Endonasal transsphenoidal approach for pituitary adenomas and other sellar lesions: an assessment of efficacy, safety, and patient impressions

Effect of preservation versus resection of turbinate on olfactory function in endoscopic trans-nasal trans-sphenoidal pituitary surgery: a systematic review and meta-analysis

BACKGROUND

Utilizing endoscopes in surgery offers advantages and concerns, including potential nasal function impacts. Hyposmia following Transseptal Transsphenoidal hypophysectomy ranges from 0% to 2.2%. Debates persist about managing the M.T. in endoscopic sinus surgery due to its impact on nasal function. While preservation is recommended for sinonasal health, debates continue, as certain cases require resection. Our meta-analysis aims to compare turbinate resection and preservation effects on olfactory function.

METHODS

We searched five electronic databases to collect all relevant studies. Records were screened for eligibility. Data were extracted from the included studies independently. Our continuous outcomes were pooled as standardized mean difference with 95% CI. Statistical analyses was done by RevMan.

RESULTS

Our meta-analysis included four studies involving 235 patients (81 males). Evaluating changes in olfaction scores, two one-month studies (82 patients) revealed no significant difference between preservation and resection groups (Std.MD = 0.05[-0.39, 0.50], p = 0.81). For three-month assessments (146 patients), SNOT tests indicated no significant difference (Std.MD = 0.21, 95% CI[-0.11, 0.54], p = 0.20). Two studies used other tests on 70 patients at three months, yielding no significant difference (Std.MD = 0.13, 95% CI [-0.35, 0.62], p = 0.59). Two six-month studies (72 patients) similarly found no significant difference (Std.MD = 0.09, 95% CI [-0.39, 0.56], p = 0.72).

CONCLUSION

Our meta-analysis involving 235 patients examined olfaction score changes over various time frames in trans-nasal trans-sphenoidal pituitary surgeries. No significant differences were observed between turbinate preservation and resection groups at one month, three months, or six months post-surgery.

Intraoperative prevention of nasal mucosal injury and surgical field contamination during single-nostril transnasal endoscopic pituitary adenomas resection

BACKGROUND

The common complications of transnasal endoscopic pituitary adenomas resection include nasal hemorrhage, olfactory disorder, nasal adhesion, and intracranial infection. Consequently, the protection of nasal mucosa and the prevention of surgical field contamination are critical.

METHOD

We presented a step-by-step description of the methods of the disinfection and protection of nasal mucosa and the prevention of surgical field contamination during transnasal endoscopic pituitary adenomas resection, and these comprehensive measures to prevent these complications have not been documented.

CONCLUSION

These measures effectively reduce the risk of nasal mucosal injury and surgical field contamination, and are easy to perform.

Frontiers of Cranial Base Surgery: Integrating Technique, Technology, and Teamwork for the Future of Neurosurgery

The landscape of cranial base surgery has undergone monumental transformations over the past several decades. This article serves as a comprehensive survey, detailing both the historical and current techniques and technologies that have propelled this field into an era of unprecedented capabilities and sophistication. In the prologue, we traverse the historical evolution from rudimentary interventions to the state-of-the-art neurosurgical methodologies that define today's practice. Subsequent sections delve into the anatomical complexities of the anterior, middle, and posterior cranial fossa, shedding light on the intricacies that dictate surgical approaches. In a section dedicated to advanced techniques and modalities, we explore cutting-edge evolutions in minimally invasive procedures, pituitary surgery, and cranial base reconstruction. Here, we highlight the seamless integration of endocrinology, biomaterial science, and engineering into neurosurgical craftsmanship. The article emphasizes the paradigm shift towards "Functionally" Guided Surgery facilitated by intraoperative neuromonitoring. We explore its historical origins, current technologies, and its invaluable role in tailoring surgical interventions across diverse pathologies. Additionally, the digital era's contributions to cranial base surgery are examined. This includes breakthroughs in endoscopic technology, robotics, augmented reality, and the potential of machine learning and AI-assisted diagnostic and surgical planning. The discussion extends to radiosurgery and radiotherapy, focusing on the harmonization of precision and efficacy through advanced modalities such as Gamma Knife and CyberKnife. The article also evaluates newer protocols that optimize tumor control while preserving neural structures. In acknowledging the holistic nature of cranial base surgery, we advocate for an interdisciplinary approach. The ecosystem of this surgical field is presented as an amalgamation of various medical disciplines, including neurology, radiology, oncology, and rehabilitation, and is further enriched by insights from patient narratives and quality-of-life metrics. The epilogue contemplates future challenges and opportunities, pinpointing potential breakthroughs in stem cell research, regenerative medicine, and genomic tailoring. Ultimately, the article reaffirms the ethos of continuous learning, global collaboration, and patient-first principles, projecting an optimistic trajectory for the field of cranial base surgery in the coming decade.

Rhinologic outcome of endoscopic transnasal-transsphenoidal pituitary surgery: an institutional series, systematic review, and meta-analysis

PURPOSE

We aimed to summarize the available data on the objective rhinologic outcome after endoscopic transnasal-transsphenoidal (ETT) surgery.

METHODS

Retrospective study on a consecutive cohort of treatment-naïve patients undergoing ETT pituitary gland surgery. Additionally, a systematic review and meta-analysis with focus on the rhinologic outcome, including postoperative smell function was performed.

RESULTS

The institutional series incorporated 168 patients. A concomitant endoscopic septoplasty was performed in 29/168 patients (17.3%). A nasoseptal flap was used for reconstruction of large skull-base defects or high-flow CSF leaks in 4/168 (2.4%) patients. Early postoperative rhinologic complications (< 4 weeks) included epistaxis (3%), acute rhinosinusitis (1.2%) and late postoperative complications (≥ 8 weeks) comprised prolonged crusting (15.6%), symptomatic synechiae (11.9%) and septal perforation (0.6%). Postoperative smell function was not impaired (Fisher's exact test, p = 1.0). The systematic review included 19 studies on 1533 patients with a median postoperative epistaxis rate of 1.4% (IQR 1.0-2.2), a postoperative acute rhinosinusitis rate of 2.3% (IQR 2.1-3.0), a postoperative synechiae rate of 7.5% (IQR 1.8-19.1) and a postoperative septal perforation rate of 2.2% (IQR 0.5-5.4). Seven studies including a total of 206 patients reported adequate outcome measures for smell function before and after ETT surgery. Only 2/7 studies reported an impairment of smell function postoperatively, especially in patients with nasoseptal flap harvesting.

CONCLUSION

Early and late postoperative rhinologic complication rates after ETT surgery for pituitary lesions seem to be low. A thorough evaluation of smell function, in particular in patients at risk for nasoseptal flap harvesting, may be an important factor in optimal postoperative care.

Modified Nasoseptal Flap Technique to Prevent the Recurrence of Rathke's Cleft Cyst

Background

Rathke's cleft cysts (RCCs) are benign epithelial lesions arising from the Rathke's pouch remnants that fail to regress during embryogenesis. Some RCCs become symptomatic and require treatment. Cyst fenestration and drainage of its contents is the preferred procedure to treat symptomatic cases but carries a risk of recurrence. We propose the use of a novel modified nasoseptal flap technique to partially line the cyst wall to avoid recurrence.

Methods

This was a prospective, observational study that included all RCC patients admitted to the Department of Neurosurgery, Aster Medcity, from April 2015 to May 2018. The modified nasoseptal flap technique was performed in all patients. They underwent preoperative and postoperative ophthalmological, endocrine, endoscopic, and MRI evaluations to look for recurrence.

Results

Ten patients underwent the modified nasoseptal flap technique. The median follow-up was 36 months. Postoperatively, all patients were relieved from headaches. Moreover, their visual fields and pituitary functions normalized. None of the patients developed recurrence of RCC on follow-up brain MRI. On endoscopic examination, all patients had retained patency of the fenestra. The longest follow-up was 72 months.

Conclusions

The modified nasoseptal flap technique maintains patency and avoids recurrence of RCCs on long-term follow-up.

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.

The Party Wall: Redefining the Indications of Transcranial Approaches for Giant Pituitary Adenomas in Endoscopic Era

The evolution of endoscopic trans-sphenoidal surgery raises the question of the role of transcranial surgery for pituitary tumors, particularly with the effectiveness of adjunct irradiation. This narrative review aims to redefine the current indications for the transcranial approaches for giant pituitary adenomas in the endoscopic era. A critical appraisal of the personal series of the senior author (O.A.-M.) was performed to characterize the patient factors and the tumor's pathological anatomy features that endorse a cranial approach. Traditional indications for transcranial approaches include the absent pneumatization of the sphenoid sinus; kissing/ectatic internal carotid arteries; reduced dimensions of the sella; lateral invasion of the cavernous sinus lateral to the carotid artery; dumbbell-shaped tumors caused by severe diaphragm constriction; fibrous/calcified tumor consistency; wide supra-, para-, and retrosellar extension; arterial encasement; brain invasion; coexisting cerebral aneurysms; and separate coexisting pathologies of the sphenoid sinus, especially infections. Residual/recurrent tumors and postoperative pituitary apoplexy after trans-sphenoidal surgery require individualized considerations. Transcranial approaches still have a critical role in giant and complex pituitary adenomas with wide intracranial extension, brain parenchymal involvement, and the encasement of neurovascular structures.

Optimizing Perioperative Care in Transsphenoidal Pituitary Surgery: Considerations for Enhanced Recovery After Surgery

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.

Pituitary Adenomas: Classification, Clinical Evaluation and Management

Pituitary adenomas are one of the most common brain tumors. They represent approximately 18% of all intracranial, and around 95% of sellar neoplasms. In recent years, our understanding of the pathophysiology and the behavior of these lesions has led to better control and higher curative rates. The treatment decision is largely dependent on type of the adenoma, clinical presentation, and the size of the lesion. In addition, incidental pituitary lesions add uncertainty in the decision-making process, especially for pituitary adenomas that can be medically managed. When surgery is indicated, the endoscopic endonasal transsphenoidal approach is the technique of choice, but open standard craniotomy approaches can also be the option in selected cases. The following chapter will review the classification, clinical presentation, pathophysiology, diagnostic work-up, selection of surgical approach, and treatment complications in pituitary adenomas.

Growth hormone secreting pituitary adenomas show distinct extrasellar extension patterns compared to nonfunctional pituitary adenomas

PURPOSE

Patterns of extension of pituitary adenomas (PA) may vary according to PA subtype. Understanding extrasellar extension patterns in growth hormone PAs (GHPA) vis-a-vis nonfunctional PAs (NFPAs) may provide insights into the biology of GHPA and future treatment avenues.

METHODS

Preoperative MR imaging (MRI) in 179 consecutive patients treated surgically for NFPA (n = 139) and GHPA (n = 40) were analyzed to determine patterns of extrasellar growth. Extension was divided into two principal directions: cranio-caudal (measured by infrasellar/suprasellar extension), and lateral cavernous sinus invasion (CSI) determined by Knosp grading score of 3-4. Suprasellar extension was defined as tumor extension superior to the tuberculum sellae- dorsum sellae line, and inferior extension as invasion through the sellar floor into the sphenoid sinus or clivus. Categorical analysis was performed using Fisher's exact test.

RESULTS

GHPAs were overall more likely to remain purely intrasellar compared to NFPA (50% vs 26%, p < 0.001). GHPAs, however, were 7 times more likely to exhibit isolated infrasellar extension compared to NFPA (20% vs 2.8%, p = 0.001). Conversely, NFPAs were twice as likely to exhibit isolated suprasellar extension compared to GHPA (60% vs 28%, p < 0.001), as well as combined suprasellar/infrasellar extension (25% vs 3%, p = 0.011). There were no overall differences in CSI between the two subgroups.

DISCUSSION

GHPA and NFPA demonstrate distinct extrasellar extension patterns on MRI. GHPAs show proclivity for inferior extension with bony invasion, whereas NFPAs are more likely to exhibit suprasellar extension through the diaphragmatic aperture. These distinctions may have implications into the biology and future treatment of PAs.

Microwaves as Diagnostic Tool for Pituitary Tumors: Preliminary Investigations

To date, tumors, the second cause of death worldwide, are a modern medicine plight. The development of rapid, cost-effective and reliable prevention and diagnostics tools is mandatory to support clinicians and ensure patients’ adequate intervention. Pituitary tumors are a class of neoplasm, which calls for suitable and ad hoc diagnostic tools. Recently, microwaves have gained interest as a non-ionizing, non-invasive valuable diagnostic approach for identifying pathologic tissues according to their dielectric properties. This work deals with the preliminary investigation of the feasibility of using microwaves to diagnose pituitary tumors. In particular, it focuses on benign tumors of the adenohypophysis, e.g., the pituitary adenomas. It is assumed to access the region of interest of the pituitary region by following a trans-sphenoidal approach. The problem was modeled by developing an equivalent transmission line model of the multi-layered, lossy tissues (front bone of sphenoid sinuses, air in the sinuses, posterior bone of sphenoid sinuses, the pituitary gland and the tumor). The forward problem was developed to investigate the transmission coefficient for identifying the most favorable propagation conditions. Then, it was analyzed if, by the solution of an inverse problem, it is possible to reconstruct the permittivity and electrical conductivity profiles and identify the tumor presence. The results are promising since a maximum reconstruction error of 8% is found, in the worst case, thus paving the way for the use of microwaves for the diagnosis of pituitary tumors.

Approach to the Patient: Differential Diagnosis of Cystic Sellar Lesions

Cystic lesions arising in the sellar region are not uncommon and encompass cystic pituitary adenomas, Rathke cleft cysts, craniopharyngiomas, and arachnoid cysts. Their clinical presentation may be similar, including headache, visual field defects, and anterior pituitary hormone deficits, which makes differential diagnosis challenging. On the other hand, imaging features may indicate certain pathologies. In this approach to the patient, we describe the case of a patient who presented with right temporal hemianopsia and a sellar/suprasellar cystic lesion, which was determined to be Rathke cleft cyst. We discuss the imaging characteristics that may suggest a particular diagnosis between Rathke cleft cyst, cystic pituitary adenoma, craniopharyngioma, and arachnoid cyst and propose a flowchart for aiding in the imaging differential diagnosis.

A Modified Microscopic-Endoscopic Bilateral Transseptal Approach for Pituitary Adenomas: Comparisons of Nasal Outcome and Quality of Life Using the Microscopic Transnasal Approach

OBJECTIVES

In this study, we introduced a novel modified microscopic-endoscopic bilateral transseptal approach for pituitary adenoma resection to minimize surgery-related nasal injury. We also retrospectively compared comprehensive nasal outcomes and quality of life between the microscopic transnasal approaches.

METHODS

Patients with pituitary adenomas who underwent modified microscopic-endoscopic bilateral transseptal or microscopic transnasal approaches were assessed for olfactory function and quality of life using the Sniffin' Sticks test, the Sino-Nasal Outcome Test-22 (SNOT-22), the SF-36, the anterior skull base (ASK) nasal inventory, and the subjective visual analog scale (VAS) before and 1 and 3 months after surgery. A nasal endoscopy procedure was also performed to evaluate structure abnormalities at 1 and 3 months after surgery.

RESULTS

Fifty-eight patients who underwent either modified microscopic-endoscopic bilateral transseptal (35 patients) or microscopic transnasal (23 patients) surgery were consecutively enrolled. Patients who underwent either transnasal approach experienced similar surgical complications, except for intraoperative cerebrospinal fluid leakage (43.5% vs 14.3% for modified microscopic-endoscopic bilateral transseptal or microscopic transnasal approach, respectively; p = 0.013). Patients who underwent the two approaches fully recovered according to the SF-36, SNOT-22, VAS, and Sniffin' Sticks surveys, but not ASK scores, 3 months post-operatively. There was no significant difference in nasal endoscopy outcome at 3 months follow-up between the two approaches.

CONCLUSIONS

The modified microscopic-endoscopic bilateral transseptal approach showed largely similar nasal mucosa protective outcomes to those of the microscopic transnasal approach for pituitary adenoma surgery. After pituitary adenoma resection using the modified approach, patients' postoperative olfactory function, nasal structure, and quality of life can be restored to preoperative status within 3 months.

Robotic and robot-assisted skull base neurosurgery: systematic review of current applications and future directions

OBJECTIVE

The utility of robotic instrumentation is expanding in neurosurgery. Despite this, successful examples of robotic implementation for endoscopic endonasal or skull base neurosurgery remain limited. Therefore, the authors performed a systematic review of the literature to identify all articles that used robotic systems to access the sella or anterior, middle, or posterior cranial fossae.

METHODS

A systematic review of MEDLINE and PubMed in accordance with PRISMA guidelines performed for articles published between January 1, 1990, and August 1, 2021, was conducted to identify all robotic systems (autonomous, semiautonomous, or surgeon-controlled) used for skull base neurosurgical procedures. Cadaveric and human clinical studies were included. Studies with exclusively otorhinolaryngological applications or using robotic microscopes were excluded.

RESULTS

A total of 561 studies were identified from the initial search, of which 22 were included following full-text review. Transoral robotic surgery (TORS) using the da Vinci Surgical System was the most widely reported system (4 studies) utilized for skull base and pituitary fossa procedures; additionally, it has been reported for resection of sellar masses in 4 patients. Seven cadaveric studies used the da Vinci Surgical System to access the skull base using alternative, non-TORS approaches (e.g., transnasal, transmaxillary, and supraorbital). Five cadaveric studies investigated alternative systems to access the skull base. Six studies investigated the use of robotic endoscope holders. Advantages to robotic applications in skull base neurosurgery included improved lighting and 3D visualization, replication of more traditional gesture-based movements, and the ability for dexterous movements ordinarily constrained by small operative corridors. Limitations included the size and angulation capacity of the robot, lack of drilling components preventing fully robotic procedures, and cost. Robotic endoscope holders may have been particularly advantageous when the use of a surgical assistant or second surgeon was limited.

CONCLUSIONS

Robotic skull base neurosurgery has been growing in popularity and feasibility, but significant limitations remain. While robotic systems seem to have allowed for greater maneuverability and 3D visualization, their size and lack of neurosurgery-specific tools have continued to prevent widespread adoption into current practice. The next generation of robotic technologies should prioritize overcoming these limitations.

Effects of nasal irrigation after endoscopic transsphenoidal resection in patients with pituitary adenomas: A randomized controlled trial

PURPOSE

We aimed to explore the methods to reduce or prevent nasal complications after endoscopic transsphenoidal pituitary adenoma resection. We also examined the effects of nasal irrigation after this procedure was performed.

METHODS

A randomized controlled trial was performed. Sixty patients of a tertiary hospital were enrolled in this study. The subjects were randomly divided into a control group and an intervention group. The subjects of the control group were given routine guidance, and 20 mL of normal saline was atomized through inhalation. The gauze was removed 7 days after surgery. The patients of the intervention group were given 50 mL of a 2% saline solution at 37°C to 38°C for bilateral nasal irrigation for 1 week. After that, patients were given 50 mL of a 0.9% normal saline solution at 37°C to 38°C for bilateral nasal irrigations. The complications of the two groups were collected at baseline, 1 week after intervention, 1 month, and 3 months after intervention. The data were analyzed using the chi-square test.

RESULTS

A 1-month after intervention, there were significant differences in dysosmia, epistaxis, and nasal adhesion between the intervention and control groups. A 3-month after intervention, only olfactory disturbances were significantly different between the two groups.

CONCLUSIONS

Nasal irrigation helps reduce the incidence of complications such as epistaxis and nasal adhesions in the early postoperative period. It can also promote the elimination or reduction of olfactory disturbances.

Postoperative Oral Antibiotics and Sinonasal Outcomes Following Endoscopic Transsphenoidal Surgery for Pituitary Tumors Study: A Multicenter, Prospective, Randomized, Double-Blinded, Placebo-Controlled Study

BACKGROUND

Postoperative prophylactic antibiotics are commonly used in pituitary surgery, but evidence supporting their use is lacking, which has implications for antibiotic stewardship.

OBJECTIVE

To evaluate whether receipt of postoperative oral antibiotics results in superior sinonasal quality of life (QOL) compared with placebo among patients who undergo endoscopic endonasal transsphenoidal pituitary surgery.

METHODS

Patients were randomized to receive either oral placebo or cefdinir (trimethoprim-sulfamethoxazole in patients intolerant to cefdinir) for 7 d after surgery. They were monitored for 12 wk. The primary outcome measure was sinonasal QOL at 2 wk on the Anterior Skull Base Nasal Inventory-12. Supplementary end points included sinonasal QOL reported on the Sinonasal Outcome Test-22 and objective endoscopy scores to assess nasal healing according to the Lund-Kennedy method.

RESULTS

A total of 461 patients were screened, 131 were randomized, and 113 (placebo arm: 55; antibiotic arm: 58) were analyzed. There was no clinically meaningful or statistically significant difference in sinonasal QOL at any measured time point (P ≥ .24) using either instrument. Nasal cavity endoscopy scores were not significantly different at 1 to 2 wk after surgery (P = .25) or at 3 to 4 wk after surgery (P = .08).

CONCLUSION

Postoperative prophylactic oral antibiotics did not result in superior sinonasal QOL compared with placebo among patients who underwent standard endoscopic transsphenoidal surgery.

Cure and Hormonal Control After Prolactinoma Resection: Case Series and Systematic Review

Context

Surgical management of prolactinomas is an important treatment for patients intolerant of dopamine agonist therapy. However, predictors of postoperative outcomes remain unclear.

Object

While transsphenoidal surgical resection (TSSR) is important second-line therapy in prolactinoma patients, predictors of surgical cure and biochemical remission following TSSR remain sparse.

Methods

A retrospective review of prolactinoma patients undergoing TSSR at the USC Pituitary Center from 1995 to 2020 was conducted. Participants were categorized as surgical cure (normalization of serum prolactin without medical treatment), surgical noncure, biochemical control (prolactin normalization with or without adjuvant therapy), and nonbiochemical control. A systematic review of the outcomes of surgically managed prolactinomas was performed.

Results

The 40 female and 16 male participants had an average age of 35.6 years. Prior treatment included transsphenoidal resection (6, 11%) and dopamine agonist treatment (47, 84%). The 40 macroadenomas and 15 microadenomas exhibited suprasellar extension (24, 43%) and parasellar invasion (20, 36%). Fifteen (27%) were purely intrasellar. Gross total resection was achieved in 25 patients (45%) and subtotal in 26 (46%). Surgical cure was achieved in 25 patients (46%) and biochemical control in 35 (64%). Surgical cure was more likely in smaller, noninvasive tumors, those that were fully resected, and patients with lower preoperative (< 1000 ng/mL) and immediately postoperative (< 7.6 ng/mL) prolactin levels. Ten of 26 patients (38%) undergoing adjuvant therapy achieved biochemical control, which was less likely in men and those with higher preoperative prolactin or invasive tumors.

Conclusion

Surgical resection of prolactinomas is a safe procedure that, when offered judiciously, can achieve symptom and/or biochemical control in a majority of patients. A variety of predictors may be useful in advising patients on likelihood of postoperative remission.

Patterns of extrasellar invasive growth of pituitary adenomas with normal sellar cavity size

BACKGROUND

Pituitary adenomas (PAs) are among the most common brain tumors which characteristically become symptomatic due to the mass effect on surrounding structures and/or hormonal imbalances. This study describes 28 cases of PAs with an extrasellar invasive growth (EIG) at the early stage of tumor growth with normal sellar cavity size.

METHODS

1200 cases of PAs either treated medically or via Endoscopic transsphenoidal surgery were reviewed during a 10-year period. Pre-operative imaging was analyzed to evaluate the tumor expansion pattern, tumor invasion sites and other relevant tumor properties. A comprehensive preoperative endocrinological along with postoperative histopathological studies were conducted to evaluate the subjects' homeostasis and further identify the lesions characteristics.

RESULTS

Of the 28 patients, patients 19, 2, 1 and 6 had a growth hormone (GH)-secreting PA, an adrenocorticotropic hormone (ACTH)-secreting PA, a nonfunctional PA (NFPA) and a mix-hormones secreting PA, respectively. There was a statistically significant difference between patients with and without EIG regarding types of PAs (P = 0.000). Post-hoc tests demonstrated that GH-secreting PAs (P = 0.0003) and mix-hormones secreting PAs (P = 0.0000) are significantly more invasive, while NFPAs (P = 0.0000) are less invasive. There was not a statistically significant difference between the invasion sites and different types of PAs (P = 0.122).

CONCLUSION

Among different histological subtypes of PAs, GH-secreting PAs revealed a remarkable tendency for EIG with normal sellar cavity size. The extra-sellar tumor extension with a normal sella did not correlate with atypical histology. Considering EIG patterns, surgeons should be vigilant to investigate and follow the tumor spreading to its enclosing boundary during surgery, the clival part of sphenoid bone should be more exposed, and both inferomedial and lateral borders of the sphenoid sinus should be carefully explored in order to remove the tumor.

Sniffin' Sticks to Measure Olfactory Function and Recovery Following Bilateral Superior Turbinate Resection as Part of Endoscopic Transsphenoidal Approach

BACKGROUND

Extended endoscopic transsphenoidal (EET) approaches can include complete resection of both superior turbinate (ST) for wider exposure. Moreover, ST resection has been associated with postoperative olfactory impairment.

OBJECTIVE

We sought to determine the impact of bilateral ST resection on olfaction during a transsphenoidal approach.

METHOD

A prospective observational study was conducted on 29 patients undergoing endoscopic skull base surgery sparing the olfactory tracts at a tertiary academic center. Olfactory function was measured with Sniffin' Sticks at the preoperative visit, 2-weeks and 6 to 8 weeks postoperatively. All components: odor threshold (OT), odor discrimination (OD), odor identification (OI) and composite scores (TDI = OT+OD+OI) were evaluated.

RESULT

Study was completed in 15 patients with 14 excluded due to a variety of reasons. At 2 weeks, a significant decrease was noted in composite scores (32.3 ± 5.4 vs. 23.8 ± 5.8, P < .05) and OT (7.7 vs. 3.2, P < .05). There was a significant increase in olfactory scores between post-op weeks 2 and 6 to 8 weeks in TDI (23.8 vs. 31.4, P < .05) as well as in OT (3.2 vs. 7.6, P < .05), OD (9.4 vs. 11.1, P < .05), and OI (11.1 vs. 12.7, P < .05). No significant difference was found between TDI (32.3 ± 5.4 vs. 31.4 ± 5.1), OT (7.7 vs. 7.6), OD (11.4 vs. 11.1) and OI (13.2 vs. 12.7) from preoperative and 6-8 weeks postoperative visits.

CONCLUSION

Patients undergoing bilateral ST resection during EET procedures experience transient hyposmia postoperatively. However, the olfactory function normalizes to preoperative levels at 6 to 8 weeks. The resection of the bilateral superior turbinate does not appear to decrease olfactory function.

Surgical Outcomes Following Repeat Transsphenoidal Surgery for Nonfunctional Pituitary Adenomas: A Retrospective Comparative Study

BACKGROUND

Endonasal transsphenoidal surgery (ETSS) remains the preferred treatment for recurrent or residual nonfunctional pituitary adenomas (NFPAs). However, surgical complications and outcomes with repeat ETSS are unclear.

OBJECTIVE

To compare outcomes from primary and repeat ETSS in patients with NFPAs.

METHODS

Retrospective review of ETSS for NFPAs at USC University Hospital and LAC + USC Medical Center between 2000 and 2015. Patients with ≥3-mo follow-up data were included. Patients were categorized as primary or repeat ETSS. Patient and tumor characteristics were compared preoperatively, and postoperative outcomes were analyzed.

RESULTS

Two hundred sixty-eight patients (89%) met the inclusion criteria (primary ETSS = 211 and repeat ETSS = 57) with a mean follow-up time of 38 mo (range 3-235 mo). Both groups had similar demographics, endocrine function, and tumor characteristics. Surgical complication rates were similar and no mortalities were observed. Repeat ETSS patients had a higher rate of new postoperative panhypopituitarism (primary ETSS: 0.5% vs repeat ETSS: 7.1%, P = .011), lower rates of gross total resection (GTR; primary ETSS: 59.2% vs repeat ETSS: 26.3%, P = .001), and greater rates of postoperative radiosurgery (36.8% vs 24.2%, P = .009). At 2-yr follow-up, progression-free survival on MRI was similar in both groups (primary ETSS: 97.9% vs repeat ETSS: 95.4%, log-rank test P = .807).

CONCLUSION

At experienced tertiary pituitary centers, repeat ETSS for NFPAs was associated with a similar incidence of surgical complications as primary ETSS. However, repeat ETSS carried a higher rate for worsening endocrine dysfunction and a lower rate of GTR.

Rhinological Consequences of Microsurgical Endonasal-Transsphenoidal Surgery for Pituitary Tumors

BACKGROUND

Transsphenoidal surgery for sellar lesions may affect patency and function of the nasal airways, smell and sinonasal quality of life. Below is our report on otorhinolaryngological data garnered from patients undergoing endonasal transsphenoidal pituitary microsurgery.

METHODS

In a prospective study, 68 patients scheduled for transsphenoidal operations (32 female, 36 male, age 17-72 years) underwent otorhinolaryngological evaluation of their nasal morphology, a standardized smell test (sniffin' sticks) and rhinomanometry to analyse nasal breathing function preoperatively, 3-5 days postoperatively (without rhinomanometry), after 3-4 months and after 9 months.

RESULTS

Immediately after surgery, a reduction in smell sensation was detected in almost all patients. Within 3 months, this impairment resolved in all cases except one. In 2 patients (3%) with preoperative anosmia, improvement of smell function to>6 out of 12 sniffin' sticks was observed. At final visit no patient was noted to have new anosmia. Within 3 months, the results of the rhinomanometry revealed that all patients except one, regained their preoperative nasal breathing function. In 6 patients (8.8%) an improvement in their nose breathing abilities compared to the preoperative state was found. Three patients (4.4%) underwent a LASER transection of mucosal synechiae. In one case with persistent nasal obstruction (1.5%), secondary septoplasty had to be performed. There was no case in which perforation of the nasal septum, nasal tip deflection, or saddle nose deformity was observed.

CONCLUSION

Microsurgical resection of pituitary tumors via the endonasal transsphenoidal approach poses an acceptable risk with regards to sinonasal complications. The incidence of secondary rhinosurgical interventions is low. Standardized comparative studies between endoscopic and microsurgical transsphenoidal operations should be undertaken.

Rathke's cleft cyst presentation mimicking craniopharyngioma: Case report

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Rathke’s cleft cysts are benign lesions from the remnants of the craniopharyngeal duct.

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Its diagnosis is often confused with craniopharyngioma.

•

Our case of this cyst demonstrates the importance of proper diagnosis and management.

Introduction

Rathke’s cleft cysts (RCCs) are benign cystic lesions from the remnant cells of the craniopharyngeal duct within Rathke’s pouch. Anticipation of such condition will help planning the treatment course.

Presentation of case

We present a case of a 46-year-old male, referred to our tertiary center with a history of seizures, confusion and agitation for the past two weeks. After thorough investigations, he was found to have hyponatremia with low serum cortisol and hypothyroidism. After being sedated, intubated and stabilized, Magnetic Resonance Imaging (MRI) brain showed relatively medium to large sellar lesion which was highly suspicious of a craniopharyngioma (CP). However, after performing an endoscopic transphenoidal surgical resection of the lesion, clinical diagnosis supported RCC.

Discussion

The best treatment approach for CP is a complete surgical resection via a transphenoidal approach. Considering the fluid component of RCC, it may be treated with a more conservative surgery and does not necessitate a surgery as invasive as that of CP.

Conclusion

Given the mixed solid and cystic nature of CPs, it is possible to confuse it with RCC and vice versa. The presented case highlights that Rathke’s cyst may be challenging in terms of pre-operative diagnosis, peri-surgical management and histopathological examination.

Expanded transnasal approaches to the skull base in the Middle East: Where do we stand?

BACKGROUND

Endoscopic transnasal surgery has gained rapid global acceptance over the last two decades. The growing literature and understanding of anterior skull base endoscopic anatomy, in addition to new dedicated endoscopic instruments and tools, have helped to expand the use of the transnasal route in skull base surgery.

OBJECTIVE

Report our early experience in expanded endoscopic transnasal surgery (EETS) and approach to skull base neoplasms.

DESIGN

Descriptive, retrospective case series.

SETTING

Major tertiary care center.

PATIENTS AND METHODS

A retrospective case review was conducted at King Saud University Medical City between December 2014 and August 2019. Cases with skull base neoplasms that underwent EETS were included. EETS was defined as endoscopic surgical exposure that extended beyond the sellar margins (prechiasmatic sulcus superiorly, clival recess inferiorly, cavernous carotid lines laterally). Routine transsphenoidal pituitary neoplasms, neoplasms of sinonasal origin and meningoencephaloceles were excluded.

MAIN OUTCOME MEASURES

Preoperative clinical assessment, imaging results, surgical approach, and hospital course were all retrieved from the patient electronic charts. Clinical follow-up, perioperative complications, and gross residual tumor rates were documented and reviewed.

SAMPLE SIZE AND CHARACTERISTICS

45 cases of EETS, 13 males and 32 females with mean age of 39.0 (17.7) years (range 2-70 years).

RESULTS

The series comprised a wide range of pathologies, including giant pituitary adenoma (8 cases), meningioma (23 cases), craniopharyngioma (4 cases), chordoma (4 cases), optic pathway glioma (2 cases), epidermoid neoplasms (2 cases), astrocytoma (1 case), and teratoma (1 case). For the entire series, gross total resection was achieved in 25/45 operations (55.5%). Postoperative cerebrospinal fluid leak was the most common complication observed in 9 patients (20%) which were all managed endoscopically. Major vascular complications occurred in 2 patients (4.4%) and are described. Other complications are outlined as well. No mortality was observed.

CONCLUSIONS

EETS to the skull base can be done with results comparable to traditional approaches. More work is needed to expand our experience, improve outcomes, and educate the public and medical community in our region about the usefulness of this approach.

LIMITATIONS

Sample size and study design.

CONFLICT OF INTEREST

None.

Perioperative nasal and paranasal sinus considerations in transsphenoidal surgery for pituitary disease

Endoscopic endonasal skull base surgery has emerged as the treatment modality of choice for a range of skull base lesions, particularly pituitary adenomas. However, navigation and manipulation of the nasal corridor and paranasal sinuses requires that surgeons are aware of effective techniques to maximize patient outcomes and avoid sinonasal morbidity postoperatively. This paper is a narrative review aimed to provide an updated and consolidated report on the perioperative management of the nasal corridor and paranasal sinuses in the setting of endoscopic skull base surgery for pituitary disease. Anatomic variants and common surgical techniques are discussed. Post-operative complications are evaluated in detail. Understanding the structural implications of the endonasal approach to the sphenoid is crucial to optimization of the surgical outcomes. We propose guidelines for perioperative management of endoscopic endonasal skull base surgery for pituitary diseases. Standardized treatment algorithms can improve patient satisfaction, and increase the comparability and the quality of reported information across research studies.

Visual Outcomes after Endoscopic Endonasal Transsphenoidal Resection of Pituitary Adenomas: Our Institutional Experience

Objectives  Visual dysfunction in patients with pituitary adenomas is a clear indication for endoscopic endonasal transsphenoidal surgery (EETS). However, the visual outcomes vary greatly among patients and it remains unclear what tumor, patient, and surgical characteristics contribute to postoperative visual outcomes. Methods  One hundred patients with pituitary adenomas who underwent EETS between January 2011 and June 2015 in a single institution were retrospectively reviewed. General patient characteristics, pre- and postoperative visual status, clinical presentation, tumor characteristics, hormone production, radiological features, and procedural characteristics were evaluated for association with presenting visual signs and visual outcomes postoperatively. Suprasellar tumor extension (SSE) was graded 0 to 4 following a grading system as formulated by Fujimoto et al. Results  Sixty-six (66/100) of all patients showed visual field defects (VFD) at the time of surgery, of whom 18% (12/66) were asymptomatic. VFD improved in 35 (35%) patients and worsened in 4 (4%) patients postoperatively. Mean visual acuity (VA) improved from 0.67 preoperatively to 0.84 postoperatively ( p  = 0.04). Nonfunctioning pituitary adenomas (NFPAs) and Fujimoto grade were independent predictors of preoperative VFD in the entire cohort ( p  = 0.02 and p  < 0.01 respectively). A higher grade of SSE was the only factor independently associated with postoperative improvement of VFD ( p  = 0.03). NFPA and Fujimoto grade 3 were independent predictors of VA improvement (both p  = 0.04). Conclusion  EETS significantly improved both VA and VFD for most patients, although a few patients showed deterioration of visual deficits postoperatively. Higher degrees of SSE and NFPA were independent predictors of favorable visual outcomes.

Three-Hand Endoscopic Endonasal Transsphenoidal Surgery: Experience With an Anatomy-Preserving Mononostril Approach Technique

BACKGROUND

Variations on the endoscopic transsphenoidal approach present unique surgical techniques that have unique effects on surgical outcomes, extent of resection (EOR), and anatomical complications.

OBJECTIVE

To analyze the learning curve and perioperative outcomes of the 3-hand endoscopic endonasal mononostril transsphenoidal technique.

METHODS

Prospective case series and retrospective data analysis of patients who were treated with the 3-hand transsphenoidal technique between January 2007 and May 2015 by a single neurosurgeon. Patient characteristics, preoperative presentation, tumor characteristics, operative times, learning curve, and postoperative outcomes were analyzed. Volumetric EOR was evaluated, and a logistic regression analysis was used to assess predictors of EOR.

RESULTS

Two hundred seventy-five patients underwent an endoscopic transsphenoidal surgery using the 3-hand technique. One hundred eighteen patients in the early group had surgery between 2007 and 2010, while 157 patients in the late group had surgery between 2011 and 2015. Operative time was significantly shorter in the late group (161.6 min) compared to the early group (211.3 min, P = .001). Both cohorts had similar EOR (early group 84.6% vs late group 85.5%, P = .846) and postoperative outcomes. The learning curve showed that it took 54 cases to achieve operative proficiency with the 3-handed technique. Multivariate modeling suggested that prior resections and preoperative tumor size are important predictors for EOR.

CONCLUSION

We describe a 3-hand, mononostril endoscopic transsphenoidal technique performed by a single neurosurgeon that has minimal anatomic distortion and postoperative complications. During the learning curve of this technique, operative time can significantly decrease, while EOR, postoperative outcomes, and complications are not jeopardized.

The Minimal Clinically Important Difference of the Anterior Skull Base Nasal Inventory-12

BACKGROUND

The minimal clinically important difference (MCID) is defined as the smallest change in health-related quality of life (QOL) that patients consider meaningful. The MCID is essential for determining clinically significant changes, rather than simply statistically significant changes, in QOL scores. The Anterior Skull Base Nasal Inventory-12 (ASK Nasal-12), a site-specific sinonasal QOL instrument, has emerged as a standard instrument for assessing QOL in patients who have undergone endonasal transsphenoidal surgery.

OBJECTIVE

To determine the MCID for the ASK Nasal-12.

METHODS

Distribution- and anchor-based methods were used to determine the MCID for the ASK Nasal-12 based on raw data from a multicenter prospective QOL study of 218 patients.

RESULTS

Two distribution-based statistical methods, the one-half standard deviation method and the effect-size method, both yielded MCIDs of 0.37 (medium effect). The first anchor-based method, using the 2-wk postoperative overall nasal functioning item as the anchor, yielded an MCID of 0.31. The second anchor-based method, using the 2-wk postoperative Short Form Health Survey 8 bodily pain item as the anchor, yielded an MCID of 0.29.

CONCLUSION

The largest MCID obtained for the ASK Nasal-12 using 4 statistical methods 2 wk postoperatively was 0.37. This information provides clinicians with an essential context for determining the clinical significance of changes in QOL scores after interventions. Our results will help clinicians better interpret QOL scores and design future studies that are powered to detect meaningful QOL changes.

Analysis of Olfaction after Bilateral Nasoseptal Rescue Flap Transsphenoidal Approach with Olfactory Mucosal Preservation

OBJECTIVE

To ascertain the impact of septal olfactory strip preservation and bilateral rescue flap elevation on the incidence of olfactory dysfunction.

STUDY DESIGN

Case series with chart review of patients undergoing endoscopic endonasal skull base surgery (2012-2014).

SETTING

Providence Saint John's Health Center and John Wayne Cancer Institute.

SUBJECTS AND METHODS

The incidences of postoperative epistaxis, hyposmia, and anosmia were analyzed using the Brief Smell Identification Test (B-SIT), which was completed in 110 of the 165 patients.

RESULTS

Seventy-eight patients required extended approaches. Bilateral nasoseptal rescue flaps were elevated in 144 patients (87.3%) and pedicled nasoseptal or middle turbinate flaps in 21 patients (12.7%). The neurovascular pedicles were preserved in all patients, and there were no episodes of postoperative arterial epistaxis. Normal olfaction was noted in 95 patients (86%), with new hyposmia noted in 5 patients (5.5%). Within the rescue flap cohort, new hyposmia occurred in 6.3% (P < .01) of patients, balanced by improvement of olfaction in 43% of patients with preoperative dysfunction (overall pre- and postoperative olfactory function: 85% vs 86%). Patients with pedicled nasoseptal flaps did not have new hyposmia, with a net improvement of olfaction (71% vs 86%, P = .07). No patients experienced new anosmia. There was no difference between flap type within either subgroup.

CONCLUSIONS

Superior olfactory strip preservation during elevation of reconstructive flaps preserves olfactory function and maintains adequate surgical exposure. In addition, rescue flaps have significantly diminished the rate of arterial postoperative epistaxis while maintaining the ability to harvest nasoseptal flaps for future reconstruction.

Postoperative CSF leakages after transsphenoidal surgery for pituitary adenomas: Analysis of a series of 302 surgical procedures

INTRODUCTION

Transsphenoidal surgical removal is the preferred treatment of most pituitary adenomas. Postoperative cerebrospinal fluid (CSF) leakage is the leading cause of morbidity after this procedure, with an incidence rate that varies from 0,5-15% in the main published series.

OBJECTIVES

The primary objective of this study was to establish the incidence of postoperative CSF leakage in a sample of surgeries performed at the University Hospital of La Ribera by the same surgical team. The secondary objectives were to: ascertain the distinctive features between patients with and without postoperative CSF leakage, identify risk factors for their development, evaluate the relationship between the surgical technique for closing the sella turcica and the onset of postoperative CSF leakage and evaluate different treatment regimens for this complication.

METHODS

The data of 302 consecutive transsphenoidal surgical procedures for pituitary adenoma removal which were performed between 1999 and 2017 were retrospectively reviewed.

RESULTS AND CONCLUSIONS

The incidence of postoperative CSF leakage in our series was 2,3% (in accordance with similar published studies). It was possible to correlate intraoperative CSF leakage with two variables: pituitary macroadenoma and tumors with suprasellar extension (P<.005). This correlation did not exist for postoperative CSF leakage. We found a statistically significant correlation between intraoperative and postoperative CSF leakage (P<.005). Due to the low incidence of postoperative CSF leakage in our series, it was not possible to identify risk factors for its development.

Early Basal Cortisol Level as a Predictor of Hypothalamic-Pituitary-Adrenal (HPA) Axis Function After Pituitary Tumor Surgery

PURPOSE

The purpose of this study was to evaluate the clinical relevance of the early postoperative basal cortisol level in assessing the postoperative hypothalamic-pituitary-adrenal (HPA) axis function after pituitary tumor surgery.

METHODS

We performed a prospective observational study that enrolled 83 patients operated for pituitary adenoma or other sellar lesions at the University Hospital Center Zagreb between December 2013 and April 2017 (44 nonfunctioning pituitary adenomas, 28 somatotropinomas, 5 craniopharyngiomas, 2 prolactinomas resistant to medical therapy and 4 other lesions - Rathke's cleft cyst, arachnoid cyst, chondroma and gangliocytoma). Exclusion criteria were Cushing's disease, chronic therapy with glucocorticoids prior to surgery and preoperative adrenal insufficiency. Early postoperative basal cortisol levels (measured on the second postoperative day) and the Synacthen stimulation test (performed 3 months after the surgery with the peak cortisol level of>500 nmol/L considered as a normal response) were analyzed to assess HPA axis function during follow-up.

RESULTS

ROC analysis showed a cut-off of the basal cortisol level of ≥300 nmol/L measured on the second postoperative day to predict normal postoperative HPA axis function with the sensitivity of 92.31%, specificity of 87.14% and positive predictive value of 57.14%.

CONCLUSION

The basal cortisol level on the second postoperative day is a valuable tool to predict integrity of the HPA axis after pituitary tumor surgery. Our data suggest that the cortisol level of ≥300 nmol/L accurately predicts adrenal sufficiency and that in these patients glucocorticoid therapy can be withdrawn.

Preventing Restenosis of Marsupialized Rathke Cleft Cysts Using a Nasoseptal Flap Lining

OBJECTIVES

Rathke cleft cysts (RCCs) are rare, benign lesions formed from remnants of Rathke pouch during embryologic development. However, following marsupialization, maintaining tract patency remains a challenge. Several techniques for decreasing stenosis have been described, including free mucosal grafting, silastic spacing, and using steroid-eluting stents. Nasoseptal flaps (NSFs) have a reliable vascular supply and are widely utilized in skull base reconstruction. We present a novel technique to maintain patency of the marsupialized RCC cavity by lining it with an NSF to promote long-term drainage and re-epithelialization of the RCC cavity.

METHODS

Retrospective chart review of all patients who underwent surgery for symptomatic RCCs. These patients underwent endoscopic endonasal surgery between February 3, 2016, and June 12, 2018, with marsupialization followed by circumferential NSF lining. Primary outcomes include symptomatic control, surgical complications, and RCC cavity patency.

RESULTS

Seven patients underwent RCC marsupialization with no intraoperative cerebrospinal fluid leak, followed by circumferential lining of the marsupialized cavity with an NSF. In each case, no cyst re-accumulation or recurrent symptoms were noted, and the NSF lining provided long-term patency of the tract in all cases to a mean of 6.7 ± 10.1 months of follow-up, including one patient with sustained patency at 29 months follow-up.

CONCLUSION

Utilization of the NSF to "stent open" the RCC cavity following marsupialization is a safe and effective means to prevent restenosis. Advantages include sustained patency of RCC cavity for complete drainage and a dependable vascular supply.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:2258-2261, 2019.

Predictive Factors, 30-Day Clinical Outcomes, and Costs Associated with Cerebrospinal Fluid Leak in Pituitary Adenoma Resection

Cerebrospinal fluid (CSF) leak is a complication of endoscopic endonasal pituitary adenoma resection. Previous studies examining complications of pituitary adenoma resection have not examined associations of an exhaustive list of clinical and financial variables with CSF leak. We designed a retrospective analysis of 334 consecutive patients that underwent endoscopic endonasal pituitary adenoma resection at a single institution over 5 years, analyzing associations between CSF leak and demographic data, operative data, comorbidities, clinical complications and outcomes, costs, charges, and payments. Of the 20 preoperative variables studied, none were positively associated with CSF leak in between-groups comparison, although multivariate analysis revealed an association with a history of radiation to the skull base (odds ratio [OR], 8.67; 95% confidence interval [CI], 0.94-57.03; p  < 0.05). CSF leak was associated with a significantly higher rate of postoperative diabetes insipidus (Δ = 33.4%, p  = 0.040) and increased length of stay after operation in between-groups comparison. Multivariate analysis on postoperative variables revealed significant associations between CSF leak and intracerebral hemorrhage (OR, 17.44; 95% CI, 0.65-275.3; p  < 0.05) and postoperative intracranial infection (OR, 28.73; 95% CI, 2.04-438.7; p  < 0.05). Also, CSF leak was associated with significantly higher costs (Δ = $15,643, p  < 0.05) and hospital charges (Δ = $46,026, p  < 0.05). Operating room time, room and board, and supplies and implants were the strongest cost drivers. This study highlights the difficulty of utilizing preoperative variables to predict CSF leak, the clinical complications and outcomes of leak, and the financial subcategories that drive the costs, charges, and payments associated with this complication.

Clinical study of pituitary tumors with EEA resection and its influence on the expression of tumor necrosis factor-α, interleukin-6, and interleukin-12 in patients

The aim of this study is to investigate the efficacy of expanded endonasal approaches (EEAs) in the treatment of pituitary adenoma, and the effects of serum levels of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and interleukin-12 (IL-12) in patients were further analyzed. A total of 80 cases of patients with pituitary adenoma admitted to our hospital from January 2013 to May 2015 were randomly divided into the observation group and control group, with 40 cases in each group. The observation group was treated with EEA technique, while the control group was treated with transcranial microsurgery. The prolactin (PRL), growth hormone (GH) and other endocrine hormone indexes, as well as inflammatory factors such as TNF-α, IL-6, and IL-12 were compared before and 1 week after the operation between the two groups. Moreover, the scores of Karnofsky performance status (KPS) and Mini-Mental State Examination (MMSE) at preoperative and postoperative 1 week were also compared between the two groups. The operation time, hospitalization time, and postoperative complications were compared between the two groups. And the patients were followed up for 2 years to observe the recurrence rate. The operation time and hospital stay in the observation group were 62.8 ± 9.3 min and 12.5 ± 2.1 days, respectively, while the operation time and length of stay in the control group were 105.6 ± 15.7 min and 18.2 ± 3.4 days, respectively. The operation time and hospitalization time were shorter than those in the control group, and the differences were statistically significant ( P < 0.05). Before surgery, there was no significant difference in serum levels of PRL and GH between the two groups ( P > 0.05). At 1 week after surgery, the levels of PRL and GH in the two groups were significantly lower than those before surgery ( P < 0.05). And the serum levels of PRL and GH in the observation group were significantly lower than those in the observation group at 1 week after the operation ( P < 0.05). Before operation, there was no significant difference between the two groups of KPS and MMSE scores ( P > 0.05). At 1 week after operation, the scores of KPS and MMSE in both groups were significantly higher than those before the operation ( P < 0.05), and the scores of KPS and MMSE in the observation group were significantly higher than those in the control group ( P < 0.05). Furthermore, there was no significant difference in the serum levels of IL-6, IL-12, and TNF-α between the two groups before operation ( P > 0.05). At 1 week after surgery, the serum levels of IL-6, IL-12, and TNF-α in the two groups were significantly lower than those before surgery ( P < 0.05), while the serum levels of IL-6, IL-12, and TNF-α in the observation group were evidently lower than those in the control group at 1 week after the operation. Besides, the incidence of postoperative complications in the observation group was 7.5%, which was significantly lower than that in the control group (17.5%) ( P < 0.05). All the patients in the two groups were followed up for 2 years. And there was no recurrence in the observation group and one case in the control group. The therapeutic effect of EEAs on pituitary adenoma is better. It can improve the level of high endocrine hormone in patients with pituitary adenoma, improve the functional status of the patients, reduce the serum level of inflammatory factors, and shorten the hospital stay. Meanwhile, it also has the characteristics of fewer complications and low recurrence rate, so it can be popularized in clinical practice.

Expression and methylation status of LAMA2 are associated with the invasiveness of nonfunctioning PitNET

The laminin subunit alpha 2 (LAMA2) gene encodes an alpha 2 chain, which constitutes one of the subunits of laminin 2 (merosin) and laminin 4 (s-merosin). In the current study, we investigated the relationship between LAMA2 promoter methylation status and the invasiveness of clinically nonfunctioning pituitary adenomas (PitNETs). Specimens from patients with nonfunctioning PitNET were classified into three groups according to preoperative computed tomography (CT)/magnetic resonance imaging findings: a normal group (n = 6), non-invasive group (n = 11) and invasive group (n = 6). LAMA2 expression was assessed using quantitative real-time polymerase chain reaction (RT-qPCR) and western blotting, and the methylation status of the LAMA2 promoter region was observed using sodium bisulfite sequencing. Furthermore, 5-aza-2-deoxycytidine was used to explore the relationship between decreased LAMA expression and methylation in PitNET cells. According to the RT-qPCR and western blotting results, LAMA2 expression was downregulated in invasive PitNET, while the methylation of the LAMA2 promoter was increased. Methylation of the LAMA2 promoter decreased the expression of LAMA2. Thus, changes in LAMA2 expression due to promoter methylation were inversely correlated with the invasiveness of PitNET and the protein functions as a tumor suppressor. In addition, overexpression and demethylation of LAMA2 suppressed the invasion of PitNET cells, partially by exerting effects on the PTEN-PI3K/AKT signaling pathway and matrix metalloproteinase-9 (MMP-9). Furthermore, a xenograft model was also generated, and LAMA2 overexpression significantly suppressed tumor growth in vivo. Thus, LAMA2 expression and methylation patterns might be used as biomarkers to predict the prognosis of patients with PitNET.

Evaluation of the Olfactory Function With the "Sniffin' Sticks" Test After Endoscopic Transsphenoidal Pituitary Surgery

The aim of this study was to evaluate the olfactory function of patients who had undergone endoscopic transsphenoidal pituitary surgery. In this prospective study, the "Sniffin' Sticks" test was performed between June 2016 and April 2017 at Izmir Katip Celebi University Ataturk Training and Research Hospital. Thirty patients who were scheduled to undergo endoscopic transsphenoidal pituitary surgery were evaluated preoperatively and 8 weeks postoperatively using the Sniffin' Sticks test battery for olfactory function, odor threshold, smell discrimination, and odor identification. The patients were evaluated preoperatively by an otolaryngologist. The patients' demographic data and olfactory functions were analyzed with a t test and Wilcoxon-labeled sequential test. The study group comprised 14 women (46.7%) and 16 men (53.3%) patients. The mean age of the patients was 37.50 ± 9.43 years (range: 16-53 years). We found a significant difference in the preoperative and postoperative values of the odor recognition test (P = 0.017); however, there was no significant difference between the preoperative and postoperative odor threshold values (P = 0.172) and odor discrimination values (P = 0.624). The threshold discrimination identification test scores were not significant (P = 0.110). The olfactory function of patients who were normosmic preoperatively was not affected postoperatively. This study shows that the endoscopic transsphenoidal technique for pituitary surgery without nasal flap has no negative effect on the olfactory function.

The endoscopic surgical resection of intrasellar lesions conserves the hormonal function: a negative correlation to the microsurgical technique

BACKGROUND

The endonasal endoscopic approach is still currently under investigation for sellar tumor surgery: a higher resection rate is to be expected and complications should be minimized. The authors report their surgical results of endonasal endoscopic neurosurgery with special focus on postoperative hypopituitarism in comparison to microsurgical procedures.

METHODS

Sixty patients received endoscopic endonasal transsphenoidal procedures for sellar pathologies. All patients were followed up prospectively. A second group of 60 patients received microsurgical transsphenoidal procedures for sellar pathologies in our neurosurgical department before and were prospectively followed until now. Special attention was paid to hormonal insufficiency and medical substitution.

RESULTS

Sixty-eight percent (41 of 60) of the patients who underwent microsurgical procedures showed a new persisting pituitary insufficiency postoperatively. Twenty-three patients (55.5%) were substituted with thyroxine, hydrocortisone and sexual hormones and one patient (2.5%) also with ADH cause of global pituitary insufficiency. In 19 cases without any hormonal insufficiency after microsurgical procedures nine patients (47%) showed remnant tumor in follow-up MRI. The patients who underwent endoscopic procedures for pituitary adenomas revealed significant (P<0.01) less new persistent hormonal insufficiency with 13% of all cases (8/60). Five patients (62.5%) were substituted with thyroxine and hydrocortisone, two patients (25%) substituted with thyroxine, hydrocortisone and sexual hormones and one patient also with ADH because of global pituitary insufficiency. Thereby, in follow-up MRI and hormonal testing, radical tumor resection was detected in 92% in the endoscopic group.

CONCLUSIONS

This study seems to indicate that a better intraoperative identification and preservation of pituitary gland is possible in endoscopic transsphenoidal surgery with consecutive lower postoperative hypopituitarism rate.

Acromegalic cardiomyopathy: Epidemiology, diagnosis, and management

Acromegalic cardiomyopathy is the leading cause of morbidity and all-cause mortality in patients with acromegaly. Though acromegaly is a rare condition, the associated derangements are vast and severe. Stemming from an increase in circulating growth hormone (GH) and insulin-like growth factor-1 levels (IGF-1), acromegalic cardiomyopathy results in pathological changes in myocyte growth and structure, cardiac contractility, and vascular function. These molecular changes manifest commonly as biventricular hypertrophy, diastolic and systolic dysfunction, and valvular regurgitation. Early recognition of the condition is paramount, though the insidious progression of the disease commonly results in a late diagnosis. Biochemical testing, based on IGF-1 measurements, is the gold standard of diagnosis. Management should be centered on normalizing serum levels of both IGF-1 and GH. Transsphenoidal resection remains the most cost-effective and permanent treatment for acromegaly, though medical therapy possesses benefit for those who are not surgical candidates. Ultimately, achieving control of hormone levels results in a severe reduction in mortality rate, underscoring the importance of early recognition and treatment.

Long-Term Endocrine Outcomes Following Endoscopic Endonasal Transsphenoidal Surgery for Acromegaly and Associated Prognostic Factors

BACKGROUND

Long-term remission rates from endoscopic transsphenoidal surgery for acromegaly and their relationship to prognostic indicators of disease aggressiveness are not well documented.

OBJECTIVE

To investigate long-term remission rates in patients with acromegaly after endoscopic transsphenoidal surgery, and correlate this with molecular and radiographic markers of disease aggressiveness.

METHODS

We identified all patients undergoing endoscopic transsphenoidal surgery for acromegaly from 2005 to 2013 at Cedars-Sinai Pituitary Center. Hormonal remission was established by normal insulin-like growth factor (IGF)-1, basal serum growth hormone <2.5 ng/mL, and growth hormone suppression to <1 ng/mL following oral glucose tolerance test. Oral glucose tolerance test was performed at 3 months after surgery, and then as indicated. IGF-1 was measured at 3 months and then at least annually. We evaluated tumor granularity, nuclear expression of p21, Ki67 index, and extent of cavernous sinus invasion, and correlated these with remission status.

RESULTS

Fifty-eight patients that underwent surgery had follow-up from 38 to 98 months (mean 64 ± 32.2 months). There were 21 microadenomas and 37 macroadenomas. Three months after surgery 40 of 58 patients (69%) were in biochemical remission. Four additional patients were in remission at 6 months after surgery, and 1 patient had recurrence within the first year after surgery. At last follow-up, 43 of 44 (74.1%) of patients remained in remission. Cavernous sinus invasion by tumor predicted failure to achieve remission.

CONCLUSIONS

Prognostic markers of disease aggressiveness other than cavernous sinus invasion did not correlate with surgical outcome. Long-term remission after surgery alone was achieved in 74% of patients, indicating long-term efficacy of endoscopic surgery.

Endoscopic Endo-Nasal Trans-Sphenoidal Excision of Pituitary Tumors: An Institutional Experience

To analyze the clinical presentation, management and outcomes of patients with pituitary adenoma treated by Endoscopic Endo-nasal Trans-sphenoidal (EETS) excision. Study was conducted on the basis of medical records of 14 patients who had undergone EETS excision of pituitary adenomas. The data obtained was assessed for demographic and clinical characteristics, radiographic features and post-operative outcomes. Study included 10 males and 4 females. Mean age of patients was 46.43 years (range 16-70 Years). Most common presentation was diminished vision reported in 79% patients. Features of acromegaly encountered in 21% cases. Location of majority of tumors was sellar with supra-sellar extension (71%) followed by sellar (14%), sellar with para-sellar extension (7%) and sellar with supra-sellar and para-sellar extensions (7%). Total tumor resection was achieved in 64% cases and sub-total resection in 36% cases. One of the lesions on biopsy revealed granulomatous pathology. No post-operative complication was seen in 71% patients. Transient Diabetes Insipidus was observed in 21% cases that resolved within 3-4 days. One patient expired due to meningitis and septicemia. One patient had CSF leak that was effectively managed by placing lumbar drain. There was significant improvement in visual symptoms and hormonal levels. Average hospital stay was 13.54 days and mean follow up period was 13 months. EETS approach is safe, minimally invasive and effective surgical technique for resection of pituitary adenomas with low post-operative morbidity, reduced hospital stay and better remission of symptoms.

Transsphenoidal pituitary surgery: comparison of two sellar reconstruction techniques and their effect on postoperative cerebrospinal fluid leakage

Transsphenoidal surgery is a common procedure in patients with pituitary adenomas. Several techniques have been previously postulated to achieve sufficient sellar reconstruction to avoid cerebrospinal fluid (CSF) leakage. We analyzed our institutional database concerning two sellar reconstruction techniques and development of postoperative CSF leakage. From 2009 to 2015, 255 patients underwent transsphenoidal pituitary surgery at our institution. According to the technique used for sellar reconstruction, patients were divided into two groups: (1) with muscle patch and fibrin glue and (2) with fibrin glue alone. Postoperative CSF leakage occurred in 7% of the patients. Occurrence of postoperative CSF leakage did not differ significantly between both sellar reconstruction techniques (p = 0.2). Patients who underwent sellar reconstruction with fibrin glue alone had significantly shorter operating time (p < 0.0001), as well as shorter length of hospital stay (p = 0.01). On multivariate analysis, occurrence of intraoperative CSF leakage was the only predictor for postoperative CSF leakage (p < 0.0001). The present data suggests that sellar reconstruction after transsphenoidal pituitary surgery seems to be equally effective in preventing postoperative CSF leakage. However, the use of fibrin glue alone results in shorter hospital stay and operating time without exposing patients to more frequent CSF leakage.

Pituitary macroadenoma: analysis of intercarotid artery distance compared to controls

Objective To evaluate the intercarotid distance (ICD) of patients with pituitary macroadenoma and compare to heatlhy controls. Method We retrospectively reviewed contrast-enhanced MRI images from twenty consecutive patients diagnosed with non-functioning pituitary macroadenoma, measured the ICD at two different levels (petrous segment - ICD1 and horizontal cavernous segment - ICD2) and compared to twenty paired controls. Results There was no statistically significant difference of the mean ICD1 between the groups and subgroups. For the ICD2 there was statistically significant difference between the case and controls. However, there was no significant difference between the patients with smaller adenomas and the controls. In contrast, the patients with giant adenomas showed statistically significantly higher ICD2 than the controls. Conclusion The ICD at the horizontal segment of the cavernous carotid tends to be wider in patients with giant pituitary adenomas than in healthy individuals or patients with smaller adenomas.

Analyses and treatments of postoperative nasal complications after endonasal transsphenoidal resection of pituitary neoplasms

In this study, we analyze and discuss the treatments of postoperative nasal complications after endonasal transsphenoidal resection of pituitary neoplasms (PNs). We performed 129 endonasal transsphenoidal resections of PNs and analyzed and treated cases with nasal complications. After endonasal transsphenoidal resection of PNs, there were 26 cases of postoperative nasal complications (20.1%), including nasal hemorrhage (4.8%), cerebrospinal fluid rhinorrhea (6.9%), sphenoid sinusitis (2.3%), atrophic rhinitis (1.6%), olfactory disorder (1.6%), perforation of nasal septum (0.8%), and nasal adhesion (2.3%). All patients clinically recovered after therapy, which included treatment of the cavity through nasal endoscopy, intranasal corticosteroids, and nasal irrigation. We propose that regular nasal endoscopic review, specific nasal medications, and regular nasal irrigation can effectively clear nasal mucosal hyperemia-induced edema and nasal/nasoantral secretions, as well as promote regeneration of nasal mucosa, prevent nasal adhesion, maintain the sinus cavity drainage, and accelerate the recovery of the physiological function of the paranasal sinus. Timely treatment of patients with nasal complications after endonasal transsphenoidal resections of PNs could greatly relieve the clinical symptoms. Nasal cleaning is very beneficial to patients after surgery recovery.

Readmission and Other Adverse Events after Transsphenoidal Surgery: Prevalence, Timing, and Predictive Factors

BACKGROUND

Transsphenoidal surgery is a common neurosurgical procedure for accessing the pituitary and anterior skull base, yet few multicenter analyses have evaluated outcomes after this procedure.

STUDY DESIGN

Patients undergoing transsphenoidal surgery from 2006 to 2015 were extracted from the American College of Surgeons NSQIP database. Logistic regression was used to identify predictors of 30-day complications.

RESULTS

Of 1,240 patients included in this analysis, 6.9% experienced a major complication, and 9.4% experienced any complication within 30 days. Other adverse events included death in 0.7% and nonroutine hospital discharge in 5.3%. Most adverse events occurred within the first 2 weeks postoperatively; 82.9% of patients experienced their first complication during the initial hospital stay. Multivariable analysis demonstrated that predictors of hospital stay longer than 4 days included American Society of Anesthesiologists classification III to V (p = 0.015), insulin-dependent diabetes mellitus (p < 0.001), and operative time in the third and fourth quartiles (both p < 0.001). American Society of Anesthesiologists classification III to V and operative time in the fourth quartile were also predictors of any adverse event (p = 0.01 and p = 0.005, respectively). Among these patients, 3.7% underwent reoperation, the most common reason for which was postoperative cerebrospinal fluid leak (63.6%). Readmission occurred after 8.5% of cases at a median of 11.0 days post-discharge. The most common cause of readmission was hyponatremia (29.5%), followed by delayed postoperative cerebrospinal fluid leak (16.0%).

CONCLUSIONS

Overall rates of adverse events in patients undergoing transsphenoidal surgery are relatively low, and most occur before discharge from the hospital. Post-discharge complications associated with transsphenoidal surgery include deep vein thrombosis, pulmonary embolism, and urinary tract infection. Delayed postoperative cerebrospinal fluid leak is the major cause of reoperation, and hyponatremia is the major cause of readmission.

Spontaneous Involution of Rathke's Cleft Cysts without Visual Symptoms

Background

There have been various reports in the literature regarding the conservative management of pituitary apoplexy, pituitary incidentalomas and Rathke cleft cysts (RCCs). However, to the best of our knowledge, spontaneous involution of cystic sellar mass has rarely been reported. We report 14 cases of cystic sellar masses with spontaneous involution.

Methods

A total of 14 patients with spontaneous regression of cystic sellar masses in our hospital were included. The median age was 35 years (range, 5–67), and 8 patients were male. Clinical symptoms, hormone study and MRI were evaluated for all patients. The initial MRI showed all 14 patients with RCCs. Eight patients were presented with sudden onset of headache, and 1 patient with dizziness. Another patient, a 5-year-old child, was presented with delayed growth. Three patients had no symptoms via regular medical work up. All 14 patients had no visual symptoms. The follow-up period ranged from 5.7 to 42.8 months, with the mean of 17.3 months.

Results

The mean initial tumor size was 1.29 cm³ (range, 0.05 to 3.23). After involution, the tumor size decreased to 0.23 cm³ (range, 0 to 0.68) without any treatments. Repeated MRI showed a spontaneous decrease in tumor volume by 78% (range, 34 to 99). The initial MRI showed that the tumor was in contact with the optic chiasm in 7 patients, while compressing on the optic chiasm in 3 patients. Five patients were initially treated with hormone replacement therapy due to hormone abnormality. After the follow-up period, only 2 patients needed a long-term hormone replacement therapy.

Conclusion

The spontaneous involution of RCCs is not well quantified before. Their incidence has not been well demonstrated, but this phenomenon might be underreported. Conservative management can be a treatment option in some RCCs without visual symptoms, even in those that are large in size and in contact with the optic nerve via imaging study.

Surgical Results of Pure Endoscopic Endonasal Transsphenoidal Surgery for 331 Pituitary Adenomas: A 15-Year Experience from a Single Institution

BACKGROUND

The aim of this study is to report the results of pure endoscopic endonasal transsphenoidal surgery (EETSS) for pituitary adenomas (PAs) and to evaluate the efficacy and safety of this procedure. In addition, we tried to determine the predicting factors for progression of PAs.

METHODS

We reviewed the medical records of 331 consecutive patients who underwent pure EETSS of newly diagnosed PAs between April 1998 and December 2014. Demographic, endocrinologic, and radiologic features and their outcomes, complications, and hospital stay durations were retrospectively assessed in these patients.

RESULTS

There were 157 (47.4%) nonfunctioning adenomas and 174 (52.6%) hormone-secreting adenomas. Fifty-one (15.4%) complications were present in 39 patients postoperatively. The frequent complications were temporary and permanent diabetes insipidus (14 and 3 cases, respectively), syndrome of inappropriate antidiuretic hormone secretion (9 cases), and cerebrospinal fluid leaks (6 cases). There was only 1 death (0.3%) related to the procedure in this series. The patient's age (P = 0.047), the tumor size (P = 0.003), and the parasellar growth (P <0.001) were associated with the occurrence of complications on multivariate analysis. Progression occurred in 92 (27.8%) patients and the mean time-to-progression was 23.7 months (range, 3.7-52.4 months) after a mean follow-up period of 68.5 months. In the multivariate analysis, the tumor size (P = 0.021), the extent of surgery (P = 0.012), the Knosp classification (P = 0.002), and the MIB-1 index (P = 0.019) were associated with progression-free survival. The mean duration of hospitalization was 4.4 (±1.6) days.

CONCLUSIONS

The pure EETSS of PA provides acceptable and reasonable results representing a safe alternative procedure to the traditional transsphenoidal microscopic approach.

Long-term outcome of macroprolactinomas

OBJECTIVE

Management of macroprolactinomas has dramatically changed in recent decades, from surgical to medical treatment as first-line therapy, with the development of dopamine agonists (DA). But few data exist on the long-term outcome of these patients.

PATIENTS AND METHODS

Retrospective descriptive multicenter study of patients with macroprolactinoma followed for at least 5 years between 1973 and 2008 at the University Hospitals of Strasbourg and Marseille.

RESULTS

Forty-eight patients were included with 27 men, hypopituitarism in 33.3% of all patients and mean serum prolactin (PRL) level at diagnosis 2218.2±4154.7μg/L. Among the patients, 58.3% received medical treatment, 25% had additional surgery and 12.5% surgery and radiotherapy. The mean follow-up duration was 196±100 months. At the end of follow-up, 10 patients (20.8%) were cured (i.e. normal PRL level and normal imaging, no symptoms and withdrawal of DA≥1 year), 33 (68.8%) were controlled (i.e. normal PRL level, normal or abnormal imaging, no symptoms, DA in progress) and 5 (10.4%) were uncontrolled. Uncontrolled patients had significant higher baseline PRL level (P=0.0412) and cabergoline cumulative dose (P=0.0065) compared to the controlled group. There was no increase in frequency of hypopituitarism. Clinically significant valvular heart disease was found in 2 patients but screening was not systematic.

CONCLUSIONS

Macroprolactinoma is currently most often a chronic disease controlled with DA. However, uncertainty about the adverse effects associated with high cumulative doses and the lack of data on the prognosis at very long-term should incite to revisit current strategies, including the role of surgery combined to medical treatment.

Delayed Hyponatremia Is the Most Common Cause of 30-Day Unplanned Readmission After Transsphenoidal Surgery for Pituitary Tumors

BACKGROUND

Unplanned readmission after surgical procedures is an important quality metric. Yet, readmission rates and causes have not been evaluated for patients after transsphenoidal surgery for pituitary tumors.

OBJECTIVE

To analyze unplanned 30-day readmissions at a pituitary center and to encourage the development of effective clinical pathways to prevent readmission.

METHODS

A retrospective review of adult patients who underwent transsphenoidal surgery for pituitary lesions at Barrow Neurological Institute (January 2011-March 2014) was performed to identify causes of unplanned readmission within 30 days of surgery. Patient demographics, tumor details, surgical complications, and endocrine function were documented.

RESULTS

Of 303 patients who had transsphenoidal surgery, 27 (8.9%) were readmitted within 30 days. Most of the 27 (15 [55.6%]) had delayed hyponatremia. Other causes were diabetes insipidus (4 [14.8%]), adrenal insufficiency (2 [7.4%]), and cerebrospinal fluid leak, epistaxis, cardiac arrhythmia, pneumonia, urinary tract infection, and hypoglycemia (1 each [3.7%]). Outpatient sodium screening was performed as needed. In cases of hyponatremia, the mean postoperative day of readmission was day 8 (range, 6-12 days) and the mean serum sodium was 119 mmol/L (range, 111-129 mmol/L). Numerous patient and surgical factors were examined, and no specific predictors of readmission were identified. We developed an outpatient care pathway for managing hyponatremia with the goal of improving readmission rates.

CONCLUSION

This study establishes a quality benchmark for readmission rates after transsphenoidal surgery for pituitary lesions and identifies delayed hyponatremia as the primary cause. Implementation of an outpatient care pathway for managing hyponatremia may improve readmission rates.