1.Background and Clinical Context

On Oct 29, the Pituitary Frontier –Global Webinar brought together neurosurgeons and clinical teams from Charlotte Maxeke Johannesburg Academic Hospital (CMJAH); West China Hospital, Sichuan University; Selective Surgical (South Africa), and Medprin Biotech. 

The live session attracted 67 registered participants from over 15 countries, who joined online to follow the case-based discussions on pituitary surgery strategy, endoscopic technique, and skull base reconstruction.

This webinar was organized as a pre-operative technical exchange for the upcoming “Pituitary Surgery Week” at CMJAH in South Africa, scheduled for 3–7 November, during which a full week of endonasal transsphenoidal pituitary tumor surgeries will be performed.

CMJAH (Charlotte Maxeke Johannesburg Academic Hospital) in South Africa is one of the neurosurgical teaching centers of the University of the Witwatersrand (Wits), serving patients from the greater Johannesburg area as well as certain other provinces and neighboring countries.

The current clinical reality is as follows:

• There is a significant backlog of surgeries for pituitary and other sellar lesions, with about 50 patients on the waiting list, some of whom have been waiting for months or longer.

  
  

• At present, the department usually has only three elective endonasal transsphenoidal cases per week. During the Pituitary Surgery Week, with the support of the Department of Anesthesiology, the goal is to increase the schedule to five cases in one week (one case per day), as a joint initiative to “clear the backlog and establish a standardized pathway.”

Importantly, from the outset the team positioned this Pituitary Surgery Week with dual objectives of “education + standardization”: not merely “doing more cases,” but simultaneously using the week to develop and consolidate a standardized departmental SOP for sellar/skull base closure and cerebrospinal fluid (CSF) leak control (i.e., a dural closure / sellar closure protocol).

Given that China has already published expert consensus documents on skull base reconstruction and several centers have mature practical pathways, Chinese neurosurgeons were invited to share their experience. In addition, Prof. Zan Xin’s team has creatively applied the T-holding “chopstick” technique in pituitary surgery, which is of high practical value for endonasal endoscopic operation and teaching, and therefore he was also invited to give a focused technical presentation.

2. Case Review and Surgical Strategy Discussion

Dr. Ashvir Rajkumar presented three representative patients, reflecting the main types of difficult cases scheduled at CMJAH in the near term. Prof. Zan commented on each case, focusing on the choice of approach, staging strategy, sellar/skull base reconstruction, and CSF leak control.

Case 1: 50-year-old female with a large pituitary macroadenoma

 Clinical overview:

•  Approximately 3 years of progressive visual deterioration with clear visual field defects (hemianopia).

•  Imaging shows a pituitary macroadenoma with marked suprasellar extension, compressing the third ventricle, with some encasement of the bilateral internal carotid arteries.

•  According to Dr. Rajkumar, the tumor is Knosp grade 4, Hardy–Wilson stage E, with downward displacement and enlargement of the sellar floor (> 10 mm).

• Hormonal workup did not show obvious endocrine hypersecretion.

Plan at CMJAH:

• Endonasal transsphenoidal endoscopic surgery was planned as the primary approach.

Prof. Zan’s perspective :

(1) Regarding the choice of approach, he mentioned there are “two ways” for this kind of case:

• For tumors manageable through the sellar region, a standard transsellar approach may suffice.

• For cases with a substantial suprasellar component, an extended endonasal approach can be considered to fully address the suprasellar portion.

(2) At his center, however, they currently tend to use a strategy that avoids starting with a very large extended approach whenever possible, by combining a transsellar route with intraoperative lumbar drainage:

•  A lumbar drain is placed and used “like a key to the tumor tunnel” to modulate intracranial pressure.

•  They first perform debulking of the intracellar portion, gradually addressing the suprasellar part so that the diaphragm can move downward or shrink, thereby creating a relatively controllable “tumor tunnel.”

•  With intracranial pressure under control and high-flow CSF egress minimized, angled endoscopes can then be used through this tunnel to work on the suprasellar remnant.

He emphasized that in many similar cases, this strategy allows them to avoid starting with a fully extended approach and still achieve near-gross total resection, while reducing the risk of high-flow CSF leakage.

He noted that this reflects a series of cases currently under analysis at his center (about 10 cases so far, with a manuscript in preparation), representing an improvement over earlier practice where extended approaches were more frequently used and high-flow leaks were more common.

(3) Role of the lumbar drain at West China Hospital:

• It is regarded as an intraoperative tool to lower intracranial pressure and expand the surgical corridor, rather than as a postoperative measure to prevent leaks.

• Typically, the lumbar drain is removed immediately after surgery, rather than being routinely left in place.

(4) Detection and management of CSF leakage:

• For focal intraoperative CSF leakage, they perform inlay reconstruction with an artificial dural patch to bridge and cover the diaphragmatic defect at the end of the procedure.

• They then inject CSF or fluid into the sellar region to deliberately raise intracranial pressure as a “stress test,” checking for continued leakage.

• If further leaks are detected, additional grafts or sealants are applied until a stable watertight closure is achieved.

• According to his experience, most patients managed in this manner do not require postoperative lumbar drainage, have a low infection rate, and are often able to be safely discharged approximately 3 days after surgery.

Key point:For large pituitary adenomas with both sellar and marked suprasellar extension, Prof. Zan’s team currently favors a strategy that remains within a transsellar framework, using intraoperative lumbar drainage to modulate intracranial pressure, create a “tumor tunnel,” and work with angled endoscopes. This allows them to avoid an extensive extended approach at the outset, while still striving for near-gross total resection and reducing the risk of high-flow CSF leak.