Morbidity of repeat transsphenoidal surgery assessed in more than 1000 operations

Abstract

Object. While transsphenoidal surgery is associated with low morbidity, the degree to which morbidity increases after reoperation remains unclear. The authors determined the morbidity associated with repeat versus initial transsphenoidal surgery after 1015 consecutive operations.Methods. The authors conducted a 5-year retrospective review of the first 916 patients undergoing transsphenoidal surgery at their institution after a pituitary center of expertise was established, and they analyzed morbidities.Results. The authors analyzed 907 initial and 108 repeat transsphenoidal surgeries performed in 916 patients (9 initial surgeries performed outside the authors' center were excluded). The most common diagnoses were endocrine inactive (30%) or active (36%) adenomas, Rathke's cleft cysts (10%), and craniopharyngioma (3%). Morbidity of initial surgery versus reoperation included diabetes insipidus ([DI] 16% vs 26%; p = 0.03), postoperative hyponatremia (20% vs 16%; p = 0.3), new postoperative hypopituitarism (5% vs 8%; p = 0.3), CSF leak requiring repair (1% vs 4%; p = 0.04), meningitis (0.4% vs 3%; p = 0.02), and length of stay ([LOS] 2.8 vs 4.5 days; p = 0.006). Of intraoperative parameters and postoperative morbidities, 1) some (use of lumbar drain and new postoperative hypopituitarism) did not increase with second or subsequent reoperations (p = 0.3-0.9); 2) some (DI and meningitis) increased upon second surgery (p = 0.02-0.04) but did not continue to increase for subsequent reoperations (p = 0.3-0.9); 3) some (LOS) increased upon second surgery and increased again for subsequent reoperations (p < 0.001); and 4) some (postoperative hyponatremia and CSF leak requiring repair) did not increase upon second surgery (p = 0.3) but went on to increase upon subsequent reoperations (p = 0.001-0.02). Multivariate analysis revealed that operation number, but not sex, age, pathology, radiation therapy, or lesion size, increased the risk of CSF leak, meningitis, and increased LOS. Separate analysis of initial versus repeat transsphenoidal surgery on the 2 most common benign pituitary lesions, pituitary adenomas and Rathke's cleft cysts, revealed that the increased incidence of DI and CSF leak requiring repair seen when all pathologies were combined remained significant when analyzing only pituitary adenomas and Rathke's cleft cysts (DI, 13% vs 35% [p = 0.001]; and CSF leak, 0.3% vs 9% [p = 0.0009 ]).Conclusions. Repeat transsphenoidal surgery was associated with somewhat more frequent postoperative DI, meningitis, CSF leak requiring repair, and greater LOS than the low morbidity characterizing initial transsphenoidal surgery. These results provide a framework for neurosurgeons in discussing reoperation for pituitary disease with their patients.

Hypophysitis: a single-center case series

“…Specifically, there were several cases where pre-treatment clinical context or radiographic appearance could not differentiate between inflammatory lesions, sarcoidosis, Langerhans cell histiocytosis, or lymphoma, each of which would necessitate a different treatment approach (e.g., glucocorticoids, focused radiotherapy or chemoradiotherapy, respectively). Given the safety of transsphenoidal surgery [59][60][61], we felt it was in the patients' best interest to achieve a definitive diagnosis.…”

Complications after transsphenoidal surgery for patients with Cushing's disease and silent corticotroph adenomas

“…Symptomatic hyponatremia is a reported complication of transsphenoidal surgery (2.1%-9.0%). 17,19,25,40,60 CD patients in particular seem to be at the same risk for postoperative development of symptomatic hyponatremia. Semple and Laws reported a 5.7% incidence of postoperative hyponatremia in CD patients.…”

ENDOCRINE TUMORS: BRAF V600E mutations in papillary craniopharyngioma

“…The tumors arise in proximity to critical structures and can compress or infiltrate these vital neurological areas 4–7 . Visual defects, pan-hypopituitarism, cognitive deficits, personality changes, hyperphagia and morbid obesity are common complications that result not only from the growth of the tumor but also often as a consequence of treatment with surgery, radiation, or both 4–11 . Moreover, scarring and reactive changes occur following surgical resection and radiation treatment.…”