Philosophy in the Endoscopic Endonasal Resection of Suprasellar Craniopharyngiomas—Handling of the Pituitary Stalk

Introduction: This article aims to evaluate the outcome and complications after endoscopic endonasal resection of suprasellar craniopharyngeomas and develop a strategy of pituitary stalk handling.

Methods: We retrospectively analyzed all patients harboring a suprasellar craniopharyngeoma who underwent endoscopic endonasal resection in our institution with special regard to the extent of resection, perioperative complications, recurrence rates, and visual and endocrinological outcome.

Results: Twenty-eight patients underwent endoscopic endonasal resection of a suprasellar craniopharyngioma. There were 15 male and 13 female patients. Mean age was 43 years ranging from 3 to 84 years. Mean follow-up time was 79 months ranging from 3 to 156 months. Eighteen patients complained of loss of visual acuity and 20 patients of visual field deficits. Three patients presented with headache. Twelve patients were endocrinological intact. Two patients presented with Addison crisis. Gross total tumor resection was achieved in 10 patients, near-total tumor resection in 14. In four patients, only a partial resection to decompress the chiasm was performed in order to preserve pituitary function (all patients were endocrinologically intact and underwent radiation after surgery). The pituitary stalk was identified early in all patients. It was preserved in 20 patients and sacrificed in 3, and in 5 patients it was damaged in previous surgeries. The skull base defect was reconstructed with a nasoseptal flap in all, but one patient in whom a fat graft was used.

There was no mortality. No deterioration of visual acuity or visual field was seen in all patients except one which had slight decrease of visual acuity in one eye. On the contrary, all patients with visual field deficits and loss of visual acuity improved after surgery. Five patients who were endocrinologically intact developed complete anterior pituitary gland deficiency. New permanent diabetes insipidus occurred in 5 patients. CSF fistulas occurred in 5 patients. Two of these patients who presented with hydrocephalus before the surgery required a vp shunt to stop the fistula. There were two recurrences in the gross total resection group. Twelve patients underwent fractionated radiotherapy (54 Gy) radiation therapy in the near/sub-total resection group, and six patients in the near-total resection group had no recurrence so far. All radiated tumors decreased in size.

Conclusion: Our recent policy is the following:

If the patient presents with pituitary insufficiency and DI we sacrifice the stalk. If the patient is endocrinologically intact and the tumor can be dissected with preservation of the stalk, gross total resection is performed. However, if tumor resection would result in destruction of the stalk, subtotal resection and fractionated stereotactic radiotherapy is applied to avoid pituitary insufficiency with DI. We think that gives the best quality of life.

Publication History

Article published online:
07 February 2025