Perioperative glucocorticoid coverage. A reassessment 42 years after emergence of a problem

Effects and mechanisms of perioperative medications on the hypothalamic pituitary adrenal response to surgical injury: A narrative review

The adrenal gland is a vital endocrine organ, and adrenal steroid synthesis and secretion are closely regulated by the hypothalamic-pituitary-adrenal (HPA) axis in response to various stimuli. Surgery or trauma can activate the HPA axis and induce the secretion of cortisol. Different cortisol responses vary with the grade of surgery. Perioperative medications have the potential to decrease the cortisol level in the body, and both excessive and insufficient cortisol levels after surgery are disadvantageous. The effect of perioperative medications on the HPA response to surgery can be divided into three levels: "adrenal insufficiency (AI)", "stress response inhibition", and "uncertainty". The clinical presentation of AI includes fatigue, nausea, vomiting, abdominal pain, muscle cramps, hypotension, hypovolemic shock and prerenal failure, which may result in fatal consequences. Stress response inhibition can reduce postoperative complications, such as pain and cognitive dysfunction. This is protective to patients during perioperative and postoperative periods. The aim of the present review is to shed light on current evidence regarding the exact effects and mechanisms of perioperative medications on the HPA response to surgical injury and provide the applicable guidance on clinical anesthesia.

Morbidities and mortality among hospitalized patients with hypopituitarism: Prevalence, causes and management

Hypopituitarism is a highly heterogeneous multisystem disorder that can have a major impact on long-term morbidity and mortality, but even more so during acute medical conditions requiring hospitalization. Recent studies suggest a significant in-hospital burden with prolonged length of stay, increased rate of intensive care unit (ICU) admission, and initiation of mechanical ventilation - all of which may lead to an increased risk of in-hospital mortality. On the one hand, patients with hypopituitarism are often burdened by metabolic complications, including obesity, hypertension, dyslipidemia, and hyperglycemia, which alone, or in combination, are known to significantly alter relevant physiological mechanisms, including metabolism, innate and adaptive immune responses, coagulation, and wound healing, thereby contributing to adverse in-hospital outcomes. On the other hand, depending on the extent and the number of pituitary hormone deficiencies, early recognition of hormone deficiencies and appropriate management and replacement strategy within a well-organized multidisciplinary team are even stronger determinants of short-term outcomes during acute hospitalization in this vulnerable patient population. This review aims to provide an up-to-date summary of recent advances in pathophysiologic understanding, clinical implications, and recommendations for optimized multidisciplinary management of hospitalized patients with hypopituitarism.

Peri-Operative Optimization of Patients with Crohn's Disease

PURPOSE OF REVIEW

The management of patients with Crohn's disease (CD) undergoing surgery is complex and optimization of modifiable factors perioperatively can improve outcomes. This review focuses on the perioperative management of CD patients undergoing surgery, emphasizing the need for a multi-disciplinary approach.

RECENT FINDINGS

Research highlights the benefits of a comprehensive strategy, involving nutritional optimization, psychological assessment, and addressing septic complications before surgery. Despite many CD patients being on immune-suppressing medications, studies indicate that most of these medications are safe to use and should not delay surgery. However, a personalized approach for each case is needed. This review underscores the importance of multi-disciplinary team led peri-operative management of CD patients. We suggest that this can be done at a dedicated perioperative clinic for prehabilitation, with the potential to enhance outcomes for CD patients undergoing surgery.

Perioperative growth hormone levels as an early predictor of new-onset secondary adrenal insufficiency following transsphenoidal pituitary tumor resection

OBJECTIVE

This study aims to predict new-onset secondary adrenal insufficiency (NOSAI) after transsphenoidal pituitary tumor resection surgery using perioperative growth hormone (GH) and prolactin (PRL) levels, among other factors.

METHODS

A cohort of 124 adult patients who underwent transsphenoidal resection for non-functioning pituitary adenoma, with routine perioperative glucocorticoid use, was used to develop the predictive regression model. An additional 46 patients served as the validation cohort. Generalized additive models were used to identify optimal cut-off points for the variables.

RESULTS

The GH level on postoperative day one (POD1) can be a simple predictor by implementing a cut-off point of 0.41 ng/ml. A value ≤ 0.41 ng/mL predicted NOSAI with 0.6316 sensitivity and 0.7810 specificity for the original cohort and 1.0000 sensitivity and 0.7143 specificity for the validation cohort. The multiple logistic regression model included perioperative PRL level difference, perioperative GH level difference, intraoperative cerebrospinal fluid (CSF) leakage, tumor size, and the combined effect of diabetes insipidus (DI) and relative perioperative GH level difference. The areas under the receiver operating characteristic curves were 0.9410 (original cohort) and 0.9494 (validation cohort) for the regression model.

CONCLUSION

Early morning GH level on POD1 can predict NOSAI with fair accuracy when perioperative stress dose glucocorticoid is administered. Prediction accuracy can be improved by considering CSF leakage, DI, and perioperative changes in GH and PRL in the final regression model.

2022 Chinese guideline for the management of pregnancy and reproduction in systemic lupus erythematosus

Systemic lupus erythematosus (SLE), a prevalent autoimmune disease predominantly affecting women of childbearing age, presents ongoing challenges despite notable advances in diagnosis and treatment. Although survival rates for SLE patients have significantly improved, pregnancy continues to pose a considerable obstacle. Addressing this critical need for enhanced reproductive and prenatal care, there is a pressing imperative to establish standardized protocols for peri-gestational monitoring and treatment in SLE patients. This guideline is jointly sponsored by the National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), the Chinese Systemic Lupus Erythematosus Treatment and Research Group (CSTAR), and the Chinese Research Committee of Pregnancy and Reproduction in Autoimmune Rheumatic Diseases (CHOPARD). Thirteen pertinent clinical questions have been generated through several rounds of rigorous clinical and methodological expert discussions and selections for a comprehensive understanding of key aspects in this domain. Guided by thorough examination of research evidence and expert perspectives, the formulated recommendations aim to optimize pregnancy success rates, reduce maternal and infant mortality rates, and ultimately enhance the overall well-being of SLE patients.

Perioperative Evaluation and Management of Patients on Glucocorticoids

Myriad questions regarding perioperative management of patients on glucocorticoids (GCs) continue to be debated including which patients are at risk for adrenal insufficiency (AI), what is the correct dose and duration of supplemental GCs, or are they necessary for everyone? These questions remain partly unanswered due to the heterogeneity and low quality of data, studies with small sample sizes, and the limited number of randomized trials. To date, we know that although all routes of GC administration can result in hypothalamic-pituitary-adrenal (HPA) axis suppression, perioperative adrenal crisis is rare. Correlation between biochemical testing for AI and clinical events is lacking. Some of the current perioperative management recommendations based on daily GC dose and duration of therapy may be difficult to follow in clinical practice. The prospective and retrospective studies consistently report that continuing the daily dose of GCs perioperatively is not associated with a higher risk for adrenal crises in patients with GC-induced AI. Considering that oral GC intake may be unreliable in the early postoperative period, providing the daily GC plus a short course of IV hydrocortisone 25 to 100 mg per day based on the degree of surgical stress seems reasonable. In patients who have stopped GC therapy before surgery, careful assessment of the HPA axis is necessary to avoid an adrenal crisis. In conclusion, our literature review indicates that lower doses and shorter duration of supplemental GCs perioperatively are sufficient to maintain homeostasis. We emphasize the need for well-designed randomized studies on this frequently encountered clinical scenario.

Safety of Withholding Perioperative Hydrocortisone for Patients With Pituitary Adenomas With an Intact Hypothalamus-Pituitary-Adrenal Axis: A Randomized Clinical Trial

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.

Management of patients at risk of adrenal crisis in the dental setting: a review of current practice in UK dental teaching hospitals

Introduction Patients with impaired corticosteroid response due to Addison's disease or systemic glucocorticoid use are at risk of adrenal crisis when undergoing dental treatment. There is a lack of conclusive evidence to support dental teams in identifying patients at risk and their management to prevent an adrenal crisis.Aim To review the current practice in UK dental teaching hospitals regarding the management of patients at risk of adrenal crisis in the dental setting.Methods An electronic survey focused on patients who may be at risk of adrenal crisis due to systemic glucocorticoid therapy was sent to all 18 UK dental teaching hospitals. Information on the use of a policy or guidance was requested. Responses were evaluated for clinical decision-making, patient risk assessment and steroid cover dosing regimens.Results A 78% response rate was achieved. Only 29% of institutions had a written policy or guidance document. Variation exists in the threshold of steroid dose and duration of treatment in identifying patients at risk of adrenal suppression. Furthermore, the dose regime for steroid cover varied.Conclusion Further evidence on the management of patients at risk of adrenal crisis is required to inform national guidance and reduce variation in patient management.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism.

BACKGROUND

Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT.

METHODS

Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.

Glucocorticoids for therapeutic immunosuppression: Clinical pearls for the practicing neurologist

Given widespread use of glucocorticoid therapy in neurologic disease, understanding glucocorticoid pharmacology and risk is paramount for the practicing neurologist. While dosing and tapering regimens vary depending on the neurological disease and indication being treated, there are important general principles of glucocorticoid prescribing and monitoring that can guide clinical decision-making. Glucocorticoid-related toxicities can occur across multiple organ systems, including hypertension; dyslipidemia; weight gain; hyperglycemia; osteoporosis and avascular necrosis; myopathy; gastrointestinal bleeding; infection; and neuropsychiatric effects with sleep, mood disturbance and cognition. This narrative review provides a practical framework for safe and responsible prescribing of this therapeutic class of medications, including appreciation of immunosuppressive consequences, risk mitigation strategies, dosing and tapering, and recognition of adrenal insufficiency and glucocorticoid withdrawal.

Adrenal crisis and mortality rate in adrenal insufficiency and congenital adrenal hyperplasia

Primary adrenal insufficiency (PAI) is characterized by the inability of the adrenal cortex to produce sufficient amounts of glucocorticoids and/or mineralocorticoids. Addison's disease (AD) and congenital adrenal hyperplasia (CAH) are the most frequent disorders in adults and children, respectively. Despite the diagnostic advances and the availability of glucocorticoid and mineralocorticoid replacements, adrenal crisis (AC) is still a potentially lethal condition contributing to the increased mortality, not only during the first year of life, but also throughout life. Failure in increasing glucocorticoid doses during acute stress, when greater amounts of glucocorticoids are required, can lead to AC and an increase morbimortality rate of PAI. Considering a mortality rate of 0.5 per 100 patient years, up to 1,500 deaths from AC are expected in Brazil in the coming decade, which represents an alarming situation. The major clinical features are hypotension and volume depletion. Nonspecific symptoms such as fatigue, lack of energy, anorexia, nausea, vomiting, and abdominal pain are common. The main precipitating factors are gastrointestinal diseases, other infectious disease, stressful events (e.g., major pain, surgery, strenuous physical activity, heat, and pregnancy), and withdrawal of glucocorticoid therapy. Suspected AC requires immediate therapeutic action with intravenous (iv) hydrocortisone, fluid infusion, monitoring support, and antibiotics if necessary. AC is best prevented through patient education, precocious identification and by adjusting the glucocorticoid dosage in stressor situations. The emergency card, warning about acute glucocorticoid replacement, has high value in reducing the morbidity and mortality of AC.

Update on Management of the Oral and Maxillofacial Surgery Patient on Corticosteroids

Corticosteroids have been the cornerstone for treatment of many inflammatory and immune disorders with these beneficial effects well recognized by the medical community. It also possesses many undesirable clinical adverse effects that can occur within 2 weeks of use. Moreover, in the past decade, chronic users of corticosteroids have been linked to skeletal (vertebral and hip) osteoporosis/osteonecrosis with some patients requiring adjunctive antiresprotive medications to counteract fracture prevention. Additionally, two case reports have implicated daily prednisone user to cause osteonecrosis of the mandible. This chapter highlights current adrenal suppression classifications, pathophysiology, drug interactions, and perioperative surgical and anesthesia management.

Adrenal suppression from exogenous glucocorticoids: Recognizing risk factors and preventing morbidity

Adrenal suppression (AS), a potential side effect of glucocorticoid therapy (including inhaled corticosteroids), can be associated with significant morbidity and even death. In Canada, adrenal crisis secondary to AS continues to be reported in children. Being aware of symptoms associated with AS, understanding the risk factors for developing this condition, and familiarity with potential strategies to reduce risks associated with AS, are essential starting points for any clinician prescribing glucocorticoids.

Peri-operative steroid management in the paediatric population

BACKGROUND

Patients with adrenal insufficiency are at risk of adrenal crisis, a potentially life-threatening emergency in the peri-operative period due to their attenuated ability to mount a cortisol response. There is a lack of standardization regarding peri-operative stress-dose glucocorticoids in paediatric clinical practice with the absence of agreed protocols. For the individual patient, the risk of adrenal crisis must be weighed against the potential adverse clinical outcomes associated with unnecessary or supra-physiologic glucocorticoid dosing in susceptible patients. Specific clinical concerns in the paediatric population include osteopenia, growth restriction and increased risk of cardiovascular disease in adulthood. This review aimed to identify and evaluate available literature in the field of peri-operative stress-dose glucocorticoids.

METHODS

A comprehensive literature search was conducted to construct a narrative review.

RESULTS

The outcome of this review identified that paediatric patients, unlike adults, do not show a graded response to surgical stress with implications for glucocorticoid stress dose regimens for general anaesthesia and less invasive surgical procedures. The studies highlight a lack of information on physiological steroid responses to stress situations and differences in the approach to glucocorticoid replacement strategies in the paediatric population.

CONCLUSION

The review identified there is a lack of high-quality paediatric-specific studies evaluating appropriate stress-dose glucocorticoid regimens in paediatric patients with or at risk of adrenal insufficiency. Further research is needed to establish clear evidence-based clinical guidelines for paediatric peri-operative practice regarding steroid stress dosing in adrenal insufficiency. Current knowledge would suggest that a balanced view of risks and benefits should be taken appropriate to the clinical context, to dictate peri-operative stress-dose glucocorticoids use that permits safe perioperative management.

Perioperative Outcomes of a Hydrocortisone Protocol after Endonasal Surgery for Pituitary Adenoma Resection

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.

Acute abdomen in the immunocompromised patient: WSES, SIS-E, WSIS, AAST, and GAIS guidelines

Immunocompromised patients are a heterogeneous and diffuse category frequently presenting to the emergency department with acute surgical diseases. Diagnosis and treatment in immunocompromised patients are often complex and must be multidisciplinary. Misdiagnosis of an acute surgical disease may be followed by increased morbidity and mortality. Delayed diagnosis and treatment of surgical disease occur; these patients may seek medical assistance late because their symptoms are often ambiguous. Also, they develop unique surgical problems that do not affect the general population. Management of this population must be multidisciplinary.This paper presents the World Society of Emergency Surgery (WSES), Surgical Infection Society Europe (SIS-E), World Surgical Infection Society (WSIS), American Association for the Surgery of Trauma (AAST), and Global Alliance for Infection in Surgery (GAIS) joined guidelines about the management of acute abdomen in immunocompromised patients.

La suppression surrénalienne causée par les glucocorticoïdes exogènes : en reconnaître les facteurs de risque et en prévenir les effets

La suppression surrénalienne, un effet secondaire potentiel du traitement aux glucocorticoïdes (y compris les corticostéroïdes inhalés), peut avoir des conséquences graves et même fatales. Au Canada, on continue de déclarer des poussées d’insuffisance corticosurrénalienne consécutives à une suppression surrénalienne chez les enfants. Avant de prescrire des glucocorticoïdes, le clinicien doit absolument connaître les symptômes de suppression surrénalienne, comprendre les facteurs de risque de cette affection et être au courant des stratégies susceptibles d’en réduire les risques.

Perioperative Management of Antirheumatic Medications in Patients with RA and SLE Undergoing Elective Foot and Ankle Surgery: A Critical Analysis Review

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Recent literature has shown that continued use rather than discontinuation of various antirheumatic agents throughout the perioperative period may present an opportunity to mitigate the risks of elective surgery.

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For patients with rheumatoid arthritis and systemic lupus erythematosus, perioperative management of medication weighs the risk of infection against the risk of disease flare when immunosuppressive medications are withheld.

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Broadly speaking, current evidence, although limited in quality, supports perioperative continuation of disease-modifying antirheumatic drugs, whereas biologic drugs should be withheld perioperatively, based on the dosing interval of the specific drug.

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For any withheld biologic drug, it is generally safe to restart these medications approximately 2 weeks after surgery, once the wound shows evidence of healing, all sutures and staples have been removed, and there is no clinical evidence of infection. The focus of this recommendation applies to the optimization of wound-healing, not bone-healing.

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In most cases, the usual daily dose of glucocorticoids is administered in the perioperative period rather than administering "stress-dose steroids" on the day of surgery.

Bone cement implantation syndrome during hip replacement in a patient with pemphigus and Parkinson’s disease: A case report

BACKGROUND

Bone cement implantation syndrome (BCIS) is characterized by hypotension, arrhythmia, diffuse pulmonary microvascular embolism, shock, cardiac arrest, any combination of these factors, or even death following bone cement implantation.

CASE SUMMARY

An 80-year-old patient with pemphigus and Parkinson’s disease underwent total hip replacement under spinal subarachnoid block and developed acute pulmonary embolism after bone cement implantation. The patient received mask mechanical ventilation with a continuous intravenous infusion of adrenaline (2 μg/mL) at a rate of 30 mL/h. Subsequently, the symptoms of BCIS were markedly alleviated, and the infusion rate of adrenaline was gradually reduced until the infusion was completely stopped 45 min later. The patient was then transferred to the Department of Orthopedics, and anticoagulation therapy began at 12 h postoperatively. No other complications were observed.

CONCLUSION

This is a rare case of BCIS in a high-risk patient with pemphigus and Parkinson’s disease.

Impact of Adrenal Function on Hemostasis/Endothelial Function in Patients Undergoing Surgery

Context

Glucocorticoids regulate hemostatic and endothelial function, and they are critical for adaptive functions during surgery. No data regarding the impact of adrenal function on hemostasis and endothelial function in the perioperative setting are available.

Objective

We assessed the association of adrenal response to adrenocorticotropic hormone (ACTH) and markers of endothelial/hemostatic function in surgical patients.

Methods

This prospective observational study, conducted at a tertiary care hospital, included 60 patients (35 male/25 female) undergoing abdominal surgery. Adrenal function was evaluated by low-dose ACTH stimulation test on the day before, during, and the day after surgery. According to their stimulated cortisol level (cutoff ≥ 500 nmol/L), patients were classified as having normal hypothalamic-pituitary-adrenal (HPA)-axis function (nHPA) or deficient HPA-axis function (dHPA). Parameters of endothelial function (soluble vascular cell adhesion molecule-1, thrombomodulin) and hemostasis (fibrinogen, von Willebrand factor antigen, factor VIII [FVIII]) were measured during surgery.

Results

Twenty-one patients had dHPA and 39 had nHPA. Compared with nHPA, patients with dHPA had significantly lower peak cortisol before (median 568 vs 425 nmol/L, P < 0.001) and during (693 vs 544 nmol/L, P < 0.001) surgery and lower postoperative hemoglobin levels (116 g/L vs 105 g/L, P = 0.049). FVIII was significantly reduced in patients with dHPA in uni- and multivariable analyses; other factors displayed no significant differences. Coagulation factors/endothelial markers changed progressively in relation to stimulated cortisol levels and showed a turning point at cortisol levels between 500 and 600 nmol/L.

Conclusions

Patients with dHPA undergoing abdominal surgery demonstrate impaired hemostasis which can translate into excessive blood loss.

Perioperative glucocorticoid management based on current evidence

Glucocorticoid preparations, adreno-cortical steroids, with strong anti-inflammatory and immunosuppressive effects, are widely used for treating various diseases. The number of patients exposed to steroid therapy prior to surgery is increasing. When these patients present for surgery, the anesthesiologist must decide whether to administer perioperative steroid supplementation. Stress-dose glucocorticoid administration is required during the perioperative period because of the possibility of failure of cortisol secretion to cope with the increased cortisol requirement due to surgical stress, adrenal insufficiency, hemodynamic instability, and the possibility of adrenal crisis. Therefore, glucocorticoids should be supplemented at the same level as that of normal physiological response to surgical stress by evaluating the invasiveness of surgery and inhibition of the hypothalamus-pituitary-adrenal axis. Various textbooks and research articles recommend the stress-dose of glucocorticoids during perioperative periods. It has been commonly suggested that glucocorticoids should be administered in an amount equivalent to about 100 mg of cortisol for major surgery because it induces approximately 5 times the normal secretion. However, more studies, with appropriate power, regarding the administration of stress-dose glucocorticoids are still required, and evaluation of patients with possible adrenal insufficiency and appropriate glucocorticoid administration based on surgical stress will help improve the prognosis.

Perioperative Evaluation and Management of Endocrine Disorders

Evaluation of endocrine issues is a sometimes overlooked yet important component of the preoperative medical evaluation. Patients with diabetes, thyroid disease, and hypothalamic-pituitary-adrenal axis suppression are commonly encountered in the surgical setting and require unique consideration to optimize perioperative risk. For patients with diabetes, perioperative glycemic control has the strongest association with postsurgical outcomes. The preoperative evaluation should include recommendations for adjustment of insulin and noninsulin diabetic medications before surgery. Recommendations differ based on the type of diabetes, the type of insulin, and the patient's predisposition to hyperglycemia or hypoglycemia. Generally, patients with thyroid dysfunction can safely undergo operations unless they have untreated hyperthyroidism or severe hypothyroidism. Patients with known primary or secondary adrenal insufficiency require supplemental glucocorticoids to prevent adrenal crisis in the perioperative setting. Evidence supporting the use of high-dose supplemental corticosteroids for patients undergoing long-term glucocorticoid therapy is sparse. We discuss an approach to these patients based on the dose and duration of ongoing or recent corticosteroid therapy. As with other components of the preoperative medical evaluation, the primary objective is identification and assessment of the severity of endocrine issues before surgery so that the surgeons, anesthesiologists, and internal medicine professionals can optimize management accordingly.

Effect of Very Low-Dose Hydrocortisone on Shock Reversal in Patients With Septic Shock

Supplemental Digital Content is available in the text.

In patients with septic shock, hydrocortisone 200–400 mg/d has been shown to reverse shock compared with placebo. Lower doses of hydrocortisone have not previously been studied, and there are no previous studies comparing two different doses of hydrocortisone. At our institution, some clinicians routinely prescribe doses less than 200 mg/d. This study aims to compare the effect of lower doses of hydrocortisone to standard doses on shock reversal and adverse events in septic shock.

Perioperative Glucocorticoid Therapy for Patients with Adrenal Insufficiency: Dosing Based on Pharmacokinetic Data

BACKGROUND

Perioperative glucocorticoid therapy for patients with adrenal insufficiency (AI) is currently based on anecdotal reports, without supporting pharmacokinetic data.

METHODS

We determined the half-life, clearance, and volume of distribution of 2 consecutive intravenously (IV)-administered doses of hydrocortisone (15 or 25 mg every 6 hours) to 22 dexamethasone-suppressed healthy individuals and used the data to develop a novel protocol to treat 68 patients with AI who required surgical procedures. Patients received 20 mg of hydrocortisone orally 2 to 4 hours before intubation and were started on 25 mg of IV hydrocortisone every 6 hours for 24 hours and 15 mg every 6 hours during the second day. Nadir cortisol concentrations were repeatedly measured during that period.

RESULTS

In healthy individuals, cortisol half-life was longer when the higher hydrocortisone dose was administered (2.02 ± 0.15 vs 1.81 ± 0.11 hours; P < 0.01), and in patients with AI, the half-life was longer than in healthy individuals given the same hydrocortisone dose. In both populations, the cortisol half-life increased further with the second hormone injection. Prolongation of cortisol half-life was due to decreased hydrocortisone clearance and an increase in its volume of distribution. Nadir cortisol levels determined throughout the 48 postoperative hours were within the range of values and often exceeded those observed perioperatively in patients without adrenal dysfunction.

CONCLUSIONS

Cortisol pharmacokinetics are altered in the postoperative period and indicate that lower doses of hydrocortisone can be safely administered to patients with AI undergoing major surgery. The findings of this investigation call into question the current practice of administering excessive glucocorticoid supplementation during stress.

Epidemiology, pathogenesis, and diagnosis of Addison's disease in adults

BACKGROUND

Addison's disease (AD) is a rare disorder and among adult population in developed countries is most commonly caused by autoimmunity. In contrast, in children genetic causes are responsible for AD in the majority of patients.

PURPOSE

This review describes epidemiology, pathogenesis, genetics, natural history, clinical manifestations, immunological markers and diagnostic strategies in patients with AD. Standard care treatments including the management of patients during pregnancy and adrenal crises consistent with the recent consensus statement of the European Consortium and the Endocrine Society Clinical Practice Guideline are described. In addition, emerging therapies designed to improve the quality of life and new strategies to modify the natural history of autoimmune AD are discussed.

CONCLUSIONS

Progress in optimizing replacement therapy for patients with AD has allowed the patients to lead a normal life. However, continuous education of patients and health care professionals of ever-present danger of adrenal crisis is essential to save lives of patients with AD.

Assessment of adrenal reserve and secretion of cortisol in patients over 60 years of age undergoing cardiac surgery

Introduction

Cortisol level affects the prognosis of patients after cardiac surgery. Meanwhile, there are no clear guidelines for steroid supplementation after a cardiac operation. The relationship between age and blood cortisol levels has not been finally clarified.

Aim

Assessment of adrenal reserve and secretion of cortisol in patients over 60 years of age undergoing cardiac surgery.

Material and methods

The study included 20 patients of both sexes referred for cardiac surgery. A short ACTH synthetic stimulation test was carried out. Assessment of cortisol secretion was carried out in the morning on the day of surgery and the 1^st, 2^nd and 4^th days after surgery in blood samples.

Results

A result within the normal range for the adrenal reserve was found in 19 of the 20 patients enrolled in the study. The short Synacthen test predicted postoperative secretion of cortisol (p = 0.04, r = 0.047). A relationship between secretion of cortisol and patients’ age was observed (p = 0.03, r = 0.48). The concentration of cortisol on the 1^st postoperative day was correlated with the total dose of dopamine (p = 0.006, r = 0.58) and adrenaline (p = 0.04, r = 0.47). The concentration of cortisol on the day of the surgery correlated with the lactate concentration on day 2 (p = 0.04, r = 0.45). The concentration of lactates on day 1 correlated with total dose of dopamine (p = 0.01, r = 0.54).

Conclusions

A short Synacthen test allows one to predict secretion of cortisol after cardiac surgery. Greater secretion of cortisol after cardiac surgery may be associated with a more difficult postoperative course. There was no decrease in cortisol secretion with age.

Endocrine Outcomes After Pituitary Surgery

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.

Adrenal function and dysfunction in critically ill patients

Critical illnesses are characterized by increased systemic cortisol availability, which is a vital part of the stress response. Relative adrenal failure (later termed critical-illness-related corticosteroid insufficiency (CIRCI)) is a condition in which the systemic availability of cortisol is assumed to be insufficiently high to face the stress of the illness and is most typically thought to occur in the acute phase of septic shock. Researchers suggested that CIRCI could be diagnosed by a suppressed incremental cortisol response to an injection of adrenocorticotropic hormone, irrespective of the baseline plasma cortisol. This concept triggered several randomized clinical trials on the impact of large stress doses of hydrocortisone to treat CIRCI, which gave conflicting results. Recent novel insights into the response of the hypothalamic-pituitary-adrenal axis to acute and prolonged critical illnesses challenge the concept of CIRCI, as currently defined, as well as the current practice guidelines for diagnosis and treatment. In this Review, these novel insights are integrated within a novel conceptual framework that can be used to re-appreciate adrenocortical function and dysfunction in the context of critical illness. This framework opens new avenues for further research and for preventive and/or therapeutic innovations.

Lower-dose perioperative steroid protocol during endoscopic endonasal pituitary adenoma resection

Background:

Perioperative steroid management for pituitary adenoma resections is multifaceted due to possible hypothalamic–pituitary–adrenal (HPA) axis disruption. Although many different strategies have been proposed, there is no standard protocol for prophylaxis of potential hypocortisolemia.

Methods:

We performed a retrospective analysis of consecutive endoscopic endonasal pituitary adenoma resections. Before March 2016, patients received ≥100 mg of hydrocortisone intraoperatively followed by 2 mg of dexamethasone immediately postoperatively in most of the patients. Subsequently, patients received only 50 mg of hydrocortisone intraoperatively. A morning cortisol level was checked on postoperative day (POD) 2, and if it was <10 mcg/dL, patients remained on maintenance hydrocortisone. At 6 weeks, serum cortisol was redrawn and low-dose therapy was weaned when indicated.

Results:

Of those who received ≥100 mg of hydrocortisone, 8 of 24 (33.3%) were discharged on hydrocortisone compared to 1 of 14 (7.1%) who received 50 mg. 18 of 24 (75%) of ≥100 mg group received dexamethasone on POD 1, and of those, 8 (44.4%) were discharged on hydrocortisone. Of those who received ≥100 mg and were on outpatient steroid therapy initially, 3 of 8 (37.5%) required continuation after 6 weeks compared to none who received 50 mg. There was an association between patient’s intraoperative/immediate postoperative steroid use and steroid continuation at discharge.

Conclusion:

Through our experience, we hypothesize that ≥100 mg of hydrocortisone intraoperatively followed by postoperative dexamethasone may be overly suppressive in patients with otherwise normally functioning HPA. A 50 mg intraoperative dose alone may be considered to lower rates of unnecessary steroid regimens postoperatively.

Chronic steroid use as an independent risk factor for perioperative complications

BACKGROUND

Corticosteroid use continues to rise nationally. Studies have evaluated the impact of chronic steroid use on surgical outcomes in smaller populations. This study investigated the impact of chronic steroid use on perioperative surgical outcomes in a surgical cohort of more than 5 million surgical patients, using a statistically rigorous methodology.

METHODS

The National Surgical Quality Improvement Program Database was queried 2008-2016 to evaluate chronic steroid use. Patient demographics, comorbidities, and outcomes were compared, using χ² and t test analysis, and then repeated after propensity score matching. Finally, a double-adjustment logistic regression was utilized, yielding odds ratios to assess the effect of chronic steroids on perioperative outcomes within the matched population.

RESULTS

Between 2008 and 2016, a total of 5,244,588 patients met inclusion criteria, of whom 181,901 (3.5%) were taking steroids for a minimum of 30 days before surgery. Patients on chronic steroids had significantly more comorbidities compared with the remaining population. After propensity score matching and double-adjusted logistic regression, chronic steroid use was found to be associated with increased surgical complications and poorer surgical outcomes. Chronic steroid use significantly increased a patient's risk of having a hospital stay longer than 30 days by 19%, risk of readmission within 30 days by 58%, risk of reoperation by 21%, and risk of death by 32%.

CONCLUSION

After controlling for differences in comorbidities and demographics, patients on chronic steroids have significantly poorer perioperative outcomes. Chronic steroid use should be evaluated and, if possible, addressed before surgery, given their significant impact on surgical outcomes.

Adrenal suppression from glucocorticoids: preventing an iatrogenic cause of morbidity and mortality in children

Adrenal suppression (AS) is an important side effect of glucocorticoids (GCs) including inhaled corticosteroids (ICS). AS can often be asymptomatic or associated with non-specific symptoms until a physiological stress such as an illness precipitates an adrenal crisis. Morbidity and death associated with adrenal crisis is preventable but continues to be reported in children. There is a lack of consensus about the management of children at risk of AS. However, healthcare professionals need to develop an awareness and approach to keep these children safe. In this article, current knowledge of the risk factors, diagnosis and management of AS are reviewed while drawing attention to knowledge gaps and areas of controversy. Possible strategies to reduce the morbidity associated with this iatrogenic condition are provided for healthcare professionals.

Perioperative "stress dose" of corticosteroid: Pharmacological and clinical perspective

Various exogenous steroid preparations have been in use for a wide range of indications. We, as an anesthesiologist often encounters a surgical patient receiving chronic steroid therapy. Perioperative use of steroid is associated with major complications such as full-blown adrenal crisis in the perioperative period due to the secondary adrenal insufficiency. Henceforth, comes the role of the perioperative “stress-dose” of steroids to mitigate this rare but potentially fatal complication. There have been opposing views regarding the need and the appropriate dosage of the perioperative steroids. The present review discusses the changing concept of perioperative “stress dose” of corticosteroids, its pharmacokinetics, clinical relevance, and the related controversies such as the need and the appropriate dose.

Postoperative stress and pain response applying fast-track protocol in patients undergoing hepatectomy

Aim

To assess the clinical parameters and compare the stress and pain response between fast-track recovery protocol and conventional treatment in patients undergoing major liver resection.

Methods

Eighty-eight patients suffering from malignant liver tumours were surgically treated from May 2012 to March 2015. After randomisation, they were prospectively divided into two groups: group fast-track patients (n = 46) and group conventional treatment patients (n = 42). Demographic and clinical data were collected and patients were assessed with pain scale (behavioural observation scale and visual analog scale), while depression levels were evaluated with Zung self-rating depression scale and three Numeric Analog Scale self-reported questions. Peripheral blood samples were collected at time points: T1 on the admission day, T2 on the day of surgery and T3 on the day of discharge examining serum levels of adrenocorticotropic hormone and cortisol.

Conclusion

Fast-track recovery protocols seem to be associated with improvement in several clinical parameters, without compromising, biologic or emotional stress in patients undergoing major liver resection.

Adrenal Crises in Children: Perspectives and Research Directions

Adrenal crises (AC) are life-threatening physiological disturbances that occur at a rate of 5-10/100 patient years in patients with adrenal insufficiency (AI). Despite their seriousness, there is a paucity of information on the epidemiology of AC events in the paediatric population specifically, as most investigations have focused on AI and ACs in adults. Improved surveillance of AC-related morbidity and mortality should improve the delineation of AC risk overall and among different subgroups of paediatric patients with AI. Valid incidence measures are essential for this purpose and also for the evaluation of interventions aimed at reducing adverse health outcomes from ACs. However, the absence of an agreed AC definition limits the potential benefit of research and surveillance in this area. While approaches to the treatment and prevention of ACs have much in common across the lifespan, there are important differences between children and adults with regards to the physiological, psychological, and social milieu in which these events occur. Education is considered to be an essential element of AC prevention but studies have shown that ACs occur even among well-educated patients, suggesting that new strategies may be needed. In this review, we examine the current knowledge regarding AC events in children with AI; assess the existing definitions of an AC and offer a new definition for use in research and the clinic; and suggest areas for further investigation that are aimed at reducing the incidence and health impact of ACs in the paediatric age group.

Perioperative Glucocorticoid Treatment of Soft Tissue Reconstruction in Patients on Long-term Steroid Therapy: The Experience of 6 Cases Using Reversed Posterior Interosseous Flap for Hand Neoplasm Surgery

Introduction

Long-term steroid therapy is associated with increased postoperative morbidity. Whether to use a stress dose of glucocorticoids (GCs) in surgical patients remains controversial. In the present study, we reported our experience in perioperative GC treatment of 6 patients on long-term steroid therapy for autoimmune diseases undergoing hand reconstruction using reversed interosseous flap.

Methods

The reversed interosseous flap reconstructions were performed after local extended resection of hand neoplasms. The patients were all diagnosed with autoimmune diseases and were undergoing long-term steroid therapy. Stress dose of GCs was not given in any case, and all the patients either remained on their baseline maintenance dose or decreased the dose until the morning of the operation day. Hypotension, water-electrolyte imbalance, hypoglycemia, and other symptoms of adrenal insufficiency were carefully assessed. Appearances of flap complications were recorded.

Results

None of the patients developed hypotension or other symptomatic adrenal insufficiency. Flap infection, venous congestion, or complete or partial loss of flap was not observed in any patient. Effusion underneath the flap was developed in only 1 case and was solved by proper drainage.

Conclusions

It is safe, reliable, and versatile to use reversed interosseous flap to repair hand defects in patients on long-term steroid therapy. A stress dose of GCs might not be necessary in this procedure and other equally moderate soft tissue reconstructive surgeries.

Perioperative corticosteroid administration: a systematic review and descriptive analysis

Background

Perioperative administration of corticosteroid is common and variable. Guidelines for perioperative corticosteroid administration before non-cardiac non-transplant surgery in patients with current or previous corticosteroid use to reduce the risk of adrenal insufficiency are lacking. Perioperative use of corticosteroid may be associated with serious adverse events, namely hyperglycemia, infection, and poor wound healing.

Objective

To determine whether perioperative administration of corticosteroids, compared to placebo or no intervention, reduces the incidence of adrenal insufficiency in adult patients undergoing non-cardiac surgery who were or are exposed to corticosteroids.

Methods

We searched MEDLINE via Ovid and PubMed, EMBASE via Ovid, and the Cochrane Central Register of Controlled Trials, all from 1995 to January 2017.

Selection criteria

We included randomized controlled trials (RCTs), cohort studies, case-studies, and systematic reviews involving adults undergoing non-cardiac non-transplant surgery and reporting the incidence of postoperative adrenal insufficiency.

Data collection and analysis

Two authors independently assessed studies' quality and extracted data. A descriptive and bias assessment analysis was performed.

Results

Two RCTs (total of 37 patients), five cohort studies (total of 462 patients), and four systematic reviews were included. Neither RCT showed a significant difference in the outcome. This result was like that of the five cohort studies. The quality of the evidence was low.

Conclusion

The current use of perioperative corticosteroid supplementation to prevent adrenal insufficiency is not supported by evidence. Given the significant studies' limitations, it is not possible to conclude that perioperative administration of corticosteroids, compared to placebo, reduces the incidence of adrenal insufficiency.

Perioperative Management of Patients with Inflammatory Rheumatic Diseases Undergoing Major Orthopaedic Surgery: A Practical Overview

Patients with inflammatory rheumatic diseases often need orthopaedic surgery due to joint involvement. Total hip replacement and total knee replacement are frequent surgical procedures in these patients. Due to the complexity of the inflammatory rheumatic diseases, the perioperative management of these patients must envisage a multidisciplinary approach. The frequent association with extraarticular comorbidities must be considered when evaluating perioperative risk of the patient and should guide the clinician in the decision-making process. However, guidelines of different medical societies may vary and are sometimes contradictory. Orthopaedics should collaborate with rheumatologists, anaesthesiologists and, when needed, cardiologists and haematologists with the common aim of minimising perioperative risk in patients with inflammatory rheumatic diseases. The aim of this review is to provide the reader with simple practical recommendations regarding perioperative management of drugs such as disease-modifying anti-rheumatic drugs, corticosteroids, non-steroidal anti-inflammatory drugs and tools for a risk stratification for cardiovascular and thromboembolic risk based on current evidence for patients with inflammatory rheumatic diseases.

Rheumatoid Arthritis, Disease Modifying Agents, and Periprosthetic Joint Infection: What Does a Joint Surgeon Need to Know?

The incidence of periprosthetic joint infection (PJI) among patients with rheumatoid arthritis (RA) is 1.6× greater than in patients undergoing the same procedure for osteoarthritis. This higher risk "may" be due to the immunosuppressive therapies for RA patients including corticosteroids, such as prednisone, and disease-modifying antirheumatic drugs (DMARDs), such as methotrexate. There is a debate about the role of DMARDs in increasing the incidence of subsequent PJI. Studies show conflicting results, with some demonstrating no significant increase in the rates of PJI and some finding otherwise. The International Consensus Meeting on PJI recommended that DMARDs should be halted prior to an elective total joint arthroplasty based on their half-life. Moreover, the International Consensus Meeting stated that cessation of immunosuppressant medications should be performed in consultation with and under the direction of the treating physician. In this review, we aimed to provide an introduction to the available treatment options and cover the recommendations on the treatment protocols for RA patients who undergo elective total joint arthroplasty.

Perioperative Steroid Management

Perioperative stress-dose steroid administration remains a controversial topic, with recent studies questioning its necessity. We discuss the current literature, largely published in nonanesthesiology journals, and suggest a practical approach to perioperative steroid management.

Perioperative management of drugs commonly used in patients with rheumatic diseases: a review

Rheumatic diseases are very prevalent, affecting about 7 million people in North America; they affect the musculoskeletal system, often with systemic involvement and potential for serious consequences and limitation on quality of life. Clinical treatment is usually long-term and includes drugs that are considered either simple or complex and are occasionally unknown to many health professionals who do not know how to manage these patients in emergency units and surgical wards. Thus, it is important for clinicians, surgeons and anesthesiologists who are involved with rheumatic patients undergoing surgery to know the basic principles of therapy and perioperative management. This study aims to do a review of the perioperative management of the most commonly used drugs in rheumatologic patients. Manuscripts used in this review were identified by surveying MEDLINE, LILACS, EMBASE, and COCHRANE databases and included studies containing i) the perioperative management of commonly used drugs in patients with rheumatic diseases: and ii) rheumatic diseases. They are didactically discussed according to the mechanism of action and pharmacokinetics; and perioperative management. In total, 259 articles related to the topic were identified. Every medical professional should be aware of the types of drugs that are appropriate for continuous use and should know the various effects of these drugs before indicating surgery or assisting a rheumatic patient postoperatively. This information could prevent possible complications that could affect a wide range of patients.

Perioperative Management of Cardiac Transplant Recipients Undergoing Noncardiac Surgery: Unique Challenges Created by Advancements in Care

Advancements in postcardiac transplant care have resulted in significant reductions in morbidity and increased life expectancy for cardiac transplant recipients. Consequently, many cardiac transplant recipients are living long enough to require subsequent noncardiac surgery. The perioperative care of heart transplant recipients presents a unique challenge as many of the common preoperative risk assessments do not apply to a transplanted heart, immunosuppressive medications have side effects and potential for drug-drug interactions, and the denervated heart results in an altered autonomic physiology and response to medications. Further adding to the challenge is that many of these noncardiac surgeries need to be performed urgently at nontransplant centers that may not be familiar with the care of these patients. This review aims to summarize the current data regarding preoperative assessment, perioperative immunosuppression management, intraoperative and anesthetic considerations, and outcomes of cardiac transplant recipients undergoing noncardiac surgery.

Perioperative use of immunosuppressive medications in patients with Crohn's disease in the new "biological era"

Crohn’s disease (CD) is characterized by transmural inflammation of the gastrointestinal tract leading to inflammatory, stricturing and/or and fistulizing disease. Once a patient develops medically refractory disease, mechanical obstruction, fistulizing disease or perforation, surgery is indicated. Unfortunately, surgery is not curative in most cases, underscoring the importance of bowel preservation and adequate perioperative medical management. As many of the medications used to treat CD are immunosuppressive, the concern for postoperative infectious complications and anastomotic healing are particularly concerning; these concerns have to be balanced with preventing and treating residual or recurrent disease. We herein review the available literature and make recommendations regarding the preoperative, perioperative and postoperative administration of immunosuppressive medications in the current era of biological therapy for CD. Standardized algorithms for perioperative medical management would greatly assist future research for optimizing surgical outcomes and preventing disease recurrence in the future.

Current best practice in the management of patients after pituitary surgery

Sellar and parasellar masses are a common finding, and most of them are treated surgically via transsphenoidal approach. This type of surgery has revolutionized the approach to several hypothalamic-pituitary diseases and is usually effective, and well-tolerated by the patient. However, given the complex anatomy and high density of glandular, neurological and vascular structures in a confined space, transsphenoidal surgery harbors a substantial risk of complications. Hypopituitarism is one of the most frequent sequelae, with central adrenal insufficiency being the deficit that requires a timely diagnosis and treatment. The perioperative management of AI is influenced by the preoperative status of the hypothalamic-pituitary-adrenal axis. Disorders of water metabolism are another common complication, and they can span from diabetes insipidus, to the syndrome of inappropriate antidiuretic hormone secretion, up to the rare cerebral salt-wasting syndrome. These abnormalities are often transient, but require careful monitoring and management in order to avoid abrupt variations of blood sodium levels. Cerebrospinal fluid leaks, damage to neurological structures such as the optic chiasm, and vascular complications can worsen the postoperative course after transsphenoidal surgery as well. Finally, long-term follow up after surgery varies depending on the underlying pathology, and is most challenging in patients with acromegaly and Cushing disease, in whom failure of primary pituitary surgery is a major concern. When these pituitary functioning adenomas persist or relapse after neurosurgery other treatment options are considered, including repeated surgery, radiotherapy, and medical therapy.