Perioperative multidisciplinary management of endoscopic transsphenoidal surgery for sellar lesions: practical suggestions from the Padova model

Barbot, Mattia; Ceccato, Filippo; Lizzul, Laura; Daniele, Andrea; Zilio, Marialuisa; Gardiman, Marina Paola; Denaro, Luca; Emanuelli, Enzo; Vianello, Federica; Lombardi, Giuseppe; Rolma, Giuseppe; Scaroni, Carla; Club, Padova Pituitary

doi:10.1007/s10143-019-01132-1

Cited by 12 publications

(14 citation statements)

References 29 publications

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“…Laparoscopic surgery, well-tolerated and accompanied by less morbidity, is effective in normalizing cortisol levels and reducing cortisol-related morbidity [ 128 , 129 ]. Perioperative management is critical, not only for overt CS [ 130 ]: patients with ACS may present cortisol-related comorbidities that could increase surgical risk [ 110 , 131 , 132 ]. After adrenalectomy, replacement therapy with hydrocortisone is mandatory in CS, and should be considered also in patients with ACS, to avoid post-surgical adrenal insufficiency [ 64 , 133 ].…”

Section: Question 5: Is Perioperative Period a Matter Of Concern?mentioning

confidence: 99%

Frequently asked questions and answers (if any) in patients with adrenal incidentaloma

Ceccato

Barbot

Scaroni

et al. 2021

J Endocrinol Invest

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Purpose Adrenal incidentalomas (AIs) are incidentally discovered adrenal masses, during an imaging study undertaken for other reasons than the suspicion of adrenal disease. Their management is not a minor concern for patients and health-care related costs, since their increasing prevalence in the aging population. The exclusion of malignancy is the first question to attempt, then a careful evaluation of adrenal hormones is suggested. Surgery should be considered in case of overt secretion (primary aldosteronism, adrenal Cushing’s Syndrome or pheochromocytoma), however the management of subclinical secretion is still a matter of debate. Methods The aim of the present narrative review is to offer a practical guidance regarding the management of AI, by providing evidence-based answers to frequently asked questions. Conclusion The clinical experience is of utmost importance: a personalized diagnostic-therapeutic approach, based upon multidisciplinary discussion, is suggested.

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Section: Question 5: Is Perioperative Period a Matter Of Concern?mentioning

confidence: 99%

Frequently asked questions and answers (if any) in patients with adrenal incidentaloma

Ceccato

Barbot

Scaroni

et al. 2021

J Endocrinol Invest

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“…In this case, anticoagulation should be held before the surgery and the timing coordinated with the surgeon [ 4 ]. Additionally, early ambulation and intermittent compression devices are recommended during the postoperative period [ 2 , 29 ].…”

Section: Should This Patient Be Anticoagulated? When and For How Long?mentioning

confidence: 99%

“…Nevertheless, patients with CD have a considerably activated hypothalamic-pituitary-adrenal (HPA) axis and cortisol levels could remain high during the first 10 hours following surgery (this is expected given the half-life of cortisol) [ 106 ]. Based on this, the second approach in many centers is not to administer any GCs until biochemical remission is confirmed or clinical symptoms of AI develop [ 29 , 84 ]. Cortisol levels are measured every 6 hours for 24 to 72 hours postoperatively [ 10 , 85 , 95 , 107 ], though some centers measure only morning cortisol on days 1 to 2 [ 29 , 94 ].…”

Section: What Glucocorticoid Regimen Is Used Postoperatively?mentioning

confidence: 99%

“…Based on this, the second approach in many centers is not to administer any GCs until biochemical remission is confirmed or clinical symptoms of AI develop [ 29 , 84 ]. Cortisol levels are measured every 6 hours for 24 to 72 hours postoperatively [ 10 , 85 , 95 , 107 ], though some centers measure only morning cortisol on days 1 to 2 [ 29 , 94 ]. Close monitoring for signs/symptoms of hypoadrenalism (eg, hypotension, lightheadedness, weakness, nausea, and abdominal pain) and a fast laboratory turnaround of serum cortisol levels are required.…”

Section: What Glucocorticoid Regimen Is Used Postoperatively?mentioning

confidence: 99%

“…Patients who had PMT could have lower cortisol levels and will often receive a GC stress dose intravenously perioperatively to prevent an adrenal crisis. Steroidogenesis inhibitors should be stopped several days before surgery to minimize the risk of AI and interference with postoperative cortisol assessment for remission [ 29 ].…”

Section: What Glucocorticoid Regimen Is Used Postoperatively?mentioning

confidence: 99%

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Perioperative Management of a Patient With Cushing Disease

Varlamov

Vila

Fleseriu

2022

Journal of the Endocrine Society

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Patients with Cushing’s disease (CD) may present with both chronic and acute perioperative complications that necessitate multidisciplinary care. This review highlights several objectives for these patients before and after transsphenoidal surgery. Preoperative management includes treatment of electrolyte disturbances, cardiovascular comorbidities, prediabetes/diabetes, as well as prophylactic consideration(s) for thromboembolism and infection(s). Preoperative medical therapy (PMT) could prove beneficial in patients with severe hypercortisolism or in cases of delayed surgery. Some centers use PMT routinely, although the clinical benefit for all patients is controversial. In this setting, steroidogenesis inhibitors are preferred because of rapid and potent inhibition of cortisol secretion. If glucocorticoids are not used perioperatively, an immediate remission assessment postoperatively is possible. However, perioperative glucocorticoid replacement is sometimes necessary for clinically unstable or medically pretreated patients and for those patients with surgical complications. A nadir serum cortisol < 2-5µg/dl during 24-74 hours postoperatively is generally accepted as remission; higher values suggest non-remission, while a few patients may display delayed remission. If remission is not achieved, additional treatments are pursued. The early postoperative period necessitates multidisciplinary awareness for early diagnosis of adrenal insufficiency (AI) to avoid adrenal crisis, which may be also potentiated by acute postoperative complications. Preferred glucocorticoid replacement is hydrocortisone, if available. Assessment of recovery from postoperative AI should be undertaken periodically. Other postoperative targets include decreasing antihypertensive/diabetic therapy if in remission, thromboprophylaxis, infection prevention/treatment, and management of electrolyte disturbances and/or potential pituitary deficiencies. Evaluation of recovery of thyroid, gonadal and growth hormone deficiencies should be also performed in the following months postoperatively.

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La gestione perioperatoria delle masse surrenaliche

Ceccato

Scaroni

2021

L'Endocrinologo

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SommarioLa gestione pre- e postoperatoria del paziente con lesione surrenalica candidato alla chirurgia richiede una diretta e costante collaborazione tra vari professionisti, formata da un team multidisciplinare. La buona pratica clinica che suggeriamo prevede di intervenire chirurgicamente solo dopo aver definito l’eventuale secrezione, ponendo particolare attenzione ai valori pressori e alla ionemia. Suggeriamo, inoltre, una gestione accorta del rischio di iposurrenalismo post-chirurgico e la prevenzione delle complicanze tromboemboliche.

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Perioperative multidisciplinary management of endoscopic transsphenoidal surgery for sellar lesions: practical suggestions from the Padova model

Cited by 12 publications

References 29 publications

Frequently asked questions and answers (if any) in patients with adrenal incidentaloma

Frequently asked questions and answers (if any) in patients with adrenal incidentaloma

Perioperative Management of a Patient With Cushing Disease

La gestione perioperatoria delle masse surrenaliche

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