Selective Use of Peri-Operative Steroids in Pituitary Tumor Surgery: Escape from Dogma

Abstract

Objective: Traditional neurosurgical practice calls for administration of peri-operative stress-dose steroids for sellar-suprasellar masses undergoing operative treatment. This practice is considered critical to prevent peri-operative complications associated with hypoadrenalism, such as hypotension and circulatory collapse. However, stress-dose steroids complicate the management of these patients. It has been our routine practice to use stress steroids during surgery only if the patient has clinical or biochemical evidence of hypocortisolism pre-operatively. We wanted to be certain that this practice was safe.Methods: We present our retrospective analysis from a consecutive series of 114 operations in 109 patients with sellar and/or suprasellar tumors, the majority of whom were managed without empirical stress-dose steroid coverage. Only patients who were hypoadrenal pre-operatively or who had suffered apoplexy were given stress-dose coverage during surgery. We screened for biochemical evidence of hypoadrenalism as a result of surgery by measuring immediate post-operative AM serum cortisol levels.Results: There were no adverse events related to the selective use of cortisol replacement in this patient population.Conclusion: Our experience demonstrates that selective use of corticosteroid replacement is safe; it simplifies the management of the patients, and has advantages over empiric “dogmatic” steroid coverage.

Is Peri-Operative Steroid Replacement Therapy Necessary for the Pituitary Adenomas Treated with Surgery? A Systematic Review and Meta Analysis

“…For the early postoperative incidence of adrenal insufficiency, we briefly summarized the morbidity of adrenal insufficiency in the preoperative HPAA integrated patients( Table 2 ) for the absence of RCT. There were 12 studies meeting our inclusion criteria[ 4 , 5 , 8 , 9 , 13 – 18 , 20 , 21 ]. The morbidity of early postoperative adrenal insufficiency ranged from 0.96% to 12.90%, with the overall morbidity of 5.55%(41/739).…”

“…The early postoperative diabetes insipidus was mentioned in 3 studies with 235 patients[ 5 , 9 , 19 , 20 ]. There was no significant difference of early postoperative diabetes insipidus in two groups, while the morbidity was 4 in no supplementation patients vs 12 in supplementation patients(P = 0.82).…”

Steroid Psychosis Caused by Perioperative Steroid Replacement for Pituitary Adenoma: A Case Report

“…Recently, Regan et al demonstrated that perioperative management without the use of any stress doses of steroid coverage results in no adverse events and is safe and beneficial in patients with a normal preoperative serum morning cortisol level who do not suffer from apoplexy. 19 The need for perioperative replacement therapy may be lower than was once thought. An excess of glucocorticoids leads to adverse clinical consequences, such as a reduced rate of tissue repair, decreased glucose tolerance, increased susceptibility to infection due to immune compromise, hypertension, gastric ulceration, weight gain, and aseptic necrosis of the femoral head.…”

Nebenniereninsuffizienz und Nebenniereninzidentalome

“…B. 100 mg Hydrocortison i. v. verabreicht wird [13,16,28,32,33] (Anmerkung: generell sind auch bei Hypophysenoperationen Glukokokortikoide intraoperativ in der Regel nicht zwingend notwendig, obwohl dies eine weit verbreitete Praxis ist). Am 1. postoperativen Tag sollte dann aber in der Früh unbedingt ein basaler Serum Cortisolwert (zur Evaluierung des operativen Erfolges bzw.…”