PNA Medical Corner: Complications from Endoscopic Endonasal Surgery

A  study looks at the outcomes and complications of the endoscopic endonasal approach (EEA) performed on patients with Cushing’s Disease at the UPMC Pituitary Center over the past 11 years. It was published by PNA members Paul Gardner and Juan Fernandez-Miranda and their coauthors Samuel Shin, Jason Ng, Amir Faraji, Nitin Agarwal, Srinivas Chivukula, Carl Snyderman, and Sue Challinor. The authors, from UPMC Departments of Neurosurgery, Medicine, and Otolaryngology, research remission rates, hormone levels, and complications with this procedure.

Endoscopic Endonasal Approach for Adrenocorticotropic Hormone-Secreting Pituitary Adenomas: Outcomes and Analysis of Remission Rates and Tumor Biochemical Activity with Respect to Tumor Invasiveness
Samuel S. Shin, Paul A. Gardner, Jason Ng, Amir H. Faraji, Nitin Agarwal, Srinivas Chivukula, Juan C. Fernandez-Miranda, Carl H. Snyderman, Sue M. Challinor


The purpose of this study was to analyze the outcomes and complications of the endoscopic endonasal approach (EEA) performed on patients with Cushing disease at our Pituitary Center during the past 11 years.


Clinical information and imaging in electronic medical records were reviewed for patients who underwent EEA. Statistical analysis was performed with χ2 testing and Student's t-test.


Remission was achieved in 39 patients (79.6%) at initial evaluation within 2 weeks of surgery. At last follow-up, remission persisted in 70% of 50 patients with EEA alone (mean follow-up time, 37.5 ± 4.6 months; median, 26.2 months; range, 2.5–155.0 months). At last follow-up, remission rates were 80% among magnetic resonance imaging-negative adenomas, 70.6% among noninvasive or minimally invasive adenomas (Knosp 0, 1, 2), and 50% among invasive adenomas (Knosp 3, 4). There were no statistical differences in the remission rates among these categories (P = 0.444). Women had higher proportions of initial remission than men (P = 0.033) and patients who had no initial remission were older (P = 0.046). Higher preoperative normalized adrenocroticotropic hormone level was associated with a greater degree of invasiveness (P = 0.021). However, there was no association between preoperative normalized urine-free cortisol levels and degree of invasiveness (P = 0.582). Complications included panhypopituitarism (n = 3), hypothyroidism (n = 3), growth hormone deficiency (n = 1), hypogonadism (n = 1), postoperative cerebrospinal fluid leak (n = 2), and transient diabetes insipidus (n = 4).


The EEA for Cushing disease resulted in remission and complication rates comparable with previous analyses of EEA, as well as microsurgical series. Preoperative adrenocorticotropic hormone levels were associated with invasiveness.



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