Endoscopic Transsphenoidal Pituitary Surgery Research Articles

Impact of preoperative dehydration on endoscopic transsphenoidal pituitary surgery

Impact of preoperative dehydration on endoscopic transsphenoidal pituitary surgery

Comparison of endoscopic and microscopic transsphenoidal pituitary surgery for managing growth hormone-secreting adenomas

Pituitary adenomas are benign tumors with various biological behaviors, including hormonal secretion, cavernous sinus invasion and others. This study aimed to access the advantages and disadvantages of the endoscopic endonasal transsphenoidal (EET) approach for managing growth hormone-secreting adenomas in achieving clinical remission compared to the microscopic endonasal transsphenoidal (MET) approach. From 2017 to 2020, a series of 29 patients with growth hormone-secreting adenomas (GH) underwent the surgical treatment via MET (n = 13) and EET (n = 16) approach. Preoperatively and postoperatively endocrinological, neuro-ophthalmological and magnetic resonance imaging (MRI) examinations were performed. According to the Knosp classification for cavernous sinus, 34.4% of all adenomas were accessed as invasive. The mean follow-up was 21.6 ± 12.2 months. The endocrinological remission in the whole group was 68.9%. The microscopic group had lower levels of remission in comparison to the endoscopic group (61.53% vs. 75%). However, no significant difference was observed (р > 0.05). Postoperative diabetes insipidus and cerebrospinal fluid (CSF) leaks rates had a similar occurrence in both groups. No other significant complications were recognized. The use of endoscopic approaches provides a couple of advantages, such as wider field of view, superior illumination and better maneuverability compared to conventional microsurgery. A longer follow-up is still needed for further evaluation of our results.

A Single Layer Synthetic Dural Substitute Inlay is an Effective Sellar Reconstruction Technique in Endoscopic Transsphenoidal Pituitary Surgery.

Objectives A variety of endonasal sellar repair techniques have been described; many are complex, multilayered, and carry potential morbidity. We propose an effective, technically simple single-layer repair for select sellar defects, including those with an intraoperative cerebrospinal fluid (CSF) leak. Our technique utilizes only a synthetic dural substitute inlay and dural sealant glue without packing or lumbar drainage. Design This is a retrospective review-based study. Setting This study was conducted at tertiary care center. Participants Patients who underwent endoscopic transsphenoidal surgery for pituitary adenoma and sellar reconstruction with the aforementioned inlay technique. Patients were selected for this technique if they had an identified intraoperative CSF leak, a patulous diaphragm (expanded and thinned diaphragma sella), or a comorbidity excluding them from a simpler onlay only reconstruction. Outcome Measures Postoperative CSF leak and sinonasal morbidity included in the study. Results A total of 409 subjects were identified; 368 were initial resections. Gross total resection of the pituitary adenoma was achieved in 356 (87.0%) cases. Average tumor size was 2.6 ± 1.1 cm. Average tumor volume was 10.8 ± 12.1 cm 3 . There were 135 intraoperative CSF leaks and 196 patulous diaphragms. There were five postoperative CSF leaks (1.2%), all of which occurred in the first half of our series. Pre- and postoperative sino-nasal outcomes test-22 scores were 19.2 ± 18.2 and 18.8 ± 21.3 ( p = 0.492), respectively. Conclusion A synthetic dural substitute inlay and dural sealant glue is an excellent single-layer repair for sellar defects, even those with an intraoperative CSF leak. This technique is highly effective in preventing postoperative CSF leaks and does not utilize packing or lumbar drainage. It also avoids the potential cost and morbidity associated with more complex and multilayered closures.

Endoscopic Versus Microscopic Pituitary Adenoma: Comparative Study of Two Different Approaches

Abstract Background: The comparisons in both techniques' out-comes, complications, and hospital stay were the study ques-tions in this article. Aim of Study: The study included two arms: Group A: Microscopic sublabial pituitary surgery was done for 18 patients. Group B: Endoscopic surgery was done for 20 patients. Patients and Methods: A retrospective comparative ob-servational trial held at two places. Microscopic sublabial pituitary surgery casesarmed as group A (n=18). While endo-scopic endonasal transsphenoidal pituitary surgery cases were abbreviated as group B (n=20). Statistical analysis: The variables of interest included age, sex, symptomatology, tumor sizes in (cm3), resection, operative time, hospital stay, blood loss, and postoperative complications using Statistical Package of Social Sciences version 25 (Chicago, IL, USA). Categorical data were presented as percentages and compared using the Chi-square t-test. Numerical data were presented as mean and standard deviation and compared by using Student's t-test. A p-value below 0.05 was regarded as statistically significant. Results: The total resection rate in group A was found in 14/18 (77.7%) which is not statistically different from group B 15/20 (75%) with p-value=0.852. As regard operative time, group A had a longer duration in comparison to group B with a slightly significant difference (2.15±0.24 vs. 1.75±0.8 hrs, p=0.049). As regard complications, It has been noticed that postoperative sinusitis/septal problems are higher in group A than group B. Conclusion: Microscopic sublabial pituitary surgery is not superior to the endoscopic approach as regard resectability in the field of purely sellar lesions. However, higher rates of postoperative complications in the naso-septal apparatus may affect patients' quality of life.

Long-term olfactory dysfunction after single-nostril endoscopic transnasal transsphenoidal pituitary adenoma surgery

BackgroundOver the past decade, the endoscopic transnasal transsphenoidal approach for pituitary adenomas has been widely adopted among neurosurgeons. However, olfactory disturbances have been observed after this procedure, and few studies on long-term (>6 mo) olfactory disturbance after endoscopic transnasal transsphenoidal pituitary adenoma surgery have been conducted. Although we perform minimally invasive endoscopic surgery, some patients continue to experience hyposmia, with some even experience long-term hyposmia. This impairment results in a considerable loss in quality of life. We present a series of patients who underwent minimally invasive single-nostril TSS for pituitary adenoma, including evaluation of their olfactory function. We further investigated the related risk factors for long-term olfactory dysfunction. MethodsOne hundred sixty-one consecutive patients who met the study criteria underwent the single-nostril endoscopic transsphenoidal approach by the senior author. The Smell Diskettes Olfaction Test was used to evaluate olfactory function. ResultsPostoperative olfactory disturbance in patients treated with endoscopic transnasal TSS is frequent. Of the study population, 67.1% of the patients were hyposmic or anosmic and 14.9% had long-term olfactory dysfunction. We also performed multivariate logistic regression analysis to compare the characteristics of patients with long-term olfactory dysfunction. Nasal symptoms (odds ratio [OR], 6.77) and smoking (OR, 14.77) were associated with long-term olfactory dysfunction after transnasal TSS. ConclusionsSignificant disturbances in olfactory performance occur after single-nostril transnasal TSS for pituitary adenoma. Furthermore, preoperative nasal disease and smoking appear to be risk factors for long-term olfactory dysfunction. Physicians should address clinical findings related to olfactory function and provide appropriate care.

The impact of endoscopic transsphenoidal pituitary adenoma surgery on endocrine function: a single-centre study.

The outcome for pituitary endocrine function following endoscopic transsphenoidal surgery remains unclear. This study aims to evaluate endocrine outcomes following endoscopic surgery in order to provide a benchmark to assist in the counselling of patients perioperatively. A prospectively held pituitary database was retrospectively analysed for all adult pituitary adenoma patients undergoing endoscopic surgery from May 2011 to May 2017. All operations were performed by a single neurosurgeon at a regional centre for pituitary surgery. Functioning and non-functioning adenomas were included. Hormonal status was assessed at most recent follow-up. One hundred forty-five patients (69 M, 76 F) were included in the study with a median age of 52years. Median follow-up was 52months. Eighty-eight patients (61%) were not taking any hormone replacement medications, whilst 57 patients (39%) required hormone replacement therapy (HRT) preoperatively. Preoperatively, 29 patients (20%) had hypothalamo-pituitary-adrenal (HPA) axis dysfunction, 39 patients (27%) had thyroid axis dysfunction, 11 males (16%) and 7 females (9%) had gonadal axis dysfunction, and one patient had preoperative diabetes insipidus. Postoperatively, 26 patients (18%) had a new deficiency in pituitary function, whilst 6 patients (11%) were able to cease HRT. Nineteen patients (13%) had new HPA axis deterioration, 12 (8%) had new thyroid axis dysfunction, 8 males (11%) and 4 females (5%) had gonadal axis deterioration, and 6 patients (4%) had new diabetes insipidus (DI). The ability to restore pituitary function following endoscopic surgery remains limited, whilst new deficits still occur. It is essential that patients are counselled accordingly as hormonal replacement therapy can have a significant impact on quality of life. Larger longer-term collaborative studies of endocrine outcome in endoscopic pituitary surgery are needed.

Improvement in the Quality of Early Postoperative Course After Endoscopic Transsphenoidal Pituitary Surgery: Description of Surgical Technique and Outcome.

Objective: The endoscopic transsphenoidal pituitary surgery has gained popularity and has shown excellent results with a more comfortable postoperative course. However, the quality of the early postoperative course is not well-established in endoscopic transsphenoidal pituitary surgery. We hypothesized that the quality of the early postoperative course would be improved when an enhanced recovery after surgery (ERAS) protocol and minimally invasive endoscopic transsphenoidal pituitary surgery is implemented.Methods: We implemented a perioperative management ERAS protocol for endoscopic transsphenoidal pituitary surgery by an experienced surgeon (Yuehui Ma) in our department from January 2018. From then the endoscopic transsphenoidal pituitary surgery was implemented with a minimally invasive technique, such as bony sella reconstruction and partial nasal packing. We compared the results of 78 endoscopic transsphenoidal pituitary surgery cases during the initiation of the ERAS protocol and minimally invasive technique implementation: 37 cases in the control group and 41 cases in the ERAS group. Outcomes assessed included the effectiveness and security of surgery, postoperative hospital length of stay (LOS), and postoperative status on postoperative day 1 (POD1).Results: Postoperative status on POD1, such as nasal ventilation, out of bed, headache score, and liquid supplement, had significant improvement (P < 0.05). The median postoperative LOS decreased from 8 days in the control group to 3 days in the ERAS group (P < 0.05). The ERAS group had better economic benefit with fewer hospital charges (P < 0.05). There was no difference in the early postoperative diabetes insipidus and 30-day readmission for epistaxis, hyponatremia, or other complications between the two groups.Conclusion: The quality of the early postoperative course was improved when a neurosurgical ERAS protocol and minimally invasive endoscopic transsphenoidal pituitary surgery with partially nasal packing were implemented. Endoscopic transsphenoidal pituitary day surgery could be recommended in some classes of patients though further evaluation in large case studies is warranted.

Quality-of-life evaluation for patients submitted to nasal endoscopic surgery for resection of pituitary tumours.

This study aimed to evaluate the pre- and post-operative quality-of-life of patients submitted to the resection of pituitary adenoma via endoscopic transsphenoidal. This was a prospective study on patients submitted to endoscopic transsphenoidal pituitary surgery with the harvest of a nasoseptal flap who responded to the questionnaires FV-36 and SNOT-22 in the pre-operative and in months 1, 3 and 6 following the surgical procedure. A total of 42 patients submitted to pituitary adenoma resection surgery via endoscopic transsphenoidal with a nasoseptal flap were recruited. In all of the physical and mental domains (SF-36) evaluated, there was an improvement in the long-term evaluation (6months), compared to the pre-operative, as well as in the site-specific evaluation (SNOT-22). The global and site-specific questionnaires in the 6th post-operative month follow-up presented an important improvement in all the physical and mental domains evaluated, as well as in nasal function in the perception of the patients submitted to pituitary adenoma resection via endoscopic transsphenoidal, demonstrating the safety and efficiency of the procedure.

Chronic rhinosinusitis due to cyano-acrylic glue after endoscopic transsphenoidal pituitary surgery

BackgroundTo reduce the risk of cerebrospinal fluid leak, clinicians utilize a filling material placed in the sella followed by floor reconstruction with various materials, including glue sealing. Cyano-acrylic glue Glubran®2 glue is commercially available and is generally used as embolizing agent and for the prevention of cerebrospinal fluid leakage.Case DescriptionA 25-year-old woman underwent endoscopic endonasal transsphenoidal surgery for pituitary adenoma. After tumor resection, sellar floor reconstruction was performed by mucosal graft and Glubran®2 glue. The early post-operative period was uneventful. However, 2 months after surgery, the patient complained of headache, facial pain and greenish foul-smelling nasal discharge with solid particles dripping from the nose. Medical treatment was unsuccessful. Brain MRI showed inflammation and thickening of the sphenoidal and para-sphenoidal mucosa. The patient underwent endoscopic endonasal surgery and a solid glass-like mass surrounded by inflamed infected mucosa was seen in the inferior and lateral aspects of the sphenoid sinus. Efforts were made to erupt and de-crust the solid mass until total resection was achieved. Early post-operative period was uneventful, and a course of antibiotics was continued until total disappearance of the discharge.ConclusionTo the best of our knowledge, this is the first case reporting of acrylic glue (Glubran®2)-related sinusitis. Surgeon should be aware about similar side effects for the glue material that would complicate the surgery.

New Approach for Endoscopic Endonasal Transsphenoidal Pituitary Surgery: Modified Nasoseptal Rescue Flap.

Endoscopic endonasal approach has become popularly preferred for pituitary surgery in recent years. In this study we described a new technique which is developed by the first author and which is modified from The Rivera-Serrano "salvage" flap approach. With this new technique the septum morbidity was completely prevented and a wider and more comfortable vision was provided for the operation. This study consists 7 patients who underwent endoscopic endonasal transsphenoidal pituitary surgery (EETPS) with the described technique (modified salvage flap technique) between 2017 and 2019 and 13 patients underwent EETPS using salvage flap technique. The follow-up period was at least 6 months (24-6 months) for septal integrity. Intraoperative septum integrity was observed in all 7 patients who were treated with modified rescue flap technique. In 9 of 13 patients who had salvage flap technique, intraoperative septum posterior defects were observed. In postoperative follow-up (min postop 3 months), endoscopic examination showed no septal perforation in 6 patients who were treated with modified rescue flap technique, and 1 patient had 2 × 2 mm perforation posteriorly. In postoperative endoscopic follow-up of 13 patients who underwent salvage flap technique (min postop 3 months), 4 patients had complete septal integrity, while 9 patients had different sizes of posterior septal perforation. According to other described approach techniques, our modification using a pedicle and septum protective-transposition technique provides improved access to the downstream side of the sphenoid sinus and clivus, allowing the pedicle to slide down and take a more horizontal position. The improved maneuverability of the pedicle created in the case of cerebrospinal fluid leakage as a complication also allows it to be used as a bilateral wing to cover the exposed bone. We think that this technique is the best method to be used for EETPS with modified saline flap technique.

Arachnoid prolapse in endoscopic transsphenoidal surgery of pituitary adenoma, technical note

Purpose An arachnoid prolapse after endoscopic transsphenoidal surgery for a pituitary adenoma is an uncommon, but important, phenomenon which should be managed. We have evaluated the efficacy of a new simple technique to correct the prolapsed arachnoid following endoscopic surgery of pituitary adenomas. Methods A total of 1352 patients with pituitary adenomas, 24–76 years old, who underwent full endoscopic transsphenoidal surgeries between February 2014 and February 2019 in Erfan and Loghman Hakim hospitals. 46 patients with arachnoid prolapse participated in this study and41 patients completed the study. Arachnoid prolapse was repaired by bipolar cauterization with either autologous fat grafts (36 patients) or without autologous fat grafts (5patients). Results Of 41 patients who completed the study, all except one, had large adenomas with significant suprasellar extension and enlarged diaphragma sellae. All patients had arachnoid prolapse at the end of the tumor removal stage and 13 patients had very minor intraoperative CSF leakage. Prolapsed arachnoid was repaired using a bipolar cautery with or without the autologous fat graft. During the postoperative follow-up period, none of the patient experienced early or delayed postoperative CSF leakage, meningitis, visual deterioration, delayed epistaxis, cranial nerve palsy, recurrence, or death. Conclusion Bipolar cauterization is a safe, effective technique to repair a suprasellar arachnoid prolapse during reconstruction of the sellar floor following endoscopic transsphenoidal pituitary surgery.

Endoscopic transsphenoidal pituitary surgery (ETPS) for pituitary tumors: Outcomes and complications

Endoscopic transsphenoidal pituitary surgery (ETPS) for pituitary tumors: Outcomes and complications

Sources of residuals after endoscopic transsphenoidal surgery for large and giant pituitary adenomas.

Giant and large pituitary adenomas (PA) constitute a specific subset of PAs, with gross total resection (GTR) rates frequently not exceeding 50%. Both an anatomical inaccessibility and an inadequate tumor visualization are thought to play a role. This study analyzes risk factors for postoperative residuals after endoscopic transsphenoidal pituitary surgery for large and giant pituitary adenomas. A retrospective analysis of patients with giant and large PA operated between 2015 and 2018 was performed. Forty patients (13 females, 27 males) were included in the analysis (30 large and 10 giant PAs). The mean MRI follow-up time was 5.9 ± 6.54months. Overall, GTR was achieved in 29 patients (72.5%), subtotal resection in 9 (22.5%), and the inconclusive result was in 2 (5%). Unexpected residuals represented 7 (77.7%) of all 9 residual tumors. The most frequent intraoperative factor associated with unexpected residual tumors was improper identification of residual tumor due to obstruction of view in 2 (28.5%) cases and inability to distinguish normal tissue from tumor in the other two (28.5%). Sub-analysis based on tumor size revealed that with large PAs, GTR was achieved in 25 (83.3%), STR in 4 (13.3%), and inconclusive in 1 (3.3%) patient. In patients with giant PAs, GTR was achieved in 4 (40%), STR in 5 (50%), and inconclusive in 1 (10%). Analysis of preoperative factors showed a significant association of residual tumors with larger suprasellar AP distance (p = 0.041), retrosellar extension (p = 0.007), and higher Zurich Score (p = 0.029). Large and giant PAs are challenging lesions with high subtotal resection rates. Suprasellar AP distance, retrosellar extension, and higher Zurich Score seem to be significant predictors of degree of resection in these tumors. Improving the intraoperative ability to distinguish tumor from a normal tissue might further decrease the number of unexpected residuals.

Vascularised Sphenoid Mucosal Flap: A Go to Flap in Endoscopic Endonasal Trans-Sphenoidal Pituitary Surgery

Vascularised Sphenoid Mucosal Flap: A Go to Flap in Endoscopic Endonasal Trans-Sphenoidal Pituitary Surgery

The manufacturing procedure of 3D printed models for endoscopic endonasal transsphenoidal pituitary surgery.

BACKGROUND: Endoscopic endonasal transsphenoidal pituitary surgery is usually difficult and risky. With limited sources of cadaveric skulls, traditional methods of using virtual images to study the surgery are difficult for neurosurgeons and students because the surgery requires spatial imagination and good understanding of the patient’s conditions as well as practical experience. The three-dimensional (3D) printing technique has played an important role in clinical medicine due to its advantages of low cost, high-efficiency and customization.OBJECTIVE: CT images are used as the source data of 3D printing. The data obtained directly from the CT machine has limited accuracy, which cannot be printed without processing. Some commercial platforms can help build an accurate model but the cost and customization are not satisfactory. In this situation, a tactile, precise and low-cost 3D model is highly desirable.METHODS: Three pieces of computer software are used in the manufacturing of medical 3D models and the processing procedure is easy to understand and operate.RESULTS: This study proposes a practical and cost-effective method to obtain the corrected digital model and produce the 3D printed skull with complete structures of the nasal cavity, sellar region and different levels of pituitary tumors. The model is used for the endoscopic endonasal transsphenoidal pituitary surgery preparation.CONCLUSION: The 3D printed medical model can directly help neurosurgeons and medical students to practice their surgery skills on both general and special cases with customized structures and different levels of tumors.

Perioperative management of endoscopic transsphenoidal pituitary surgery.

The contemporary embrace of endoscopic technology in the approach to the anterior skull base has altered the perioperative landscape for patients requiring pituitary surgery. Utility of a multi-disciplinary unit in management decisions facilitates the delivery of optimal care. Evolution of technology and surgical expertise in pituitary surgery mandates ongoing review of all components of the care central to these patients. The many areas of potential variability in the pre, intra and post-operative timeline of pituitary surgery are readily identifiable. Core undertakings and contemporary controversies in the peri-operative management of patients undergoing endoscopic transsphenoidal pituitary surgery are assessed against the available literature with a view to providing guidance for the best evidence-based practice.

Impact of Medicaid insurance on outcomes following endoscopic transsphenoidal pituitary surgery.

Despite the rise of studies in the neurosurgical literature suggesting that patients with Medicaid insurance have inferior outcomes, there remains a paucity of data on the impact of insurance on outcomes after endonasal endoscopic transsphenoidal surgery (EETS). Given the increasing importance of complications in quality-based healthcare metrics, the objective of this study was to assess whether Medicaid insurance type influences outcomes in EETS for pituitary adenoma. The authors analyzed a prospectively acquired database of EETS for pituitary adenoma from 2005 to 2018 at NewYork-Presbyterian Hospital, Weill Cornell Medicine. All patients with Medicaid insurance were identified. As a control group, the clinical, socioeconomic, and radiographic data of all other patients in the series with non-Medicaid insurance were reviewed. Statistical significance was determined with an alpha < 0.05 using Pearson chi-square and Fisher's exact tests for categorical variables and the independent-samples t-test for continuous variables. Of 584 patients undergoing EETS for pituitary adenoma, 57 (10%) had Medicaid insurance. The maximum tumor diameter was significantly larger for Medicaid patients (26.1 ± 12 vs 23.1 ± 11 mm for controls, p < 0.05). Baseline comorbidities including diabetes mellitus, hypertension, smoking history, and BMI were not significantly different between Medicaid patients and controls. Patients with Medicaid insurance had a significantly higher rate of any complication (14% vs 7% for controls, p < 0.05) and long-term cranial neuropathy (5% vs 1% for controls, p < 0.05). There were no statistically significant differences in endocrine outcome or vision outcome. The mean postoperative length of stay was significantly longer for Medicaid patients compared to the controls (9.4 ± 31 vs 3.6 ± 3 days, p < 0.05). This difference remained significant even when accounting for outliers (5.6 ± 2.5 vs 3.0 ± 2.7 days for controls, p < 0.05). The most common causes of extended length of stay greater than 1 standard deviation for Medicaid patients were management of perioperative complications and disposition challenges. The rate of 30-day readmission was 7% for Medicaid patients and 4.4% for controls, which was not a statistically significant difference. The authors found that larger tumor diameter, longer postoperative length of stay, higher rate of complications, and long-term cranial neuropathy were significantly associated with Medicaid insurance. There were no statistically significant differences in baseline comorbidities, apoplexy, endocrine outcome, vision outcome, or 30-day readmission.

Prevalence and risk factors of hemodynamic instability during endoscopic transsphenoidal pituitary surgery: a retrospective analysis

Objective: Intraoperative hemodynamic instability in patients undergoing endoscopic transsphenoidal pituitary surgery (ETSS) for pituitary adenoma may lead to significant complications. We aimed to investigate the prevalence of hemodynamic instability and its associated risk factors in these patients. Methods: This retrospective study included patients who underwent ETSS at Ankara Numune Training and Research Hospital between 14 January 2010 and 20 March 2014. Intraoperatively occurring episodes of bradycardia, hypotension, and hypertension were recorded. Distribution of hemodynamic instability was determined based on age groups, ASA class, tumor type, and anesthesia method. Results: A total of 323 patients met the study criteria. Mean age of the patients was 46.88 ± 13.91 years and 54.5% were female. Intraoperative bradycardia was detected in 137 patients (42.41%), hypotension in 57 patients (17.65%), and hypertension in five patients (1.55%). Hemodynamic instability occurred in all of the patients over the age of 51. Patients classified as ASA III were more likely to have hemodynamic instability than patients with ASA I and ASA II (p&amp;lt;0.05). All 18 patients who were transferred to intensive care unit were in the age group of 61 years and over. The rate of hemodynamic instability was higher in patients with non-functioning tumor compared to that in patients with functioning tumors. Conclusion: The rate of intraoperative hemodynamic instability in patients undergoing ETSS is higher in older patients than that in young patients. The elderly has multiple comorbidities and are more sensitive to anesthetic agents. This group needs a carefully planned anesthetic management during perioperative period.

Enhanced recovery and accelerated discharge after endoscopic transsphenoidal pituitary surgery: safety, patient feedback, and cost implications.

Enhanced recovery after surgery (ERAS) is a constant motivation. There is growing evidence that an endoscopic (rather than microscopic) transsphenoidal approach to pituitary tumours can play a role, facilitating faster recovery and a commensurate reduction in length of stay (LOS). Reducing LOS is beneficial to both patients and healthcare systems. We sought to assess the safety, patient feedback, and resource implications of adopting an enhanced recovery and accelerated discharge policy for elective pituitary surgery. We retrospectively assessed two consecutive cohorts of patients undergoing elective surgery for pituitary adenoma in a single UK centre between July 2016 and November 2019. The pre-ERAS cohort included 52 sequential patients operated prior to protocol change. The ERAS cohort included 55 sequential patients operated after a protocol change. Patient demographic data, tumour characteristics, intra- and post-operative CSF leak, the rate and cause of readmission (within 30days), and the mean and median LOS were recorded. Patient feedback was collected from a subset of patients (n = 23) in the ERAS group. The two cohorts were well-matched with respect to their demographic, pathological, and operative characteristics. The rates of readmission within 30days of discharge were similar between the two groups (8% pre-ERAS cohort, 9% ERAS cohort, p = 0.75). In the pre-ERAS cohort, the mean LOS was 4.5days and median LOS was 3days. This compares with significant reduction in LOS for the ERAS group: mean of 1.7days and median of 1day (p < 0.05). Thirty-nine of 55 patients in the ERAS group were discharged on post-operative day 1. Patient feedback was very positive in the ERAS group (mean patient satisfaction score of 9.7/10 using a Likert scale). An enhanced recovery protocol after elective endoscopic pituitary surgery is safe, reduces length of stay, and is associated with high patient satisfaction.

Comparison of Bispectral Index-Guided Administration of Desflurane and Propofol for Endoscopic Transnasal Transsphenoidal Resection of Pituitary Tumors

Abstract Background Use of short-acting anesthetic agents such as propofol and desflurane allows rapid awakening and prompt neurological assessment of patients undergoing endoscopic transnasal transsphenoidal resection of pituitary tumors. However, there are no studies comparing the effect of these two agents in these patients. We performed this study to compare the intraoperative hemodynamics and postoperative recovery characteristics of patients undergoing endoscopic transnasal transsphenoidal (TNTS) pituitary tumor surgery using bispectral index (BIS)-guided administration of desflurane and propofol. Materials and Methods In this prospective, randomized trial, 60 patients undergoing endoscopic TNTS pituitary surgery were randomized to receive BIS-guided administration of either propofol (Group P) or desflurane (Group D) for the maintenance of anesthesia. Heart rate (HR), mean arterial pressure (MAP), intraoperative complications, time to emergence, extubation, cognition, and modified Aldrete score were evaluated. Statistical analysis was performed using STATA 12.0. Categorical and continuous variables were compared between the groups using Fisher’s exact test and t-test, respectively. Emergence from anesthesia and hemodynamics at various stages of surgery was compared between the groups using Wilcoxon rank sum test. The p-value &lt; 0.05 was considered statistically significant. Results The HR was significantly higher at all stages of surgery in group P (p = 0.01). MAP was comparable between the groups at various time points (p &gt; 0.05). Both emergence time (8.5 vs. 15 minutes; p &lt; 0.00) and extubation time (10 vs. 17.5 minutes; p &lt; 0.00) were significantly shorter in Group D compared with Group P. Modified Aldrete score at 5 and 10 minutes after extubation was higher with desflurane than propofol, but early cognition was comparable between the two groups. Conclusion The hemodynamics and early cognition score were comparable in patients receiving propofol or desflurane. Desflurane provides rapid emergence and recovery when compared with propofol.