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==Overview==
 
== Overview ==
Surgery is the mainstay of treatment for acromegaly due to [[pituitary adenoma]]. The goal of the surgery will be the removal of the [[pituitary]] mass that causes acromegaly. The best sugical technique is endonasal transsphenoidal surgery.
 
==Surgery==
==Surgery==
Surgery is a rapid and effective treatment, of which there are two alternative methods. The first method, a procedure known as [http://www.skullbaseinstitute.com/pituitary_tumor.htm'''Endonasal Transphenoidal surgery'''], involves the surgeon reaching the pituitary through an incision in the nasal cavity wall.  The wall is reached by passing through the nostrils with microsurgical instruments. The second method is Transphenoidal surgery during which an incision is made into the gum beneath the upper lip.  Further incisions are made to cut through the septum to reach the nasal cavity, where the pituitary is located.  Endonasal Transphenoidal surgery is a less invasive procedure with a shorter recovery time than the older method of Transphenoidal surgery, and the likelihood of removing the entire tumor is greater with reduced side-effects. Consequently, Endosnasal Transphenoidal surgery is often used as a first option, with Transphenoidal and other treatments, such as, medicinal therapy or radiostatic neurosurgery being used to reduce the remaining adverse effects of the remaining tumor.


These procedures normally relieve the pressure on the surrounding brain regions and lead to a lowering of GH levels. If the surgery is successful, facial appearance and soft tissue swelling improve within a few days. Surgery is most successful in patients with blood GH levels below 40 ng/ml before the operation and with pituitary tumors no larger than 10 mm in diameter. Success depends on the skill and experience of the surgeon. The success rate also depends on what level of GH is defined as a cure. The best measure of surgical success is normalization of GH and IGF-1 levels. Ideally, GH should be less than 2 ng/ml after an oral glucose load. A review of GH levels in 1,360 patients worldwide immediately after surgery revealed that 60 percent had random GH levels below 5 ng/ml. Complications of surgery may include [[cerebrospinal fluid]] leaks, [[meningitis]], or damage to the surrounding normal pituitary tissue, requiring lifelong pituitary hormone replacement.
*Surgery is the mainstay of treatment for acromegaly due to [[pituitary adenoma]]. The goal of the surgery will be the removal of the pituitary mass that causes acromegaly. The best sugical technique is endonasal transsphenoidal surgery.<ref name="pmid1521518">{{cite journal| author=Fahlbusch R, Honegger J, Buchfelder M| title=Surgical management of acromegaly. | journal=Endocrinol Metab Clin North Am | year= 1992 | volume= 21 | issue= 3 | pages= 669-92 | pmid=1521518 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1521518  }}</ref><ref name="pmid25356808">{{cite journal| author=Katznelson L, Laws ER, Melmed S, Molitch ME, Murad MH, Utz A et al.| title=Acromegaly: an endocrine society clinical practice guideline. | journal=J Clin Endocrinol Metab | year= 2014 | volume= 99 | issue= 11 | pages= 3933-51 | pmid=25356808 | doi=10.1210/jc.2014-2700 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25356808  }}</ref>
 
=== '''Endonasal transsphenoidal surgery''' ===
Most of the patients with acromegaly due to [[pituitary adenoma]] undergo transsphenoidal [[surgery]]. Although it is a challenging operation due to the anatomical location of the [[pituitary gland]], tthe rate of complete successful resection in patients with adenomas smaller than 10 cm and [[GH]] level below 40ng is very high. It is important to remove the pituitary masses for this reasons:
* They may invade the [[cavernous sinus]].
* They may be associated with [[Aneurysm|microaneurysms]].
MRI and CT imaging are used in guidance during the [[surgery]] and they have been linked with high safety and effectiveness of the surgery.<ref name="pmid12182410">{{cite journal| author=Lasio G, Ferroli P, Felisati G, Broggi G| title=Image-guided endoscopic transnasal removal of recurrent pituitary adenomas. | journal=Neurosurgery | year= 2002 | volume= 51 | issue= 1 | pages= 132-6; discussion 136-7 | pmid=12182410 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12182410  }}</ref>
 
In case the surgery is performed successfully, the acral features of acromegaly will improve within days.
 
Although it is very rare, some complications may occur. These complications include the following:<ref name="pmid19884662">{{cite journal| author=Melmed S| title=Acromegaly pathogenesis and treatment. | journal=J Clin Invest | year= 2009 | volume= 119 | issue= 11 | pages= 3189-202 | pmid=19884662 | doi=10.1172/JCI39375 | pmc=2769196 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19884662  }} </ref><ref name="pmid12186456">{{cite journal| author=Cappabianca P, Cavallo LM, Colao A, de Divitiis E| title=Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. | journal=J Neurosurg | year= 2002 | volume= 97 | issue= 2 | pages= 293-8 | pmid=12186456 | doi=10.3171/jns.2002.97.2.0293 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12186456  }} </ref> 
*  [[Hemorrhage|Local hemorrhage]]
*  [[CSF]] leakage
*  [[Diabetes insipidus]]
*  [[Infection]]  
*  [[Meningitis]]
*  Damage of the normal [[Pituitary gland|pituitary tissue]] 
Postoperatively, [[somatostatin]] analogs and [[radiotherapy]] are recommended in case of remaining excess of [[growth hormone]].


Even when surgery is successful and hormone levels return to normal, patients must be carefully monitored for years for possible recurrence. More commonly, hormone levels may improve, but not return completely to normal. These patients may then require additional treatment, usually with medications.
Indicators of successful surgery:<ref name="pmid16159936">{{cite journal| author=Feelders RA, Bidlingmaier M, Strasburger CJ, Janssen JA, Uitterlinden P, Hofland LJ et al.| title=Postoperative evaluation of patients with acromegaly: clinical significance and timing of oral glucose tolerance testing and measurement of (free) insulin-like growth factor I, acid-labile subunit, and growth hormone-binding protein levels. | journal=J Clin Endocrinol Metab | year= 2005 | volume= 90 | issue= 12 | pages= 6480-9 | pmid=16159936 | doi=10.1210/jc.2005-0901 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16159936  }}</ref>
*  [[GH]] level falls to the normal level within few hours.
*  [[IGF-1]] falls to the normal level within few days.
A video showing the procedure of endonasal transsphenoidal surgery:{{#ev:youtube|v=xllKSOXDuNM|}}


==References==
==References==
{{Reflist|2}}


{{reflist|2}}
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Latest revision as of 18:58, 24 August 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Elsaiey, MBBCH [2]

Overview

Surgery is the mainstay of treatment for acromegaly due to pituitary adenoma. The goal of the surgery will be the removal of the pituitary mass that causes acromegaly. The best sugical technique is endonasal transsphenoidal surgery.

Surgery

  • Surgery is the mainstay of treatment for acromegaly due to pituitary adenoma. The goal of the surgery will be the removal of the pituitary mass that causes acromegaly. The best sugical technique is endonasal transsphenoidal surgery.[1][2]

Endonasal transsphenoidal surgery

Most of the patients with acromegaly due to pituitary adenoma undergo transsphenoidal surgery. Although it is a challenging operation due to the anatomical location of the pituitary gland, tthe rate of complete successful resection in patients with adenomas smaller than 10 cm and GH level below 40ng is very high. It is important to remove the pituitary masses for this reasons:

MRI and CT imaging are used in guidance during the surgery and they have been linked with high safety and effectiveness of the surgery.[3]

In case the surgery is performed successfully, the acral features of acromegaly will improve within days.

Although it is very rare, some complications may occur. These complications include the following:[4][5]

Postoperatively, somatostatin analogs and radiotherapy are recommended in case of remaining excess of growth hormone.

Indicators of successful surgery:[6]

  • GH level falls to the normal level within few hours.
  • IGF-1 falls to the normal level within few days.

A video showing the procedure of endonasal transsphenoidal surgery:{{#ev:youtube|v=xllKSOXDuNM|}}

References

  1. ↑ Fahlbusch R, Honegger J, Buchfelder M (1992). "Surgical management of acromegaly". Endocrinol Metab Clin North Am. 21 (3): 669–92. PMID 1521518.
  2. ↑ Katznelson L, Laws ER, Melmed S, Molitch ME, Murad MH, Utz A; et al. (2014). "Acromegaly: an endocrine society clinical practice guideline". J Clin Endocrinol Metab. 99 (11): 3933–51. doi:10.1210/jc.2014-2700. PMID 25356808.
  3. ↑ Lasio G, Ferroli P, Felisati G, Broggi G (2002). "Image-guided endoscopic transnasal removal of recurrent pituitary adenomas". Neurosurgery. 51 (1): 132–6, discussion 136-7. PMID 12182410.
  4. ↑ Melmed S (2009). "Acromegaly pathogenesis and treatment". J Clin Invest. 119 (11): 3189–202. doi:10.1172/JCI39375. PMC 2769196. PMID 19884662.
  5. ↑ Cappabianca P, Cavallo LM, Colao A, de Divitiis E (2002). "Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas". J Neurosurg. 97 (2): 293–8. doi:10.3171/jns.2002.97.2.0293. PMID 12186456.
  6. ↑ Feelders RA, Bidlingmaier M, Strasburger CJ, Janssen JA, Uitterlinden P, Hofland LJ; et al. (2005). "Postoperative evaluation of patients with acromegaly: clinical significance and timing of oral glucose tolerance testing and measurement of (free) insulin-like growth factor I, acid-labile subunit, and growth hormone-binding protein levels". J Clin Endocrinol Metab. 90 (12): 6480–9. doi:10.1210/jc.2005-0901. PMID 16159936.

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