Miss Diagnosis: Approved for surgery!

Sunday, March 1, 2009

Approved for surgery!

We got the call from Dr. Friedman this evening. He has no doubt that Alex still has Cushing's and has given her his approval for surgery. He gave us the choice between a repeat of the pituitary surgery or bilateral adrenalectomy- henceforth known as BLA. After much thought and internal debate we are opting for the BLA. It will mean a life time of steroid replacement but the chance that it will be a cure for Cushing's is 99% vs, at best, 50% with another pituitary surgery. Alex's pituitary surgery, while unsuccessful, at least left her pituitary function intact. We feel that alone is enough reason to avoid going in again; considering the neurosurgeon would plan on removing half of the pituitary itself instead of just tumor the second time around.

We are being referred to Dr. Duh at UCSF, he is one of the few surgeons in the country skilled at bilateral adrenalectomy using a laprascopic approach. Hopefully he will be "on board" with the idea and diagnosis. For now we wait for the referral process.

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Transphenoidal Pituitary Surgery- From the UCSF web site

What happens during surgery?
The surgical removal of the pituitary adenoma is performed by a technique called a transsphenoidal operation. The word 'transsphenoidal' describes the path the surgeon follows to reach the pituitary gland. The word comes from 'trans', meaning 'to cross or pass through', and 'sphenoid', the name of the cavity (the sphenoid sinus) that is passed through to reach the pituitary gland. Newer techniques and improvements in technology now allow removal of these tumors without the need for an incision under the lip or within the nostril. The surgeon begins the approach by entering through the nostril on one side. The surgeon uses a brilliant fiber optic light to illuminate the internal anatomy, a microscope to magnify the area of surgery to 12 times the actual size, and very tiny microsurgical instruments especially designed for this particular operation. The surgeon guides the surgical instrument into the nasal cavity and an opening is made in the sphenoid bone. The sphenoid sinus is entered, and then an opening is made in the wall of the sella turcica to expose the pituitary gland. The adenoma can be readily distinguished from the normal pituitary gland tissue and is removed without removing the normal gland. After the surgeon removes all the tumor tissue, the small cavity that is left is treated with alcohol to destroy any tumor cells that may remain. This cavity is then sealed, sometimes with a piece of fat that the surgeon removes from the patient's abdomen. The surgeon then applies a biological 'glue' that helps seal the pituitary area from the nose and promotes natural healing. No nasal packs are used with this approach.