Comparative Cost Analysis of Endoscopic versus Microscopic Endonasal Transsphenoidal Surgery for Pituitary Adenomas

Endocrine Outcomes and Associated Predictive Factors for Somatotrophin Pituitary Adenoma after Endoscopic Endonasal Transsphenoidal Surgery: 10 Years of Experience in a Single Institute

Objective  Biochemical remission rates of endoscopic endonasal transsphenoidal surgery (EETS) and its associated predictive factors were evaluated in patients with somatotrophin pituitary adenomas. Methods  The patients who underwent EETS in Jinling Hospital were identified between 2011 and 2020. The surgeons' experience, preoperative insulin-like growth factor 1 (IGF-1), basal growth hormone (GH) levels, nadir GH levels, and the tumor characteristics were analyzed for their relationships with endocrine outcomes. Total 98 patients were included for single factor analysis and regression analysis. They were divided into three groups according to the admission chronologic order. Results  The overall remission rate of the patients was 57% (56/98) for all the patients over 10 years. In the single factor analysis, we found that the tumor size, cavernous invasion, and sellar invasion were valuable to predict the endocrine outcome after surgery. As for the suprasellar invasion, no significant difference was found between the noninvasive group and the invasive group. The preoperative IGF-1 level ( p  = 0.166), basal GH level ( p  = 0.001), and nadir GH level ( p  = 0.004) were also different between the remission group and the nonremission group in the single factor analysis. The logistic regression analysis indicated that the preoperative nadir GH (odds ratio = 0.930, 95% confidence interval = 0.891-0.972, p  = 0.001) was a significant predictor for the endocrine outcomes after surgery. Conclusion  The surgeons' experience is an important factor that can affect the patients' endocrine outcomes after surgery. The macroadenomas with lateral invasion are more difficult to cure. Patients with higher preoperative nadir GH levels are less likely to achieve remission.

Clinical and Operative Risk Factors Associated With Prolonged Length of Stay After Endoscopic Pituitary Adenoma Resection

BACKGROUND AND OBJECTIVES

Pituitary adenomas (PAs) are the most common intrasellar tumor. Clinically relevant adenomas have a prevalence of 1 per 1000 in the general population. Transsphenoidal surgery (TSS) is the most common surgical treatment and is the first-line management for most PAs. Most patients fare well postoperatively, but a subset of patients experience a prolonged length of stay (PLOS). In this article, we aim to identify demographic and clinical factors associated with PLOS after TSS for PA.

METHODS

Patients with sellar pathologies surgically treated at a single tertiary center from March 1, 2009, to May 31, 2020, were retrospectively reviewed. All patients older than 18 years receiving nonemergent endoscopic TSS for pituitary adenoma were included. Clinical and demographic characteristics were analyzed using χ 2 -tests and student t -tests. For those factors with a P -value less than .01, multivariate logistic regression and negative binomial regression models were constructed to estimate the adjusted odds of PLOS across predictive factors.

RESULTS

A total of 301 patients were included in the study. This cohort had an average age of 54.65 ± 15.06 years and an average body mass index of 29.47 ± 6.69. The median length of stay was 54.9 hours [25th-75th percentiles: 43.5-72.9]. Postoperative cerebrospinal fluid leak ( P < .01), postoperative diabetes insipidus (DI) ( P < .01), increased surgery duration ( P = .01), and elevated maximal tumor dimension ( P = .01) were predictive of PLOS in logistic regression. Increased surgery duration, previous pituitary radiation, intraoperative complications, and postoperative DI (all P < .01) were associated with increased rate of PLOS in negative binomial regression.

CONCLUSION

Patients undergoing endoscopic TSS for PA resection demonstrate prolonged lengths of stay if they have higher tumor burden, have lengthier surgeries with intraoperative complications, or develop postoperative complications such as cerebrospinal fluid leak or DI. Careful monitoring of these factors will allow for better resource optimization, reducing costs to both the hospital and the patient.

Endoscopic Endonasal Transsphenoidal Surgery for the Resection of Pituitary Adenomas: A Prime Candidate for a Shortened Length of Stay Enhanced Recovery after Surgery Protocol? A Systematic Review

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a perioperative model of care aimed at optimizing postoperative rehabilitation and reducing hospital length of stay (LOS). Decreasing LOS avoids hospital-acquired complications, reduces cost of care, and improves patient satisfaction. Given the lack of ERAS protocols for endoscopic endonasal transsphenoidal surgery (EETS) resection of pituitary adenomas, a systematic review of EETS was performed to compile patient outcomes and analyze factors that may lead to increased LOS, reoperation, and readmission rates with the intention to contribute to the development of a successful ERAS protocol for EETS.

METHODS

The authors performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines-based systematic review of the literature. Information was extracted regarding patient LOS, surgery complications, and readmission/reoperation rates. Pearson's correlations to LOS and reoperation/readmission rates were performed with variables normalized to the number of participants. Statistical significance was set at P value <0.05.

RESULTS

Fourteen studies were included, consisting of 2083 patients. The most common complications were cerebrospinal fluid leaks (37%) and postoperative diabetes insipidus (DI) (9%). Transient DI was significantly correlated with shorter LOS. Functional pituitary adenomas were significantly correlated with lower readmission rates while nonfunctional pituitary adenomas were correlated with higher readmission rates. No other factor was found to be significantly correlated with a change in LOS or reoperation rate.

CONCLUSIONS

EETS may be an ideal candidate for the development of ERAS cranial protocols. While our data largely supports the safe implementation of shortened LOS protocols in EETS, our findings highlight the importance of transient DI and nonfunctional pituitary adenomas management when formulating ERAS protocols.

Equivalent outcomes in nasal symptoms following microscopic or endoscopic transsphenoidal surgery: results from multi-centre, prospective study

Background

T ranssphenoidal surgery (TSS) is the standard approach for resection of pituitary lesions. Historically, this has utilized the microscopic approach (mTSS); however, the past decade has seen widespread uptake of the endoscopic approach (eTSS). The purported benefits of this include improved visualization and illumination, resulting in improved surgical and endocrinological patient outcomes. It is also believed that eTSS results in fewer post-operative nasal symptoms compared to mTSS; however, few papers have directly compared these groups.

Objectives

We sought to compare nasal symptoms after endoscopic uninostril (eTSS-uni), endoscopic binostril (eTSS-bi) and microscopic endoscopic transsphenoidal surgery (mTSS).

Methods

The General Nasal Patient Inventory (GNPI) was prospectively administered to 136 patients (71 non-functioning adenomas, 26 functioning adenomas, 39 other pathology) undergoing transsphenoidal surgery at multiple time points (pre-operatively; days 1, 3 and 7–14; months 1, 3 and 6 and 1 year post-operatively). All surgeries were performed by subspecialist pituitary surgeons in three subgroups — mTSS (25), eTSS-uni (74) and eTSS-bi (37). The total GNPI scores (0–135) and subscores for the 45 individual components were compared across three groups assessing for temporal and absolute changes.

Results

Irrespective of surgical approach used, GNPI scores were significantly higher on post-operative day 1 (p < 0.001) and day 3 (p ≤ 0.03) compared to pre-treatment baseline (mixed-effects model). By 1 month post-operatively, however, post-operative GNPI scores were no different from pre-treatment (p > 0.05, mixed-effects model). Whilst the eTSS-uni group demonstrated significantly lower GNPI scores at day 1 post-op compared to the mTSS group (p = 0.05) and eTSS-bi group (p < 0.001), there was no significant difference in post-operative scores between approaches beyond 1–2 weeks post-operatively. Similar results were obtained when the non-functioning tumour group was analysed separately.

Conclusions

Transsphenoidal pituitary surgery is well tolerated. Post-operative nasal symptoms transiently worsen but ultimately improve compared to pre-operative baseline. Operative approach (microscopic, endoscopic uninostril or endoscopic binostril) only has a transient effect on severity of post-operative nasal symptoms.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00701-022-05138-5.

Characteristics and overall survival in pediatric versus adult pituitary adenoma: a National Cancer Database analysis

OBJECTIVE

Pituitary adenomas in the pediatric population are extremely rare, resulting in limited information in the literature on these patients. In this study, data from the National Cancer Database (NCDB) to compare pituitary adenoma clinical presentations, treatment management patterns, and overall survival between pediatric and adult patients.

METHODS

The NCDB was queried for all cases of histologically confirmed pituitary adenoma treated between 2004 and 2015. Patients were primarily stratified as either pediatric (< 18 years) or adult (≥ 18 years). Patient demographics/socioeconomics and resulting outcomes were then compared.

RESULTS

1893 pediatric and 77,993 adult patients with pituitary adenomas were evaluated. Average tumor size for pediatric and adult patients was 13.6 ± 13.2 mm and 20.1 ± 13.1 mm, respectively (p < 0.001). Pediatric patients were more likely to undergo gross total resection, less likely to receive adjuvant radiation, more likely to receive medical therapy, more likely to undergo active surveillance, and exhibited improved 5-year and 10-year overall survival (OS) (all p < 0.001). Temporal analysis demonstrated a significant increase in endoscopic approach over time (from 48 to 65%) in the pediatric population (R² = 0.722, p = 0.03). On univariate analysis in the pediatric population, African American race compared to Caucasians (HR: 5.85, 95% CI 1.79-19.2, p < 0.003), patients with government insurance compared to those with private insurance (HR: 5.07, 95% CI 1.31-19.6, p < 0.02) and uninsured patients compared to those with private insurance (HR: 14.4, 95% CI 2.41-86.5, p < 0.003) were associated with decreased OS. Lastly, patients who underwent GTR had improved OS compared to those who underwent subtotal resection (HR: 0.08, 95% CI 0.008-0.93, p < 0.04) in the pediatric population.

CONCLUSIONS

Compared to adults, children with pituitary adenomas more commonly underwent GTR, less frequently underwent adjuvant radiotherapy, more frequently underwent medical management and active surveillance, and had improved survival. Temporal analysis demonstrated increasing utilization of the endoscopic approach for surgical treatment of pediatric and adult pituitary adenoma patients.

LEVEL OF EVIDENCE

Level III.

Insurance type impacts the economic burden and survival of patients with newly diagnosed glioblastoma

OBJECTIVE

Glioblastoma (GBM) carries a high economic burden for patients and caregivers, much of which is associated with initial surgery. The authors investigated the impact of insurance status on the inpatient hospital costs of surgery for patients with GBM.

METHODS

The authors conducted a retrospective review of patients with GBM (2010-2015) undergoing their first resection at the University of California, San Francisco, and corresponding inpatient hospital costs.

RESULTS

Of 227 patients with GBM (median age 62 years, 37.9% females), 31 (13.7%) had Medicaid, 94 (41.4%) had Medicare, and 102 (44.9%) had private insurance. Medicaid patients had 30% higher overall hospital costs for surgery compared to non-Medicaid patients ($50,285 vs $38,779, p = 0.01). Medicaid patients had higher intensive care unit (ICU; p < 0.01), operating room (p < 0.03), imaging (p < 0.001), room and board (p < 0001), and pharmacy (p < 0.02) costs versus non-Medicaid patients. Medicaid patients had significantly longer overall and ICU lengths of stay (6.9 and 2.6 days) versus Medicare (4.0 and 1.5 days) and privately insured patients (3.9 and 1.8 days, p < 0.01). Medicaid patients had similar comorbidity rates to Medicare patients (67.8% vs 68.1%), and both groups had higher comorbidity rates than privately insured patients (37.3%, p < 0.0001). Only 67.7% of Medicaid patients had primary care providers (PCPs) versus 91.5% of Medicare and 86.3% of privately insured patients (p = 0.009) at the time of presentation. Tumor diameter at diagnosis was largest for Medicaid (4.7 cm) versus Medicare (4.1 cm) and privately insured patients (4.2 cm, p = 0.03). Preoperative (70 vs 90, p = 0.02) and postoperative (80 vs 90, p = 0.03) Karnofsky Performance Scale (KPS) scores were lowest for Medicaid versus non-Medicaid patients, while in subgroup analysis, postoperative KPS score was lowest for Medicaid patients (80, vs 90 for Medicare and 90 for private insurance; p = 0.03). Medicaid patients had significantly shorter median overall survival (10.7 months vs 12.8 months for Medicare and 15.8 months for private insurance; p = 0.02). Quality-adjusted life year (QALY) scores were 0.66 and 1.05 for Medicaid and non-Medicaid patients, respectively (p = 0.036). The incremental cost per QALY was $29,963 lower for the non-Medicaid cohort.

CONCLUSIONS

Patients with GBMs and Medicaid have higher surgical costs, longer lengths of stay, poorer survival, and lower QALY scores. This study indicates that these patients lack PCPs, have more comorbidities, and present later in the disease course with larger tumors; these factors may drive the poorer postoperative function and greater consumption of hospital resources that were identified. Given limited resources and rising healthcare costs, factors such as access to PCPs, equitable adjuvant therapy, and early screening/diagnosis of disease need to be improved in order to improve prognosis and reduce hospital costs for patients with GBM.

Pituitary surgery's epidemiology using a national inpatient database in Japan

BACKGROUND

Between 2010 and 2014, microscopic transsphenoidal surgery (mTSS) was performed more frequently than endoscopic TSS (eTSS) in the USA. However, few epidemiological studies on pituitary surgery are currently available.

METHODS

We performed a retrospective study on patients who had undergone pituitary surgery between July 2010 and March 2016. To this end, a nationwide inpatient database in Japan was used. Patients' characteristics, diagnoses, types of surgery, complications, and discharge status were examined.

RESULTS

A total of 16,253 inpatients who received pituitary surgery were identified. Patients were diagnosed with diseases for insurance claims described below: pituitary adenoma, hyperprolactinemia, other pituitary disorders (e.g., Rathke's cleft cyst), hyperpituitarism, craniopharyngioma, acromegaly, Cushing's disease, and pituitary cancer. Among them, pituitary adenomas, primarily the non-functioning ones, were the most frequent (66.9%). A total of 14,285 (88%) patients underwent TSS, while 1968 (12%) patients were treated using transcranial surgery. The number of patients undergoing TSS increased each year. The number of eTSS operations was 8140 (77%) and that of mTSS operations was 2419 (23%). Of note, eTSS increased each year. We found that high-volume hospitals more frequently selected eTSS. Compared with mTSS, eTSS was associated with a reduction of hyponatremia incidence (odds ratio, 0.69; p = 0.019). Additionally, it was not associated with other major complications.

CONCLUSION

The present study showed that both TSS and eTSS increased on a yearly basis. We believe that the present study will be the basis of future epidemiological investigations of pituitary surgery.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Predicting prolonged length of stay after endoscopic transsphenoidal surgery for pituitary adenoma

BACKGROUND

Endoscopic transsphenoidal surgery (ETS) for the resection of pituitary adenoma has become more common throughout the past decade. Although most patients have a short postoperative hospitalization, others require a more prolonged stay. We aimed to identify predictors for prolonged hospitalization in the setting of ETS for pituitary adenomas.

METHODS

A retrospective chart review as performed on 658 patients undergoing ETS for pituitary adenoma at a single tertiary care academic center from 2005 to 2019. Length of stay (LoS) was defined as date of surgery to date of discharge. Patients with LoS in the top 10th percentile (prolonged LoS [PLS] >4 days, N = 72) were compared with the remainder (standard LoS [SLS], N = 586).

RESULTS

The average age was 54 years and 52.5% were male. The mean LoS was 2.1 days vs 7.5 days (SLS vs PLS). On univariate analysis, atrial fibrillation (p = 0.002), hypertension (p = 0.033), partial tumor resection (p < 0.001), apoplexy (p = 0.020), intraoperative cerebrospinal fluid (ioCSF) leak (p = 0.001), nasoseptal flap (p = 0.049), postoperative diabetes insipidus (DI) (p = 0.010), and readmission within 30 days (p = 0.025) were significantly associated with PLS. Preoperative continuous positive airway pressure (CPAP) (odds ratio, 15.144; 95% confidence interval, 2.596-88.346; p = 0.003) and presence of an ioCSF leak (OR, 10.362; 95% CI, 2.143-50.104; p = 0.004) remained significant on multivariable analysis.

CONCLUSION

For patients undergoing ETS for pituitary adenomas, an ioCSF leak or preoperative use of CPAP predicted PLS. Additional common reasons for PLS included postoperative CSF leak (10 of 72), management of DI or hypopituitarism (15 of 72), or reoperation due to surgical or medical complications (14 of 72).

Endoscopic versus nonendoscopic surgery for resection of pituitary adenomas: a national database study

OBJECTIVE

For symptomatic nonsecreting pituitary adenomas (PAs), resection remains a critical option for treatment. In this study, the authors used a large-population national database to compare endoscopic surgery (ES) to nonendoscopic surgery (NES) for the surgical management of PA.

METHODS

The National Cancer Database was queried for all patients diagnosed with histologically confirmed PA who underwent resection between 2010 and 2016 in which the surgical approach was specified. Due to database limitations, microsurgery and craniotomy were both categorized as NES.

RESULTS

Of 30,488 identified patients, 16,373 (53.7%) underwent ES and 14,115 (46.3%) underwent NES. There was a significant increase in the use of ES over time (OR 1.16, p < 0.01). Furthermore, there was a significant temporal increase in ES approach for tumors ≥ 2 cm (OR 1.17, p < 0.01). Compared to NES, patients who underwent ES were younger (p = 0.01), were treated at academic centers (p < 0.01), lived a greater distance from their treatment site (p < 0.01), had smaller tumors (p < 0.01), had greater medical comorbidity burden (p = 0.04), had private insurance (p < 0.01), and had a higher household income (p < 0.01). After propensity score matching to control for age, tumor size, Charlson/Deyo score, and type of treatment center, patients who underwent ES had a shorter length of hospital stay (LOS) (3.9 ± 4.9 days vs 4.3 ± 5.4 days, p < 0.01), although rates of gross-total resection (GTR; p = 0.34), adjuvant radiotherapy (p = 0.41), and 90-day mortality (p = 0.45) were similar. On multivariate logistic regression, African American race (OR 0.85, p < 0.01) and tumor size ≥ 2 cm (OR 0.89, p = 0.01) were negative predictors of receiving ES, whereas diagnosis in more recent years (OR 1.16, p < 0.01), greater Charlson/Deyo score (OR 1.10, p = 0.01), receiving treatment at an academic institution (OR 1.67, p < 0.01) or at a treatment site ≥ 20 miles away (OR 1.17, p < 0.01), having private insurance (OR 1.09, p = 0.01), and having a higher household income (OR 1.11, p = 0.01) were predictive of receiving ES. Compared to the ES cohort, patients who started with ES and converted to NES (n = 293) had a higher ratio of nonwhite race (p < 0.01), uninsured insurance status (p < 0.01), longer LOS (p < 0.01), and higher rates of GTR (p = 0.04).

CONCLUSIONS

There is an increasing trend toward ES for PA resection including its use for larger tumors. Although ES may result in shorter LOS compared to NES, rates of GTR, need for adjuvant therapy, and short-term mortality may be similar. Factors such as tumor size, insurance status, facility type, income, race, and existing comorbidities may predict receiving ES.