Endonasal endoscopic surgery in pituitary adenomas: Surgical results in a series of 86 consecutive patients

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Picó Alfonso, Pedro Moreno-López, Juan Ramón Gras-Albert" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Raquel" "apellidos" => "López-García" "email" => array:1 [ 0 => "Raquelncgalicante@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Javier" "apellidos" => "Abarca-Olivas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Irene" "apellidos" => "Monjas-Cánovas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Antonio M." "apellidos" => "Picó Alfonso" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "Pedro" "apellidos" => "Moreno-López" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Juan Ramón" "apellidos" => "Gras-Albert" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Neurocirugía, Hospital General Universitario de Alicante, Alicante, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Otorrinolaringología, Hospital General Universitario de Alicante, Alicante, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Endocrinología, Hospital General Universitario de Alicante, Alicante, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cirugía endoscópica endonasal en adenomas hipofisarios: resultados quirúrgicos en una serie de 86 pacientes consecutivos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1341 "Ancho" => 2333 "Tamanyo" => 171907 ] ] "descripcion" => array:1 [ "en" => "Intraoperative image of essential intrasphenoid anatomical references." ] ] ] "textoCompleto" => "IntroductionPituitary adenomas are the third most common type of intracranial neoplasm, accounting for 10–25% of all primary brain tumours, and are defined as the most common form of intrasellar lesion. They are benign lesions, although approximately 5% have a more aggressive clinical course, associated with a high recurrence rate. One of the worst characteristics, and the main cause of incomplete surgical resection, is invasion of the cavernous sinus.The transsphenoidal endonasal approach is currently the most used for pituitary surgery, as it allows direct access to the sella turcica without manipulation of the healthy cerebral parenchyma.This technique has two modes: microscopic and endoscopic.Thanks to technological advances, the endoscopic technique has now become the approach of choice. Among the main advantages are the better illumination and visualisation.However, as there are no randomised double-blind prospective studies, the level of evidence when we try to compare the classic microscopic technique with the endoscopic approach is low.The aim of this article is to present our experience in the surgical treatment of pituitary adenomas using the transsphenoidal endoscopic approach. We describe our surgical technique, the results obtained, and the complications observed.Material and methodsWe carried out a prospective, descriptive study from February 2011 to August 2016, reviewing all 86 patients who underwent surgery for pituitary adenoma using a purely endoscopic endonasal approach at Hospital General Universitario in Alicante. All were operated on jointly by otolaryngologists and neurosurgeons.Sellar lesions other than adenomas were not included.The mean follow-up was 32 months.Diagnosis and preoperative testsAll the patients were assessed according to clinical, radiological, endocrine and ophthalmological criteria.We analysed the clinical symptoms to determine which was the most common.All patients had preoperative visual field testing to assess the degree of visual loss.The endocrine tests consisted of determining baseline plasma concentrations of the hormones FSH, LH, ACTH, IGF1, PRL, TSH, free T4, cortisol, oestradiol (females) and testosterone (males) to check the integrity of the hypothalamic–pituitary axis.All patients had a magnetic resonance imaging (MRI) scan to assess tumour size, suprasellar extension and invasion of the cavernous sinus according to the Knosp scale.Surgical techniquePatients are placed in the supine position, with their heads slightly hyperextended and slightly rotated to the right towards the surgeon.Their faces are prepared with Betadine diluted with normal saline and oxymetazoline-soaked patties are inserted to decongest their nasal passages.We normally use a rigid 0° endoscope. Occasionally, we use 45° optics to check regions of the tumour bed that may be hidden from view with 0°.We use navigation based on thin-slice CT angiography systematically, as it allows us to identify bone and vascular structures.The surgical procedure is divided into three phases: a nasal phase, until the floor of the sella is reached; an excision phase, where the sella turcica is opened to resect the tumour; and a final phase for closure and reconstruction of the defect in the base of the skull.In the nasal phase, we introduce a rigid 0° endoscope through the right nostril, tangential to the floor of the nasal cavity. We identify the inferior turbinate laterally and, above that, the middle turbinate; medially the nasal septum can be observed. We routinely resect the middle turbinate to give us wider access to the sphenoid region. This makes it easier to create the nasoseptal flap and we can also use its mucosa at the end of surgery for sellar reconstruction if the pedicled flap is not required.In cases where a high-flow cerebrospinal fluid (CSF) leak is expected (large tumours or large suprasellar invasion), we perform the pedicled nasoseptal flap at the beginning of the intervention. To do this, we make an incision in the lower margin of the choana and extend it horizontally along the floor of the nasal cavity to the nasal vestibule; we make another second upper incision just below the sphenoid ostium and extend it anteriorly, locating it approximately 1cm below the upper edge of the nasal septum, in order to respect the olfactory epithelium; and finally, we make an anterior vertical incision connecting the first two incisions. We then lift the mucosa of the nasal septum, dissecting it in an anterior–posterior direction, and store it in the choana to be used at the end of the intervention.Next, we identify the sphenoid ostium, located behind the tail of the superior turbinate. We resect the posterior part of the nasal septum, approximately 1.5cm just in front of the anterior wall of the sphenoid sinus. The posterior septostomy makes a two-nostril, four-hand approach possible, and also exposes the contralateral sphenoid ostium.We then begin the resection of the anterior wall of the sphenoid sinus in a procedure known as “sphenoidotomy”. We start to expand the sphenoid ostium with a Kerrison, and then use the electric drill with cutting burr. Although the aim of this surgical intervention is to be minimally invasive, it is very important to perform a wide opening of the anterior wall of the sphenoid in order to better recognise intrasphenoid landmarks and be able to work properly with instruments within the sinus (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Next, the intrasphenoid septa are resected. As there can be a great deal of anatomical variation, this procedure requires having a precise knowledge of the location and trajectory of said septa. We have to rely on intraoperative navigation or, failing that, on having carefully studied the septa with a preoperative CT angiogram. This manoeuvre is carried out with a diamond burr.When the endonasal phase is complete, we should be able to identify the following structures: the floor of the sella in the centre, the tuberculum sellae above, the clival recess below, the carotid prominences laterally and the optic nerves superolaterally. At the confluence of the optic nerves and carotid arteries there are two landmarks of interest: the medial optic-carotid recess and the lateral optic-carotid recess (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The degree of exposure of these landmarks will depend on the degree of pneumatisation of the sphenoid sinus.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>We begin the excision phase drilling through the floor of the sella, expanding it laterally to both cavernous sinuses. We open the dura in the shape of an “X”. We begin with tumour resection, always sequentially and extracapsularly whenever possible. First we perform the tumour excision in the lower part. We then check the lateral margins and finally we explore the suprasellar region, trying not to open the arachnoid. If alternatively we performed early superior excision, the diaphragm and the arachnoid would descend into the surgical field, hindering the view of the lateral portions. We always try to respect the healthy gland when it is visible.The final part is the reconstruction phase. In all cases we place a synthetic dura substitute as an inlay. If we have confirmed the absence of intraoperative fistula and we have not prepared a nasoseptal flap at the start, we place the free mucosa obtained from the middle turbinate as closure. If there is an intraoperative CSF leak (especially high-flow), we place the nasoseptal flap previously designed and stored in the choana. If it was not previously prepared, we can rescue it at the end of the surgery. For that purpose, in all cases, when we start the nasal phase we usually keep the area of mucosa that would form the Hadad flap just in case. It is important that the nasoseptal flap is well applied to the bony margins of the defect created during surgery. Then we fix it by placing synthetic fibrin meshes over it (Surgicel®) and biological glue (Tissucol®).Postoperative studiesOnce the patients have undergone surgery, our postoperative assessment protocol is based on the following parameters:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-Postoperative MRI: we perform an MRI in the immediate postoperative period (about 2–4 days), which gives us an approximate idea of remnants of the tumour and hormone preservation. We also check for postoperative complications more methodically than with a CT and without using radiation.</li><li class="elsevierStyleListItem" id="lsti0010">-Further MRI scans are performed at three months and one year. In our series, we measured the degree of resection based on the three-month MRI. We consider complete resection when the radiologist cannot detect remnants of the tumour. Subtotal is considered when the visible remnants are less than 50% of the initial mass. Partial excision is when the remnants detected represent more than 50% of the initial mass.</li><li class="elsevierStyleListItem" id="lsti0015">-Visual field testing: all patients whose adenoma is in contact with the optic chiasma preoperatively have a postoperative visual field study three months after surgery.</li><li class="elsevierStyleListItem" id="lsti0020">-Endocrine assessment: this is performed while the patient remains in hospital based on baseline determinations. In functioning tumours, the endocrinologist uses these tests to determine whether or not complete remission is achieved. In our series, the early tests were not helpful in determining cure in two patients with acromegaly, as they had received medication up to the time of surgery. As far as detecting hormone deficiencies not present before surgery is concerned, our results do not consider the need for hormone replacement therapy until one month after surgery. We did not measure the incidence of transient diabetes insipidus.</li></ul>Statistical analysisFirst of all, we described the characteristics of the patients who underwent surgery; to do this, we calculated the absolute and the relative frequencies as percentages of each of the categories of variables. We then studied the association between the tumour characteristics (size, cavernous sinus invasion, etc.) and complete resection using the Chi-square test, and to quantify the magnitude of the association we used the odds ratio (OR) with its 95% confidence intervals (95% CI). In all hypothesis tests the statistical significance level was p<0.05, and IBM-SPSS v.19.0 was used for the analysis.ResultsDemographic resultsWe had a sample of 86 patients; our average therefore being 17 adenomas per year. In our sample, 53% were female and 47% male. The patient's ranged from 14 to 84 in age (mean 54); the majority group was aged 40–60.Clinical presentationIn our sample, it was more common for patients to present with non-hormonal symptoms. The most frequently reported symptom at onset was visual impairment (affecting 21% of our patients), followed by hormone hyperfunction, where acromegaly was the most common clinical syndrome observed.In this series there was only one case of pituitary apoplexy, which began with hormone deficiency and sudden-onset of cranial nerve palsy.Preoperative imagingWe classified the adenomas according to their size, with the majority (76%) being macroadenomas (>1cm in diameter) and 13% giant (≥4cm in diameter), while only 11% were microadenomas (≤1cm in diameter).We sub-classified them, in turn, according to the Knosp scale (Knosp 0: 8 cases; Knosp 1: 25 cases; Knosp 2: 21 cases; Knosp 3: 23 cases; Knosp 4: 9 cases). In order to analyse the results, we divided the macroadenomas into groups of minimally invasive (Knosp 0, 1 and 2) and highly invasive (Knosp 3 and 4). We consider that only Knosp grades 3 and 4 represent true invasion of the cavernous sinus, so in our study the incidence of sinus invasion was 37%.However, 63% of our tumours had suprasellar extension.Preoperative hormone functionIn the distribution according to endocrine function, 73% in our series were non-functioning adenomas and 27% functioning, among which the most common was the GH-producing adenoma (representing 65%).Surgical outcomesIn terms of surgical outcomes, there are three distinct groups according to the postoperative MRI findings: complete resection, when there is no evidence of residual tumour; subtotal resection, when removal of more than 50% is achieved; and partial resection, when less than 50% of the tumour is removed.In our series, complete resection was achieved in 77%, subtotal in 22% and partial in only 1%.In other words, the incomplete resection rate was 23%. We studied the relationship between tumour size (≥2.5cm in diameter), invasion of the cavernous sinus (understood as Knosp 3 and 4) and suprasellar extension of the tumour and the degree of tumour resection, and found that all of these elements were risk factors for incomplete resection, with the difference being statistically significant (p<0.05).In our series, complete resection was achieved in 88.4% of cases with tumours smaller than 2.5cm, but in only 65.9% of cases with tumours larger than 2.5cm. Analysing invasion of the cavernous sinus, complete resection was achieved in 87.0% of cases with no invasion (Knosp 1 and 2), compared to 60.0% of cases with sinus invasion (Knosp 3 and 4). In a more thorough analysis, examining Knosp grade 4 tumours separately, we found that complete resection was only achieved in 14.3% of these cases. In patients with suprasellar extension, 69.8% had complete resection, while in purely intrasellar tumours, complete resection was achieved in 90.3%.In terms of clinical outcomes, of the 46 patients who had visual deficits prior to the intervention, 91% experienced improvement, while only one patient reported worsening.We achieved remission of endocrine hyperfunction in 73% of the functioning adenomas (for this analysis we excluded two subjects with prolactinomas who presented with severe vision loss at onset and for whom the objective of surgery was not complete resection, but rather decompression prior to control with dopamine agonists).ComplicationsWe had no cases of CSF leak in our series. There was one case of meningitis, but the patient recovered well after antibiotic therapy. A haematoma was visualised at the intervention site in one patient, who had visual impairment after surgery. Endonasal surgery was required for urgent evacuation, but without subsequent improvement in vision. Two patients had transient paresis of a cranial nerve after the intervention.Among the endocrine complications, our incidence of permanent insipid diabetes was 3%, and our most common endocrine dysfunction was deficit in one or more axes of the anterior pituitary, which was found in 9% of the cases and was permanent. We had a permanent panhypopituitarism rate of 5%.There were no deaths in the first month post-intervention directly related to surgery in our entire series.DiscussionThe transsphenoidal endonasal approach is currently the technique of choice in pituitary tumours, as it allows direct access to the sella turcica, without manipulation of the healthy cerebral parenchyma (see <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a> for the contraindications to the transsphenoidal approach and its associated complications respectively).<a class="elsevierStyleCrossRef" href="#bib0145">1</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Although there are two techniques for transsphenoidal surgery, microscopic (which includes classic sublabial and transseptal approaches) and endoscopic (introduced in the late 1990s by Jho and Carrau from the University of Pittsburgh), there have been no prospective, randomised studies to compare the two techniques (see <a class="elsevierStyleCrossRefs" href="#tbl0015">Tables 3 and 4</a> for the advantages and disadvantages of the microscopic and endoscopic approaches respectively).<a class="elsevierStyleCrossRefs" href="#bib0150">2–11</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>However, we know that the microscopic technique is limited by the narrow corridor offered by the nasal retractor, with only a conical view in a straight line towards the sella. The sellar region can be seen clearly, but areas such as the suprasellar or parasellar area are often hidden from view. Therefore, in large macroadenomas, especially with invasion of cavernous sinuses, our field of vision is incomplete and there will be areas which are inaccessible or where we have to work blind.The endoscopic approach, however, is more anatomical as it does not require the use of nasal retractors and nasal structures useful for facilitating the technique can be manipulated (middle turbinate resection, preparation of the nasoseptal flap or resection of the intrasphenoid septum).The main advantages of the endoscope are definitely the greater illumination and superior visualisation, which provide a panoramic view of the surgical field, with better visualisation of the parasellar and suprasellar area. This has enabled us to push back the limits of transsphenoidal surgery, visualising and resecting tumours which previously could not be assessed (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). In addition, with the endoscope we have the option of using optics with added angulation which give us more control in the lateral extension of the tumour.<a class="elsevierStyleCrossRefs" href="#bib0200">12–21</a><elsevierMultimedia ident="fig0015"></elsevierMultimedia>The main drawback is the two-dimensional (2D) view. However, the surgeon can obtain a pseudo-depth perception with the dynamic movement of the endoscope (approaching and moving away from the area of interest).From a meta-analysis comparing the microscopic transsphenoidal approach with the purely endoscopic approach,<a class="elsevierStyleCrossRef" href="#bib0250">22</a> we concluded that:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025">-The success of the endoscopic approach is comparable to the microscopic in terms of complete tumour resection, but can be superior in macroadenomas with extrasellar extension.</li><li class="elsevierStyleListItem" id="lsti0030">-Some authors suggest a higher rate of endocrine remission for functioning adenomas with the endoscopic approach, as well as a lower incidence of diabetes insipidus.</li><li class="elsevierStyleListItem" id="lsti0035">-Surgery and postoperative time are shorter with the endoscopic technique.</li><li class="elsevierStyleListItem" id="lsti0040">-The main complication of transsphenoidal surgery is CSF leak, with a similar risk in both techniques (19.5% endoscopy vs 14.4% microscopy).</li></ul>The increased risk of leakage with the endoscopic approach found in many studies seems to be a consequence of endoscopy being used for more complex cases, with more expanded procedures performed than with the microscopic technique.Another advantage is that with endoscopy it is easier to see normal pituitary tissue, suggesting that greater preservation of pituitary function is possible.The aim of this article was to analyse our results using a purely endoscopic transsphenoidal approach in 86 patients over five years, and to compare our data with the results reported in the meta-analysis published by Ammirati et al. (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>). We found that:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0045">-Our rates for complete tumour resection (77%) and remission of functioning tumours (73%) are higher than the published rates (68% and 66% respectively).</li></ul><elsevierMultimedia ident="tbl0025"></elsevierMultimedia>One of the most negative prognostic factors in pituitary adenomas is invasion of the cavernous sinus, as it reduces the likelihood of successful surgery, both in terms of complete tumour resection and hormone remission in functioning tumours.MRI with gadolinium-enhanced coronal sections is the best technique for preoperative assessment of cavernous sinus invasion. In 1993, Knosp established a classification system for parasellar growth of pituitary adenomas<a class="elsevierStyleCrossRefs" href="#bib0255">23–25</a>:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0050">-Grade 0: the tumour does not extend beyond the tangential line joining the medial wall of the supra- and intracavernous internal carotid arteries.</li><li class="elsevierStyleListItem" id="lsti0055">-Grade 1: the tumour extends beyond the medial tangent, but not the tangent that joins the centres of the two arteries.</li><li class="elsevierStyleListItem" id="lsti0060">-Grade 2: the tumour extends beyond the intercarotid line but not the lateral tangent.</li><li class="elsevierStyleListItem" id="lsti0065">-Grade 3: the tumour extends to the lateral tangent.</li><li class="elsevierStyleListItem" id="lsti0070">-Grade 4: the carotid artery is completely encased by the tumour.</li></ul>In our series, 32 patients had high-grade invasion of the cavernous sinus (Knosp 3 and 4) with a complete resection rate of 59.3%. The remaining 54 patients had slight or no invasion of the cavernous sinus (Knosp 0, 1 and 2) and a complete resection rate of 87%.Such is the importance of sinus invasion that, taken in conjunction with other variables, it is a predictor of the degree of resection and also therefore of the cure rate.<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0075">-In our series, the most common presenting symptom was loss of visual field. We achieved visual improvement in 91%, with our results being similar to those found in the literature.</li><li class="elsevierStyleListItem" id="lsti0080">-Our incidence of CSF leak was 0%, well below the published data (7%).</li></ul>The risk of CSF leakage in standard transsphenoidal endoscopic surgery is 0.5–10%. In expanded approaches, it increases to 5–30%. When a CSF leak occurs, early revision surgery (first 48h) is advisable in view of the impact it has on reducing the postoperative meningitis rate.The generalised use of the vascularised flap can increase postoperative nasal morbidity (increase the percentage of scabs, synechiae, septal perforation or anosmia). We therefore only use the vascularised nasoseptal flap when there is a diaphragmatic defect with intraoperative CSF leakage. In the remaining cases we reconstructed the defect with middle turbinate mucosa.<a class="elsevierStyleCrossRefs" href="#bib0270">26–28</a><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0085">-Our incidence of meningitis was 1.16%, in line with data published in the literature (0.5–1.9%).</li><li class="elsevierStyleListItem" id="lsti0090">-Endocrine complications are an important aspect to be taken into account in pituitary tumour surgery, with an incidence of 17.9% reported in the literature.</li></ul>Our rates of permanent diabetes insipidus and anterior–pituitary axis damage were 3% and 9% respectively, also in line with the published data.ConclusionThe transsphenoidal route is a direct and extracerebral route to the sellar region; it uses the nostrils, which form a real cavity and do not require dilation to gain entry, providing direct access to the sella turcica. The endoscopic approach gives us a panoramic view of the surgical field, with minimal trauma and a low rate of complications.In terms of surgical quality, our results are comparable to the best published series. Our aim has been to add to the scientific evidence on the effectiveness and safety of this technique.However, a study with a larger number of cases is necessary to obtain results with clinical significance.Conflict of interestsThe authors declare that there are no conflicts of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1046290" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objectives" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec998155" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1046291" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec998154" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Diagnosis and preoperative tests" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Surgical technique" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Postoperative studies" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Demographic results" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Clinical presentation" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Preoperative imaging" ] 3 => array:2 [ "identificador" => "sec0055" "titulo" => "Preoperative hormone function" ] 4 => array:2 [ "identificador" => "sec0060" "titulo" => "Surgical outcomes" ] 5 => array:2 [ "identificador" => "sec0065" "titulo" => "Complications" ] ] ] 7 => array:2 [ "identificador" => "sec0070" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0075" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0080" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-08-07" "fechaAceptado" => "2018-02-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec998155" "palabras" => array:6 [ 0 => "Adenoma" 1 => "Endonasal" 2 => "Transsphenoidal" 3 => "Endoscopic" 4 => "Sellar" 5 => "Suprasellar" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec998154" "palabras" => array:6 [ 0 => "Adenoma" 1 => "Endonasal" 2 => "Transesfenoidal" 3 => "Endoscópico" 4 => "Selar" 5 => "Supraselar" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionThe endoscopic endonasal approach has become the gold standard for the surgical treatment of pituitary adenomas. ObjectivesThe aim of this study is to present the results obtained in our hospital in purely endoscopic surgery of pituitary adenomas. MethodsFrom February 2011 to August 2016, we conducted a prospective study on a series of 86 patients with pituitary adenoma, all of whom underwent surgery with a purely endoscopic endonasal approach. The ‘four hands-two nostrils’ technique was performed in all cases by a surgical team composed of an ENT surgeon and a neurosurgeon. Mean follow-up was 32 months. All patients were evaluated according to clinical, radiological and endocrinological criteria. ResultsIn our series, 53% were women and 47% men. The age ranged from 14 to 84 years of age, with a mean of 54 years of age. The most common initial symptom was visual deficit (42%), followed by hormonal hyperfunction (21%), with acromegaly being the most common clinical syndrome. The most common tumours were non-functioning tumours (73%), while GH-secreting tumours (65%) were the most common functioning adenoma. Regarding tumour size, 76% were macroadenomas, 11% microadenomas and 13% giant adenomas. Approximately 63% of the adenomas exhibited suprasellar extension and 37% involved invasion of the cavernous sinus (Knosp grade ≥3). Total excision was achieved in 77% of the cases. After the intervention, visual improvement was achieved in 91% and remission of endocrine hyperfunction in up to a 73% of cases. The most common complication was anterior pituitary insufficiency of at least one axis (9%). There were no cases of postoperative cerebrospinal fluid fistula. ConclusionsIn terms of surgical quality, our results are similar to those of published series, and demonstrate the efficacy and safety of the endoscopic endonasal approach as the surgical treatment of choice for pituitary adenomas. However, further studies with a higher sample size are necessary to obtain clinically significant results." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objectives" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónEl abordaje endoscópico endonasal se ha convertido en la técnica quirúrgica de elección para el tratamiento de los adenomas hipofisarios. ObjetivosEl objetivo de este trabajo es presentar los resultados obtenidos en nuestro hospital en cirugía puramente endoscópica de los adenomas hipofisarios. MétodosHemos realizado un estudio prospectivo, recogiendo a los pacientes intervenidos de adenoma hipofisario mediante un abordaje endonasal puramente endoscópico, desde febrero de 2011 hasta agosto de 2016, obteniendo una muestra total de 86 pacientes. Todos los pacientes fueron intervenidos conjuntamente por un ORL y un neurocirujano con la técnica de four hands-two nostrils. El seguimiento medio postoperatorio fue de 32 meses. Todos los pacientes fueron evaluados según criterios clínicos, radiológicos y endocrinológicos. ResultadosEn nuestra serie un 53% eran mujeres y un 47% hombres; el rango de edad variaba desde los 14 hasta los 84 años, siendo la media de 54 años. El síntoma inicial más habitual fue el déficit visual (42%), seguido por la hiperfunción hormonal (21%), siendo la acromegalia el síndrome clínico observado con más frecuencia. Los tumores más frecuentes fueron los no funcionantes (73%), y de entre los adenomas funcionantes el más frecuente fue el productor de GH (65%). En cuanto a tamaño tumoral, un 76% eran macroadenomas, un 11% microadenomas y un 13% gigantes. Un 63% presentaban extensión supraselar y un 37% invasión de seno cavernoso (grado de Knosp ≥3). Se consiguió una exéresis total en un 77% de los casos. Tras la intervención se consiguió en un 91% mejoría visual y hasta en un 73% remisión de la hiperfunción endocrina. En cuanto a las complicaciones, la más frecuente fue la insuficiencia de al menos un eje de la hipófisis anterior (9%), sin presentar casos de fístula de LCR posquirúrgica. ConclusionesNuestros resultados, en términos de calidad quirúrgica, se asemejan a las series publicadas y avalan la eficacia y seguridad del abordaje endoscópico endonasal como técnica de elección en el manejo quirúrgico de la glándula hipofisaria. Sin embargo, es necesario un estudio con mayor número de casos para obtener resultados con significación clínica." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: López-García R, Abarca-Olivas J, Monjas-Cánovas I, Picó Alfonso AM, Moreno-López P, Gras-Albert JR. Cirugía endoscópica endonasal en adenomas hipofisarios: resultados quirúrgicos en una serie de 86 pacientes consecutivos. Neurocirugía. 2018;29:161–169." ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1341 "Ancho" => 2333 "Tamanyo" => 171907 ] ] "descripcion" => array:1 [ "en" => "Intraoperative image of essential intrasphenoid anatomical references." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1187 "Ancho" => 1583 "Tamanyo" => 157357 ] ] "descripcion" => array:1 [ "en" => "Image of anatomical dissection in cadaver with surgically important intrasphenoid references. ICA: prominences of the parasellar internal carotid artery; ON: optical nerves; CR: clival recess; lat OCR: lateral optic-carotid recess; med OCR: medial optic-carotid recess; ST: sella turcica; TS: tuberculum sellae." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2899 "Ancho" => 2333 "Tamanyo" => 332083 ] ] "descripcion" => array:1 [ "en" => "Example of adenoma resection with Knosp grade 3 invasion in left cavernous sinus. In the centre we can see the sella turcica empty of tumour with lowering of the diaphragma sellae and the arachnoid, while on the right of the image we see how the adenoma component that was invading the left cavernous sinus has been completely evacuated." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Asymmetric suprasellar growth; constrictive diaphragma sellae \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tumour with epicentre lateral to the carotid artery (simple invasion of the cavernous sinus is not a contraindication) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tumour purely suprasellar, with a normal-sized sella \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sphenoid sinusitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intrasellar vascular defect \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1778179.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Factors contraindicating the transsphenoidal approach." ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">The main complication is CSF leak \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Damage to the internal carotid artery (0–0.68%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sinusitis, mucoceles \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Perforation of the nasal septum \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Visual impairment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Brain haemorrhage \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Added hormonal damage \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1778178.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Complications of the transsphenoidal approach." ] ] 5 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Advantages \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Disadvantages \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3D vision (three-dimensional) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Poor visualisation. Field of vision is conical and in a straight line, limited by the nasal speculum \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Familiar technique for the neurosurgeon \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Visualisation of the anatomical references of the limits of the sella is not good. There is no view of the cavernous sinuses or the suprasellar space \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Microscope located outside the surgical field, so does not obstruct the manoeuvrability of the instruments and nor is vision obstructed in the case of bleeding in the field \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">It is not easy to check for optic nerve decompression \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Greater precision under direct vision \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Higher incidence of nasal complications. Greater discomfort for the patient \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1778176.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Advantages and disadvantages of the microscopic approach." ] ] 6 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Advantages \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Disadvantages \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Less traumatic. Does not require self-retaining nasal retractor. Faster access. Shorter surgery time \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Opacification of the lens due to blood or moisture \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Procedure more comfortable for the patient, with faster recovery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Two-dimensional view \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Shorter hospital stay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Need for special instruments \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Panoramic view of the surgical field and a better working angle, resulting in greater tumour resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Learning curve \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Higher rate of hormone preservation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fewer nasal complications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Enables confirmation of optic nerve decompression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1778180.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Advantages and disadvantages of the endoscopic approach." ] ] 7 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Meta-analysis Ammirati et al. \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">This study \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Remission rate in functioning tumours \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Complete resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Improvement of vision (cases with pre-surgical visual impairment) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62–100% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">91% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CSF leak rate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Permanent diabetes insipidus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypopituitarism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Postoperative visual loss \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.72% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.16% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Infection/meningitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.16% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1778177.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Ammirati meta-analysis vs HGUA." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0145" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Complications of transsphenoidal surgery: results of a national survey review of the literature, and personal experience" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "I. 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Clinical Research

Endonasal endoscopic surgery in pituitary adenomas: Surgical results in a series of 86 consecutive patients

Cirugía endoscópica endonasal en adenomas hipofisarios: resultados quirúrgicos en una serie de 86 pacientes consecutivos

Raquel López-Garcíaa,

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Raquelncgalicante@gmail.com

Corresponding author.

, Javier Abarca-Olivasa, Irene Monjas-Cánovasb, Antonio M. Picó Alfonsoc, Pedro Moreno-Lópeza, Juan Ramón Gras-Albertb

a Servicio de Neurocirugía, Hospital General Universitario de Alicante, Alicante, Spain

b Servicio de Otorrinolaringología, Hospital General Universitario de Alicante, Alicante, Spain

c Servicio de Endocrinología, Hospital General Universitario de Alicante, Alicante, Spain

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    "titulo" => "Endonasal endoscopic surgery in pituitary adenomas&#58; Surgical results in a series of 86 consecutive patients"
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        "titulo" => "Cirug&#237;a endosc&#243;pica endonasal en adenomas hipofisarios&#58; resultados quir&#250;rgicos en una serie de 86 pacientes consecutivos"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Intraoperative image of essential intrasphenoid anatomical references&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pituitary adenomas are the third most common type of intracranial neoplasm&#44; accounting for 10&#8211;25&#37; of all primary brain tumours&#44; and are defined as the most common form of intrasellar lesion&#46; They are benign lesions&#44; although approximately 5&#37; have a more aggressive clinical course&#44; associated with a high recurrence rate&#46; One of the worst characteristics&#44; and the main cause of incomplete surgical resection&#44; is invasion of the cavernous sinus&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The transsphenoidal endonasal approach is currently the most used for pituitary surgery&#44; as it allows direct access to the sella turcica without manipulation of the healthy cerebral parenchyma&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">This technique has two modes&#58; microscopic and endoscopic&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Thanks to technological advances&#44; the endoscopic technique has now become the approach of choice&#46; Among the main advantages are the better illumination and visualisation&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">However&#44; as there are no randomised double-blind prospective studies&#44; the level of evidence when we try to compare the classic microscopic technique with the endoscopic approach is low&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The aim of this article is to present our experience in the surgical treatment of pituitary adenomas using the transsphenoidal endoscopic approach&#46; We describe our surgical technique&#44; the results obtained&#44; and the complications observed&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">We carried out a prospective&#44; descriptive study from February 2011 to August 2016&#44; reviewing all 86 patients who underwent surgery for pituitary adenoma using a purely endoscopic endonasal approach at Hospital General Universitario in Alicante&#46; All were operated on jointly by otolaryngologists and neurosurgeons&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Sellar lesions other than adenomas were not included&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The mean follow-up was 32 months&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Diagnosis and preoperative tests</span><p id="par0050" class="elsevierStylePara elsevierViewall">All the patients were assessed according to clinical&#44; radiological&#44; endocrine and ophthalmological criteria&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">We analysed the clinical symptoms to determine which was the most common&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">All patients had preoperative visual field testing to assess the degree of visual loss&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The endocrine tests consisted of determining baseline plasma concentrations of the hormones FSH&#44; LH&#44; ACTH&#44; IGF1&#44; PRL&#44; TSH&#44; free T4&#44; cortisol&#44; oestradiol &#40;females&#41; and testosterone &#40;males&#41; to check the integrity of the hypothalamic&#8211;pituitary axis&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">All patients had a magnetic resonance imaging &#40;MRI&#41; scan to assess tumour size&#44; suprasellar extension and invasion of the cavernous sinus according to the Knosp scale&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Surgical technique</span><p id="par0075" class="elsevierStylePara elsevierViewall">Patients are placed in the supine position&#44; with their heads slightly hyperextended and slightly rotated to the right towards the surgeon&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Their faces are prepared with Betadine diluted with normal saline and oxymetazoline-soaked patties are inserted to decongest their nasal passages&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">We normally use a rigid 0&#176; endoscope&#46; Occasionally&#44; we use 45&#176; optics to check regions of the tumour bed that may be hidden from view with 0&#176;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">We use navigation based on thin-slice CT angiography systematically&#44; as it allows us to identify bone and vascular structures&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The surgical procedure is divided into three phases&#58; a nasal phase&#44; until the floor of the sella is reached&#59; an excision phase&#44; where the sella turcica is opened to resect the tumour&#59; and a final phase for closure and reconstruction of the defect in the base of the skull&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In the nasal phase&#44; we introduce a rigid 0&#176; endoscope through the right nostril&#44; tangential to the floor of the nasal cavity&#46; We identify the inferior turbinate laterally and&#44; above that&#44; the middle turbinate&#59; medially the nasal septum can be observed&#46; We routinely resect the middle turbinate to give us wider access to the sphenoid region&#46; This makes it easier to create the nasoseptal flap and we can also use its mucosa at the end of surgery for sellar reconstruction if the pedicled flap is not required&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In cases where a high-flow cerebrospinal fluid &#40;CSF&#41; leak is expected &#40;large tumours or large suprasellar invasion&#41;&#44; we perform the pedicled nasoseptal flap at the beginning of the intervention&#46; To do this&#44; we make an incision in the lower margin of the choana and extend it horizontally along the floor of the nasal cavity to the nasal vestibule&#59; we make another second upper incision just below the sphenoid ostium and extend it anteriorly&#44; locating it approximately 1<span class="elsevierStyleHsp" style=""></span>cm below the upper edge of the nasal septum&#44; in order to respect the olfactory epithelium&#59; and finally&#44; we make an anterior vertical incision connecting the first two incisions&#46; We then lift the mucosa of the nasal septum&#44; dissecting it in an anterior&#8211;posterior direction&#44; and store it in the choana to be used at the end of the intervention&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Next&#44; we identify the sphenoid ostium&#44; located behind the tail of the superior turbinate&#46; We resect the posterior part of the nasal septum&#44; approximately 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm just in front of the anterior wall of the sphenoid sinus&#46; The posterior septostomy makes a two-nostril&#44; four-hand approach possible&#44; and also exposes the contralateral sphenoid ostium&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">We then begin the resection of the anterior wall of the sphenoid sinus in a procedure known as &#8220;sphenoidotomy&#8221;&#46; We start to expand the sphenoid ostium with a Kerrison&#44; and then use the electric drill with cutting burr&#46; Although the aim of this surgical intervention is to be minimally invasive&#44; it is very important to perform a wide opening of the anterior wall of the sphenoid in order to better recognise intrasphenoid landmarks and be able to work properly with instruments within the sinus &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Next&#44; the intrasphenoid septa are resected&#46; As there can be a great deal of anatomical variation&#44; this procedure requires having a precise knowledge of the location and trajectory of said septa&#46; We have to rely on intraoperative navigation or&#44; failing that&#44; on having carefully studied the septa with a preoperative CT angiogram&#46; This manoeuvre is carried out with a diamond burr&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">When the endonasal phase is complete&#44; we should be able to identify the following structures&#58; the floor of the sella in the centre&#44; the tuberculum sellae above&#44; the clival recess below&#44; the carotid prominences laterally and the optic nerves superolaterally&#46; At the confluence of the optic nerves and carotid arteries there are two landmarks of interest&#58; the medial optic-carotid recess and the lateral optic-carotid recess &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The degree of exposure of these landmarks will depend on the degree of pneumatisation of the sphenoid sinus&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">We begin the excision phase drilling through the floor of the sella&#44; expanding it laterally to both cavernous sinuses&#46; We open the dura in the shape of an &#8220;X&#8221;&#46; We begin with tumour resection&#44; always sequentially and extracapsularly whenever possible&#46; First we perform the tumour excision in the lower part&#46; We then check the lateral margins and finally we explore the suprasellar region&#44; trying not to open the arachnoid&#46; If alternatively we performed early superior excision&#44; the diaphragm and the arachnoid would descend into the surgical field&#44; hindering the view of the lateral portions&#46; We always try to respect the healthy gland when it is visible&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The final part is the reconstruction phase&#46; In all cases we place a synthetic dura substitute as an inlay&#46; If we have confirmed the absence of intraoperative fistula and we have not prepared a nasoseptal flap at the start&#44; we place the free mucosa obtained from the middle turbinate as closure&#46; If there is an intraoperative CSF leak &#40;especially high-flow&#41;&#44; we place the nasoseptal flap previously designed and stored in the choana&#46; If it was not previously prepared&#44; we can rescue it at the end of the surgery&#46; For that purpose&#44; in all cases&#44; when we start the nasal phase we usually keep the area of mucosa that would form the Hadad flap just in case&#46; It is important that the nasoseptal flap is well applied to the bony margins of the defect created during surgery&#46; Then we fix it by placing synthetic fibrin meshes over it &#40;Surgicel<span class="elsevierStyleSup">&#174;</span>&#41; and biological glue &#40;Tissucol<span class="elsevierStyleSup">&#174;</span>&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Postoperative studies</span><p id="par0140" class="elsevierStylePara elsevierViewall">Once the patients have undergone surgery&#44; our postoperative assessment protocol is based on the following parameters&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0145" class="elsevierStylePara elsevierViewall">Postoperative MRI&#58; we perform an MRI in the immediate postoperative period &#40;about 2&#8211;4 days&#41;&#44; which gives us an approximate idea of remnants of the tumour and hormone preservation&#46; We also check for postoperative complications more methodically than with a CT and without using radiation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0150" class="elsevierStylePara elsevierViewall">Further MRI scans are performed at three months and one year&#46; In our series&#44; we measured the degree of resection based on the three-month MRI&#46; We consider complete resection when the radiologist cannot detect remnants of the tumour&#46; Subtotal is considered when the visible remnants are less than 50&#37; of the initial mass&#46; Partial excision is when the remnants detected represent more than 50&#37; of the initial mass&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0155" class="elsevierStylePara elsevierViewall">Visual field testing&#58; all patients whose adenoma is in contact with the optic chiasma preoperatively have a postoperative visual field study three months after surgery&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">Endocrine assessment&#58; this is performed while the patient remains in hospital based on baseline determinations&#46; In functioning tumours&#44; the endocrinologist uses these tests to determine whether or not complete remission is achieved&#46; In our series&#44; the early tests were not helpful in determining cure in two patients with acromegaly&#44; as they had received medication up to the time of surgery&#46; As far as detecting hormone deficiencies not present before surgery is concerned&#44; our results do not consider the need for hormone replacement therapy until one month after surgery&#46; We did not measure the incidence of transient diabetes insipidus&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0165" class="elsevierStylePara elsevierViewall">First of all&#44; we described the characteristics of the patients who underwent surgery&#59; to do this&#44; we calculated the absolute and the relative frequencies as percentages of each of the categories of variables&#46; We then studied the association between the tumour characteristics &#40;size&#44; cavernous sinus invasion&#44; etc&#46;&#41; and complete resection using the Chi-square test&#44; and to quantify the magnitude of the association we used the odds ratio &#40;OR&#41; with its 95&#37; confidence intervals &#40;95&#37; CI&#41;&#46; In all hypothesis tests the statistical significance level was <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#44; and IBM-SPSS v&#46;19&#46;0 was used for the analysis&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Demographic results</span><p id="par0170" class="elsevierStylePara elsevierViewall">We had a sample of 86 patients&#59; our average therefore being 17 adenomas per year&#46; In our sample&#44; 53&#37; were female and 47&#37; male&#46; The patient&#39;s ranged from 14 to 84 in age &#40;mean 54&#41;&#59; the majority group was aged 40&#8211;60&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Clinical presentation</span><p id="par0175" class="elsevierStylePara elsevierViewall">In our sample&#44; it was more common for patients to present with non-hormonal symptoms&#46; The most frequently reported symptom at onset was visual impairment &#40;affecting 21&#37; of our patients&#41;&#44; followed by hormone hyperfunction&#44; where acromegaly was the most common clinical syndrome observed&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">In this series there was only one case of pituitary apoplexy&#44; which began with hormone deficiency and sudden-onset of cranial nerve palsy&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Preoperative imaging</span><p id="par0185" class="elsevierStylePara elsevierViewall">We classified the adenomas according to their size&#44; with the majority &#40;76&#37;&#41; being macroadenomas &#40;&#62;1<span class="elsevierStyleHsp" style=""></span>cm in diameter&#41; and 13&#37; giant &#40;&#8805;4<span class="elsevierStyleHsp" style=""></span>cm in diameter&#41;&#44; while only 11&#37; were microadenomas &#40;&#8804;1<span class="elsevierStyleHsp" style=""></span>cm in diameter&#41;&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">We sub-classified them&#44; in turn&#44; according to the Knosp scale &#40;Knosp 0&#58; 8 cases&#59; Knosp 1&#58; 25 cases&#59; Knosp 2&#58; 21 cases&#59; Knosp 3&#58; 23 cases&#59; Knosp 4&#58; 9 cases&#41;&#46; In order to analyse the results&#44; we divided the macroadenomas into groups of minimally invasive &#40;Knosp 0&#44; 1 and 2&#41; and highly invasive &#40;Knosp 3 and 4&#41;&#46; We consider that only Knosp grades 3 and 4 represent true invasion of the cavernous sinus&#44; so in our study the incidence of sinus invasion was 37&#37;&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">However&#44; 63&#37; of our tumours had suprasellar extension&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Preoperative hormone function</span><p id="par0200" class="elsevierStylePara elsevierViewall">In the distribution according to endocrine function&#44; 73&#37; in our series were non-functioning adenomas and 27&#37; functioning&#44; among which the most common was the GH-producing adenoma &#40;representing 65&#37;&#41;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Surgical outcomes</span><p id="par0205" class="elsevierStylePara elsevierViewall">In terms of surgical outcomes&#44; there are three distinct groups according to the postoperative MRI findings&#58; complete resection&#44; when there is no evidence of residual tumour&#59; subtotal resection&#44; when removal of more than 50&#37; is achieved&#59; and partial resection&#44; when less than 50&#37; of the tumour is removed&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">In our series&#44; complete resection was achieved in 77&#37;&#44; subtotal in 22&#37; and partial in only 1&#37;&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">In other words&#44; the incomplete resection rate was 23&#37;&#46; We studied the relationship between tumour size &#40;&#8805;2&#46;5<span class="elsevierStyleHsp" style=""></span>cm in diameter&#41;&#44; invasion of the cavernous sinus &#40;understood as Knosp 3 and 4&#41; and suprasellar extension of the tumour and the degree of tumour resection&#44; and found that all of these elements were risk factors for incomplete resection&#44; with the difference being statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">In our series&#44; complete resection was achieved in 88&#46;4&#37; of cases with tumours smaller than 2&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#44; but in only 65&#46;9&#37; of cases with tumours larger than 2&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#46; Analysing invasion of the cavernous sinus&#44; complete resection was achieved in 87&#46;0&#37; of cases with no invasion &#40;Knosp 1 and 2&#41;&#44; compared to 60&#46;0&#37; of cases with sinus invasion &#40;Knosp 3 and 4&#41;&#46; In a more thorough analysis&#44; examining Knosp grade 4 tumours separately&#44; we found that complete resection was only achieved in 14&#46;3&#37; of these cases&#46; In patients with suprasellar extension&#44; 69&#46;8&#37; had complete resection&#44; while in purely intrasellar tumours&#44; complete resection was achieved in 90&#46;3&#37;&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">In terms of clinical outcomes&#44; of the 46 patients who had visual deficits prior to the intervention&#44; 91&#37; experienced improvement&#44; while only one patient reported worsening&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">We achieved remission of endocrine hyperfunction in 73&#37; of the functioning adenomas &#40;for this analysis we excluded two subjects with prolactinomas who presented with severe vision loss at onset and for whom the objective of surgery was not complete resection&#44; but rather decompression prior to control with dopamine agonists&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Complications</span><p id="par0235" class="elsevierStylePara elsevierViewall">We had no cases of CSF leak in our series&#46; There was one case of meningitis&#44; but the patient recovered well after antibiotic therapy&#46; A haematoma was visualised at the intervention site in one patient&#44; who had visual impairment after surgery&#46; Endonasal surgery was required for urgent evacuation&#44; but without subsequent improvement in vision&#46; Two patients had transient paresis of a cranial nerve after the intervention&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Among the endocrine complications&#44; our incidence of permanent insipid diabetes was 3&#37;&#44; and our most common endocrine dysfunction was deficit in one or more axes of the anterior pituitary&#44; which was found in 9&#37; of the cases and was permanent&#46; We had a permanent panhypopituitarism rate of 5&#37;&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">There were no deaths in the first month post-intervention directly related to surgery in our entire series&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Discussion</span><p id="par0250" class="elsevierStylePara elsevierViewall">The transsphenoidal endonasal approach is currently the technique of choice in pituitary tumours&#44; as it allows direct access to the sella turcica&#44; without manipulation of the healthy cerebral parenchyma &#40;see <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a> for the contraindications to the transsphenoidal approach and its associated complications respectively&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">1</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0255" class="elsevierStylePara elsevierViewall">Although there are two techniques for transsphenoidal surgery&#44; microscopic &#40;which includes classic sublabial and transseptal approaches&#41; and endoscopic &#40;introduced in the late 1990s by Jho and Carrau from the University of Pittsburgh&#41;&#44; there have been no prospective&#44; randomised studies to compare the two techniques &#40;see <a class="elsevierStyleCrossRefs" href="#tbl0015">Tables 3 and 4</a> for the advantages and disadvantages of the microscopic and endoscopic approaches respectively&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">2&#8211;11</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0260" class="elsevierStylePara elsevierViewall">However&#44; we know that the microscopic technique is limited by the narrow corridor offered by the nasal retractor&#44; with only a conical view in a straight line towards the sella&#46; The sellar region can be seen clearly&#44; but areas such as the suprasellar or parasellar area are often hidden from view&#46; Therefore&#44; in large macroadenomas&#44; especially with invasion of cavernous sinuses&#44; our field of vision is incomplete and there will be areas which are inaccessible or where we have to work blind&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">The endoscopic approach&#44; however&#44; is more anatomical as it does not require the use of nasal retractors and nasal structures useful for facilitating the technique can be manipulated &#40;middle turbinate resection&#44; preparation of the nasoseptal flap or resection of the intrasphenoid septum&#41;&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">The main advantages of the endoscope are definitely the greater illumination and superior visualisation&#44; which provide a panoramic view of the surgical field&#44; with better visualisation of the parasellar and suprasellar area&#46; This has enabled us to push back the limits of transsphenoidal surgery&#44; visualising and resecting tumours which previously could not be assessed &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; In addition&#44; with the endoscope we have the option of using optics with added angulation which give us more control in the lateral extension of the tumour&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">12&#8211;21</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0275" class="elsevierStylePara elsevierViewall">The main drawback is the two-dimensional &#40;2D&#41; view&#46; However&#44; the surgeon can obtain a pseudo-depth perception with the dynamic movement of the endoscope &#40;approaching and moving away from the area of interest&#41;&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">From a meta-analysis comparing the microscopic transsphenoidal approach with the purely endoscopic approach&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">22</span></a> we concluded that&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0285" class="elsevierStylePara elsevierViewall">The success of the endoscopic approach is comparable to the microscopic in terms of complete tumour resection&#44; but can be superior in macroadenomas with extrasellar extension&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0290" class="elsevierStylePara elsevierViewall">Some authors suggest a higher rate of endocrine remission for functioning adenomas with the endoscopic approach&#44; as well as a lower incidence of diabetes insipidus&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0295" class="elsevierStylePara elsevierViewall">Surgery and postoperative time are shorter with the endoscopic technique&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0300" class="elsevierStylePara elsevierViewall">The main complication of transsphenoidal surgery is CSF leak&#44; with a similar risk in both techniques &#40;19&#46;5&#37; endoscopy vs 14&#46;4&#37; microscopy&#41;&#46;</p></li></ul></p><p id="par0305" class="elsevierStylePara elsevierViewall">The increased risk of leakage with the endoscopic approach found in many studies seems to be a consequence of endoscopy being used for more complex cases&#44; with more expanded procedures performed than with the microscopic technique&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall">Another advantage is that with endoscopy it is easier to see normal pituitary tissue&#44; suggesting that greater preservation of pituitary function is possible&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">The aim of this article was to analyse our results using a purely endoscopic transsphenoidal approach in 86 patients over five years&#44; and to compare our data with the results reported in the meta-analysis published by Ammirati et al&#46; &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46; We found that&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0320" class="elsevierStylePara elsevierViewall">Our rates for complete tumour resection &#40;77&#37;&#41; and remission of functioning tumours &#40;73&#37;&#41; are higher than the published rates &#40;68&#37; and 66&#37; respectively&#41;&#46;</p></li></ul></p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0325" class="elsevierStylePara elsevierViewall">One of the most negative prognostic factors in pituitary adenomas is invasion of the cavernous sinus&#44; as it reduces the likelihood of successful surgery&#44; both in terms of complete tumour resection and hormone remission in functioning tumours&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">MRI with gadolinium-enhanced coronal sections is the best technique for preoperative assessment of cavernous sinus invasion&#46; In 1993&#44; Knosp established a classification system for parasellar growth of pituitary adenomas<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">23&#8211;25</span></a>&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0335" class="elsevierStylePara elsevierViewall">Grade 0&#58; the tumour does not extend beyond the tangential line joining the medial wall of the supra- and intracavernous internal carotid arteries&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0340" class="elsevierStylePara elsevierViewall">Grade 1&#58; the tumour extends beyond the medial tangent&#44; but not the tangent that joins the centres of the two arteries&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0345" class="elsevierStylePara elsevierViewall">Grade 2&#58; the tumour extends beyond the intercarotid line but not the lateral tangent&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0350" class="elsevierStylePara elsevierViewall">Grade 3&#58; the tumour extends to the lateral tangent&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0355" class="elsevierStylePara elsevierViewall">Grade 4&#58; the carotid artery is completely encased by the tumour&#46;</p></li></ul></p><p id="par0360" class="elsevierStylePara elsevierViewall">In our series&#44; 32 patients had high-grade invasion of the cavernous sinus &#40;Knosp 3 and 4&#41; with a complete resection rate of 59&#46;3&#37;&#46; The remaining 54 patients had slight or no invasion of the cavernous sinus &#40;Knosp 0&#44; 1 and 2&#41; and a complete resection rate of 87&#37;&#46;</p><p id="par0365" class="elsevierStylePara elsevierViewall">Such is the importance of sinus invasion that&#44; taken in conjunction with other variables&#44; it is a predictor of the degree of resection and also therefore of the cure rate&#46;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0370" class="elsevierStylePara elsevierViewall">In our series&#44; the most common presenting symptom was loss of visual field&#46; We achieved visual improvement in 91&#37;&#44; with our results being similar to those found in the literature&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0375" class="elsevierStylePara elsevierViewall">Our incidence of CSF leak was 0&#37;&#44; well below the published data &#40;7&#37;&#41;&#46;</p></li></ul></p><p id="par0380" class="elsevierStylePara elsevierViewall">The risk of CSF leakage in standard transsphenoidal endoscopic surgery is 0&#46;5&#8211;10&#37;&#46; In expanded approaches&#44; it increases to 5&#8211;30&#37;&#46; When a CSF leak occurs&#44; early revision surgery &#40;first 48<span class="elsevierStyleHsp" style=""></span>h&#41; is advisable in view of the impact it has on reducing the postoperative meningitis rate&#46;</p><p id="par0385" class="elsevierStylePara elsevierViewall">The generalised use of the vascularised flap can increase postoperative nasal morbidity &#40;increase the percentage of scabs&#44; synechiae&#44; septal perforation or anosmia&#41;&#46; We therefore only use the vascularised nasoseptal flap when there is a diaphragmatic defect with intraoperative CSF leakage&#46; In the remaining cases we reconstructed the defect with middle turbinate mucosa&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">26&#8211;28</span></a><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0390" class="elsevierStylePara elsevierViewall">Our incidence of meningitis was 1&#46;16&#37;&#44; in line with data published in the literature &#40;0&#46;5&#8211;1&#46;9&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0395" class="elsevierStylePara elsevierViewall">Endocrine complications are an important aspect to be taken into account in pituitary tumour surgery&#44; with an incidence of 17&#46;9&#37; reported in the literature&#46;</p></li></ul></p><p id="par0400" class="elsevierStylePara elsevierViewall">Our rates of permanent diabetes insipidus and anterior&#8211;pituitary axis damage were 3&#37; and 9&#37; respectively&#44; also in line with the published data&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conclusion</span><p id="par0405" class="elsevierStylePara elsevierViewall">The transsphenoidal route is a direct and extracerebral route to the sellar region&#59; it uses the nostrils&#44; which form a real cavity and do not require dilation to gain entry&#44; providing direct access to the sella turcica&#46; The endoscopic approach gives us a panoramic view of the surgical field&#44; with minimal trauma and a low rate of complications&#46;</p><p id="par0410" class="elsevierStylePara elsevierViewall">In terms of surgical quality&#44; our results are comparable to the best published series&#46; Our aim has been to add to the scientific evidence on the effectiveness and safety of this technique&#46;</p><p id="par0415" class="elsevierStylePara elsevierViewall">However&#44; a study with a larger number of cases is necessary to obtain results with clinical significance&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflict of interests</span><p id="par0420" class="elsevierStylePara elsevierViewall">The authors declare that there are no conflicts of interests&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The endoscopic endonasal approach has become the gold standard for the surgical treatment of pituitary adenomas&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The aim of this study is to present the results obtained in our hospital in purely endoscopic surgery of pituitary adenomas&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">From February 2011 to August 2016&#44; we conducted a prospective study on a series of 86 patients with pituitary adenoma&#44; all of whom underwent surgery with a purely endoscopic endonasal approach&#46; The &#8216;four hands-two nostrils&#8217; technique was performed in all cases by a surgical team composed of an ENT surgeon and a neurosurgeon&#46; Mean follow-up was 32 months&#46; All patients were evaluated according to clinical&#44; radiological and endocrinological criteria&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In our series&#44; 53&#37; were women and 47&#37; men&#46; The age ranged from 14 to 84 years of age&#44; with a mean of 54 years of age&#46; The most common initial symptom was visual deficit &#40;42&#37;&#41;&#44; followed by hormonal hyperfunction &#40;21&#37;&#41;&#44; with acromegaly being the most common clinical syndrome&#46; The most common tumours were non-functioning tumours &#40;73&#37;&#41;&#44; while GH-secreting tumours &#40;65&#37;&#41; were the most common functioning adenoma&#46; Regarding tumour size&#44; 76&#37; were macroadenomas&#44; 11&#37; microadenomas and 13&#37; giant adenomas&#46; Approximately 63&#37; of the adenomas exhibited suprasellar extension and 37&#37; involved invasion of the cavernous sinus &#40;Knosp grade &#8805;3&#41;&#46; Total excision was achieved in 77&#37; of the cases&#46; After the intervention&#44; visual improvement was achieved in 91&#37; and remission of endocrine hyperfunction in up to a 73&#37; of cases&#46; The most common complication was anterior pituitary insufficiency of at least one axis &#40;9&#37;&#41;&#46; There were no cases of postoperative cerebrospinal fluid fistula&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">In terms of surgical quality&#44; our results are similar to those of published series&#44; and demonstrate the efficacy and safety of the endoscopic endonasal approach as the surgical treatment of choice for pituitary adenomas&#46; However&#44; further studies with a higher sample size are necessary to obtain clinically significant results&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El abordaje endosc&#243;pico endonasal se ha convertido en la t&#233;cnica quir&#250;rgica de elecci&#243;n para el tratamiento de los adenomas hipofisarios&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El objetivo de este trabajo es presentar los resultados obtenidos en nuestro hospital en cirug&#237;a puramente endosc&#243;pica de los adenomas hipofisarios&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Hemos realizado un estudio prospectivo&#44; recogiendo a los pacientes intervenidos de adenoma hipofisario mediante un abordaje endonasal puramente endosc&#243;pico&#44; desde febrero de 2011 hasta agosto de 2016&#44; obteniendo una muestra total de 86 pacientes&#46; Todos los pacientes fueron intervenidos conjuntamente por un ORL y un neurocirujano con la t&#233;cnica de <span class="elsevierStyleItalic">four hands-two nostrils</span>&#46; El seguimiento medio postoperatorio fue de 32 meses&#46; Todos los pacientes fueron evaluados seg&#250;n criterios cl&#237;nicos&#44; radiol&#243;gicos y endocrinol&#243;gicos&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">En nuestra serie un 53&#37; eran mujeres y un 47&#37; hombres&#59; el rango de edad variaba desde los 14 hasta los 84 a&#241;os&#44; siendo la media de 54 a&#241;os&#46; El s&#237;ntoma inicial m&#225;s habitual fue el d&#233;ficit visual &#40;42&#37;&#41;&#44; seguido por la hiperfunci&#243;n hormonal &#40;21&#37;&#41;&#44; siendo la acromegalia el s&#237;ndrome cl&#237;nico observado con m&#225;s frecuencia&#46; Los tumores m&#225;s frecuentes fueron los no funcionantes &#40;73&#37;&#41;&#44; y de entre los adenomas funcionantes el m&#225;s frecuente fue el productor de GH &#40;65&#37;&#41;&#46; En cuanto a tama&#241;o tumoral&#44; un 76&#37; eran macroadenomas&#44; un 11&#37; microadenomas y un 13&#37; gigantes&#46; Un 63&#37; presentaban extensi&#243;n supraselar y un 37&#37; invasi&#243;n de seno cavernoso &#40;grado de Knosp &#8805;3&#41;&#46; Se consigui&#243; una ex&#233;resis total en un 77&#37; de los casos&#46; Tras la intervenci&#243;n se consigui&#243; en un 91&#37; mejor&#237;a visual y hasta en un 73&#37; remisi&#243;n de la hiperfunci&#243;n endocrina&#46; En cuanto a las complicaciones&#44; la m&#225;s frecuente fue la insuficiencia de al menos un eje de la hip&#243;fisis anterior &#40;9&#37;&#41;&#44; sin presentar casos de f&#237;stula de LCR posquir&#250;rgica&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Nuestros resultados&#44; en t&#233;rminos de calidad quir&#250;rgica&#44; se asemejan a las series publicadas y avalan la eficacia y seguridad del abordaje endosc&#243;pico endonasal como t&#233;cnica de elecci&#243;n en el manejo quir&#250;rgico de la gl&#225;ndula hipofisaria&#46; Sin embargo&#44; es necesario un estudio con mayor n&#250;mero de casos para obtener resultados con significaci&#243;n cl&#237;nica&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; L&#243;pez-Garc&#237;a R&#44; Abarca-Olivas J&#44; Monjas-C&#225;novas I&#44; Pic&#243; Alfonso AM&#44; Moreno-L&#243;pez P&#44; Gras-Albert JR&#46; Cirug&#237;a endosc&#243;pica endonasal en adenomas hipofisarios&#58; resultados quir&#250;rgicos en una serie de 86 pacientes consecutivos&#46; Neurocirug&#237;a&#46; 2018&#59;29&#58;161&#8211;169&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Image of anatomical dissection in cadaver with surgically important intrasphenoid references&#46; ICA&#58; prominences of the parasellar internal carotid artery&#59; ON&#58; optical nerves&#59; CR&#58; clival recess&#59; lat OCR&#58; lateral optic-carotid recess&#59; med OCR&#58; medial optic-carotid recess&#59; ST&#58; sella turcica&#59; TS&#58; tuberculum sellae&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Example of adenoma resection with Knosp grade 3 invasion in left cavernous sinus&#46; In the centre we can see the sella turcica empty of tumour with lowering of the diaphragma sellae and the arachnoid&#44; while on the right of the image we see how the adenoma component that was invading the left cavernous sinus has been completely evacuated&#46;</p>"
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Asymmetric suprasellar growth&#59; constrictive diaphragma sellae&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tumour with epicentre lateral to the carotid artery &#40;simple invasion of the cavernous sinus is not a contraindication&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tumour purely suprasellar&#44; with a normal-sized sella&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sphenoid sinusitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intrasellar vascular defect&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Factors contraindicating the transsphenoidal approach&#46;</p>"
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">The main complication is CSF leak&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Damage to the internal carotid artery &#40;0&#8211;0&#46;68&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sinusitis&#44; mucoceles&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Perforation of the nasal septum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Visual impairment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Brain haemorrhage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Added hormonal damage&nbsp;\t\t\t\t\t\t\n
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Advantages&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Disadvantages&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3D vision &#40;three-dimensional&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Poor visualisation&#46; Field of vision is conical and in a straight line&#44; limited by the nasal speculum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Familiar technique for the neurosurgeon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Visualisation of the anatomical references of the limits of the sella is not good&#46; There is no view of the cavernous sinuses or the suprasellar space&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Microscope located outside the surgical field&#44; so does not obstruct the manoeuvrability of the instruments and nor is vision obstructed in the case of bleeding in the field&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">It is not easy to check for optic nerve decompression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Greater precision under direct vision&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Higher incidence of nasal complications&#46; Greater discomfort for the patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Advantages and disadvantages of the microscopic approach&#46;</p>"
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      6 => array:8 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Advantages&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Disadvantages&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Less traumatic&#46; Does not require self-retaining nasal retractor&#46; Faster access&#46; Shorter surgery time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Opacification of the lens due to blood or moisture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Procedure more comfortable for the patient&#44; with faster recovery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Two-dimensional view&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Shorter hospital stay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Need for special instruments&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Panoramic view of the surgical field and a better working angle&#44; resulting in greater tumour resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Learning curve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Higher rate of hormone preservation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fewer nasal complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Enables confirmation of optic nerve decompression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Advantages and disadvantages of the endoscopic approach&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Meta-analysis<br>Ammirati et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">This study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Remission rate in functioning tumours&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">66&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Complete resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Improvement of vision &#40;cases with pre-surgical visual impairment&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">62&#8211;100&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CSF leak rate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Permanent diabetes insipidus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypopituitarism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Postoperative visual loss&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;72&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;16&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Infection&#47;meningitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;16&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab1778177.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Ammirati meta-analysis vs HGUA&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:28 [
            0 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Complications of transsphenoidal surgery&#58; results of a national survey review of the literature&#44; and personal experience"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "I&#46; Ciric"
                            1 => "A&#46; Ragin"
                            2 => "C&#46; Baumgartner"
                            3 => "D&#46; Pierce"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Neurosurgery"
                        "fecha" => "1997"
                        "volumen" => "40"
                        "paginaInicial" => "225"
                        "paginaFinal" => "237"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9007854"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Microscopic versus endoscopic pituitary surgery"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;A&#46; Simal-Juli&#225;n"
                            1 => "P&#46; Miranda-Lloret"
                            2 => "G&#46; Pancucci"
                            3 => "R&#46; Evangelista-Zamora"
                            4 => "P&#46; P&#233;rez-Borreda"
                            5 => "P&#46; Sanrom&#225;n &#193;lvarez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.neucir.2013.12.001"
                      "Revista" => array:6 [
                        "tituloSerie" => "Neurocirug&#237;a"
                        "fecha" => "2014"
                        "volumen" => "25"
                        "paginaInicial" => "170"
                        "paginaFinal" => "178"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24747035"
                            "web" => "Medline"
                          ]
                        ]
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Article information

ISSN: 25298496
Original language: English

DOI:10.1016/j.neucie.2018.02.002

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