The learning curve in endoscopic transsphenoidal skull-base surgery: a systematic review.
Endonasal
Endoscopic skull base
Endoscopy
Learning curve
Transsphenoidal surgery
Journal
BMC surgery
ISSN: 1471-2482
Titre abrégé: BMC Surg
Pays: England
ID NLM: 100968567
Informations de publication
Date de publication:
05 May 2024
05 May 2024
Historique:
received:
21
09
2023
accepted:
20
04
2024
medline:
6
5
2024
pubmed:
6
5
2024
entrez:
5
5
2024
Statut:
epublish
Résumé
The endoscopic endonasal transsphenoidal approach (EETA) has revolutionized skull-base surgery; however, it is associated with a steep learning curve (LC), necessitating additional attention from surgeons to ensure patient safety and surgical efficacy. The current literature is constrained by the small sample sizes of studies and their observational nature. This systematic review aims to evaluate the literature and identify strengths and weaknesses related to the assessment of EETA-LC. A systematic review was conducted following the PRISMA guidelines. PubMed and Google Scholar were searched for clinical studies on EETA-LC using detailed search strategies, including pertinent keywords and Medical Subject Headings. The selection criteria included studies comparing the outcomes of skull-base surgeries involving pure EETA in the early and late stages of surgeons' experience, studies that assessed the learning curve of at least one surgical parameter, and articles published in English. The systematic review identified 34 studies encompassing 5,648 patients published between 2002 and 2022, focusing on the EETA learning curve. Most studies were retrospective cohort designs (88%). Various patient assortment methods were noted, including group-based and case-based analyses. Statistical analyses included descriptive and comparative methods, along with regression analyses and curve modeling techniques. Pituitary adenoma (PA) being the most studied pathology (82%). Among the evaluated variables, improvements in outcomes across variables like EC, OT, postoperative CSF leak, and GTR. Overcoming the initial EETA learning curve was associated with sustained outcome improvements, with a median estimated case requirement of 32, ranging from 9 to 120 cases. These findings underscore the complexity of EETA-LC assessment and the importance of sustained outcome improvement as a marker of proficiency. The review highlights the complexity of assessing the learning curve in EETA and underscores the need for standardized reporting and prospective studies to enhance the reliability of findings and guide clinical practice effectively.
Sections du résumé
BACKGROUND
BACKGROUND
The endoscopic endonasal transsphenoidal approach (EETA) has revolutionized skull-base surgery; however, it is associated with a steep learning curve (LC), necessitating additional attention from surgeons to ensure patient safety and surgical efficacy. The current literature is constrained by the small sample sizes of studies and their observational nature. This systematic review aims to evaluate the literature and identify strengths and weaknesses related to the assessment of EETA-LC.
METHODS
METHODS
A systematic review was conducted following the PRISMA guidelines. PubMed and Google Scholar were searched for clinical studies on EETA-LC using detailed search strategies, including pertinent keywords and Medical Subject Headings. The selection criteria included studies comparing the outcomes of skull-base surgeries involving pure EETA in the early and late stages of surgeons' experience, studies that assessed the learning curve of at least one surgical parameter, and articles published in English.
RESULTS
RESULTS
The systematic review identified 34 studies encompassing 5,648 patients published between 2002 and 2022, focusing on the EETA learning curve. Most studies were retrospective cohort designs (88%). Various patient assortment methods were noted, including group-based and case-based analyses. Statistical analyses included descriptive and comparative methods, along with regression analyses and curve modeling techniques. Pituitary adenoma (PA) being the most studied pathology (82%). Among the evaluated variables, improvements in outcomes across variables like EC, OT, postoperative CSF leak, and GTR. Overcoming the initial EETA learning curve was associated with sustained outcome improvements, with a median estimated case requirement of 32, ranging from 9 to 120 cases. These findings underscore the complexity of EETA-LC assessment and the importance of sustained outcome improvement as a marker of proficiency.
CONCLUSIONS
CONCLUSIONS
The review highlights the complexity of assessing the learning curve in EETA and underscores the need for standardized reporting and prospective studies to enhance the reliability of findings and guide clinical practice effectively.
Identifiants
pubmed: 38705991
doi: 10.1186/s12893-024-02418-y
pii: 10.1186/s12893-024-02418-y
doi:
Types de publication
Systematic Review
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
135Informations de copyright
© 2024. The Author(s).
Références
Cappabianca P, de Divitiis E. Endoscopy and transsphenoidal surgery. Neurosurgery. 2004;54:1043–50.
pubmed: 15113457
doi: 10.1227/01.NEU.0000119325.14116.9C
Gandhi CD, Post KD. Historical movements in transsphenoidal surgery. Neurosurg Focus. 2001;11:1–4.
doi: 10.3171/foc.2001.11.4.8
Gandhi CD, Christiano LD, Eloy JA, Prestigiacomo CJ, Post KD. The historical evolution of transsphenoidal surgery: facilitation by technological advances. Neurosurg Focus. 2009;27:E8.
pubmed: 19722823
doi: 10.3171/2009.6.FOCUS09119
de Divitiis E. Endoscopic transsphenoidal surgery: stone-in-the-pond effect. Neurosurgery. 2006;59:512–20.
pubmed: 16955032
doi: 10.1227/01.NEU.0000227475.69682.77
Rotenberg B, Tam S, Ryu WHA, Duggal N. Microscopic versus endoscopic pituitary surgery: a systematic review. Laryngoscope. 2010;120:1292–7.
pubmed: 20578228
doi: 10.1002/lary.20949
Tabaee A, Anand VK, Barrón Y, Hiltzik DH, Brown SM, Kacker A, et al. Endoscopic pituitary surgery: a systematic review and meta-analysis. J Neurosurg. 2009;111:545–54.
pubmed: 19199461
doi: 10.3171/2007.12.17635
Younus I, Gerges MM, Uribe-Cardenas R, Morgenstern PF, Eljalby M, Tabaee A, et al. How long is the tail end of the learning curve? Results from 1000 consecutive endoscopic endonasal skull base cases following the initial 200 cases. J Neurosurg. 2020;134:750–60.
pubmed: 32032942
doi: 10.3171/2019.12.JNS192600
Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Int J Surg. 2021;88:105906.
pubmed: 33789826
doi: 10.1016/j.ijsu.2021.105906
Wells G, Shea B, O'Connell D, Peterson J, Welch V, Losos M, Tugwell P. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. 2013. Retrieved from http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp .
Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, Vist GE, Falck-Ytter Y, Meerpohl J, Norris S, Guyatt GH. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64(4):401–6. https://doi.org/10.1016/j.jclinepi.2010.07.015 .
doi: 10.1016/j.jclinepi.2010.07.015
pubmed: 21208779
Cappabianca P, Cavallo L, Colao A, Del Basso De Caro M, Esposito F, Cirillo S, et al. Endoscopic endonasal transsphenoidal approach: outcome analysis of 100 consecutive procedures. Minim Invasive Neurosurg. 2002;45:193–200.
pubmed: 12494353
doi: 10.1055/s-2002-36197
Sonnenburg RE, White D, Ewend MG, Senior B. The learning curve in minimally invasive pituitary surgery. Am J Rhinol. 2004;18:259–63.
pubmed: 15490574
doi: 10.1177/194589240401800412
Kenan K, İhsan A, Dilek O, Burak C, Gurkan K, Savas C. The learning curve in endoscopic pituitary surgery and our experience. Neurosurg Rev. 2006;29:298–305.
doi: 10.1007/s10143-006-0033-9
Yano S, Kawano T, Kudo M, Makino K, Nakamura H, Kai Y, et al. Endoscopic endonasal transsphenoidal approach through the bilateral nostrils for pituitary adenomas. Neurol Med Chir (Tokyo). 2009;49:1–7.
pubmed: 19168995
doi: 10.2176/nmc.49.1
Gondim JA, Schops M, de Almeida JPC, de Albuquerque LAF, Gomes E, Ferraz T, et al. Endoscopic endonasal transsphenoidal surgery: surgical results of 228 pituitary adenomas treated in a pituitary center. Pituitary. 2010;13:68–77.
pubmed: 19697135
doi: 10.1007/s11102-009-0195-x
Leach P, Abou-Zeid AH, Kearney T, Davis J, Trainer PJ, Gnanalingham KK. Endoscopic transsphenoidal pituitary surgery: evidence of an operative learning curve. Neurosurgery. 2010;67:1205–12.
pubmed: 20871457
doi: 10.1227/NEU.0b013e3181ef25c5
Smith SJ, Eralil G, Woon K, Sama A, Dow G, Robertson I. Light at the end of the tunnel: the learning curve associated with endoscopic transsphenoidal skull base surgery. Skull Base. 2010;20:69–74.
pubmed: 20808530
pmcid: 2853078
doi: 10.1055/s-0029-1238214
Wagenmakers MAE, Netea-Maier RT, van Lindert EJ, Pieters GF, Grotenhuis AJ, Hermus AR. Results of endoscopic transsphenoidal pituitary surgery in 40 patients with a growth hormone-secreting macroadenoma. Acta Neurochir (Wien). 2011;153:1391–9.
pubmed: 21347581
doi: 10.1007/s00701-011-0959-8
Kumar S, Darr A, Hobbs C, Carlin W. Endoscopic, endonasal, trans-sphenoidal hypophysectomy: retrospective analysis of 171 procedures. J Laryngol Otol. 2012;126:1033–40.
pubmed: 22992270
doi: 10.1017/S0022215112001223
Snyderman CH, Pant H, Kassam AB, Carrau RL, Prevedello DM, Gardner PA. The learning curve for endonasal surgery of the cranial base: A systematic approach to training. In: Kassam AB, Gardner PA, editors. Endoscopic approaches to the skull base. Ettlingen: Karger Publishers; 2012. p. 222–31.
doi: 10.1159/000329250
Bokhari AR, Davies MA, Diamond T. Endoscopic transsphenoidal pituitary surgery: a single surgeon experience and the learning curve. Br J Neurosurg. 2013;27:449.
doi: 10.3109/02688697.2012.709554
Chi F, Wang Y, Lin Y, Ge J, Qiu Y, Guo L. A learning curve of endoscopic transsphenoidal surgery for pituitary adenoma. J Craniofac Surg. 2013;24:2064–7.
pubmed: 24220407
doi: 10.1097/SCS.0b013e3182a24328
de los Santos G, Fragola C, Del Castillo R, Rodríguez V, D’oleo C, Reyes P. Endoscopic approaches to pituitary lesions: difficulties and challenges. Acta Otorrinolaringol Esp. 2013;64(258):64.
Hazer DB, Işık S, Berker D, Güler S, Gürlek A, Yücel T, et al. Treatment of acromegaly by endoscopic transsphenoidal surgery: surgical experience in 214 cases and cure rates according to current consensus criteria. J Neurosurg. 2013;119:1467–77.
pubmed: 24074496
doi: 10.3171/2013.8.JNS13224
Jakimovski D, Bonci G, Attia M, Shao H, Hofstetter C, Tsiouris AJ, et al. Incidence and significance of intraoperative cerebrospinal fluid leak in endoscopic pituitary surgery using intrathecal fluorescein. World Neurosurg. 2014;82:e513–23.
pubmed: 23811068
doi: 10.1016/j.wneu.2013.06.005
Koutourousiou M, Fernandez-Miranda JC, Wang EW, Snyderman CH, Gardner PA. Endoscopic endonasal surgery for olfactory groove meningiomas: outcomes and limitations in 50 patients. Neurosurg Focus. 2014;37:E8.
pubmed: 25391163
doi: 10.3171/2014.7.FOCUS14330
Mascarenhas L, Moshel YA, Bayad F, Szentirmai O, Salek AA, Leng LZ, et al. The transplanum transtuberculum approaches for suprasellar and sellar-suprasellar lesions: avoidance of cerebrospinal fluid leak and lessons learned. World Neurosurg. 2014;82:186–95.
pubmed: 23403355
doi: 10.1016/j.wneu.2013.02.032
Ottenhausen M, Banu MA, Placantonakis DG, Tsiouris AJ, Khan OH, Anand VK, et al. Endoscopic endonasal resection of suprasellar meningiomas: the importance of case selection and experience in determining extent of resection, visual improvement, and complications. World Neurosurg. 2014;82:442–9.
pubmed: 24657254
doi: 10.1016/j.wneu.2014.03.032
Ananth G, Hosmath AV, Varadaraju DN, Patil SR, Usman MM, Patil RP, et al. Learning curve in endoscopic transnasal sellar region surgery. J Evid Based Med Healthc. 2016;3:3166–72.
doi: 10.18410/jebmh/2016/688
Jang JH, Kim KH, Lee YM, Kim JS, Kim YZ. Surgical results of pure endoscopic endonasal transsphenoidal surgery for 331 pituitary adenomas: a 15-year experience from a single institution. World Neurosurg. 2016;96:545–55.
pubmed: 27663264
doi: 10.1016/j.wneu.2016.09.051
Kshettry VR, Do H, Elshazly K, Farrell CJ, Nyquist G, Rosen M, et al. The learning curve in endoscopic endonasal resection of craniopharyngiomas. Neurosurg Focus. 2016;41:E9.
pubmed: 27903119
doi: 10.3171/2016.9.FOCUS16292
Qureshi T, Chaus F, Fogg L, Dasgupta M, Straus D, Byrne RW. Learning curve for the transsphenoidal endoscopic endonasal approach to pituitary tumors. Br J Neurosurg. 2016;30:637–42.
pubmed: 27332969
doi: 10.1080/02688697.2016.1199786
Shou X, Shen M, Zhang Q, Zhang Y, He W, Ma Z, et al. Endoscopic endonasal pituitary adenomas surgery: the surgical experience of 178 consecutive patients and learning curve of two neurosurgeons. BMC Neurol. 2016;16:1–8.
doi: 10.1186/s12883-016-0767-0
Ding H, Gu Y, Zhang X, Xie T, Liu T, Hu F, et al. Learning curve for the endoscopic endonasal approach for suprasellar craniopharyngiomas. J Clin Neurosci. 2017;42:209–16.
pubmed: 28511971
doi: 10.1016/j.jocn.2017.04.021
Shikary T, Andaluz N, Meinzen-Derr J, Edwards C, Theodosopoulos P, Zimmer LA. Operative learning curve after transition to endoscopic transsphenoidal pituitary surgery. World Neurosurg. 2017;102:608–12.
pubmed: 28300715
doi: 10.1016/j.wneu.2017.03.008
Eseonu CI, ReFaey K, Pamias-Portalatin E, Asensio J, Garcia O, Boahene KD, et al. Three-hand endoscopic endonasal transsphenoidal surgery: experience with an anatomy-preserving mononostril approach technique. Oper Neurosurg (Hagerstown). 2018;14:158–65.
pubmed: 29351688
doi: 10.1093/ons/opx110
Kim JH, Lee JH, Lee JH, Hong AR, Kim YJ, Kim YH. Endoscopic transsphenoidal surgery outcomes in 331 nonfunctioning pituitary adenoma cases after a single surgeon learning curve. World Neurosurg. 2018;109:e409–16.
pubmed: 29017983
doi: 10.1016/j.wneu.2017.09.194
Lofrese G, Vigo V, Rigante M, Grieco DL, Maresca M, Anile C, et al. Learning curve of endoscopic pituitary surgery: experience of a neurosurgery/ENT collaboration. J Clin Neurosci. 2018;47:299–303.
pubmed: 28988650
doi: 10.1016/j.jocn.2017.09.011
Robins JM, Alavi SA, Tyagi AK, Nix PA, Wilson TM, Phillips NI. The learning curve for endoscopic trans-sphenoidal resection of pituitary macroadenomas. A single institution experience, Leeds, UK. Acta Neurochir (Wien). 2018;160:39–47.
pubmed: 29063272
doi: 10.1007/s00701-017-3355-1
Algattas H, Setty P, Goldschmidt E, Wang EW, Tyler-Kabara EC, Snyderman CH, et al. Endoscopic endonasal approach for craniopharyngiomas with intraventricular extension: case series, long-term outcomes, and review. World Neurosurg. 2020;144:e447–59.
pubmed: 32890848
doi: 10.1016/j.wneu.2020.08.184
Soliman MA, Eaton S, Quint E, Alkhamees AF, Shahab S, O’Connor A, et al. Challenges, learning curve, and safety of endoscopic endonasal surgery of sellar-suprasellar lesions in a community hospital. World Neurosurg. 2020;138:e940–54.
pubmed: 32298827
pmcid: 7195030
doi: 10.1016/j.wneu.2020.04.028
Nix P, Alavi SA, Tyagi A, Phillips N. Endoscopic repair of the anterior skull base-is there a learning curve? Br J Neurosurg. 2018;32:407–11.
pubmed: 29799278
doi: 10.1080/02688697.2018.1478062
Park W, Nam D-H, Kong D-S, Lee KE, Park SI, Kim HY, et al. Learning curve and technical nuances of endoscopic skull base reconstruction with nasoseptal flap to control high-flow cerebrospinal fluid leakage: reconstruction after endoscopic skull base surgery other than pituitary surgery. Eur Arch Otorhinolaryngol. 2022;279:1335–40.
pubmed: 34028580
doi: 10.1007/s00405-021-06877-4
Lubowitz JH, Sahasrabudhe A, Appleby D. Minimally invasive surgery in total knee arthroplasty: the learning curve. Orthopedics. 2007;30:80.
pubmed: 17824342
Hoppe DJ, Simunovic N, Bhandari M, Safran MR, Larson CM, Ayeni OR. The learning curve for hip arthroscopy: a systematic review. Arthroscopy. 2014;30:389–97.
pubmed: 24461140
doi: 10.1016/j.arthro.2013.11.012
Sclafani JA, Kim CW. Complications associated with the initial learning curve of minimally invasive spine surgery: a systematic review. Clin Orthop Relat Res. 2014;472:1711–7.
pubmed: 24510358
pmcid: 4016470
doi: 10.1007/s11999-014-3495-z
Pernar LI, Robertson FC, Tavakkoli A, Sheu EG, Brooks DC, Smink DS. An appraisal of the learning curve in robotic general surgery. Surg Endosc. 2017;31:4583–96.
pubmed: 28411345
doi: 10.1007/s00464-017-5520-2
Wright TP. Factors affecting the cost of airplanes. J Aeronaut Sci. 1936;3:122–8.
doi: 10.2514/8.155
Cook JA, Ramsay CR, Fayers P. Using the literature to quantify the learning curve: a case study. Int J Technol Assess Health Care. 2007;23:255–60.
pubmed: 17493312
doi: 10.1017/S0266462307070341
Hopper A, Jamison M, Lewis W. Learning curves in surgical practice. Postgrad Med J. 2007;83:777–9.
pubmed: 18057179
pmcid: 2750931
doi: 10.1136/pgmj.2007.057190
Ramsay CR, Grant AM, Wallace SA, Garthwaite PH, Monk AF, Russell IT. Assessment of the learning curve in health technologies: a systematic review. Int J Technol Assess Health Care. 2000;16:1095–108.
pubmed: 11155830
doi: 10.1017/S0266462300103149
Khan N, Abboudi H, Khan MS, Dasgupta P, Ahmed K. Measuring the surgical ‘learning curve’: methods, variables and competency. BJU Int. 2014;113:504–8.
pubmed: 23819461
doi: 10.1111/bju.12197