Journal Reading

Presenter: PGY1 林奕廷

2020/07/30
 Background-I
Sellar Lesions and Treatment

 Sellar region is one of the most common site of

intracranial tumors
- pituitary adenoma, Rathke’s cyst, craniopharyngioma,
metastasis, lymphoma
 Common presentation: headache, visual disturbance
and hypopituitarism
 Surgical intervention: transsphenoid surgery (TSS)
 Modifiable shared variables which help to optimize
surgical outcomes
 Common adverse events: hyponatremia,
hypopituitarism, CSF leak, hemorrhage
 Background-II
Modifiable Shared Variables

Intraoperative
 Operating room ergonomics
 Preservation of normal pituitary gland
 Proper reconstruction of the skull base
 Operative time

Postoperative
 Pain control
 Monitoring for new hypopituitarism
 Prevention of hyponatremia
 Method
Experience from a Single Center

 Retrospective review of all transsphenoidal operations

carried out by the senior author at a single center
 from April 2008 through November 2018
 Records:
 adult patients
 Preoperative demographics
 Lesion characteristics
 Clinical practices at the center
 Results
Patient Demographics and Characteristics
 Results
Preoperative Management - I
 Patients undergo preoperative evaluation with
neurosurgeon and neuroendocrinologist
 Laboratory studies: all pituitary axes and Na
 Results
Preoperative Management - II

 ↓Thyroxine or morning cortisol: replacement therapy

 ↑prolactin: consider dopamine agonist
 Prolactin cutoff varies by adenoma size
(stalk compression effect)
 Preoperative MRI with dedicated sequences for image
guidance
 Discontinue anticoagulants, antiplatelets, NSAIDs,
fish oil
 Consults are ordered as needed: cardiology,
hematology, ENT, etc
 Results
Intraoperative Management

Medication
 Fasting cortisol <10 ug/dL):
50-100 mg hydrocortisone
bolus pre-OP
 Antibiotics continued post-OP
only if nasal packing placed
Anesthesia
 Acromegaly: risk of airway
complication
(discuss with anesthesiologist)
 Foley or A-line rarely required
 IV fluids given sparingly
(prevent hyponatremia)

Procedure
 Patients position: thorax elevated
20-30 degrees
 Image guidance used in every OP
 Abdominal flap / vascularized
nasoseptal flap used if large skull
base defect or CSF leak
 Results
Immediate Post-OP Care

Fluid / Hormone Bleeding / Infection

 Check visual field Q8H
 Check serum Na & SpGr Q6H
 Check nose & abdominal
 Check fasting cortisol QD
wound each shift
(if Cushing’s disease-> Q6H)
 Afrin & saline spray on POD 2
 Measure I/O & body weight QD
 If tolerating clear liquid
-> discontinue IV fluid Thrombosis
 Restrict daily fluid intake: 1L
 Pneumatic boot & early
 Use of desmopressin only
ambulation
reserved for Na >145mEq/L and
 Cusing’s disease:
inability to achieve euvolemia
Aspirin 81 mg started on POD1

Pain
 Avoid use of narcotics: prevent oversedation and early mobility
 IV Ketolorac sometimes required in addition to regular regimen
 Results
Post-OP Care after Discharge

Follow-up
 Post-OP 1 week: return to clinic, check serum Na & cortisol
 Post-OP 6 weeks: repeat pituitary & endocrine assessment
ENT physician evaluates nasal cavity
 Post-OP 3 months: post-OP MRI
 Overall readmission rate: 9.0% (92/1023) in the cohort
 Discussion-I
Pre-OP and Intra-OP

 The practice incorporates evidence-based

recommendations but there is a lack of high-quality,
randomized evidence
 Patient evaluated by both neurosurgeon &
endocrinologist: improved accuracy of diagnosis,
interpretation of specialized test (e.g. OGTT,
dexamethasone suppression test, IPSS)
 Intra-OP: follow the previously published surgical
checklist
Christian E, Harris B, Wrobel B, Zada G. Endoscopic endonasal transsphenoidal surgery:
implementation of an operative and perioperative checklist. Neurosurg Focus. 2014;37(4)
 Discussion-II
Prevention and Management of Complication

DI/SIADH CSF leakage

 Predictor: obesity, intra-OP
 Fluid restriction (<1 L)
CSF leak, pre-OP
decrease readmission rate
hydrocephalus
 Overall DI rate= 14.7%,
 Abdominal fat grafting
Permanent DI rate= 4.6%
 Pedicled nasoseptal flap

Hypopituitarism
 Pt at risk: large/invasive lesion,
functioning adenoma
 Instruct pt to report symptoms of
hypocortisolemia
 Discussion-II
Prevention and Management of Complication
Summary
Thank You For Your Listening.