title: Suboptimal sphenoid and sellar exposure: a consistent finding in patients treated with repeat transsphenoidal surgery for residual endocrine-inactive macroadenomas.
abstract: OBJECTIVE
  In a series of patients with residual endocrine-inactive macroadenomas who underwent repeat surgery, we assess possible reasons for prior subtotal removal, reoperative success, complication rates, and patient impressions.
  
  
  METHODS
  All patients were identified who had a prior subtotal removal of an endocrine-inactive macroadenoma and were reoperated on for residual sellar tumor via an endonasal approach.
  
  
  RESULTS
  Over 6 years, of 188 consecutive patients with endocrine-inactive adenomas, 30 (16%) had repeat surgery (age, 15-77 yr; median interval between surgeries, 25 mo; median follow-up, 20 mo). Maximal tumor diameter averaged 2.4 +/- 0.9 cm. At reoperation, a suboptimal bony exposure was seen in all 30 patients: at the sphenoid keel, the sella, or both in 97, 93, and 90% of patients, respectively. Cavernous sinus invasion was seen in 16 (53%) patients and a fibrous/rubbery consistency in 12 (40%). Gross total tumor removal was achieved in 17 (57%) patients, including 12 of 14 (86%) with noninvasive tumors and 5 of 16 (31%) with invasive tumors, (P < 0.01). All six fibrous/rubbery but noninvasive tumors were totally removed. Of 16 patients with preoperative visual loss, 15 (94%) improved. Complications included one each of cerebrospinal fluid leak, delayed sinusitis, and new hypothyroidism. In 17 patients with prior sublabial surgery who completed questionnaires, the second (endonasal) surgery was associated with an easier recovery, less pain, and better nasal airflow in 82, 88, and 93%, respectively (P < 0.0001).
  
  
  CONCLUSIONS
  In patients with residual sellar endocrine-inactive adenomas, a suboptimal opening at the sphenoid keel or sella at the first surgery and a high proportion of fibrous/rubbery tumors likely contributed to prior subtotal removal of otherwise accessible tumor. With a wider exposure, most noninvasive tumors can be totally removed, whereas invasive tumors can be effectively debulked. An endonasal reoperation is well tolerated with a low complication rate.
authors.affiliation: Division of Neurosurgery, University of California at Los Angeles, David Geffen School of Medicine, USA.
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Mattozo
authors.forename: Joshua R
authors.initials: JR
authors.lastname: Dusick
authors.forename: Felice
authors.initials: F
authors.lastname: Esposito
authors.forename: Hugo
authors.initials: H
authors.lastname: Mora
authors.forename: Pejman
authors.initials: P
authors.lastname: Cohan
authors.forename: Dennis
authors.initials: D
authors.lastname: Malkasian
authors.forename: Daniel F
authors.initials: DF
authors.lastname: Kelly
mesh_terms: D000236:Adenoma / Q000473:pathology / Q000601:surgery*; D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000379:methods*; D012086:Reoperation / Q000379:methods; D012189:Retrospective Studies; D012658:Sella Turcica / Q000473:pathology / Q000601:surgery*; D012888:Skull Neoplasms / Q000473:pathology / Q000601:surgery*; D013100:Sphenoid Bone / Q000473:pathology / Q000601:surgery