Abstract：
OBJECTIVE: Tumors located in the retrochiasmatic region with extension to the third ventricle might be difficult to access when the pituitary-chiasmatic corridor is narrow. Similarly, tumor extension into the interpeduncular and retrosellar space poses a major surgical challenge. Pituitary transposition techniques have been developed to gain additional access. However, when preoperative pituitary function is already impaired or the risk of postoperative panhypopituitarism (PH) is considered to be particularly high, removal of the pituitary gland (PG) might be the preferred option to increase the working corridor. The aim of this study was to describe the relevant surgical anatomy, operative steps, and clinical experience with the endoscopic endonasal pituitary sacrifice (EEPS) and transsellar approach.
METHODS: This study comprised anatomical dissections to highlight the relevant surgical steps and a retrospective case series reporting clinical characteristics, indications, and outcomes of patients who underwent EEPS. The surgical technique is as follows: both lateral opticocarotid recesses are exposed laterally, the limbus sphenoidale superiorly, and the sellar floor inferiorly. After opening the dura, the PG is detached circumferentially and mobilized off the medial walls of the cavernous sinuses. The descending branches of the superior hypophyseal artery are coagulated, and the stalk is transected. After removal of the PG, drilling of the dorsum sellae and bilateral posterior clinoidectomies are performed to gain access to the hypothalamic region, interpeduncular, and prepontine cisterns.
RESULTS: From 2018 to 2023, 11 patients underwent EEPS. The cohort comprised mostly tuberoinfundibular craniopharyngiomas (n = 8, 73%). Seven (64%) patients had partial or complete anterior PG dysfunction preoperatively, while 4 (36%) had preoperative diabetes insipidus. Because of the specific tumor configuration, the chance of preserving endocrine function was estimated to be very low in patients with intact function. The main reasons for pituitary sacrifice were impaired visibility and surgical accessibility to the retrochiasmatic and retrosellar spaces. Gross-total tumor resection was achieved in 10 (91%) patients and near-total resection in 1 (9%) patient. Two (18%) patients experienced a postoperative CSF leak, requiring surgical revision.
CONCLUSIONS: When preoperative pituitary function is already impaired or the risk for postoperative PH is considered particularly high, the EEPS and transsellar approach appears to be a feasible surgical option to improve visibility and accessibility to the retrochiasmatic hypothalamic and retrosellar spaces, thus increasing tumor resectability.
METHODS: This study comprised anatomical dissections to highlight the relevant surgical steps and a retrospective case series reporting clinical characteristics, indications, and outcomes of patients who underwent EEPS. The surgical technique is as follows: both lateral opticocarotid recesses are exposed laterally, the limbus sphenoidale superiorly, and the sellar floor inferiorly. After opening the dura, the PG is detached circumferentially and mobilized off the medial walls of the cavernous sinuses. The descending branches of the superior hypophyseal artery are coagulated, and the stalk is transected. After removal of the PG, drilling of the dorsum sellae and bilateral posterior clinoidectomies are performed to gain access to the hypothalamic region, interpeduncular, and prepontine cisterns.
RESULTS: From 2018 to 2023, 11 patients underwent EEPS. The cohort comprised mostly tuberoinfundibular craniopharyngiomas (n = 8, 73%). Seven (64%) patients had partial or complete anterior PG dysfunction preoperatively, while 4 (36%) had preoperative diabetes insipidus. Because of the specific tumor configuration, the chance of preserving endocrine function was estimated to be very low in patients with intact function. The main reasons for pituitary sacrifice were impaired visibility and surgical accessibility to the retrochiasmatic and retrosellar spaces. Gross-total tumor resection was achieved in 10 (91%) patients and near-total resection in 1 (9%) patient. Two (18%) patients experienced a postoperative CSF leak, requiring surgical revision.
CONCLUSIONS: When preoperative pituitary function is already impaired or the risk for postoperative PH is considered particularly high, the EEPS and transsellar approach appears to be a feasible surgical option to improve visibility and accessibility to the retrochiasmatic hypothalamic and retrosellar spaces, thus increasing tumor resectability.
摘要：
目的：当垂体-交叉走廊狭窄时，位于交叉后区域并延伸至第三脑室的肿瘤可能难以进入。同样，肿瘤向椎间和鞍后空间的扩展构成了重大的手术挑战。已经开发了垂体转座技术以获得额外的访问。然而,当术前垂体功能已经受损或术后全垂体功能减退（PH）的风险被认为特别高时，切除垂体（PG）可能是增加工作走廊的首选选择。这项研究的目的是描述相关的手术解剖，操作步骤,内镜鼻内垂体处死（EEPS）和经鞍入路的临床经验。
方法：本研究包括解剖解剖，以突出相关的手术步骤和回顾性病例系列报告临床特征，适应症,以及接受EEPS的患者的结局。手术技术如下:两个外侧视颈动脉凹陷都横向暴露，上缘蝶骨，和鞍层底层。打开硬脑膜后，PG沿圆周分离，并从海绵窦的内壁移动。垂体上动脉降支凝结,茎被横切。移除PG后,进行背囊钻孔和双侧后路临床切除术以进入下丘脑区域。椎间,和脑前蓄水池.
结果：从2018年到2023年，有11例患者接受了EEPS。该队列主要包括结节漏斗颅咽管瘤（n=8，73％）。7例（64%）患者术前出现部分或完全前PG功能障碍，4例（36%）术前有尿崩症。由于特定的肿瘤构型，在功能完整的患者中,维持内分泌功能的机会估计非常低.垂体牺牲的主要原因是能见度受损以及对裂后和鞍后间隙的手术可及性。10例（91％）患者实现了全部肿瘤切除，1例（9％）患者实现了几乎全部切除。两名（18％）患者经历了术后脑脊液漏，需要手术翻修.
结论：当术前垂体功能已经受损或术后PH的风险被认为特别高时，EEPS和经鞍入路似乎是一种可行的手术选择，可以提高下丘脑和鞍后间隙的能见度和可及性，从而增加肿瘤的可切除性。
方法：本研究包括解剖解剖，以突出相关的手术步骤和回顾性病例系列报告临床特征，适应症,以及接受EEPS的患者的结局。手术技术如下:两个外侧视颈动脉凹陷都横向暴露，上缘蝶骨，和鞍层底层。打开硬脑膜后，PG沿圆周分离，并从海绵窦的内壁移动。垂体上动脉降支凝结,茎被横切。移除PG后,进行背囊钻孔和双侧后路临床切除术以进入下丘脑区域。椎间,和脑前蓄水池.
结果：从2018年到2023年，有11例患者接受了EEPS。该队列主要包括结节漏斗颅咽管瘤（n=8，73％）。7例（64%）患者术前出现部分或完全前PG功能障碍，4例（36%）术前有尿崩症。由于特定的肿瘤构型，在功能完整的患者中,维持内分泌功能的机会估计非常低.垂体牺牲的主要原因是能见度受损以及对裂后和鞍后间隙的手术可及性。10例（91％）患者实现了全部肿瘤切除，1例（9％）患者实现了几乎全部切除。两名（18％）患者经历了术后脑脊液漏，需要手术翻修.
结论：当术前垂体功能已经受损或术后PH的风险被认为特别高时，EEPS和经鞍入路似乎是一种可行的手术选择，可以提高下丘脑和鞍后间隙的能见度和可及性，从而增加肿瘤的可切除性。
