Principles of Pituitary Surgery

Key Points 1. Understand the principles of pituitary surgery including the key-elements of surgical planning and decision-making 2. Identify the technical nuances distinguishing the endoscopic from the microscopic transsphenoidal approach 3. Understand the strategies utilized during the nasal, sphenoidal, and sellar stages of surgery that maximize tumor resection while minimizing complications and preserving sino- nasal anatomy/functio

Unlocking the Doors to Patient Satisfaction in Pediatric Orthopaedics

Background Many hospitals continue to struggle to improve patient satisfaction as the identification of tangible quality improvement areas remains difficult Medicare hospital payments are linked to patient satisfaction and hospitals\u27 HCAHPS scores, which has contributed to the growing influence of patient satisfaction measures Investigation into the major drivers of patient satisfaction in the pediatric clinical arena has not been thoroughly pursued To determine the main drivers of patient experience in pediatric orthopaedics, we performed an analysis of patient satisfaction surveys collected from outpatient pediatric orthopaedic practices at 5 locations in 3 states Hypothesis: the patient-physician relationship is the most important factor in patients\u27 assessment of their experiences These results may have significance in aiding pediatric orthopaedic clinics in their Quality Assurance/Quality Improvement plans of enhancing the patient experiencehttps://jdc.jefferson.edu/pedsposters/1000/thumbnail.jp

Minimally Invasive Surgery for Skull Base Tumors

The Jefferson Center for Minimally Invasive Cranial Base Surgery and Endoscopic Neurosurgery reflects three of the current evolutions in neurological surgery. The first of these is reflected in the name of the Center itself. Surgical Procedures, Minimally Invasive, a Medline Subject Heading since 1998, is defined as: Procedures that avoid use of open invasive surgery in favor of closed or local surgery. These generally involve use of laparoscopic devices and remote-control manipulation of instruments with indirect observation of the surgical field through an endoscope or similar device. With the reduced trauma associated with minimally invasive surgery, long hospital stays may be reduced with increased rates of short stay or day surgery. Traditionally, cranial base tumors have been removed by making craniotomies or cranial base ostomies, and possibly by removing facial bones. To access these areas, surgeons usually need to make potentially disfiguring incisions in the face and scalp. Sometimes the morbidity from the “open” cranial base approach alone could be significant, even with an uneventful removal of the tumor. At the Center, the endoscopic approaches are usually through the nose or nasal passages (Figure 1), however transoral endoscopic approaches to the cranial base and cervical spine are also performed. Because morbidity from the minimally invasive endoscopic approaches is so low, it becomes possible to treat patients with tumors that were previously considered non-resectable or as having too poor a prognosis for more invasive surgery. Even partial resection of such tumors can relieve pain, preserve function, and permit earlier adjuvant radiation and chemotherapy

Malignant melanoma metastatic to the thyroid gland: a case report and review of the literature.

The thyroid gland is a relatively uncommon site for a secondary malignancy; even less common is a case of malignant melanoma metastatic to the thyroid. We describe the case of a 68-year-old man who presented with a neck mass in the posterior triangle. Fine-needle aspiration biopsy (FNAB) identified the mass as a malignant melanoma. The patient had had no known primary skin melanoma. He underwent a left modified radical neck dissection, and the mass was discovered to be a positive lymph node. Postoperatively, he declined to undergo radio- and chemotherapy. Eighteen months later, he returned with a diffusely enlarged thyroid. FNAB again attributed the enlargement to malignant melanoma. Soon thereafter, the patient began experiencing seizures, and on magnetic resonance imaging, he was found to have metastatic disease to the brain. He developed ventilator-dependent respiratory failure and required a subtotal thyroidectomy for the placement of a tracheostomy tube. Patients who present with a thyroid nodule and who have a history of malignancy present a diagnostic dilemma: Is the nodule benign, a new primary, or a distant metastasis? The findings of this case and a review of the literature strengthen the argument that any patient with a thyroid mass and a history of malignancy should be considered to have a metastasis until proven otherwise

Prevention and Management of Bleeding During Endoscopic Approaches to Skull Base Pathologies

The rate of serious permanent morbidity and mortality with endonasal approaches has declined secondary to increased knowledge of the pertinent anatomy, advanced neuroimaging and navigation techniques, better surgical instruments, and improved exposure and reconstruction strategies.1-3 Although rare, vascular injury remains a potentially serious complication. However, with limited systematically-collected and reported data, the exact incidence rate of vascular injuries is difficult to determine. In terms of arterial injuries, the incidence based on reported series likely ranges from 0.3%-9% (Table 1),4-11 with higher rates most commonly associated with chordomas and chondrosarcomas involving the clivus. Venous injury is comparatively less severe and easier to manage. As a result, there is a comparatively lower impetus to publish epidemiological data and management strategies for these injuries. The consequences of arterial injury include fatal hemorrhage, vessel occlusion or thromboembolism causing infarction, development of a pseudoaneurysm (PA), carotid-cavernous fistula (CCF), subarachnoid hemorrhage (SAH), and vasospasm.6,7,9 Surgical expertise and detailed knowledge of the neurovascular anatomy is critical to the avoidance and management of vascular injuries. Pages: 20-2

Comprehensive Management of the Paranasal Sinuses in Patients Undergoing Endoscopic Endonasal Skull Base Surgery.

OBJECTIVE: The endonasal route often provides the most direct and safe approach to skull base pathology. In this article we review the literature with regard to management of the paranasal sinuses in the setting of skull base surgery. METHODS: We describe our institutional experience and review the literature of concurrent management of the sinusitis in patients undergoing endoscopic skull base surgery. RESULTS: Patients should be optimized preoperatively to ensure the endonasal route is a safe corridor to enter the intracranial cavity. Often the paranasal sinuses can be surgically addressed at the same time as endoscopic skull base surgery. We describe the technical details of management of the paranasal sinuses when addressing skull base pathology. CONCLUSIONS: Careful management of the paranasal sinuses throughout the peri-operative course is paramount to optimizing sinonasal function and safety

Is Reconstruction of the Sella Necessary to Prevent Optic Chiasm Prolapse and Cerebrospinal Fluid Leakage Following Endoscopic Resection of Pituitary Macroadenomas?

Visual compromise is a common presentation of pituitary macroadenomas and is related to direct optic nerve and chiasm compression. Although the extent of visual recovery following treatment depends on the duration and severity of the visual compromise, the majority of patients experience gradual improvement in their vision. Delayed visual deterioration following treatment is typically related to either tumor recurrence or radiation-induced optic neuropathy, although visual worsening due to prolapse of the optic apparatus into a secondary empty sella has rarely been reported. In 1968, Guiot reported the first a case of reversible visual deterioration associated with optic chiasm prolapse following resection of a large pituitary macroadenoma (Guiot). Based on their observations, Guiot and collaborators recommended that a “prop” be placed in the sella at the time of transsphenoidal pituitary adenoma resection to prevent progressive herniation of the optic structures. Similarly, Hardy coined the term “preventive chiasmopexy” to describe filling of the sella cavity with autologous tissue such as muscle or fat following resection of large tumors to prevent this herniation phenomenon. While optic chiasm prolapse with associated visual deterioration appears to represent a rare occurrence, its true incidence and pathophysiological basis remain uncertain. Reconstruction of the sella with autologous tissues is also widely employed as a means to prevent postoperative cerebrospinal fluid leakage with these tissues typically harvested from a secondary operative site such as the abdomen. Although not frequently reported in the pituitary literature, complications of abdominal fat graft harvest include hematoma and seroma formation as well as infection with an incidence ranging from 1-7%. At our institution, we do not routinely perform dural reconstruction following transsphenoidal resection of pituitary macroadenomas using adipose tissue to prevent cerebrospinal fluid leakage or optic chiasm prolapse. In this study, we sought to determine the incidence of optic chiasm prolapse into the sellar defect by determining the radiographic position of the optic chiasm following surgery and incidence of delayed visual deterioration. Pages: 13-1

Endonasal Vascularized Flaps For Cranial Base Reconstruction

Since the introduction of extended endoscopic cranial base surgery, postoperative cerebrospinal fluid (CSF) leak has been a formidable and troublesome issue resulting in complications such meningitis, pneumocephalus, and the need for additional surgical interventions. Establishment of a watertight cranial base reconstruction is the most critical step in preventing postoperative CSF leakage. Historically, various free grafts, both synthetic and autologous, were utilized as repair materials for reconstruction of the cranial base defect often in combination with temporary CSF diversion. Free grafts are often sufficient for repair of small low flow, low pressure dural defects. High postoperative CSF leak rates reported in the initial endoscopic skull base literature are evidence that free grafts do not provide a reliably competent repair for large defects or direct high-flow CSF leaks. The introduction of the Hadad-Bassagasteguy vascularized nasoseptal flap has significantly reduced the reported CSF leak rate with a recent meta-analysis reporting that use of the vascularized flap is associated with a 7% rate of postoperative CSF leakage compared to 16% with free grafts alone for large dural defects.6 Since the initial description of the vascularized pedicled nasoseptal flap in 2006, many surgeons have developed a variety of alternative vascularized flaps for endonasal cranial base reconstruction. In this article, we summarize and compare several of the most clinically useful vascularized flaps including their harvest technique, indications and limitations, and potential complications. Pages: 28-3

Computational fluid dynamics as surgical planning tool: a pilot study on middle turbinate resection.

Controversies exist regarding the resection or preservation of the middle turbinate (MT) during functional endoscopic sinus surgery. Any MT resection will perturb nasal airflow and may affect the mucociliary dynamics of the osteomeatal complex. Neither rhinometry nor computed tomography (CT) can adequately quantify nasal airflow pattern changes following surgery. This study explores the feasibility of assessing changes in nasal airflow dynamics following partial MT resection using computational fluid dynamics (CFD) techniques. We retrospectively converted the pre- and postoperative CT scans of a patient who underwent isolated partial MT concha bullosa resection into anatomically accurate three-dimensional numerical nasal models. Pre- and postsurgery nasal airflow simulations showed that the partial MT resection resulted in a shift of regional airflow towards the area of MT removal with a resultant decreased airflow velocity, decreased wall shear stress and increased local air pressure. However, the resection did not strongly affect the overall nasal airflow patterns, flow distributions in other areas of the nose, nor the odorant uptake rate to the olfactory cleft mucosa. Moreover, CFD predicted the patient\u27s failure to perceive an improvement in his unilateral nasal obstruction following surgery. Accordingly, CFD techniques can be used to predict changes in nasal airflow dynamics following partial MT resection. However, the functional implications of this analysis await further clinical studies. Nevertheless, such techniques may potentially provide a quantitative evaluation of surgical effectiveness and may prove useful in preoperatively modeling the effects of surgical interventions

NUT Midline Carcinoma in a Pregnant Woman

NUT midline carcinoma is a rare, highly aggressive tumor that involves midline structures, particularly in the head, neck and mediastinum. It is characterized by NUT gene translocations on chromosome 15. It typically impacts teenagers or young adults, and has a fulminant course leading to death in less than a year in most cases despite aggressive chemoradiotherapy. Due to its location, this tumor is frequently considered inoperable. We present a case of a sinonasal NUT midline carcinoma with orbital invasion discovered during the workup of sinusitis in a young, pregnant woman. The tumor was managed with definitive excision to negative margins followed by aggressive chemoradiation, with no evidence of recurrence for 12 months. We propose that diagnosis of NUT midline carcinoma should prompt recognition of the limitations of current medical therapy and rapid surgical intervention should be undertaken when possible