Re:Microscopy versus endoscopy in pituitary surgery

Mario Ammirati, ,

Other Contributors:

March 14, 2013

We thank Dr. Juan A Simal-Julian and collaborators (1) for their interest in our paper (2). We also appreciate the commentaries of Drs. Oldfield and Jane jr (3), Laws (4) and Warnke (5).

We will first address the letter of Dr. Simal-Julian and then will offer a few words on the commentaries of Drs. Oldfield and Jane jr, Laws and Warnke.

Mortini et al (6) use the microscope to remove the adenoma via a sub labial trans-septal avenue. This is the classic microscopic approach for the removal of pituitary adenoma. The word endoscope does not appear in the key words and, in a 12 page long paper containing more than 6,000 words, is mentioned only once in the following paragraph "After the removal of large macro adenomas and completion of hemostasis, the inspection of the intrasellar space is carried out using rigid endoscop 4-mm in diameter with 0- and 30- degree lenses (Karl Storz, Tuttlingen, Germany)" (6). We really do not think that the Mortini's paper may be accurately characterized as endoscopic assisted. The readers may make their own judgment. Regarding vascular complications we included "...carotid or other vessels injury, intracerebral hematoma, or any symptomatic intratumoral or intrasellar hemorrhage. Venous bleeding from the cavernous sinus was tabulated as a vascular complication (only) when it prevented the completion of the surgical procedure. Epistaxis was not included among the vascular complications" (2). We feel that this is a reasonable list of vascular complications. Spheno-palatine artery injury, contrary to what our colleagues state, was not tabulated as vascular complication even when it required treatment be it cauterization or packing, because we recognized that this is often, but not always, a minor complication. Again the readers may make their own judgment. We looked at the relationship between the tumor size in the endoscopic or microscopic group and the vascular injury rate and we commented on that "Furthermore the macro tumors or the extent of complete tumor resection, 2 variables that could have affected the vascular complication rate, were found to be not statistically significant in the endoscopic or microscopic series reporting vascular complications (p=0.24 and 0.10 for macro tumor size and complete resection respectively)"(2) The methodology we used was the same used by Tabaee et al (7)in a widely quoted paper on endoscopic pituitary surgery "Tabaee et al have used this methodological approach in 2009 when reviewing endoscopic pituitary surgery." (2)

We agree with Drs. Oldfield and Jane (3) that there might be indications where one or the other technique has superior results, everything else being equal; we also agree with their statement that we should identify these indications. As we said in our paper ,quoting a source8 that has nothing to do with endoscopic/microscopic pituitary surgery, the majority of surgical innovations are incremental and are " ...prone to overoptimistic assessments by their developers and ,therefore, need controlled randomized studies, when possible" (2). We disagree with Dr. Laws (4) that we denigrate endoscopic pituitary surgery; on the contrary by trying to define what is that new technologies/new processes bring to the fore we make them , in the long term, more sustainable. Indeed we use endoscopy to deal with extradural cranial base lesions and often inspect the resection cavity with endoscopes after microsurgical removal of pituitary adenomas. It is conceivable that in the medium term we, doctors and health care organizations, will be reimbursed for the use of new technology/processes only when the advantages associated with them are clearly evident and measurable. So we agree with Dr. Warnke (5) that " ...if we want to establish new techniques and get funding for its use: sound randomized controlled trials with appropriate primary and secondary outcome measures" (5) are sorely needed. In summary, our paper is not pro or against anything but serves, we hope, to remind us that we need to get better at how we introduce new technology/processes, especially when any improvement might be at the margins. We wish more attention would have been paid to the perspective section of our contribution. The general concept of how we introduce surgical innovations is, in our opinion, a progressive concept , not a regressive or a naysayer posture and it is extremely relevant to the whole field of surgery/neurosurgery.

References 1. Simal-Julian JA, Miranda-Lloret P, Perez-Borreda P et al: Microscopy versus endoscopy in pituitary surgery. J Neurol Neurosurg Psychiatry. Published Online First:January 18-2013 2. Ammirati M, Wei L, Ciric I. Short-term outcome of endoscopic versus microscopic pituitary adenoma surgery: a systematic review and metaanalysis.?J Neurol Neurosurg Psychiatry. Published Online First: 15 December 2012 doi:10.1136/jnnp-2012-303194 3. Oldfield EH, Jane JA Jr: Endoscopic versus microscopic pituitary surgery. J Neurol Neurosurg Psychiatry. Published Online First: 23 January 2013 doi:10.1136/ jnnp-2012-304583 4. Laws ER. Complications of transsphenoidal surgery: the shortcomings of meta-analysis. J Neurol Neurosurg Psychiatry. Published Online First: 16 February 2013 doi:10.1136/jnnp-2012-304541 5. Warnke P: Case series analysis, meta-analysis or no analysis in the evaluation of neurosurgical techniques: get better or get out J Neurol Neurosurg Psychiatry. Published Online First: March 5, 2013 doi:10.1136/ jnnp-2013-305130 6. Mortini P, Losa M, Barzaghi R et al. Results of transsphenoidal surgery in a large series of patients with pituitary adenoma. Neurosurgery 2005; 56:1222-33 7. Tabaee A, Anand VK, Barron Y, et al. Endoscopic pituitary surgery: a systematic review and meta-analysis. J Neurosurg 2009;111:545-54 8. McCulloch P, Altman DG, Campbell WB et al No surgical innovation without evaluation: the IDEAL recommendations. Lancet 2009;374:1105-12

Conflict of Interest:

None declared

Conflict of Interest

None declared