Types, Procedure & Purpose Of Endoscopic Pituitary Surgery

Overview

Pituitary tumour surgery is the mainstay treatment for the majority of pituitary gland tumours. The most frequent surgical procedure used to remove pituitary tumours is endoscopic pituitary surgery, also known as transsphenoidal endoscopic surgery. The pituitary gland is situated above the interior of the nose and at the base of the brain. The majority of the body’s hormones, which act as chemical messengers and circulate in the blood, are controlled by this gland . Hormonal issues and loss of vision are two effects of pituitary tumours. Removing the tumour can frequently fix eye issues and return the body’s hormones to normal.

An endoscope is a surgical tool used in endoscopic pituitary surgery. It is a small, rigid tube that is often introduced through the nose and has a camera, light, and microscope incorporated into it. With the aid of the camera, the surgeon can do the tumour removal procedure while watching on a television screen.

Continue reading to learn more about pituitary tumour surgical treatment options.

Reasons for endoscopic pituitary surgery

Endoscopic pituitary surgery is used to remove the following types of pituitary tumours:

• Hormone-secreting tumours: These tumours release chemical messengers (hormones) that circulate in the bloodstream.
• Non-hormone-secreting tumours: These tumours, also known as ”endocrine inactive pituitary adenomas”, are surgically removed because they can cause headaches and vision issues as they grow in size.
• Cancerous tumours: These tumours are treated using a multimodality approach, including chemotherapy, surgery, and X-rays.

Pituitary tumour surgeries

The primary line of treatment for pituitary gland tumours is surgery.
Although pituitary tumours are not cancerous in the majority of patients, they can disrupt hormone levels and cause vision problems if they press on the optic nerve.
Pituitary tumours usually require treatment if they cause bothersome symptoms. Craniotomy and transsphenoidal surgery are the most commonly performed surgical techniques.

Endoscopic transsphenoidal surgery

Transsphenoidal, by its literal meaning, means ”across the sphenoid sinus”.  To remove pituitary tumours, the procedure is conducted through the sphenoid sinus and nose. An endoscope may be used during transsphenoidal surgery. It is frequently a collaborative effort between ENT surgeons and neurosurgeons.

Endonasal transsphenoidal pituitary surgery is a minimally invasive procedure that involves a nasal septum incision along the cartilage that partitions each side of the nose. This technique causes less destruction of the nasal tissues. The ENT surgeon uses an endoscope to work through the nasal passages to reach the pituitary gland. Then osseous (bony) openings are created in the sphenoid sinus, nasal septum, and sella, where the pituitary gland is situated, and the tumour is removed after the pituitary gland is exposed by the neurosurgeon.

Craniotomy
Craniotomies may be required for larger or more difficult-to-remove tumours. Although there is a greater risk of brain injury with this procedure, it is usually safer for large tumours because the surgeon has access to the tumour directly.

Endoscopic pituitary surgery risks

Endoscopic pituitary tumour surgery is a relatively safe procedure; however, all surgeries have some risk of anaesthesia reaction, infection, and bleeding. Complications and risks associated with this kind of surgery include:

• Cerebrospinal fluid (CSF) rhinorrhoea: CSF is the fluid surrounding the brain, and this may leak through the nose following the surgical procedure. In some circumstances, additional surgery may be required to repair the leak.
• Meningitis: This infection type can appear after surgery in the spinal cord and the lining of the brain (meninges). It is often seen when there is a CSF leak.
• Bleeding: If a large blood vessel is ruptured during surgery, persistent and heavy bleeding in the brain or through the nose may occur. Surgery may be required to correct this.
• Visual issues: The nerves that supply the eyes can be damaged if they are close to the pituitary gland.
• Damage to pituitary gland normal parts: When normal components of the pituitary that produce hormones are damaged, it may necessitate hormone replacement following surgery.
• Diabetes insipidus: Any damage to the pituitary gland part that controls urination may result in frequent thirst and urination.
• Sinus congestion: This occurs when small adhesions stick together, forming scars and obstructing the flow of air through the nose.
• Nasal deformity: It is caused by bone removal during surgery and may necessitate another surgery to correct it.
• Stroke: If the cavernous sinuses and carotid arteries on either side of the pituitary get damaged, there may be a disruption in the blood supply to the brain.

Other risks may exist, depending on the patient’s medical condition. Before the procedure, discuss any issues with the doctor.

Before undergoing endoscopic pituitary surgery

Before surgery, one may be required to see an endocrinologist for an evaluation. Endocrinologists are doctors who specialise in glands and hormones. Also, before surgery, individuals should have their vision checked.

Since endoscopic pituitary surgery is typically performed under general anaesthesia, individuals will be advised to refrain from drinking and eating after midnight the night prior to surgery. Some medicines that may cause excessive bleeding during the surgery may need to be discontinued. It is recommended not to consume any over-the-counter (OTC) or non-prescription medicines without first consulting a doctor. Numerous blood tests, a chest X-ray, and a heart rhythm test may be performed. All of these will be checked before surgery and will be examined by the doctor who administers anaesthesia.

During endoscopic pituitary surgery

The actual surgery could take several hours. A neurosurgeon and an ENT specialist frequently collaborate on the surgical procedure. These steps could occur:

• The endoscope is usually inserted through the nasal passage by the ENT surgeon. In some patients, an incision (cut) is made underneath the upper-lip to insert the endoscope.
• The endoscope is advanced until it comes into contact with the osseous wall of the sphenoid sinus behind the nose.
• The sphenoid sinus is opened, and the scope is allowed to pass through to the back of the sinus.
• A tiny hole is created in the sinus’s back wall.
• MRI scans may be used during surgery to generate images of the pituitary region to aid surgeons in their work.
• The pituitary tumour is excised (removed) by the neurosurgeon when the pituitary area is clearly accessible.
• The endoscope is removed once all accessible parts of the tumour have been removed. To complete the operation, some packing is placed in the nose.

After undergoing endoscopic pituitary surgery

The patient will be shifted to the intensive care unit after surgery, where their vital signs will be monitored as they awaken from anaesthesia. After that, the patient will be under monitoring and observation.

Individuals may experience nausea, nasal congestion, and headaches after surgery. These symptoms can be managed with medication. An endocrinology specialist may examine them one day post-surgery to ensure adequate levels of hormonal secretions by the pituitary; because if not, hormonal replacement therapy may be administered. Also, a brain MRI may be taken a day post-surgery. Individuals will be discharged after a few day stay in the hospital.

In general, expect:

Restrictions

• Avoiding nose blowing. coughing or sneezing with the mouth open if necessary.
• Until the follow-up, avoid using straws, straining while using the bathroom, or bending over from the waist.
• If someone has sleep apnoea, they should wait until the surgeon says it is safe to use a CPAP.Do not use tobacco-containing products such as vapes and cigarettes because they could delay healing.
• Lift nothing more than five pounds.
• Do not go back to work, drive, or fly until the surgeon gives the all-clear.
  Medications
• Following surgery, headaches are not uncommon. Taking acetaminophen (Tylenol) can help.
• Take pain relievers as directed. As the pain subsides, reduce the dosage and frequency. Do not take the pain reliever if not needed.
• Constipation can be caused by narcotics (a type of pain-relieving medicine). Drink ample water and consume foods high in fibre. Laxatives and stool softeners can aid in bowel movements.
• During bowel motions, avoid straining. It causes strain and may lead to a CSF leak.
• To maintain hormones, a prescription medication may be advised. Follow the doctor’s instructions exactly and never skip a dose.

When to consult a doctor

• A clear fluid with a metallic taste that drips down the throat or from the nose. This could be a leak of CSF. Call as soon as possible and avoid extreme physical activity.
• Vision loss or aggravated issues including loss of peripheral vision and having double or blurry vision.
• Persistent bleeding from the nose
• Excessive urination or thirst.
• A fever of more than 101.5° (not relieved by paracetamol).
• Increased nausea, vomiting, confusion, drowsiness, or headache
• Infection signs appear at the site of the incision.
• Itching or rash at the site of the incision.
• Seizures.

Endoscopic pituitary surgery cost in India

The cost of an endoscopic pituitary tumour surgery in India can vary based on several factors, including the surgeon’s experience, the severity of a patient’s medical condition, the hospital or clinic where the surgery is performed, and the specific procedure. The estimated cost for endoscopic pituitary tumour surgery in India can range from Rs. 3,00,000 to Rs. 6,00,000

It is important to note that these figures are only estimates, and patients should consult with their healthcare provider to get an accurate estimate based on their specific medical condition and treatment plan.

Takeaway
Overall, endoscopic pituitary tumour surgery is a safe and effective procedure that can help relieve the symptoms associated with a pituitary tumour and improve the patient’s quality of life. Patients should work closely with their healthcare provider to determine if endoscopic pituitary tumour surgery is the right treatment option for their specific needs.