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Name:
10.3171/2023.4.FOCVID2320
Description:
10.3171/2023.4.FOCVID2320
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https://cadmoremediastorage.blob.core.windows.net/30023d62-ded8-41e2-ab33-ea244535496a/videoscrubberimages/Scrubber_477.jpg
Duration:
T00H10M27S
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https://stream.cadmore.media/player/30023d62-ded8-41e2-ab33-ea244535496a
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https://cadmoreoriginalmedia.blob.core.windows.net/30023d62-ded8-41e2-ab33-ea244535496a/23-20.mp4?sv=2019-02-02&sr=c&sig=lSGzE7MhAJYTLPsi1oTAC2fhev4QE9huq2efqLOKOpo%3D&st=2026-04-02T05%3A55%3A49Z&se=2026-04-02T08%3A00%3A49Z&sp=r
Upload Date:
2023-05-23T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
JAMIE J. VAN GOMPEL: On behalf of my authors, Dr. Bancos, Dr. Choby, and myself, here I present a case of subtotal gland resection for a MR-negative Cushing disease with no detectable tumor on gland exploration: an operative video. This is a 40-year-old woman, ACTH-dependent Cushing syndrome complicated by diabetes mellitus, obesity, and hypertension. Her BMI was 47.5. MRI demonstrated no discrete lesion within her pituitary gland.
JAMIE J. VAN GOMPEL: IPSS was inconclusive and repeated twice. DOTATATE PET did not demonstrate any peripheral lesions. CT PET-- sorry, CT chest and abdomen, no lesions, in addition. Here is imaging outside 3T dynamic MRI, demonstrating a presellar type sella with no evident tumor to be seen or found in this particular case. We repeated a 7T MRI here with no additional lesions identified.
JAMIE J. VAN GOMPEL: Operation was performed in a supine position. We used CTA sterotaxis. Binostril technique was utilized. We had a planned subtotal resection if there was no tumor found on exploration. TXA, as previously described in our protocol, was used. My friend Dr. Lillehei described this technique in 1989, 2011, where 22 patients were treated with subtotal gland resection.
JAMIE J. VAN GOMPEL: 82% of patients went into remission. I found this technique to be extremely valuable. Here we are operating through the naris. A posterior--limited posterior septectomy is performed. And a wide expanse of sphenoidotomy is performed. In this conical-type sella, we drill out the gland as well as we can, although do not expend excessive amounts of time drilling out the whole inferior clivus.
JAMIE J. VAN GOMPEL: It is important, however, still to be, with bone work, cavernous sinus to cavernous sinus, as we are here. Utilizing a caudal elevator, it is helpful to feel from the paraclival carotid to paraclival carotid to ensure that there is no additional bone work that is necessary. Once this is performed, we carefully open up the dura, ensuring not to violate the pseudocapsule or the capsule around the pituitary gland in order to explore completely.
JAMIE J. VAN GOMPEL: This is critical, especially in Cushing's patients. This is a case from approximately 4 years ago, so no intraoperative ultrasound was utilized to attempt to identify the tumor. Further, this is before the-- my adaptation of medial wall to cavernous sinus resection. Here, we're taking our time to still look for a tumor. And as typically is the case, even despite the TXA, we see bleeding from the circular sinus.
JAMIE J. VAN GOMPEL: We take our time to push the gland away from the inferior dura and inspect that surface through it, through a curette. It is helpful to take a right-angle hook to feel the gland for abnormalities and expand your dural openings. Here is the technique of subtotal gland resection, as described by Lillehei, in which you divide the anterior gland into thirds and cut back from the anterior aspect as well as the inferior 125%, preserving a block of pituitary gland in the middle portion of the gland as well as the posterior gland in order to avoid DI and postoperative complications.
JAMIE J. VAN GOMPEL: This technique has approximately a 10% chance of pituitary failure. Here, we see side to side and make our cuts in one-thirds. And an inferior cut. Here, we have some milky white tissue coming out, commonly with these cuts, which was a problem with prior exploration. You see this milky white substance come out, which can fool you to be pituitary tumor. We then take this dissector and work to the back of the pituitary gland, feeling those posterior clinoids.
JAMIE J. VAN GOMPEL: Here, I'm also suspicious that we see a tumor midgland, but continue on with the plan of subtotal gland resection. I do not explain-- explore dramatically in these cases. I take a pituitary right-angle curette and take these pieces out and allow the pathologists to examine them postoperatively. So we try to take them on larger pieces.
JAMIE J. VAN GOMPEL: So that's a portion of that lateral gland. There's a little bit more posteriorly, so we'll continue to work that plane in order to provide less manipulation and damage to the intact block we plan to keep behind. Here, again, we're going to take another separate piece out and keep that as the right side of the gland. We're going to also inspect inferiorly and then to the left.
JAMIE J. VAN GOMPEL: And we'll take this out as a separate specimen on the left side. In a similar technique, and you'll see again that milky white tissue come out that people believe is tumor sometimes, that's simply a necrotic or infarcted gland from your compression of the gland. And we're going to send this now as left gland. You'll see here in the middle portion as we explore that left cavernous sinus wall there appears to start to be a tumor evident, just above the sucker, currently.
JAMIE J. VAN GOMPEL: We're going to continue and look and see if there's anything attached to those cavernous sinus walls. Here, we've also removed that inferior block and set that as a separate specimen as we continue to explore the gland. However, right here, we're going to start to become suspicious of a gland-- of a tumor right in the middle portion of the gland.
JAMIE J. VAN GOMPEL: Kind of see a whitish tissue extending just above our sucker. You can see now there's some very clear different type of material coming out. And we'll find a pseudocapsule right here. You can see a tumor right there in the middle of our field, ultimately, on pathology, this will prove to be the tumor. We're going to stop, and rather than do a pseudocapsular technique, I want to ensure, because I've already violated, that we have pathologic tissues.
JAMIE J. VAN GOMPEL: So we'll send this as a separate specimen, despite already having the left, right, and inferior gland specimen. You see how white and different that is from the rest of that yellowish gland. And again, in Cushing's disease, the gland oftentimes is very yellowish from the Crooke’s changes that we see. Now we're going to inspect that cavity and try to take out that pseudocapsule width. Some additional gland and try to get a margin plus resection in this particular circumstance.
JAMIE J. VAN GOMPEL: There's an additional portion of inferior gland posteriorly that we'll remove as part of our planned subtotal gland resection right here. And again, we try to remove these all in separate blocks. At this time as well, we're going to continue to-- after we believe the complete exoneration of that capsule-- we're going to take a lot of time to, again, inspect for separate tumors.
JAMIE J. VAN GOMPEL: That is not uncommon to see, more than one tumor in these cases. We have no CSF leak, as can be seen, although you can see the diaphragm off to the left there. And we're going to look through that right-angle curette. You can see how the subtotal gland resection allows you to really-- provides a lot of room within the pituitary sella itself to allow inspection.
JAMIE J. VAN GOMPEL: And that bleeding is now controlled. It is important in this first operation to be very thorough and take your time, as we are here. I try to do minimal manipulation with the posterior gland. You can see that yellowish posterior gland on the inferior left-hand side. We just were just down by it. Again, it's going to be right back, on the back side of the left side.
JAMIE J. VAN GOMPEL: It isn't uncommon for us to submarine here. Here, I'm trying to ensure you can see that area of gland that resected adjacent to that prior tumor. I'm trying to ensure there's no additional tumor in that location. There's the posterior gland again right there.
JAMIE J. VAN GOMPEL: Right to the back side, right there. You can see that medial wall of the cavernous sinus there really well. Then we're just going to take some liquid Gelfoam and fill the cavity and put some bloody Gelfoam in there. Nowadays, we would place a floor flap in there as well. But this is adequate closure for this. This demonstrates all the other specimens being negative.
JAMIE J. VAN GOMPEL: However, there is a tumor found, as we showed. Postop day 1, the cortisol was 1.5 micrograms per deciliter, proving cure. Dismissed postop day 2. Three years out after surgery, she remains in remission and cure. She had a postop adrenal suppression for between 6 and 12 months, diabetes improved. Hypertension is resolved.
JAMIE J. VAN GOMPEL: And here is what an MRI looks like after this. You can see a fair amount of pituitary tissue done, but the pituitary gland is intact. I have found this subtotal technique very helpful in my practice. There appears to be low complication rates with this. However, I will emphasize that I do not perform this in patients contemplating pregnancy in the future.
JAMIE J. VAN GOMPEL: Here are some additional references. We appreciate your time.
Segment:0 .
[MUSIC PLAYING]
JAMIE J. VAN GOMPEL: On behalf of my authors, Dr. Bancos, Dr. Choby, and myself, here I present a case of subtotal gland resection for a MR-negative Cushing disease with no detectable tumor on gland exploration: an operative video. This is a 40-year-old woman, ACTH-dependent Cushing syndrome complicated by diabetes mellitus, obesity, and hypertension. Her BMI was 47.5. MRI demonstrated no discrete lesion within her pituitary gland.
JAMIE J. VAN GOMPEL: IPSS was inconclusive and repeated twice. DOTATATE PET did not demonstrate any peripheral lesions. CT PET-- sorry, CT chest and abdomen, no lesions, in addition. Here is imaging outside 3T dynamic MRI, demonstrating a presellar type sella with no evident tumor to be seen or found in this particular case. We repeated a 7T MRI here with no additional lesions identified.
JAMIE J. VAN GOMPEL: Operation was performed in a supine position. We used CTA sterotaxis. Binostril technique was utilized. We had a planned subtotal resection if there was no tumor found on exploration. TXA, as previously described in our protocol, was used. My friend Dr. Lillehei described this technique in 1989, 2011, where 22 patients were treated with subtotal gland resection.
JAMIE J. VAN GOMPEL: 82% of patients went into remission. I found this technique to be extremely valuable. Here we are operating through the naris. A posterior--limited posterior septectomy is performed. And a wide expanse of sphenoidotomy is performed. In this conical-type sella, we drill out the gland as well as we can, although do not expend excessive amounts of time drilling out the whole inferior clivus.
JAMIE J. VAN GOMPEL: It is important, however, still to be, with bone work, cavernous sinus to cavernous sinus, as we are here. Utilizing a caudal elevator, it is helpful to feel from the paraclival carotid to paraclival carotid to ensure that there is no additional bone work that is necessary. Once this is performed, we carefully open up the dura, ensuring not to violate the pseudocapsule or the capsule around the pituitary gland in order to explore completely.
JAMIE J. VAN GOMPEL: This is critical, especially in Cushing's patients. This is a case from approximately 4 years ago, so no intraoperative ultrasound was utilized to attempt to identify the tumor. Further, this is before the-- my adaptation of medial wall to cavernous sinus resection. Here, we're taking our time to still look for a tumor. And as typically is the case, even despite the TXA, we see bleeding from the circular sinus.
JAMIE J. VAN GOMPEL: We take our time to push the gland away from the inferior dura and inspect that surface through it, through a curette. It is helpful to take a right-angle hook to feel the gland for abnormalities and expand your dural openings. Here is the technique of subtotal gland resection, as described by Lillehei, in which you divide the anterior gland into thirds and cut back from the anterior aspect as well as the inferior 125%, preserving a block of pituitary gland in the middle portion of the gland as well as the posterior gland in order to avoid DI and postoperative complications.
JAMIE J. VAN GOMPEL: This technique has approximately a 10% chance of pituitary failure. Here, we see side to side and make our cuts in one-thirds. And an inferior cut. Here, we have some milky white tissue coming out, commonly with these cuts, which was a problem with prior exploration. You see this milky white substance come out, which can fool you to be pituitary tumor. We then take this dissector and work to the back of the pituitary gland, feeling those posterior clinoids.
JAMIE J. VAN GOMPEL: Here, I'm also suspicious that we see a tumor midgland, but continue on with the plan of subtotal gland resection. I do not explain-- explore dramatically in these cases. I take a pituitary right-angle curette and take these pieces out and allow the pathologists to examine them postoperatively. So we try to take them on larger pieces.
JAMIE J. VAN GOMPEL: So that's a portion of that lateral gland. There's a little bit more posteriorly, so we'll continue to work that plane in order to provide less manipulation and damage to the intact block we plan to keep behind. Here, again, we're going to take another separate piece out and keep that as the right side of the gland. We're going to also inspect inferiorly and then to the left.
JAMIE J. VAN GOMPEL: And we'll take this out as a separate specimen on the left side. In a similar technique, and you'll see again that milky white tissue come out that people believe is tumor sometimes, that's simply a necrotic or infarcted gland from your compression of the gland. And we're going to send this now as left gland. You'll see here in the middle portion as we explore that left cavernous sinus wall there appears to start to be a tumor evident, just above the sucker, currently.
JAMIE J. VAN GOMPEL: We're going to continue and look and see if there's anything attached to those cavernous sinus walls. Here, we've also removed that inferior block and set that as a separate specimen as we continue to explore the gland. However, right here, we're going to start to become suspicious of a gland-- of a tumor right in the middle portion of the gland.
JAMIE J. VAN GOMPEL: Kind of see a whitish tissue extending just above our sucker. You can see now there's some very clear different type of material coming out. And we'll find a pseudocapsule right here. You can see a tumor right there in the middle of our field, ultimately, on pathology, this will prove to be the tumor. We're going to stop, and rather than do a pseudocapsular technique, I want to ensure, because I've already violated, that we have pathologic tissues.
JAMIE J. VAN GOMPEL: So we'll send this as a separate specimen, despite already having the left, right, and inferior gland specimen. You see how white and different that is from the rest of that yellowish gland. And again, in Cushing's disease, the gland oftentimes is very yellowish from the Crooke’s changes that we see. Now we're going to inspect that cavity and try to take out that pseudocapsule width. Some additional gland and try to get a margin plus resection in this particular circumstance.
JAMIE J. VAN GOMPEL: There's an additional portion of inferior gland posteriorly that we'll remove as part of our planned subtotal gland resection right here. And again, we try to remove these all in separate blocks. At this time as well, we're going to continue to-- after we believe the complete exoneration of that capsule-- we're going to take a lot of time to, again, inspect for separate tumors.
JAMIE J. VAN GOMPEL: That is not uncommon to see, more than one tumor in these cases. We have no CSF leak, as can be seen, although you can see the diaphragm off to the left there. And we're going to look through that right-angle curette. You can see how the subtotal gland resection allows you to really-- provides a lot of room within the pituitary sella itself to allow inspection.
JAMIE J. VAN GOMPEL: And that bleeding is now controlled. It is important in this first operation to be very thorough and take your time, as we are here. I try to do minimal manipulation with the posterior gland. You can see that yellowish posterior gland on the inferior left-hand side. We just were just down by it. Again, it's going to be right back, on the back side of the left side.
JAMIE J. VAN GOMPEL: It isn't uncommon for us to submarine here. Here, I'm trying to ensure you can see that area of gland that resected adjacent to that prior tumor. I'm trying to ensure there's no additional tumor in that location. There's the posterior gland again right there.
JAMIE J. VAN GOMPEL: Right to the back side, right there. You can see that medial wall of the cavernous sinus there really well. Then we're just going to take some liquid Gelfoam and fill the cavity and put some bloody Gelfoam in there. Nowadays, we would place a floor flap in there as well. But this is adequate closure for this. This demonstrates all the other specimens being negative.
JAMIE J. VAN GOMPEL: However, there is a tumor found, as we showed. Postop day 1, the cortisol was 1.5 micrograms per deciliter, proving cure. Dismissed postop day 2. Three years out after surgery, she remains in remission and cure. She had a postop adrenal suppression for between 6 and 12 months, diabetes improved. Hypertension is resolved.
JAMIE J. VAN GOMPEL: And here is what an MRI looks like after this. You can see a fair amount of pituitary tissue done, but the pituitary gland is intact. I have found this subtotal technique very helpful in my practice. There appears to be low complication rates with this. However, I will emphasize that I do not perform this in patients contemplating pregnancy in the future.
JAMIE J. VAN GOMPEL: Here are some additional references. We appreciate your time.
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