Letter: Commentary: Is It Justified to Sacrifice the Pituitary Stalk During Craniopharyngioma Surgery? A Systematic Review and Meta-Analysis

To the Editor: We thank Abou-Al-Shaar et al,1 for their valuable comments on our study.2 Unsurprisingly, we noted that most of their comments have been extensively discussed both in the Discussion and Limitations sections. We designed this meta-analysis to answer a specific question of the impact of pituitary stalk (PS) sacrifice and preservation on postoperative endocrine functions and/or tumor recurrence or progression based on “the current literature,” so it is logical to include “only” the studies that directly compared the PS sacrifice vs no sacrifice and answered this question in their results. We mentioned clearly in the Limitations section that our inclusion criteria excluded many highly valuable craniopharyngioma studies for example, but not limited to, a study by Algattas et al including 62 patients using the Extended Endonasal Approach (EEA) mentioned only some data about PS infiltration and did not mention details about the PS preservation or sacrifice and the impact of each,3 a study by Koutourousiou et al4 including 64 patients, by Cavallo et al5 including 103 patients, and by Chakrabarti et al6 including 86 patients, and all of them did not mention data regarding PS preservation or sacrifice. So, one can understand that the main core of the issue is the reporting of craniopharyngioma studies in the literature, and Abou-Al-Shaar et al1 admitted this problem. Although the authors1 initially assumed that our methodology would not allow us to accurately address the questions regarding endocrine preservation or recurrence, a recent meta-analysis using a different methodology reached similar conclusions. This meta-analysis, which investigated the effects of PS preservation vs sacrifice, found that PS preservation significantly reduced the risk of Diabetes Insipidus (DI) at the last follow-up and helped preserve normal anterior pituitary function. Furthermore, no significant differences were observed between the preservation and sacrifice groups regarding incomplete resection or tumor recurrence.7 Moreover, a recent preprint of a study on 99 patients with papillary craniopharyngioma from 14 skull base expert centers in the United States reported that permanent arginine vasopressin deficiency was significantly related to PS sacrifice and patients with preserved PS showed lower rates of permanent 90-day panhypopituitarism including in arginine vasopressin deficiency, adrenal insufficiency, and hypothyroidism, and they did not comment on tumor recurrence/progression in relation to PS sacrifice or preservation.8 Knowing the importance of preoperative endocrine dysfunction, we mentioned that many authors reported that the patients with preserved PS and had preoperative severe hypopituitarism (≥3 hormonal deficiency) or panhypopituitarism did not show any postoperative endocrine recovery. We agree with the authors1 that postoperative endocrine dysfunction has many forms, and patients with DI alone should be treated equally or grouped with patients with panhypopituitarism; however, we mentioned below in Table (2) that postoperative endocrine dysfunction refers to patients who had partial hypopituitarism, panhypopituitarism, and/or DI. On the same ground, the other meta-analysis with a different methodology reached the same conclusion of the evident effect of stalk sacrifice on long-term DI.7 We agree with the authors1 that patients with recurrent craniopharyngioma were known to have a higher incidence of pituitary dysfunction and DI compared with primary craniopharyngiomas; they should not be grouped. However, those studies were 50% of our meta-analysis, and the other 50% included patients with primary craniopharyngioma, careful looking at the numbers in the table, one will realize that the separation of two groups mostly will not add any difference to the study objective. The authors1 stated that the entire topic of PS preservation has become more relevant with the increased ability to distinguish the stalk using the EEA, but the authors neglected the more important part “reporting operative data of the stalk”: preserved, sacrificed, shredded, infiltrated, or not identified at all, and the impact of each finding on endocrine function and recurrence. On the same ground of defective reporting in literature, many studies on craniopharyngioma reporting the EEA did not mention clear data about the impact of PS sacrifice or preservation.3-6 We neither adopt nor defend the concept of subtotal resection followed by radiation therapy as a primary paradigm rather than gross total resection for craniopharyngioma. The literature is flooded with the debate of the superiority of both concepts, and each school rationalizes its opinion with results. We mentioned that we recommend PS preservation whenever possible, especially in patients with normal preoperative endocrine dysfunction, and this should not contradict gross total resection. Our results showed that PS sacrifice did not affect the recurrence or progression of craniopharyngioma, an experienced neurosurgeon should weigh each decision and tailor this important step according to each patient. In accordance, expert opinion in the field of craniopharyngioma is respected. Our article is a meta-analysis of the existing literature, rather than a clinical study, and as such, it is subject to the limitations inherent in the clinical studies we reviewed. Many of these studies are case series or cohort studies, with only a few directly comparing outcomes of surgeries with and without stalk sacrifice. Until more robust comparative studies with better outcome reporting emerge, the current body of evidence will remain a significant reference point. In conclusion, given the under-reporting of stalk sacrifice, our study lays the foundation for understanding the existing data in the literature and highlights the need for further research with rigorous reporting on stalk sacrifice and its outcomes. We also appreciate the authors' call for future prospective studies from experienced centers to report their outcomes more systematically.

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