Endoscopic Transsphenoidal Pituitary Surgery Research Articles

The volume-outcome relationship for endoscopic transsphenoidal pituitary surgery for benign neoplasm: analysis of an administrative dataset for England

Background Setting minimum annual volume thresholds for pituitary surgery in England is seen as one way of improving outcomes for patients and service efficiency. However, there are few recent studies from the UK on whether a volume-outcome effect exists, particularly in the era of endoscopic surgery. Such data are needed to allow evidence-based decision making. The aim of this study was to use administrative data to investigate volume-outcome effects for endoscopic transsphenoidal pituitary surgery in England. Methods Data from the Hospital Episodes Statistics database for adult endoscopic transsphenoidal pituitary surgery for benign neoplasm conducted in England from April 2013 to March 2019 (inclusive) were extracted. Annual surgeon and trust volume was defined as the number of procedures conducted in the 12 months prior to the index procedure. Volume was categorised as < 10, 10–19, 20–29, 30–39 and ≥40 procedures for surgeon volume and < 20, 20–39, 40–59, 60–79 and ≥80 procedures for trust volume. The primary outcome was repeat ETSPS during the index procedure or during a hospital admission within one-year of discharge from the index procedure. Results Data were available for 4590 endoscopic transsphenoidal pituitary procedures. After adjustment for covariates, higher surgeon volume was significantly associated with reduced risk of repeat surgery within one year (odds ratio (OR) 0.991 (95% confidence interval (CI) 0.982–1.000)), post-procedural haemorrhage (OR 0.977 (95% CI 0.967–0.987)) and length of stay greater than the median (0.716 (0.597–0.859)). A higher trust volume was associated with reduced risk of post-procedural haemorrhage (OR 0.992 (95% CI 0.985–0.999)), but with none of the other patient outcomes studied. Conclusions A surgeon volume-outcome relationship exists for endoscopic transsphenoidal pituitary surgery in England.

Retrospective analysis of anesthesia management in endoscopic transsphenoidal pituitary surgery

Retrospective analysis of anesthesia management in endoscopic transsphenoidal pituitary surgery

Advantages of endoscopic transsphenoidal pituitary gland tumor surgery.

The aim of the study was to hihglight the benefits and safety of the endoscopic transsphenoidal pituitary gland tumor surgery. The endoscopic transsphenoidal approach to the Turkish sella minimizes traumatization of nasal cavity structures, allows direct access to the tumor and intra, para and suprasellar views (13). The surgical procedure was described. We monitored postoperative complication such aspostoperative bleeding, cerebrospinal fluid leak, infection in 136 patients who underwent endoscopic transsphenoidal pituitary gland tumos resection. Bleeding from the bed after tumor removal occured in 3 patients (2.2 %). Bleeding from the nasal cavity requiring surgical intervention was in 1 patient (0.7 %). Postoperative cerebrospinal fluid leak was detected in 12 cases (8.8 %). Duroplasty with itratecal cerebrospinal fluid drainage led to the cessation of the cerebrospinal fluid leak in all cases. We recorded meningitis in 4 patients (2.9 %) Rhinosinusitis was not recorded. The endoscopic transsphenoidal surgery of pituitary gland tumors has become preferred becouse of its safety, low rate of complications and minimal trauma to the patient (Fig. 5, Ref. 13).

Combination of transsphenoidal endoscopic surgery and presurgical somatostatin analogs in thyrotropin (TSH)-secreting pituitary adenomas: Treatment outcome and long-term remission at a single pituitary center.

Thyrotropin (TSH)-secreting pituitary adenomas (TSHomas) account for an extremely rare group of pituitary adenomas. Few studies examined the sensitivity and efficacy of presurgical somatostatin analogs (SSAs) and described the long-term remission under such treatment modality. The aim of the present study was to assess the efficacy of presurgical SSA treatment and long-term remission after surgery. A retrospective cohort of 65 TSHoma patients who received endoscopic transsphenoidal pituitary surgery between 2011 and 2020 in a single pituitary center in China was established. Data were analyzed for sex differences and different types of SSA and ultimately to explore the hormonal cutoff for remission prediction. TSHomas had a predominant female preference in this cohort (43 women vs. 22 men). Baseline FT3 was higher in men [7.543 ± 2.407 vs. 5.58 (4.99, 6.58), p = 0.019], which was consistent with its longer diagnosis time and larger tumor volume. The median medication time for hormonal control was 2. 5 days for short-acting SSA and 4. 0 weeks for long-term SSA. Patients with long-acting SSA had a shrinking maximum tumor diameter at a median of 1.0 (-1.6, 4.925) mm. Only 10 patients (15.38%) were not in complete remission among whom 8 patients were not en-bloc resected and 2 patients had tumor recurrence after 81.6 and 10. 7 months of complete removal. Postsurgical thyroid hormones (within 1 week) of TSH <0.094 μIU/ml were identified as the cutoff for remission using the ROC curve. The combination of endoscopic transsphenoidal surgery and presurgical SSA TSHomas provided a higher long-term remission for TSHomas.

Multidisciplinary Postoperative Care Pathway to Reduce Readmissions following Endoscopic Transsphenoidal Pituitary Surgery: Improving Quality of Patient Care.

Background Thirty-day unplanned readmission following endoscopic transsphenoidal pituitary surgery (ETPS) occurs in up to 14% of patients. Delayed hyponatremia is one of the most common causes, accounting for 30% of readmissions and often occurs within 1 week of surgery. The authors' prior retrospective review identified endocrinology follow-up as protective factor. Objectives Implementation of a multidisciplinary postoperative care (POC) pathway: (1) to reduce 30-day hospital readmissions following ETPS and (2) improve inpatient and outpatient coordination of care with endocrinologist. Methods This study is a single institution temporal cohort study of patients prior to (control cohort) and after implementation of the POC pathway (intervention cohort). The POC pathway utilized postdischarge 1 to 1.5 L/d fluid restriction, postoperative days 5 to 7 serum sodium, and endocrinology follow-up within 1 week of discharge to stratify patients into tiered hyponatremia regimens. Results A total of 542 patients were included in the study, 409 (75%) in the control cohort and 133 (25%) in the intervention cohort. All-cause readmission was significantly reduced following implementation of the POC pathway (14 vs. 6%, p = 0.015). Coordination with endocrinologist significantly increased in the inpatient (96 vs. 83%, p < 0.001) and outpatient (77 vs. 68%, p = 0.042) settings. Patients who were not in the POC pathway had the highest risk of readmission (odds ratio: 2.5; 95% confidence interval: 1.1-5.5). Conclusion A multidisciplinary POC pathway incorporating endocrinologist in conjunction with postdischarge weight-based fluid restriction and postoperative serum sodium levels can safely be used to reduce 30-day readmissions following ETPS.

Association between Preoperative Medication Lists and Postoperative Hospital Length of Stay after Endoscopic Transsphenoidal Pituitary Surgery.

Background: Endoscopic transsphenoidal surgery is the most common technique for the resection of pituitary adenoma. Data on factors associated with extended hospital stay after this surgery are limited. We aimed to characterize the relationship between preoperative medications and the risk of prolonged postoperative length of stay after this procedure. Methods: This single-center, retrospective cohort study included all adult patients scheduled for transsphenoidal pituitary surgery from 1 July 2016 to 31 December 2019. Anatomical Therapeutic Chemical codes were used to identify patients’ preoperative medications. The primary outcome was a prolonged postoperative hospital length of stay. Secondary outcomes included unplanned admission to the Intensive Care Unit, and in-hospital and one-year mortality. We developed a descriptive logistic model that included preoperative medications, obesity and age. Results: Median postoperative length of stay was 3 days for the 704 analyzed patients. Patients taking ATC-H drugs were at an increased risk of prolonged length of stay (OR 1.56, 95% CI 1.26–1.95, p < 0.001). No association was found between preoperative ATC-H medication and unplanned ICU admission or in-hospital mortality. Patients with multiple preoperative ATC-H medications had a significantly higher mean LOS (5.4 ± 7.6 days) and one-year mortality (p < 0.02). Conclusions: Clinicians should be aware of the possible vulnerability of patients taking systemic hormones preoperatively. Future studies should test this medication-based approach on endoscopic transsphenoidal pituitary surgery populations from different hospitals and countries.

The Hitchhiker Position in Endoscopic Pituitary Surgery.

Technically and ergonomically correct positioning is essential in endoscopic transsphenoidal pituitary surgery. To propose a safe, ergonomic approach to conduct endoscopic endonasal pituitary and skull base surgery in large patients without sacrificing important aspects of current standard practice. The patient's right arm is outstretched and secured in a supine position, with the primary surgeon standing in the axillary area. Considerations include maintaining comfort, immobility, anesthesia access, endotracheal tube fixation, intravenous lines, thorax elevated 25° to 30° for optimization of respiration, free and exposed abdomen for fat graft, legs positioned with no sciatic stretch or venous strain, and the patient's head in parallel with the surrounding area to sustain a strict midline. Ten patients who underwent transsphenoidal pituitary tumor resections conducted using the hitchhiker position from October 2019 to June 2021 comprised our study cohort. The patients' mean height was 168.70 ± 9.29 cm, their mean weight was 114.35 ± 19.32 kg, and their mean body mass index was 40.19 ± 6.39 kg/m 2 . Twenty percent (n = 2) patients had a body mass index classified as "obesity class 1," 50% (n = 5) as "obesity class 2," and 30% (n = 3) as "extreme obesity class 3." The primary surgeon consistently reported decreased bodily strain and improved ergonomic access to the surgical site using the hitchhiker position. The hitchhiker position offers the opportunity to improve both patient and physician well-being in the context of endoscopic pituitary surgery.

The ‘muscle wonton’ repair – A case series of internal carotid artery injuries at a single Centre during its 10-year experience in endoscopic transsphenoidal pituitary surgery

Introduction Although rare, injury to the internal carotid artery (ICA) during pituitary surgery may result in serious morbidity such as stroke or death. This case series explores a single centre’s incidence and outcomes of ICA injury during endoscopic transsphenoidal pituitary surgery, discusses the current management options, and introduces the ‘muscle wonton’ (morcellised muscle wrapped in a single sheet of Surgicel®) as being a viable repair option. Methods All patients undergoing pituitary operations from January 2010 to December 2019 at the Queen Elizabeth Hospital, Birmingham, UK were included. Primary outcome was number of internal carotid artery injuries during pituitary surgery. Secondary outcome measures included pre-operative (demographic, risk factors such as previous radiotherapy, number of previous operations, imaging available), operative (intra-operative image guidance, intra-operative doppler ultrasound, which side ICA was damaged, repair technique) and post-operative result (death, cranial nerve VI palsy, or stroke). Results 7 out of 893 patients (0.8%) were identified as having an ICA injury. Four of the injuries were left sided. Average age was 54 years old, five were male. In four of the ICA injuries intra-operative navigation imaging was used, and a further two concurrently used ultrasound doppler. Three of the seven cases resulted in permanent morbidity (stroke). There were no other consistent demographic, pre-operative, operative, or post-operative similarities. The two patients with muscle wonton repair suffered no permanent serious complication of ICA injury (i.e. death, abducens nerve palsy, stroke). Discussion Our findings resemble the current literature, with left sided ICA injury being more common. Different methods for repairing ICA injury exist, however morcellised muscle patches have shown significant promise in animal models, and the perforated Surgicel® helps create an easy delivery method. The muscle wonton is a viable surgical option for repairing ICA injuries during pituitary surgery.

Abstract No.: ABS2881: Comparison of cardiac indices using two different concentrations of adrenaline wicks during endoscopic trans-sphenoidal pituitary surgery: a prospective randomised observational study

Background & Aims:Trans-nasal trans-sphenoidal approach is preferred for surgical excision of pituitary tumours. Adrenaline is a generally usedvasoconstrictor for instillation or infiltration to decrease bleeding and improve the operative field quality. We aimed to compare the cardiac indices (Flotrac guided) and hemodynamic parameters while using two different doses of adrenaline for instillationMethods:60 ASA I/II patients, aged 18-65 years, undergoing transsphenoidal surgery for pituitary tumours were enrolled and allocatedto two groups. Group 1 received 1:200,000 concentration and Group 2 receiving 1:100,000 concentration of adrenalinetopically using cotton strips for 10-15 minutes. Cardiac indices and haemodynamic parameters were noted at baseline, every 5 minutes for first hour followed by every 10 minutes till the end of the procedure. Blood loss, quality of thefield and any adverse events were notedResults:Significant reductions in cardiac indices (CO, CI) were noted in Group 2 at 60 and 70 minutes of the procedure compared to Group 1. There was no difference in haemodynamic parameters (HR, SBP, DBP, MAP, SPO2,) between the 1:100,000 and 1:200,000 adrenaline groups. However, hypertension and tachycardia were higher following instillation of 1:100,000 adrenaline concentration when compared with the baseline (p<0.005)Conclusion:1:200,000 concentrations of adrenaline for nasal decongestion was associated with lowered cardiac indices compared to1:100,000 concentration. Field quality and usage of rescue drugs were comparable in both the study groups

Sinonasal outcomes associated with the use of BioGlue® in endoscopic transsphenoidal pituitary surgery.

Concerns have been raised in the neurosurgical literature regarding the use of BioGlue®, a tissue sealant initially developed for cardiothoracic surgery, due to reports of an increased incidence of infection, wound breakdown, and CSF fistulae. The aim of this study was to determine if the use of BioGlue® in skull base repair impacts on the sinonasal outcomes and the incidence of post-operative infection following endoscopic pituitary surgery. SNOT-22 questionnaires were completed pre-operatively, and at 6, 12, and 24weeks post-operatively by 50 patients. Pre- and post-operative MRI scans were reviewed and assessed for evidence of post-operative sinusitis. Patient records were consulted to ascertain the incidence of post-operative infection. Repeated measures ANOVA and Wilcoxon signed rank test were used for data analysis. Statistical analysis revealed a significant difference in the mean SNOT-22 scores across the four time intervals (F(1.605, 78.642) = 9.180, p = 0.001). This difference was powered by a deterioration at 6weeks that recovered completely by 12weeks. The mean SNOT-22 score in the study cohort at 24weeks was 16.84/110 (range 0-57, ± 2.04) which was lower than the mean pre-operative score and is consistent with mild rhinosinusitis. There were no cases of post-operative meningitis and 1/50 (2%) case of post-operative sinusitis in this cohort. The use of BioGlue® in endoscopic endonasal pituitary surgery does not appear to lead to significant sinonasal morbidity. Previous concerns about the use of BioGlue® in transcranial procedures may not apply to extradural application of this tissue sealant in endoscopic transnasal surgery.

Comparison of the effects of inhalational and total intravenous anesthesia on quality of recovery in patients undergoing endoscopic transsphenoidal pituitary surgery: a randomized controlled trial

Background: Endoscopic transsphenoidal pituitary surgery has shown promising results. However, fast and high-quality recovery after this procedure remains a challenge for neuroanesthesiologists. This study aimed to compare the quality of recovery after transsphenoidal pituitary surgery between patients who received inhalational anesthesia with sevoflurane and patients who received propofol-based total intravenous anesthesia (TIVA).Methods: Eighty-two patients undergoing transsphenoidal pituitary surgery were randomized to receive either sevoflurane inhalation with manual infusion of remifentanil (sevoflurane group) or effect-site target-controlled infusion of propofol and remifentanil (TIVA group). The primary outcome was the 40-item Quality of Recovery (QoR-40) score on postoperative day 1. The QoR-40 questionnaire was completed by patients the day before surgery and on postoperative days 1 and 2. Emergence agitation and recovery characteristics were also assessed.Results: There were no significant differences between the groups in the global QoR-40 scores on both postoperative days 1 and 2 (difference -8.7, 95% CI -18.0 to 0.7, and P = 0.204; -3.6, 95% CI -13.0 to 5.8, and P > 0.999, respectively). The time to verbal response and time to extubation were significantly shorter in the sevoflurane group than in the TIVA group (P < 0.001 and P < 0.001, respectively). However, the incidence of emergence agitation was lower in the TIVA group than in the sevoflurane group (P < 0.001).Conclusions: Both inhalational anesthesia with sevoflurane and propofol-based TIVA were appropriate anesthetic techniques for patients undergoing endoscopic transsphenoidal pituitary surgery in terms of the quality of recovery up to 2 days postoperatively. Rapid emergence was observed in the sevoflurane group, while smooth emergence was observed in the TIVA group.

Utilizing a Novel Pituitary Retractor for Early Descent of the Diaphragma Sellae during Endoscopic Transsphenoidal Pituitary Surgery.

ObjectiveEarly descent of the diaphragm sellae (DS) during endoscopic endonasal transsphenoidal surgery (EETS) for pituitary macroadenoma surgery is occasionally a troublesome event by blocking the surgical field. Here we introduce an alternative technique with the new pituitary retractor and present our clinical experiences. MethodsWe designed a simple and rigid pituitary retractor with the least space occupation in the nasal cavity to be compatible in EETS. The pituitary retractor was held by external holder system to support the herniated DS stably. We retrospectively reviewed a clinical 22 cases of pituitary macroadenomas underwent EETS using the pituitary retractor. ResultsThe pituitary retractor stably pushed up the herniated DS in all cases, and the surgeon proceeded the procedure with bimanual maneuver. The pituitary retractor was helpful to remove tumors around the medial cavernous sinus and behind the DS in 16 and seven cases, respectively. In four cases, the meticulous hemostasis was completed with the direct visualization by the DS elevation with this retractor. Gross total tumor resection was performed in 20/22 patients (91%). The impaired visual function and hypopituitarism were improved in 18/20 (90%) and 7/14 (50%) patients after surgery, respectively. There was no complication related with the pituitary retractor. ConclusionDuring EETS for pituitary macroadenomas, the novel pituitary retractor reported in this study is a very useful technique when the herniated DS block the surgical field and bimanual maneuver. This pituitary retractor can help to result in the excellent surgical outcomes with minimal morbidity.

Venous thromboembolism chemical prophylaxis after endoscopic trans-sphenoidal pituitary surgery

PurposeThere is no compelling outcome data or clear guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using low molecular weight heparin (chemoprophylaxis) in patients undergoing pituitary surgery. Here we describe our experience of early chemoprophylaxis (post-operative day 1) following trans-sphenoidal pituitary surgery.MethodsSingle-centre review of a prospective surgical database and VTE records. Adults undergoing first time trans-sphenoidal pituitary surgery were included (2009–2018). VTE was defined as either deep vein thrombosis and/or pulmonary embolism within 3 months of surgery. Postoperative haematomas were those associated with a clinical deterioration together with radiological evidence.Results651 Patients included with a median age of 55 years (range 16–86 years). Most (99%) patients underwent trans-sphenoidal surgery using a standard endoscopic single nostril or bi-nostril trans-sphenoidal technique. More than three quarters had pituitary adenomas (n = 520, 80%). Postoperative chemoprophylaxis to prevent VTE was administered in 478 patients (73%). Chemoprophylaxis was initiated at a median of 1 day post-procedure (range 1–5 days postoperatively; 92% on postoperative day 1). Tinzaparin was used in 465/478 patients (97%) and enoxaparin was used in 14/478 (3%). There were no cases of VTE, even in 78 ACTH-dependent Cushing’s disease patients. Six patients (1%) developed postoperative haematomas. Chemoprophylaxis was not associated with a significantly higher rate of postoperative haematoma formation (Fisher’s Exact, p = 0.99) or epistaxis (Fisher’s Exact, p > 0.99).ConclusionsChemoprophylaxis after trans-sphenoidal pituitary surgery on post-operative day 1 is a safe strategy to reduce the risk of VTE without significantly increasing the risk of postoperative bleeding events.

Superiority of endoscopic transsphenoidal pituitary surgery to microscopic transseptal pituitary surgery for treatment of Cushing's disease.

This study aims to compare the efficacy and safety of endoscopic transsphenoidal pituitary surgery and microscopic transseptal pituitary surgery in the treatment of Cushing's disease (CD). A total of 46 patients with CD were randomized into endoscopic group and microscopic group, with 23 cases in each group. The endoscopic group received the endoscopic transsphenoidal pituitary surgery, and the microscopic group received the microscopic transseptal pituitary surgery. The retrospective data, surgical outcomes, surgical cure rates, and complications in two groups were compared. Compared with microscopic group, the operative time was significantly shorter (p<0.05), the estimated blood loss was significantly less (p<0.05), and the hospital stay was significantly shorter (p<0.05) in endoscopic group. The surgical cure rate in endoscopic and microscopic groups was 69.56% and 60.86%, respectively, with no significant difference between the two groups (p>0.05). The incidence of complications in endoscopic group was significantly lower than that in microscopic group (p<0.01). For the treatment of CD, the efficacy of endoscopic transsphenoidal pituitary surgery is basically the same as that of traditional microscopic transseptal pituitary surgery. However, the endoscopic surgery can further shorten the operative time, reduce the estimated blood loss, shorten the hospital stay, and reduce the complications.

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

Postoperative prophylactic antibiotics are commonly used in pituitary surgery, but evidence supporting their use is lacking, which has implications for antibiotic stewardship. 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. 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. 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). Postoperative prophylactic oral antibiotics did not result in superior sinonasal QOL compared with placebo among patients who underwent standard endoscopic transsphenoidal surgery.

Venous thromboembolic (VTE) prophylaxis in Cushing disease patients undergoing transsphenoidal surgery

IntroductionThe association between Cushing syndrome and a hypercoagulable state has been demonstrated in the literature. A standard venous thromboembolism (VTE) prophylaxis regimen has yet to be established for patients undergoing surgery for Cushing disease. Here we present outcomes associated with VTE prophylaxis in patients with Cushing disease undergoing endoscopic transsphenoidal surgery for pituitary tumor resection. MethodsA review of Cushing disease patients undergoing endoscopic transsphenoidal pituitary surgery between January 2010 and June 2020 was performed. Administration and type of VTE prophylaxis was recorded, and comparison was made between VTE and hemorrhagic complications before and after institution of a VTE prophylaxis protocol. ResultsA total of 65 patients were identified, 98.5% of which underwent VTE prophylaxis with either 5,000 units of subcutaneous heparin twice daily (n = 44) or 40 mg enoxaparin nightly (n = 20). VTE complications were not significantly different between the subcutaneous heparin and enoxaparin cohorts (4.5% v 0%; p = 0.61). The overall incidence of hemorrhagic complications requiring blood transfusion was 1.5%, and there was no significant difference in hemorrhagic complications between heparin and enoxaparin cohorts (0% v 5%; p = 0.32). ConclusionVTE prophylaxis in addition to sequential compression devices and early ambulation are critical in reducing VTE complications in patients with hypercortisolism from Cushing disease. Pharmacologic prophylaxis can be safely instituted in these patients with low risk of hemorrhagic complications.

Comparison of serum dynamic thiol/disulphide homeostasis and nitric oxide levels of total intravenous vs inhaled anaesthesia in endoscopic transsphenoidal pituitary surgery.

Transsphenoidal pituitary surgery (TPS) is traditionally performed under general anaesthesia. This study aimed to compare the effects of total intravenous anaesthesia (TIVA) or sevoflurane, an inhalation anaesthetic, on thiol-disulphide homeostasis in patients undergoing endoscopic endonasal TPS. In this study, 84 patients scheduled for TPS were randomly categorised into two groups: propofol (n=42, the TIVA group) or sevoflurane (n=42, the SEVO group). Blood samples were taken before induction of general anaesthesia and at the 30minutes of postoperation. Serum native thiol and total thiol levels were detected, and the number of dynamic disulphide bonds and related ratios were calculated from these values. Serum nitric oxide (NO) levels were measured using a chemiluminescence method. Although native thiol levels in TIVA postoperation group were markedly increased (P<.05), total thiol levels in SEVO postoperation group were significantly decreased (P<.01). Disulphide levels were declined in both groups (P<.05 for TIVA and P=.001 for SEVO groups). Disulphide/native thiol (P<.05 for both groups) and disulphide/total thiol ratios (P<.05 for TIVA and P<.01 for SEVO groups) were depressed in postoperation groups. We found a marked elevation in native thiol/total thiol ratio in both groups (P<.05 for TIVA and P<.01 for SEVO groups). There was significant augmentation in serum NO levels in the SEVO postoperation group (P<.05). These results are the first to show that both TIVA and sevoflurane showed similar antioxidant effect with reduced disulphide levels, but sevoflurane may offer more robust oxidative stress protection and augmented NO production than TIVA during TPS. However, the clinical effect is needed to further investigate.

Safety of Endoscopic Transsphenoidal Pituitary Surgery during the COVID-19 Pandemic and Comparison to the Pre-Pandemic Era.

Objective The COVID-19 pandemic has caused significant disruption to the surgical care of patients with pituitary tumors. Guidance issued early during the pandemic suggested avoiding transnasal approaches to minimize risks of transmitting COVID-19 to health care professionals involved in these procedures. Methods This observational, single-center study compares results of endoscopic transsphenoidal approach (TSA) for pituitary tumors since the start of the pandemic to a pre-pandemic period. Anesthetic time, surgical time, and complication rates were compared. Newly acquired COVID-19 infections and transmission rates to patients and staff were reviewed. Data were analyzed by using the independent t -test, Mann-Whitney U test, and Pearson Chi-square test, significance set at p <0.05. Results Over a 12-month period, a total of 50 and 69 patients underwent endoscopic TSA for pituitary tumor during and before the pandemic, respectively. All patients tested negative for COVID-19 preoperatively. Median duration of anesthesia was 35 minutes (interquartile range [IQR]: 22) during the pandemic and 25 minutes (IQR: 8, p = 0.0002) pre-pandemic. Median duration of surgery was 70 minutes (IQR: 28) during the pandemic and 79 minutes (IQR: 33.75, p = 0.126) pre-pandemic. There were no statistically significant differences between intraoperative CSF leaks and complication rates. No staff members tested positive for COVID-19. Three patients tested positive for COVID-19 postdischarge, but the infections were community acquired. Conclusion In contrast to published guidelines, adequate preoperative testing, a multidisciplinary approach and the implementation of standardized protocols and vaccination against COVID-19 allow for endoscopic transsphenoidal surgery to be performed safely in patients with pituitary pathology during the pandemic.

30-Day Readmissions and Coordination of Care Following Endoscopic Transsphenoidal Pituitary Surgery: Experience with 409 Patients.

Objective The study aimed to (1) quantify readmission rates and common causes of readmission following endoscopic transsphenoidal pituitary surgery (ETPS); (2) identify risk factors that may predict readmission within 30 days; (3) assess postoperative care coordination with endocrinology follow-up; and (4) identify patients for whom targeted interventions may reduce 30-day readmissions. Methods Retrospective quality improvement review of patients with pituitary adenoma who underwent ETPS from December 2010 to 2018 at a single tertiary care center. Results A total of 409 patients were included in the study, of which 57 (13.9%) were readmitted within 30 days. Hyponatremia was the most common cause of readmission (4.2%) followed by pain/headache (3.9%), cerebrospinal fluid leak (3.4%), epistaxis (2.7%), hypernatremia (1.2%), and adrenal insufficiency (1.2%). Patients with hyponatremia were readmitted significantly earlier than other causes (4.3 ± 2.2 vs. 10.6 ± 10.9 days from discharge, p = 0.032). Readmitted patients had significantly less frequent outpatient follow-up with an endocrinologist than the nonreadmitted cohort (56.1 vs. 70.5%, p = 0.031). Patients who had outpatient follow-up with an endocrinologist were at lower risk of readmission compared with those without (odds ratio: 0.46; 95% confidence interval: 0.24-0.88). Conclusion Delayed hyponatremia is one of the most common causes of 30-day readmission following ETPS. Postoperative follow-up with an endocrinologist may reduce risk of 30-day readmission following ETPS. Implications for Clinical Practice A multidisciplinary team incorporating otolaryngologist, neurosurgeons, and endocrinologist may identify patients at risk of 30-day readmissions. Protocols checking serum sodium within 1 week of surgery in conjunction with endocrinologist to tailor fluid restriction may reduce readmissions from delayed hyponatremia.

Outcomes of intraoperative ultrasound for endoscopic endonasal transsphenoidal pituitary surgery in adenomas with parasellar extension

BackgroundPituitary adenomas with parasellar extension present a technical challenge for adequate visualization and gross total resection (GTR). The endoscope improves identification of parasellar extension, however, additional intraoperative imaging adjuncts can further augment visualization. Intraoperative ultrasound (iUS) may provide a viable and cost-effective solution for intraoperative imaging. We sought to assess the ability of intraoperative ultrasound to predict extent of resection on 3-month postoperative magnetic resonance imaging (MRI) in pituitary adenomas with parasellar extension. MethodsTwenty consecutive patients undergoing endoscopic endonasal transsphenoidal surgery for pituitary adenomas with the assistance of intraoperative ultrasound were prospectively collected. Intraoperative ultrasound findings were recorded during each case. 3-month postoperative MRI studies were reviewed in a blinded fashion to assess for residual tumor and compared with the intraoperative ultrasound findings. ResultsMedian preoperative Knosp grade was 2. Cavernous sinus invasion was encountered intraoperatively in 3 patients, all of whom were Knosp grade 3 preoperatively. Median operative time was 152 min. Based on iUS findings, 17 patients were expected to have a GTR while 3 patients underwent subtotal resection. 18 patients completed a 3-month postoperative MRI. The iUS and MRI findings were concordant in 16 cases (88.9%) with only two instances of discordance. ConclusionIntraoperative ultrasound can reliably predict tumor resection as assessed by 3-month postoperative MRI in pituitary adenomas with parasellar extension. Image capture and interpretation may vary based on operator experience. Ultrasound provides reliable immediate assessment of extent of resection, identification of normal pituitary gland and other important neurovascular structures.