Current best practice in the management of patients after pituitary surgery

Abstract

Sellar and parasellar masses are a common finding, and most of them are treated surgically via transsphenoidal approach. This type of surgery has revolutionized the approach to several hypothalamic-pituitary diseases and is usually effective, and well-tolerated by the patient. However, given the complex anatomy and high density of glandular, neurological and vascular structures in a confined space, transsphenoidal surgery harbors a substantial risk of complications. Hypopituitarism is one of the most frequent sequelae, with central adrenal insufficiency being the deficit that requires a timely diagnosis and treatment. The perioperative management of AI is influenced by the preoperative status of the hypothalamic-pituitary-adrenal axis. Disorders of water metabolism are another common complication, and they can span from diabetes insipidus, to the syndrome of inappropriate antidiuretic hormone secretion, up to the rare cerebral salt-wasting syndrome. These abnormalities are often transient, but require careful monitoring and management in order to avoid abrupt variations of blood sodium levels. Cerebrospinal fluid leaks, damage to neurological structures such as the optic chiasm, and vascular complications can worsen the postoperative course after transsphenoidal surgery as well. Finally, long-term follow up after surgery varies depending on the underlying pathology, and is most challenging in patients with acromegaly and Cushing disease, in whom failure of primary pituitary surgery is a major concern. When these pituitary functioning adenomas persist or relapse after neurosurgery other treatment options are considered, including repeated surgery, radiotherapy, and medical therapy.

A Literature Review on Peri-Operative Steroid Replacement Therapy in Pituitary Adenomas Surgery

“…Although prolactinomas are usually treated medically, other secretory pituitary adenomas and nonfunctioning sellar and parasellar masses that cause mass effect symptoms are usually treated surgically, with a majority of cases performed via the transsphenoidal approach. Postoperative care by a multidisciplinary team including neurosurgeons, endocrinologists, and intensive care teams is a crucial component of the management [2].…”

“…Patients undergoing transsphenoidal surgery (TSS) often receive "stress dose" steroids whether the hypothalamic-pituitaryadrenal axis (HPAA) is deficient or preserved during TSS [5]. One of the gray areas in the management of non-Cushing disease patients with normal preoperative HPAA is whether to give empiric glucocorticoid (GC) coverage after surgery or to apply a steroid-sparing method, giving GC only if AI develops [2]. There are limited studies examining the safety of withholding glucocorticoids in the perioperative period.…”

“…A recent meta-analysis found that there is no difference in the incidence of postoperative AI or complications such as DI between patients receiving and those not receiving perioperative steroids [15]. Whatever approach is chosen, it is important to take several factors into account which include the followings: the preoperative status of the hypothalamic-pituitary-adrenal axis, the extent of surgery, the postoperative course, the percentage of postoperative AI at each center or each surgeon, the expertise of the team taking care of the patient after surgery, the turnaround time of serum cortisol measurements at the institution [2] and the ability to follow-up the patient closely in the postoperative period with a good accessibility to outpatient resources.…”

Preoperative Factors Associated with Postoperative Diabetes Insipidus after Transsphenoidal Pituitary Adenectomy

“…Post-operative diabetes insipidus is one of the common complication following transsphenoidal pituitary adenectomy reported between 10 to 30% 2,5 . In this study we have analyzed preoperative factors that may be associated with DI following this procedure.…”

“Letter to the Editor: Predictors of Postoperative Diabetes Insipidus Following Endoscopic Resection of Pituitary Adenomas”

“…Based on this fact, several studies recommend that patients must stop their DI medication weekly during a 6-month postsurgery period, to assess for DI symptoms and therefore decide upon continuation of the therapy, classifying these patients with permanent DI [2, 3]. Nevertheless, this approach could have a recall bias, which could underestimate or overestimate the incidence of permanent DI cases.…”