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Neurosurgery

New pituitary tumor resection technique offers better visualization and more complete tumor removal

08/01/2008

A team of UCLA neurosurgeons and head and neck surgeons are helping to pioneer a minimally invasive, endoscopic sugical approach that offers greatly improved visualization and freedom of movement to remove pituitary tumors more precisely.A team of UCLA neurosurgeons and head and neck surgeons are helping to pioneer a minimally invasive, endoscopic surgical approach that offers greatly improved visualization and freedom of movement to remove pituitary tumors more confidently and precisely. Working through the natural pathway of the nostrils without the need for a speculum, the purely endoscopic technique relies on creating an adequate working space deep within the nasal cavity that allows surgical exposure of the entire tumor. This breakthrough surgical approach avoids “blind” tumor removal techniques, which can lead to incomplete tumor resections and/or injury to critical adjacent structures.

Diagnosis and medical management

Pituitary tumors that are endocrinologically active usually present with manifestations of hormone over-secretion. The most common hormones involved are prolactin (typically presenting with irregular menstruation), ACTH (leading to excessive cortisol production and Cushing’s disease) and human growth hormone (leading to acromegaly). Non-endocrine-active pituitary tumors are usually clinically detected when they grow large enough to compress the optic chiasm, causing tunnel vision. Patients with pituitary tumors require a comprehensive endocrinologic evaluation to assess both excessive and inadequate hormone secretion. Pituitary tumors are almost always benign, and sometimes can be managed medically without the need for surgery. In many cases, however, relief from the ailments caused by excessive hormone production, which can be fatal in Cushing’s disease and acromegaly, is possible only with complete surgical removal of the tumor.

New technique offers better visualization and freer movement

For patients who need pituitary tumor resection, the new technique being used at UCLA offers some important advantages over the conventional surgical approach. Working through the natural passages of the nostrils, surgeons more extensively remove mucosa and bone from the base of the skull to create a larger working space than is possible when working through a speculum (the narrow tube through which pituitary tumor removal is conventionally performed). UCLA surgeons use an endoscope inserted through one nostril to provide outstanding illumination and magnification of the surgical site. Instruments can be used through the same nostril and through the other nostril to allow precise, bi-manual microsurgery.

Reconstructing the skull base

Once tumor removal is complete, the surgical team must reconstruct the sinus nasal cavity to facilitate healing and reduce the risk of postoperative complications. UCLA surgeons use a vascularized nasoseptal flap to cover the area directly over the tumor resection site. Because it is living tissue with a retained blood supply, the flap quickly heals and restores nearly normal nasal function.

With this technique, postoperative complication rates are held to a very low level. Experience at UCLA and at other academic medical centers using the technique indicate that serious complications, including cerebrospinal fluid leads, occur at acceptably low rates. UCLA researchers are in the process of compiling data for publication regarding surgical outcomes.

New technique offers clear advantages, but requires special expertise and equipment

The expanded endoscopic endonasal approach is a quantum leap over traditional pituitary surgery techniques.“The expanded endoscopic endonasal approach is a quantum leap over traditional pituitary surgery techniques,” says Marvin Bergsneider, M.D., professor of neurosurgery at the UCLA Pituitary Tumor Program. “We no longer have to blindly work around corners using ‘one-handed’ surgical techniques We no longer have to explore around blind corners, guessing and hoping that there isn’t tumor being left behind; we can now directly visualize, in HD resolution, that all the tumor has been removed. Because this approach requires specialized training and the expertise of a neurosurgeon and a head-and-neck surgeon team, plus state-of-the-art endoscopic surgical equipment, only a few hospitals in the world are currently capable of performing it.


Participating Physician

Neurosurgery
Marvin Bergsneider, M.D.
Neil Martin, M.D., FAANS

Head & Neck Surgery
Marilene Wang, M.D.

Pituitary Endocrinology
Anthony Heaney, M.D., Ph.D.

Contact information

Patient referral: (310) 825-5111
UCLA Transfer Center: (310) 825-0909
www.pituitary.ucla.edu





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