Recognition and management of delayed hyponatremia following transsphenoidal pituitary surgery

2007 ◽  
Vol 106 (1) ◽  
pp. 66-71 ◽  
Author(s):  
Gabriel Zada ◽  
Charles Y. Liu ◽  
Dawn Fishback ◽  
Peter A. Singer ◽  
Martin H. Weiss
Keyword(s):  
Serum Sodium ◽  
Transsphenoidal Surgery ◽  
Pituitary Surgery ◽  
University Hospital ◽  
Outpatient Basis ◽  
Tumor Type ◽  
University Of Southern California ◽  
Female Patients ◽  
Transsphenoidal Pituitary Surgery ◽  
The University

Object The goal of this study was to assess the incidence of symptomatic and occult hyponatremia in patients who had undergone transsphenoidal pituitary surgery. Methods Patients who underwent transsphenoidal surgery at the University of Southern California University Hospital between 1997 and 2004 had serum sodium levels drawn on an outpatient basis on postoperative Day 7. Patient records were retrospectively reviewed to determine the incidence of, and risk factors for, symptomatic and asymptomatic hyponatremia. Two hundred forty-one patients had routine serum sodium levels drawn as outpatients on postoperative Day 7. Twenty-three percent of these patients were found to be hyponatremic (Na ≤ 135 mEq/L). The overall incidence rate of symptomatic hyponatremia in the 241 patients was 5%. The majority of hyponatremic patients (80%) remained asymptomatic, whereas 20% became symptomatic. In patients with symptomatic hyponatremia, the mean sodium level at diagnosis was 120.5 mEq/L, compared with 128.4 mEq/L in asymptomatic, hyponatremic patients (p < 0.0001). Female patients were more likely to develop hyponatremia than male patients (33% compared with 22%, p < 0.03). Fifty-two percent of patients who had transient diabetes insipidus (DI) early in their postoperative course subsequently developed hyponatremia, compared with 21% of those who did not have DI (p < 0.001). Patient age, tumor type, and tumor size did not correlate with development of delayed hyponatremia. Outpatients with moderately and severely low sodium levels were 5 and 12.5 times more likely, respectively, to be symptomatic than were patients with mild hyponatremia. Conclusions Delayed hyponatremia occurs more frequently than was previously suspected in patients who have undergone transsphenoidal surgery, especially in female patients and those who have previously had transient DI. The majority of hyponatremic patients remain asymptomatic. Obtaining a serum sodium value on an outpatient basis 1 week after pituitary surgery is helpful in recognition, risk stratification, and subsequent intervention, and may prevent potentially serious complications.

Hermann Schloffer and the origin of transsphenoidal pituitary surgery

2012 ◽  
Vol 33 (2) ◽  
pp. E5 ◽  
Author(s):  
Richard F. Schmidt ◽  
Osamah J. Choudhry ◽  
Ramya Takkellapati ◽  
Jean Anderson Eloy ◽  
William T. Couldwell ◽  
...  
Keyword(s):  
Transsphenoidal Surgery ◽  
Skull Base Surgery ◽  
Sella Turcica ◽  
Pituitary Surgery ◽  
Transsphenoidal Approach ◽  
Harvey Cushing ◽  
Transsphenoidal Pituitary Surgery ◽  
Transsphenoidal Operation ◽  
Technological Limitations ◽  
The University

A little over a century ago, in 1907, at the University of Innsbruck, Hermann Schloffer performed the first transsphenoidal surgery on a living patient harboring a pituitary adenoma. Schloffer used a superior nasal route via a transfacial lateral rhinotomy incision. This was perhaps his greatest academic contribution to neurosurgery. Despite the technological limitations of that time, Schloffer's operation was groundbreaking in that it laid the foundation for future development and refinement of transsphenoidal pituitary surgery, influencing prominent surgeons such as Oskar Hirsch and Harvey Cushing. Even after undergoing multiple modifications and a brief fall into obscurity, the transsphenoidal approach has endured through generations of surgeons and remains the preferred approach for lesions of the sella turcica to this day. Although Schloffer performed primarily abdominal surgery in his practice, his contributions to the transsphenoidal approach have had a lasting impact in the field of pituitary and skull base surgery. The authors review the life and career of Hermann Schloffer, the surgical details of his transsphenoidal operation, and the legacy that it has left on the field of pituitary surgery.

scholarly journals Increased oxytocin release precedes hyponatremia after pituitary surgery

Pituitary ◽  
2021 ◽  
Author(s):  
Paul Eugène Constanthin ◽  
Nathalie Isidor ◽  
Sophie de Seigneux ◽  
Shahan Momjian
Keyword(s):  
Transsphenoidal Surgery ◽  
Pituitary Surgery ◽  
Sodium Balance ◽  
Posterior Pituitary ◽  
Axon Terminals ◽  
Early Marker ◽  
Inappropriate Secretion ◽  
Oxytocin Release ◽  
Transsphenoidal Pituitary Surgery ◽  
First Time

Abstract Purpose The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a well-known complication of transsphenoidal pituitary surgery, related to inappropriate secretion of arginine vasopressin (AVP). Its diagnosis is based on hyponatremia, with a peak of occurrence around day 7 after surgery and, to date, no early marker has been reported. In particular, copeptin levels are not predictive of hyponatremia in this case. Oxytocin (OXT) is secreted into the peripheral blood by axon terminals adjacent to those of AVP neurons in the posterior pituitary. Besides its role in childbirth and lactation, recent evidences suggested a role for OXT in sodium balance. The contribution of this hormone in the dysnatremias observed after pituitary surgery has however never been investigated. Methods We analyzed the urinary output of OXT in patients subjected to transsphenoidal pituitary surgery. Results While OXT excretion remained stable in patients who presented a normonatremic postoperative course, patients who were later diagnosed with SIADH-related hyponatremia presented with a significantly increased urinary secretion of OXT 4 days after surgery. Conclusion Taken together, these results show for the first time that urinary OXT output remains normally stable after transsphenoidal pituitary surgery. OXT excretion however becomes abnormally high on or around 4 days after surgery in patients later developing hyponatremia, suggesting that this abnormal dynamics of OXT secretion might serve as an early marker for transsphenoidal surgery-related hyponatremia attributed to SIADH.

scholarly journals Tolvaptan Versus Fluid Restriction in the Treatment of Hyponatremia Resulting from SIADH Following Pituitary Surgery

2020 ◽  
Vol 4 (7) ◽  
Author(s):  
Andrea Kleindienst ◽  
Simeon Georgiev ◽  
Sven Martin Schlaffer ◽  
Michael Buchfelder
Keyword(s):  
Serum Sodium ◽  
Pituitary Surgery ◽  
The United States ◽  
University Hospital ◽  
Hormone Deficiency ◽  
Urine Specific Gravity ◽  
Fluid Restriction ◽  
Moderate Dose ◽  
Neurosurgical Department ◽  
Water Excretion

Abstract Context The relevance of hyponatremia has been acknowledged by guidelines from the United States (2013) and Europe (2014). However, treatment recommendations differ due to limited evidence. Objective In hyponatremia following pituitary surgery—caused by the syndrome of inappropriate antidiuretic hormone (SIADH) secretion—we compared fluid restriction with the pharmacological increase of water excretion by blocking the vasopressin 2 receptors with tolvaptan at a low and a moderate dose. Design Prospective observational study. Setting Neurosurgical Department of a University hospital with more than 200 surgical pituitary procedures per year. Patients Patients undergoing pituitary surgery and developing serum sodium below 136 mmol/L. The diagnosis of SIADH was established by euvolemia (daily measurement of body weight and fluid balance), inappropriately concentrated urine (specific gravity), and exclusion of adrenocorticotropic and thyroid-stimulating hormone deficiency. Intervention Patients were treated with fluid restriction (n = 40) or tolvaptan at 3.75 (n = 38) or 7.5 mg (n = 48). Main Outcome Measures Treatment efficacy was assessed by the duration of hyponatremia, sodium nadir, and length of hospitalization. Safety was established by a sodium increment below 10 mmol/L per day and exclusion of side effects. Results Treatment with 7.5 mg of tolvaptan resulted in a significant attenuation of hyponatremia and in a significant overcorrection of serum sodium in 30% of patients. The duration of hospitalization did not differ between treatment groups. Conclusions Tolvaptan at a moderate dose is more effective than fluid restriction in the treatment of SIADH. Overcorrection of serum sodium may be a side effect of tolvaptan even at low doses.

A novel transnasal transsphenoidal speculum: a design for both microscopic and endoscopic transsphenoidal pituitary surgery

2011 ◽  
Vol 114 (5) ◽  
pp. 1380-1385 ◽  
Author(s):  
Richard A. Chole ◽  
Chris Lim ◽  
Brian Dunham ◽  
Michael R. Chicoine ◽  
Ralph G. Dacey
Keyword(s):  
Transsphenoidal Surgery ◽  
Sella Turcica ◽  
Pituitary Surgery ◽  
Transsphenoidal Approach ◽  
Surgical Approaches ◽  
Surgical Experience ◽  
Endoscopic Techniques ◽  
Minimally Invasive Surgical ◽  
Transsphenoidal Pituitary Surgery ◽  
Microscopic Techniques

Over the last several years minimally invasive surgical approaches to the sella turcica and parasellar regions have undergone significant change. The transsphenoidal approach to this region has evolved from a sublabial transnasal, to transnasal, to pure endonasal approaches with the increasing popularity of endoscopic over microscopic techniques. Endoscopic and microscopic techniques individually or in combination have their own unique advantages, and the preference of one over the other awaits further technological refinements and surgical experience. In parallel with this evolution in techniques for transsphenoidal surgery, the authors designed an adaptable versatile speculum for the endonasal/transnasal transsphenoidal approach to the sella turcica and parasellar regions that can be used equally effectively with a microscope or an endoscope. The development of this instrument and its unique features are described, and its initial clinical use is summarized. This transnasal transsphenoidal speculum has interchangeable blades, unique blade angulations, and independent blade opening mechanisms and allows safe, optimal exposure in all patients regardless of the size and anatomical aberrations of individual nasal and endonasal regions. An attached endoscope carrier further allows it to be used interchangeably with microscopic or endoscopic techniques without having to remove the speculum; likewise, a single surgeon can use both hands without need of an assistant. A forehead headrest component adds further stabilization. This device has been used successfully in 90 transsphenoidal procedures.

scholarly journals Changes in copeptin levels before and 3 months after transsphenoidal surgery according to the presence of postoperative central diabetes insipidus

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Yoo Hyung Kim ◽  
Yong Hwy Kim ◽  
Young Soo Je ◽  
Kyoung Ryul Lee ◽  
Hwan Sub Lim ◽  
...  
Keyword(s):  
Diabetes Insipidus ◽  
Serum Sodium ◽  
Transsphenoidal Surgery ◽  
Pituitary Surgery ◽  
Diagnostic Value ◽  
Normal Serum ◽  
Central Diabetes Insipidus ◽  
Copeptin Level ◽  
Percentage Difference ◽  
Normal Serum Sodium

AbstractCopeptin levels reflect arginine vasopressin (AVP) release from the hypothalamus. Pituitary surgery often impairs AVP release and results in central diabetes insipidus (CDI). Here, we aimed to investigate how serum copeptin level changes 3 months after pituitary surgery and whether it has a diagnostic value for postoperative permanent CDI. Consecutive patients who underwent endoscopic transsphenoidal surgery at a single tertiary hospital were recruited. Serum copeptin levels were measured preoperatively and 3 months postoperatively. Among 88 patients, transient and permanent CDI occurred in 17 (19.3%) and 23 (26.1%), respectively. Three-month postoperative copeptin levels significantly declined from preoperative levels in permanent CDI group (P < 0.001, percentage difference =  − 42.2%) and also in the transient CDI group (P = 0.002, − 27.2%). Three months postoperative copeptin level < 1.9 pmol/L under normal serum sodium levels was the optimal cutoff value for diagnosing permanent CDI with an accuracy of 81.8%, while 3-month postoperative copeptin level ≥ 3.5 pmol/L excluded the CDI with a negative predictive value of 100%. Conclusively, 3 months postoperative copeptin levels significantly decreased from preoperative levels in the transient CDI group as well as the permanent CDI group. Three-month postoperative copeptin levels ≥ 3.5 pmol/L under normal serum sodium levels may be diagnostic for excluding postoperative CDI.

scholarly journals Endonasal Arteriovenous Fistula Following Transsphenoidal Resection of Pituitary Adenoma Treated with N-Butyl-2-Cyanoacrylate

2019 ◽  
Vol 08 (03) ◽  
pp. 196-198
Author(s):  
Giancarlo Saal-Zapata ◽  
Walter Durand Castro ◽  
Rodolfo Rodriguez Varela
Keyword(s):  
Pituitary Adenoma ◽  
Carotid Artery ◽  
Arteriovenous Fistula ◽  
Transsphenoidal Surgery ◽  
Pituitary Surgery ◽  
Endovascular Embolization ◽  
External Carotid Artery ◽  
Vascular Lesions ◽  
External Carotid ◽  
Transsphenoidal Pituitary Surgery

AbstractVascular lesions of the external carotid artery after transsphenoidal pituitary surgery are rare. Immediate diagnosis must be done and endovascular embolization is the treatment of choice.We report the case of a 53-year-old woman with visual complaints who underwent transsphenoidal surgery of a pituitary adenoma with good clinical and radiological evolution. Five days after surgery nasal tampons were removed and suddenly the patient started to bleed: nasal packing and air way protection were required. Digital subtraction angiography revealed an endonasal arteriovenous fistula with a feeder from the sphenopalatine artery and drainage to sphenopalatine veins. Embolization with N-butyl-2-cyanoacrylate was performed with total obliteration of the arteriovenous fistula. We suggest that endovascular treatment of external carotid artery lesions after transsphenoidal surgery is the best alternative in cases of active bleeding.

159 Factors Associated with Postoperative Complications Following Transsphenoidal Surgery for Pituitary Tumor resection from the national Surgical Quality Improvement Program (NSQIP)

Neurosurgery ◽  
2017 ◽  
Vol 64 (CN_suppl_1) ◽  
pp. 239-240
Author(s):  
Andrew Karl Rock ◽  
Charles Frederick Opalak ◽  
Kathryn Workman ◽  
Matthew Carr ◽  
William C Broaddus
Keyword(s):  
Postoperative Complications ◽  
Transsphenoidal Surgery ◽  
Tumor Resection ◽  
Pituitary Tumors ◽  
Pituitary Surgery ◽  
Improvement Program ◽  
Surgical Quality ◽  
Duration Of Surgery ◽  
Transsphenoidal Pituitary Surgery ◽  
Complications And Mortality

Abstract INTRODUCTION Pituitary tumors are the second most common brain tumor (15.9%) in the United States. Transsphenoidal surgery is commonly indicated for pituitary tumors and few studies have investigated postoperative complications following this procedure. Our objective was to utilize the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to estimate the prevalence of and risk factors for complications following transsphenoidal pituitary surgery. METHODS Patients undergoing transsphenoidal surgery for pituitary tumor resection (CPT codes: 61 548, 62 165) from 2005 to 2015 were extracted from the ACS-NSQIP. The prevalence of postoperative complications was determined. Multivariable logistic regression was used to identify demographic, comorbid, and perioperative characteristics associated with any morbidity, severe (Clavien IV) complications, and mortality. RESULTS >Within 1177 transsphenoidal surgeries, there were 105 (8.92%) cases with at least one non-fatal complication, 29 (2.46%) cases with a severe complication, and 11 (0.93%) cases of mortality. The three most common complications were: reoperation (3.40%), transfusion (2.04%), and unplanned intubation (2.70%). In multivariable logistic regression analysis, the only significant predictors for postoperative complications were: 1) duration of surgery in hours for any morbidity (Odds Ratio [OR]: 1.30; 95% Confidence Interval [CI]: 1.15-1.46; P < 0.001), severe complications (OR: 1.38; 95% CI; 1.18-1.61; P < 0.001), and mortality (OR: 1.36; 95% CI: 1.11-1.67; P < 0.01); and 2) American Society of Anesthesiologists (ASA) class III-V for any morbidity (OR: 1.99; 95% CI: 1.23-3.21; P < 0.05) and severe complications (OR: 2.99; 95% CI: 1.13-7.94; P < 0.05). The area under the curve for any morbidity, severe complications, and mortality were 0.67, 0.74, and 0.77, respectively. CONCLUSION Transsphenoidal pituitary surgery is a relatively safe procedure with any morbidity occurring in approximately 1 in 10 patients and mortality occurring in approximately 1 in 100 patients. Our findings demonstrate duration of surgery and higher ASA classification is associated with increased risk for postoperative complications following transsphenoidal pituitary surgery.

scholarly journals Early postoperative MRI and detection of residual adenoma after transsphenoidal pituitary surgery

2020 ◽  
pp. 1-10 ◽  
Author(s):  
Lea M. Alhilali ◽  
Andrew S. Little ◽  
Kevin C. J. Yuen ◽  
Jae Lee ◽  
Timothy K. Ho ◽  
...  
Keyword(s):  
Tumor Growth ◽  
Negative Predictive Value ◽  
Predictive Value ◽  
Pituitary Adenomas ◽  
Transsphenoidal Surgery ◽  
Residual Tumor ◽  
Pituitary Surgery ◽  
Intraoperative Assessment ◽  
Postoperative Mri ◽  
Transsphenoidal Pituitary Surgery

OBJECTIVECurrent practice guidelines recommend delayed (≥ 3 months after operation) postoperative MRI after transsphenoidal surgery for pituitary adenomas, although this practice defers obtaining important information, such as the presence of a residual adenoma, that might influence patient management during the perioperative period. In this study, the authors compared detection of residual adenomas by means of early postoperative (EPO) MRI (< 48 hours postsurgery) with both surgeon intraoperative assessment and late postoperative (LPO) MRI at 3 months.METHODSAdult patients who underwent microscopic transsphenoidal surgery for pituitary adenomas with MRI preoperatively, < 48 hours after the operation, 3 months postoperatively, and yearly for 4 years were included. The presence or absence of residual tumor was assessed intraoperatively by a single surgeon and postoperatively by 2 neuroradiologists blinded to the intraoperative assessment and other postoperative imaging studies. The presence of residual tumor was confirmed by reresection, tumor growth on imaging, or hormonal evidence. Interreader reliability was calculated at each imaging time point. Specificity, sensitivity, positive predictive value, and negative predictive value for EPO and LPO imaging and intraoperative assessment were determined.RESULTSIn total, 102 consecutive patients who underwent microscopic transsphenoidal resection of a pituitary adenoma were included. Eighteen patients (18%) had confirmed residual tumors (12 confirmed by tumor growth, 5 by surgery, and 1 by biochemical evidence of persistent disease). Interreader reliability for detecting residual tumor on EPO MRI was almost perfect (κ = 0.88) and significantly higher than that for LPO MRI (κ = 0.69, p = 0.03). EPO MRI was highly specific for residual tumor (98%), a finding similar to that for intraoperative assessment (99%, p = 0.60) and significantly higher than that for LPO MRI (81%, p < 0.001). Notably, EPO MRI was significantly more sensitive for residual tumor (100%) than both intraoperative assessment (78%, p = 0.04) and LPO MRI (78%, p = 0.04). EPO MRI had a 100% negative predictive value and was used to find 4 residual tumors that were not identified intraoperatively. Residual tumors found on EPO MRI allowed for reresection during the same hospitalization for 3 patients.CONCLUSIONSEPO MRI after transsphenoidal pituitary surgery can be reliably interpreted and has greater sensitivity for detecting residual tumor than intraoperative assessment and LPO MRI. This result challenges current guidelines stating that delayed postoperative imaging is preferable to early imaging. Pituitary surgeons should consider performing EPO MRI either in addition to or instead of delayed imaging.

scholarly journals Cataract Surgery in One-Eyed Patients: A Cohort Study of 100 Patients

2021 ◽  
Vol 2021 ◽  
pp. 1-7
Author(s):  
Alexis Charles ◽  
Pascal Staccini ◽  
Arnaud Martel ◽  
Stéphanie Baillif
Keyword(s):  
Cohort Study ◽  
Cataract Surgery ◽  
Surgical Complication ◽  
Intraoperative Complications ◽  
Sociodemographic Factors ◽  
University Hospital ◽  
Outpatient Basis ◽  
Locoregional Anesthesia ◽  
The Mean ◽  
The University

Purpose. To determine the course and outcomes of cataract surgery in one-eyed patients. Methods. This retrospective cohort study was conducted at the University Hospital of Nice, France. All one-eyed patients who underwent cataract surgery in their functional eye between January 2014 and December 2018 were included. A one-eyed patient was defined as having a visual acuity (VA) ≤20/200 in the other eye. Data were collected from the medical records and included the sociodemographic factors, the past medical history, data from the preoperative and postoperative clinical examinations, the surgical course, and the visual outcomes. Results. One hundred one-eyed patients with a mean age of 74.01 years were included (48 men/52 women). The mean preoperative VA was 20/100 (+0.74 logMAR). The VA ranged between 20/200 and 20/40 in 75 (75%) patients, was >20/40 in 8 (8%), and was <20/200 in 17 (17%) patients. Fifty-eight (58%) patients were operated on an outpatient basis. General or locoregional anesthesia was used in 29 (29%) and 9 (9%) patients, respectively. All cataract surgery procedures were performed by phacoemulsification. Five (5%) patients experienced intraoperative complications. Seventy-three (73%) one-eyed patients achieved a final VA ≥20/40. The mean final VA was 20/50 (+0.37 logMAR) ( p < 0.001 ). Conclusion. A low rate of intraoperative complications was observed in one-eyed patients during cataract surgery. In most cases, a good visual recovery was achieved after cataract surgery, even in patients who experienced a surgical complication.

Midline Filum of the Sellar Dura: A Useful Landmark During Endoscopic Transsphenoidal Pituitary Surgery

2010 ◽  
Vol 67 (suppl_2) ◽  
pp. ons391-ons394
Author(s):  
Gabriel Zada ◽  
Albert H. Kim ◽  
Lance S. Governale ◽  
Edward R. Laws
Keyword(s):  
Transsphenoidal Surgery ◽  
Carotid Arteries ◽  
Pituitary Surgery ◽  
Histopathological Analysis ◽  
Endoscopic Transsphenoidal Surgery ◽  
Video Recordings ◽  
Transsphenoidal Pituitary Surgery ◽  
Venous Bleeding ◽  
Lateral Structures ◽  
Internal Carotid Arteries

ABSTRACT BACKGROUND: During endoscopic transsphenoidal pituitary surgery, identification and constant awareness of the midline is imperative to prevent injury to critical lateral structures, such as the internal carotid arteries. OBJECTIVE: To describe the relevance of a midline filum of the sellar dura which, when present, can serve as a useful intraoperative anatomic marker. METHODS: Intraoperative video recordings of twenty patients undergoing endoscopic transsphenoidal surgery were retrospectively reviewed to assess for the presence and location of a midline dural filum or apparent central dural vascular structure. Prospective intraoperative data were gathered on an additional 16 patients. RESULTS: A midline dural filum was identified in 18 of 36 patients (50%) undergoing endoscopic transsphenoidal surgery. This structure was identified on the midline in all cases, as confirmed by intraoperative neuronavigation and comparison with the vomer. The midline dural filum was identified as a strand-like dural extension (13 patients) or as a small vascular dural structure usually exhibiting low pressure venous bleeding (5 patients). Samples of the midline dural filum were obtained from 2 patients for histopathological analysis, which demonstrated dense collagenous connective tissue without evidence of vessel wall or ductal epithelium. CONCLUSION: In addition to anatomic structures such as the vomer and midline sphenoid sinus septations, a midline dural filum serves as a useful marker during the sellar phase of endoscopic transsphenoidal surgery. Along with intraoperative neuronavigation and Doppler ultrasonography of the cavernous carotid arteries, identification of this structure may further aid in safeguarding against injury to critical paramedian structures.

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