Endoscopic sellar surgery, especially for adenomas, is a relatively safe, straightforward surgery with (mostly) reproducible results and few complications. However, the evolution of pituitary surgery was a long process, starting from open/transfrontal approaches all the way to transsphenoid to the current endoscopic techniques, that almost all the current centres of excellence use. However, it is not so clear in paediatric pituitary surgery. The authors looked at the database of paediatric admissions in the USA and found 1071 cases of paediatric pituitary surgery. They found that 23% (as opposed to 2% in adults) of children underwent transfrontal approaches and these were more often in younger children (younger than 10 years of age). All of the six commonest complications (diabetes insipidus, panhypopituiarism, postoperative visual changes, stroke, hydrocephalus and CSF leak) were significantly more common in the transfrontal approaches. Although the transfrontal approach is used for more complex and extended tumours, the discrepancy between its use in adult and paediatric cases more likely reflects a lack of training and familiarity with the transsphenoid approach in paediatric neurosurgeons. Indeed, the predilection for using the transfrontal approach more commonly in younger children seems to favour that hypothesis, despite the fact that we now have enough evidence showing that we can use the endoscopic approach, including the use of nasoseptal flap for reconstruction (and the author certainly does that) in children as young as eight, with excellent results.

Pediatric pituitary resection: characterizing surgical approaches and complications.
Hanba C, Svider PF, Shkoukani MA, et al.
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Christos Georgalas

Academic Medical Center, The Netherlands.

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