Abstract
BackgroundPatients with pituitary adenomas usually receive “stress dose” steroids in the peri-operative peroids. Though randomized controlled trials(RCT) have not been performed to assess the necessity of steroid coverage, there are several studies that explained the changes of adrenal function during peri-operative peroids. The aim of the present study is to investigate whether it is necessary to employ conventional peri-operative glucocorticoid replacement therapy to all the patients undergoing surgery.MethodsWe searched studies addressing peri-operative steroids coverage for pituitary adenomas in the Web of Science, Medline and the Cochrane Library. Then we extracted studies about peri-operative morning serum cortisol(MSC) levels, morbidity of early postoperative adrenal insufficiency, postoperative diabetes insipidus, relationships between MSC levels and adrenal integrity. We used RevMan Software to combine the results for meta-analysis. We used fixed-effects models for there was no significant heterogeneity existed.FindingsThere are 18 studies from 11 countries published between 1987 and 2013 including 1224 patients. The postoperative serum cortisol levels were significantly increased compared with the preoperative one in hypothalamic-pituitary-adrenal axis(HPAA) functions preserved patients(P<0.00001). The morbidity of early postoperative adrenal insufficiency ranged from 0.96% to 12.90%, with the overall morbidity of 5.55%(41/739). There was no significant differences of early postoperative diabetes insipidus between no supplementation patients and in supplementation patients(P=0.82). Conversely, there may be some disadvantages of high levels of cortisols such as high incidence of osteopenia and bone derangement and even the increased mortality rate. The patients with MSC levels of less than 60 nmol/l at 3 days after operation is considered as adrenal insufficient and more than 270 nmol/l as adrenal sufficient. To patients with MSC levels of 60–270 nmol/l, we need more clinical data to establish further cortisol supplementation criteria.
Highlights
Pituitary adenomas makes up 10%~15% of intracranial tumors
There may be some disadvantages of high levels of cortisols such as high incidence of osteopenia and bone derangement and even the increased mortality rate
Cushing disease was excluded from these studies for its specificity, for the majority were GH secreting, PRL secreting and non-functioning pituitary adenomas
Summary
Pituitary adenomas makes up 10%~15% of intracranial tumors. Over the last four decades, the preferred treatment to pituitary adenomas has been the transsphenoidal surgery(TSS) for its obvious advantages such as the quick relief of signs and symptoms, the arrest of permanent damage to organ systems caused by the hormonal excess[1].Patients undergoing TSS usually receive “stress dose” steroids whether the hypothalamicpituitary-adrenal axis(HPAA) is deficient or preserved during TSS[2]. Though randomized controlled trials(RCT) have not been performed to assess the necessity of steroid coverage[3], there are several studies on the changes of HPAA functions associated with pituitary surgery. The aim of present study is to investigate whether it is necessary to employ conventional peri-operative glucocorticoid replacement therapy to all patients by analyzing peri-operative cortisol changes in serum of patients undergoing TSS. Patients with pituitary adenomas usually receive “stress dose” steroids in the peri-operative peroids. Though randomized controlled trials(RCT) have not been performed to assess the necessity of steroid coverage, there are several studies that explained the changes of adrenal function during peri-operative peroids. The aim of the present study is to investigate whether it is necessary to employ conventional peri-operative glucocorticoid replacement therapy to all the patients undergoing surgery.
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