No more open surgery, PGI removes 2K pituitary tumours via endoscopic procedure
No more opening of the skull, no scars on the face or head, but a faster and smoother recovery. These are the hallmarks of endoscopic endonasal transsphenoidal surgery through which the doctors at Post Graduate Institute of Medical Education and Research (PGIMER) here successfully removed at least 2,300 pituitary tumours in the past decade.
“It is a minimally invasive surgical technique used to remove pituitary tumours through the nasal passage, without any external incisions or opening of the skull,” Dr Rajesh Chhabra, Professor at Department of Neurosurgery, PGIMER, told The Tribune.
Although pituitary adenomas (benign tumours) are rare in children, the PGIMER doctors have also operated on paediatric cases, including non-functioning tumours and hormone-secreting adenomas like Cushing’s disease and acromegaly — in as young as eight-year-old patients.
Besides, more than 80 patients above the age of 70, including the oldest one aged 84, have also been successfully treated.
“A comparative analysis between elderly and younger patients showed encouraging and comparable outcomes, extending the reach of endoscopic surgery to both extremes of age,” he said.
Another unique case which was treated recently was of gigantism/acromegaly in the tallest patient with 7.7 feet height.
Dr Chhabra said the success rate was 90–95% in small to medium-sized tumours, 80–90% for large masses and 60–70% for giant tumours as success decreases with increasing size.
“Success is defined as complete or near-complete tumour removal, with relief from symptoms like vision loss, headaches and improved hormonal balance,” he shared.
Post-surgery, the treated patients can begin their office work within two or three weeks while physical jobs can be resumed within four or six weeks, depending on recovery.
Dr Chhabra said preoperative optimisation is done in coordination with the endocrinology and anaesthesia teams.
Divulging the surgical technique, he said the patient is placed in a supine position with the head slightly elevated and extended. Under general anaesthesia, nasal decongestion is carried out.
The surgery begins with a binostril approach using a 0° or 30° endoscope. A nasoseptal flap is harvested if there is a risk of cerebrospinal fluid (CSF) leak in giant pituitary tumours. The sphenoid sinus is identified and widely opened to expose the sellar (a saddle-shaped bony structure at the base of the skull that houses the pituitary gland) floor.
Under the neurosurgical phase, the sellar floor is carefully drilled or removed to expose the dura (tough outermost membrane enveloping the brain) covering the pituitary gland.
The dura is incised, and the tumour is removed in a piecemeal fashion using special instruments and suction under endoscopic visualisation.
“Every effort is made to preserve the normal gland, optic apparatus, and carotid arteries and even arachnoid membrane,” the doctor said, while adding that the surgical cavity is inspected for residual tumour and bleeding.
In cases of intraoperative CSF leak, a multilayer reconstruction is done using fat graft, fascia lata and nasoseptal flap. Fibrin sealants or tissue glue may be used to support the repair.
Without doing nasal packing post-surgery, the PGIMER experts monitor the patients in high-dependency or intensive care units for vision changes, endocrine status and electrolyte balance.
An early CT scan is performed after surgery to assess the extent of resection and to rule out any hematoma. Hormonal replacement therapy is initiated as required, under endocrinology supervision.
EARLY DETECTION MUST: DOC
“Early detection can help prevent complications like permanent vision loss or hormone imbalance. If someone is experiencing headaches, vision changes or unexplained hormonal symptoms, one has to consult a neurologist or endocrinologist or ophthalmologist for further evaluation, " said Dr Rajesh Chhabra.
Chandigarh