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Nollen JM, Brunsveld-Reinders AH, Peul WC, van Furth WR. Decision-making around removal of indwelling urinary catheters after pituitary surgery. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2024; 33:S4-S12. [PMID: 39392332 DOI: 10.12968/bjon.2024.0182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Abstract
BACKGROUND Diabetes insipidus (DI) is a common complication following pituitary surgery, causing significant health issues if left untreated. As part of the diagnostic process, accurate urinary output monitoring via indwelling urinary catheters (IDUCs) is essential, despite risks such as urinary tract infections and hindered recovery. Research on IDUC removal after pituitary surgery remains scarce. AIM To explore health professionals' perspectives on IDUC management following pituitary surgery. METHODS Employing a qualitative design, semistructured interviews were conducted with 15 professionals in the neurosurgical ward of a Dutch academic hospital. FINDINGS Four themes emerged: Concerns about missing identifying DI, patient-nurse dynamics, workload management, and lack of shared decision making. CONCLUSION The findings underscore the need to balance clinical needs with patient care efficiency. There is a need for evidence-based guidelines and a multidisciplinary approach to optimise IDUC management, given the importance of patient-centred care and shared decision-making.
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Affiliation(s)
- Jeanne-Marie Nollen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Wouter R van Furth
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
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2
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Wang W, Xiaoxu H. Analysis of the Status Quo and Influencing Factors of Revisiting Patients After Pituitary Tumor Resection: Based on a Chinese Patient Population. J Craniofac Surg 2024:00001665-990000000-01902. [PMID: 39254319 DOI: 10.1097/scs.0000000000010635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2024] [Accepted: 08/19/2024] [Indexed: 09/11/2024] Open
Abstract
OBJECTIVE To investigate the status of patients' post-pituitary tumor resection and analyze influencing factors, providing evidence for improved long-term management. METHODS The authors screened 1209 patients who underwent pituitary tumor resection at Zhejiang University's Second Affiliated Hospital from August 2020 to July 2022 using electronic medical records. Patients were classified into return visits (≥2 reviews/y or within 6 mo) and missing visit groups. Demographic and disease-related data were extracted from inpatient records, whereas return visits and prognosis data were collected from outpatient records and phone inquiries. Propensity score matching (1:1) was used to balance the groups, followed by univariate and multivariate logistic regression analyses to identify influencing factors. RESULTS Of the 1209 patients, 113 were unreachable. The study included 1095 patients, with 553 (50.5%) in the missing visit group and 542 (49.5%) in the return visit group. The authors matched 421 pairs, achieving balanced baseline data. Univariate analysis revealed significant differences in residence, unplanned readmission history, and current outcomes (P < 0.05). Multivariate analysis identified unplanned readmission history (odds ratio = 0.495, 95% CI: 0.307-0.799) as a protective factor. City residents had higher return visit rates than those from other provinces (odds ratio = 0.269, 95% CI: 0.610-1.579). CONCLUSION Postdischarge return rates for pituitary tumor resection patients are low and influenced by various factors. Improving return visit policies and systems is essential for facilitating outpatient follow-ups.
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Affiliation(s)
- Wei Wang
- Department of Nursing, School of Medicine, the Second Affiliated Hospital of Zhejiang University
- Department of Neurosurgery, School of Medicine, The Second Affiliated Hospital of Zhejiang University, Hangzhou, P.R. China
| | - Han Xiaoxu
- Department of Nursing, School of Medicine, the Second Affiliated Hospital of Zhejiang University
- Department of Neurosurgery, School of Medicine, The Second Affiliated Hospital of Zhejiang University, Hangzhou, P.R. China
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Behzadi F, Pickles AC, Ciecierska SS, Choe S, Prabhu VC, Germanwala AV. Patients at Greatest Risk of Missing Initial 1-Year Follow-Up After Pituitary Adenoma Resection. World Neurosurg 2024; 189:e1092-e1097. [PMID: 39032634 DOI: 10.1016/j.wneu.2024.07.091] [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: 07/05/2024] [Accepted: 07/10/2024] [Indexed: 07/23/2024]
Abstract
OBJECTIVE Routine evaluation and surveillance imaging after pituitary adenoma (PA) endoscopic endonasal transsphenoidal resection (EETS) is a neurosurgical practice to identify tumor recurrence. This study aims to identify social and clinical factors that may contribute to patients missing their initial 1-year follow-up appointment and provide guidance for targeted education to improve patient adherence with postoperative treatment plans, ultimately reducing unknown adenoma recurrence. METHODS The authors performed a single-center retrospective review of patients who underwent EETS for PAs from 2007 to 2023. Patients were analyzed for sociodemographic factors, presenting symptoms, time to surgery, surgical outcomes, and adherence to postoperative follow-up visits at 1 year after surgery. RESULTS A total of 256 patients with PAs treated by EETS met inclusion criteria; 218 (85%) of these patients attended 1-year follow-up, and 38 (15%) missed this visit. Twenty-nine (76%) individuals who missed their 1-year follow up were men (P = 0.006). Divorced/widowed/separated patients were 2 times more likely to miss their follow-up compared with their married counterparts (P = 0.008). Additional significant risk factors included older age, as the mean age for patients who missed their 1-year appointment was 60.1 years compared with 54.7 years (P = 0.028). Patients with visual field deficits at initial presentation were also less likely to follow-up at 1 year (P = 0.03). CONCLUSIONS Risk factors of missed 1-year follow-up appointments after PA resection include male sex, divorced/widowed/separated marital status, older age, and the presence of visual deficits at initial presentation. Increased education efforts can be selectively aimed at these at-risk patient cohorts to improve patient compliance and reduce consequences of undetected tumor recurrence.
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Affiliation(s)
- Faraz Behzadi
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Andrew C Pickles
- Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, USA
| | - Shiau-Sing Ciecierska
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Shawn Choe
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Vikram C Prabhu
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA; Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, USA
| | - Anand V Germanwala
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA; Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, USA.
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Binu A, Hv E, Nair P, Stanley A, Patel BK, Urulangodi M, Mandagini G, Jose T. Role of Copeptin in Predicting Postoperative Hyponatremia and Hypernatremia in Patients Undergoing Endoscopic Pituitary Adenoma Surgery. Neurosurgery 2024; 95:641-650. [PMID: 38551356 DOI: 10.1227/neu.0000000000002927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 01/25/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Arginine vasopressin (AVP) is an important hormone responsible for maintaining sodium homeostasis after pituitary surgery. The measurement of AVP levels is difficult because of its short half-life (t 1/2 ). Copeptin is a preprohormone of AVP, and it is a more stable peptide, which can be used as surrogate marker for AVP. This study aims to assess the role of copeptin as a predictor of postoperative hyponatremia and hypernatremia in patients undergoing endoscopic pituitary adenoma surgery. METHODS This prospective study included 50 patients who underwent endoscopic pituitary adenoma surgery. Serum copeptin levels of these patients were assessed (1) preoperatively (C1), (2) at extubation (C2), and (3) postoperative day 4 (C3). Perioperative data regarding fluid and sodium balance were collected from patients. Statistical analysis was done using the above data. RESULTS The copeptin values were assessed against the sodium disturbances. 100% of patients who developed transient diabetes insipidus had a relative decrease in C2 from C1 ( P - .0002). 88% of patients who developed early hyponatremia had a relative increase in C2 as compared with C1 ( P < .01). 75% of patients who developed delayed hyponatremia had a relative increase in C3 as compared with C1 ( P = .003). CONCLUSION A relative increase or decrease in early change in copeptin (C2-C1) can predict development of early hyponatremia or transient central diabetes insipidus, respectively. A relative increase in delayed change in copeptin (C3-C1) can predict development of delayed hyponatremia.
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Affiliation(s)
- Anand Binu
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Science and Technology, Thiruvananthapuram , Kerala , India
| | - Easwer Hv
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Science and Technology, Thiruvananthapuram , Kerala , India
| | - Prakash Nair
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Science and Technology, Thiruvananthapuram , Kerala , India
| | - Antony Stanley
- Regional Technical Resource Centre for Health Technology Assessment, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram , Kerala , India
| | - Biren Khimji Patel
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Science and Technology, Thiruvananthapuram , Kerala , India
| | - Madhusoodanan Urulangodi
- Department of Biochemistry, Sree Chitra Tirunal Institute for Medical Science and Technology, Thiruvananthapuram , Kerala , India
| | - Geetha Mandagini
- Department of Biochemistry, Sree Chitra Tirunal Institute for Medical Science and Technology, Thiruvananthapuram , Kerala , India
| | - Tania Jose
- Department of Anaesthesiology, Sree Chitra Tirunal Institute for Medical Science and Technology, Thiruvananthapuram , Kerala , India
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Wang MTM, Meyer JA, Danesh-Meyer HV. Neuro-ophthalmic evaluation and management of pituitary disease. Eye (Lond) 2024; 38:2279-2288. [PMID: 39039214 PMCID: PMC11306754 DOI: 10.1038/s41433-024-03187-x] [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: 02/04/2024] [Revised: 06/07/2024] [Accepted: 06/13/2024] [Indexed: 07/24/2024] Open
Abstract
Neuro-ophthalmic evaluation is a crucial component of the diagnostic and prognostic assessment of pituitary disease and compressive chiasmopathy, and can inform the timing of vision-restoring tumour resection surgery. The most common disease affecting the pituitary with neuro-ophthalmic implications are pituitary adenomas. Neuro-ophthalmic manifestations include decreased vision, abnormal colour vision and impaired visual field or diplopia. The recognition of these syndromes is critical to achieve early diagnosis and treatment and to improve prognosis. The pattern of vision loss in chiasmal compression is determined by the anatomical relationship between the pituitary lesion and optic chiasm, and potential visual field defects include bitemporal deficits, junctional scotomas, monocular cecocentral defects, and incongruous homonymous hemianopias. Rarer neuro-ophthalmic manifestations of pituitary disease include ophthalmoplegia, nystagmus, and obstructive hydrocephalus. There is growing evidence that demonstrates the strong diagnostic utility of optical coherence tomography (OCT) parameters in detecting the presence of compressive chiasmopathy, as well as the prognostic ability to predict the rate and degree of visual recovery following decompression surgery. Long-term neuro-ophthalmic monitoring is critical for detecting delayed vision loss following resection surgery, which may represent tumour recurrence or secondary complications.
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Affiliation(s)
- Michael T M Wang
- Department of Ophthalmology, New Zealand National Eye Centre, University of Auckland, Auckland, New Zealand
| | - Juliette A Meyer
- Vision Research Foundation, Auckland, New Zealand
- Auckland District Health Board, Auckland, New Zealand
| | - Helen V Danesh-Meyer
- Department of Ophthalmology, New Zealand National Eye Centre, University of Auckland, Auckland, New Zealand.
- Vision Research Foundation, Auckland, New Zealand.
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Richards E, Pankhania M, Thomas C, Jolly K, Ayuk J, Ahmed S. Perioperative management of lithium in the patient undergoing pituitary surgery: a case report. Br J Neurosurg 2024; 38:1042-1044. [PMID: 35531871 DOI: 10.1080/02688697.2021.2010651] [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: 08/20/2020] [Revised: 09/21/2021] [Accepted: 11/21/2021] [Indexed: 11/02/2022]
Abstract
Lithium is a psychotropic drug used primarily in the treatment of bipolar disorder. It is renally excreted and characteristically causes nephrogenic diabetes insipidus as an adverse drug reaction. Lithium also requires serum level monitoring as there is a narrow therapeutic window and untreated toxicity can result in neurological sequelae including drowsiness, coma, seizures, and ultimately death. We present the case of a 65-year old man admitted for pituitary surgery complicated by post-operative difficult fluid management and subsequent lithium toxicity. We highlight this rare situation and the need to be vigilant in the peri-operative period with any patients on lithium who undergo pituitary surgery.
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Affiliation(s)
- Emma Richards
- CT2 in Otolaryngology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Miran Pankhania
- Anterior Skull Base & Rhinology Fellow, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Charlotte Thomas
- CT2 in Otolaryngology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Karan Jolly
- ENT Specialty Registrar, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - John Ayuk
- Consultant Endocrinologist, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Shahzada Ahmed
- Consultant ENT & Skull Base Surgeon, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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Niño MC, Calle S, Ruiz D, Barón MA, Cohen D, Martínez JE, Benítez DS, Mejía JA, Guerra JD, Kattah L. Rethinking postoperative nausea and vomiting prevention beyond perioperative medications. J Clin Anesth 2024; 95:111457. [PMID: 38554569 DOI: 10.1016/j.jclinane.2024.111457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 03/26/2024] [Indexed: 04/01/2024]
Affiliation(s)
- María C Niño
- University Hospital Fundación Santa Fe de Bogotá, Carrera 7 # 117-15, 110121 Bogotá, Colombia.
| | - Sofía Calle
- University Hospital Fundación Santa Fe de Bogotá, Carrera 7 # 117-15, 110121 Bogotá, Colombia
| | - Diego Ruiz
- University Hospital Fundación Santa Fe de Bogotá, Carrera 7 # 117-15, 110121 Bogotá, Colombia
| | - María A Barón
- University Hospital Fundación Santa Fe de Bogotá, Carrera 7 # 117-15, 110121 Bogotá, Colombia
| | - Darwin Cohen
- University Hospital Fundación Santa Fe de Bogotá, Carrera 7 # 117-15, 110121 Bogotá, Colombia
| | - Jesús E Martínez
- University Hospital Fundación Santa Fe de Bogotá, Carrera 7 # 117-15, 110121 Bogotá, Colombia
| | - Daniel S Benítez
- University Hospital Fundación Santa Fe de Bogotá, Carrera 7 # 117-15, 110121 Bogotá, Colombia
| | - Juan A Mejía
- University Hospital Fundación Santa Fe de Bogotá, Carrera 7 # 117-15, 110121 Bogotá, Colombia
| | - José D Guerra
- University Hospital Fundación Santa Fe de Bogotá, Carrera 7 # 117-15, 110121 Bogotá, Colombia.
| | - Laura Kattah
- University Hospital Fundación Santa Fe de Bogotá, Carrera 7 # 117-15, 110121 Bogotá, Colombia
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Shafiq I, Williams ZR, Vates GE. Advancement in perioperative management of pituitary adenomas-Current concepts and best practices. J Neuroendocrinol 2024:e13427. [PMID: 38964869 DOI: 10.1111/jne.13427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/30/2024] [Accepted: 06/16/2024] [Indexed: 07/06/2024]
Abstract
Pituitary adenomas are very common representing 18.1% of all brain tumors and are the second most common brain pathology. Transsphenoidal surgery is the mainstay of treatment for all pituitary adenomas except for prolactinomas which are primarily treated medically with dopamine agonists. A thorough endocrine evaluation of pituitary adenoma preoperatively is crucial to identify hormonal compromise caused by the large sellar mass, identifying prolactin-producing tumors and comorbidities associated with Cushing and acromegaly to improve patient care and outcome. Transsphenoidal surgery is relatively safe in the hands of experienced surgeons, but still carries a substantial risk of causing hypopituitarism that required close follow-up in the immediate postoperative period to decrease mortality. A multidisciplinary team approach with endocrinologists, ophthalmologists, and neurosurgeons is the cornerstone in the perioperative management of pituitary adenomas.
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Affiliation(s)
- Ismat Shafiq
- Division of Endocrinology, Diabetes, and Metabolism, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Zoë R Williams
- Department of Ophthalmology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - G Edward Vates
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
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Bhardwaj S, Jaiswal AK, Yadav SC, Gupta D, Yadav R, Singh AP, Bhatia E. Prevalence and Clinical Course of Water and Electrolyte Disturbances Following Transsphenoidal Pituitary Adenoma Surgery in Immediate and Early Postoperative Period: A Prospective Observational Study. Indian J Endocrinol Metab 2024; 28:370-377. [PMID: 39371656 PMCID: PMC11451951 DOI: 10.4103/ijem.ijem_79_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 04/24/2024] [Accepted: 05/09/2024] [Indexed: 10/08/2024] Open
Abstract
Introduction Transsphenoidal pituitary adenoma surgery (TSS) was commonly associated with water and electrolyte disturbances (WEDs) in the postoperative period, which could lead to prolonged hospital stay, readmission and is rarely life threatening. The present study aimed to investigate the prevalence and predictive factors of WEDs following TSS. Methods Fifty-eight patients with pituitary adenoma were prospectively studied for the occurrence of WEDs. Patients were checked at 6 weeks postoperatively for persistence of diabetes insipidus and new-onset hormone deficiencies or recovery. Multivariate regression was applied to determine predictive factors for the occurrence of WEDs. Results A total of 58 patients underwent TSS (median age: 43 years, 66% male). In the immediate postoperative period, 16 (27.6%) had transient diabetes insipidus (DI), two (3%) had transient DI followed by syndrome of inappropriate antidiuretic hormone (SIADH), five (8.6%) had isolated SIADH, five (8.6%) had persistent DI and only one patient had a triple-phase response. At 6 weeks, five (11%) patients continued to have persistent DI. In multivariate analysis, apoplexy and duration of surgery were predictive of DI occurrence. Recovery rate at 6 weeks was 11.1%, 13% and 9.3% for cortisol, thyroid and gonad axis, respectively. New-onset hormone deficiencies at 6 weeks were 5.6%, 5.6% and 7.4% for cortisol, thyroid and gonad axis, respectively. Conclusions WEDs remain an important concern post-TSS. Timely follow-up should always be integral part of postoperative care for early diagnosis of new hormone deficiencies and avoiding unnecessary treatment in those with recovered axis.
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Affiliation(s)
- Shivendu Bhardwaj
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Awadhesh K. Jaiswal
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Subhash C. Yadav
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Devendra Gupta
- Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rajanikant Yadav
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Alok P. Singh
- Department of Ophthalmology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Eesh Bhatia
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Birtolo MF, Giannini E, Antonini S, Lavezzi E, Lasio G, Da Rin G, Mazziotti G, Lania AG. Prediction of adrenal insufficiency after pituitary surgery: a retrospective study using beckman access cortisol assay. Pituitary 2024; 27:160-168. [PMID: 38170374 DOI: 10.1007/s11102-023-01368-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE Identifying patients requiring glucocorticoid replacement therapy after pituitary surgery is challenging as the tests commonly used for the diagnosis of secondary adrenal insufficiency (SAI) are not recommended in the immediate postoperative period. There are controversial data on the role of postoperative days' morning cortisol, with no specific data for each cortisol assay. The aim of this study is to investigate the reliability of 8.00 a.m. cortisol of the first and second postoperative days in predicting SAI. METHODS Data of patients underwent pituitary surgery in Humanitas Research Hospital in Italy, from March 2017 to August 2022, were retrospectively analyzed. Definitive diagnosis of SAI was made through ACTH test 1 µg six weeks after surgery. Cortisol was measured through Beckman Access Cortisol and the diagnosis of SAI was made if cortisol peak was below 14.8 µg/dL (408 nmol/L) at 30 or 60 min after stimulus. RESULTS Of the sixty-four patients enrolled, seven developed SAI. The ROC curves demonstrated that both first- and second-day postoperative 8.00 a.m. cortisol predict SAI (AUC 0.94 and 0.95, respectively). The optimal thresholds were 15.6 µg/dL (430.3 nmol/L; accuracy 89%) for the first day and 11.5 µg/dL (317.2 nmol/L, accuracy 81%) for the second day. Patients who developed SAI had larger tumors (p = 0.004) and lower fT4 (p = 0.038) before surgery. CONCLUSIONS Clinicians might rely on the first- and second- postoperative days 8.00 a.m. cortisol to identify patients to discharge with glucocorticoid replacement therapy waiting for the confirmation of SAI through the ACTH test.
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Affiliation(s)
- Maria Francesca Birtolo
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Emma Giannini
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
| | - Simone Antonini
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Elisabetta Lavezzi
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Giovanni Lasio
- Department of Neurosurgery, IRCCS Humanitas Clinical and Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Giorgio Da Rin
- Laboratory Medicine, IRCCS Humanitas Clinical and Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Gherardo Mazziotti
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy.
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy.
| | - Andrea G Lania
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
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Martin-Grace J, Tomkins M, O'Reilly MW, Sherlock M. Iatrogenic adrenal insufficiency in adults. Nat Rev Endocrinol 2024; 20:209-227. [PMID: 38272995 DOI: 10.1038/s41574-023-00929-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 01/27/2024]
Abstract
Iatrogenic adrenal insufficiency (IAI) is the most common form of adrenal insufficiency in adult patients, although its overall exact prevalence remains unclear. IAI is associated with adverse clinical outcomes, including adrenal crisis, impaired quality of life and increased mortality; therefore, it is imperative that clinicians maintain a high index of suspicion in patients at risk of IAI to facilitate timely diagnosis and appropriate management. Herein, we review the major causes, clinical consequences, diagnosis and care of patients with IAI. The management of IAI, particularly glucocorticoid-induced (or tertiary) adrenal insufficiency, can be particularly challenging, and the provision of adequate glucocorticoid replacement must be balanced against minimizing the cardiometabolic effects of excess glucocorticoid exposure and optimizing recovery of the hypothalamic-pituitary-adrenal axis. We review current treatment strategies and their limitations and discuss developments in optimizing treatment of IAI. This comprehensive Review aims to aid clinicians in identifying who is at risk of IAI, how to approach screening of at-risk populations and how to treat patients with IAI, with a focus on emergency management and prevention of an adrenal crisis.
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Affiliation(s)
- Julie Martin-Grace
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Maria Tomkins
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Michael W O'Reilly
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Mark Sherlock
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland.
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Behzadi F, Ruiz GM, Tran DH, Schaible PA, Allen MB, Germanwala AV. Evaluation of Retrospective Patient Preference on Extent of Resection of Nonfunctioning Pituitary Adenomas. World Neurosurg 2024; 182:e98-e106. [PMID: 37995987 DOI: 10.1016/j.wneu.2023.11.053] [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: 11/09/2023] [Accepted: 11/15/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Neurosurgeons treat nonfunctioning pituitary adenomas by surgical resection. Based on the adherence of the tumor to the normal pituitary gland, operative risks may include hormone replacement therapy for postoperative hypopituitarism with gross total resection that injures the gland or recurrent tumor with subtotal resection and purposeful avoidance of gland manipulation. None of the patients presented in this article had a preoperative preference regarding extent of resection. This study aimed to evaluate postoperative patient preferences regarding extent of resection. METHODS Adult patients who underwent resection of adenomas between 2015 and 2023 were retrospectively reviewed and surveyed. After surgery, participating patients were asked for their preference regarding 100% tumor resection with lifelong daily hormone replacement therapy versus 90% tumor resection with a chance of recurrence in the hypothetical situation where the neurosurgeon encounters tumor adherent to the normal gland. RESULTS Of the 73 patients included, 54 (74.0%) responded to the survey, with the majority (36 [66.7%]) preferring 90% resection with the chance of tumor recurrence. Tumor recurrence (odds ratio 2.3, 95% confidence interval 2.1-2.5, P = 0.03) and steroid avoidance (odds ratio 2.2, 95% confidence interval 2.0-2.4, P = 0.04) were the 2 variables that were significant predictors of patient preference in multivariate regression analysis. CONCLUSIONS Although patients may not have the preoperative insight or experience to have a strong conviction regarding the extent of adenoma resection, the consequences following surgery clearly influence their preference. Most patients in our study, including patients with gross total resection and especially patients who experienced side effects of steroid therapy, preferred subtotal resection with the chance of tumor recurrence over hormone replacement therapy.
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Affiliation(s)
- Faraz Behzadi
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Gianna M Ruiz
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Dana H Tran
- Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, USA
| | - Peter A Schaible
- Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, Illinois, USA
| | - Matthew B Allen
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Anand V Germanwala
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA; Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, USA.
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13
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Poupore NS, Chidarala S, Nguyen SA, Teufel RJ, Patel KG, Pecha PP, Carroll WW. Cleft Lip and/or Palate Repair in Children With Hypopituitarism: Analysis of the Kids' Inpatient Database. Cleft Palate Craniofac J 2024; 61:94-102. [PMID: 35903934 DOI: 10.1177/10556656221117435] [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] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Children with hypopituitarism (CwHP) can present with orofacial clefting, frequently in the setting of multiple midline anomalies. Hypopituitarism (HP) can complicate medical and surgical care; the perioperative risk in CwHP during the traditionally lower risk cleft lip and/or palate (CL/P) repair is not well described. The objective of this study is to examine the differences in complications and mortality of CL/P repair in CwHP compared to children without hypopituitarism (CwoHP). DESIGN A retrospective cross-sectional analysis. SETTING The 1997 to 2019 Kids' Inpatient Databases (KID). PATIENTS Children 3 years old and younger who underwent CL/P repair. MAIN OUTCOME MEASURE(S) Complications and mortality. RESULTS A total of 34 106 weighted cases were analyzed, with 86 having HP. CwHP had a longer length of stay (3.0 days [IQR 2.0-10.0] vs 1.0 day [IQR 1.0-2.0], P < .001) and higher rates of complications and mortality (12.8% vs 2.9%, P < .001) compared to CwoHP. Controlling for demographic factors, CwHP had 6.61 higher odds of complications and mortality than CwoHP (95% CI 3.38-12.94, P < .001). CONCLUSIONS CwHP can present with a CL/P and other midline defects that can increase the complexity of their care. These data show a significant increase in length of stay, complications, and mortality in CwHP undergoing CL/P repair. Increased multidisciplinary attention and monitoring may be needed for these children peri- and postoperatively, especially if additional comorbidities are present. Further studies on perioperative management in this population are warranted to reduce morbidity and mortality.
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Affiliation(s)
- Nicolas S Poupore
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
- School of Medicine Greenville, University of South Carolina, Greenville, SC, USA
| | - Shreya Chidarala
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Shaun A Nguyen
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Ronald J Teufel
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Krishna G Patel
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Phayvanh P Pecha
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - William W Carroll
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
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14
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Becker R, Hlavac M, Etzrodt-Walter G, Sommer F, Wirtz CR, Schmitz B, Pala A. Pituitary Stalk Morphology as a Predictor of New-Onset Adrenocortical Insufficiency and Arginine Vasopressin Deficiency after Transsphenoidal Resections of Pituitary Macroadenomas: A Retrospective Single-Center Study with a Focus on iMRI. Cancers (Basel) 2023; 15:3929. [PMID: 37568744 PMCID: PMC10417128 DOI: 10.3390/cancers15153929] [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: 06/30/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND A new-onset adrenocortical insufficiency (NAI) is the most critical postoperative endocrinological complication after transsphenoidal surgery for macroadenomas. Because of increased mortality risk, arginine vasopressin deficiency (AVP-D) is also a relevant postoperative complication. This study aimed to identify easy-to-acquire magnet resonance imaging (MRI) aspects of the pituitary stalk to predict these insufficiencies after transsphenoidal surgery. METHODS Pituitary stalk morphology was reviewed intraoperatively and three months postoperatively in the MRIs of 48 transsphenoidal surgeries for macroadenomas. NAI was validated in endocrinological follow-up controls 10-14 months post-surgery. RESULTS Intraoperative pituitary stalk diameters were 0.5 mm larger in patients who developed NAI and AVP-D. The odds ratio was 29 for NAI and 6 for AVP-D in binary regression analysis. A value of 2.9 mm was identified as the optimal cut-off for the minimal pituitary stalk diameter regarding NAI, with a high specificity of 89%. There was no difference in pituitary stalk diameter regarding these insufficiencies three months post-surgery. CONCLUSIONS We identified an increased pituitary stalk diameter in intraoperative MRIs as a predictive factor of NAI and AVP-D after transsphenoidal surgery. These findings might improve the early detection of NAI and, thus, optimal management. However, validating these retrospective findings in prospective studies is obligatory.
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Affiliation(s)
- Ralf Becker
- Department of Neuroradiology, University of Ulm, Lindenallee 2, 89312 Günzburg, Germany;
| | - Michal Hlavac
- Department of Neurosurgery, University of Ulm, Lindenallee 2, 89312 Günzburg, Germany
| | | | - Fabian Sommer
- Department of Otorhinolaryngology, University of Ulm, Frauensteige 12, 89075 Ulm, Germany
| | | | - Bernd Schmitz
- Department of Neuroradiology, University of Ulm, Lindenallee 2, 89312 Günzburg, Germany;
| | - Andrej Pala
- Department of Neurosurgery, University of Ulm, Lindenallee 2, 89312 Günzburg, Germany
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15
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Abdollahifard S, Taherifard E, Sadeghi A, Farrokhi A, Cohen-Gadol AA, Palmisciano P. Early Morning Cortisol Level as a Predictive Factor for Long-Term Glucocorticoid Replacement After Pituitary Surgery: A Systematic Review and Meta-Analysis. World Neurosurg 2023; 176:168-178. [PMID: 37201788 DOI: 10.1016/j.wneu.2023.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/06/2023] [Accepted: 05/08/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND A reliable strategy for predicting long-term adrenal insufficiency after pituitary surgery can reduce the risk of glucocorticoid overexposure or missing patients with pituitary insufficiency. For this purpose, we aimed to assess the predictive value of early postoperative morning serum cortisol level for the detection of hypothalamic-pituitary-adrenal axis dysfunction in patients who underwent pituitary surgery. METHODS A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-based systematic review was conducted to include articles investigating morning blood cortisol levels after pituitary surgery for lesions of the pituitary gland as a determinant for administration of long-term supplemental glucocorticoids. Bayesian statistics were used to pool the sensitivity and specificity rates. Sensitivity and specificity were also determined for each potential cortisol level on postoperative day (POD) 1 and POD 2. RESULTS The study included 17 articles encompassing 1648 patients. Morning cortisol levels on POD 1 and POD 2 showed pooled sensitivity rates of 86.4% and 86.6% and pooled specificity rates of 73.1% and 78.2%, respectively, for predicting long-term glucocorticoid replacement after surgery. A cortisol level of 2.1 μg/dL showed the highest sensitivity rate (98.78%), and 22.5 μg/dL showed the highest specificity rate (72.5%) on POD 1. CONCLUSIONS In this review and Bayesian meta-analysis, we found that postoperative serum cortisol measurement may have high accuracy in prediction of the long-term need for glucocorticoid administration in patients who underwent pituitary surgery.
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Affiliation(s)
| | - Erfan Taherifard
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran; MPH Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Sadeghi
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | | | - Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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16
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Osorio RC, Aabedi AA, Carson W, Badani A, Chalif E, Theodosopoulos PV, Kunwar S, Aghi MK, Goldschmidt E. Risk Factors for Significant Postoperative Hemorrhage After Pituitary Neuroendocrine Tumor Resection: A Case-Control Study of 1066 Surgeries. Neurosurgery 2023; 93:206-214. [PMID: 36794944 DOI: 10.1227/neu.0000000000002404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/12/2022] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Postoperative hemorrhage is a rare but potentially serious complication after pituitary surgery. The risk factors for this complication are mostly unknown, and further knowledge would help guide postoperative management. OBJECTIVE To investigate the perioperative risks and clinical presentation of significant postoperative hemorrhage (SPH) after endonasal surgery for pituitary neuroendocrine tumors. METHODS A population of 1066 patients undergoing endonasal (microscopic and endoscopic) surgery for pituitary neuroendocrine tumor resection at a high-volume academic center was reviewed. SPH cases were defined as postoperative hematoma evident on imaging requiring return to the operating room for evacuation. Patient and tumor characteristics were analyzed with uni- and multivariable logistic regression, and postoperative courses were descriptively examined. RESULTS Ten patients were found to have SPH. On univariable analysis, these cases were significantly more likely to present with apoplexy ( P = .004), have larger tumors ( P < .001), and lower gross total resection rates ( P = .019). A multivariate regression analysis showed that tumor size (odds ratio 1.94, P = .008) and apoplexy at presentation (odds ratio 6.00, P = .018) were significantly associated with higher odds of SPH. The most common symptoms for patients with SPH were vision deficits and headache, and the median time for symptom onset was 1 day after surgery. CONCLUSION Larger tumor size and presentation with apoplexy were associated with clinically significant postoperative hemorrhage. Patients presenting with pituitary apoplexy are more likely to experience a significant postoperative hemorrhage and should be carefully monitored for headache and vision changes in the days after surgery.
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Affiliation(s)
- Robert C Osorio
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
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17
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Ma J, Gooderham P, Akagami R, Makarenko S. Correlation of Pituitary Descent and Diabetes Insipidus After Transsphenoidal Pituitary Macroadenoma Resection. Neurosurgery 2023; 92:1269-1275. [PMID: 36700759 DOI: 10.1227/neu.0000000000002360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 11/10/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Endoscopic transsphenoidal surgery remains the technique of choice for resection of pituitary adenoma. Postoperative diabetes insipidus (DI) is most often transient and observed in 1.6% to 34% of patients, whereas permanent DI has been reported in 0% to 2.7% of patients. The proposed mechanism was the transduction of traction forces exerted by the surgeon on the descended diaphragma sellae and through the pituitary stalk. OBJECTIVE To quantify and correlate the degree of pituitary gland descent with postoperative DI. METHODS Of 374 patients who underwent transsphenoidal resection of a pituitary adenoma between 2010 and 2020 at our institution, we report a cohort of 30 patients (Group A) DI. We also report a matched cohort by tumor volume of 30 patients who did not develop DI (Group B). We quantified the tension on the pituitary stalk by calculating pituitary descent interval (PDI) by comparing preoperative and postoperative position of the pituitary gland and using Pythagoras' formula where , with craniocaudal (CC) and anterior-posterior (AP) representing measurements of pituitary translation in respective directions after resection. RESULTS Patients who developed DI had significantly greater pituitary gland translations in the craniocaudal (23.0 vs 16.3 mm, P = .0015) and anteroposterior (2.4 vs 1.5 mm, P = .0168) directions. Furthermore, Group A had a statistically greater PDI, which was associated with development of DI (23.2 vs 16.6 mm, P = .0017). CONCLUSION We were able to quantify pituitary descent and subsequent tension on the pituitary stalk, while also associating it with development of postoperative DI after pituitary adenoma resection.
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Affiliation(s)
- Josh Ma
- Division of Neurosurgery, Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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18
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Nollen JM, Brunsveld-Reinders AH, Peul WC, van Furth WR. Patient perspectives on indwelling urinary catheters and fluid balances after transsphenoidal pituitary surgery: a qualitative study. BMJ Open 2023; 13:e069598. [PMID: 36940939 PMCID: PMC10030659 DOI: 10.1136/bmjopen-2022-069598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
OBJECTIVES To explore the perceptions and experiences of patients who underwent transsphenoidal pituitary gland and (para)sellar tumour surgery regarding indwelling urinary catheters (IDUCs) and the postoperative fluid balance. DESIGN Qualitative study using semistructured interviews based on the attitudes, social influence and self-efficacy model and expert knowledge. PARTICIPANTS Twelve patients who underwent transsphenoidal pituitary gland tumour surgery and received an IDUC during or after surgery. SETTING One patient was interviewed in the endocrinology outpatient clinic and 11 patients were interviewed on the neurosurgery ward. RESULTS Five major themes emerged: (1) conflicting information and preoperative expectations, (2) IDUCs perceived as patient-friendly during bedrest, particularly for women, (3) little room for patients' opinions, (4) physical and emotional limitations and (5) fluid balance causes confusion. Information regarding IDUC placement and fluid balance given to patients both preoperatively and postoperatively did not meet their expectations, which led to confusion and uncertainty. The IDUC was perceived as preferable if bedrest was mandatory, preferred particularly by women. Patient could not mobilise freely due to the IDUC and felt ashamed, judged by others and dependent on nurses. CONCLUSIONS This study provides insight into the challenges patients experience in relation to the IDUC and fluid balance. Perceptions on the necessity of an IDUC varied among patients and were influenced by both physical and emotional impediments. A clear, frequent and daily communication between healthcare professionals and patients to evaluate IDUC and fluid balance use is necessary to increase patient satisfaction.
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Affiliation(s)
- Jeanne-Marie Nollen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | | | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | - Wouter R van Furth
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
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19
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Keating O, Hale AT, Smith AA, Jimenez V, Ashraf AP, Rocque BG. Hyponatremia after craniotomy in children: a single-institution review. Childs Nerv Syst 2023; 39:617-623. [PMID: 36308540 DOI: 10.1007/s00381-022-05729-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 10/25/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Hyponatremia after craniotomy can be associated with increased morbidity. However, the incidence of and factors associated with post-craniotomy hyponatremia in children are not known. METHODS We performed a retrospective cohort study of patients aged 0-21 years who underwent craniotomy in 2017-2019 at a single center to determine the incidence of and to identify risk factors for hyponatremia after craniotomy. Indications for craniotomy included tumors (excluding craniopharyngioma), epilepsy, intracranial infection, trauma, craniofacial, suboccipital decompression for the treatment of Chiari malformation, and cerebrovascular disease. Hyponatremia was defined as a serum sodium level ≤ 135 mEq/L any time during the postoperative hospital stay. Statistical significance was defined a priori at p < 0.05. RESULTS Postoperative hyponatremia occurred in 61 (25%) of 240 children. On univariate analysis, hyponatremia was associated with younger age (8.5 vs 6.3 years, p = 0.01), use of preoperative anti-epileptic drugs (p = 0.02), need for blood transfusion (p = 0.02), government/private insurance (p = 0.04), and pre-existing hydrocephalus, defined as the requirement for permanent cerebrospinal fluid (CSF) diversion (p = 0.04). On multivariate analysis, only hydrocephalus (OR 2.95, 95% CI 1.03-8.40) remained statistically significant. Hyponatremia most occurred on the first postoperative day, with normonatremia achieved in a median of 14 (IQR 9.8-24.3) h. Hyponatremia was significantly associated with longer length of stay (median 8 vs 3 days, p < 0.01). CONCLUSION Hyponatremia was present in 25% of children after craniotomy. Preoperative hydrocephalus as an independent risk factor for hyponatremia after craniotomy.
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Affiliation(s)
- Olivia Keating
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Andrew T Hale
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA.
| | - Anastasia A Smith
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Victoria Jimenez
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Ambika P Ashraf
- Division of Pediatric Endocrinology, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | - Brandon G Rocque
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
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20
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Hoang AN, McGahan BG, Cua S, Magill ST, Nayak P, Montaser AS, Ghalib L, Prevedello LM, Hardesty DA, Carrau RL, Prevedello DM. Pituitary Stalk Stretch Predicts Postoperative Diabetes Insipidus After Pituitary Macroadenoma Transsphenoidal Resection. Oper Neurosurg (Hagerstown) 2023; 24:248-255. [PMID: 36701694 DOI: 10.1227/ons.0000000000000501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 09/07/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Manipulation of the pituitary stalk, posterior pituitary gland, and hypothalamus during transsphenoidal pituitary adenoma resection can cause disruption of water electrolyte regulation leading to diabetes insipidus (DI). OBJECTIVE To determine whether pituitary stalk stretch is an independent risk factor for postoperative DI after pituitary adenoma resection. METHODS A retrospective review was performed of patients undergoing endoscopic endonasal resection of pituitary macroadenoma between July 2010 and December 2016 by a single neurosurgeon. We analyzed preoperative and postoperative imaging metrics to assess predictors for postoperative DI. RESULTS Of the 234 patients undergoing resection, 41 (17.5%) developed postoperative DI. DI was permanent in 10 (4.3%) and transient in 31 (13.2%). The pituitary stalk stretch, measured as the change in stalk length from preoperative to postoperative imaging, was greater in the DI compared with the non-DI group (10.1 mm vs 5.9 mm, P < .0001). The pituitary stalk stretch was associated with DI with significant difference in mean pituitary stalk stretch between non-DI group vs DI group (5.9 mm vs 10.1 mm, P < .0001). Multivariate analysis revealed that pituitary stalk stretch >10 mm was a significant independent predictor of postoperative DI [odds ratios = 2.56 (1.10-5.96), P = .029]. When stratified into transient and permanent DI, multivariable analysis showed that pituitary stalk stretch >10 mm was a significant independent predictor of transient DI [odds ratios = 2.71 (1.0-7.1), P = .046] but not permanent DI. CONCLUSION Postoperative pituitary stalk stretch after transsphenoidal pituitary adenoma surgery is an important factor for postoperative DI. We propose a reconstruction strategy to mitigate stalk stretch.
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Affiliation(s)
- Alex Nguyen Hoang
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Benjamin G McGahan
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Santino Cua
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Stephen T Magill
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois, USA
| | - Pratima Nayak
- Department of Endocrinology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alaa S Montaser
- Department of Neurological Surgery, Ain Shams University, Cairo, Egypt
| | - Luma Ghalib
- Department of Endocrinology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Luciano M Prevedello
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Douglas A Hardesty
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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21
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Optimizing Perioperative Care in Transsphenoidal Pituitary Surgery: Considerations for Enhanced Recovery After Surgery. J Craniofac Surg 2023; 34:83-91. [PMID: 35968948 DOI: 10.1097/scs.0000000000008893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/04/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To identify key recommendations for maximizing the efficiency and efficacy of perioperative care in transsphenoidal pituitary surgery. METHODS The authors performed a comprehensive literature search of Enhanced Recovery After Surgery protocols implemented for patients undergoing transsphenoidal adenomectomy (TSA); individual recommendations were abstracted, and the evidence base thoroughly reviewed. RESULTS The authors identified 19 individual recommendations pertinent to the care of patients undergoing TSA, which were subdivided into preoperative (n=6), intraoperative (n=6), and postoperative (n=7) interventions. Key factors recommended for minimizing length of stay, preventing readmission, and improving patient outcomes included comprehensive patient education, multidisciplinary evaluation, avoidance of routine lumbar drain placement and nasal packing, and rigorous postoperative monitoring of pituitary function and salt-water imbalances. The overall level of evidence for 7/19 (37%) implemented recommendations was found to be low, suggesting a need for continued research in this patient population. CONCLUSION Several key interventions should be considered in the development of Enhanced Recovery After Surgery protocols for TSA, which may aid in further decreasing length of stay and promoting positive patient outcomes.
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22
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Brooks EK, Inder WJ. Disorders of Salt and Water Balance After Pituitary Surgery. J Clin Endocrinol Metab 2022; 108:198-208. [PMID: 36300330 PMCID: PMC9759173 DOI: 10.1210/clinem/dgac622] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 10/17/2022] [Indexed: 02/03/2023]
Abstract
Transsphenoidal surgery is the first-line treatment for many clinically significant pituitary tumors and sellar lesions. Although complication rates are low when performed at high-volume centers, disorders of salt and water balance are relatively common postoperatively. Both, or either, central diabetes insipidus (recently renamed arginine vasopressin deficiency - AVP-D), caused by a deficiency in production and/or secretion of arginine vasopressin, and hyponatremia, most commonly secondary to the syndrome of inappropriate antidiuresis, may occur. These conditions can extend hospital stay and increase the risk of readmission. This article discusses common presentations of salt and water balance disorders following pituitary surgery, the pathophysiology of these conditions, and their diagnosis and management.
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Affiliation(s)
- Emily K Brooks
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane 4102, Australia
- Faculty of Medicine, University of Queensland, Brisbane 4072, Australia
| | - Warrick J Inder
- Correspondence: Warrick Inder MD, FRACP, Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Woolloongabba, QLD 4102, Australia. E-mail:
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23
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Benjamin CG, Dastagirzada Y, Bevilacqua J, Kurland DB, Fujita K, Sen C, Golfinos JG, Placantonakis DG, Jafar JJ, Lieberman S, Lebowitz R, Lewis A, Agrawal N, Pacione D. The Cost Effectiveness of Implementation of a Postoperative Endocrinopathy Management Protocol after Resection of Pituitary Adenomas. J Neurol Surg B Skull Base 2022; 83:618-625. [PMID: 36393880 PMCID: PMC9653289 DOI: 10.1055/s-0042-1750718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 05/23/2022] [Indexed: 10/17/2022] Open
Abstract
Purpose After developing a protocol for evaluating, diagnosing, and treating postoperative endocrinopathy both during the hospitalization and during the immediate discharge period following resection of pituitary adenomas, we sought to assess the impact of this protocol on quality outcomes. Methods An IRB-exempt, quality improvement initiated, Health Insurance Portability and Accountability Act (HIPAA)-compliant retrospective comparison of a pre-and-post-protocol cohort of all patients undergoing endoscopic endonasal resection of pituitary adenomas at NYU Langone Medical Center from January 2013 to December 2018. Demographic characteristics of the patients and their tumors with their postoperative outcomes were recorded. Quality outcomes regarding number of laboratory studies sent, rate of diabetes insipidus, length of stay, and readmission rate were also recorded. Statistical analysis was performed between the pre- and post-protocol groups. Results There was a significant reduction in laboratory studies sent per patient (55.66 vs. 18.82, p <0.001). This corresponded with an overall cost reduction in laboratory studies of $255.95 per patient. There was a decrease in the overall number of patients treated with DDAVP (21.4% in the pre-protocol group vs. 8.9% in the post-protocol group, p = 0.04). All post-protocol patients requiring DDAVP at discharge were identified by 48 hours. There was no significant change in length of stay or need for hydrocortisone supplementation postoperatively between the two groups. Length of stay was driven mostly by need for reoperation during initial hospitalization. There was no significant change in the rate of 30-day readmission. Conclusion Implementation of a postoperative management protocol results in a more efficient diagnosis and management of endocrinopathy after pituitary adenoma surgery which translates to decreased cost.
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Affiliation(s)
- Carolina G. Benjamin
- Department of Neurosurgery, University of Miami, Miami, Florida, United States
- Address for correspondence Carolina Gesteira Benjamin, MD University of MiamiMiami, FL 33146United States
| | - Yosef Dastagirzada
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, United States
| | - Julia Bevilacqua
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, United States
| | - David B. Kurland
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, United States
| | - Kevin Fujita
- Department of Neurosurgery, Yale Medical Center, New Haven, Connecticut, United States
| | - Chandra Sen
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, United States
| | - John G. Golfinos
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, United States
| | | | - Jafar J. Jafar
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, United States
| | - Seth Lieberman
- Department of Otolaryngology, NYU Langone Medical Center, New York, New York, United States
| | - Richard Lebowitz
- Department of Otolaryngology, NYU Langone Medical Center, New York, New York, United States
| | - Ariane Lewis
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, United States
- Department of Neurology, NYU Langone Medical Center, New York, New York, United States
| | - Nidhi Agrawal
- Department of Endocrinology, NYU Langone Medical Center, New York, New York, United States
| | - Donato Pacione
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, United States
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Muacevic A, Adler JR, Gelinne A, Quig N, Thorp B, Zanation A, Ewend M, Sasaki-Adams D, Quinsey C. Disparities in Postoperative Endocrine Outcomes After Endoscopic-Assisted Transsphenoidal Pituitary Adenoma Resection. Cureus 2022; 14:e31934. [PMID: 36582567 PMCID: PMC9794913 DOI: 10.7759/cureus.31934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2022] [Indexed: 11/28/2022] Open
Abstract
Objectives Socioeconomic factors can influence morbidity in patients with pituitary adenoma. This study aims to identify associations between socioeconomic factors and postoperative outcomes in patients with pituitary adenomas. Methods A retrospective medical chart review was conducted on adult patients who underwent resection of purely sellar nonfunctional and functional pituitary adenomas between May 1, 2014, and May 31, 2020, at the University of North Carolina Medical Center. The main outcome measures included the incidence of postoperative diabetes insipidus (PDI), postoperative hyponatremia (PHN), and postoperative hypopituitarism (PHP). Outcome measures were analyzed using univariate and multivariate analyses against preoperative tumor volume as well as socioeconomic and demographic factors (self-identified race/ethnicity, age, gender, address assessed by the Area Deprivation Index (ADI), and insurance status). Results On univariate analysis, patients of Hispanic race/ethnicity and patients living in more disadvantaged neighborhoods had an increased incidence of postoperative diabetes insipidus. Patients who experienced PDI were significantly younger on average in both univariate and multivariate analyses. When analyzed further, patients of Hispanic race/ethnicity were significantly younger and more likely to be uninsured compared to their respective racial/ethnic counterparts. No significant correlations were found for PHN or PHP. Conclusions Patients of Hispanic race/ethnicity and patients living in more disadvantaged neighborhoods were more likely to experience PDI. This finding, when combined with findings regarding age and insurance status, suggests complex disparities in medical care that are confirmed or corroborated by prior literature. These results may enhance clinicians' management of patients from disadvantaged socioeconomic backgrounds through increased awareness of disparities and the provision of resources for assistance.
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Claude F, Ubertini G, Szinnai G. Endocrine Disorders in Children with Brain Tumors: At Diagnosis, after Surgery, Radiotherapy and Chemotherapy. CHILDREN (BASEL, SWITZERLAND) 2022; 9:1617. [PMID: 36360345 PMCID: PMC9688119 DOI: 10.3390/children9111617] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 10/12/2022] [Accepted: 10/20/2022] [Indexed: 10/28/2023]
Abstract
INTRODUCTION Brain tumors are the second most frequent type of all pediatric malignancies. Depending on their localization, patients with brain tumors may present neurological or ophthalmological symptoms, but also weight anomalies and endocrine disorders ranging from growth hormone deficiency, anomalies of puberty, diabetes insipidus to panhypopituitarism. Immediately at diagnosis, all patients with brain tumors require a complete assessment of the hypothalamic-pituitary function in order to address eventual endocrine disorders. Moreover, children and adolescents undergoing brain surgery must receive peri- and postoperative hydrocortisone stress therapy. Post-operative disorders of water homeostasis are frequent, ranging from transient diabetes insipidus, as well as syndrome of inappropriate antidiuretic hormone secretion to persistent diabetes insipidus. Late endocrine disorders may result from surgery near or within the hypothalamic-pituitary region. Pituitary deficits are frequent after radiotherapy, especially growth hormone deficiency. Thyroid nodules or secondary thyroid cancers may arise years after radiotherapy. Gonadal dysfunction is frequent after chemotherapy especially with alkylating agents. CONCLUSION Early detection and treatment of specific endocrine disorders at diagnosis, perioperatively, and during long-term follow-up result in improved general and metabolic health and quality of life.
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Affiliation(s)
- Fabien Claude
- Department of Pediatric Endocrinology and Diabetology, University Children’s Hospital Basel, University of Basel, 4056 Basel, Switzerland
| | - Graziamaria Ubertini
- Department of Pediatric Endocrinology, Bambino Gesù Children’s Hospital, 00165 Rome, Italy
| | - Gabor Szinnai
- Department of Pediatric Endocrinology and Diabetology, University Children’s Hospital Basel, University of Basel, 4056 Basel, Switzerland
- Department of Clinical Research, University Hospital Basel, University of Basel, 4056 Basel, Switzerland
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26
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Vargas BC, de la Maza MV, Aracena J. Primary Intracranial Choriocarcinoma in the Suprasellar Region: A Case Report. JOURNAL OF PEDIATRIC NEUROLOGY 2022. [DOI: 10.1055/s-0042-1756446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
AbstractA 17-year-old boy was admitted to our hospital with history of headache, nausea, and visual field disturbances for about a year. A suprasellar tumor was found by computed tomography and magnetic resonance imaging. Biopsy of this lesion showed primary intracranial choriocarcinoma on histopathological examination. The human chorionic gonadotropin (hCG) level was measured in serum and cerebrospinal fluid after the biopsy, and was elevated in both. The patient went into chemotherapy and surgery with no complications or recurrence. If young patients present with a suprasellar lobulated mass with hemorrhage, the serum hCG level should be measured before surgery.
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Affiliation(s)
| | | | - Joaquín Aracena
- Department of Radiology, University of Antofagasta, Antofagasta, Chile
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Qian A, Zhou J, Yu J, Huo G, Wang X. Incidence and risk factors of delayed postoperative hyponatremia after endoscopic endonasal surgery for Rathke’s cleft cyst: A single-center study. Front Surg 2022; 9:953802. [PMID: 35910473 PMCID: PMC9334746 DOI: 10.3389/fsurg.2022.953802] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroudDelayed postoperative hyponatremia (DPH) is common for sellar lesions. However, the true prevalence and associated factors of DPH after endoscopic endonasal surgery (EES) for Rathke’s cleft cyst (RCC) have not been studied in a large patient cohort.MethodsA retrospective analysis was conducted over 6 years at our institution, and patients with RCC treated by EES were enrolled according to our inclusion criteria. Patient demographics, clinical characteristics, images, and surgical procedures were documented. Serum sodium was routinely measured before surgery, on postoperative day 1, and every 2 days thereafter until discharge. For patients with DPH, electrolyte, hematocrit, serum protein levels, and plasma and urinary osmolality were daily measured to explore potential etiology.ResultsOf the 149 eligible patients, 25 (16.8%) developed DPH, which was similar to other sellar lesions, except craniopharyngioma, in the same period in our institution. Significant risk factors suggested by univariate analysis were cyst location, requirement of postoperative hydrocortisone therapy, postoperative meningitis, intraoperative cerebrospinal fluid (CSF) leakage, and subtotal resection (STR) of the cyst wall (all p < 0.05). In addition, other supplementary 11 cases of suprasellar RCC with different surgical strategies (aggressive resection) and relevant factors were enrolled into multivariate analysis. Suprasellar location [odds ratio (OR) 8.387, 95% confidence interval (CI) 1.014–69.365, p = 0.049], requirement of postoperative hydrocortisone therapy (OR 4.208, 95%CI 1.246–14.209, p = 0.021), and intraoperative CSF leakage (OR 6.631, 95%CI 1.728–25.440, p = 0.006) were found to be the independent predictors of DPH.ConclusionDPH is a common complication after EES for RCC. Suprasellar location, requirement of postoperative hydrocortisone therapy, and intraoperative CSF leakage are the most reliable risk factors. Cortisol deficiency and syndrome of inappropriate antidiuretic hormone (SIADH) are considered as the main etiologies of DPH in RCC. Conservative excision of the cyst wall may reduce DPH occurrence.
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Ohta J, Kadoi Y, Tosaka M, Saito S. Pseudo-intestinal obstruction after transsphenoidal surgery for craniopharyngioma. J Surg Case Rep 2022; 2022:rjac254. [PMID: 35665389 PMCID: PMC9156015 DOI: 10.1093/jscr/rjac254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/16/2022] [Indexed: 12/18/2022] Open
Abstract
Craniopharyngioma surgery is frequently associated with the occurrence of central diabetes insipidus, and oral rehydration therapy is reliable for postoperative management if the patient’s thirst is normal. A 61-year-old Japanese male patient underwent extended endoscopic transsphenoidal surgery for craniopharyngioma. He was undergoing acute treatment for postoperative central diabetes insipidus and hypopituitarism in the intensive care unit. Two days after the surgery, he started to vomit occasionally, despite receiving oral rehydration therapy for central diabetes insipidus. Despite increasing the dose of parenteral hydrocortisone, the periodic vomiting persisted during fasting periods and progressed to aspiration pneumonia and severe sepsis. Abdominal computed tomography was performed to identify the cause of persistent vomiting and revealed the presence of a pseudo-intestinal obstruction extending from the small to large intestine. When oral rehydration therapy for central diabetes insipidus is accompanied by vomiting symptoms suggestive of hypopituitarism, a holistic evaluation of the gastrointestinal system is advisable.
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Affiliation(s)
- Jo Ohta
- Department of Anesthesiology, Gunma University Graduate School of Medicine, Maebashi City, Japan
| | - Yuji Kadoi
- Department of Anesthesiology, Gunma University Graduate School of Medicine, Maebashi City, Japan
| | - Masahiko Tosaka
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi City, Japan
| | - Shigeru Saito
- Department of Anesthesiology, Gunma University Graduate School of Medicine, Maebashi City, Japan
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Harary M, Bommakanti K, Nakhla MN, Kosaraju N, Heaney A, Kim W, Lee JT, Suh JD, Bergsneider M, Wang MB. Audit of postoperative readmissions and patient messages following endoscopic transnasal transsphenoidal surgery. Skull Base Surg 2022; 83:611-617. [DOI: 10.1055/a-1840-9874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 04/26/2022] [Indexed: 10/18/2022]
Abstract
Objectives:To identify the reasons for patient messages, phone calls and Emergency Department (ED) visits prior to the first postoperative visit following discharge after endoscopic transnasal transsphenoidal (eTNTS) surgery.
Design: Retrospective review of patients at a tertiary care academic center who underwent eTNTS for resection of a sellar region tumor between May 2020-August 2021. Patient, tumor, and surgical characteristics were collected, along with post-operative, post-discharge, and readmission information. Regression analyses were performed to investigate risk factors associated with post-discharge phone calls, messages, ED visits, and readmissions.
Main Outcome Measures: Number of and reasons for phone calls, patient messages, and ED visits between hospital discharge and the first postoperative visit. We additionally determined whether these reasons were addressed in each patient’s discharge instructions.
Results: A total of 98 patients underwent eTNTS during the study period. Median length of hospital stay was 2-days (Interquartile range [IQR] 1-4days), at which point most patients (82%) were provided with eTNTS-specific discharge instructions. First postoperative visit took place 9-days after discharge (IQR 7-10days). Within that time, 54% of patients made/sent at least one phone call or electronic message and 17% presented to the ED. Most common reasons for call/message were nasal care, appointment scheduling, symptom and medication questions.
Conclusions: Through this work, we highlight the most common reasons for resource utilization via patient phone calls, messages, and ED visits among our cohort to better understand any shortfall or gap in the discharge process that may reduce these events.
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Affiliation(s)
| | | | | | | | | | - Won Kim
- , Los Angeles, United States
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Varlamov EV, Vila G, Fleseriu M. Perioperative Management of a Patient with Cushing’s Disease. J Endocr Soc 2022; 6:bvac010. [PMID: 35178493 PMCID: PMC8845122 DOI: 10.1210/jendso/bvac010] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Indexed: 11/19/2022] Open
Abstract
Abstract
Patients with Cushing’s disease (CD) may present with both chronic and acute perioperative complications that necessitate multidisciplinary care. This review highlights several objectives for these patients before and after transsphenoidal surgery. Preoperative management includes treatment of electrolyte disturbances, cardiovascular comorbidities, prediabetes/diabetes, as well as prophylactic consideration(s) for thromboembolism and infection(s). Preoperative medical therapy (PMT) could prove beneficial in patients with severe hypercortisolism or in cases of delayed surgery. Some centers use PMT routinely, although the clinical benefit for all patients is controversial. In this setting, steroidogenesis inhibitors are preferred because of rapid and potent inhibition of cortisol secretion. If glucocorticoids are not used perioperatively, an immediate remission assessment postoperatively is possible. However, perioperative glucocorticoid replacement is sometimes necessary for clinically unstable or medically pretreated patients and for those patients with surgical complications. A nadir serum cortisol < 2-5µg/dl during 24-74 hours postoperatively is generally accepted as remission; higher values suggest non-remission, while a few patients may display delayed remission. If remission is not achieved, additional treatments are pursued. The early postoperative period necessitates multidisciplinary awareness for early diagnosis of adrenal insufficiency (AI) to avoid adrenal crisis, which may be also potentiated by acute postoperative complications. Preferred glucocorticoid replacement is hydrocortisone, if available. Assessment of recovery from postoperative AI should be undertaken periodically. Other postoperative targets include decreasing antihypertensive/diabetic therapy if in remission, thromboprophylaxis, infection prevention/treatment, and management of electrolyte disturbances and/or potential pituitary deficiencies. Evaluation of recovery of thyroid, gonadal and growth hormone deficiencies should be also performed in the following months postoperatively.
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Affiliation(s)
- Elena V Varlamov
- Departments of Medicine (Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Greisa Vila
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Maria Fleseriu
- Departments of Medicine (Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
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Shekhawat V, Das A, Pan S, Sudhan MD. Central diabetes insipidus: A case series and literature review. JOURNAL OF MARINE MEDICAL SOCIETY 2022. [DOI: 10.4103/jmms.jmms_124_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Bi Y, Adam S, Chatzimavridou V, Lorigan P, Huang Y. Potential pitfalls in diagnosis of immunotherapy-induced hypothalamic-pituitary-adrenal axis abnormalities: a clinical case. ENDOCRINE ONCOLOGY (BRISTOL, ENGLAND) 2022; 2:K5-K9. [PMID: 37435468 PMCID: PMC10259291 DOI: 10.1530/eo-21-0023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 06/28/2022] [Indexed: 07/13/2023]
Abstract
SUMMARY Short synacthen tests (SST) are frequently used for assessing adrenocorticotropin hormone (ACTH) deficiency. In this study, we present the case of a 53-year-old man receiving immunotherapy for metastatic melanoma, who subsequently developed immune checkpoint inhibitor (ICI)-induced hypothyroidism and was investigated for the presence of ICI-induced hypocortisolaemia on different occasions. Despite two reassuring SSTs, he subsequently developed clinical and biochemical evidence of ACTH deficiency. The ACTH on local measurement was not conclusive in keeping with ICI-related ACTH deficiency but when repeated using an alternative assay confirmed the diagnosis. The case illustrates the evolution of ACTH deficiency and exposes the potential pitfalls of screening strategies. Two important lessons may be gleaned from this case: (i) SSTs can be normal in early cases of secondary adrenal insufficiency, for example, hypophysitis due to adrenal reserve and (ii) when there is mismatch between the clinical and biochemical presentation, the ACTH should be repeated using a different assay. LEARNING POINTS Short synacthen tests, useful for ruling out adrenalitis and primary adrenal failure, may be normal in early adrenocorticotrophic hormone deficiency and secondary adrenal failure due to residual adrenal reserve.If clinical suspicion of adrenal insufficiency persists despite an initial satisfactory SST, it is important to recognise the need for re-assessment of cortisol levels.Insulin tolerance test remains a useful tool in the investigation of secondary adrenal insufficiency.Levothyroxine replacement may accelerate the metabolism of cortisol in cases of concurrent hypothyroidism and hypoadrenalism, and therefore, glucocorticoid replacement must precede levothyroxine treatment, to avoid adrenal crisis.The prevalence of immunotherapy-related endocrinopathies is likely to increase with increasing use of ICI and it is crucial that clinicians are alert to their subtle symptoms.
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Affiliation(s)
- Yixi Bi
- The Christie’s NHS Foundation Trust, Manchester, UK
| | - Safwaan Adam
- The Christie’s NHS Foundation Trust, Manchester, UK
| | | | - Paul Lorigan
- The Christie’s NHS Foundation Trust, Manchester, UK
| | - Yinglai Huang
- Division of Breast and Endocrine Surgery, Borås Hospital, Borås, Sweden
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Lin K, Zeng R, Mu S, Lin Y, Wang S. Novel Nomograms to Predict Delayed Hyponatremia After Transsphenoidal Surgery for Pituitary Adenoma. Front Endocrinol (Lausanne) 2022; 13:900121. [PMID: 35837309 PMCID: PMC9273860 DOI: 10.3389/fendo.2022.900121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 05/30/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE This study aimed to develop a nomogram of clinical variables and magnetic resonance imaging scans to predict delayed hyponatremia after transsphenoidal surgery for pituitary adenoma. METHODS Patients who underwent transsphenoidal surgery for pituitary adenoma in Fuzong Clinical Medical College of Fujian Medical University between January 2012 and December 2020 were retrospectively investigated. Medical records, MRI findings, and laboratory examination results were recorded as candidate variable predictors of delayed hyponatremia. A nomogram to predict delayed hyponatremia was formulated based on the multivariable model of risk factors. The predictive accuracy and discriminative ability of the nomogram were assessed using the receiver operating characteristic (ROC) curve, calibration plot, and decision curve analyses. The model underwent prospective validation in three medical centers with patients who underwent transsphenoidal surgery for pituitary adenoma between January 2021 and February 2022. RESULTS The model that incorporated the postoperative length of "measurable pituitary stalk," pituitary stalk deviation angle difference, postoperative diabetes insipidus, sinking depth of diaphragma sellae, and blood sodium level on the second postoperative day was developed and presented as the nomogram of the training cohort. The nomogram achieved area under the ROC curve (AUCs) of 0.806 and 0.849 for the training cohort and the testing cohort, respectively, and displayed good calibration. Decision curve analysis showed that the nomogram was clinically useful when the threshold probability was 13-96%. CONCLUSIONS We developed a nomogram to evaluate the individualized prediction of delayed hyponatremia after transsphenoidal surgery for pituitary adenomas.
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Affiliation(s)
- Kunzhe Lin
- Department of Neurosurgery, Affiliated Fuzhou First Hospital of Fujian Medical University, Fuzhou, China
- Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Ran Zeng
- Department of Neurosurgery, Shanghai Donglei Brain Hospital, Shanghai, China
| | - Shuwen Mu
- Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Yinghong Lin
- College of Integrated Chinese and Western Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Shousen Wang
- Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, 900th Hospital, Fuzhou, China
- *Correspondence: Shousen Wang,
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Du C, Leng Y, Zhou Q, Xiao JX, Yuan XR, Yuan J. Relationship between postoperative hypothalamic injury and water and sodium disturbance in patients with craniopharyngioma: A retrospective study of 178 cases. Front Endocrinol (Lausanne) 2022; 13:958295. [PMID: 36120435 PMCID: PMC9478176 DOI: 10.3389/fendo.2022.958295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/15/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To investigate the relationship between postoperative hypothalamo-hypophyseal injury (HHI) and postoperative water and sodium disturbances in patients with craniopharyngioma. METHODS The medical records, radiological data, and laboratory results of 178 patients (44 children and 134 adults) who underwent microsurgery for craniopharyngioma in a single center were reviewed. Postoperative HHI was assessed using magnetic resonance imaging. Structural defects of the hypothalamo-hypophyseal system (pituitary, pituitary stalk, floor and lateral wall of the third ventricle) were assessed in four standard T1-weighted images. The defect of each structure was assigned 1 score (0.5 for the unilateral injury of the third ventricle wall), and a HHI score was calculated. RESULTS The number of patients with HHI scores of 0-1, 2, 2.5-3, and >3 was 35, 49, 61, and 33, respectively. Diabetes insipidus (DI) worsened in 56 (31.5%) patients with preoperative DI, while 119 (66.9%) patients were diagnosed with new-onset DI. Hypernatremia and hyponatremia developed in 127 (71.3%) and 128 (71.9%) patients after surgery, respectively. Syndrome of inappropriate antidiuresis occurred in 97(54.5%) patients. During hospitalization, hypernatremia recurred in 33 (18.5%) patients and in 54 (35.7%) during follow-up, of which 18 (11.9%) were severe. DI persisted in 140 (78.7%) patients before discharge. No relationship was found between the HHI score and incidence of early DI, hyponatremia, syndrome of inappropriate diuretic hormone, or prolonged DI. Compared with patients with a score of 0-1, those with scores =2.5-3 (OR = 5.289, 95% CI:1.098-25.477, P = 0.038) and >3 (OR = 10.815, 95% CI:2.148-54.457, P = 0.004) had higher risk of developing recurrent hypernatremia. Patients with a score >3 had higher risk of developing severe hypernatremia during hospitalization (OR = 15.487, 95% CI:1.852-129.539, P = 0.011) and at follow-up (OR = 28.637, 95% CI:3.060-267.981, P = 0.003). CONCLUSIONS The neuroimaging scoring scale is a simple tool to semi-quantify HHI after surgery. Recurrent and severe hypernatremia should be considered in patients with a high HHI score (>2.5). An HHI score >3 is a potential predictor of adipsic DI development. Preventive efforts should be implemented in the perioperative period to reduce the incidence of potentially catastrophic complications.
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Affiliation(s)
- Can Du
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Yueshuang Leng
- Radiological Intervention Center, Department of Radiology, Xiangya Hospital, Central South University, Changsha, China
| | - Quanwei Zhou
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Ju-Xiong Xiao
- Radiological Intervention Center, Department of Radiology, Xiangya Hospital, Central South University, Changsha, China
| | - Xian-Rui Yuan
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- Department of Neurosurgery, The Institute of Skull Base Surgery and Neuro-oncology at Hunan, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Jian Yuan
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- Department of Neurosurgery, The Institute of Skull Base Surgery and Neuro-oncology at Hunan, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Jian Yuan,
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Jameel PZ, Lohiya S, Vagha K, Ahmed T, Pujari D, Vagha J, Varma A. Concurrent central diabetes insipidus and cerebral salt wasting disease in a post-operative case of craniopharyngioma: a case report. BMC Pediatr 2021; 21:502. [PMID: 34758770 PMCID: PMC8579628 DOI: 10.1186/s12887-021-02982-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Water and electrolyte disorders commonly encountered in children post-surgery involving hypothalamus and posterior pituitary, are central diabetes insipidus, syndrome of inappropriate secretion of anti-diuretic hormone and cerebral salt wasting disease. Delayed diagnosis and inadequate management of such cases may lead to worsened neurological outcomes with a high mortality rate. CASE PRESENTATION Here we report the case of a 7-year-old girl who underwent surgical resection of a craniopharyngioma, following which she initially developed central diabetes insipidus. However, later on in the course of her illness she developed symptomatic hyponatremia with natriuresis which was diagnosed to be due to cerebral salt wasting disease. This combination of central diabetes insipidus and cerebral salt wasting syndrome is a rare occurrence and poses a diagnostic challenge. Diagnosis and management can be even more difficult when these conditions precede or coexist with each other. CONCLUSION In such cases development of hyponatremia should always prompt consideration of unusual causes like cerebral salt wasting disease in addition to the classically described syndrome of inappropriate secretion of anti-diuretic hormone. Hence, a thorough knowledge of these disorders along with intensive monitoring of fluid and sodium status is critical for timely diagnosis and management of these patients.
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Affiliation(s)
- Patel Zeeshan Jameel
- Department of Paediatrics, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra, 442001, India.
| | - Sham Lohiya
- Department of Paediatrics, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra, 442001, India
| | - Keta Vagha
- Department of Paediatrics, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra, 442001, India
| | - Tauheed Ahmed
- Department of Medicine, Tata Main Hospital, Jamshedpur, Jharkhand, India
| | - Divya Pujari
- Division of Paediatric Endocrinology, Department of Paediatrics, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Jayant Vagha
- Department of Paediatrics, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra, 442001, India
| | - Ashish Varma
- Department of Paediatrics, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra, 442001, India
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Alghamdi K, Albakri LA, Alotaibi Y, Alghamdi AH, Alaidarous S. Coexistence of Triphasic Diabetes Insipidus and Cerebral Salt Wasting Syndrome Following Extraction of Sellar/Suprasellar Grade I Pilocytic Astrocytoma. Cureus 2021; 13:e17661. [PMID: 34646703 PMCID: PMC8487248 DOI: 10.7759/cureus.17661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 11/06/2022] Open
Abstract
Water homeostasis disorders, such as syndrome of inappropriate antidiuretic hormone secretion (SIADH), diabetes insipidus (DI), and cerebral salt-wasting syndrome (CSWS), can develop after neurosurgery. Additionally, DI, SIADH, and CSWS have been reported concurrently in association with some neurosurgical conditions, in particular after pituitary gland surgery or as sequelae of post-traumatic brain injury. Therefore, neurosurgeons should expect water homeostasis disorders after the removal of tumors of the sellar/suprasellar region and be prepared to aggressively manage them.
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Affiliation(s)
- Khalid Alghamdi
- Neurosurgery, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guards Health Affairs, King Abdullah International Medical Research Centre, Jeddah, SAU
| | - Lamair A Albakri
- College of Medicine, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guards Health Affairs, King Abdullah International Medical Research Centre, Jeddah, SAU
| | - Yazeed Alotaibi
- Neurological Surgery, Alnoor Specialist Hospital, Makkah, SAU
| | - Ahmed H Alghamdi
- Endocrinology, King Faisal Specialist Hospital and Research Center, Jeddah, SAU
| | - Salwa Alaidarous
- Endocrinology, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guards Health Affairs, Jeddah, SAU
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Taka TM, Yang CY, Limbo JN, Chan AY, Davies J, Kuan EC, Turner SG, Hsu FPK. Pituitary spindle cell oncocytoma: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21356. [PMID: 36131568 PMCID: PMC9563951 DOI: 10.3171/case21356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 06/30/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Spindle cell oncocytoma (SCO) of the pituitary gland is an extremely rare nonfunctional World Health Organization grade I tumor. SCOs are often misdiagnosed as nonfunctional pituitary adenomas on the basis of preoperative imaging. They are often hypervascular and locally adherent, which increases hemorrhage risk and limits resection, leading to increased risk of recurrence. The authors report a case of SCO treated at their institution and provide a review of the current literature. OBSERVATIONS SCO of the pituitary gland can be a rare cause of progressively growing pituitary tumors that presents similarly to nonfunctional pituitary adenoma. Endoscopic transsphenoidal resection of the tumor by a multidisciplinary team allowed total resection despite local adherence of the tumor. Postoperatively, the patient’s visual symptoms improved with persistence of secondary adrenal insufficiency and secondary hypothyroidism. LESSONS Careful resection is needed due to SCO’s characteristic hypervascularity and strong adherence to minimize local structure damage. Long-term follow-up is recommended due to the tendency for recurrence.
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Affiliation(s)
| | | | | | | | | | | | - Scott G. Turner
- Neuro-Oncology, University of California, Irvine, Orange, California
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Almalki MH, Ahmad MM, Brema I, Almehthel M, AlDahmani KM, Mahzari M, Beshyah SA. Management of Diabetes Insipidus following Surgery for Pituitary and Suprasellar Tumours. Sultan Qaboos Univ Med J 2021; 21:354-364. [PMID: 34522399 PMCID: PMC8407907 DOI: 10.18295/squmj.4.2021.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/14/2020] [Accepted: 08/09/2020] [Indexed: 12/03/2022] Open
Abstract
Central diabetes insipidus (CDI) is a common complication after pituitary surgery. However, it is most frequently transient. It is defined by the excretion of an abnormally large volume of dilute urine with increasing serum osmolality. The reported incidence of CDI after pituitary surgery ranges from 0–90%. Large tumour size, gross total resection and intraoperative cerebrospinal fluid leak usually pose an increased risk of CDI as observed with craniopharyngioma and Rathke’s cleft cysts. CDI can be associated with high morbidity and mortality if not promptly recognised and treated on time. It is also essential to rule out other causes of postoperative polyuria to avoid unnecessary pharmacotherapy and iatrogenic hyponatremia. Once the diagnosis of CDI is established, close monitoring is required to evaluate the response to treatment and to determine whether the CDI is transient or permanent. This review outlines the evaluation and management of patients with CDI following pituitary and suprasellar tumour surgery to help recognise the diagnosis, consider the differential diagnosis, initiate therapeutic interventions and guide monitoring and long-term management.
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Affiliation(s)
- Mussa H Almalki
- Obesity, Endocrine and Metabolism Centre, King Fahad Medical City, Riyadh, Saudi Arabia.,Faculty of Medicine, King Saud Bin Abdul Aziz University of Health Sciences, Riyadh, Saudi Arabia
| | - Maswood M Ahmad
- Obesity, Endocrine and Metabolism Centre, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Imad Brema
- Obesity, Endocrine and Metabolism Centre, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Mohammed Almehthel
- Obesity, Endocrine and Metabolism Centre, King Fahad Medical City, Riyadh, Saudi Arabia.,Division of Endocrinology, University of British Columbia, Vancouver, Canada
| | - Khaled M AlDahmani
- Division of Endocrinology, Tawam Hospital, Al Ain, United Arab Emirates.,Department of Medicine, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Moeber Mahzari
- Faculty of Medicine, King Saud Bin Abdul Aziz University of Health Sciences, Riyadh, Saudi Arabia.,Department of Medicine, Ministry of National Guard Health Affair, Riyadh, Saudi Arabia
| | - Salem A Beshyah
- Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates.,Department of Endocrinology, Mediclinic Airport Road, Abu Dhabi, United Arab Emirates
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Abdali A, Astafeva LI, Trunin YY, Chernov IV, Sidneva YG, Abdilatipov AA, Kalinin PL. [Modern aspects of surgery for cushing's disease]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:111-117. [PMID: 34463458 DOI: 10.17116/neiro202185041111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cushing's disease is a severe neuroendocrine disorder caused by chronic hypersecretion of ACTH by pituitary adenoma (corticotropinoma). Surgical resection is a gold standard for this disease resulting stable remission in about 65-95% of cases. Despite benign nature of corticotropinoma, recurrence rate is still higher (25-35%) even in specialized neurosurgical centers. Modifications in surgical strategy can prolong recurrence-free period.
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Affiliation(s)
- A Abdali
- Peoples' Friendship University of Russia, Moscow, Russia
| | | | | | - I V Chernov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | | | - P L Kalinin
- Burdenko Neurosurgical Center, Moscow, Russia
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Staby I, Krogh J, Klose M, Baekdal J, Feldt-Rasmussen U, Poulsgaard L, Springborg JB, Andreassen M. Pituitary function after transsphenoidal surgery including measurement of basal morning cortisol as predictor of adrenal insufficiency. Endocr Connect 2021; 10:750-757. [PMID: 34137733 PMCID: PMC8346196 DOI: 10.1530/ec-21-0155] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 06/16/2021] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Patients with pituitary adenomas undergoing transsphenoidal surgery require pre- and post-surgery examination of pituitary hormones. There is currently no consensus on how to evaluate the adrenal axis post-surgery. The aims of this study were to investigate factors that may predict postoperative adrenal insufficiency (AI) and to investigate the overall effect of transsphenoidal surgery on pituitary function. METHODS One hundred and forty-three consecutive patients who had undergone transsphenoidal surgery for pituitary adenomas were included. Data on tumour size, pituitary function pre-surgery, plasma basal cortisol measured within 48 h post-surgery and pituitary function 6 months post-surgery were collected. Patients with AI prior to surgery, perioperative glucocorticoid treatment, Cushing's disease and no re-evaluation after 1 month were excluded (n = 93) in the basal cortisol analysis. RESULTS Low plasma basal cortisol post-surgery, tumour size and previous pituitary surgery were predictors of AI (all P < 0.05). A basal cortisol cut-off concentration of 300 nmol/L predicted AI 6 months post-surgery with sensitivity and negative predictive value of 100%, specificity of 81% and positive predictive value of 25%. New gonadal, thyroid and adrenal axis insufficiencies accounted for 2, 10 and 10%, respectively. The corresponding recovery rates were 17, 7 and 24%, respectively. CONCLUSION Transsphenoidal surgery had an overall beneficial effect on pituitary endocrine function. Low basal plasma cortisol measured within 48 h after surgery, tumour size and previous surgery were identified as risk factors for AI. Measurement of basal cortisol post-surgery may help to identify patients at risk of developing AI.
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Affiliation(s)
- Ida Staby
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jesper Krogh
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marianne Klose
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jonas Baekdal
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Clinical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Lars Poulsgaard
- Department of Neurosurgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Mikkel Andreassen
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Clinical Sciences, Copenhagen University, Copenhagen, Denmark
- Correspondence should be addressed to M Andreassen:
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Araujo-Castro M, Mariño-Sánchez F, Acitores Cancela A, García Fernández A, García Duque S, Rodríguez Berrocal V. Is it possible to predict the development of diabetes insipidus after pituitary surgery? Study of 241 endoscopic transsphenoidal pituitary surgeries. J Endocrinol Invest 2021; 44:1457-1464. [PMID: 33043415 DOI: 10.1007/s40618-020-01448-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/07/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE To identify presurgical and surgical factors associated with the development of diabetes insipidus (DI) after pituitary adenoma (PA) resection through an endoscopic endonasal transsphenoidal approach. METHODS Data from 231 patients with functioning and non-functioning PAs who underwent an endoscopic endonasal transsphenoidal approach in the last ten years. RESULTS 231 patients with 241 pituitary surgeries were included. Eighty-five percent harbored macroadenomas and 38.1% of them were invasive. After pituitary surgery, 12.5% (n = 30) developed transient DI and 5.0% (n = 12) permanent DI. The global risk of DI was higher in patients younger than 65 years (OR = 2.94, p = 0.029), with total tumoral resection (OR = 2.86, p = 0.007) and with diaphragm opening during pituitary resection (OR = 3.63, p = 0.0003). Once postoperative DI developed, the risk of permanent DI increased in those patients with larger PA (OR = 1.07 for each mm of craniocaudal diameter, p = 0.020), especially in those greater than 30 mm (OR = 8.33, p = 0.004). Moreover, diaphragm opening during pituitary resection (OR = 28.3, p = 0.018) predicted long-term DI independently of pituitary tumor size. The risk of permanent DI increased as PA craniocaudal diameter increased (r = 0.20, p = 0.002). CONCLUSION In patients with PAs younger than 65 years, in whom diaphragm has been opened during pituitary surgery and/or with a total tumor resection, special hydric balance monitoring should be maintained in the postoperative period due to the increased risk of developing DI. The risk of permanent DI increases as PA craniocaudal diameter increased.
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Affiliation(s)
- M Araujo-Castro
- Neuroendocrinology Unit, Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Instituto de Investigación Biomédica Hospital Ramón Y Cajal (IRYCIS), Madrid, Spain.
| | - F Mariño-Sánchez
- Rhinology and Skull Base Surgery Unit, Otorhinolaryngology Department, Ramón y Cajal University Hospital, Madrid, Spain
| | - A Acitores Cancela
- Pituitary Surgery Unit, Department of Neurosurgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - A García Fernández
- Rhinology and Skull Base Surgery Unit, Otorhinolaryngology Department, Hospital HM Puerta del Sur, Madrid, Spain
| | - S García Duque
- Pituitary Surgery Unit, Department of Neurosurgery, Hospital Universitario Puerta del Sur, Madrid, Spain
| | - V Rodríguez Berrocal
- Pituitary Surgery Unit, Department of Neurosurgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Pituitary Surgery Unit, Department of Neurosurgery, Hospital Universitario Puerta del Sur, Madrid, Spain
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Koundal H, Dhandapani M, Thakur P, Dutta P, Walia R, Sahoo SK, Chhabra R, Dhandapani S. Effectiveness of dietary diabetes insipidus bundle on the severity of postoperative fluid imbalance in pituitary region tumours: A randomized controlled trial. J Adv Nurs 2021; 77:3911-3920. [PMID: 34028859 DOI: 10.1111/jan.14894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 04/16/2021] [Accepted: 04/25/2021] [Indexed: 01/31/2023]
Abstract
AIM To test the effectiveness of nurse-led dietary diabetes insipidus (DI) bundle on the severity of postoperative fluid imbalance in pituitary region tumours. DESIGN Blinded randomized controlled trial. METHODS Patients aged 18-65 operated for sellar-suprasellar tumours in an Indian tertiary care centre were enrolled through total enumeration sampling and underwent randomization with allocation concealment during Sep 2018-Feb 2019. Pre-operative DI, postoperative ventilation, renal failure or decompensated diabetes mellitus were excluded. Patients in the intervention group received a nurse-led DI bundle (validated by three Delphi rounds) with four dietary components: intake of only water during thirst and avoidance of the following-added salt, high-protein foods and caffeinated drinks. Treating clinicians and the investigator assessing outcome were blinded about enrolment. Urine output, serum sodium, vasopressin requirement and hospital stay were assessed as primary outcomes. The outcome measures were monitored daily till the 6th postoperative day. Analyses were performed on 'intention-to-treat' basis, irrespective of compliance. Independent t-test and Chi-square test were used. RESULTS Of the initial 63 patients, 50 fulfilling criteria were randomized to two groups and assessed over six days yielding 150 patient-days per group. There were no significant baseline differences between groups. The mean daily urine output was significantly lower in the DI bundle group than in control, both overall and among endonasal operated pituitary adenomas [3000.09(462.7) vs. 4095.71(896.4)ml & 2987.14(419.5) vs. 4064.73(1051)ml], with the greatest difference on the second postoperative day. Though hypernatraemia in controls became most prominent during days 2-3 and resolved in a week, it was significantly lower in the intervention group (12.7% vs. 30.7% overall, 11.4% vs. 29.4% endonasal adenomas). The need for vasopressin analogues and hospital stay were also significantly lower with DI bundle (p < 0.001). CONCLUSION This is probably the first ever report of dietary DI bundle among operated pituitary patients, which seem to flatten the DI trend with significant benefits in polyuria, hypernatraemia, vasopressin requirement and hospital stay. TRIAL REGISTRATION CTRI/2018/07/015127 of ICMR. IMPACT The nurse-led dietary DI bundle has effectively reduced the severity of DI among operated pituitary patients with significant benefits in polyuria, hypernatraemia, vasopressin requirement and hospital stay. Its implementation is simple and easy to carry out, especially in resource-constrained institutions, where continuous monitoring and repeated serum sodium estimation are difficult.
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Affiliation(s)
- Hemlata Koundal
- National Institute of Nursing Education (NINE), PGIMER, Chandigarh, India
| | - Manju Dhandapani
- National Institute of Nursing Education (NINE), PGIMER, Chandigarh, India
| | - Pratibha Thakur
- National Institute of Nursing Education (NINE), PGIMER, Chandigarh, India
| | - Pinaki Dutta
- Department of Endocrinology, PGIMER, Chandigarh, India
| | - Rama Walia
- Department of Endocrinology, PGIMER, Chandigarh, India
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Lin K, Wang S. Letter: Focus on Syndrome of Inappropriate Antidiuretic Hormone After Resection of Pituitary Lesions via Transsphenoidal Approach. Neurosurgery 2021; 89:E80-E81. [PMID: 33826708 DOI: 10.1093/neuros/nyab110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Kunzhe Lin
- Department of Neurosurgery Affiliated Fuzhou First Hospital of Fujian Medical University Fuzhou, China.,Fuzong Clinical Medical College of Fujian Medical University Fuzhou, China
| | - Shousen Wang
- Department of Neurosurgery 900th Hospital Fuzong Clinical Medical College of Fujian Medical University Fuzhou, China
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Lakomkin N, Van Gompel JJ, Post KD, Cho SS, Lee JYK, Hadjipanayis CG. Fluorescence guided surgery for pituitary adenomas. J Neurooncol 2021; 151:403-413. [PMID: 33611707 DOI: 10.1007/s11060-020-03420-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 01/31/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE Resection of pituitary adenomas presents a number of unique challenges in neuro-oncology. The proximity of these lesions to key vascular and endocrine structures as well as the need to interpret neuronavigation in the context of shifting tumor position increases the complexity of the operation. More recently, substantial advances in fluorescence-guided surgery have been demonstrated to facilitate the identification of numerous tumor types and result in increased rates of complete resection and overall survival. METHODS A review of the literature was performed, and data regarding the mechanism of the fluorescence agents, their administration, and intraoperative tumor visualization were extracted. Both in vitro and in vivo studies were assessed. The application of these agents to pituitary tumors, their advantages and limitations, as well as future directions are presented here. RESULTS Numerous laboratory and clinical studies have described the use of 5-ALA, fluorescein, indocyanine green, and OTL38 in pituitary lesions. All of these drugs have been demonstrated to accumulate in tumor cells. Several studies have reported the successful use of the majority of the agents in inducing intraoperative tumor fluorescence. However, their sensitivity and specificity varies across the literature and between functioning and non-functioning adenomas. CONCLUSIONS At present, numerous studies have shown the feasibility and safety of these agents for pituitary adenomas. However, further research is needed to assess the applicability of fluorescence-guided surgery across different tumor subtypes as well as explore the relationship between their use and postoperative clinical outcomes.
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Affiliation(s)
- Nikita Lakomkin
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, Mount Sinai Downtown Union Square, 10 Union Square East, Suite 5E, New York, NY, 10003, USA.,Department of Neurosurgery, Icahn School of Medicine, Mount Sinai Beth Israel, Mount Sinai Health System, New York, USA
| | | | - Kalmon D Post
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, Mount Sinai Downtown Union Square, 10 Union Square East, Suite 5E, New York, NY, 10003, USA
| | - Steve S Cho
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, USA
| | - John Y K Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, USA
| | - Constantinos G Hadjipanayis
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, Mount Sinai Downtown Union Square, 10 Union Square East, Suite 5E, New York, NY, 10003, USA. .,Department of Neurosurgery, Icahn School of Medicine, Mount Sinai Beth Israel, Mount Sinai Health System, New York, USA.
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Lee HC, Yoon HK, Kim JH, Kim YH, Park HP. Comparison of intraoperative cortisol levels after preoperative hydrocortisone administration versus placebo in patients without adrenal insufficiency undergoing endoscopic transsphenoidal removal of nonfunctioning pituitary adenomas: a double-blind randomized trial. J Neurosurg 2021; 134:526-534. [PMID: 31978882 DOI: 10.3171/2019.11.jns192381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 11/15/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In this double-blind randomized trial, the necessity of preoperative steroid administration in patients without adrenal insufficiency (AI) undergoing endoscopic transsphenoidal surgery (ETSS) for pituitary adenoma was evaluated. METHODS Forty patients with and without AI, defined as a peak cortisol level > 18 µg/dl on the insulin tolerance test or rapid adrenocorticotropic hormone (ACTH) test, undergoing ETSS for nonfunctioning pituitary adenomas were randomly allocated to treatment with either 100 mg of preoperative hydrocortisone (group HC, n = 20) or normal saline (group C, n = 20). The patients with pituitary apoplexy, the use of a drug within the last 3 months that could affect the hypothalamic-pituitary-adrenal axis, or a previous history of brain or adrenal surgery were excluded. Intraoperative cortisol and ACTH levels were measured after anesthesia induction, dura incision, and tumor removal, and at the end of surgery. Intraoperative hypotension, early postoperative AI, and postoperative 3-month pituitary function were investigated. RESULTS Intraoperative serum cortisol levels were significantly higher in the HC group than in the C group after anesthesia induction (median 69.0 µg/dl [IQR 62.2-89.6 µg/dl] vs 12.7 µg/dl [IQR 8.4-18.2 µg/dl], median difference 57.5 µg/dl [95% CI 33.0-172.9 µg/dl]), after dura incision (median 53.2 µg/dl [IQR 44.9-63.8 µg/dl] vs 6.4 [IQR 4.8-9.2 µg/dl], median difference 46.6 µg/dl [95% CI 13.3-89.2 µg/dl]), after tumor removal (median 49.5 µg/dl [IQR 43.6-62.4 µg/dl] vs 9.2 µg/dl [IQR 5.75-16.7 µg/dl], median difference 39.4 µg/dl [95% CI 0.3-78.1 µg/dl]), and at the end of surgery (median 46.9 µg/dl [IQR 40.1-63.4 µg/dl] vs 16.9 µg/dl [IQR 12.1-23.2 µg/dl], median difference 32.2 µg/dl [95% CI -42.0 to 228.1 µg/dl]). Serum ACTH levels were significantly lower in group HC than in group C after anesthesia induction (median 3.9 pmol/L [IQR 1.7-5.2 pmol/L] vs 6.9 pmol/L [IQR 3.9-11.9 pmol/L], p = 0.007). No patient showed intraoperative hypotension due to AI. Early postoperative AI was observed in 3 and 5 patients in groups HC and C, respectively. The postoperative 3-month pituitary hormone outcomes including ACTH deficiency were not different between groups. CONCLUSIONS Preoperative steroid administration may be unnecessary in patients without AI undergoing ETSS for nonfunctioning pituitary adenomas. However, a further large-scale study is needed to determine whether preoperative steroid administration has a significant impact on clinically meaningful events such as perioperative AI and postoperative 3-month ACTH deficiency in these patients.Korean Clinical Trial Registry no.: KCT0002426 (https://cris.nih.go.kr/cris/).
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Affiliation(s)
| | | | | | - Yong Hwy Kim
- 3Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
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Sunoki K, Otsuka Y, Iwai H, Nagano T, Taga N, Kawada M, Takeuchi M. Perioperative management of Fontan operation for the child with panhypopituitarism: a case report. J Anesth 2021; 35:303-306. [PMID: 33449198 DOI: 10.1007/s00540-020-02894-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 12/27/2020] [Indexed: 10/22/2022]
Abstract
With the surgical improvement of congenital heart disease, Fontan operation has been applied to many complicated patients in recent years. This is the first report of a child with panhypopituitarism who underwent Fontan operation. A 5-year-old boy was scheduled for Fontan operation. He previously underwent Blalock-Taussig shunt and bidirectional Glenn operations for univentricular heart with double-outlet right ventricle and pulmonary atresia. He was receiving hydrocortisone and 1-desamino-8-D-arginine vasopressin (DDAVP) for panhypopituitarism secondary to removal of craniopharyngioma performed at the age of three years. Although urine output and serum sodium concentration were adequately controlled by adjustment of vasopressin infusion rate during surgery, massive pleural effusions and ascites developed postoperatively, which required several days for control by adjusting the dose of oral DDAVP and normalize the serum sodium level. Intraoperative management of Fontan operation for a patient with panhypopituitarism was controllable by appropriate hormone replacement. However, postoperative fluid management was complicated by the clinical features of panhypopituitarism and Fontan physiology.
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Affiliation(s)
- Kohei Sunoki
- Department of Pediatric Intensive Care and Anesthesia, Jichi Children's Medical Center Tochigi, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Yoji Otsuka
- Department of Pediatric Intensive Care and Anesthesia, Jichi Children's Medical Center Tochigi, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
| | - Hidetaka Iwai
- Department of Pediatric Intensive Care and Anesthesia, Jichi Children's Medical Center Tochigi, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
| | - Tatsuya Nagano
- Department of Pediatric Intensive Care and Anesthesia, Jichi Children's Medical Center Tochigi, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
| | - Naoyuki Taga
- Department of Pediatric Intensive Care and Anesthesia, Jichi Children's Medical Center Tochigi, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
| | - Masaaki Kawada
- Department of Pediatric and Congenital Cardiovascular Surgery, Jichi Children's Medical Center Tochigi, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
| | - Mamoru Takeuchi
- Department of Pediatric Intensive Care and Anesthesia, Jichi Children's Medical Center Tochigi, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.,Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
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47
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Castle-Kirszbaum M, Kyi M, Wright C, Goldschlager T, Danks RA, Parkin WG. Hyponatraemia and hypernatraemia: Disorders of Water Balance in Neurosurgery. Neurosurg Rev 2021; 44:2433-2458. [PMID: 33389341 DOI: 10.1007/s10143-020-01450-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/26/2020] [Accepted: 11/25/2020] [Indexed: 12/23/2022]
Abstract
Disorders of tonicity, hyponatraemia and hypernatraemia, are common in neurosurgical patients. Tonicity is sensed by the circumventricular organs while the volume state is sensed by the kidney and peripheral baroreceptors; these two signals are integrated in the hypothalamus. Volume is maintained through the renin-angiotensin-aldosterone axis, while tonicity is defended by arginine vasopressin (antidiuretic hormone) and the thirst response. Edelman found that plasma sodium is dependent on the exchangeable sodium, potassium and free-water in the body. Thus, changes in tonicity must be due to disproportionate flux of these species in and out of the body. Sodium concentration may be measured by flame photometry and indirect, or direct, ion-sensitive electrodes. Only the latter method is not affected by changes in plasma composition. Classification of hyponatraemia by the volume state is imprecise. We compare the tonicity of the urine, given by the sodium potassium sum, to that of the plasma to determine the renal response to the dysnatraemia. We may then assess the activity of the renin-angiotensin-aldosterone axis using urinary sodium and fractional excretion of sodium, urate or urea. Together, with clinical context, these help us determine the aetiology of the dysnatraemia. Symptomatic individuals and those with intracranial catastrophes require prompt treatment and vigilant monitoring. Otherwise, in the absence of hypovolaemia, free-water restriction and correction of any reversible causes should be the mainstay of treatment for hyponatraemia. Hypernatraemia should be corrected with free-water, and concurrent disorders of volume should be addressed. Monitoring for overcorrection of hyponatraemia is necessary to avoid osmotic demyelination.
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Affiliation(s)
| | - Mervyn Kyi
- Department of Endocrinology, Melbourne Health, Melbourne, Australia
| | - Christopher Wright
- Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Tony Goldschlager
- Department of Neurosurgery, Monash Health, Melbourne, Australia.,Department of Surgery, Monash University, Melbourne, Australia
| | - R Andrew Danks
- Department of Neurosurgery, Monash Health, Melbourne, Australia.,Department of Surgery, Monash University, Melbourne, Australia
| | - W Geoffrey Parkin
- Department of Surgery, Monash University, Melbourne, Australia.,Department of Intensive Care, Monash Health, Melbourne, Australia
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Rhyu J, Yu R. Development of Inappropriate Vasopressin Secretion in Association With Lumbar Cerebrospinal Fluid Drainage in an Adult With Traumatic Basilar Skull Fracture. AACE Clin Case Rep 2020; 7:124-126. [PMID: 34095469 PMCID: PMC8053618 DOI: 10.1016/j.aace.2020.11.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective Hyponatremia associated with cerebrospinal fluid (CSF) drainage is primarily limited to pediatric patients. Only 1 case in an adult, after pituitary surgery, has been described. We present the first adult case, to our knowledge, of lumbar CSF drainage associated with the syndrome of inappropriate antidiuretic hormone (SIADH) in a patient with a traumatic basilar skull fracture. Methods Serum and urine samples were evaluated for hyponatremia. Computed tomography and magnetic resonance imaging were performed to evaluate the fractures. Results A 31-year-old woman was hospitalized with traumatic facial and skull base fractures and managed conservatively. Four days into her hospital stay, she underwent lumbar CSF drainage for 6 days to treat a CSF leak. On examination, the patient remained hemodynamically stable and euvolemic. Sodium levels decreased from 142 to 136 mmol/L (normal, 135-146 mmol/L) on the day before and after lumbar drain placement, respectively, down to a nadir of 124 mmol/L over 3 subsequent days. Serum osmolality was 260 mOsm/kg (275-295 mOsm/kg); urine osmolality, 482 mOsm/kg; urine Na, 175 mmol/L; and thyroid-stimulating hormone, 4.0 μIU/mL (0.3-4.7 μIU/mL). The patient received treatment with sodium tablets, fluid restriction, and hypertonic saline for a diagnosis of SIADH. Sodium levels normalized from 131 to 136 mmol/L within 16 hours after lumbar drain removal. Conclusion This case illustrated a temporal association of SIADH with CSF drainage in an adult. Although this could be coincidental because a basilar skull fracture can lead to SIADH, it raises the possibility that CSF lumbar drainage contributed to the patient’s SIADH.
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Affiliation(s)
- Jane Rhyu
- University of California Los Angeles (UCLA), Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, Los Angeles, California
| | - Run Yu
- University of California Los Angeles (UCLA), Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, Los Angeles, California
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Postoperative Copeptin as a Biomarker for Development of Diabetes Insipidus Following Hypothalamic-Pituitary Surgery. Endocr Pract 2020; 27:463-470. [PMID: 33645512 DOI: 10.1016/j.eprac.2020.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/29/2020] [Accepted: 11/07/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Copeptin is a surrogate marker of arginine vasopressin release with better stability and simplicity of measurement. Postoperative copeptin levels may guide clinicians in stratifying patients who need close monitoring of fluid balance. The objective is to determine whether copeptin is a predictive marker of postoperative diabetes insipidus (DI). METHODS This is a prospective diagnostic study. Patients who underwent neurosurgical intervention of the sellar-suprasellar regions were recruited. Serum copeptin levels were measured before and after surgery, within 24 hours. Logistic regression analysis and diagnostic performance measures were calculated to determine the relationship between postoperative copeptin levels and DI. RESULTS Of 82 patients, 26 (31.7%) developed postoperative DI, with 7 patients (8.5%) having permanent DI. The samples for copeptin measurement were taken at 13 ± 2.1 hours postoperatively. From the receiver operating characteristic analysis, low postoperative copeptin levels (<2.5 pmol/L) demonstrated an acceptable ability to predict DI (area under the curve, 0.72; 95% CI, 0.60-0.84). Discriminative power was stronger in the permanent DI group (area under the curve, 0.82; 95% CI, 0.64-1.00). Postoperative copeptin levels <2.5 pmol/L were associated with DI (specificity > 91%). However, postoperative copeptin levels >20 pmol/L were rarely associated with DI, with a negative predictive value of 100%. CONCLUSIONS In patients undergoing sellar-suprasellar interventions, low postoperative copeptin levels within the first postoperative day predict postoperative DI, whereas high levels exclude it. Copeptin measurement should be applied in the clinical practice of postoperative care in patients following hypothalamic-pituitary surgery. This study may expand the potential use of copeptin, including in the Asian population.
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In-Hospital Endocrinology Consultation After Transsphenoidal Surgery: Is It Always Necessary? Can J Neurol Sci 2020; 48:534-539. [PMID: 33059786 DOI: 10.1017/cjn.2020.226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Patients with sellar masses undergoing transsphenoidal surgery (TSS) frequently develop endocrine dysfunction; therefore, in-hospital endocrinology consultation (IHEC) is recommended. However, we wondered whether routine endocrinology assessment of all TSS patients is always necessary. METHODS We developed an IHEC Physician's Guide to identify patients who would require peri-operative IHEC. An analysis of all patients undergoing TSS for a sellar mass over a 4-year period was conducted to assess the predictive value of the IHEC Physician's Guide in identifying patients who required IHEC. RESULTS A total of 116 patients underwent TSS; 24 required IHEC. As expected, the risk of endocrine complications requiring peri-operative endocrine management was significantly higher in the IHEC group versus no-IHEC group (96% vs. 1%; p < 0.001). The negative predictive value of the IHEC Physician's Guide in identifying patients who did not require IHEC was 0.99 (95% CI 0.9409-0.9997); Fisher's exact test, p < 0.001), meaning that the IHEC Physician's Guide successfully identified all but one patient who truly required IHEC. CONCLUSION Results from our study show that most patients do not need IHEC after TSS and that those patients requiring IHEC can be reliably predicted at surgery by using a simple IHEC Physician's Guide.
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