Current and Future Advances in Surgical Therapy for Pituitary Adenoma

The vital physiological role of the pituitary gland, alongside its proximal critical neurovascular structures means pituitary adenomas cause significant morbidity or mortality. Whilst enormous advancements have been made in the surgical care of pituitary adenomas, treatment failure and recurrence remain challenges. To meet these clinical challenges, there has been an enormous expansion of novel medical technologies (e.g. endoscopy, advanced imaging, artificial intelligence). These innovations have the potential to benefit each step of the patient journey, and ultimately, drive improved outcomes. Earlier and more accurate diagnosis addresses this in part. Analysis of novel patient data sets, such as automated facial analysis or natural language processing of medical records holds potential in achieving an earlier diagnosis. After diagnosis, treatment decision-making and planning will benefit from radiomics and multimodal machine learning models. Surgical safety and effectiveness will be transformed by smart simulation methods for trainees. Next-generation imaging techniques and augmented reality will enhance surgical planning and intraoperative navigation. Similarly, the future armamentarium of pituitary surgeons, including advanced optical devices, smart instruments and surgical robotics, will augment the surgeon's abilities. Intraoperative support to team members will benefit from a surgical data science approach, utilising machine learning analysis of operative videos to improve patient safety and orientate team members to a common workflow. Postoperatively, early detection of individuals at risk of complications and prediction of treatment failure through neural networks of multimodal datasets will support earlier intervention, safer hospital discharge, guide follow-up and adjuvant treatment decisions. Whilst advancements in pituitary surgery hold promise to enhance the quality of care, clinicians must be the gatekeepers of technological translation, ensuring systematic assessment of risk and benefit. In doing so, the synergy between these innovations can be leveraged to drive improved outcomes for patients of the future

A Virtual-Based Haptic Endoscopic Sinus Surgery (ESS) Training System: from Development to Validation

Simulated training platforms offer a suitable avenue for surgical students and professionals to build and improve upon their skills, without the hassle of traditional training methods. To enhance the degree of realistic interaction paradigms of training simulators, great work has been done to both model simulated anatomy in more realistic fashion, as well as providing appropriate haptic feedback to the trainee. As such, this chapter seeks to discuss the ongoing research being conducted on haptic feedback-incorporated simulators specifically for Endoscopic Sinus Surgery (ESS). This chapter offers a brief comparative analysis of some EES simulators, in addition to a deeper quantitative and qualitative look into our approach to designing and prototyping a complete virtual-based haptic EES training platform

Endoscopic Endonasal Transclival Approach versus Dual Transorbital Port Technique for Clip Application to the Posterior Circulation: A Cadaveric Anatomical and Cerebral Circulation Simulation Study

Purpose  Simulation training offers a useful opportunity to appreciate vascular anatomy and develop the technical expertise required to clip intracranial aneurysms of the posterior circulation. Materials and Methods  In cadavers, a comparison was made between the endoscopic transclival approach (ETA) alone and a combined multiportal approach using the ETA and a transorbital precaruncular approach (TOPA) to evaluate degrees of freedom, angles of visualization, and ergonomics of aneurysm clip application to the posterior circulation depending on basilar apex position relative to the posterior clinoids. Results  ETA alone provided improved access to the posterior circulation when the basilar apex was high riding compared with the posterior clinoids. ETA + TOPA provided a significantly improved functional working area for instruments and visualization of the posterior circulation for a midlevel basilar apex. A single-shaft clip applier provided improved visualization and space for instruments. Proximal and distal vascular control and feasibility of aneurysmal clipping were demonstrated. Conclusions  TOPA is a medial orbital approach to the central skull base; a transorbital neuroendoscopic surgery approach. This anatomical simulation provides surgical teams an alternative to the ETA approach alone to address posterior circulation aneurysms, and a means to preoperatively prepare for intraoperative anatomical and surgical instrumentation challenges

Radiation therapy in pituitary adenomas

De plaats van radiotherapie bij de behandeling van het hypofyseadenoom, een goedaardige tumor in het hoofd, is wereldwijd niet éénsluidend. De veronderstelde bijwerkingen van de radiotherapie worden als argument aangegrepen om radiotherapie - ondanks zijn gunstige werking - niet toe te passen of uit te stellen. Het Groningse onderzoek bij patiënten met een tumorrest van een niet functionerend hypofyseadenoom laat zien dat direct postoperatief geven van radiotherapie een zéér gunstig effect heeft op het onder controle houden van de tumor en dat het niet geven van radiotherapie een hoge kans op terugkeer van de tumor tot gevolg heeft. Het onthouden van radiotherapie leidt niet tot een verondersteld beter behoud van de hypofysefunctie, het cognitief functioneren, de kwaliteit van leven en de overleving van de patiënt, maar leidt tot meer onzekerheid gezien de hoge kans op terugkeer van de tumor. Tevens wordt radiatie-opticus neuropathie - een plotseling, ernstig onomkeerbaar gezichtsvermogenverlies ten gevolge van schade aan de oogzenuwen door de radiotherapie - zelden of niet waargenomen in de bestraalde patiënten met een niet-functionerend of groeihormoonproducerend hypofyseadenoom in het UMCG en in de door de Groningse onderzoekers gerapporteerde literatuuroverzichten. Nog minder bijwerkingen worden verwacht met toekomstige nog meer geavanceerde radiotherapie. Met Tyrosine positron emissie tomografie (PET), een nieuwe beeldvormingmodaliteit, is de eiwit aanmaak in het hypofyseadenoom zichtbaar te maken, in tegenstelling tot de gehanteerde standaard magnetische resonantie beeldvorming (MRI). Drie jaar na radiotherapie is het postoperatieve tumorvolume gehalveerd, zichtbaar op PET, maar ongewijzigd op MRI, suggererend dat met PET de biologische tumoractiviteit te volgen is. Dit is van nieuwe additionele waarde. De noodzaak van multidisciplinaire samenwerking bij de behandeling van het hypofyseadenoom wordt onderstreept

Haemostasis in endoscopic skull base surgery

The endoscopic approach to the skull base has revolutionised surgery in this region. Neurosurgery involves working around anatomical structures that are uniquely sensitive to damage and manipulation and patients may be left with the potentially devastating consequences of violating these structures. The endoscope allows the surgeon to visualise and reach areas that were previously only accessible with large amounts of destructive dissection. Tumours are able to be removed and aneurysms clipped without the need for large craniotomies and bony drilling. There are, however, drawbacks. The midline endoscopic route takes the surgeon between the carotid arteries. It potentially violates the anterior communicating artery complex and the basilar artery region anterior to the brainstem. These are important arteries that supply critical structures. Damage to these, or diminution of blood flow through them, results in profound neurological dysfunction or death. The rate of damage to the carotid artery with these approaches ranges from 1.1-9% depending on the specific approach and pathology. The carotid artery in this region does not generally lend itself to suturing, clipping or direct closure methods. Currently, the gold standard for repair is the application of crushed muscle patch to stop the bleeding and seal the vessel. The drawbacks to this are that it takes time to harvest and control the bleed (generally requiring 2 surgeons), and that there is a risk of pseudoaneurysm formation post recovery. This thesis describes novel techniques that may replace the muscle patch in order that a single surgeon may have this technique available to them immediately. Aims: To demonstrate the use of fibrin/thrombin/gelatin patches, fibrin/thrombin glues, beta-chitosan patches and self-assembling peptides on a sheep model of carotid artery haemorrhage and quantify the rate of pseudoaneurysm formation. To show the percentage of platelets activated by crushed and uncrushed muscle, chitosan, and fibrin and thrombin patches and gels using flow cytometry to further delineate the mechanism of action of crushed muscle as a haemostatic agent. To quantify the stress response in surgeons training on this sheep vascular haemorrhage model de novo, to quantify its effect on surgeons’ teamwork and communication skills, and determine the effect and value of training on modulation of this stress response.Thesis (Ph.D.) (Research by Publication) -- University of Adelaide, Adelaide Medical School, 201

Clinical situations for which 3D printing is considered an appropriate representation or extension of data contained in a medical imaging examination: Neurosurgical and otolaryngologic conditions

BACKGROUND: Medical three dimensional (3D) printing is performed for neurosurgical and otolaryngologic conditions, but without evidence-based guidance on clinical appropriateness. A writing group composed of the Radiological Society of North America (RSNA) Special Interest Group on 3D Printing (SIG) provides appropriateness recommendations for neurologic 3D printing conditions. METHODS: A structured literature search was conducted to identify all relevant articles using 3D printing technology associated with neurologic and otolaryngologic conditions. Each study was vetted by the authors and strength of evidence was assessed according to published guidelines. RESULTS: Evidence-based recommendations for when 3D printing is appropriate are provided for diseases of the calvaria and skull base, brain tumors and cerebrovascular disease. Recommendations are provided in accordance with strength of evidence of publications corresponding to each neurologic condition combined with expert opinion from members of the 3D printing SIG. CONCLUSIONS: This consensus guidance document, created by the members of the 3D printing SIG, provides a reference for clinical standards of 3D printing for neurologic conditions

Virtual reality and surgical oncology

More than 80% of people diagnosed with cancer will require surgery. However, less than 5% have access to safe, affordable and timely surgery in low- and middle-income countries (LMICs) settings mostly due to the lack of trained workforce. Since its creation, virtual reality (VR) has been heralded as a viable adjunct to surgical training, but its adoption in surgical oncology to date is poorly understood. We undertook a systematic review to determine the application of VR across different surgical specialties, modalities and cancer pathway globally between January 2011 and 2021. We reviewed their characteristics and respective methods of validation of 24 articles. The results revealed gaps in application and accessibility of VR with a proclivity for high-income countries and high-risk, complex oncological surgeries. There is a lack of standardisation of clinical evaluation of VR, both in terms of clinical trials and implementation science. While all VR illustrated face and content validity, only around two-third exhibited construct validity and predictive validity was lacking overall. In conclusion, the asynchrony between VR development and actual global cancer surgery demand means the technology is not effectively, efficiently and equitably utilised to realise its surgical capacity-building potential. Future research should prioritise cost-effective VR technologies with predictive validity for high demand, open cancer surgeries required in LMICs.</p

Cirurgia endoscópica endonasal transesfenoidal : o impacto da tecnologia de impressão 3D

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2021Introdução: A cirurgia endoscópica endonasal transesfenoidal (CEET) é uma técnica cirúrgica de abordagem da base do crânio. Atualmente, os recursos de treino de CEET são limitados. Neste estudo foi desenvolvido um modelo multimaterial obtido por tecnologia de impressão 3D para treino de CEET. Objetivos: Avaliar o impacto do modelo produzido na aprendizagem da anatomia da base do crânio e no treino cirúrgico. Métodos: O modelo 3D foi criado a partir de imagens de tomografia computorizada (TC) de um doente com macroadenoma não funcionante da hipófise. Para simular a consistência real das várias estruturas anatómicas, as peças do modelo, depois de segmentadas e pós-processadas, foram construídas com diferentes materiais: as partes ósseas com Z-ULTRAT e resina; as partes moles com silicone. O modelo foi validado por uma equipa multidisciplinar e aplicado num curso dirigido a onze participantes. Neste curso avaliou-se o desempenho prático dos participantes e o impacto do modelo desenvolvido na aprendizagem da anatomia da base do crânio e no treino cirúrgico. Obtiveram-se também dados dos participantes relativos ao seu nível de treino em neurocirurgia e à sua experiência prévia de CEET. Resultados: Construiu-se um modelo 3D com grande precisão anatómica. O curso desenvolvido contou com participantes em diferentes níveis da sua formação em Neurocirurgia. Todos conseguiram identificar no modelo as estruturas anatómicas pré-selecionadas. No entanto, existiram erros durante a abordagem prática. Dez dos participantes não tinham disponível um método de treino de CEET no hospital onde exercem funções. Apenas cinco dos participantes já tinham tido uma intervenção prática numa CEET, apesar de não ter sido como cirurgião principal. Conclusão: A utilização de modelos obtidos por tecnologia de impressão 3D é um método prático, económico e fidedigno de treino. Esta tecnologia tem um impacto benéfico no treino de CEET.Background: Endoscopic endonasal transsphenoidal surgery (EETS) is a surgical technique to approach the skull base. Currently, EETS training resources are limited. In this study, multimaterial model was obtained by 3D printing technology for EETS training. Objectives: To evaluate the impact of the produced model in learning the anatomy of the skull base and in surgical training. Methods: 3D model was created from computed tomography (CT) images of a patient with non-functioning pituitary macroadenoma. To simulate the real consistence of the various anatomical structures, the model was produced with different materials: the bone parts with Z-ULTRAT and resin; the soft parts with silicone. The model was validated by a multidisciplinary team and applied in a course addressed to eleven participants. In this course, the practical performance of the participants and the impact of the model in learning anatomy of the skull base and in surgical training were evaluated. Data on the degree of specialization in neurosurgery and previous experience in EETS were also obtained. Results: Model was built with great anatomical precision. Course participants were in different stages of their training in Neurosurgery. Participants were able to identify pre-selected anatomical structures. However, they made mistakes when approaching the model. Ten participants did not have EETS training available at their hospital. Only five participants had already a practical intervention in an EETS, despite not having been a main surgeon. Conclusion: The use of models obtained by 3D printing technology is a practical, economical and reliable method of training. This technology has a beneficial impact in the acquisition of skills that allow the improvement of EETS performance