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Physicians Update


Physicians Update

Spring 2009

New Endoscopic Approach to Pituitary Surgery has "Transformed the Operation"


Pituitary Surgery RoomThe latest development in the trend toward less invasive neurosurgery has dramatically improved the way certain neurological tumors are removed, particularly those involving the pituitary gland.

Previously, the minimally invasive approach — one that avoided a craniotomy to access the gland beneath the brain at the base of the skull, atop the sphenoid sinus — involved using a speculum to stretch the tissues of the nasal passage to create a corridor through which a surgical microscope was employed to shine a light and perform the operation.

But that approach was limiting, explains Marvin Bergsneider, M.D., one of three UCLA neurosurgeons who performs the newer endoscopic procedure. “The corridor you could work in was only so wide, there was only so much light we could get into it, and we were working with instruments that could block our view,” he says.

The newer approach employs a high-definition video in combination with an endoscope, and has “transformed the operation,” says Neil A. Martin, M.D., FAANS, chair of neurosurgery at UCLA. “Rather than looking through the opening with a microscope in a very constricted field, we are able to get a broad, high-definition view within the area of the sphenoid sinus, which allows for a much better result.” To perform the procedure, the UCLA surgical team includes a neurosurgeon, a headand- neck surgeon and a neuroendocrinologist.

With the endoscope, the neurosurgeons go through both nostrils and create a working cavern in front of the tumor by removing bone. The result, Neuro Head and Neck ImagingDr. Bergsneider says, is the ability to use the endoscope with markedly expanded degrees of freedom. As the neurological surgeon manipulates tissue, the head-and-neck surgeon, Marilene Wang, M.D., guides the endoscope to ensure a clear field of view.

“This represents a quantum leap forward from the use of the speculum,” Dr. Bergsneider says. “It’s as if we were, in the past, operating with handcuffs on compared to the freedom we have now to use the finest microsurgical techniques, and we are able to see it all with stunning resolution.”

The improved visualization of the tumor during the surgery has enabled the multidisciplinary team to more completely remove tumors than before, says pituitary endocrinologist Anthony Heaney, M.D., Ph.D. Follow-up studies have shown that the percentage of patients who still had tumor visible on an MRI scan after surgery has gone from 60 percent to 35 percent since implementation of the newer procedure, with similar morbidity.

The new approach is an outgrowth of a recent trend that began in gastrointestinal surgery, in which endoscopic surgery is being performed via the esophagus to avoid the need for an abdominal incision — a procedure referred to as natural orifice transluminal endoscopic surgery (NOTES). “This is the neurosurgical NOTES operation, transcranial instead of transluminal,” explains Dr. Martin. Although the bulk of the cases involve pituitary tumors, the UCLA team also uses the NOTES operation for certain skull-based tumors, including meningiomas, chordomas and craniopharyngiomas.

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