Name:
Contact endoscopy as a novel technique for intra-operative identification of normal pituitary gland and adenoma
Description:
Contact endoscopy as a novel technique for intra-operative identification of normal pituitary gland and adenoma
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/6432dc07-675b-408c-8ecc-fc3caaa80213/videoscrubberimages/Scrubber_492.jpg
Duration:
T00H09M13S
Embed URL:
https://stream.cadmore.media/player/6432dc07-675b-408c-8ecc-fc3caaa80213
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/6432dc07-675b-408c-8ecc-fc3caaa80213/21-199.mp4?sv=2019-02-02&sr=c&sig=VO89TV5opXc53Pe%2B6dJ4wzj7wL6qoGNIjrVjl%2BzjTXY%3D&st=2024-05-01T22%3A12%3A35Z&se=2024-05-02T00%3A17%3A35Z&sp=r
Upload Date:
2021-12-07T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: This is a video demonstrating a new concept using contact endoscopy to try to differentiate between normal pituitary gland and adenoma during endoscopic surgery. Now, a normal pituitary gland typically demonstrates very classic microvascular pattern, which we can sometimes differentiate. Now, this kind of differentiation in the vascular has been used successfully and with contact endoscopy in head and neck surgery, especially for laryngeal surgery.
SPEAKER: We took the same endoscope, which in this case was produced by the KARL STORZ company, and used it to try to look at pituitary tumors and adenoma. Here's an example of using the contact endoscopy. You can see the type of microscopic view, essentially, that we can get by placing the contact endoscope very close or on the tissue. Here you can see a microvascular pattern. And as we come in contact and adjust the focus, we can start to see that microvascular pattern come in to closer view.
SPEAKER: This does require a certain learning curve with understanding using of the scope. But we can really pick out that microvascular pattern that may not be evident and usually is not so evident under simple white light endoscopy. Here's a beautiful example of normal gland with a really very hypervascular pattern to it. And using this over several cases, we've started to gain an appreciation for the differentiation between normal gland and tumor.
SPEAKER: So here's an example where we're looking at both. You can see the endoscopy of the tumor on the left clearly has almost no vascularity to it. You can see a few random blood cells. Whereas on the right, the gland has a very typical microvascular pattern with a very clear archetypal network to it. Here's that visualization.
SPEAKER: And again, using this to differentiate between tumor and gland. Here's yet another example of a different tumor. Again, you can see the lack of vascularity in the tumor. And then once we focus on the gland tissue itself, you can really see a bit of that microvascular pattern. Case demonstrates 68-year-old man who presented with more than a year of double vision and also decreased libido.
SPEAKER: Neurologic exam showed a complete sixth nerve palsy. And we find a large sellar and suprasellar mass with clear extension into left cavernous sinus. There's some evidence of mild pituitary dysfunction. Intraoperatively after wide exposure within the indocyanine green fluorescence, we can certainly see vasculature well. And the edge of the tumor shows appropriate bleeding from the gland.
SPEAKER: When we expose the tumor itself and perform contact endoscopy, we see what seems to be a relatively common pattern, which is that there's very bland architecture in the tumor. We don't see any clear vascular patterns. We don't see a network of vasculature. And certainly see small areas of capillaries around the edge and bleeding from the edge but no frank, visible network.
SPEAKER: There's some learning curve with using the contact endoscope to appropriately focus it within the tumor itself. But rather quickly, we're able to do this reliably on every case. Then proceeded with resection in the standard fashion will send some specimen for pathology. And then using two suctions, resected the tumor back to the posterior aspect of the sellar. And then visualize the left cavernous wall, which clearly had invasion through it.
SPEAKER: And here we can see after filling the cavernous sinus with SURGIFLO, Floseal, and then working up to the right cavernous wall, the right cavernous wall here is not invaded. In fact, there's evidence of a small amount of gland on that right cavernous wall. Very clear examples of the medial cavernous wall in this case on both sides. And clearing first the left and now the right side.
SPEAKER: And then that allows us to finally peel the tumor from the diaphragm. Again, some specimen being grasped here with the pituitary. A very gentle counterretraction and dissection can even be done with the suction. Care is taken to not just pull the tumor out. And here we sharply dissect the gland pseudocapsule from the tumor. Here we can see very clear separation of the medial cavernous wall and then resection by cutting the caroticoclinoidal ligament as
SPEAKER: The last cut to perform our final resection of this invaded medial cavernous wall. Inferior aspect of it is probably the most invaded portion here as we cut the inferior parasellar ligaments. And finally, remove the medial cavernous wall. Angled endoscopy is used to inspect the area between the diaphragma and the anterior dura. Here, we can clearly see a classic pattern with visualization of the gland along the diaphragma.
SPEAKER: We completely resected the cavernous wall. And then contact endoscopy on the gland shows what seems to be a typical pattern of the vascular network, which shows the architecture of the gland itself. And helps us identify and separate the gland from the tumor itself. No evidence of any damage with the contact endoscopy with any heat transmission.
SPEAKER: Of note, we do use an LED light source at this point, which is not quite at full power, but you can see the visualization is really quite good. You can even see red blood cells flowing through the capillaries in this vascular network on the gland. Tissue without this vascular network which was felt to be tumor was sent for pathology.
SPEAKER: And a histology was confirmed to be adenoma without normal pituitary architecture. Another case, a 75-year-old man who presented, you can see his notable labs have some stalk effect, hyperprolactinemia. An Indocyanine green fluorescence does not really differentiate in some cases, and it really has a narrow window. Here, we see an area that we think might be a layer of gland overlying the tumor.
SPEAKER: But as is always the case., it can be very difficult to try to differentiate the two simply through white light. By adding contact endoscopy to view the tumor, here, we can clearly see the lack of any vascular pattern, any vascular network. And we can see very low vascularity, which is very typical for tumor in this case. Does have some vessels in it or some red blood cells in it, but no organized network.
SPEAKER: This again differentiates between gland. And where we do contact endoscopy here on the gland, and you can see the network and the architecture of the gland itself. And here we can see that vasculature. Even though this is a very thin layer, that thin layer still has its vasculature and its architecture preserved. So this allows us in situ, in vivo to evaluate this without having to cut out any of the tissue, send it to pathology, or cut it to see whether or not it bleeds, which is another technique that can be used.
SPEAKER: In this case, then we can be confident of this capsule and able to perform an extracapsular dissection of the tumor by peeling it free from the area that we were now convinced was gland. This is typical after extracapsular dissection; we can then peel the tumor out. And here you can see where that pseudocapsule, which remember, is comprised of pituicytes, has been separated from the tumor. And here's our final view with very obvious gland now preserved on the surface.
SPEAKER: And this tissue, which was felt to be tumor without any sort of vascular pattern to it was sent for histopathology confirmed to be adenoma. Obviously, further study is necessary to confirm or differentiate between these areas and ensure that what we are seeing with contact endoscopy always fits the histology, which remains to be determined in a large series. However, I think this is an exciting technique that can be used to help preserve gland and help ensure the most complete resection of pituitary tumors.
SPEAKER: This allows, again, for real- time assessment in situ of the architecture of pituitary gland. It has this great advantage of examining multiple areas without having to cut into the tissue itself. It requires further study, but we're excited to look into this further. Thank you very much.