Endoscopic Surgery for Primary Empty Sella Syndrome: The "7 E" Technique

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Villalonga, Andrea L. Castillo, Jose I. Pailler, Agustín Martinez-Font, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5379692/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Extradural reconstruction of the sellar floor is indicated in patients with primary empty sella syndrome and visual deficits without any other apparent cause. Our team in Tucumán has developed an endoscopic technique called the "7 E" (i.e., endoscopic endonasal approach, exposure, extradural, elevate, egress, embed, exclude). This technique involves the exposure of the sella turcica using a Guanti Bianchi approach and reconstructing the sellar floor with heterologous material. This study aims to present the preliminary results of the "7 E" technique. Materials and Methods A prospective study was conducted from January 2020 through April 2024 at a single center in Tucumán, Argentina. All surgical procedures were performed by the same surgeon. Patients with idiopathic primary empty sella syndrome and confirmed visual deficits were included, excluding those with other causes of visual deficits. An endoscopic endonasal approach and reconstruction of the sellar floor with heterologous material were used. Patients were evaluated pre- and postoperatively with MRI and visual field testing. Results Thirteen female patients with a mean age of 48.31 years were included. Nine patients (69.2%) had excellent visual field improvement, three (23.1%) had acceptable results, and one (7.7%) showed worsening. Regarding headaches, ten patients (76.9%) showed significant improvement. Three patients presented complications: one with panhypopituitarism and two with transitory diabetes insipidus. Conclusion The "7 E" technique proved effective in treating primary empty sella syndrome without associated increased intracranial pressure. empty sella syndrome endoscopic primary technique Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Empty sella (ES) is a condition frequently observed in daily practice. Most of the time, it is an incidental finding with no surgical indication. However, it can sometimes be associated with clinical manifestations and constitute the primary empty sella syndrome (PESS)[ 1 ]. Extradural reconstruction of the sellar floor is indicated in certain patients with PESS, particularly when they present visual deficits without any other justifiable cause[ 1 – 4 ]. Previous descriptions of this procedure with microscopic techniques have been reported[ 1 , 5 ]. Results have been published using various autologous and heterologous materials[ 1 , 6 – 9 ]. Our team in Tucumán has developed an endoscopic technique we call the "7 E" (i.e., endoscopic endonasal approach, exposure, extradural, elevate, egress, embed, exclude). This technique involves exposing the sella turcica using a Guanti Bianchi approach[ 10 , 11 ] and reconstructing the sellar floor with heterologous material. This study aims to present the preliminary results of the "7 E" technique. MATERIALS AND METHODS Study Design From January 2020 through April 2024, a description of a new surgical technique and an analysis of a prospective case series were conducted. All surgeries were performed by the same surgeon (JFV) at a single center in Tucumán, Argentina. The institution's Ethics Committee approved the study protocol where the surgeries were conducted. Informed consent was obtained from all patients for using their medical records and neuroimages in the present research. The study adhered to the STROBE guidelines. Patients and Setting Data collection was recorded in a coded Excel spreadsheet (Excel 16.79.1, Microsoft, Redmond, Washington, USA) and included age, sex, history of sellar pathology, type of ES, and symptoms at onset. Inclusion and Exclusion Criteria A strict selection process was applied for the patients presenting with empty sella (n=277) (Figure 1). Initially, patients were distinguished between primary and secondary ES. Secondary ES was considered for those with a history of surgical, pharmacological, or radiotherapy treatment for their sellar pathology. Patients with secondary ES (n=61) were excluded. Next, symptomatic and asymptomatic patients with primary ES were filtered. Those considered with an incidental radiological finding (n=170) were excluded. Symptomatic patients were referred to as PESS (n=46). The PESS patients (n=46) were then divided into two groups based on whether they had (n=21) or did not have (n=25) increased intracranial pressure (ICP). Routine questioning, fundoscopy with a slit lamp, MRI (magnetic resonance image) with a specific protocol, and lumbar puncture with manometry were performed. Those with ICP (e.g., PESS associated with Chiari-1 malformation, hydrocephalus, CSF circulation disorder, tumor, pseudotumor cerebri, fungal pathology, among others) were excluded and directed to other treatments based on their specific pathology. In the fourth stage, idiopathic PESS patients (n=25) were filtered. Those with visual deficits (n=17) were selected based on computerized campimetry. Patients without visual deficits (n=8) were excluded. In the fifth stage, idiopathic PESS patients with visual deficits (n=17) were referred for an exhaustive ophthalmological study to rule out other common causes of visual deficits (e.g., diabetic retinopathy, hypertensive retinopathy). Patients whose visual deficits were attributed to other causes by the ophthalmologist were excluded (n=4). In the sixth stage, endoscopic reconstruction of the sellar floor with the ´´7 E´´ technique was indicated for patients who met our strict selection protocol (n=13). Surgical Imaging Documentation During all cases, a Storz Decq® endoscope, with 0° optics (Karl Storz SE & Co, Tuttlingen, Germany) connected to a Stryker® 1588 AIM (Advanced Imaging Modalities) HD Endoscopy camera was used (Strycker, Michigan, USA). The surgical procedures were recorded using a video capture device, AVerMedia ER130 EzRecorder 130® (AverMedia Technologies, Taipei, Taiwan). Images were edited in PowerPoint version 16.79.1 (Microsoft, New Mexico, USA). Follow-up A standardized set of images was obtained for all cases pre-and post-operatively, including: Brain and sellar region MRI with gadolinium in sagittal T2 and T2-weighted planes. Standard brain CT with reconstruction in three planes. These imaging studies were performed before the surgery, on the first day post-op (CT), and then repeated at 90 days (MRI) and at 6 and 12 months, if applicable (MRI). The minimum follow-up period was six months. Clinical outcomes were evaluated by categorizing patients according to visual field testing during the pre- and postoperative periods. Radiological outcomes were assessed by comparing the pre-and postoperative images. Patients were categorized into three groups based on their visual field outcomes: Excellent: patients with improvement in visual deficit. Acceptable: patients without progression of visual deficit. Poor: patients with worsening visual deficit. Blinding and Bias Avoidance The neurosurgeon who recorded the pre-and postoperative data did not participate in the surgeries, and the neuroradiologist who measured the sellar region was blinded to the clinical outcomes. Surgical Technique All surgeries were performed by the same surgeon (JFV). The step-by-step technique is shown in Figure 2. The key points of the 7 “E”s technique are summarized: Endoscopic Endonasal Approach: A standard endoscopic endonasal approach is performed. Our team uses the Guanti Bianchi approach. Exposure: Wide opening of the rostrum, drilling to frame the floor of the sella turcica. Extradural: It is important to note that from this point on, the entire technique is extradural. Elevate: Elevation is performed with cottonoid to avoid damaging the dura and causing an intraoperative CSF fistula. The cottonoid is placed in tandem. Egress: The cotton is removed. This causes a relatively noticeable bleeding from the inferior intercavernous sinus, which is easily controlled with a hemostatic matrix (Surgiflo) and does not have hemodynamic significance. Additionally, removing the cottonoid does not automatically lower the dura-covered gland; a memory effect keeps it elevated for a few seconds, allowing for final remodeling. Embed: Heterologous cement is placed to elevate the dura covering the gland. It generates minimal exothermic reaction while setting, requiring washing with saline solution to dissipate the heat. The self-curing acrylic polymer used is Subiton RO with antibiotic (Subiton, Buenos Aires, Argentina). Exclude: Subiton is a heterologous material. To prevent it from being in close contact with the nasal cavity and its bacterial flora, a film of biological adhesive (Beriplast® P Combi set, CSL Behring, Montevideo, Uruguay) is applied. Our team has a recent publication about this topic with an illustrative video with the technique [12]. RESULTS This study included 13 patients whose visual field outcomes, headache improvement, and complications were evaluated. Patients ranged in age from 37 to 66 years, with a mean age of approximately 48.31 years. All patients were female. Regarding visual field outcomes, nine patients (69.2%) had excellent results, three patients (23.1%) had acceptable results, and one patient (7.7%) had poor results. In terms of headache improvement, ten patients (76.9%) experienced significant improvement, two patients (15.4%) reported transient improvements, and one patient (7.7%) did not experience any improvement. Regarding complications, most patients (76.9%) had no complications. However, one patient (7.7%) suffered from panhypopituitarism, and two patients (15.4%) had transient diabetes insipidus (Table 1 ). During follow-up, it was found that the patient with panhypopituitarism was diagnosed with central nervous system histoplasmosis. Table 1 Clinical features and outcomes of patients that underwent surgery by the ´´7 E´´ technique for PESS. F: female No. Gender/Age Visual Field outcome Improvement of Headaches Complications 1 F/47 Excellent Yes No 2 F/37 Excellent Yes No 3 F/52 Acceptable Transitory No 4 F/48 Excellent Yes No 5 F/66 Excellent Yes No 6 F/39 Acceptable Transitory Transitory DI 7 F/31 Excellent Yes No 8 F/59 Excellent Yes No 9 F/55 Excellent Yes No 10 F/45 Poor No Panhypopituitarism 11 F/52 Acceptable Yes No 12 F/42 Excellent Yes No 13 F/55 Excellent Yes Transitory DI Illustrative Case A 54-year-old patient presented with headaches and visual deficits. Computerized campimetry confirmed visual deficits with scotoma patterns. MRI revealed a sellar arachnoidocele with the gland flattened at the floor of the sella turcica. An endoscopic white glove approach and an extradural reconstruction of the sellar floor with a heterologous graft were performed. The patient showed clinical and radiological improvement with significant visual improvement and headache remission during follow-up (Figs. 2 – 3 ). DISCUSSION Empty sella (ES) is a term used to commonly refer to a sellar arachnoidocele [ 13 ]. In this condition, the arachnoid invaginates through the sellar diaphragm, enters the sella turcica, and compresses the gland towards the floor, giving the impression of an empty sella[ 6 , 14 , 15 ]. Classifying ES To classify the type of ES, several questions should be asked: Does the patient have a history of treatment for sellar pathology? This information helps to determine whether it is primary or secondary ES. A history of surgical, radiological, or pharmacological treatment for sellar pathology indicates secondary ES. Primary ES occurs when there is no such history. Does the patient present with congruent symptoms? This helps determine if it is an incidental finding or constitutes PESS. Is there a specific cause? Is there evidence of ICP on CSF (Cerebrospinal fluid) manometry and fundoscopy? This helps determine if PESS is due to a particular cause associated with intracranial hypertension or is idiopathic multifactorial. Specific causes include tumors, benign intracranial hypertension, hydrocephalus, Chiari type 1, and fungal brain pathology, among others. Surgical Indication Guinto et al.[ 1 , 6 , 16 ] propose indicating sellar reconstruction surgery in patients with visual deficits and/or nasal CSF fistula. We agree with the first scenario. The author disagrees with the second scenario, as nasal CSF fistula is likely associated with ICP. In such cases, the underlying cause should be identified and treated. In summary, we suggest performing endoscopic reconstruction with the 7 E technique in patients with PESS with visual deficits confirmed by campimetry and other ophthalmological causes excluded. About the Embedding Grafts Various autologous and heterologous grafts have been described for definitive gland elevation[ 1 , 6 – 9 ]. The author prefers using self-curing polymer (Subiton) as it offers several advantages: shorter surgical time, no extra incision required, and avoids complications at the autologous graft site. Potential disadvantages could include infections associated with inert material and/or gland damage from the exothermic reaction of the polymer during setting. To avoid infections, we use antibiotic prophylaxis with ampicillin-sulbactam, thoroughly wash the material once placed, and isolate this inert heterologous material from the nasal cavity with a layer of biological adhesive. The exothermic reaction of the polymer is directly proportional to its volume; in this case, we used a small circumference of 6 cc, so the heat release is not significant. Additionally, thorough washing helps dissipate the heat. In this series (n = 13), we had no complications related to the use of this cement. Results in Our Series Most patients (76.9%) showed improvement in their headache condition. This may be due to the reconstruction of the sella, which prevents constant downward traction of the dural diaphragm, reducing trigeminal nociceptive stimulation. Nine patients showed visual improvement, and three had no deficit progression; in other words, 12 out of 13 patients had a favorable outcome. In the one case where the deficit progressed, the patient also had panhypopituitarism. During follow-up, it was revealed that the patient was diagnosed with central nervous system histoplasmosis. We interpreted this as an error in patient management due to a misdiagnosis. This patient had primary ES associated with increased intracranial pressure due to fungal pathology; therefore, intracranial hypertension should have been treated, and sellar reconstruction should not have been performed. After this case, we added histoplasmosis (endemic in our region) to our management algorithm as a cause of primary ES associated with increased intracranial pressure. Additionally, two patients had transient diabetes insipidus, one during hospitalization and another requiring rehospitalization for hyponatremia on the fifth day after discharge. Both cases had favorable outcomes due to appropriate clinical management—neither required long-term desmopressin. We interpreted transient diabetes insipidus as secondary to mechanical manipulation of the gland due to the displacement in the cephalic direction with tandem cotton and later with the heterologous graft rather than due to an exothermic reaction of Subiton. If it were an exothermic reaction, the deficit would have been persistent in more patients. LIMITATIONS Although the number of patients studied was considerable, the patients selected for reconstruction with the "7 E" technique represent a small series. A more extensive series is needed to validate this technique. CONCLUSION The "7 E" technique proved to be effective in treating PESS in this preliminary study. Declarations CONFLICT OF INTEREST: The authors declare no conflict of interest Ethical Approval: The institution's Ethics Committee approved the study protocol where the surgeries were conducted. Informed consent was obtained from all patients for using their medical records and neuroimages in the present research. The study adhered to the STROBE guidelines. Funding: No fundings were received for this research. Author Contribution Authors Contributions:• Conceptualization: JFV; AMG; AC• Data curation: JFV; ALC; JIP; AMF; AC• Formal analysis: JFV; ALC; JIP; AMF; AC• Investigation: JFV; ALC; AMF; AC• Methodology: JFV; ALC; AMF; AC• Project administration: JFV; AC • Software: JFV; ALC; JIP; AMF; AC• Supervision: JFV; AMF; AC• Validation: JFV; AMF; AC• Visualization: JFV; ALC; AMF; AC• Writing – original draft: JFV; ALC; AMF; AC• Writing – review and editing: JFV; ALC; AMF; AC ACKNOWLEDGMENTS: None References Guinto G, Nettel B, Hernández E, Gallardo D, Aréchiga N, Mercado M (2019) Osseous Remodeling Technique of the Sella Turcica: A New Surgical Option for Primary Empty Sella Syndrome. World Neurosurg 126:e953–e8. 10.1016/j.wneu.2019.02.195 Chiloiro S, Giampietro A, Bianchi A, Tartaglione T, Capobianco A, Anile C et al (2017) Diagnosis of endocrine disease: Primary empty sella: a comprehensive review. Eur J Endocrinol 177(6):R275–r85. 10.1530/eje-17-0505 Lenz AM, Root AW (2012) Empty sella syndrome. Pediatr Endocrinol Rev 9(4):710–715 Zona G, Testa V, Sbaffi PF, Spaziante R (2002) Transsphenoidal treatment of empty sella by means of a silastic coil: technical note. Neurosurgery 51(5):1299–1303 discussion 303. 10.1097/00006123-200211000-00032 Campero A, Baldoncini M, Martinez-Font A, Villalonga JF (2021) Extradural Remodeling in Empty Sella Syndrome: 3-Dimensional Operative Video. World Neurosurg 147:66. 10.1016/j.wneu.2020.12.065 Guinto G, Mercado M, Nishimura MA, Aréchiga E, Nettel N (2007) Primary empty sella syndrome. Contemp Neurosurg 29(11):1–6 Arita K, Kurisu K, Tominaga A, Ikawa F, Iida K, Hama S et al (1999) Size-adjustable titanium plate for reconstruction of the sella turcica. Technical note. J Neurosurg 91(6):1055–1057. 10.3171/jns.1999.91.6.1055 Cybulski GR, Stone JL, Geremia G, Anson J (1989) Intrasellar balloon inflation for treatment of symptomatic empty sella syndrome. Neurosurgery 24(1):105–109. 10.1227/00006123-198901000-00019 Gazioğlu N, Akar Z, Ak H, Işlak C, Koçer N, Seçkin MS et al (1999) Extradural balloon obliteration of the empty sella report of three cases (intrasellar balloon obliteration). Acta Neurochir (Wien) 141(5):487–494. 10.1007/s007010050329 Villalonga JF, Burroni M, Fabozzi GL, Solari D, Campero A, Cappabianca P et al (2023) Guanti bianchi technique for resection of selected pituitary adenomas. Brain Spine 3:101724. 10.1016/j.bas.2023.101724 Villalonga JF, Martinez-Font A, Campero A et al (2022) Abordaje de ´´Guante Blanco´´para reseccion de adenomas hipofisiarios. Rev Arg Neuroc 36(4):196–203 Villalonga JF, Ardisana E, Martínez-Font A, Pailler JI, Campero Á (2024) Endoscopic reconstruction to primary empty sella: 7 E technique. J Clin Neurosci 129:110854. 10.1016/j.jocn.2024.110854 Leclercq TA, Hardy J, Vezina JL, Mercky F (1974) Intrasellar arachnoidocele and the so-called empty sella syndrome. Surg Neurol 2(5):295–299 Spaziante R, de Divitiis E, Stella L, Cappabianca P, Genovese L (1981) The empty sella. Surg Neurol 16(6):418–426. 10.1016/0090-3019(81)90234-2 Ajler P, Plou P (2021) Osseous remodeling technique of the sella turcica: a new surgical option for primary empty sella syndrome. Rev Arg Neuroc. ;35(5) Guinto G, del Valle R, Nishimura E, Mercado M, Nettel B, Salazar F (2002) Primary empty sella syndrome: the role of visual system herniation. Surg Neurol 58(1):42–47 discussion 7–8. 10.1016/s0090-3019(02)00766-8 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5379692","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":378415362,"identity":"c9d8c7e0-cfa9-458b-88e7-ca6d9d3b9c75","order_by":0,"name":"Juan F. Villalonga","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYBACxuYDDAceFDDIgHkfgJiNnZCWtgSGAwkGDDxgzgyQFmZC1rAlMDDAtDBDSAI6mNt4DIG22PHwS7df/Gzza5s8HzMD44ePOfgcxmMA1JLMIznnTLF0bt9twzZmBmbJmdvwaJnflgDUwsxjcCMnQTq35zYjUAsbMy8+LW1sIC31IC3Jvy17btsToYX5AFDLYaCW9GPSDD9uJxKr5TiP5IwcNsvehtvJbcyMzXj9YtjG2PzhQ0W1HL9E+uMbP/7ctp3f3nzww0d8WhrgTB4DoJ1gmxtwKIYAeQST/QEDwx+8ikfBKBgFo2CEAgAw1lBCAEkF5AAAAABJRU5ErkJggg==","orcid":"","institution":"LINT, Facultad de Medicina, Universidad Nacional de Tucumán","correspondingAuthor":true,"prefix":"","firstName":"Juan","middleName":"F.","lastName":"Villalonga","suffix":""},{"id":378415363,"identity":"1c1c9753-b569-4842-a80b-17ddcf6ecd9b","order_by":1,"name":"Andrea L. 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A-B 1st E - Endoscopic technique; and 2nd E – Exposure; C: 3rd E - Extradural; D: 4th - Elevate; E-F: 5th E – Egress; G: 6th – Embed; H: 7th E – Exclude.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5379692/v1/7cdca821715952454c117abc.png"},{"id":70958978,"identity":"26db21a2-e685-4f64-b538-efe65e4b3111","added_by":"auto","created_at":"2024-12-09 14:58:33","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2132918,"visible":true,"origin":"","legend":"\u003cp\u003eIllustrative case. A-B. Preoperative TW-2 MRI; C-D: Pre-operative TW1-G MRI; E-F: Pre-operative Visual field examination; G-H: Post-operative CT; I-J: Post-operative visual field examination.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-5379692/v1/2b3b47529d7a385d03d50456.png"},{"id":100563547,"identity":"34c95de6-36ec-466c-af8e-064ecd069148","added_by":"auto","created_at":"2026-01-19 08:46:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5404918,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5379692/v1/54777008-a830-47b0-97e6-097784774c23.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Endoscopic Surgery for Primary Empty Sella Syndrome: The \"7 E\" Technique","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eEmpty sella (ES) is a condition frequently observed in daily practice. Most of the time, it is an incidental finding with no surgical indication. However, it can sometimes be associated with clinical manifestations and constitute the primary empty sella syndrome (PESS)[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eExtradural reconstruction of the sellar floor is indicated in certain patients with PESS, particularly when they present visual deficits without any other justifiable cause[\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Previous descriptions of this procedure with microscopic techniques have been reported[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Results have been published using various autologous and heterologous materials[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur team in Tucum\u0026aacute;n has developed an endoscopic technique we call the \"7 E\" (i.e., endoscopic endonasal approach, exposure, extradural, elevate, egress, embed, exclude). This technique involves exposing the sella turcica using a Guanti Bianchi approach[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and reconstructing the sellar floor with heterologous material.\u003c/p\u003e \u003cp\u003eThis study aims to present the preliminary results of the \"7 E\" technique.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom January 2020 through April 2024, a description of a new surgical technique and an analysis of a prospective case series were conducted. All surgeries were performed by the same surgeon (JFV) at a single center in Tucum\u0026aacute;n, Argentina. The institution\u0026apos;s Ethics Committee approved the study protocol where the surgeries were conducted. Informed consent was obtained from all patients for using their medical records and neuroimages in the present research. The study adhered to the STROBE guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients and Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collection was recorded in a coded Excel spreadsheet (Excel 16.79.1, Microsoft, Redmond, Washington, USA) and included age, sex, history of sellar pathology, type of ES, and symptoms at onset.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion and Exclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA strict selection process was applied for the patients presenting with empty sella (n=277) (Figure 1). Initially, patients were distinguished between primary and secondary ES. Secondary ES was considered for those with a history of surgical, pharmacological, or radiotherapy treatment for their sellar pathology. Patients with secondary ES (n=61) were excluded.\u003c/p\u003e\n\u003cp\u003eNext, symptomatic and asymptomatic patients with primary ES were filtered. Those considered with an incidental radiological finding (n=170) were excluded. Symptomatic patients were referred to as PESS (n=46).\u003c/p\u003e\n\u003cp\u003eThe PESS patients (n=46) were then divided into two groups based on whether they had (n=21) or did not have (n=25) increased intracranial pressure (ICP). Routine questioning, fundoscopy with a slit lamp, MRI (magnetic resonance image) with a specific protocol, and lumbar puncture with manometry were performed. Those with ICP (e.g., PESS associated with Chiari-1 malformation, hydrocephalus, CSF circulation disorder, tumor, pseudotumor cerebri, fungal pathology, among others) were excluded and directed to other treatments based on their specific pathology.\u003c/p\u003e\n\u003cp\u003eIn the fourth stage, idiopathic PESS patients (n=25) were filtered. Those with visual deficits (n=17) were selected based on computerized campimetry. Patients without visual deficits (n=8) were excluded.\u003c/p\u003e\n\u003cp\u003eIn the fifth stage, idiopathic PESS patients with visual deficits (n=17) were referred for an exhaustive ophthalmological study to rule out other common causes of visual deficits (e.g., diabetic retinopathy, hypertensive retinopathy). Patients whose visual deficits were attributed to other causes by the ophthalmologist were excluded (n=4).\u003c/p\u003e\n\u003cp\u003eIn the sixth stage, endoscopic reconstruction of the sellar floor with the \u0026acute;\u0026acute;7 E\u0026acute;\u0026acute; technique was indicated for patients who met our strict selection protocol (n=13).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Imaging Documentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring all cases, a Storz Decq\u0026reg; endoscope, with 0\u0026deg; optics (Karl Storz SE \u0026amp; Co, Tuttlingen, Germany) connected to a Stryker\u0026reg; 1588 AIM (Advanced Imaging Modalities) HD Endoscopy camera was used (Strycker, Michigan, USA). The surgical procedures were recorded using a video capture device, AVerMedia ER130 EzRecorder 130\u0026reg; (AverMedia Technologies, Taipei, Taiwan). Images were edited in PowerPoint version 16.79.1 (Microsoft, New Mexico, USA).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFollow-up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA standardized set of images was obtained for all cases pre-and post-operatively, including:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eBrain and sellar region MRI with gadolinium in sagittal T2 and T2-weighted planes.\u003c/li\u003e\n \u003cli\u003eStandard brain CT with reconstruction in three planes.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThese imaging studies were performed before the surgery, on the first day post-op (CT), and then repeated at 90 days (MRI) and at 6 and 12 months, if applicable (MRI). The minimum follow-up period was six months.\u003c/p\u003e\n\u003cp\u003eClinical outcomes were evaluated by categorizing patients according to visual field testing during the pre- and postoperative periods. Radiological outcomes were assessed by comparing the pre-and postoperative images.\u003c/p\u003e\n\u003cp\u003ePatients were categorized into three groups based on their visual field outcomes:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eExcellent: patients with improvement in visual deficit.\u003c/li\u003e\n \u003cli\u003eAcceptable: patients without progression of visual deficit.\u003c/li\u003e\n \u003cli\u003ePoor: patients with worsening visual deficit.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eBlinding and Bias Avoidance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe neurosurgeon who recorded the pre-and postoperative data did not participate in the surgeries, and the neuroradiologist who measured the sellar region was blinded to the clinical outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll surgeries were performed by the same surgeon (JFV). The step-by-step technique is shown in Figure 2. The key points of the 7 \u0026ldquo;E\u0026rdquo;s technique are summarized:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eEndoscopic Endonasal Approach: A standard endoscopic endonasal approach is performed. Our team uses the Guanti Bianchi approach.\u003c/li\u003e\n \u003cli\u003eExposure: Wide opening of the rostrum, drilling to frame the floor of the sella turcica.\u003c/li\u003e\n \u003cli\u003eExtradural: It is important to note that from this point on, the entire technique is extradural.\u003c/li\u003e\n \u003cli\u003eElevate: Elevation is performed with cottonoid to avoid damaging the dura and causing an intraoperative CSF fistula. The cottonoid is placed in tandem.\u003c/li\u003e\n \u003cli\u003eEgress: The cotton is removed. This causes a relatively noticeable bleeding from the inferior intercavernous sinus, which is easily controlled with a hemostatic matrix (Surgiflo) and does not have hemodynamic significance. Additionally, removing the cottonoid does not automatically lower the dura-covered gland; a memory effect keeps it elevated for a few seconds, allowing for final remodeling.\u003c/li\u003e\n \u003cli\u003eEmbed: Heterologous cement is placed to elevate the dura covering the gland. It generates minimal exothermic reaction while setting, requiring washing with saline solution to dissipate the heat. The self-curing acrylic polymer used is Subiton RO with antibiotic (Subiton, Buenos Aires, Argentina).\u003c/li\u003e\n \u003cli\u003eExclude: Subiton is a heterologous material. To prevent it from being in close contact with the nasal cavity and its bacterial flora, a film of biological adhesive (Beriplast\u0026reg; P Combi set, CSL Behring, Montevideo, Uruguay) is applied.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eOur team has a recent publication about this topic with an illustrative video with the technique [12].\u0026nbsp;\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThis study included 13 patients whose visual field outcomes, headache improvement, and complications were evaluated. Patients ranged in age from 37 to 66 years, with a mean age of approximately 48.31 years. All patients were female.\u003c/p\u003e \u003cp\u003eRegarding visual field outcomes, nine patients (69.2%) had excellent results, three patients (23.1%) had acceptable results, and one patient (7.7%) had poor results.\u003c/p\u003e \u003cp\u003eIn terms of headache improvement, ten patients (76.9%) experienced significant improvement, two patients (15.4%) reported transient improvements, and one patient (7.7%) did not experience any improvement.\u003c/p\u003e \u003cp\u003eRegarding complications, most patients (76.9%) had no complications. However, one patient (7.7%) suffered from panhypopituitarism, and two patients (15.4%) had transient diabetes insipidus (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). During follow-up, it was found that the patient with panhypopituitarism was diagnosed with central nervous system histoplasmosis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical features and outcomes of patients that underwent surgery by the \u0026acute;\u0026acute;7 E\u0026acute;\u0026acute; technique for PESS. F: female\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender/Age\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVisual Field outcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eImprovement of Headaches\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAcceptable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTransitory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAcceptable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTransitory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTransitory DI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePanhypopituitarism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAcceptable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTransitory DI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIllustrative Case\u003c/h2\u003e \u003cp\u003eA 54-year-old patient presented with headaches and visual deficits. Computerized campimetry confirmed visual deficits with scotoma patterns. MRI revealed a sellar arachnoidocele with the gland flattened at the floor of the sella turcica. An endoscopic white glove approach and an extradural reconstruction of the sellar floor with a heterologous graft were performed. The patient showed clinical and radiological improvement with significant visual improvement and headache remission during follow-up (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eEmpty sella (ES) is a term used to commonly refer to a sellar arachnoidocele [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In this condition, the arachnoid invaginates through the sellar diaphragm, enters the sella turcica, and compresses the gland towards the floor, giving the impression of an empty sella[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eClassifying ES\u003c/h2\u003e \u003cp\u003eTo classify the type of ES, several questions should be asked:\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDoes the patient have a history of treatment for sellar pathology? This information helps to determine whether it is primary or secondary ES. A history of surgical, radiological, or pharmacological treatment for sellar pathology indicates secondary ES. Primary ES occurs when there is no such history.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDoes the patient present with congruent symptoms? This helps determine if it is an incidental finding or constitutes PESS.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIs there a specific cause? Is there evidence of ICP on CSF (Cerebrospinal fluid) manometry and fundoscopy? This helps determine if PESS is due to a particular cause associated with intracranial hypertension or is idiopathic multifactorial. Specific causes include tumors, benign intracranial hypertension, hydrocephalus, Chiari type 1, and fungal brain pathology, among others.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003cp\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSurgical Indication\u003c/h2\u003e \u003cp\u003eGuinto et al.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] propose indicating sellar reconstruction surgery in patients with visual deficits and/or nasal CSF fistula. We agree with the first scenario. The author disagrees with the second scenario, as nasal CSF fistula is likely associated with ICP. In such cases, the underlying cause should be identified and treated.\u003c/p\u003e \u003cp\u003eIn summary, we suggest performing endoscopic reconstruction with the 7 E technique in patients with PESS with visual deficits confirmed by campimetry and other ophthalmological causes excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eAbout the Embedding Grafts\u003c/h2\u003e \u003cp\u003eVarious autologous and heterologous grafts have been described for definitive gland elevation[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e–\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The author prefers using self-curing polymer (Subiton) as it offers several advantages: shorter surgical time, no extra incision required, and avoids complications at the autologous graft site.\u003c/p\u003e \u003cp\u003ePotential disadvantages could include infections associated with inert material and/or gland damage from the exothermic reaction of the polymer during setting. To avoid infections, we use antibiotic prophylaxis with ampicillin-sulbactam, thoroughly wash the material once placed, and isolate this inert heterologous material from the nasal cavity with a layer of biological adhesive. The exothermic reaction of the polymer is directly proportional to its volume; in this case, we used a small circumference of 6 cc, so the heat release is not significant. Additionally, thorough washing helps dissipate the heat. In this series (n = 13), we had no complications related to the use of this cement.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eResults in Our Series\u003c/h2\u003e \u003cp\u003eMost patients (76.9%) showed improvement in their headache condition. This may be due to the reconstruction of the sella, which prevents constant downward traction of the dural diaphragm, reducing trigeminal nociceptive stimulation.\u003c/p\u003e \u003cp\u003eNine patients showed visual improvement, and three had no deficit progression; in other words, 12 out of 13 patients had a favorable outcome.\u003c/p\u003e \u003cp\u003eIn the one case where the deficit progressed, the patient also had panhypopituitarism. During follow-up, it was revealed that the patient was diagnosed with central nervous system histoplasmosis. We interpreted this as an error in patient management due to a misdiagnosis. This patient had primary ES associated with increased intracranial pressure due to fungal pathology; therefore, intracranial hypertension should have been treated, and sellar reconstruction should not have been performed. After this case, we added histoplasmosis (endemic in our region) to our management algorithm as a cause of primary ES associated with increased intracranial pressure.\u003c/p\u003e \u003cp\u003eAdditionally, two patients had transient diabetes insipidus, one during hospitalization and another requiring rehospitalization for hyponatremia on the fifth day after discharge. Both cases had favorable outcomes due to appropriate clinical management—neither required long-term desmopressin. We interpreted transient diabetes insipidus as secondary to mechanical manipulation of the gland due to the displacement in the cephalic direction with tandem cotton and later with the heterologous graft rather than due to an exothermic reaction of Subiton. If it were an exothermic reaction, the deficit would have been persistent in more patients.\u003c/p\u003e \u003c/div\u003e "},{"header":"LIMITATIONS","content":"\u003cp\u003eAlthough the number of patients studied was considerable, the patients selected for reconstruction with the \"7 E\" technique represent a small series. A more extensive series is needed to validate this technique.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe \"7 E\" technique proved to be effective in treating PESS in this preliminary study.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eCONFLICT OF INTEREST:\u003c/h2\u003e\n\u003cp\u003eThe authors declare no conflict of interest\u003c/p\u003e\n\u003ch2\u003eEthical Approval:\u003c/h2\u003e\n\u003cp\u003eThe institution\u0026apos;s Ethics Committee approved the study protocol where the surgeries were conducted. Informed consent was obtained from all patients for using their medical records and neuroimages in the present research. The study adhered to the STROBE guidelines.\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eNo fundings were received for this research.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eAuthors Contributions:\u0026bull; Conceptualization: JFV; AMG; AC\u0026bull; Data curation: JFV; ALC; JIP; AMF; AC\u0026bull; Formal analysis: JFV; ALC; JIP; AMF; AC\u0026bull; Investigation: JFV; ALC; AMF; AC\u0026bull; Methodology: JFV; ALC; AMF; AC\u0026bull; Project administration: JFV; AC \u0026bull; Software: JFV; ALC; JIP; AMF; AC\u0026bull; Supervision: JFV; AMF; AC\u0026bull; Validation: JFV; AMF; AC\u0026bull; Visualization: JFV; ALC; AMF; AC\u0026bull; Writing \u0026ndash; original draft: JFV; ALC; AMF; AC\u0026bull; Writing \u0026ndash; review and editing: JFV; ALC; AMF; AC\u003c/p\u003e\n\u003ch2\u003eACKNOWLEDGMENTS:\u003c/h2\u003e\n\u003cp\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGuinto G, Nettel B, Hern\u0026aacute;ndez E, Gallardo D, Ar\u0026eacute;chiga N, Mercado M (2019) Osseous Remodeling Technique of the Sella Turcica: A New Surgical Option for Primary Empty Sella Syndrome. 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World Neurosurg 147:66. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.wneu.2020.12.065\u003c/span\u003e\u003cspan address=\"10.1016/j.wneu.2020.12.065\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuinto G, Mercado M, Nishimura MA, Ar\u0026eacute;chiga E, Nettel N (2007) Primary empty sella syndrome. Contemp Neurosurg 29(11):1\u0026ndash;6\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArita K, Kurisu K, Tominaga A, Ikawa F, Iida K, Hama S et al (1999) Size-adjustable titanium plate for reconstruction of the sella turcica. Technical note. J Neurosurg 91(6):1055\u0026ndash;1057. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3171/jns.1999.91.6.1055\u003c/span\u003e\u003cspan address=\"10.3171/jns.1999.91.6.1055\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCybulski GR, Stone JL, Geremia G, Anson J (1989) Intrasellar balloon inflation for treatment of symptomatic empty sella syndrome. Neurosurgery 24(1):105\u0026ndash;109. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1227/00006123-198901000-00019\u003c/span\u003e\u003cspan address=\"10.1227/00006123-198901000-00019\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGazioğlu N, Akar Z, Ak H, Işlak C, Ko\u0026ccedil;er N, Se\u0026ccedil;kin MS et al (1999) Extradural balloon obliteration of the empty sella report of three cases (intrasellar balloon obliteration). 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J Clin Neurosci 129:110854. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jocn.2024.110854\u003c/span\u003e\u003cspan address=\"10.1016/j.jocn.2024.110854\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeclercq TA, Hardy J, Vezina JL, Mercky F (1974) Intrasellar arachnoidocele and the so-called empty sella syndrome. Surg Neurol 2(5):295\u0026ndash;299\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpaziante R, de Divitiis E, Stella L, Cappabianca P, Genovese L (1981) The empty sella. Surg Neurol 16(6):418\u0026ndash;426. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/0090-3019(81)90234-2\u003c/span\u003e\u003cspan address=\"10.1016/0090-3019(81)90234-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAjler P, Plou P (2021) Osseous remodeling technique of the sella turcica: a new surgical option for primary empty sella syndrome. Rev Arg Neuroc. ;35(5)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuinto G, del Valle R, Nishimura E, Mercado M, Nettel B, Salazar F (2002) Primary empty sella syndrome: the role of visual system herniation. Surg Neurol 58(1):42\u0026ndash;47 discussion 7\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/s0090-3019(02)00766-8\u003c/span\u003e\u003cspan address=\"10.1016/s0090-3019(02)00766-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"empty sella syndrome, endoscopic, primary, technique","lastPublishedDoi":"10.21203/rs.3.rs-5379692/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5379692/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eExtradural reconstruction of the sellar floor is indicated in patients with primary empty sella syndrome and visual deficits without any other apparent cause. Our team in Tucum\u0026aacute;n has developed an endoscopic technique called the \"7 E\" (i.e., endoscopic endonasal approach, exposure, extradural, elevate, egress, embed, exclude). This technique involves the exposure of the sella turcica using a Guanti Bianchi approach and reconstructing the sellar floor with heterologous material. This study aims to present the preliminary results of the \"7 E\" technique.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003eA prospective study was conducted from January 2020 through April 2024 at a single center in Tucum\u0026aacute;n, Argentina. All surgical procedures were performed by the same surgeon. Patients with idiopathic primary empty sella syndrome and confirmed visual deficits were included, excluding those with other causes of visual deficits. An endoscopic endonasal approach and reconstruction of the sellar floor with heterologous material were used. Patients were evaluated pre- and postoperatively with MRI and visual field testing.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThirteen female patients with a mean age of 48.31 years were included. Nine patients (69.2%) had excellent visual field improvement, three (23.1%) had acceptable results, and one (7.7%) showed worsening. Regarding headaches, ten patients (76.9%) showed significant improvement. Three patients presented complications: one with panhypopituitarism and two with transitory diabetes insipidus.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe \"7 E\" technique proved effective in treating primary empty sella syndrome without associated increased intracranial pressure.\u003c/p\u003e","manuscriptTitle":"Endoscopic Surgery for Primary Empty Sella Syndrome: The \"7 E\" Technique","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-09 14:58:28","doi":"10.21203/rs.3.rs-5379692/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d1621782-3f4d-4c67-a53f-6eb1dd514e6f","owner":[],"postedDate":"December 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T08:43:56+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-09 14:58:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5379692","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5379692","identity":"rs-5379692","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}