|Year : 2014 | Volume
| Issue : 1 | Page : 31-34
Endoscopic endonasal trans-sphenoidal management of cystic sellar lesions
M Amer, M Barakat
Neurosurgical Department, Tanta University, Tanta, Egypt
|Date of Submission||12-Jan-2013|
|Date of Acceptance||15-Mar-2013|
|Date of Web Publication||7-Apr-2014|
Assistant Prof. of Neurosurgery, Faculty of Medicine, Tanta University, Tanta
The trans-sphenoidal route is now considered the standard approach for pituitary adenomas. This approach is increasingly safe with the use of endoscope.
Aim of the study
The aim of this study was to assess 11 patients with cystic sellar lesion operated by an endoscopic endonasal trans-sphenoidal approach.
Patients and methods
Between January 2007 and January 2011, 11 patients underwent standard endoscopic endonasal trans-sphenoidal surgery in the neurosurgical department, Tanta University, Egypt. All patients underwent complete clinical, endocrinological, and visual field evaluation before operation. The imaging study was performed by MRI of the sellar region with and without intravenous gadolinium contrast.
The study included 11 patients: six female patients and five male patients, with a mean age of 34 years. The aim of the procedure for cystic lesion was to open the cyst cavity and remove a part of its wall through the sphenoid sinus and to remove the solid component if present.
The use of endoscopy in the treatment of cystic lesion is considered a very useful tool with its panoramic view that permits better exploration of the cystic cavity to assess the completeness of tumor removal.
Keywords: Cystic sellar lesion, endoscopic, trans-sphenoidal approach
|How to cite this article:|
Amer M, Barakat M. Endoscopic endonasal trans-sphenoidal management of cystic sellar lesions. Tanta Med J 2014;42:31-4
| Introduction|| |
The trans-sphenoidal route is now considered the standard approach for pituitary adenomas. In the last two decades, this approach was refined and progressed with the use of endoscopy for lesions involving the sellar and suprasellar area, with increasing safety [1-3]. Cystic lesions affecting the sella are common and include Rathke's cleft cyst (RCC), cystic adenomas, craniopharyngiomas (CRP), arachnoid cyst, and mucoceles. Although the preoperative differentiation between these lesions is difficult, they were subjected to many studies [4,5]. The use of endoscopy for treating such lesions is optimum, as its cystic nature allows bringing the eye of the surgeon inside the cystic cavity; hence, it gives superior visualization and exploration of the lesion .
| Materials and methods|| |
Between January 2007 and January 2011, 11 patients underwent standard endoscopic endonasal trans-sphenoidal surgery in the neurosurgical department, Tanta University, Egypt. The series consisted of five patients with Rathke's cyst, four patients with cystic adenoma [three nonfunctioning macroadenoma (NFMA) and one GH secreting macroadenoma], one patient with arachnoid cyst, and one patient with cystic CRP. All patients underwent complete clinical, endocrinological, and visual field evaluation before operation. The imaging study was performed by MRI of the sellar region with and without intravenous gadolinium contrast.
The operative intervention was through an endoscopic endonasal trans-sphenoidal approach using 0° rigid, 18-cm telescope mounted on a single-chip video camera (Karl Storz endovision telecam SL II). We followed the technique used by Cappabianca et al. . Intraoperative cerebrospinal fluid (CSF) leaks can be avoided by lumbar CSF drainage. As the main complication of the trans-sphenoidal route is CSF leak, our strategy in repair was as follows: if there was no leak, we did not use any repair material and if there was intraoperative leak, we usually repaired the sellar by multilayer technique using autologous fat graft and fascia lata with or without fibrin glue .
All patients underwent another clinical evaluation postoperatively to determine the improvement in the presenting symptoms, endocrinological evaluation on the first postoperative day by evaluation of prolactin (PRL) and 8 a.m. cortisol level, and re-evaluation of the basal pituitary hormonal status again at 1, 3, and 6 months postoperatively. Visual field was performed 1 and 3 months postoperatively. A postoperative neuroradiological evaluation was performed using MRI of sella with intravenous contrast 3 months after surgery and annually thereafter.
| Results|| |
The study included six female patients and five male patients, with a mean age of 34 years. The main presentation of patients was visual impairment with varying degrees of visual field affection (nine patients), and then headache (seven patients). The endocrinological presentation was the main clinical issue in two patients; the first patient had acromegalic features because of GH secreting macroadenoma and the other had menstrual irregularities with nonfunctioning adenoma because of hyperprolactinemia (PRL; 60 ng/ml) and effect of stalk sectioning [Table 1].
Patient no. 1 underwent previous surgery using the transcranial route for partial removal of the cyst and improvement, but because of the recurrence of symptoms she underwent trans-sphenoidal surgery. One patient presented with impotence and decreased libido.
The hormonal profile of the patients was normal except in three patients: one patient with GH secreting adenoma (patient no. 4) who showed GH level of 50 ng/ml and insulin-like growth factor 1 level of 952 ng/ml and the other two patients (patient no. 8 and 11) showed elevated PRL (54 and 60 ng/ml, respectively).
The visual field assessment showed varying degrees of bitemporal field affection from bilateral hemianopsia to superior quadrantanopsia.
The radiologic images in macroadenoma patients showed that the lesion was partly cystic with solid component in all patients [Figure 1].
With respect to Rathke's cyst and CRP, they were cystic with varying degrees of signal intensity in T1WI and T2WI denoting cystic nature of the lesion, and was found in the intrasuprasellar location [Figure 2].
The diagnosis of arachnoidocele was straightforward, with signal intensity similar to CSF in all sequences of MRI [Figure 3].
The aim of the procedure for cystic lesion was to open the cyst cavity and remove a part of its wall through the sphenoid sinus (as in RCC and CRP) and to remove the solid component if present (as in cystic macroadenoma). The ability to explore the sellar cavity using the endoscope is directly related to its size; hence, it was easily performed following evacuation of the cystic lesion in case of cystic macroadenoma and arachnoid cyst, but it was difficult in cases of RCC and CRP. This was because of enlargement of the sella allowing complete removal of the remaining solid part and visualization of the dorsum sella and both the medial walls of the cavernous sinus . When the suprasellar cistern prolapse early in the sella, it can make this exploration difficult; however, it can be gently elevated using cottonoid and blunt ring curette to complete the exploration [Table 2].
In case of the arachnoid cyst, we were sure of the communication with the subarachnoid space because of refill of the cavity with CSF after evacuation, and we could see the defect in the arachnoid with gentle elevation of the cistern. We tried to remove the cystic wall in the CRP patient after evacuation of the content, but it needed vigorous manipulation; hence, we removed just a part of its cystic wall. There were intraoperative CSF leaks in three patients (CRP, arachnoid cyst, and NFMA-No. 8) that necessitated multilayer repair of the sella.
The postoperative course was uneventful in eight patients with improvement in the preoperative presenting signs and symptoms: this included four patients with RCC, five patients with NFMA, and one with new panhypopituitarism [Table 3].
The CRP patient developed diabetes insipidus and constriction of the visual field in both eyes after operation; this was thought to be because of the manipulation and traction of the capsule that was transmitted to both optic chiasm and pituitary stalk.
The patient with arachnoid cyst developed a CSF leak on the second postoperative day that was confirmed using the control endoscope. Thereafter, we decided to reconstruct the defect without waiting for conservative treatment using, again, multilayer repair, and it successfully sealed the defect.
| Discussion|| |
Cystic lesions affecting the sellar region are relatively common, especially cystic adenomas, CRP, and RCC ,. Because of its cystic component, it is considered to be ideal for treatment using an endoscope, as it has intrinsic advantages, particularly its wide angle of view, close-up and multiangle vision, and its minimal invasive nature. These advantages are directly related to the size of the cyst; that is, if the cyst is large it will add more safety to the procedure. In contrast, if the cyst is small it may be difficult or impossible to explore the cystic cavity.
Although the use of angled endoscope (30°, 45°) may give more information with respect to the cystic cavity , we did not find much difficulty in using a 0° endoscope only for exploration. Sufficient information could be obtained by changing the nostril from which we introduce the shaft of the endoscope; that is, when exploring the right side of the sella we can introduce the endoscope from the left nostril to see the medial cavernous sinus and vice versa.
Although many authors have reported good results with transcranial treatment of sellar cysts ,, we believe that this procedure is justified only for lesions with a large and predominant suprasellar development. Several authors reported their experience in the treatment of cystic sellar lesions by the microsurgical trans-sphenoidal approach ,,.
There is a well-known strategy in the removal of pituitary noncystic lesion, beginning by the removal of the posterior part followed by the lateral part, and finally the upper part of the lesion ,. In cystic lesion, this sequence is not feasible because of rapid descent of the suprasellar cistern as soon as the opening of the sellar floor and evacuation of its contents are performed; however, gentle elevation of the suprasellar cistern using cotton allows removal of the remaining solid part, sparing the normal pituitary gland that usually presents on the wall of the cyst in case of cystic adenomas. With respect to CRP and RCC, the aim was to drain the cystic cavity and remove a part of its wall. This was satisfactory for RCC, but in case of CRP we tried to dissect the wall of CRP to radically remove the tumor so as to decrease the incidence of recurrence as advised by some authors ,,,. However, the result was unsatisfactory because of its intimate relationship with the optic chiasm and pituitary stalk.
One of the most important problems in the trans-sphenoidal management of intrasellar and suprasellar arachnoid cysts is to determine whether they communicate with the subarachnoid space. One empirical method is refilling of the sellar cavity after it has been emptied, confirming the communication of the cyst with the subarachnoid space. Sometimes, the communication is very small,  and even after the marsupialization of the cyst, a CSF leak may not be visible. In our experience, endoscopic exploration of the sellar cavity may facilitate identification of an eventual communication of the cyst with the subarachnoid space.
| Conclusion|| |
Despite the limited number of patients presented in this study, it proves that the use of an endoscope in the treatment of cystic lesion is considered a very useful tool, with its panoramic view that permits better exploration of the cystic cavity to assess the completeness of tumor removal and possibly, if there is, communication with the suprasellar cistern in a minimally invasive manner. Although in contrast to the transcranial route, it drains the cyst from its most dependant part, ensuring complete removal.
We believe that, with better refinement of the instruments and growing experience, the endoscopic endonasal trans-sphenoidal route will be a much safer and valuable route for the removal of cystic sellar lesions.
| Acknowledgements|| |
Conflicts of interest
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]