Abstract
PurposeTo 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.MethodsAll 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.ResultsOf 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.ConclusionThis 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.
Highlights
Pituitary adenomas are the third most common primary intracranial tumor accounting for approximately 15% of all intracranial tumors, and surgical resection is considered first-line therapy for all adenoma subtypes except prolactinomas [1, 2]
Over the study period of April 2010–August 2020, there were a total of 820 endoscopic endonasal operations for tumor or cyst
12 (2.2%) 0 a All patients with only headaches or an incidentally discovered adenoma, had at least one other surgical indication: endocrine-active adenoma, hemorrhage/apoplexy, visual deficit, hypopituitarism, severe gland compression, tumor recurrence, large or invasive macroadenoma, tumor growth on serial MRIs, concern for metastatic carcinoma, patient preference. # In total, 100 patients had a prior surgery endocrine-active adenomas and visual field and/or acuity deficits
Summary
Pituitary adenomas are the third most common primary intracranial tumor accounting for approximately 15% of all intracranial tumors, and surgical resection is considered first-line therapy for all adenoma subtypes except prolactinomas [1, 2]. The most important advance is the application of endoscopy which has Pituitary (2021) 24:930–942 become the predominant visualization tool and replaced the operating microscope at many centers [4, 5, 17]. This transition has fueled collaboration between otolaryngologists and neurosurgeons in endoscopic skull base surgery, resulting in expanded knowledge of skull base and parasellar anatomy and refined surgical approaches, resection and reconstruction techniques (Fig. 1). Consensus guidelines have been produced by endocrinology and neurosurgical experts in the field that have provided recommendations on optimal multidisciplinary management of specific adenoma subtypes such as acromegaly and Cushing’s disease [20, 21]
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