Perioperative Outcomes of a Hydrocortisone Protocol after Endonasal Surgery for Pituitary Adenoma Resection

Abstract

Introduction In pituitary adenomas (PAs), the use of postoperative steroid supplementation remains controversial, as it reduces peritumoral edema and sinonasal complaints but disrupts the detection of adrenal insufficiency (AI). It is unclear whether postoperative cortisol supplementation has a measurable effect on improving outcomes in patients with pituitary adenoma undergoing endoscopic transsphenoidal surgery (ETS). The objective of the study was to evaluate a postoperative steroid treatment protocol on various surgical outcomes in patients with PA undergoing ETS. Methods A retrospective cohort study was performed for patients undergoing ETS from 2005 to 2020 for PA at a single tertiary academic center. Patients were divided into two groups: those managed by a routine postoperative glucocorticoid supplementation protocol (steroid protocol) and those who received supplementation based on postoperative cortisol laboratory assessment (steroid sparing protocol). Management was otherwise the same between groups. Evaluation of length of stay (LOS), sinonasal outcomes, 30-day readmission, and perioperative complications, including AI, were performed. Results Among 535 patients, 21% (n = 111) received postoperative steroids, while the remainder (n = 424) did not. There were no differences in mean LOS (3 vs. 3 days, p = 0.72), sinonasal complaints (27 vs. 19%, p = 0.12), 30-day readmission (5% vs. 5%, p = 0.44), and perioperative complications (5 vs. 5%, p = 0.79) between both the groups. A multivariate model supported that both groups were comparable in predicting LOS, 30-day readmission, and complications. No reduction in readmission for AI was seen. Conclusion Routine administration of postoperative glucocorticoids did not significantly improve patient outcomes in patients with PA who underwent ETS.

Pituitary Stalk Morphology as a Predictor of New-Onset Adrenocortical Insufficiency and Arginine Vasopressin Deficiency after Transsphenoidal Resections of Pituitary Macroadenomas: A Retrospective Single-Center Study with a Focus on iMRI

“…The transient and permanent AVP-D frequencies were within values encountered in the peer-reviewed literature [10]. However, the frequency of NAI in 11 out of 29 patients (38%) was higher than the rates reported in the literature of up to 18% [4,5]. Still, when determining the frequency of new-onset adrenocortical insufficiency in all patients with macroadenomas in our collective, the frequency of NAI was much lower at 15% (15 out of 94 with no preoperative adrenocortical insufficiencies).…”

“…Endocrinologically, because of the possibility of adrenal crisis, postoperative new-onset adrenocortical insufficiency (NAI) is the most relevant endocrinological complication in TSS [2]. Since 2-12% of all patients undergoing TSS and up to 18% of patients after microscopic transsphenoidal pituitary surgery develop NAI post-surgery, monitoring and treating this potentially life-threatening insufficiency is essential [2,4,5]. However, because common adverse events in glucocorticoid replacement therapy include osteopenia, weight gain, and cardiovascular disease, the superiority of either empiric substitution after TSS or substitution only in those patients developing evident NAI has not yet been shown [5][6][7].…”

“…Since 2-12% of all patients undergoing TSS and up to 18% of patients after microscopic transsphenoidal pituitary surgery develop NAI post-surgery, monitoring and treating this potentially life-threatening insufficiency is essential [2,4,5]. However, because common adverse events in glucocorticoid replacement therapy include osteopenia, weight gain, and cardiovascular disease, the superiority of either empiric substitution after TSS or substitution only in those patients developing evident NAI has not yet been shown [5][6][7]. Still, considering the risk of adrenal crisis, some patients are over-supplemented, and there is an ongoing effort to rapidly diagnose NAI via early-morning cortisol level measurements after TSS instead of delaying diagnostics until dynamic testing of the hypothalamic-pituitaryadrenal axis can be conducted using the insulin tolerance test (ITT), corticotropin-releasing hormone (CRH), or the Synacthen ® test 4-6 weeks post-surgery [2,8,9].…”