Incidence and risk factors associated with reoperation for sellar hematoma following endoscopic transsphenoidal pituitary surgery

The incidence and risk factors of unplanned reoperation in endoscopic endonasal surgeries: a single center study

The incidence of unplanned reoperation after surgery during the same hospitalization is considered one of most important evaluation indicators for health care quality. The purpose of this study was to determine the incidence and risk factors related to unplanned reoperation after an endoscopic endonasal approach (EEA). All patients who underwent elective endoscopic endonasal surgery from January 2016 to December 2021 in the Department of Neurosurgery, Tangdu Hospital, Air Force Military Medical University, were included. We identified the patients who underwent an unplanned reoperation and those who did not and divided them into two groups. The demographic data and risk factors were compared between the groups by univariate and multivariate logistic regression analyses. Of the 1783 patients undergoing EEA for various lesions of the skull base, the incidence of unplanned reoperation was 2.3%. The most common unplanned reoperations were repair of cerebrospinal fluid (CSF) leakage (39%), sellar hematoma evacuation (34.1%), hemostasis of epistaxis (14.6%) and external ventricular drainage for obstructive hydrocephalus (9.8%). The maximum diameter of tumor ≥ 3 cm (OR 2.654, CI 1.236-5.698; p = 0.012), meningioma (OR 4.198, CI 1.169-15.072; p = 0.028), craniopharyngioma (OR 5.020, CI 2.020-12.476; p = 0.001) and other sellar lesions (OR 4.336, CI 1.390-13.527; p = 0.012) and an operation time ≥ 240 min (OR 2.299, CI 1.170-4.518; p = 0.016) were the independent risk factors for unplanned reoperations in multivariate regression analysis. Of the 41 patients undergoing unplanned reoperation, 16 patients died, twenty-one patients had panhypopituitarism, 13 patients had transient and 6 had permanent diabetes insipidus, and 11 patients presented with intracranial infection and 6 of these patients were cured. By reviewing our department's data, we stated the incidence and risk factors for unplanned reoperation. It is important for the hospital administration and neurosurgeons to place more emphasis on these indicators. Furthermore, we suggest some effective quality improvement initiatives to reduce the incidence of unplanned reoperation.

Risk Factors for Significant Postoperative Hemorrhage After Pituitary Neuroendocrine Tumor Resection: A Case-Control Study of 1066 Surgeries

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.

Postoperative complications after endoscope-assisted transsphenoidal surgery for pituitary adenomas: a case series, systematic review, and meta-analysis of the literature

PURPOSE

Endoscope-assisted transsphenoidal surgery over the last few years has led to more radical excision of pituitary adenomas (PAs) with a low complication rate. Systematic registration of complications by experienced surgical teams could help to improve this technique while ameliorating the patients' quality of life.

MATERIALS AND METHODS

One hundred ten endoscopic procedures were performed in 94 patients with PAs (37 functional) by the same neurosurgical team of a tertiary center during the period 2014-2019. Post-surgical complications were analyzed and compared with data published during the last 5 years in the PubMed and Cochrane databases by performing a systematic review and meta-analysis of the literature.

RESULTS

The overall complication rate in our series was 23.4%. Diabetes insipidus (DI) and intraoperative cerebrospinal fluid (CSF) leakage were the commonest complications (12.8%), followed by postoperative hypopituitarism (9.2%) and hematoma (8.5%) during the follow-up of 2.15 ± 1.4 years. Syndrome of inappropriate antidiuretic hormone secretion, meningitis, deep vein thrombosis, and hyposmia were rare (< 3%). Postoperative hypopituitarism was significantly associated with incidence of hematoma. No statistically significant association was found between PAs Hardy and Knosp scale grading or between patients' characteristics with the occurrence of postoperative complications. Our meta-analysis including nine studies found no significant differences comparing the complications of endoscopic versus microscopic surgery.

CONCLUSION

The endoscopic approach is safe when performed by experienced surgical teams. CSF leakage and DI were the commonest complications in our series; however, confirmation by larger studies is required. Meta-analysis showed no statistically significant differences in complication rates comparing endoscopic versus microscopic surgery.

Visual deterioration after endonasal endoscopic skull base surgery: causes, treatments, and outcomes

OBJECTIVE

Visual deterioration after endoscopic endonasal transsphenoidal surgery (EETS) for sellar and parasellar masses is a rare but serious complication caused by either compressive or ischemic mechanisms. Timely diagnosis and intervention may restore vision if instituted appropriately. The associated risk factors and their relation to the success of intervention are not well understood.

METHODS

The authors examined a series of 1200 consecutive EETS cases performed by the senior author at Weill Cornell/NewYork-Presbyterian Hospital from 2010 to 2020. Cases with postoperative visual deterioration were identified. Pre- and postoperative clinical data, mechanism of visual decline, latency to intervention, and long-term visual outcome were retrospectively collected and analyzed with appropriate statistical methods.

RESULTS

Twenty-one patients (1.75%) complained of early postoperative visual deterioration. The most common pathology associated with postoperative visual loss was craniopharyngioma (7.69%), followed by meningioma (5.43%) and then pituitary adenoma (1.94%). Timely intervention restored vision in 81% of patients for a 0.33% rate of permanent visual deterioration. Average time to visual deterioration was 28.8 hours, and over 70% of patients experienced vision loss within the first 13 hours. Compressive etiology (n = 11), consisting of either hematoma (n = 8) or graft displacement (n = 3), occurred 7.3 hours and 70.3 hours after surgery, respectively, and was more common in adenomas. Acute postoperative visual deterioration was more common in firm closures (4.78%) compared with soft closures (1.03%; p = 0.0006). Ischemic etiology (n = 10) occurred 10.3 hours after surgery and was more common with craniopharyngiomas and meningiomas (p = 0.08). Sixteen patients (76.2%) underwent early reoperation to explore and decompress the optic apparatus. Vision was restored to baseline after reoperation in all 11 compressive cases, whereas 6/10 ischemic cases improved with supplemental oxygen and hypervolemic hypertensive therapy (p = 0.02). Fluid expansion from 8 to 16 hours (p = 0.034) and systolic blood pressure elevation from 32 to 48 hours (p = 0.05) after surgery were significantly higher in those ischemic patients who recovered some vision compared with those with persistent visual deficits.

CONCLUSIONS

Visual deterioration after EETS is a rare event but can be effectively treated if acted upon appropriately and in a timely fashion. Compressive etiology is reversible with early reoperation. Ischemic etiology can be successfully treated in roughly half of cases with supplemental oxygen and hypertensive hypervolemic therapy but may result in permanent visual deterioration if not instituted appropriately or if delayed with unnecessary exploratory surgery.

Venous thromboembolism chemical prophylaxis after endoscopic trans-sphenoidal pituitary surgery

PURPOSE

There is no compelling outcome data or clear guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using low molecular weight heparin (chemoprophylaxis) in patients undergoing pituitary surgery. Here we describe our experience of early chemoprophylaxis (post-operative day 1) following trans-sphenoidal pituitary surgery.

METHODS

Single-centre review of a prospective surgical database and VTE records. Adults undergoing first time trans-sphenoidal pituitary surgery were included (2009-2018). VTE was defined as either deep vein thrombosis and/or pulmonary embolism within 3 months of surgery. Postoperative haematomas were those associated with a clinical deterioration together with radiological evidence.

RESULTS

651 Patients included with a median age of 55 years (range 16-86 years). Most (99%) patients underwent trans-sphenoidal surgery using a standard endoscopic single nostril or bi-nostril trans-sphenoidal technique. More than three quarters had pituitary adenomas (n = 520, 80%). Postoperative chemoprophylaxis to prevent VTE was administered in 478 patients (73%). Chemoprophylaxis was initiated at a median of 1 day post-procedure (range 1-5 days postoperatively; 92% on postoperative day 1). Tinzaparin was used in 465/478 patients (97%) and enoxaparin was used in 14/478 (3%). There were no cases of VTE, even in 78 ACTH-dependent Cushing's disease patients. Six patients (1%) developed postoperative haematomas. Chemoprophylaxis was not associated with a significantly higher rate of postoperative haematoma formation (Fisher's Exact, p = 0.99) or epistaxis (Fisher's Exact, p > 0.99).

CONCLUSIONS

Chemoprophylaxis after trans-sphenoidal pituitary surgery on post-operative day 1 is a safe strategy to reduce the risk of VTE without significantly increasing the risk of postoperative bleeding events.

Complication avoidance protocols in endoscopic pituitary adenoma surgery: a retrospective cohort study in 514 patients

PURPOSE

To evaluate the impact of using consistent complication-avoidance protocols in patients undergoing endoscopic pituitary adenoma surgery including techniques for avoiding anosmia, epistaxis, carotid artery injury, hypopituitarism, cerebrospinal fluid leaks and meningitis.

METHODS

All patients undergoing endoscopic adenoma resection from 2010 to 2020 were included. Primary outcomes included 90-day complication rates, gland function outcomes, reoperations, readmissions and length of stay. Secondary outcomes were extent of resection, short-term endocrine remission, vision recovery.

RESULTS

Of 514 patients, (mean age 51 ± 16 years; 78% macroadenomas, 19% prior surgery) major complications occurred in 18(3.5%) patients, most commonly CSF leak (9, 1.7%) and meningitis (4, 0.8%). In 14 of 18 patients, complications were deemed preventable. Four (0.8%) had complications with permanent sequelae (3 before 2016): one unexplained mortality, one stroke, one oculomotor nerve palsy, one oculoparesis. There were no internal carotid artery injuries, permanent visual worsening or permanent anosmia. New hypopituitarism occurred in 23/485(4.7%). Partial or complete hypopituitarism resolution occurred in 102/193(52.8%) patients. Median LOS was 2 days; 98.3% of patients were discharged home. Comparing 18 patients with major complications versus 496 without, median LOS was 7 versus 2 days, respectively p < 0.001. Readmissions occurred in 6%(31/535), mostly for hyponatremia (18/31). Gross total resection was achieved in 214/312(69%) endocrine-inactive adenomas; biochemical remission was achieved in 148/209(71%) endocrine-active adenomas. Visual field or acuity defects improved in 126/138(91.3%) patients.

CONCLUSION

This study suggests that conformance to established protocols for endoscopic pituitary surgery may minimize complications, re-admissions and LOS while enhancing the likelihood of preserving gland function, although there remains opportunity for further improvements.

Early outcomes of endoscopic endonasal approach pituitary adenomas resection with minimal nasal injury

To report the results of a consecutive series of pituitary adenomas resected through endoscopic endonasal approach (EEA) with minimal nasal injury.Retrospectively review tumor characteristics and surgical outcomes of a consecutive series of EEA pituitary adenomas resection performed mainly by a single author between March 2018 and June 2019.A total of 75 endoscopic endonasal approach pituitary adenoma resections were performed by the authors' team. Of the 75 patients, 28 through mononostril EEA, 47 through Binonostril EEA. Hadad-Bassagasteguy vascularized nasoseptal flap was harvested in only 4 (5.3%) patients with a high risk of postoperative cerebrospinal fluid leak, and one side middle turbinate only been resected in 2 (2.7%) patients, other patients preserved bilateral middle turbinate. Of the 75 patients, gross total resection is 74.7%, near-total resection is 16.0%. Endocrinological remission was achieved in 76.9% of GH-secreting adenomas, 61.5% of prolactin-secreting adenomas. The postoperative cerebrospinal fluid leak rate was 2.7%. Two patients had suprasellar hemorrhage, 1 patient had perioperative stroke, 2 patients had permanent diabetes insipidus, no cranial nerve deficits, internal carotid artery injury, anosmia, and death. The sino-nasal function was measured with the Sino-Nasal Outcome Test-22 and visual analog scale for olfaction preoperatively and postoperatively, and there was no statistically significant difference.The EEA is an effective approach to resect pituitary adenomas, the gross total resection and near-total resection rate and endocrinological remission rate are satisfactory. The EEA is a safe approach, as the complication rate is acceptable compared with those reported in the previous series of microscopic and endoscopic approaches. These results can be achieved with minimal nasal injury.

Avoiding Complications in Endoscopic Trans-Sphenoidal Surgery for Pituitary Adenoma: A Beginner's Perspective

Introduction:

We aimed to analyze the difficulties and complications experienced while as a beginner in endoscopic transnasal transsphenoidal approach for pituitary adenomas.

Materials and Methods:

We retrospectively analyzed 83 cases done from June 2016 to August 2019. Navigation-guided endoscopic transnasal transsphenoidal approach was used in all the cases.

Results:

Gross total tumor removal was achieved in 55 (66.26%) patients. We found that gross total resection rate was inversely proportional to Knosp grading, and the extent of resection was found to have a statistically significant correlation with grade of tumor (P < 0.05). Surgery-related complications were present in 33 of our patients. Nasal complications occurred in six patients: three epistaxis (3.6%) and two hyposmia (2.4%) and one case of septal hematoma (1.2%). Postoperative cerebrospinal fluid leak occurred in six (7.2%) cases, two (2.4%) cases had sinusitis, while two (2.4%) cases had meningitis. There was a very rare case of subarachnoid hemorrhage and one case had sellar hematoma. Endocrinologic complications occurred in 15 (18.07%) patients: anterior pituitary deficiency in five (6.02%) patients, transient diabetes insipidus (DI) in nine (10.84%) patients, and permanent DI in one (1.2%) patient. There was no vascular injury or mortality noted in our study.

Conclusion:

Endoscopic approach is an effective modality for pituitary surgery; with patience, learning lessons from your own mistakes and by adopting right technique, learning curve can be flattened significantly.