Endoscopic Endonasal Pituitary Sacrifice for Selected Complex Tumors with Retrochiasmatic and Retroclival Extension: Surgical Anatomy, Step-by-Step Operative Technique and Case Series
Recommended Citation
Rychen J, Asmaro K, Ljubimov V, Lee M, Rinaldi M, Xiao L, Constanzo F, Gambatesa E, Vigo V, Fernandez-Miranda JC. Endoscopic Endonasal Pituitary Sacrifice for Selected Complex Tumors with Retrochiasmatic and Retroclival Extension: Surgical Anatomy, Step-by-Step Operative Technique and Case Series. J Neurol Surg B Skull Base 2024; 85(S1).
Document Type
Conference Proceeding
Publication Date
2-5-2024
Publication Title
J Neurol Surg B Skull Base
Abstract
Background: 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 retroclival space poses a surgical challenge. Pituitary transposition techniques have been developed to gain additional access to the retroclival space. However, when preoperative pituitary function is already impaired or the risk for postoperative panhypopituitarism (PH) is considered particularly high, removal of the pituitary gland might be the preferred option. Objective: Aim of this study is to describe the relevant surgical anatomy, the operative steps and our clinical experience with the endoscopic endonasal pituitary sacrifice (EE-PS) technique. Methods: Anatomical dissections of five postmortem specimens were performed. In addition, a retrospective analysis of clinical data was performed to report clinical characteristics, indications, and outcomes. Results: After a standard endoscopic endonasal approach, a wide exposure of the sella turcica and anterior walls of the cavernous sinus (CS) is performed. The boundaries of the bony exposure are as follows: the lateral opticocarotid recesses laterally, the limbus sphenoidale superiorly, and the sellar floor inferiorly. After opening of the dura, the gland is mobilized off the medial walls of the CS ([Figs. 1A] and [2A]). The descending branches of the superior hypophyseal artery are coagulated and the stalk transected ([Fig. 1B] and [2B]). After removal of the gland, bilateral posterior clinoidectomy followed by drilling of the dorsum sellae is performed ([Figs. 1C] and [2C]). The dura is opened again to access the hypothalamic region, interpeduncular and prepontine cisterns ([Figs. 1D] and [2D]). A total of 13 patients underwent EE-PS. The cohort comprised 10 (77%) craniopharyngiomas, 2 (15%) teratomas, and 1 (8%) hemangioblastoma. Nine (69%) patients had partial or complete anterior gland dysfunction preoperatively while 6 (46%) had preoperative diabetes insipidus. Due to 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 PS were impaired surgical accessibility to the retrochiasmatic and retroclival space. Ten patients (77%) had gross total tumor resection (GTR) and 3 (23%) had a near total resection. Two (15%) patients experienced a postoperative cerebrospinal fluid leak, requiring surgical revision. Illustrative case 1: A 15-year-old male with a craniopharyngioma and partial pituitary dysfunction. The lesion extended extensively to the retrochiasmatic and retroclival space ([Fig. 3A, B]), which justified EE-PS. GTR could be achieved without hypothalamic injury ([Fig. 3C, D]). Illustrative case 2: A 16-year-old male with a nongerminomatous germ cell tumor ([Fig. 4A]) and PH. Despite chemotherapy, a vital tumor portion remained in the hypothalamic region ([Fig. 4B]). Due to the very limited pituitarychiasmatic corridor and the narrow space between the chiasm and the dorsum sella, PS was deemed necessary to access the retrochiasmatic space. GTR was achieved with no complications ([Fig. 4C, D]). Conclusion:: When preoperative pituitary function is already impaired or the risk for postoperative PH is considered particularly high, PS is a feasible surgical option to improve visibility and accessibility to the retroclival and retrochiasmatic space, thus increasing tumor resectability. (Figure Presented).
Volume
85
Issue
S1