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Ali A, Cai X, Zhu J, Geng Y, Du C, Yuan F, Yang J, Tang C, Cong Z, Ma C. A Preoperative Nomogram for Prediction of Postoperative Hypocortisolism in Patients with Pituitary Adenomas: A Single-Center Retrospective Cohort Study. World Neurosurg 2023; 179:e135-e149. [PMID: 37586551 DOI: 10.1016/j.wneu.2023.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/06/2023] [Accepted: 08/07/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Patients with pituitary adenomas (PAs) are at an increased risk preoperatively and postoperatively for hypopituitarism. Postoperative hypocortisolism is associated with increased mortality and morbidity as well as poor quality of life. However, research about the risk factors for postoperative hypocortisolism is limited, and a predictive nomogram for postoperative hypocortisolism has not yet been developed. We aimed to investigate the predictive factors for postoperative hypocortisolism and construct a dynamic online nomogram. METHODS Our database included 438 consecutive PA patients who were hospitalized and treated with transsphenoidal surgery by experienced neurosurgeons from the different medical teams in the Neurosurgery Department, Jinling Hospital, between January 2018 and October 2020. The final study group included 238 eligible patients. Data on possible predictors, including age, sex, treatment history of PAs, preoperative signs and symptoms, primary recurrence subtype, and clinical subtypes, were collected. Univariable and multivariable logistic regression analyses were applied to identify independent predictors, which were included in constructing the nomogram model. The calibration curve and receiver operating characteristic curve were computed to evaluate the predictive performance of the nomogram model. RESULTS The incidence of postoperative hypocortisolism was 12.08%. Three preoperative predictors were identified to construct the nomogram: surgical type (microscopic or endoscopic, with endoscopic surgery proven to be the protective factor) (odds ratio, 0.24; 95% confidence interval [CI], 0.093-0.610; P = 0.003), prothrombin time (odds ratio, 2.40; 95% CI, 1.332-4.326; P = 0.004), and basophil cell count (odds ratio, 5.25; 95% CI, 1.270-21.816; P = 0.022,). The area under the curve of receiver operating characteristic curve for the constructed nomogram was 0.749 (95% CI, 0.640-0.763); a well-fixed calibration curve was generated for the nomogram model. An interactive web-based dynamic nomogram application was also constructed. CONCLUSIONS In this study, surgical type, prothrombin time, and basophil cell count were the most relevant predictive factors for postoperative hypocortisolism. A predictive nomogram that can preoperatively assess the risk of hypocortisolism after surgical treatment of PAs was developed. This nomogram could be helpful in identifying high-risk patients who require close monitoring of serum cortisol levels and initiating clinical procedures for patients requiring cortisol administration therapy as a lifesaving strategy.
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Affiliation(s)
- Alleyar Ali
- Department of Neurosurgery, The Affiliated Jinling Hospital of Nanjing Medical University, Nanjing, China
| | - Xiangming Cai
- School of Medicine, Southeast University, Nanjing, China
| | - Junhao Zhu
- Department of Neurosurgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yuanming Geng
- Department of Neurosurgery, The Affiliated Jinling Hospital of Nanjing Medical University, Nanjing, China
| | - Chaonan Du
- Department of Neurosurgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Feng Yuan
- Department of Neurosurgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jin Yang
- Department of Neurosurgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Chao Tang
- Department of Neurosurgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Zixiang Cong
- Department of Neurosurgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Chiyuan Ma
- Department of Neurosurgery, The Affiliated Jinling Hospital of Nanjing Medical University, Nanjing, China; School of Medicine, Southeast University, Nanjing, China; Department of Neurosurgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China; Department of Neurosurgery, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Guangzhou, China.
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Abdollahifard S, Taherifard E, Sadeghi A, Farrokhi A, Cohen-Gadol AA, Palmisciano P. Early Morning Cortisol Level as a Predictive Factor for Long-Term Glucocorticoid Replacement After Pituitary Surgery: A Systematic Review and Meta-Analysis. World Neurosurg 2023; 176:168-178. [PMID: 37201788 DOI: 10.1016/j.wneu.2023.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/06/2023] [Accepted: 05/08/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND A reliable strategy for predicting long-term adrenal insufficiency after pituitary surgery can reduce the risk of glucocorticoid overexposure or missing patients with pituitary insufficiency. For this purpose, we aimed to assess the predictive value of early postoperative morning serum cortisol level for the detection of hypothalamic-pituitary-adrenal axis dysfunction in patients who underwent pituitary surgery. METHODS A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-based systematic review was conducted to include articles investigating morning blood cortisol levels after pituitary surgery for lesions of the pituitary gland as a determinant for administration of long-term supplemental glucocorticoids. Bayesian statistics were used to pool the sensitivity and specificity rates. Sensitivity and specificity were also determined for each potential cortisol level on postoperative day (POD) 1 and POD 2. RESULTS The study included 17 articles encompassing 1648 patients. Morning cortisol levels on POD 1 and POD 2 showed pooled sensitivity rates of 86.4% and 86.6% and pooled specificity rates of 73.1% and 78.2%, respectively, for predicting long-term glucocorticoid replacement after surgery. A cortisol level of 2.1 μg/dL showed the highest sensitivity rate (98.78%), and 22.5 μg/dL showed the highest specificity rate (72.5%) on POD 1. CONCLUSIONS In this review and Bayesian meta-analysis, we found that postoperative serum cortisol measurement may have high accuracy in prediction of the long-term need for glucocorticoid administration in patients who underwent pituitary surgery.
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Affiliation(s)
| | - Erfan Taherifard
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran; MPH Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Sadeghi
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | | | - Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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Benjamin CG, Dastagirzada Y, Bevilacqua J, Kurland DB, Fujita K, Sen C, Golfinos JG, Placantonakis DG, Jafar JJ, Lieberman S, Lebowitz R, Lewis A, Agrawal N, Pacione D. The Cost Effectiveness of Implementation of a Postoperative Endocrinopathy Management Protocol after Resection of Pituitary Adenomas. J Neurol Surg B Skull Base 2022; 83:618-625. [PMID: 36393880 PMCID: PMC9653289 DOI: 10.1055/s-0042-1750718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 05/23/2022] [Indexed: 10/17/2022] Open
Abstract
Purpose After developing a protocol for evaluating, diagnosing, and treating postoperative endocrinopathy both during the hospitalization and during the immediate discharge period following resection of pituitary adenomas, we sought to assess the impact of this protocol on quality outcomes. Methods An IRB-exempt, quality improvement initiated, Health Insurance Portability and Accountability Act (HIPAA)-compliant retrospective comparison of a pre-and-post-protocol cohort of all patients undergoing endoscopic endonasal resection of pituitary adenomas at NYU Langone Medical Center from January 2013 to December 2018. Demographic characteristics of the patients and their tumors with their postoperative outcomes were recorded. Quality outcomes regarding number of laboratory studies sent, rate of diabetes insipidus, length of stay, and readmission rate were also recorded. Statistical analysis was performed between the pre- and post-protocol groups. Results There was a significant reduction in laboratory studies sent per patient (55.66 vs. 18.82, p <0.001). This corresponded with an overall cost reduction in laboratory studies of $255.95 per patient. There was a decrease in the overall number of patients treated with DDAVP (21.4% in the pre-protocol group vs. 8.9% in the post-protocol group, p = 0.04). All post-protocol patients requiring DDAVP at discharge were identified by 48 hours. There was no significant change in length of stay or need for hydrocortisone supplementation postoperatively between the two groups. Length of stay was driven mostly by need for reoperation during initial hospitalization. There was no significant change in the rate of 30-day readmission. Conclusion Implementation of a postoperative management protocol results in a more efficient diagnosis and management of endocrinopathy after pituitary adenoma surgery which translates to decreased cost.
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Affiliation(s)
- Carolina G. Benjamin
- Department of Neurosurgery, University of Miami, Miami, Florida, United States
- Address for correspondence Carolina Gesteira Benjamin, MD University of MiamiMiami, FL 33146United States
| | - Yosef Dastagirzada
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, United States
| | - Julia Bevilacqua
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, United States
| | - David B. Kurland
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, United States
| | - Kevin Fujita
- Department of Neurosurgery, Yale Medical Center, New Haven, Connecticut, United States
| | - Chandra Sen
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, United States
| | - John G. Golfinos
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, United States
| | | | - Jafar J. Jafar
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, United States
| | - Seth Lieberman
- Department of Otolaryngology, NYU Langone Medical Center, New York, New York, United States
| | - Richard Lebowitz
- Department of Otolaryngology, NYU Langone Medical Center, New York, New York, United States
| | - Ariane Lewis
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, United States
- Department of Neurology, NYU Langone Medical Center, New York, New York, United States
| | - Nidhi Agrawal
- Department of Endocrinology, NYU Langone Medical Center, New York, New York, United States
| | - Donato Pacione
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, United States
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Sarris CE, Brigeman ST, Doris E, Bobrowitz M, Rowe T, Duran EM, Santarelli GD, Rehl RM, Ovanessoff G, Rodriguez MC, Buddhdev K, Yuen KCJ, Little AS. Effects of a transsphenoidal surgery quality improvement program on patient outcomes and hospital financial performance. J Neurosurg 2022; 137:59-68. [PMID: 34798599 DOI: 10.3171/2021.7.jns21286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 07/12/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE A comprehensive quality improvement (QI) program aimed at all aspects of patient care after pituitary surgery was initiated at a single center. This initiative was guided by standard quality principles to improve patient outcomes and optimize healthcare value. The programmatic goal was to discharge most elective patients within 1 day after surgery, improve patient safety, and limit unplanned readmissions. The program is described, and its effect on patient outcomes and hospital financial performance over a 5-year period are investigated. METHODS Details of the patient care pathway are presented. Foundational elements of the QI program include evidence-based care pathways (e.g., for hyponatremia and pain), an in-house research program designed to fortify care pathways, patient education, expectation setting, multidisciplinary team care, standard order sets, high-touch postdischarge care, outcomes auditing, and a patient navigator, among other elements. Length of stay (LOS), outcome variability, 30-day unplanned readmissions, and hospital financial performance were identified as surrogate endpoints for healthcare value for the surgical epoch. To assess the effect of these protocols, all patients undergoing elective transsphenoidal surgery for pituitary tumors and Rathke's cleft cysts between January 2015 and December 2019 were reviewed. RESULTS A total of 609 adult patients who underwent elective surgery by experienced pituitary surgeons were identified. Patient demographics, comorbidities, and payer mix did not change significantly over the study period (p ≥ 0.10). The mean LOS was significantly shorter in 2019 versus 2015 (1.6 ± 1.0 vs 2.9 ± 2.2 midnights, p < 0.001). The percentage of patients discharged after 1 midnight was significantly higher in 2019 versus 2015 (75.4% vs 15.6%, p < 0.001). The 30-day unplanned hospital readmission rate decreased to 2.8% in 2019 from 8.3% in 2015. Per-patient hospital profit increased 71.3% ($10,613 ± $19,321 in 2015; $18,180 ± $21,930 in 2019), and the contribution margin increased 42.3% ($18,925 ± $19,236 in 2015; $26,939 ± $22,057 in 2019), while costs increased by only 3.4% ($18,829 ± $6611 in 2015; $19,469 ± $4291 in 2019). CONCLUSIONS After implementation of a comprehensive pituitary surgery QI program, patient outcomes significantly improved, outcome variability decreased, and hospital financial performance was enhanced. Future studies designed to evaluate disease remission, patient satisfaction, and how the surgeon learning curve may synergize with other quality efforts may provide additional context.
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Affiliation(s)
| | | | | | | | | | | | - Griffin D Santarelli
- 3Otolaryngology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | | | - Garineh Ovanessoff
- 5Department of Endocrinology, Dignity Health Medical Group, Phoenix, Arizona
| | - Monica C Rodriguez
- 5Department of Endocrinology, Dignity Health Medical Group, Phoenix, Arizona
| | - Kajalben Buddhdev
- 5Department of Endocrinology, Dignity Health Medical Group, Phoenix, Arizona
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Madapoosi A, Uram Z, Tsiang J, Pecoraro N, Patel C, Germanwala AV. Rathke's cleft cyst marsupialization and repair with a free mucosal graft - Video case report and literature review. Am J Otolaryngol 2022; 43:103519. [PMID: 35690516 DOI: 10.1016/j.amjoto.2022.103519] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 05/30/2022] [Indexed: 11/18/2022]
Abstract
Rathke's cleft cysts (RCCs) are sellar or suprasellar cystic lesions arising from the remnants of the embryological Rathke's pouch. When symptomatic, RCCs are usually treated surgically via marsupialization. Free mucosal graft (FMG) repair has shown promise in decreasing recurrence versus marsupialization alone. The authors present a case report with operative video of a patient with visual and endocrinological symptoms with a RCC treated with FMG following marsupialization. A search of the PubMed database from July 1997 through April 2022 was conducted using the terms 'Rathke's cleft cyst', 'Rathke's cleft cyst management', 'Rathke's cleft cyst repair', 'mucosal graft', 'mucosal coupling', 'transsphenoidal', and 'endoscopic endonasal'. Clinical and pathological aspects of the case presented were compared with information obtained from literature review. A 25-year-old female presented with a six-year history of amenorrhea, one-year history of anemia, headaches, and progressive visual loss. Imaging revealed an RCC. The patient underwent surgical treatment via an endoscopic endonasal approach. Marsupialization was achieved with placement of an FMG to help prevent restenosis. Post-operative examination revealed that the patient's OD vision returned to normal, although her OS vision was only slightly improved. Our review of the English literature resulted in 35 full-length articles that were published between 1997 and 2022. The literature suggests that FMG prevents scar formation by allowing for adequate epithelialization, thus decreasing the recurrence rate and being well tolerated by patients. Our findings support the utility of the FMG as a superior surgical treatment option for RCC management.
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Affiliation(s)
- Adrusht Madapoosi
- Chicago Medical School, Rosalind Franklin University, North Chicago, IL, United States of America
| | - Zachary Uram
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, United States of America
| | - John Tsiang
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL, United States of America
| | - Nathan Pecoraro
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL, United States of America
| | - Chirag Patel
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, United States of America; Department of Otolaryngology, Head and Neck Surgery, Loyola University Medical Center, Maywood, IL, United States of America
| | - Anand V Germanwala
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, United States of America; Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL, United States of America; Department of Otolaryngology, Head and Neck Surgery, Loyola University Medical Center, Maywood, IL, United States of America.
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Irigaray Echarri A, Ollero García-Agulló MD, Iriarte Beroiz A, García Mouriz M, Zazpe Cenoz I, Laguna Muro S, Muñoz de Dios L, Anda Apiñániz E. Evaluation of a perioperative steroid coverage after pituitary surgery. ENDOCRINOL DIAB NUTR 2022; 69:338-344. [PMID: 35538002 DOI: 10.1016/j.endien.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/01/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Serum cortisol levels within the first days after pituitary surgery have been shown to be a predictor of post-surgical adrenal insufficiency. However, the indication of empirical glucocorticoids to avoid this complication remains controversial. The objective is to assess the role of cortisol in the early postoperative period as a predictor of long-term corticotropic function according to the pituitary perisurgical protocol with corticosteroid replacement followed in our center. METHODS One hundred eighteen patients who underwent surgery in a single center between December 2012 and January 2020 for a pituitary adenoma were included. Of these, 54 patients with previous adrenal insufficiency (AI), Cushing's disease, or tumors that required treatment with high-dose glucocorticoids (GC) were excluded. A treatment protocol with glucocorticoids was established, consisting of its empirical administration at rapidly decreasing doses, and serum cortisol was determined on the third day after surgery. Subsequent adrenal status was assessed through follow-up biochemical and clinical evaluations. RESULTS Out of the 64 patients treated, there were 56 macroadenomas and 8 microadenomas. The incidence of adrenal insufficiency after pituitary surgery was 4.7%. The optimal cut-off value that predicted an adequate corticotropic reserve, taking into account the best relationship of specificity and sensitivity, was ≥4.1 μg/dl for serum cortisol on the third day (sensitivity 95.1%, specificity 100%). CONCLUSION Serum cortisol on the third day predicts the development of adrenal insufficiency. We suggest a cortisol cut-off point of ≥4.1 μg/dl on postoperative on the third day after surgery as a predictor of the adrenal reserve in the long-term.
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Affiliation(s)
- Ana Irigaray Echarri
- Sección de Endocrinología y Nutrición, Hospital García Orcoyen, Estella, Navarra, Spain.
| | | | - Ana Iriarte Beroiz
- Servicio de Endocrinología y Nutrición, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain
| | - Marta García Mouriz
- Servicio de Endocrinología y Nutrición, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain
| | - Idoya Zazpe Cenoz
- Servicio de Neurocirugía, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain
| | - Sara Laguna Muro
- Sección de Endocrinología y Nutrición, Fundación Hospital de Calahorra, Calahorra, La Rioja, Spain
| | - Luis Muñoz de Dios
- Servicio de Endocrinología y Nutrición, Hospital San Pedro, Logroño, La Rioja, Spain
| | - Emma Anda Apiñániz
- Servicio de Endocrinología y Nutrición, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain
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Irigaray Echarri A, Ollero García-Agulló MD, Iriarte Beroiz A, García Mouriz M, Zazpe Cenoz I, Laguna Muro S, Muñoz de Dios L, Anda Apiñániz E. Evaluación de protocolo de manejo periquirúrgico con glucocorticoides tras cirugía hipofisaria. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Sheldon BL, O'Brien MW, Adamo MA. Growth hormone replacement therapy: is it safe to use in children with asymptomatic pituitary lesions? J Pediatr Endocrinol Metab 2021; 34:1525-1529. [PMID: 34407327 DOI: 10.1515/jpem-2021-0479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 08/04/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Small pituitary cysts are commonly discovered on pediatric brain magnetic resonance imagings (MRIs), particularly in patients with growth hormone deficiency (GHD). We examined the need for operative management in children with these masses as well as the effect of growth hormone replacement (GHR) on these lesions. METHODS This was a retrospective review of pituitary protocol MRIs conducted in children 0-19 at a single center between April 2010-November 2020. Sex, indication for initial MRI, volume, and whether surgery was performed was determined. Records were reviewed to determine whether GHD was present and treatment with GHR documented. For patients with subsequent MRIs, volume on most recent scan was calculated. RESULTS Of the 101 children with cysts, 25 had laboratory-confirmed GHD and 76 did not. GHD patients had a higher mean age compared to no growth hormone deficiency (NGHD) cohort (11.2 and 8.4 years, respectively; p=0.02) and a larger proportion of males (p<0.001). The mean cyst volume on initial MRI was not significantly smaller in patients with GHD (0.063 ± 0.012 cm3) vs. those without GHD (0.171 ± 0.039 cm3, p=0.11). Of the 21 GHD patients who received GHR and had follow-up MRIs, 10 had no change in pituitary cyst size, two had cysts that shrank, and seven disappeared. The remaining two cysts enlarged an average of 0.061 ± 0.033 cm3. Zero GHR recipients required surgical intervention. CONCLUSIONS Small sellar cysts discovered incidentally on imaging in children are unlikely to require surgical intervention. GHR does not appear to significantly enlarge these pediatric pituitary lesions and is safe for use.
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Affiliation(s)
| | | | - Matthew A Adamo
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA.,Department of Pediatrics, Albany Medical Center, Albany, NY, USA
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Thakur JD, Corlin A, Mallari RJ, Yawitz S, Eisenberg A, Sivakumar W, Griffiths C, Carrau RL, Rettinger S, Cohan P, Krauss H, Araque KA, Barkhoudarian G, Kelly DF. Complication avoidance protocols in endoscopic pituitary adenoma surgery: a retrospective cohort study in 514 patients. Pituitary 2021; 24:930-942. [PMID: 34215990 PMCID: PMC8252985 DOI: 10.1007/s11102-021-01167-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2021] [Indexed: 12/02/2022]
Abstract
PURPOSE To evaluate the impact of using consistent complication-avoidance protocols in patients undergoing endoscopic pituitary adenoma surgery including techniques for avoiding anosmia, epistaxis, carotid artery injury, hypopituitarism, cerebrospinal fluid leaks and meningitis. METHODS All patients undergoing endoscopic adenoma resection from 2010 to 2020 were included. Primary outcomes included 90-day complication rates, gland function outcomes, reoperations, readmissions and length of stay. Secondary outcomes were extent of resection, short-term endocrine remission, vision recovery. RESULTS Of 514 patients, (mean age 51 ± 16 years; 78% macroadenomas, 19% prior surgery) major complications occurred in 18(3.5%) patients, most commonly CSF leak (9, 1.7%) and meningitis (4, 0.8%). In 14 of 18 patients, complications were deemed preventable. Four (0.8%) had complications with permanent sequelae (3 before 2016): one unexplained mortality, one stroke, one oculomotor nerve palsy, one oculoparesis. There were no internal carotid artery injuries, permanent visual worsening or permanent anosmia. New hypopituitarism occurred in 23/485(4.7%). Partial or complete hypopituitarism resolution occurred in 102/193(52.8%) patients. Median LOS was 2 days; 98.3% of patients were discharged home. Comparing 18 patients with major complications versus 496 without, median LOS was 7 versus 2 days, respectively p < 0.001. Readmissions occurred in 6%(31/535), mostly for hyponatremia (18/31). Gross total resection was achieved in 214/312(69%) endocrine-inactive adenomas; biochemical remission was achieved in 148/209(71%) endocrine-active adenomas. Visual field or acuity defects improved in 126/138(91.3%) patients. CONCLUSION This study suggests that conformance to established protocols for endoscopic pituitary surgery may minimize complications, re-admissions and LOS while enhancing the likelihood of preserving gland function, although there remains opportunity for further improvements.
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Affiliation(s)
| | - Alex Corlin
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Regin Jay Mallari
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Samantha Yawitz
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Amalia Eisenberg
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Walavan Sivakumar
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Chester Griffiths
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA
| | | | - Sarah Rettinger
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Pejman Cohan
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Howard Krauss
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Katherine A Araque
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA.
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA.
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10
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Alexander TD, Collopy S, Yu S, Karsy M, Chitguppi C, Farrell CJ, Evans JJ. Perioperative Outcomes of a Hydrocortisone Protocol after Endonasal Surgery for Pituitary Adenoma Resection. Skull Base Surg 2021; 83:383-389. [DOI: 10.1055/s-0041-1735588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
Abstract
Abstract
Introduction In pituitary adenomas (PAs), the use of postoperative steroid supplementation remains controversial, as it reduces peritumoral edema and sinonasal complaints but disrupts the detection of adrenal insufficiency (AI). It is unclear whether postoperative cortisol supplementation has a measurable effect on improving outcomes in patients with pituitary adenoma undergoing endoscopic transsphenoidal surgery (ETS). The objective of the study was to evaluate a postoperative steroid treatment protocol on various surgical outcomes in patients with PA undergoing ETS.
Methods A retrospective cohort study was performed for patients undergoing ETS from 2005 to 2020 for PA at a single tertiary academic center. Patients were divided into two groups: those managed by a routine postoperative glucocorticoid supplementation protocol (steroid protocol) and those who received supplementation based on postoperative cortisol laboratory assessment (steroid sparing protocol). Management was otherwise the same between groups. Evaluation of length of stay (LOS), sinonasal outcomes, 30-day readmission, and perioperative complications, including AI, were performed.
Results Among 535 patients, 21% (n = 111) received postoperative steroids, while the remainder (n = 424) did not. There were no differences in mean LOS (3 vs. 3 days, p = 0.72), sinonasal complaints (27 vs. 19%, p = 0.12), 30-day readmission (5% vs. 5%, p = 0.44), and perioperative complications (5 vs. 5%, p = 0.79) between both the groups. A multivariate model supported that both groups were comparable in predicting LOS, 30-day readmission, and complications. No reduction in readmission for AI was seen.
Conclusion Routine administration of postoperative glucocorticoids did not significantly improve patient outcomes in patients with PA who underwent ETS.
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Affiliation(s)
- Tyler D. Alexander
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United Sates
| | - Sarah Collopy
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United Sates
| | - Siyuan Yu
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United Sates
| | - Michael Karsy
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United Sates
| | - Chandala Chitguppi
- Department of Otolaryngology and Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United Sates
| | - Christopher J. Farrell
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United Sates
| | - James J. Evans
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United Sates
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11
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Transsphenoidal pituitary adenoma resection: do early post-operative cortisol levels predict permanent long-term hypocortisolism? Neurosurg Rev 2021; 45:1353-1362. [PMID: 34545507 PMCID: PMC8976765 DOI: 10.1007/s10143-021-01643-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/31/2021] [Accepted: 09/07/2021] [Indexed: 11/08/2022]
Abstract
Transsphenoidal surgery provides a minimal invasive treatment for pituitary adenoma. Our aim is to evaluate the endocrinological outcomes after adenoma resection focusing on the corticotroph function, and to identify prognostic factors for an impaired hypothalamic–pituitary–adrenal-axis function (HPA) and the reliability of postoperative early morning serum cortisol measurements. We performed a retrospective analysis of all patients treated for pituitary adenoma from April 2006 to January 2019 in our neurosurgical department. Pituitary function was assessed pre- and postoperatively as well as at 6 weeks to 12 weeks and at 1-year follow-up. Two hundred eleven patients were included. Nine percent of the patients recovered from a preoperative adrenal insufficiency, 10.4% developed a new need for hormone substitution, and a long-term deficiency of the hypothalamic–pituitary–adrenal-axis was observed in 30.9%. Cortisol measurements 5 days after surgery had a lower area under the curve (AUC) than cortisol levels detected after 6 to 12 weeks (AUC 0.740 vs. AUC 0.808) in predicting an intact corticotrope function. The cut-off value determined for cortisol measured after 6 weeks was 6.95 µg/dl (sensitivity of 94%, specificity of 68%). Postoperative early morning cortisol levels seem to be less sensitive and specific in predicting long-term corticotroph function than measurements after 6 weeks and 1 year, emphasizing the importance of endocrine follow-up testing.
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12
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Venema AM, Kuijlen JMA, van Beek AP, Absalom AR. Perioperative glucocorticoid supplementation for patients undergoing endoscopic transsphenoidal pituitary tumour surgery: using a sledgehammer to crack a nut? Br J Anaesth 2021; 127:181-184. [PMID: 34119309 DOI: 10.1016/j.bja.2021.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/07/2021] [Accepted: 05/07/2021] [Indexed: 10/21/2022] Open
Affiliation(s)
- Allart M Venema
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Jos M A Kuijlen
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - André P van Beek
- Department of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Anthony R Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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13
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Prencipe N, Parasiliti-Caprino M, Gatti F, Penner F, Berton AM, Bona C, Caputo M, D'Angelo V, Cappiello V, Gasco V, Ghigo E, Zenga F, Grottoli S. Second-Day Morning Cortisol Levels after Transsphenoidal Surgery Are Accurate Predictors of Secondary Adrenal Insufficiency with Diagnostic Cut-Offs Similar to Those in Non-Stressed Conditions. Neuroendocrinology 2021; 111:639-649. [PMID: 32492678 DOI: 10.1159/000509092] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/02/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Multiple studies tried to identify cortisol cut-offs after pituitary surgery that could accurately assess hypothalamic-pituitary-adrenal (HPA) axis function; however, there is no consensus nowadays. This study aimed to evaluate the accuracy of morning cortisol after transsphenoidal surgery in predicting long-term secondary adrenal insufficiency. METHODS In our tertiary center, we prospectively determined first- and second-day cortisol after transsphenoidal surgery in 92 patients without preoperative adrenal -insufficiency and not treated with glucocorticoids perioperatively. Definitive diagnosis of secondary adrenal insufficiency was obtained with re-evaluation 3 months after trans-sphenoidal surgery and clinical follow-up of at least 1 year. RESULTS Ten patients (10.8%) developed long-term postoperative secondary adrenal insufficiency. The ROC curves demonstrated that first-day cortisol had a moderate diagnostic accuracy, while a second-day cortisol ≤9.3 µg/dL (257 nmol/L) showed the best performance in predicting adrenal insufficiency (sensitivity [Se] 88.9%, specificity [Sp] 86.9%, AUC 0.921). Moreover, a second-day cortisol ≤3.2 µg/dL (89 nmol/L) was able to diagnose adrenal insufficiency in 100% of cases (Se 22.2%, Sp 100%) and >14 µg/dL (386 nmol/L) was able to exclude ACTH deficiency (Se 100%, Sp 57.4%). CONCLUSIONS Adrenal function can be carefully studied on the second day after pituitary surgery, using cut-off values that international guidelines suggested for non-stressed conditions. In fact, second-day cortisol levels ≤3.2 μg/dL (89 nmol/L) and >14 μg/dL (386 nmol/L) are diagnostic of secondary adrenal insufficiency and normal function, respectively. We also suggest performing a definitive re-evaluation with an HPA axis stimulation test when second-day cortisol values are between 3.3 and 14 μg/dL (90-386 nmol/L).
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Affiliation(s)
- Nunzia Prencipe
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Mirko Parasiliti-Caprino
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy,
| | - Filippo Gatti
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Federica Penner
- Neurosurgery, Department of Neuroscience, University of Turin, Turin, Italy
| | - Alessandro Maria Berton
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Chiara Bona
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Marina Caputo
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Valentina D'Angelo
- Oncologic Endocrinology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Vincenzo Cappiello
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Valentina Gasco
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Ezio Ghigo
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Francesco Zenga
- Neurosurgery, Department of Neuroscience, University of Turin, Turin, Italy
| | - Silvia Grottoli
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
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14
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Selective perioperative steroid supplementation protocol in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas. Acta Neurochir (Wien) 2020; 162:2381-2388. [PMID: 32772164 DOI: 10.1007/s00701-020-04530-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/04/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND There is no consensus regarding the use of perioperative steroids for transsphenoidal pituitary surgery. We audited the effectiveness and safety of our selective perioperative steroid supplementation protocol in patients with pituitary adenomas. METHODS Two hundred ninety-seven patients underwent 306 endoscopic transsphenoidal surgeries for removal of their pituitary tumors. Steroids were given to those with an impaired hypothalamic-pituitary-adrenal (HPA) axis, age ≥ 60 years, clinical apoplexy, hyponatremia, or if the pituitary gland was not preserved at surgery. We excluded 111 patients in whom the integrity of the HPA axis could not be determined. We compared the incidence of early postoperative adrenal insufficiency and complications in 135 patients with intact HPA axes who underwent surgery without steroids (group A) with 60 patients who had compromised preoperative HPA axes and received perioperative steroids (group B). In addition, we audited the total number of protocol violations during this period. RESULTS Five patients (3.7%) in group A developed postoperative hypocortisolemia. There was no significant difference in the incidence of cerebrospinal fluid leak, diabetes insipidus, or hyponatremia between both groups. There were protocol deviations in 47 (15.4%) patients. Twenty one of these patients did not receive perioperative steroids in violation of the protocol, of whom 4 (19%) developed postoperative hypocortisolemia. CONCLUSIONS Our steroid sparing protocol was both safe and effective. The 15% incidence of protocol deviations is a reminder that the rigorous usage of checklists is mandatory for successful clinical practice.
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15
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Solari D, Pivonello R, Caggiano C, Guadagno E, Chiaramonte C, Miccoli G, Cavallo LM, Del Basso De Caro M, Colao A, Cappabianca P. Pituitary Adenomas: What Are the Key Features? What Are the Current Treatments? Where Is the Future Taking Us? World Neurosurg 2020; 127:695-709. [PMID: 31266132 DOI: 10.1016/j.wneu.2019.03.049] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/05/2019] [Indexed: 12/18/2022]
Abstract
Pituitary tumors are a heterogeneous group of lesions (usually benign) and proper understanding of the anatomy, physiology, and pathology of the hypothalamic/pituitary region is essential to make an accurate diagnosis and define the essential treatment options (i.e., surgery, medical therapies, and radiotherapy, alone or in combination). Surgery is the primary treatment for acromegaly, Cushing disease, thyroid-stimulating hormone-secreting adenomas, resistant prolactinomas, and nonfunctioning pituitary adenomas causing mass effect. Medical and radiation therapy are reserved in cases in which surgery is not possible or does not provide a complete cure. In the last decades, tremendous innovations (i.e., targeted drugs and refined surgical tools and techniques) have expanded the treatment strategies for pituitary adenomas. We herein report the current indications for and depiction of the surgical techniques in pituitary surgery, review current medical treatments, and provide a glimpse of future possibilities.
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Affiliation(s)
- Domenico Solari
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy.
| | - Rosario Pivonello
- Division of Endocrinology, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Chiara Caggiano
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Elia Guadagno
- Department of Advanced Biomedical Sciences, Section of Pathology, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Carmela Chiaramonte
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Giovanni Miccoli
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Luigi M Cavallo
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Marialaura Del Basso De Caro
- Department of Advanced Biomedical Sciences, Section of Pathology, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Annamaria Colao
- Division of Endocrinology, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Paolo Cappabianca
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
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16
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de Vries F, Lobatto DJ, Bakker LEH, van Furth WR, Biermasz NR, Pereira AM. Early postoperative HPA-axis testing after pituitary tumor surgery: reliability and safety of basal cortisol and CRH test. Endocrine 2020; 67:161-171. [PMID: 31556005 PMCID: PMC6969009 DOI: 10.1007/s12020-019-02094-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 09/13/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE To assess the reliability and safety of a postsurgical evaluation strategy of adrenal function using CRH stimulation and basal cortisol concentrations after transsphenoidal pituitary surgery. METHODS Retrospective cohort study of all patients undergoing endoscopic transsphenoidal surgery from 2010 to 2017, in whom early postoperative basal cortisol and/or CRH-stimulated cortisol secretion were available, including confirmation of adrenal function during follow-up. Patients with Cushing's disease were excluded. Optimal test performances were assessed using ROC analysis. RESULTS A total of 156 patients were included. Sensitivity and specificity of the CRH test were 78% and 90%, respectively, and 86% and 92% for basal cortisol, respectively, using an optimal cutoff of 220 nmol/L. Eight patients had false-negative test results with the CRH test (normal test but adrenal insufficient at follow-up), and six patients with basal cortisol, the majority of which had multiple pituitary hormone deficiencies and fluid imbalances. No clinical adverse events occurred in patients with false-negative test results. The diagnostic performance of a single basal cortisol measurement was superior to the CRH test. CONCLUSIONS The early postoperative basal cortisol is a safe and simple measurement to guide (dis)continuation of hydrocortisone replacement. However, disturbing factors, e.g., sodium balance disorders, contraceptives, untreated hypopituitarism, and illness impact the interpretation and in those cases this measure is unreliable. We propose an algorithm in which hydrocortisone replacement at discharge is based on basal cortisol <220 nmol/L on postoperative day 2 or 3 in a stable condition.
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Affiliation(s)
- Friso de Vries
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, The Netherlands.
- Center for Endocrine Tumors Leiden (CETL), Center for Pituitary Care, Leiden University Medical Center, Leiden, The Netherlands.
| | - Daniel J Lobatto
- Center for Endocrine Tumors Leiden (CETL), Center for Pituitary Care, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurosurgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Leontine E H Bakker
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, The Netherlands
- Center for Endocrine Tumors Leiden (CETL), Center for Pituitary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Wouter R van Furth
- Center for Endocrine Tumors Leiden (CETL), Center for Pituitary Care, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurosurgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Nienke R Biermasz
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, The Netherlands
- Center for Endocrine Tumors Leiden (CETL), Center for Pituitary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Alberto M Pereira
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, The Netherlands
- Center for Endocrine Tumors Leiden (CETL), Center for Pituitary Care, Leiden University Medical Center, Leiden, The Netherlands
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17
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Qaddoura A, Shalung TN, Meier MP, Goguen J, Jing R, Zhang S, Kovacs K, Cusimano MD. Recovery Room Cortisol Predicts Long-Term Glucocorticoid Need After Transsphenoidal Surgery for Pituitary Tumors. Neurosurgery 2019; 84:616-623. [PMID: 30767017 PMCID: PMC6375723 DOI: 10.1093/neuros/nyy070] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/19/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Accurate assessment of the need for glucocorticoid therapy is essential after transsphenoidal surgery (TSS) for pituitary tumors. Agreement on the best test to use in the early postoperative setting is lacking. OBJECTIVE To examine recovery room (RR) cortisol as a predictor of long-term need for glucocorticoids. METHODS We conducted a retrospective cohort study of 149 patients who underwent TSS for pituitary tumors between January 2007 and December 2014. Pathological tumor diagnoses were confirmed. Endocrinologists assessed the need for glucocorticoid supplementation within 6 to 8 wk after TSS. We extracted data on preoperative, RR, and day 1 to 3 post-TSS morning serum cortisol (MSC). We reported areas under the receiver operating characteristic curve (AUC) and diagnostic measures for different cortisol measures. We also conducted a logistic regression to identify the most predictive variables. RESULTS Eighteen patients required glucocorticoid supplementation at follow-up. RR cortisol was the most accurate measurement in the early postoperative period (AUC [95% confidence interval (CI)], .92 [.85-.99]; P < .001), followed by day 1, 2, and 3 post-TSS MSC, respectively. A threshold RR cortisol of 744.0 nmol/L (26.97 μg/dL) had 90.9% sensitivity and 73.7% specificity for detecting patients in the hypocortisolism group, while 757.5 nmol/L (27.46 μg/dL) had 100% and 70.0%, respectively. The logistic regression identified RR cortisol as the sole significant predictor (odds ratio [CI], .36[.18-.71] for every 100 nmol/L increase; P = .0033). CONCLUSION The RR cortisol is accurate in predicting long-term glucocorticoid supplementation and may be the best early postoperative measure. Future larger studies should validate these findings and derive optimal RR cortisol threshold values.
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Affiliation(s)
- Amro Qaddoura
- Keenan Research Centre for Biomedical Science, The Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Tenzin N Shalung
- Keenan Research Centre for Biomedical Science, The Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Michael P Meier
- Department of Surgery, Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Jeannette Goguen
- Department of Medicine, Division of Endocrinology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Rowan Jing
- Keenan Research Centre for Biomedical Science, The Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Stanley Zhang
- Keenan Research Centre for Biomedical Science, The Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Kalman Kovacs
- Department of Laboratory Medicine, Division of Pathology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Michael D Cusimano
- Keenan Research Centre for Biomedical Science, The Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.,Department of Surgery, Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
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18
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Dupepe E, Patel D, Miller J, Rizo I, Vaughan TB, Riley K. Postoperative day 1 versus postoperative day 5 morning cortisol for predicting an intact hypothalamic-pituitary axis: A cohort analysis. Surg Neurol Int 2019; 10:91. [PMID: 31528429 PMCID: PMC6744762 DOI: 10.25259/sni-105-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 02/19/2019] [Indexed: 11/04/2022] Open
Abstract
Background A reliable standard for evaluating postoperative hypothalamic-pituitary-axis (HPA) function following transsphenoidal pituitary surgery (TSS) could reduce hospital stays and unnecessary prolonged steroid therapy. We retrospectively examined the predictive role of morning cortisol levels on long-term HPA function to develop an institutional protocol. Here, we report the results of this analysis, which is the first to report the predictive strength of multiple variables (i.e., timing of measurement and values of serum cortisol cutoffs) within the same cohort. Methods A retrospective chart review was performed in 183 patients at a single institution from 2007 to 2012. 67 patients met inclusion criteria. The predictive value of postoperative day (POD) 1 and POD 5 morning cortisol for HPA function as determined by 1 ug cosyntropin stimulation test was evaluated using standard confusion matrix calculations and receiver-operator control curve analysis. Results In our cohort, an early POD 5 serum morning cortisol ≥15 ug/dl predicted an intact HPA axis with 100% specificity, 51% sensitivity, and a positive predictive value (PPV) of 100%. A POD 1 serum cortisol ≥25 ug/dl was needed to achieve a specificity of 100% and PPV of 100% to predict an intact HPA axis with a sensitivity of 30%. A POD 1 serum cortisol ≥18 ug/dl predicted an intact HPA axis with 33.3% specificity, PPV of 90.9%, and a sensitivity of 51.3%. Conclusion A POD 5 morning cortisol level ≥15 ug/dl is an excellent predictor of normal postoperative HPA function in patients undergoing TSS for pituitary adenoma.
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Affiliation(s)
- Esther Dupepe
- Department of Neurosurgery, University of Alabama, Birmingham, United States
| | - Daxa Patel
- Joe DiMaggio Children's Hospital, Hollywood, Fla., United States
| | - Joseph Miller
- Erlanger Neurosurgery and Spine, Chattanooga, TN., United States
| | - Ivania Rizo
- Department of Medicine in Endocrinology, Diabetes and Nutrition, Boston Medical Center, Boston MA, United States
| | - Tom Brooks Vaughan
- Department of Medicine, Endocrinology Division, University of Alabama, Birmingham, United States
| | - Kristen Riley
- Department of Neurosurgery, University of Alabama, Birmingham, United States
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19
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Evaluation of different hydrocortisone treatment strategies in transsphenoidal pituitary surgery. Acta Neurochir (Wien) 2019; 161:1715-1721. [PMID: 31065892 PMCID: PMC6616203 DOI: 10.1007/s00701-019-03885-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 03/20/2019] [Indexed: 12/26/2022]
Abstract
Background Hydrocortisone treatment in transsphenoidal pituitary surgery has been debated. Although several publications advocate restrictive treatment, centers around the world administer stress doses of hydrocortisone in patients with presumed intact cortisol production. Our aim with this analysis was to compare postoperative hypocortisolism in patients who received three different protocols of hydrocortisone therapy during and after surgery. Method This was a retrospective observational study. Based on perioperative hydrocortisone dose given, patients were divided in three groups: high dose (HD), intermediate dose (ID), and low dose (LD). Postoperative evaluation of the pituitary function was performed using S-cortisol at day 4 and short Synacthen test (SST) at 6–8 weeks. Patients with ACTH-producing adenomas or preoperative hydrocortisone treatment were excluded. Result There was no difference between the groups regarding failure rate of SST. The rate of failed SST (all groups) was 51/186 (27%), 24/74 (32%) in the HD group and 26/74 (35%) and 11/38 (29%) in the ID and LD groups respectively. There was no significant difference between the ID and LD groups regarding S-cortisol at postoperative day 4 regarding serum cortisol level below 200 nmol/L. There was a significant but weak correlation, rs 0.330 (P < 0.01) between S-cortisol day 4 and SST at 4–6 weeks. Conclusions Peri and postoperative hydrocortisone treatment did not affect SST response 6–8 weeks postoperatively, whereas the rate of patients with S-cortisol below 200 nmol/L at postoperative day 4 did. LD hydrocortisone therapy seems to favor a better endogenous production in the early postoperative phase.
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20
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Abstract
Although removal of pituitary tumors yields excellent surgical outcomes, perturbations in the hypothalamic-pituitary axis are not uncommon. Careful assessment of postoperative hormone status with supplementation or further medical therapy is critical to successful outcomes. Although many centers routinely use perioperative steroids, they can be associated with worse outcomes in the absence of intact preoperative adrenal function or damage to the pituitary gland or stalk during surgery. Postoperative assessment of prolactin, cortisol, and growth hormone can be prognostic of surgical cure. Hormonal axes should be reevaluated routinely several weeks after surgery, because longitudinal monitoring is important for surgical and medical outcomes.
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Affiliation(s)
- Anshu Buttan
- Department of Medicine, Division of Endocrinology, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Becker B-131, Los Angeles, CA 90048, USA
| | - Adam N Mamelak
- Department of Neurosurgery, Cedars-Sinai Medical Center, 127 S San Vicente Boulevard, A6600, Los Angeles, CA 90048, USA.
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21
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Silverstein JM, Goss CW, Kim AH. In Reply: Withholding Perioperative Steroids in Patients Undergoing Transsphenoidal Resection for Pituitary Disease: Randomized Prospective Clinical Trial to Assess Safety. Neurosurgery 2019; 85:E162. [PMID: 30989222 DOI: 10.1093/neuros/nyz108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Julie M Silverstein
- Division of Endocrinology, Metabolism, and Lipid Research Washington University School of Medicine St. Louis, Missouri.,Department of Neurosurgery Washington University School of Medicine St. Louis, Missouri
| | - Charles W Goss
- Division of Biostatistics Washington University School of Medicine, St. Louis, Missouri
| | - Albert H Kim
- Department of Neurosurgery Washington University School of Medicine St. Louis, Missouri
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22
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Polovina TS, Kraljevic I, Solak M, Balasko A, Haxhiu A, Haxhiu A, Dusek T, Poljicanin T, Kastelan D. Early Basal Cortisol Level as a Predictor of Hypothalamic-Pituitary-Adrenal (HPA) Axis Function After Pituitary Tumor Surgery. Exp Clin Endocrinol Diabetes 2019; 128:709-714. [PMID: 31091548 DOI: 10.1055/a-0885-1568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the clinical relevance of the early postoperative basal cortisol level in assessing the postoperative hypothalamic-pituitary-adrenal (HPA) axis function after pituitary tumor surgery. METHODS We performed a prospective observational study that enrolled 83 patients operated for pituitary adenoma or other sellar lesions at the University Hospital Center Zagreb between December 2013 and April 2017 (44 nonfunctioning pituitary adenomas, 28 somatotropinomas, 5 craniopharyngiomas, 2 prolactinomas resistant to medical therapy and 4 other lesions - Rathke's cleft cyst, arachnoid cyst, chondroma and gangliocytoma). Exclusion criteria were Cushing's disease, chronic therapy with glucocorticoids prior to surgery and preoperative adrenal insufficiency. Early postoperative basal cortisol levels (measured on the second postoperative day) and the Synacthen stimulation test (performed 3 months after the surgery with the peak cortisol level of>500 nmol/L considered as a normal response) were analyzed to assess HPA axis function during follow-up. RESULTS ROC analysis showed a cut-off of the basal cortisol level of ≥300 nmol/L measured on the second postoperative day to predict normal postoperative HPA axis function with the sensitivity of 92.31%, specificity of 87.14% and positive predictive value of 57.14%. CONCLUSION The basal cortisol level on the second postoperative day is a valuable tool to predict integrity of the HPA axis after pituitary tumor surgery. Our data suggest that the cortisol level of ≥300 nmol/L accurately predicts adrenal sufficiency and that in these patients glucocorticoid therapy can be withdrawn.
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Affiliation(s)
| | - Ivana Kraljevic
- Department of Endocrinology, University Hospital Center Zagreb, Coatia
| | - Mirsala Solak
- Department of Endocrinology, University Hospital Center Zagreb, Coatia
| | - Annemarie Balasko
- Department of Endocrinology, University Hospital Center Zagreb, Coatia
| | - Arta Haxhiu
- Department of Endocrinology, University Hospital Center Zagreb, Coatia
| | - Arita Haxhiu
- Department of Endocrinology, University Hospital Center Zagreb, Coatia
| | - Tina Dusek
- Department of Endocrinology, University Hospital Center Zagreb, Coatia.,School of Medicine University of Zagreb, Coatia
| | | | - Darko Kastelan
- Department of Endocrinology, University Hospital Center Zagreb, Coatia.,School of Medicine University of Zagreb, Coatia
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23
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Jackanich A, Tavakol S, Strickland BA, Rutkowski M, Kamel D, Carmichael JD, Weiss M, Zada G. Clinical utility of routine postoperative morning cortisol monitoring in detecting new hypothalamic-pituitary-adrenal axis insufficiency following endoscopic transsphenoidal surgery for sellar lesions. J Neurosurg 2019; 132:1054-1058. [PMID: 30835697 DOI: 10.3171/2018.11.jns182521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/21/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hypothalamic-pituitary-adrenal (HPA) axis dysfunction is a well-documented complication of transsphenoidal craniotomy (TSC) for sellar lesions. The authors aimed to assess their multidisciplinary approach to the diagnosis and treatment of postoperative hypocortisolemia utilizing conservative screening methods. METHODS The authors performed a retrospective review of 257 patients who underwent TSC for pituitary adenoma (PA) or Rathke cleft cyst (RCC) at the University of Southern California between 2012 and 2017. Patients with preoperative adrenal insufficiency, Cushing's disease, or < 3 months of postoperative follow-up were excluded. Patient demographics, pathology, tumor characteristics, and complications were recorded. Postoperative day 1 (POD1) morning serum cortisol was assessed in all patients. Hypocortisolemia on POD1 (serum cortisol < 5 μg/dl) prompted a 7 am cortisol level measurement on POD 2 (POD2). Clinical signs and symptoms of hypocortisolemia were consistently monitored. After two serum cortisol levels < 5 μg/dl, or one serum level < 5 μg/dl plus a high clinical suspicion for HPA dysfunction, high-risk patients received glucocorticoid supplementation. RESULTS Data on 165 patients were included in the analysis; there were 101 women (61.2%) and 64 men (38.7%). Preoperative diagnoses included nonfunctional adenoma (n = 97, 58.7%), growth hormone-secreting adenoma (n = 37, 22.4%), RCC (n = 18, 10.9%), prolactinoma (n = 8, 4.8%), and other (n = 5, 3.0%). One hundred thirty-eight patients (63.0%) had either suprasellar extension or cavernous sinus invasion. POD1 hypocortisolemia was diagnosed in 8 patients (4.8%). Of these patients, 2 (1.2%) were clinically asymptomatic and had normalized POD2 cortisol levels. Six patients (3.6%) had clinical symptoms and POD2 cortisol levels confirming HPA axis deficiency. Of these 6 patients treated with early glucocorticoid replacement, 2 patients recovered HPA axis function during follow-up, making the incidence of new, permanent HPA axis deficiency 2.5%. CONCLUSIONS In the authors' institutional review, all patients warranting postoperative glucocorticoid replacement had both complicated surgical courses and associated clinical symptoms of hypocortisolemia. The authors' algorithm of withholding steroids until patients demonstrate clear evidence of postoperative hypocortisolemia is safe and clinically efficacious. Their data further suggest that routine postoperative cortisol screening may not be necessary following an uncomplicated operative resection, with gland preservation and the absence of clinical symptoms indicative of HPA dysfunction.
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Affiliation(s)
| | | | | | | | - Dina Kamel
- 2Division of Endocrinology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - John D Carmichael
- 2Division of Endocrinology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
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Sterl K, Thompson B, Goss CW, Dacey RG, Rich KM, Zipfel GJ, Chicoine MR, Kim AH, Silverstein JM. Withholding Perioperative Steroids in Patients Undergoing Transsphenoidal Resection for Pituitary Disease: Randomized Prospective Clinical Trial to Assess Safety. Neurosurgery 2018; 85:E226-E232. [DOI: 10.1093/neuros/nyy479] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 09/18/2018] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Perioperative steroid protocols for patients undergoing transsphenoidal surgery (TSS) for pituitary pathology vary by institution.
OBJECTIVE
To assess the safety of withholding glucocorticoids in patients undergoing TSS.
METHODS
Patients with an intact hypothalamic-pituitary-adrenal (HPA) axis undergoing TSS for a pituitary tumor at the same academic institution between 2012 and 2015 were randomized to either receive 100 mg of intravenous hydrocortisone followed by 0.5 mg of intravenous dexamethasone every 6 h for 4 doses (STER, n = 23) or to undergo surgery without steroids (NOSTER, n = 20). Postoperative cortisol levels were then used to determine the need for glucocorticoids after surgery. Data regarding postoperative cortisol levels, hospital stay length, and complications were collected.
RESULTS
Mean postoperative 8 am cortisol levels were higher in the NOSTER group compared to the STER group (745 ± 359 nmol/L and 386 ± 193 nmol/L, respectively, P = .001) and more patients were discharged on glucocorticoids in the STER group (42% vs 12%, P = .07). There was no difference in the incidence of postoperative complications, including hyperglycemia, diabetes insipidus, or permanent adrenal insufficiency. Permanent adrenal insufficiency occurred in 8% of patients.
CONCLUSION
Perioperative steroids can be safely withheld in patients with an intact HPA axis undergoing TSS. Although administration of perioperative glucocorticoids does not appear to increase the risk of complications, it may interfere with assessment of the HPA axis after surgery.
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Affiliation(s)
- Karin Sterl
- Divsion of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, Missouri
| | - Bithika Thompson
- Division of Endocrinology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Charles W Goss
- Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri
| | - Ralph G Dacey
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Keith M Rich
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Gregory J Zipfel
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Michael R Chicoine
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Albert H Kim
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Julie M Silverstein
- Divsion of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, Missouri
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
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Adrenal Axis Insufficiency After Endoscopic Transsphenoidal Resection of Pituitary Adenomas. World Neurosurg 2018; 112:e869-e875. [DOI: 10.1016/j.wneu.2018.01.182] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 01/24/2018] [Accepted: 01/25/2018] [Indexed: 12/23/2022]
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Munro V, Tugwell B, Doucette S, Clarke DB, Lacroix A, Imran SA. Recovery of adrenal function after chronic secondary adrenal insufficiency in patients with hypopituitarism. Clin Endocrinol (Oxf) 2016; 85:216-22. [PMID: 26928716 DOI: 10.1111/cen.13048] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 02/12/2016] [Accepted: 02/24/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Previous studies have reported recovery of secondary adrenal insufficiency (SAI) in patients with pituitary disorders, generally immediately after pituitary surgery; however, data regarding recovery of long-term SAI are lacking. We conducted a study to assess the longer term recovery rate of SAI in patients with pituitary disorders. METHODS We identified all SAI patients in the Halifax Neuropituitary Database from 1 November 2005 to 30 September 2014, who had required glucocorticoid therapy for ≥3 months, and had a minimum follow-up of 6 months. Patients with ACTH-secreting adenomas, those receiving glucocorticoids only in the routine peri-operative period for pituitary surgery and those on glucocorticoids for nonpituitary conditions were excluded. SAI was defined as either basal serum cortisol < 130 nm and/or a subnormal cortisol response to ACTH-(1-24) stimulation test or insulin tolerance test response. RESULTS Fifty-one patients fulfilled the criteria. Nine (17·6%) patients had complete recovery of SAI over a median of 20 months (range: 8-51) after initiating glucocorticoid replacement. Patients with smaller tumour size had increased likelihood of hypothalamic-pituitary-adrenal (HPA) axis recovery, whereas those with secondary hypogonadism or growth hormone deficiency were less likely to recover. Those with initial cortisol >175 nm had an almost one in two chance of recovery. CONCLUSION Results from our study show that approximately one in six patients with SAI recover adrenal function, even up to 5 years after diagnosis. We recommend that patients with SAI undergo regular testing to assess recovery in order to prevent unnecessary glucocorticoid therapy.
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Affiliation(s)
- V Munro
- Division of Endocrinology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - B Tugwell
- Division of Endocrinology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - S Doucette
- Research Methods Unit, Department of Community Health and Epidemiology, Nova Scotia Health Authority, Halifax, NS, Canada
| | - D B Clarke
- Division of Endocrinology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
- Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - A Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, QC, Canada
| | - S A Imran
- Division of Endocrinology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
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Bohl MA, Ahmad S, Jahnke H, Shepherd D, Knecht L, White WL, Little AS. Delayed Hyponatremia Is the Most Common Cause of 30-Day Unplanned Readmission After Transsphenoidal Surgery for Pituitary Tumors. Neurosurgery 2016; 78:84-90. [PMID: 26348011 DOI: 10.1227/neu.0000000000001003] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Unplanned readmission after surgical procedures is an important quality metric. Yet, readmission rates and causes have not been evaluated for patients after transsphenoidal surgery for pituitary tumors. OBJECTIVE To analyze unplanned 30-day readmissions at a pituitary center and to encourage the development of effective clinical pathways to prevent readmission. METHODS A retrospective review of adult patients who underwent transsphenoidal surgery for pituitary lesions at Barrow Neurological Institute (January 2011-March 2014) was performed to identify causes of unplanned readmission within 30 days of surgery. Patient demographics, tumor details, surgical complications, and endocrine function were documented. RESULTS Of 303 patients who had transsphenoidal surgery, 27 (8.9%) were readmitted within 30 days. Most of the 27 (15 [55.6%]) had delayed hyponatremia. Other causes were diabetes insipidus (4 [14.8%]), adrenal insufficiency (2 [7.4%]), and cerebrospinal fluid leak, epistaxis, cardiac arrhythmia, pneumonia, urinary tract infection, and hypoglycemia (1 each [3.7%]). Outpatient sodium screening was performed as needed. In cases of hyponatremia, the mean postoperative day of readmission was day 8 (range, 6-12 days) and the mean serum sodium was 119 mmol/L (range, 111-129 mmol/L). Numerous patient and surgical factors were examined, and no specific predictors of readmission were identified. We developed an outpatient care pathway for managing hyponatremia with the goal of improving readmission rates. CONCLUSION This study establishes a quality benchmark for readmission rates after transsphenoidal surgery for pituitary lesions and identifies delayed hyponatremia as the primary cause. Implementation of an outpatient care pathway for managing hyponatremia may improve readmission rates.
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Affiliation(s)
- Michael A Bohl
- *Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona;‡University of Arizona College of Medicine-Phoenix, Phoenix, Arizona;§Department of Internal Medicine, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Carminucci AS, Ausiello JC, Page-Wilson G, Lee M, Good L, Bruce JN, Freda PU. OUTCOME OF IMPLEMENTATION OF A MULTIDISCIPLINARY TEAM APPROACH TO THE CARE OF PATIENTS AFTER TRANSSPHENOIDAL SURGERY. Endocr Pract 2015; 22:36-44. [PMID: 26437216 DOI: 10.4158/ep15894.or] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Transsphenoidal surgery (TS) for sellar lesions is an established and safe procedure, but complications can occur, particularly involving the neuroendocrine system. We hypothesized that postoperative care of TS patients would be optimized when performed by a coordinated team including a pituitary neurosurgeon, endocrinologists, and a specialty nurse. METHODS We implemented a formalized, multidisciplinary team approach and standardized postoperative protocols for the care of adult patients undergoing TS by a single surgeon (J.N.B.) at our institution beginning in July 2009. We retrospectively compared the outcomes of 214 consecutive TS-treated cases: 113 cases prior to and 101 following the initiation of the team approach and protocol implementation. Outcomes assessed included the incidence of neurosurgical and endocrine complications, length of stay (LOS), and rates of hospital readmission and unscheduled clinical visits. RESULTS The median LOS decreased from 3 days preteam to 2 days postteam (P<.01). Discharge occurred on postoperative day 2 in 46% of the preteam group patients compared to 69% of the postteam group (P<.01). Rates of early postoperative diabetes insipidus (DI) and readmissions within 30 days for syndrome of inappropriate antidiuretic hormone (SIADH) or other complications did not differ between groups. CONCLUSION Implementation of a multidisciplinary team approach was associated with a reduction of LOS. Despite earlier discharge, postoperative outcomes were not compromised. The endocrinologist is central to the success of this team approach, which could be successfully applied to care of patients undergoing TS, as well as other types of endocrine surgery at other centers.
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Bondugulapati LNR, Campbell C, Chowdhury SR, Goetz P, Davies JS, Rees DA, Hayhurst C. Use of day 1 early morning cortisol to predict the need for glucocorticoid replacement after pituitary surgery. Br J Neurosurg 2015; 30:76-9. [PMID: 26313503 DOI: 10.3109/02688697.2015.1071325] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Assessment of adrenal reserve in patients who have undergone pituitary surgery is crucial. However, there is no clear consensus with regards to the type and timing of the test that should be used in the immediate post-operative period. Recently, there has been increased interest in measuring post-operative cortisol levels. We present our data utilising day 1 post-operative early morning cortisol as a tool to assess adrenal reserve in steroid-naive patients. METHODS A retrospective analysis of endoscopic pituitary surgery undertaken over a 2-year period. 82 patients underwent 84 surgeries in total. Patients who were already on glucocorticoids pre-operatively and patients with Cushing's disease, pituitary apoplexy and those without follow-up data were excluded, leaving a study group of 44 patients with 45 operations. A 9am day 1 post-operative cortisol value of > 400 nmol/L was taken as an indicator of adequate adrenal reserve. All the patients were reassessed at 6 weeks with a standard short synacthen test (SST) using 250 micrograms of intravenous synacthen. RESULTS 22 out of 45 patients had a cortisol value of > 400 nmol/L on day 1 post-operatively and were discharged without glucocorticoid supplementation. Of these, only 2 patients subsequently failed the SST when reassessed at 6-8 weeks. The remaining 23 patients had a cortisol value of < 400 nmol/L on day 1 post-operatively and were discharged on hydrocortisone 10 mg twice daily. At 6-8 weeks, nine continued to show suboptimal stimulated cortisol levels whereas the remaining fourteen patients showed adequate adrenal reserve. The 9 am cortisol value had high specificity (81.8%) and positive predictive value (90.9%) for integrity of the HPA axis. Sensitivity was 58.8% and negative predictive value was 39.1%. CONCLUSION A day 1 post-operative early morning cortisol is a useful tool to predict adrenal reserve post-pituitary surgery, enabling clinicians to avoid unnecessary blanket glucocorticoid replacement.
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Affiliation(s)
| | - Christopher Campbell
- b Institute of Molecular and Experimental Medicine, Cardiff University , Cardiff , UK
| | | | - Pablo Goetz
- c Department of Neurosurgery , University Hospital of Wales , Cardiff , UK
| | - J Stephen Davies
- a Department of Endocrinology , University Hospital of Wales , Cardiff , UK
| | - D Aled Rees
- a Department of Endocrinology , University Hospital of Wales , Cardiff , UK.,b Institute of Molecular and Experimental Medicine, Cardiff University , Cardiff , UK
| | - Caroline Hayhurst
- c Department of Neurosurgery , University Hospital of Wales , Cardiff , UK
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Manuylova E, Calvi LM, Vates GE, Hastings C, Shafiq I. MORNING SERUM CORTISOL LEVEL AFTER TRANSSPHENOIDAL SURGERY FOR PITUITARY ADENOMA PREDICTS HYPOTHALAMIC-PITUITARY-ADRENAL FUNCTION DESPITE INTRAOPERATIVE DEXAMETHASONE USE. Endocr Pract 2015; 21:897-902. [PMID: 26121454 DOI: 10.4158/ep15652.or] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Perioperative glucocorticoid (GC) is rarely needed in patients undergoing transsphenoidal surgery (TSS). We instituted a steroid-sparing protocol in the settings of intraoperative dexamethasone use. We evaluated the safety of using a cut off cortisol level of 14 μg/dL on postoperative day (POD)-1 and -6 after dexamethasone use during the surgery. We also analyzed the efficacy of serial morning cortisol levels for weaning GC replacement. METHODS The charts of 48 adult patients who received dexamethasone 4 mg intraoperatively were reviewed. Morning cortisol levels were measured on POD-1. Patients with cortisol ≥14 μg/dL were discharged without CG replacement. Morning cortisol level was checked routinely on POD-6, and GC replacement was initiated when the level was <14 μg/dL. Serial cortisol levels were measured in patients requiring GC after the first postoperative week. RESULTS Overall, 67% patients had POD-1 cortisol ≥14 μg/dL and did not require GC on discharge. After POD-6, 83% of patients were not on GC replacement. A cosyntropin stimulation testing (CST) was only performed in 3 patients. There were no hospital admissions for adrenal crisis during the postoperative period. CONCLUSION A steroid-sparing protocol with POD-1 and -6 morning cortisol levels can be safely and effectively used in the settings of intraoperative dexamethasone administration. It leads to avoidance of GC in more than two-thirds of patients on discharge and more than 80% of patients after the first postoperative week. We found that dynamic adrenal testing could be omitted in the majority of patients by using serial morning cortisol levels to assess the hypothalamic-pituitary-adrenal (HPA) axis.
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Tohti M, Li J, Zhou Y, Hu Y, Yu Z, Ma C. Is peri-operative steroid replacement therapy necessary for the pituitary adenomas treated with surgery? A systematic review and meta analysis. PLoS One 2015; 10:e0119621. [PMID: 25775019 PMCID: PMC4361329 DOI: 10.1371/journal.pone.0119621] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Accepted: 01/14/2015] [Indexed: 11/18/2022] Open
Abstract
Background Patients with pituitary adenomas usually receive “stress dose” steroids in the peri-operative peroids. Though randomized controlled trials(RCT) have not been performed to assess the necessity of steroid coverage, there are several studies that explained the changes of adrenal function during peri-operative peroids. The aim of the present study is to investigate whether it is necessary to employ conventional peri-operative glucocorticoid replacement therapy to all the patients undergoing surgery. Methods We searched studies addressing peri-operative steroids coverage for pituitary adenomas in the Web of Science, Medline and the Cochrane Library. Then we extracted studies about peri-operative morning serum cortisol(MSC) levels, morbidity of early postoperative adrenal insufficiency, postoperative diabetes insipidus, relationships between MSC levels and adrenal integrity. We used RevMan Software to combine the results for meta-analysis. We used fixed-effects models for there was no significant heterogeneity existed. Findings There are 18 studies from 11 countries published between 1987 and 2013 including 1224 patients. The postoperative serum cortisol levels were significantly increased compared with the preoperative one in hypothalamic-pituitary-adrenal axis(HPAA) functions preserved patients(P<0.00001). The morbidity of early postoperative adrenal insufficiency ranged from 0.96% to 12.90%, with the overall morbidity of 5.55%(41/739). There was no significant differences of early postoperative diabetes insipidus between no supplementation patients and in supplementation patients(P=0.82). Conversely, there may be some disadvantages of high levels of cortisols such as high incidence of osteopenia and bone derangement and even the increased mortality rate. The patients with MSC levels of less than 60 nmol/l at 3 days after operation is considered as adrenal insufficient and more than 270 nmol/l as adrenal sufficient. To patients with MSC levels of 60–270 nmol/l, we need more clinical data to establish further cortisol supplementation criteria.
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Affiliation(s)
- Mamatemin Tohti
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Junyang Li
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Yuan Zhou
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Yuebing Hu
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Zhuang Yu
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Chiyuan Ma
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
- * E-mail:
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Dexamethasone and hypothalamic-pituitary-adrenal axis suppression after transsphenoidal pituitary surgery. J Neurosurg Anesthesiol 2014; 27:181. [PMID: 25222644 DOI: 10.1097/ana.0000000000000126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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