Optimizing pre-, intra-, and postoperative management of patients with sellar pathology undergoing transsphenoidal surgery

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Perioperative management of patients with sellar lesions is complex, requiring input from a multidisciplinary team of specialists for ongoing management of both endocrinological and neurosurgical issues. Here, the authors reviewed the experience of a single multidisciplinary center over 10 years to identify key postoperative practices that ensure positive outcomes for patients with sellar lesions who undergo transsphenoidal surgery.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors performed a retrospective review of all transsphenoidal operations carried out by the senior author at a single center from April 2008 through November 2018. They included only adult patients and recorded perioperative management. They also reviewed the evolution of clinical practices for perioperative care at their institution to identify strategies for ensuring positive patient outcomes, and they reviewed the literature on select related topics.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>In total, 1023 operations in 928 patients were reviewed. Of these, 712 operations were for pituitary adenomas (69.6%), and 122 were for Rathke cleft cysts (11.9%). The remainder included operations for craniopharyngiomas (3.6%), arachnoid cysts (1.7%), pituitary tumor apoplexy (1.0%), and other sellar pathologies (12.2%). Among the reviewed operations, the median hospital stay was 3 days (IQR 2–3). Patient management details during the pre-, intra-, and postoperative periods were identified, including both shared characteristics of all patients undergoing transsphenoidal surgery and unique characteristics that are specific to certain lesion types or patient populations.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>Patients with sellar lesions who undergo transsphenoidal surgery require complex, multidisciplinary perioperative care to monitor for common adverse events and to improve outcomes, but there is a dearth of high-quality evidence guiding most perioperative practices. Here, the authors reviewed practices at their institution across more than 1000 transsphenoidal operations that may help ensure successful patient outcomes.</jats:p></jats:sec>

Impact of surgical factors on delayed hyponatremia in patients with nonfunctioning pituitary adenoma after endonasal endoscopic transsphenoidal procedure

“…These patients should be treated as soon as possible to avoid deterioration and several reports regarding treatment of delayed hyponatremia to prevent severe symptoms have been presented [25,[40][41][42], with the latter by Deaver et al noting that mild fluid restriction (up to 1.5 liters daily) was an effective approach for preventing readmission for hyponatremia after TSS for a pituitary adenoma. Based on the report by D. J. Cote [43], restrictions of fluid (to 1.0 liters daily) and oral salt intake (3-6 g/day) were used for patients in the present cohort with delayed hyponatremia to improve symptoms. Finally, though treatment with the oral vasopressin receptor antagonist tolvaptan can be useful for cases with SIADH [9], that drug was not available in Japan until 2020.…”

Predictive Factors for Postoperative Opioid Use in Elective Endoscopic Endonasal Skull Base Surgery

“…Since the declaration of the opioid epidemic as a United States public health emergency in 2017, recent research has identified alternatives to opioid use in the perioperative period 36 . Nonsteroidal anti‐inflammatory drugs and anticonvulsants have been shown to reduce postoperative opioid use 6,37 . A randomized controlled trial demonstrated that scheduled postoperative intravenous ibuprofen in patients undergoing EESBS decreased pain scores and opioid use, with no increased risk of hemorrhagic complications compared with placebo 6 .…”

“…36 Nonsteroidal anti-inflammatory drugs and anticonvulsants have been shown to reduce postoperative opioid use. 6,37 A randomized controlled trial demonstrated that scheduled postoperative intravenous ibuprofen in patients undergoing EESBS decreased pain scores and opioid use, with no increased risk of hemorrhagic complications compared with placebo. 6 Anticonvulsants such as pregabalin have been shown to reduce postoperative pain scores and inpatient and outpatient opioid use compared with placebo in patients who underwent elective craniotomies.…”

Endocrine Disorder in Patients With Craniopharyngioma

“…The use of glucocorticoids is the most important in the perioperative period of patients with craniopharyngioma. Patients after surgery undergo assessments serum cortisol daily morning (102). At most centers, all patients are given stress doses of hydrocortisone (100 mg IV) or other glucocorticoid at the time of surgery, and this dose is tapered quickly over 2-3 days for a total of about five doses (106)(107)(108).…”

“…Acute disorders of water metabolism can manifest in a triphasic pattern (in ~3% of patients): an initial polyuric phase, a subsequent antidiuretic phase (the patients can temporarily concentrate urine and syndrome of inappropriate ADH secretion (SIADH) and hyponatremia develops), and a final polyuric phase that is usually chronic ( 101 ). To screen for potential development of postoperative DI and SIADH, patients after surgery undergo assessments of serum sodium and urine-specific gravity every 6 h ( 102 ).…”