Discussion
hypothyroidism, samatotropinoma, hypocortisolismus, tumor, postoperative pain, diabetes insipidus, nasal tamponade, tumors, liquorrhea, adenoma, acromegaly, intraoperative liquorrhea
TUMOR, TUMOR GROWTH, DISEASE, DIABETES INSIPIDUS, COMPLICATION, ACROMEGALY, REMISSION, ADENOMA, HYPOTHYROIDISM, TUMORS, COMPLICATIONS
This research endeavor undertook a comparative investigation of two distinct adenomectomy techniques in the context of acromegaly patients: transnasal transsphenoidal adenomectomy employing a traditional microscope versus utilizing an endoscope. According to the results of the study, it was found that the endoscopic technique increases the radicality of tumor removal in comparison with microscope one. For example, total elimination of samatotropinoma was performed in 88.4% of endoscopic patients and 67.5% of microscopic patients (OR=5.10, 95% CI [1.51–17.24], p<0.05). When using a microscope, the percentage of subtotal tumor removal was relatively high (25%). However, it was significantly lower (9.3%) in endoscopic cases (OR=4.55, 95% CI [1.20–17.24], p<0.05). Such advantages of the endoscope over the microscope are associated with better illumination of an operating field during endoscopic operations, better angle of vision, increased handling capabilities, etc.In this study, anesthesia time during endoscopic operations was shorter than microscopic procedures (202 ± 77 minutes versus 237 ± 68 minutes, Р<0.001). Endoscopic procedures were also shorter (142 ± 54 minutes versus 176 ± 56 minutes, Р<0.001). However, the operation time strongly depends on a tumor’s density, size, and localization; therefore, there was a considerable difference in the operating time in both the endoscopic (52 to 312 min) and microscopic (64 to 355 min) groups. Russian neurosurgeons reported that on average, endoscopic operations take 25-30 minutes less time (The number of patients with improved visual function following surgical treatment also confirmed the increased efficiency of endoscopic adenomectomy for acromegaly. In particular, the endoscopic technique improved eyesight in 51.8% of patients, while the microscopic procedure had the same effect in 25.9%. The intergroup difference was statistically significant (OR=3.07, 95% CI [1.12–8.41], p < 0.05). It can be due to the tumor removing radicality that presses on the area of the sella turcica stool (compressing the optical nerves) when using the endoscopic technique.In the postoperative period, mild complications prevailed when using the endoscopic technique of tumor removal compared to the microscopic technique Most of them were hormonal (diabetes insipidus, hypocortisolismus, hypothyroidism), but there was no statistically significant difference among the groups in the frequency of these complications.However, intraoperative liquorrhea was significantly higher with the microscope compared to the endoscope: 51.9% vs. 35.7% (OR=3.02, 95% CI [1.21–7.50], p<0.05). Intraoperative liquorrhea is common in endoscopic surgery, but this complication can also occur after microscopic operations. It is more often detected in cases of more radical tumor removal during endoscopic operations. Broersen et al. (It is worth noting that the incidence of intraoperative liquorrhea depends rather on the direction of tumor growth, its size, and the sella turcica diaphragm structure than on the illumination quality of the operating wound. However, when working with the suprasellar part of the tumor, it is vital to achieve the best visual control possible under endoscopic illumination because it allows the detection of even the small CSF fistulas and successfully prevents the increase in CSF leak rates.The overall disease remission evaluation revealed that the studied approaches had no clear advantages over one another. However, patients had a slightly higher remission rate after endoscopic adenomectomy (44% vs. 48%, respectively, P = 1.000). The results obtained in this study are consistent with those of other studies on the issue. For example, in a study by Fathalla et al. (Another study involved 113 patients with acromegaly who underwent surgical removal of the adenoma (endoscopic – 66 patients, microscopic – 47 patients). This study reported more frequent cases of diabetes insipidus development after the endoscopic (9.1% vs. 4.3% of cases, p = 0.466). At the same time, microscopic treatment resulted in a higher incidence of hypothyroidism (in 21.2% of cases in microscopic compared to 12.2% in endoscopic procedures, p < 0.001) (A recent meta-analysis of 21 studies (involving 292 patients with acromegaly who underwent endoscopic adenomectomy and 648 patients who underwent microscopic adenomectomy) showed that endoscopic technique was more likely to result in total tumor resection compared to microscopic one (53.5% vs. 46.6%, respectively). In addition, vision improvement occurred in 73.2% and 49.6% of patients in endoscopic and microscopic groups (Some studies note that the microscopic transsphenoidal approach provides a limited view due to the narrow corridor to the Turkish saddle. The endoscopic methods, on the other hand, offer a wider view of the medial and inferior walls of the cavernous sinus, enabling a complete tumor resection and, consequently, hormonal remission (Thus, applying endoscopes with different viewing angles can significantly facilitate examining the surgical intervention area in good light conditions. The ability to remove the tumor under direct visual control increases the operation radicality and reduces the risk of damaging vital anatomical structures. Another advantage of endoscopic interventions is the safer placement of a nasal port in a narrow or curved nasal passage. The presence of postoperative nasal tamponade several days after the surgery increases (twofold on average) the duration of hospital stay. Therefore, the endoscopic technique is safer since it eliminates the need for postoperative nasal tamponade and reduces postoperative pain.At the same time, microscopic somatotropin removal is a completely reliable and proven method. If the hospital has equipment for microscopic operations only, there is no fundamental need to purchase additional endoscopic equipment to enable operations in the chiasmal-sellar regions. However, patients with large tumors and significant extracellular extension require treatment in specialized centers.The present study has several limitations. First, the tumor removal radicality and procedure time depend on the tumor size, the invasion direction and degree, and the tumor density. The present study was limited to tumors <30 mm in size, located within the sella turcica and extending moderately in multiple directions. Secondly, the segmentation of patients according to their tumor characteristics poses challenges, primarily owing to the rarity of acromegaly as a disease. This problem was solved by differentiating tumor sizes and extension directions in comparison groups. In addition, there were not enough patients with dense tumors in the sample to draw any conclusions.