The Jakarta Post - JPlus - - Between The Lines -

A look at trans-sphe­noidal surgery

The men­tion of the word “surgery” evokes im­ages of lengthy and elab­o­rate pro­ce­dures that in­volve del­i­cate acts of cut­ting, abrad­ing or su­tur­ing dif­fer­ent parts of the body to treat an in­jury or disease.

This widely-held per­cep­tion has led some to de­velop an ir­ra­tional fear of surgery–es­pe­cially if an op­er­a­tion in­volves a crit­i­cal or­gan, such as the heart, or in the case of trans-sphe­noidal surgery, a pro­ce­dure used to re­move tu­mors from the hor­mone-reg­u­lat­ing pi­tu­itary gland lo­cated at the base of the brain.

Though the pro­ce­dure has been around in dif­fer­ent forms for the past three decades, in­di­vid­u­als who may be in dire need of it might fear or avoid it.

To de­mys­tify this spe­cific method of surgery, J+ spoke with Julius July, a neu­ro­sur­geon at the Neu­ro­science Cen­ter of Siloam Hos­pi­tals Lippo Vil­lage Karawaci. He has per­formed hun­dreds of trans-sphe­noidal op­er­a­tions on pa­tients through­out the coun­try since 2008. Be­low is our in­ter­view, edited for length and clar­ity.

Tell us more about trans-sphe­noidal surgery.

The goal is to ex­tract be­nign tu­mors of the pi­tu­itary gland that are called pi­tu­itary ade­noma. The pi­tu­itary gland con­trols dif­fer­ent se­cre­tions of hor­mones. If there is a tu­mor and it grows large, one of the con­se­quences could be that a pa­tient goes blind. It can also lead to symp­toms man­i­fest­ing in other parts of the body due to ex­cess hor­mone pro­duc­tion, de­pend­ing on the type of hor­mone af­fected by the tu­mor.

What does a neu­ro­sur­geon do dur­ing the pro­ce­dure?

As neu­ro­sur­geons we use an en­do­scope with a cam­era at­tached to it and in­sert the in­stru­ment through the nostril. We go through the right nostril and through the si­nus to reach the tu­mor and re­move it. Once that is done, we add a co­ag­u­lant to pre­vent bleed­ing. The op­er­a­tion takes only an hour to 90 min­utes to per­form and is min­i­mally in­va­sive. Peo­ple come in and ex­pect the surgery to last five or six hours. They hear “surgery” and fear­fully as­sume that. But mod­ern trans-sphe­noidal surgery is sim­ple, only last­ing one to two hours.

What’s the prog­no­sis af­ter surgery?

In 80 per­cent of cases, all it takes is one surgery to re­move a tu­mor. How­ever, some need re­peated in­ter­ven­tion, while oth­ers re­quire ra­di­a­tion. Some tu­mors want to in­vade their sur­round­ings. In these cases, the sur­round­ing area is a blood ves­sel. We can’t to­tally re­move that type of tu­mor. But such cases are rare. If a pa­tient needs more than two op­er­a­tions, we usu­ally rec­om­mend ra­di­a­tion, be­cause who wants to have a lot of op­er­a­tions?

What are the symp­toms of pi­tu­itary ade­noma?

Symp­toms de­pend on whether a tu­mor af­fects hor­mone pro­duc­tion or the op­tic nerve. The prin­ci­pal com­plaints are re­lated to a pa­tient’s field of vi­sion be­com­ing nar­rower. If there is a tu­mor in the pi­tu­itary gland area, the eye can’t see too widely. The tu­mors would press on the op­tic nerve, which leads to the pe­riph­ery of your vi­sion get­ting blurry. If the tu­mor af­fects hor­mone pro­duc­tion, the symp­toms de­pend on the spe­cific type of hor­mone that the tu­mor has af­fected. Dif­fer­ent hor­mones have dif­fer­ent roles. Ex­cess pro­lactin hor­mones can lead to women–or even men–pro­duc­ing breast milk. If a woman who isn’t preg­nant is pro­duc­ing breast milk, they need to be checked. The ba­sic in­gre­di­ent of milk is cal­cium. With­out treat­ment, the woman will have por­ous bone prob­lems. It also leads to re­duced li­bido. If men have an ex­cess of these pro­lactin hor­mones, they can­not get erec­tions and will be­come im­po­tent.

How does these prob­lem de­velop in the first place?

Mu­ta­tions lead to the cre­ation of these be­nign tu­mors. Some things make mu­ta­tions eas­ier, such as smok­ing or ex­po­sure to ra­di­a­tion or spe­cific chem­i­cals. It could be any­thing. You could have eaten tofu and it had for­ma­lin or some meat­balls with bo­rax. Pre­vent­ing it ob­vi­ously re­quires a healthy life­style, but that’s eas­ier said than done.

It’s not just one thing that causes these tu­mors.

Who does this pi­tu­itary tu­mor af­fect?

It af­fects both gen­ders equally, more or less. The risk of pi­tu­itary ade­noma com­pared to all other types of brain tu­mors is 15 per­cent. Chil­dren are also af­fected, though the con­di­tion is sta­tis­ti­cally much more likely to af­flict adults. Of my pa­tients, two in 70 would be chil­dren.

How is it di­ag­nosed?

The doc­tor will check your hor­mones af­ter a blood test and iden­tify the prob­lem. For ex­am­ple, if the con­di­tion af­fects growth hor­mones, a per­son can grow to two me­ters or more in height, which leads to gi­gan­tism. Al­ter­na­tively, a con­di­tion could lead to hor­i­zon­tal growth–a big­ger tongue, big­ger fin­gers and chang­ing shoes each month. The tongue can be­come so big that it causes breath­ing prob­lems. Growth hor­mone over­pro­duc­tion is like a fac­tory with the ma­chine work­ing over­time. As a re­sult, a per­son’s life span can get cut in half. The heart works over­time, they keep grow­ing and they die pre­ma­turely.

How many op­er­a­tions do you per­form a year?

I’ve been do­ing these op­er­a­tions since 2008. I han­dle 60 to 70 such surg­eries a year.

Any no­table suc­cess sto­ries to share?

One pa­tient from Cen­tral Java came in blind. I ex­am­ined him and said that there was no way we could save his vi­sion by re­mov­ing his tu­mor. He was cry­ing. He had been blind for a week. But if no ac­tion was taken, the tu­mor would keep grow­ing and would lead him to be­com­ing crip­pled. At the end, he de­cided that he still wanted the op­er­a­tion. Sur­pris­ingly though, af­ter the op­er­a­tion, he was able to see. Three months later, he was driv­ing and read­ing newspapers. It was a fas­ci­nat­ing case.

This ar­ti­cle is part of a series spon­sored by Siloam In­ter­na­tional Hos­pi­tals.

DR. JULIUS JULY Neu­ro­sur­geon at the Neu­ro­science Cen­ter of Siloam Hos­pi­tals Lippo Vil­lage Karawaci

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