Endonasal endoscopic pituitary surgery in the elderly

Abstract

OBJECTIVE Pituitary adenomas are benign, slow-growing tumors that cause symptoms either through mass effect or hormone overproduction. The decision to operate on a healthy young person is relatively straightforward. In the elderly population, however, the risks of complications may increase, rendering the decision more complex. Few studies have documented the risks of surgery using the endonasal endoscopic approach in a large number of elderly patients. The purpose of this study was to audit a single center's data regarding outcomes of purely endoscopic endonasal transsphenoidal resection of pituitary adenomas in elderly patients and to compare them to the current literature. METHODS A retrospective review of a prospectively acquired database of all endonasal endoscopic surgeries done by the senior authors was queried for patients aged 60-69 years and for those aged 70 years or older. Demographic and radiographic preoperative data were reviewed. Outcomes with respect to extent of resection and complications were examined and compared with appropriate statistical tests. RESULTS A total of 135 patents were identified (81 aged 60-69 years and 54 aged 70 years or older [70+]). The average tumor diameter was slightly larger for the patients in the 70+ age group (mean [SD] 25.7 ± 9.2 mm) than for patients aged 60-69 years (23.1 ± 9.8 mm, p = 0.056). There was no significant difference in intraoperative blood loss (p > 0.99), length of stay (p = 0.22), or duration of follow-up (p = 0.21) between the 2 groups. There was a 7.4% complication rate in patients aged 60-69 years (3 nasal and 3 medical complications) and an 18.5% complication rate in patients older than 70 years (4 cranial, 3 nasal, 1 visual, and 2 medical complications; p = 0.05 overall and 0.013 for cranial complications). Cranial complications in the 70+ age category included 2 postoperative hematomas, 1 pseudoaneurysm formation, and 1 case of symptomatic subdural hygromas. CONCLUSIONS Endonasal endoscopic surgery in elderly patients is safe, but there is a graded increase in complication rates with increasing age. The decision to operate on an asymptomatic or mildly symptomatic patient in these age groups should take this increasing complication rate into account. The use of a lumbar drain or lumbar punctures should be weighed against the risk of subdural hematoma in patients with preexisting atrophy.

ICAR: endoscopic skull‐base surgery

“…A total of 15 studies met the inclusion and exclusion criteria . Overall, the evidence level was low with the majority of studies comprising level 4 evidence (Table ).…”

Upfront Gamma Knife radiosurgery for Cushing’s disease and acromegaly: a multicenter, international study

“…They noted a complication rate of 7.4% in patients in the 60-to 69-year age group versus 18.5% in patients older than 70 years (for both overall and cranial complications), and concluded that in elderly patients there was a graded increase in complication rates with increasing age. 42 In elderly patients with functioning pituitary adenomas or with small to moderate-size adenomas invading the CS, there might be a role for upfront GKS. GKS is typically used as an adjuvant treatment in patients with persistent CD and acromegaly after one or more failed surgeries.…”

MANAGEMENT OF ENDOCRINE DISEASE: Visual morbidity in patients with pituitary adenoma

“…In this series, visual deterioration was observed in only 1.5% of the total group and the authors suggested that visual deficits should not result in very elderly patients being denied surgery (40). Review of seven further studies on post-operative visual outcomes in patients aged from ≥65 to ≥80 years showed improvement in 34-92%, stability in 3-63% and deterioration in 0-8%, and comparison with various control groups (ranging in age from 18 to <80 years) demonstrated no difference in visual improvement rates (39,40,41,42,43,44,45).…”