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Postoperative worsening of visual function occurred in ventricle atorlip-20 20 mg amex cholesterol ratio paleo, and to minimize brain retraction (orbitozygo­ two (9 order atorlip-20 20mg otc cholesterol ratio blood test. Following transcranial surgery there was one peri­ The operative mortality after transcranial surgery for operative mortality secondary to a pulmonary embolism 2 giant pituitary adenomas was unacceptably high in the months after surgery cheap atorlip-20 20 mg mastercard cholesterol levels too high. These complications were greater in the transcranial 250 Endoscopic Pituitary Surgery Table 24. In one series of 40 patients with giant pituitary rate, 57%, seen in the group who underwent radical surgical 24 Extended Endonasal, Endoscopic Transsphenoidal Approach versus Craniotomy for Giant Pituitary Macroadenomas 251 removal. This decreased to 26% in the partial­removal I Transsphenoidal Surgery for Giant group. Worsening postoperative vision was noted in 10% Macroadenomas after transcranial surgery, and the authors did not spe­ cifcally report on endocrinologic outcomes7 (Table 24. The transsphenoidal approach for the resection of a pituitary The high mortality rate led them to shift to an initial trans­ tumor was frst described by Herman Schlofer54 at the Uni­ sphenoidal removal of the intrasellar component of the versity Clinic in Innsbruck, Austria. He performed a superior tumor and decompression of the suprasellar component if nasal transsphenoidal approach on a 30­year­old man with it descends during the operation. At that who was found to have an enlarged sella on a lateral skull time, suprasellar components descended into the vacant x­ray. Although the surgery proceeded without serious com­ sella space and a second transsphenoidal or transcranial plications, the patient died postoperatively from obstructive operation was performed. During the following years the transsphe­ tients no operative mortality or major complications were noidal approach was modifed, and Harvey Cushing was the reported; however, specifc endocrine outcomes were not frst to present a large clinical series of 231 transsphenoidal reported. However, the cause of death presented with visual loss had postoperative resolution, and was diferent depending on the approach. Clinical follow-up use of skull base techniques substantially decreased the data were available for almost all patients. Ten years after operative morbidity and mortality of giant pituitary ad­ the operation half of the patients were still alive. In a series of 210 patients with large or giant pitu­ tive impaired vision improved in approximately two thirds itary adenomas with suprasellar and parasellar extension, of patients. Two major disadvantages of the transsphenoidal a classic frontotemporal transcranial approach was used approach prompted Cushing to abandon the transsphenoidal for the frst 120 patients and an extradural transcavernous approach. First, given the lack of preoperative imaging, pos­ skull base approach was used for the next 90 patients. Consequently, tumor was left tradural exposure of the cavernous sinus, and it combined behind and caused half of the perioperative mortality associ­ intradural and extradural transcavernous tumor resection. Second, high­power Although the author’s exact defnition of giant adenoma illumination or magnifcation was not available, which se­ was unclear, these tumors required transcranial surgery verely limited access and visibility. Hence, in the late 1920s for removal of their various suprasellar and parasellar ex­ Cushing preferentially used the transfrontal approach, as it tensions. With the classic approach in patients undergoing allowed for intraoperative visualization of suprasellar tumor their frst operation, complete resection was achieved in extension and better decompression of the optic chiasm. Two technologic milestones paved In contrast, with the extradural skull base approach, com­ the way for the revival of the transsphenoidal technique. None of the intraoperative use of the operating microscope improved the patients who underwent the skull base approach had intraoperative illumination and visualization. Specifc anterior or posterior pi­ a high incidence of complete tumor removal and low compli­ tuitary endocrine defcits were not reported. No periop­ cation rate was reported for the transsphenoidal resection of erative mortalities were described with either approach pituitary microadenomas.

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Invest Oph- J Neuroophthalmol 2004;24:243–250 thalmol Vis Sci 2006;47:4827–4835 59 buy discount atorlip-20 20mg online cholesterol in salmon. In vivo retinal nerve fber layer thickness measured by optical mol 1986;104:1028–1034 Endoscopic Transsphenoidal Approach 15 to the Sella Lewis Z discount 20mg atorlip-20 visa cholesterol test particle size. Schwartz First performed by Schlofer over a hundred years ago proven atorlip-20 20mg cholesterol lowering diet in spanish, the For surgery within the sella, the endoscope has numer- transsphenoidal approach has become the standard ap- ous advantages over the microscope. However, the approach fell out of favor less postoperative swelling, avoidance of nasal packing, im- after Cushing abandoned it for the transcranial approach. It proved patient comfort, decreased length of stay, and less was not until the 1950s and 1960s, with the addition of in- postoperative complications. Most importantly, the endoscope dra- began when Guiot et al6 introduced the use of endoscopy matically improves intra- and suprasellar visualization, es- into transsphenoidal surgery in 1963. Similarly, extended approaches can be used to remove as an accepted technique and arguably new standard of care tumor in the suprasellar cistern and cavernous sinus. However, this is not a signifcant limitation once the surgeon gains sufcient experience. Other lesions that are confned to the sella or that enlarge the sella and extend into the suprasellar cistern, such as some craniopharyngiomas and Rathke cleft cysts, are also suitable candidates for this approach (Fig. Surgery continues to be the standard of care for hormone- producing pituitary tumors, such as ones that cause Cushing’s disease or acromegaly, and for nonsecreting pituitary mac- Fig. San Diego: Plu- ing pituitary tumors that are stable in size and not com- ral Publishing; 2007. A unilateral left-sided approach can be used for tumors that are extensions, (B) pituitary microadenomas, (C) macroadenomas with on the right side of the sella, such as the adenoma shown in F. Note that in this case, a right-sided 148 Endoscopic Pituitary Surgery surgical resection is considered, a preoperative prolactin optic chiasm compression improve in 98%. If the prolactin level is <250 mg/L, and the tumor recommend aggressive removal of the cyst wall to prevent is a microadenoma with no cavernous sinus involvement, recurrence, this strategy increases the risk of postoperative then the chance of surgical cure is almost 90%. Hypopituitarism is improved in idence of squamous metaplasia in the cyst wall predicts re- only approximately 20 to 30% of patients, but symptoms of currence, as does residual cyst on postoperative imaging. This tumor cannot reliably be completely re- of the tuberculum sellae can extend into the sella and mimic pituitary moved with a sellar approach but requires a more extensive approach adenomas. These tumors require a larger transtuberculum opening for such as the endonasal, endoscopic, transplanum, transtuberculum ap- removal. San Diego: Plural Publishing; remove the entire tumor, a transcavernous approach is required. In such cases, a transplanum, transtu- proach is appropriate when an enlarged sella is present. Intra- or suprasellar lesions occur 21% sellar component of the tumor to allow a safe and maximal of the time, and primarily suprasellar lesions are observed resection. Only associated with better control but also greater morbidity when the tumor completely encircles the carotid artery can secondary to hypothalamic and pituitary injury. Lat- niopharyngiomas takes advantage of the less invasive na- eral extension into the cavernous sinus is not an absolute ture of the approach with improved intra- and suprasellar contraindication, but the decision should be made preop- visualization. If the goal is to remove tumor from I Contraindications and Considerations the cavernous sinus, there are two options. In some circum- The endonasal, endoscopic, transsphenoidal approach to stances, the tumor passes through a fenestration in the me- the sella can be used to resect the majority of suprasel- dial wall of the cavernous sinus. By using angled endoscopes lar tumors that arise within and enlarge the sella by using and instruments, this opening can be followed from within straight and angled endoscopes.