinct population Assuming different surgeons and distinct population 16 articles for endoscopic group articles for endoscopic group articles for microscopic group articles for microscopic group 1971 NASBS-2008 A Systematic Literature Review III.RESULTS (Cont’d)

AuthorsYearType of StudyStudy Population Mean Age(Y)FHDuration of Study MacroMicro Jho H D and Carrau R L 1997Clinical, R4438(14-88) Sheehan MT et al1998Clinical, RC2659.2(25-80) ILan K et al1999Clinical, RC Badie B et al1999Clinical, PC Ogawa T et al2000Clinical, RC1349.1(19-73) Cappabianca P et al2002Clinical, R (16-74) Cho D Y et al2002clinical, PC2245.3(22-60) White D R et al2004Clinical, RC Kabil M S et al2005Clinical, RC30046(16-75) Netea-Maier R T et al2006Clinical, R3541(14-68) Rudnik A et al2006Clinical, R6348.3(11-77) Kenan K et al2006Clinical, R7844.7(11-67) Jain A.K. et al2007Clinical, P Dehdashiti AR et al2007Clinical, R Charalampaki P et al2007Clinical, R5056(28-84) Zhang X et al2007Clinical, R7845.1(15-76)

AuthorsYearType of StudyStudy Population Mean Age(Y)FHDuration of Study MacroMicro Sheehan MT et al1998Clinical, RC4457.8(32-85) Laws and Semple1999Clinical, R (6-78) Zhang X et al1999Clinical, R (16-71) ILan K et al1999Clinical, RC Badie B et al1999Clinical, PC Ogawa T et al2000Clinical, RC1849.4(23-73) Kaltsas et al2001Clinical, R Kreutzer et al2001Clinical, R5743.9(16-71) Rees D A et al2001Clinical, R5441.3(14-73) Shimon I et al2002Clinical, R7439(8-72) Cho D Y et al2002Clinical, PC2246.7(18-56) DE P. et al2003Clinical, R4761(29-86) Höybye C et al2004Clinical, R3440(13-74) White D R et al2004Clinical, RC Mortini P et al2005Clinical, R114043(8-82) Jain A.K. et al2007Clinical, PR

A Systematic Literature Review A.Comparability: Sex, Age and Adenoma Size EndoscopeMicroscopeP-value Mean Age Sex 495F, 381M1189F, 795M Macro adenoma 77%78% Micro adenoma 23%22% Functioning 52%77% Nonfunctioning 48%33% NASBS-2008

EndoscopeMicroscopeCiric National Survey 1997 Relative Risk P-value CSF 3.6%2.6%3.9% Meningitis 0.71%0.2%1.5% Sinusitis 1.9%0.3%8.5% Vascular injury 1.3%0.57%1.1% DI-Transient 5.6%8.1% DI permanent 3.5%3.6%17.8% Visual loss 1.7%0.36%1.4% Major Complications 14.7%10.7% B.Major Complications and Comparisons NASBS-2008 A Systematic Literature Review

C.Minor Complications and Comparisons EndoscopeMicroscopeCiric National survey 1997Relative RiskP-value Epistaxis 0.72%0.26%3.4% Septum perf 0.62%0.67%6.7% Nerves injury 0%0.1%1.3% Anosmia 0.31%0% Crusting 0.62%0.21% Synechia 0.52%0.36% Saddle nose 0%0.05% Minor complications 2.8% 2.3% NASBS-2008 A Systematic Literature Review

D.Length of Stay in Hospital EndoscopeMicroscopeP-value Length of stay in hospital 3.34 days6.1 days too few values in micro gp NASBS-2008 A Systematic Literature Review

E.Death, Follow-up and Remission EndoscopeMicroscopeCiric National survey 1997Relative Risk P-value Death 0.6%0.4%0.9% Follow up 19.2 months 43.3 months Remission 65.2%65.3% Recurrence 0.1%4.2% * too few values in endosc gp NASBS-2008 A Systematic Literature Review

CONCLUSIONS Two accurate observations that: Statistics seem SIGNIFICANT for microscope performed on major complications but… Statistics seem SIGNIFICANT for microscope performed on major complications but… NON SIGNIFICANT on minor complications NON SIGNIFICANT on minor complications NASBS-2008 A Systematic Literature Review A. Preliminary Remarks

Study accuracy would require more … Study accuracy would require more … Report data about length of stay in hospital for microscopic group Report data about length of stay in hospital for microscopic group Report data about recurrence and follow-up for endoscopic group Report data about recurrence and follow-up for endoscopic group Comparative studies to further meta-analysis study Comparative studies to further meta-analysis study NASBS-2008 A Systematic Literature Review B.Research recommendations