The cruciform drain: a technical note on the surgical management of cystic lesions of the sella

Background: The postoperative recurrence of cystic lesions of the sella is frequent and may require further surgery for re-drainage. / Objective: To tackle this problem, we propose to insert a small cross-shaped drain coursing from the cyst lumen to the suprasellar cistern. At this early stage of innovation, the technique is primarily intended for patients who present with a recurrence. / Methods: The cruciform drain is fashioned from the tip of a ventricular catheter and is inserted under endoscopic vision. We retrospectively reviewed the pre- and postoperative records of patients in whom this technique was implemented. / Results: A cruciform drain was placed in five patients since the introduction of the technique into our practice in 2018. The use of the cruciform drain did not impact upon the expected surgical workflow nor was it associated with adverse intraoperative events, but three patients did develop a postoperative CSF leak that was successfully treated in all cases. None of the patients showed re-collection of their cysts on early radiological follow-up. / Conclusion: The cruciform drain is intended to prevent the renewed build-up of cystic fluid by allowing it to flow through and around the drain into the subarachnoid space. We have modified our repair protocol in response to the observed high CSF leak rate, as a basis for further development of the technique. Studies involving long-term follow-up will also be required to assess its efficacy in reducing cyst recurrence

Surgical Video Motion Magnification with Suppression of Instrument Artefacts

Video motion magnification can make blood vessels in surgical video more apparent by exaggerating their pulsatile motion and could prevent inadvertent damage and bleeding due to their increased prominence. It could also indicate the success of restricting blood supply to an organ when using a vessel clamp. However, the direct application to surgical video could result in aberration artefacts caused by its sensitivity to residual motion from the surgical instruments and would impede its practical usage in the operating theatre. By storing the previously obtained jerk filter response of each spatial component of each image frame - both prior to surgical instrument introduction and adhering to a Eulerian frame of reference - it is possible to prevent such aberrations from occurring. The comparison of the current readings to the prior readings of a single cardiac cycle at the corresponding cycle point, are used to determine if motion magnification should be active for each spatial component of the surgical video at that given point in time. In this paper, we demonstrate this technique and incorporate a scaling variable to loosen the effect which accounts for variabilities and misalignments in the temporal domain. We present promising results on endoscopic transnasal transsphenoidal pituitary surgery with a quantitative comparison to recent methods using Structural Similarity (SSIM), as well as qualitative analysis by comparing spatio-temporal cross sections of the videos and individual frames

A spherical joint robotic end-effector for the Expanded Endoscopic Endonasal Approach

The endonasal transsphenoidal approach allows surgeons to access the pituitary gland through the natural orifice of the nose. Recently, surgeons have also described an Expanded Endoscopic Endonasal Approach (EEEA) for the treatment of other tumours around the base of the brain. However, operating in this way with nonarticulated tools is technically very difficult and not widely adopted. The goal of this study is to develop an articulated end-effector for a novel handheld robotic tool for the EEEA. We present a design and implementation of a 3.6mm diameter, three degrees-of-freedom, tendon-driven robotic end-effector that, contrary to rigid instruments which operate under fulcrum, will give the surgeon the ability to reach areas on the surface of the brain that were previously inaccessible. We model the end-effector kinematics in simulation to study the theoretical workspace it can achieve prior to implementing a test-bench device to validate the efficacy of the end-effector. We find promising repeatability of the proposed robotic end-effector of 0.42mm with an effective workspace with limits of ±30∘, which is greater than conventional neurosurgical tools. Additionally, although the tool’s end-effector has a small enough diameter to operate through the narrow nasal access path and the constrained workspace of EEEA, it showcased promising structural integrity and was able to support approximately a 6N load, despite a large deflection angle the limiting of which is scope of future work. These preliminary results indicate the end-effector is a promising first step towards developing appropriate handheld robotic instrumentation to drive EEEA adoption

An intuitive surgical handle design for robotic neurosurgery.

PURPOSE: The expanded endoscopic endonasal approach, a representative example of keyhole brain surgery, allows access to the pituitary gland and surrounding areas through the nasal and sphenoid cavities. Manipulating rigid instruments through these constrained spaces makes this approach technically challenging, and thus, a handheld robotic instrument could expand the surgeon's capabilities. In this study, we present an intuitive handle prototype for such a robotic instrument. METHODS: We have designed and fabricated a surgical instrument handle prototype that maps the surgeon's wrist directly to the robot joints. To alleviate the surgeon's wrist of any excessive strain and fatigue, the tool is mounted on the surgeon's forearm, making it parallel with the instrument's shaft. To evaluate the handle's performance and limitations, we constructed a surgical task simulator and compared our novel handle with a standard neurosurgical tool, with the tasks being performed by a consultant neurosurgeon. RESULTS: While using the proposed handle, the surgeon's average success rate was [Formula: see text], compared to [Formula: see text] when using a conventional tool. Additionally, the surgeon's body posture while using the suggested prototype was deemed acceptable by the Rapid Upper Limb Assessment ergonomic survey, while early results indicate the absence of a learning curve. CONCLUSIONS: Based on these preliminary results, the proposed handle prototype could offer an improvement over current neurosurgical tools and procedural ergonomics. By redirecting forces applied during the procedure to the forearm of the surgeon, and allowing for intuitive surgeon wrist to robot-joints movement mapping without compromising the robotic end effector's expanded workspace, we believe that this handle could prove a substantial step toward improved neurosurgical instrumentation

Historical and future trends in emergency pituitary referrals: a machine learning analysis

Purpose: Acute pituitary referrals to neurosurgical services frequently necessitate emergency care. Yet, a detailed characterisation of pituitary emergency referral patterns, including how they may change prospectively is lacking. This study aims to evaluate historical and current pituitary referral patterns and utilise state-of-the-art machine learning tools to predict future service use. Methods: A data-driven analysis was performed using all available electronic neurosurgical referrals (2014–2021) to the busiest U.K. pituitary centre. Pituitary referrals were characterised and volumes were predicted using an auto-regressive moving average model with a preceding seasonal and trend decomposition using Loess step (STL-ARIMA), compared against a Convolutional Neural Network-Long Short-Term Memory (CNN-LSTM) algorithm, Prophet and two standard baseline forecasting models. Median absolute, and median percentage error scoring metrics with cross-validation were employed to evaluate algorithm performance. Results: 462 of 36,224 emergency referrals were included (referring centres = 48; mean patient age = 56.7 years, female:male = 0.49:0.51). Emergency medicine and endocrinology accounted for the majority of referrals (67%). The most common presentations were headache (47%) and visual field deficits (32%). Lesions mainly comprised tumours or haemorrhage (85%) and involved the pituitary gland or fossa (70%). The STL-ARIMA pipeline outperformed CNN-LSTM, Prophet and baseline algorithms across scoring metrics, with standard accuracy being achieved for yearly predictions. Referral volumes significantly increased from the start of data collection with future projected increases (p < 0.001) and did not significantly reduce during the COVID-19 pandemic. Conclusion: This work is the first to employ large-scale data and machine learning to describe and predict acute pituitary referral volumes, estimate future service demands, explore the impact of system stressors (e.g. COVID pandemic), and highlight areas for service improvement

Intraoperative monitoring of visual evoked potentials in patients undergoing transsphenoidal surgery for pituitary adenoma: a systematic review

BACKGROUND: Transsphenoidal surgery is the gold standard for pituitary adenoma resection. Although rare, a serious complication of surgery is worsened vision post-operatively. OBJECTIVE: To determine whether, in patients undergoing transsphenoidal surgery for pituitary adenoma, intraoperative monitoring of visual evoked potentials (VEP) is a safe, reproducible, and effective technological adjunct in predicting postoperative visual function. METHODS: The PubMed and OVID platforms were searched between January 1993 and December 2020 to identify publications that (1) featured patients undergoing transsphenoidal surgery for pituitary adenoma, (2) used intraoperative optic nerve monitoring with VEP and (3) reported on safety or effectiveness. Reference lists were cross-checked and expert opinion sought to identify further publications. RESULTS: Eleven studies were included comprising ten case series and one prospective cohort study. All employed techniques to improve reliability. No safety issues were reported. The only comparative study included described a statistically significant improvement in post-operative visual field testing when VEP monitoring was used. The remaining case-series varied in conclusion. In nine studies, surgical manipulation was halted in the event of a VEP amplitude decrease suggesting a widespread consensus that this is a warning sign of injury to the anterior optic apparatus. CONCLUSIONS: Despite limited and low-quality published evidence regarding intra-operative VEP monitoring, our review suggests that it is a safe, reproducible, and increasingly effective technique of predicting postoperative visual deficits. Further studies specific to transsphenoidal surgery are required to determine its utility in protecting visual function in the resection of complex pituitary tumours

IgG4-related hypophysitis: a retrospective cohort study

Purpose: IgG4-related hypophysitis (IgG4-RH) is a rare chronic inflammatory condition of the pituitary gland. This study reports the presentation, management and outcomes for patients with histologically proven IgG4-related hypophysitis. Methods: A prospectively maintained electronic database was searched over a 14-year period from 1 January 2007 to 31 December 2020 at a single academic centre to identify all patients with a histological diagnosis of IgG4-RH. A retrospective case note review from electronic health records was conducted for each case to extract data on their presentation, management and outcomes. Results: A total of 8 patients (5 male) with a median age of 51 years were identified. The most common presenting symptoms were headache (4/8; 50%), fatigue (3/8; 37.5%) and visual impairment (2/8; 25%). Three patients were initially treated with high-dose steroids aiming for reduction of the pituitary mass. However, ultimately all patients underwent transsphenoidal surgery. Post-operative changes included radiological reduction in pituitary mass in all patients that had imaging (7/7; 100%), improvement in vision (1/2; 50%), residual thick pituitary stalk (5/7; 71.4%), persistent anterior hypopituitarism (4/8; 50%) and panhypopopituitarism including diabetes insipidus (3/8; 37.5%). Conclusions: IgG4-RH is an increasingly recognised entity presenting with a variety of symptoms and signs. Clinical presentation is similar to other forms of hypophysitis. It is therefore important to consider IgG4-RH as a differential and to have a low threshold for pituitary biopsy, the diagnostic gold standard. The diagnosis of IgG4-RH will guide decisions for additional workup for IgG4-related disease, multi-disciplinary team involvement and follow-up

A Novel Intraoperative Ultrasound Probe for Transsphenoidal Surgery: First-in-human study.

Background. Ultrasound has been explored as an alternative, less bulky, less time-consuming and less expensive means of intraoperative imaging in pituitary surgery. However, its use has been limited by the size of its probes relative to the transsphenoidal corridor. We developed a novel prototype that is more slender than previously reported forward-viewing probes and, in this report, we assess its feasibility and safety in an initial patient cohort. Method. The probe was integrated into the transsphenoidal approach in patients with pituitary adenoma, following a single-centre prospective proof of concept study design, as defined by the Innovation, Development, Exploration, Assessment and Long-Term Study (IDEAL) guidelines for assessing innovation in surgery (IDEAL stage 1 - Idea phase). Results. The probe was employed in 5 cases, and its ability to be used alongside the standard surgical equipment was demonstrated in each case. No adverse events were encountered. The average surgical time was 20 minutes longer than that of 30 contemporaneous cases operated without intraoperative ultrasound. Conclusion. We demonstrate the safety and feasibility of our novel ultrasound probe during transsphenoidal procedures to the pituitary fossa, and, as a next step, plan to integrate the device into a surgical navigation system (IDEAL Stage 2a - Development phase)

Craniopharyngioma in children: trends from a third consecutive single-center cohort study

OBJECTIVE: The management of children with craniopharyngioma has evolved over time, with a trend toward less invasive neurosurgical approaches as surgeons have sought to balance oncological control and treatment-related morbidity. To this end, the aim of this study was to evaluate the safety and effectiveness of the current management of children with craniopharyngioma compared to the previous management methods used at the authors’ treatment center. METHODS: A prospectively maintained database was searched over a 14-year period between January 1, 2005, and December 31, 2018, to identify all children 17 years of age or younger with a new diagnosis of craniopharyngioma. A retrospective case note review was performed for each child to extract data on the presentation, investigation, treatment, and outcome of their illness. Morbidity was assessed in the same fashion as in previous cohorts, according to the following categories: visual loss, pituitary dysfunction, hypothalamic dysfunction, neurological deficits, and cognitive impairment. RESULTS: In total, 59 children were identified with craniopharyngioma during the study period. A total of 92 operations were performed, including cyst drainage (35/92; 38.0%), craniotomy and resection (30/92; 32.6%), and transsphenoidal resection (16/92; 17.4%). Approximately two-thirds of all operations were performed using image guidance (66/92; 71.7%) and one-third were performed using endoscopy (27/92; 29.3%). The majority of children had adjuvant therapy comprising proton beam therapy (18/59; 30.5%) or conventional radiotherapy (16/59; 27.1%). The median follow-up duration was 44 months (range 1–142 months), and approximately one-half of the children had no evidence of residual disease on MRI studies (28/59; 47.5%). Of the remaining 31 children, there was a reduction in the volume of residual disease in 8 patients (8/59; 13.6%), stable residual disease in 18 (18/59; 30.5%), and tumor growth in 5 patients (5/59; 8.5%). There was significantly reduced morbidity (p < 0.05) in all categories in the current cohort compared with our last cohort (1996–2004). CONCLUSIONS: The authors’ institutional experience of pediatric craniopharyngioma confirms a trend toward less invasive neurosurgical procedures, most of which are now performed with the benefit of image guidance or endoscopy. Moreover, the authors have identified an expanding role for more targeted radiotherapy for children with residual disease. These advances have allowed for tumor control comparable to that achieved in previous cohorts, but with significantly reduced morbidity and mortality