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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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Guo X, Zhang D, Pang H, Wang Z, Gao L, Wang Y, Ma W, Lian W, Xing B. Safety of Withholding Perioperative Hydrocortisone for Patients With Pituitary Adenomas With an Intact Hypothalamus-Pituitary-Adrenal Axis: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2242221. [PMID: 36383383 PMCID: PMC9669812 DOI: 10.1001/jamanetworkopen.2022.42221] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Pituitary adenoma is the second most common primary brain tumor. Perioperative hydrocortisone has been used for decades to avoid postoperative adrenal insufficiency. Recent studies suggest that withholding perioperative hydrocortisone may be safe for patients with an intact hypothalamus-pituitary-adrenal (HPA) axis. OBJECTIVE To assess the safety of withholding hydrocortisone during the perioperative period of pituitary adenoma surgery for patients with an intact HPA axis. DESIGN, SETTING, AND PARTICIPANTS A parallel-group, triple-masked, noninferiority randomized clinical trial was conducted at Peking Union Medical College Hospital from November 1, 2020, to January 31, 2022, among 436 patients aged 18 to 70 years with an intact HPA axis undergoing surgery for pituitary adenomas. INTERVENTIONS Hydrocortisone supplementation protocol (intravenous and subsequent oral hydrocortisone, using a taper program) or no-hydrocortisone protocol. MAIN OUTCOMES AND MEASURES The primary outcome was the incidence of new-onset adrenal insufficiency (morning cortisol level, <5 μg/dL with adrenal insufficiency-related symptoms) during the perioperative period (on the day of operation and the following 2 days). The secondary outcome was the incidence of adrenal insufficiency in postoperative month 3. Analysis was on an intention-to-treat basis. RESULTS Of the 436 eligible patients, 218 were randomly assigned to the hydrocortisone group (136 women [62.4%]; mean [SD] age, 45.4 [13.0] years) and 218 to the no-hydrocortisone group (128 women [58.7%]; mean [SD] age, 44.5 [13.8] years). All patients completed 3-month postoperative follow-up. The incidence of new-onset adrenal insufficiency during the perioperative period was 11.0% (24 of 218; 95% CI, 6.9%-15.2%) in the no-hydrocortisone group and 6.4% (14 of 218; 95% CI, 3.2%-9.7%) in the hydrocortisone group, with a difference of 4.6% (95% CI, -0.7% to 9.9%), meeting the prespecified noninferiority margin of 10 percentage points. The incidence of adrenal insufficiency at the 3-month follow-up was 3.7% (8 of 218) in the no-hydrocortisone group and 3.2% (7 of 218) in the hydrocortisone group (difference, 0.5%; 95% CI, -3.0% to 3.9%). Incidences of new-onset diabetes mellitus (1 of 218 [0.5%] vs 9 of 218 [4.1%]), hypernatremia (9 of 218 [4.1%] vs 21 of 218 [9.6%]), hypokalemia (23 of 218 [10.6%] vs 34 of 218 [15.6%]), and hypocalcemia (6 of 218 [2.8%] vs 19 of 218 [8.7%]) were lower in the no-hydrocortisone group than in the hydrocortisone group. Lower preoperative morning cortisol levels were associated with higher risks of the primary event (<9.3 µg/dL; odds ratio, 3.0; 95% CI, 1.5-5.9) and the secondary event (<8.8 µg/dL; odds ratio, 7.8; 95% CI, 2.6-23.4) events. CONCLUSIONS AND RELEVANCE This study found that withholding hydrocortisone was safe and demonstrated noninferiority to the conventional hydrocortisone supplementation regimen regarding the incidence of new-onset adrenal insufficiency among patients with an intact HPA axis undergoing pituitary adenomectomy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04621565.
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Affiliation(s)
- Xiaopeng Guo
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| | - Duoxing Zhang
- Peking Union Medical College, Tsinghua University, Dongcheng District, Beijing, China
| | - Haiyu Pang
- Medical Research Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| | - Zihao Wang
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| | - Lu Gao
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| | - Yu Wang
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| | - Wenbin Ma
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| | - Wei Lian
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| | - Bing Xing
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
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Ratanasrimetha P, Workeneh BT, Seethapathy H. Sodium and Potassium Dysregulation in the Patient With Cancer. Adv Chronic Kidney Dis 2022; 29:171-179.e1. [PMID: 35817524 DOI: 10.1053/j.ackd.2022.01.003] [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: 08/07/2021] [Revised: 12/20/2021] [Accepted: 01/18/2022] [Indexed: 11/11/2022]
Abstract
Sodium and potassium disorders are pervasive in patients with cancer. The causes of these abnormalities are wide-ranging, are often primary or second-order consequences of the underlying cancer, and have prognostic implications. The approach to hyponatremia should focus on cancer-related etiologies, such as syndrome of inappropriate antidiuretic hormone, to the exclusion of other causes. Hypernatremia in non-iatrogenic forms is generally due to water loss rather than excessive sodium intake. Debilitated or dependent patients with cancer are particularly vulnerable to hypernatremia. Hypokalemia can occur in patients with cancer due to gastrointestinal disturbances, resulting from decreased intake or increased losses. Renal losses can occur as a result of excessive mineralocorticoid secretion or therapy-related nephrotoxicity. The approach to hyperkalemia should be informed by historical and laboratory clues, and pseudohyperkalemia is particularly common in patients with hematological cancers. Hyperkalemia can be seen in primary or metastatic disease that interrupts the adrenal axis. It can also develop as a consequence of immunotherapy, which can cause adrenalitis or hypophysitis. Tumor lysis syndrome (TLS) is defined by the development of hyperkalemia and is a medical emergency. Awareness of the electrolyte abnormalities that can befall patients with cancer is vital for its prompt recognition and management.
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Affiliation(s)
| | - Biruh T Workeneh
- Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Ghiam MK, Chyou DE, Dable CL, Katz AP, Eichberg DG, Zhang H, Ayala AR, Kargi AY, Komotar RJ, Sargi Z. 30-Day Readmissions and Coordination of Care Following Endoscopic Transsphenoidal Pituitary Surgery: Experience with 409 Patients. Skull Base Surg 2021; 83:e410-e418. [DOI: 10.1055/s-0041-1729980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 03/26/2021] [Indexed: 10/21/2022]
Abstract
Abstract
Objective The study aimed to (1) quantify readmission rates and common causes of readmission following endoscopic transsphenoidal pituitary surgery (ETPS); (2) identify risk factors that may predict readmission within 30 days; (3) assess postoperative care coordination with endocrinology follow-up; and (4) identify patients for whom targeted interventions may reduce 30-day readmissions.
Methods Retrospective quality improvement review of patients with pituitary adenoma who underwent ETPS from December 2010 to 2018 at a single tertiary care center.
Results A total of 409 patients were included in the study, of which 57 (13.9%) were readmitted within 30 days. Hyponatremia was the most common cause of readmission (4.2%) followed by pain/headache (3.9%), cerebrospinal fluid leak (3.4%), epistaxis (2.7%), hypernatremia (1.2%), and adrenal insufficiency (1.2%). Patients with hyponatremia were readmitted significantly earlier than other causes (4.3 ± 2.2 vs. 10.6 ± 10.9 days from discharge, p = 0.032). Readmitted patients had significantly less frequent outpatient follow-up with an endocrinologist than the nonreadmitted cohort (56.1 vs. 70.5%, p = 0.031). Patients who had outpatient follow-up with an endocrinologist were at lower risk of readmission compared with those without (odds ratio: 0.46; 95% confidence interval: 0.24–0.88).
Conclusion Delayed hyponatremia is one of the most common causes of 30-day readmission following ETPS. Postoperative follow-up with an endocrinologist may reduce risk of 30-day readmission following ETPS.
Implications for Clinical Practice A multidisciplinary team incorporating otolaryngologist, neurosurgeons, and endocrinologist may identify patients at risk of 30-day readmissions. Protocols checking serum sodium within 1 week of surgery in conjunction with endocrinologist to tailor fluid restriction may reduce readmissions from delayed hyponatremia.
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Affiliation(s)
- Michael K. Ghiam
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Darius E. Chyou
- University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Cortney L. Dable
- University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Andrew P. Katz
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Daniel G. Eichberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Hang Zhang
- Division of Biostatistics, Department of Public Health Sciences, University of Miami, Miami, Florida, United States
| | - Alejandro R. Ayala
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Atil Y. Kargi
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Ricardo J. Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Zoukaa Sargi
- Department of Otolaryngology, Head and Neck Surgery, Sylvester Comprehensive Cancer Center, Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, Florida, United States
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Abhinav K, Tyler M, Dale OT, Mohyeldin A, Fernandez-Miranda JC, Katznelson L. Managing complications of endoscopic transsphenoidal surgery in pituitary adenomas. Expert Rev Endocrinol Metab 2020; 15:311-319. [PMID: 32744080 DOI: 10.1080/17446651.2020.1800452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 07/21/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Over the last two decades there has been a gradual shift from the traditional microscopic approach toward the use of endoscopic endonasal approach for resection of pituitary adenomas. Multiple medical and surgical complications can occur following endoscopic transsphenoidal resection of adenomas. AREAS COVERED We discuss the evolution of the surgical practice from the use of the 'microscope' to the 'endoscope' in the resection of pituitary adenomas. We present a comprehensive review of the medical and surgical complications following surgery with particular emphasis on both the prevention and management of electrolyte disturbance, cerebrospinal fluid leak and the rare but dreaded complication of internal carotid injury (ICA). We also searched the PubMed database to identify relevant literature between 1984 and 2019. EXPERT OPINION Use of endoscope compared with microscope may be associated with better preservation of pituitary gland function with similar extent of resection. Overall medical and surgical complications can be safely managed in high volume centers in association with endocrinologists and skull base trained otolaryngologists. Understanding of anatomico-technical nuances and meticulous surgical technique are important toward preventing ICA injury. Ongoing surgical and technical developments coupled with imaging advances will likely lead to better future outcomes for patients with functioning and nonfunctioning adenomas.
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Affiliation(s)
- Kumar Abhinav
- Department of Neurosurgery, Institute of Clinical Neuroscience, Center for Endoscopic and Pituitary Skull Base Surgery, Southmead Hospital , Bristol, UK
| | - Matthew Tyler
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota , Minneapolis, MN, USA
| | - Oliver T Dale
- Department of ENT-Head and Neck Surgery, University Hospitals Bristol , Bristol, UK
| | - Ahmed Mohyeldin
- Department of Neurosurgery, Stanford University School of Medicine , Stanford, CA, USA
| | | | - Laurence Katznelson
- Department of Neurosurgery, Stanford University School of Medicine , Stanford, CA, USA
- Department of Medicine, Stanford University School of Medicine , Stanford, CA, USA
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Kolnes AJ, Øystese KA, Dahlberg D, Berg-Johnsen J, Niehusmann P, Pahnke J, Bollerslev J, Jørgensen AP. Cut-off values for sufficient cortisol response to low dose Short Synacthen Test after surgery for non-functioning pituitary adenoma. Acta Neurochir (Wien) 2020; 162:845-852. [PMID: 31907611 DOI: 10.1007/s00701-019-04068-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 09/09/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim was to study the prevalence of secondary adrenal insufficiency before and after surgery for non-functioning pituitary adenomas, as well as determine risk factors for developing secondary adrenal insufficiency. A secondary aim was to determine adequate p-cortisol response to a 1-μg Short Synacthen Test after surgery. DESIGN Longitudinal cohort study. METHODS One hundred seventeen patients (52/65 females/males, age 59 years) undergoing primary surgery for clinically non-functioning pituitary adenomas were included. P-cortisol was measured in morning blood samples. Three months after surgery, a Short Synacthen Test was performed. RESULTS All tumours were macroadenomas (mean size 26.9 mm, range 13-61 mm). The surgical indications were visual impairment (93), tumour growth (16), pituitary apoplexy (6) and headache (2). Before surgery, 17% of the patients had secondary adrenal insufficiency (SAI), decreasing to 15% 3 months postoperatively. Risk of SAI was increased in patients operated for pituitary apoplexy (p < 0.001), while age, sex, tumour size and complication rate were not different from the remaining cohort. Three months after surgery, all patients with baseline p-cortisol ≥ 172 nmol/l (6.2 μg/dl) and peak p-cortisol during Short Synacthen Test ≥ 320 nmol/l (11.6 μg/dl) tapered cortisone unproblematically. In patients with intact hypothalamic-pituitary-adrenal axis, p-cortisol peaked < 500 nmol/l (18.1 μg/dl) during Short Synacthen Test in 48% of patient. CONCLUSION Pituitary surgery is safe and transsphenoidal surgery rarely causes new SAI. Relying solely on morning p-cortisol for diagnosing secondary adrenal insufficiency gives false positives and the Short Synacthen Test remains useful. A peak p-cortisol ≥ 320 during (11.6 μg/dl) Short Synacthen Test indicates a sufficient response, while < 309 nmol/l (11.2 μg/dl) indicates secondary adrenal insufficiency.
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Affiliation(s)
- Anders Jensen Kolnes
- Section of Specialized Endocrinology, Rikshospitalet, Oslo University Hospital, Oslo, Norway.
- Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Kristin Astrid Øystese
- Section of Specialized Endocrinology, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Daniel Dahlberg
- Department of Neurosurgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Jon Berg-Johnsen
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Neurosurgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Pitt Niehusmann
- Department of Neuro-/pathology, Oslo University Hospital, Oslo, Norway
| | - Jens Pahnke
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Neuro-/pathology, Oslo University Hospital, Oslo, Norway
| | - Jens Bollerslev
- Section of Specialized Endocrinology, Rikshospitalet, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
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Manosroi W, Phimphilai M, Khorana J, Atthakomol P, Pipanmekaporn T. Predictive Factors of Adrenal Insufficiency in Outpatients with Indeterminate Serum Cortisol Levels: A Retrospective Study. ACTA ACUST UNITED AC 2020; 56:medicina56010023. [PMID: 31936335 PMCID: PMC7022503 DOI: 10.3390/medicina56010023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 12/26/2019] [Accepted: 01/06/2020] [Indexed: 11/17/2022]
Abstract
Background and Objectives: To diagnose adrenal insufficiency (AI), adrenocorticotropic hormone (ACTH) stimulation tests may need to be performed, but those tests may not be available in some institutions. In addition, they may not be necessary for some patients. The objective of this study was to identify clinical and biochemical factors that could facilitate AI diagnosis in outpatient departments and decrease the number of unnecessary dynamic tests. Materials and Methods: This seven-year retrospective study was performed in a tertiary care medical center. A total of 517 patients who had undergone ACTH stimulation tests in the outpatient department were identified. AI was described as a peak serum cortisol level of <18 µg/dL at 30 or 60 min after stimulation. The associations between clinical factors, biochemical factors, and AI were analyzed using the Poisson regression model and reported by the risk ratio (RR). Results: AI was identified in 128 patients (24.7%). Significant predictive factors for the diagnosis of AI were chronic kidney disease (RR = 2.52, p < 0.001), Cushingoid appearance (RR = 3.44, p < 0.001), nausea and/or vomiting (RR = 1.84, p = 0.003), fatigue (RR = 1.23, p < 0.001), serum basal cortisol <9 µg/dL (RR = 3.36, p < 0.001), serum cholesterol <150 mg/dL (RR = 1.26, p < 0.001), and serum sodium <135 mEq/L (RR = 1.09, p = 0.001). The predictive ability of the model was 83% based on the area under the curve. Conclusion: The easy-to-obtain clinical and biochemical factors identified may facilitate AI diagnosis and help identify patients with suspected AI. Using these factors in clinical practice may also reduce the number of nonessential dynamic tests for AI.
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Affiliation(s)
- Worapaka Manosroi
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (W.M.); (M.P.)
- Clinical Epidemiology and Clinical Statistic Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
| | - Mattabhorn Phimphilai
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (W.M.); (M.P.)
| | - Jiraporn Khorana
- Clinical Epidemiology and Clinical Statistic Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
- Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Pichitchai Atthakomol
- Department of Orthopedics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
| | - Tanyong Pipanmekaporn
- Clinical Epidemiology and Clinical Statistic Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200 Thailand
- Correspondence: ; Tel.: +66-53-936453
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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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