1. Marginal dissection for mid-sized pituitary adenomas
Andrew Law
Marginal dissection for mid-sized pituitary adenomas

2. Goals Maximise tumour resection Maximise functional cure rates
Minimise recurrence
Reduce need for Radiotherapy
Not affect rates of hypopituitarism
Minimise complication rates

3. Pure endoscopic technique
Began in Endoscopic approach / Septal pushover  Microscope for tumour resection Progression to - Pure endoscopic surgery 2007 Technique Improved camera / monitor systems Liquid coagulants Approx 50% with ENT - Functioning - Difficult cases

4. Complications of Transsphenoidal Surgery: Results of a National Survey, Review of the Literature, and Personal Experience
Ciric, Ivan MD; Ragin, Ann PhD; Baumgartner, Craig PA-C, MBA; Pierce, Debi BS
Neurosurgery
Issue: Volume 40(2), February 1997, pp

5. Exposure Utilisation of pseudo-capsule
Actual dissection of adenomas
Utilisation of pseudo-capsule
E Oldfield
Using sublabial / microscopic approach
Extending to Endoscopic approach

6. Surgical Management of Cushing’s Disease:
A Personal Perspective
Edward H. Oldfield, MD
Clinical Neurosurgery Volume 58, 2011

7. Pituitary Series
Andrew Law
681 Pituitary Tumour Operations (to Sept 15)
(Excluding meningiomas/craniopharyngiomas/others)
Non Functioning 460
Functioning 221
FU 3m-15yrs

8. GH secreting tumours

13. GH secreting tumour operations
Total

14. GH 2012-2015 38 Operations (34 patients)
4 repeat surgery
2 cured / 2 ongoing
Biochem cure (Surgery alone) – (54%)
Biochem cure (Surgery +/- Octreotide LAR +/- DXT) (88%)
(2 cases awaiting response to Rx)
1 uncontrolled progression  Death
Long term remission rate – 80%

15. Issues Mixed tumours GH-PL Preoperative medications Difficult tumours
Cabergoline
Octreotide
Some evidence that may improve cure rates
But increases surgical difficulty
Difficult tumours
Size
Cavernous sinus invasion
Sphenoid anatomy

19. ACTH Tumours 2000-2011 59 Remission 50 85%
Total 78
Visible microadenomas 100%
Cavernous sinus invasion
Stereotactic radiosurgery
“Invisible microadenomas”
Near total “85%”gland resection
Tumour outside pituitary fossa

21. Non-Functioning Adenomas 2012-15
Early MRI (3/12) – 0 cases of significant residual (sellar/suprasellar)
Postoperative DXT – 3 patients
Recurrence rates?

22. CSF Leaks Intraoperative 46% Postoperative 4.8% 2000-2011 8.8%
(Req repacking surgery)
Includes extended procedures
0 last 2 years %

23. Complications 2012-2015 No perioperative deaths
SIADH “Approx 30%” – At least
Late postop abscess (post extended) - 1
Carotid puncture – Clipped - 1
Visual decline – 2 (Both for recurrence)
Surgery abandoned due to sinus infection - 1
Sphenoid mucocoele - 1
Sinusitis – Common

29. Technique Exposure Arachnoid knife Rhoton dissector Ring curettes
Bony margins
Stopping instrument contact. “Touch”
Arachnoid knife
Rhoton dissector
Ring curettes
Malleable endoscopic instruments
Water dissection
Micro patties
Patience
Microsurgical approach

30. Videos of the actual transphenoidal surgery are available to view.
If you are interested in seeing some real life action, please

31. Followup Imaging (MRI) Work in progress!! Functioning Non Functioning
Only if fail to cure – Biochemically
Non Functioning
(3m),1yr, 2yr, 4yr, 4yr
More frequent if residual / recurrent tumour evident
Work in progress!!