Outcome of Purely Endoscopic
Surgery for Pituitary Adenoma
A Systematic Literature Review
Orphee Makiese MD, Promod Pillai MD
Venko Filipce MD, Mario Ammirati MD,MBA
Dept. of Neurological Surgery
Ohio State University Medical Center
Columbus , OH
NASBS-2008
A Systematic Literature Review
I. INTRODUCTION

Applying new technology: a challenging
change to surgical routines

After feasibility study, using technology to treat
patients requires strict follow-ups and
comparisons with reference (s) technique (s)

In order to fully and safely benefit patients
NASBS-2008
A Systematic Literature Review
I. INTRODUCTION (Cont’d)

Over last decade, endoscopic used to
assist trans-sphenoidal approaches

Review of the literature outcome of pure
endoscopic assisted pituitary surgery
NASBS-2008
A Systematic Literature Review
II. MATERIALS & METHODS
A.
Materials

Medline Pubmed (PM) data base (English)

Publications ranging from early 1990’s to 2007

Eligible studies all included outcome
measurements
NASBS-2008
A Systematic Literature Review
B. Methods Objectives

Outcomes measurement of
 Major
and
 Minor complications
Remission and recurrence rates evaluation
 Comparison to microscopic survey and
systematic literature review

NASBS-2008
A Systematic Literature Review
C.
Inclusion Criteria
Purely endoscopic studies for pituitary
adenoma (+10 patients)
 Adult pituitary surgery
 Trans-sphenoidal surgery (sub labial or nostril)

NASBS-2008
A Systematic Literature Review
C.
Inclusion Criteria (Cont’d)
Diagnosis confirmed by MRI and
endocrinology screening
 Histopathology-definite diagnosis of pituitary
adenoma
 Studies including outcome measurements
 Follow-up more than 6 months
 First surgery

NASBS-2008
A Systematic Literature Review
D.
Exclusion Criteria
 Following
cases were disregarded…
 Recurrent
pituitary tumors
 Subjects to previous endoscopic approach
 Submitted to prior radiation
NASBS-2008
A Systematic Literature Review
III. RESULTS

16 Articles:





2 Class II
2 Class III
12 Class IV
From 105 articles “Pituitary and Endoscope
Surgery’’, PM terms
Selection from a pool of 26617 articles on
“Pituitary surgery” PM terms
NASBS-2008
A Systematic Literature Review
III. RESULTS (Cont’d)
37.5% NA, 25% EU, 25% Asia, 12.5% ME
 974 patients:
444 non functioning
480 functioning
709 macro adenoma
265 micro adenoma
 Mean age=46 yrs; 51% female

NASBS-2008
A Systematic Literature Review
III. RESULTS (Cont’d)
Identical methodology for microscopic group
 Statistical comparison of groups based on
homogeneity and known epidemiologic
pathology
 Assuming different surgeons and distinct
population
 16 articles for endoscopic group 974
 16 articles for microscopic group 1971

NASBS-2008
Authors
Year
Type of Study
Study
Population
Mean Age(Y)
F
H
Jho H D and Carrau R
L
1997
Clinical, R
44
38(14-88)
19
25
Sheehan MT et al
1998
Clinical, RC
26
59.2(25-80)
8
18
ILan K et al
1999
Clinical, RC
18
Badie B et al
1999
Clinical, PC
16
48
6
Ogawa T et al
2000
Clinical, RC
13
49.1(19-73)
Cappabianca P et al
2002
Clinical, R
146
Cho D Y et al
2002
clinical, PC
White D R et al
2004
Kabil M S et al
Duration of
Study
Macro
Micro
1993-1996
31
13
1995-1997
26
0
1996-1997
12
6
10
1996-1999
9
7
6
7
1996-1999
11
2
46.1(16-74)
76
68
1997-2001
125
21
22
45.3(22-60)
22
0
1996-2000
11
11
Clinical, RC
50
41.1
26
24
2000-2002
2005
Clinical, RC
300
46(16-75)
176
124
1998-2004
235
65
Netea-Maier R T et al
2006
Clinical, R
35
41(14-68)
25
10
1998-2004
6
29
Rudnik A et al
2006
Clinical, R
63
48.3(11-77)
34
29
52
11
Kenan K et al
2006
Clinical, R
78
44.7(11-67)
67
11
Jain A.K. et al
2007
Clinical, P
10
40.1
6
4
9
1
Dehdashiti AR et al
2007
Clinical, R
25
42
19
6
2004 -2007
7
18
Charalampaki P et al
2007
Clinical, R
50
56(28-84)
30
20
2004-2005
41
9
Zhang X et al
2007
Clinical, R
78
45.1(15-76)
42
36
1998-2005
67
11
2001-2002
1997-2005
Authors
Year
Type of Study
Sheehan MT et al
1998
Clinical, RC
Laws and Semple
1999
Zhang X et al
Study
Population
Mean Age(Y)
F
H
44
57.8(32-85)
13
31
Clinical, R
105
38.5 (6-78)
83
22
1992-1997
13
92
1999
Clinical, R
208
47.5(16-71)
110
98
1982-1997
189
0
ILan K et al
1999
Clinical, RC
20
1993-1995
11
8
Badie B et al
1999
Clinical, PC
21
43
11
10
1996-1999
12
6
Ogawa T et al
2000
Clinical, RC
18
49.4(23-73)
8
10
1996-1999
16
2
Kaltsas et al
2001
Clinical, R
67
1993-1998
50
17
Kreutzer et al
2001
Clinical, R
57
43.9(16-71)
37
20
1992-1998
38
19
Rees D A et al
2001
Clinical, R
54
41.3(14-73)
42
12
1980-2000
Shimon I et al
2002
Clinical, R
74
39(8-72)
64
10
1990-2000
3
71
Cho D Y et al
2002
Clinical, PC
22
46.7(18-56)
21
1
1996-2000
10
12
DE P. et al
2003
Clinical, R
47
61(29-86)
24
23
1990-2001
35
12
Höybye C et al
2004
Clinical, R
34
40(13-74)
26
8
1990-1999
2
32
White D R et al
2004
Clinical, RC
50
43.5
17
33
1996-1999
Mortini P et al
2005
Clinical, R
43(8-82)
681
459
1990-2002
788
72
Jain A.K. et al
2007
Clinical, PR
5
5
8
2
1140
10
31.6
Duration of
Study
1995-1997
Macro
Micro
44
A Systematic Literature Review
A.
Comparability: Sex, Age and
Adenoma Size
Endoscope
Microscope
P-value
Mean Age
46
44.6
0.6276
Sex
495F, 381M
1189F, 795M
0.0942
Macro adenoma
77%
78%
0.5168
Micro adenoma
23%
22%
0.5168
Functioning
52%
77%
0.0001
Nonfunctioning
48%
33%
0.0001
NASBS-2008
A Systematic Literature Review
B.
Major Complications and
Comparisons
Endoscope
Microscope
Ciric National Survey
1997
Relative
Risk
P-value
CSF
3.6%
2.6%
3.9%
1.45
0.0736
Meningitis
0.71%
0.2%
1.5%
3.48
0.0435
Sinusitis
1.9%
0.3%
8.5%
6.34
0.0027
Vascular injury
1.3%
0.57%
1.1%
2.38
0.0563
DI-Transient
5.6%
8.1%
0.68
0.0697
DI permanent
3.5%
3.6%
17.8%
0.99
0.9632
Visual loss
1.7%
0.36%
1.4%
4.88
0.0005
Major Complications
14.7%
10.7%
1.26
0.002
NASBS-2008
A Systematic Literature Review
C.
Minor Complications and
Comparisons
Endoscope
Microscope
Ciric National survey 1997
Relative Risk
P-value
Epistaxis
0.72%
0.26%
3.4%
2.72
0.1286
Septum perf
0.62%
0.67%
6.7%
0.92
0.8583
Nerves injury
0%
0.1%
1.3%
Anosmia
0.31%
0%
Crusting
0.62%
0.21%
3.0
0.1491
Synechia
0.52%
0.36%
1.42
0.7689
Saddle nose
0%
0.05%
Minor
complications
2.8%
2.3%
1.138
0.4955
NASBS-2008
A Systematic Literature Review
D.
Length of stay in hospital
Length of Stay in Hospital
Endoscope
Microscope
P-value
3.34 days
6.1 days
0.0984
too few
values in
micro gp
NASBS-2008
A Systematic Literature Review
E.
Death, Follow-up and
Remission
Endoscope
Microscope
Ciric National survey 1997
Relative
Risk
P-value
Death
0.6%
0.4%
0.9%
1.44
0.73
Follow up
19.2
months
43.3 months
Remission
65.2%
65.3%
0.998
0.947726
Recurrence
0.1%
4.2%
0.024
1.78*10-10
too few values
in endosc gp
NASBS-2008
A Systematic Literature Review
CONCLUSIONS
A.
Preliminary Remarks
Two accurate observations that:
 Statistics
seem SIGNIFICANT for microscope
performed on major complications but…
 NON
SIGNIFICANT on minor complications
NASBS-2008
A Systematic Literature Review
B.

Research recommendations
Study accuracy would require more …
 Report
data about length of stay in hospital for
microscopic group
 Report data about recurrence and follow-up for
endoscopic group
 Comparative studies to further meta-analysis study
NASBS-2008