Weill Medical College of Cornell University

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Endoscopic Transsphenoidal Surgery

The neurological surgeons of Weill Cornell have developed a minimally invasive technique for removal of tumors located at the anterior skull base that would otherwise require a cranial opening and might produce facial scarring.

In this novel approach, a tiny endoscope (tube) is advanced through the nostril, allowing the surgeon to safely and more easily access different types of tumors in diverse locations, using normal facial sinus cavities to position the endoscope at the desired location.

Minimally Invasive Skull Base and Pituitary Surgery

The Team Approach

Weill Cornell emphasizes a multidisciplinary approach to the management of disease in this area, since the anterior skull base comprises a number of important structures that differ in function:

• Pituitary gland
• Optic nerves
• Carotid arteries

The Weill Cornell team for endoscopic transsphenoidal surgery involves a neurosurgeon as well as

• Otolaryngologist
• Endocrinologist
• Neuro-opthalmologist
• Interventional neuroradiologist

Conditions Treated

Pituitary Tumors
The pituitary gland is a major communication link between the brain and the body. The gland is responsible for the production of cortisol, thyroid hormones, growth hormones, and a variety of other hormones involved in lactation, menstruation and urination. Tumors of the pituitary gland are the third most common form of brain tumor in adults. Generally benign, these tumors can produce hormones and may be discovered even when quite small in size, based on the effects that hormone overproduction may have on the body. Tumors that do not produce hormones can grow to be quite large in size and compress brain structures such as the optic nerves, which can affect vision. For this reason, both hormone-producing and non hormone-producing tumors are usually removed surgically.

Craniopharyngiomas and Rathke's Cleft Cysts
Both craniopharyngiomas and Rathke's cleft cysts can compress adjacent structures, such as the optic nerves, carotid arteries, or cranial nerves. The treatment of choice for both craniopharyngiomas and Rathke's cleft cysts is surgical removal. Using transsphenoidal surgery, these tumors can now be safely and effectively removed and drained without opening the skull. Since the chance of recurrence for craniopharygiomas is based on the amount of tumor left behind after surgery, the improved visualization provided by the endoscope can dramatically reduce recurrence rate. It should be noted that large craniopharyngiomas may not be completely removable with this technique. In this case, conventional surgery would be performed.

Chordomas and Chondrosarcomas
These slow-growing tumors are difficult to remove entirely and often require additional radiation therapy. However, using the endoscopic, endonasal technique small, midline tumors can be removed without the need for a large cranial opening. In addition, larger tumors can be biopsied and reduced in size as much as possible (debulked) in preparation for radiation therapy. This increases the quality of life in patients with these indolent but progressive tumors.

Meningiomas
Meningiomas are also benign slow growing tumors that can arise in the covering of the brain at the base of the skull. In particular, tumors underneath the frontal lobe can be removed endoscopically if they are small in size and have not spread extensively to other areas.

Cerebrospinal Fluid Leaks
Leakage of cerebrospinal fluid (CSF), the liquid that bathes and cushions the brain and spinal cord, can occur following injury or for other reasons. If this happens, there is a risk of acquiring an infection of the brain called meningitis or encephalitis. Traditionally, a large skull opening was required to identify the site of the leak. Now, with a minimally invasive endoscopic surgical technique, the site of the fluid leak can be approached through the nose and safely and easily repaired without touching the brain or opening the skull.

Surgical Procedure and Follow Up

As indicated previously, the endoscopic transsphenoidal approach is performed through the nostrils. A natural passageway at the back of the nose can be enlarged so that the endoscope and instruments can safely pass into the air-filled space located there called the sphenoid sinus. From this region tumors located at a variety of locations at the skull base are easily accessed.

By directing the endoscope downward, the surgeon can easily see the back of the throat and palate and remove other types of tumors. After endoscopic surgery, the patient's nose may feel stuffed for a few days but there will be no packing.

The risk of damaging the normal pituitary gland is quite low, but increases with the size of the tumor. The patient with a large tumor may therefore need hormone replacement after surgery.

The patient should not blow his/her nose for two weeks so that the reconstruction of the skull base is not dislodged. Most people go home between 2-4 days after surgery depending on tumor size, risk of leakage of cerebrospinal fluid and pituitary gland function.

Most benign tumors in the brain are slow growing and can invade adjacent structures. If the tumor has spread to adjacent structures, radiation therapy is usually recommended following surgery. If the tumor has been completely removed, the risk of recurrence may be as low as 10%. Overall, using the endoscopic technique, with improved visualization compared to traditional microscope-based surgery, the risk of tumor recurrence should be even lower.