Opiate Use After Endoscopic Endonasal Transsphenoidal Surgery

Background The literature on opiate use after endoscopic endonasal transsphenoidal surgery (EETS) is limited. Objective To determine the risk factors for higher opiate use following EETS and the quantity of opiates used after discharge. Methods A retrospective review of 144 patients undergoing EETS from July 2018 to July 2020 was conducted. Patient, tumor, and surgical factors were documented. Pain scores and medications used on postoperative days (POD) 0 and 1, and discharge prescriptions, were recorded. Opiate use was quantified using morphine milligram equivalents (MME) dose. Multiple linear regression determined risk factors independently associated with POD0 to 1 opiate use. Results On POD 0 to 1, mean pain score was 4.9/10 (standard deviation [SD] ± 2.0). Mean acetaminophen use was 3.4 tablets (SD ± 1.6; 650 mg per tablet). Mean opiate use was 35.6 MME (SD ± 36.3), equivalent to 4.7 tablets (SD ± 4.8) of oxycodone 5 mg. Multiple linear regression showed that current smokers required an additional 37.1 MME ( P = .011), and patients with grade 3 intraoperative cerebrospinal fluid leaks required an additional 36.7 MME ( P = .046) on POD0 to 1. On discharge, mean opiate prescription was 117.7 MME (SD ± 102.1), equivalent to 15.7 tablets (SD ± 13.6) of oxycodone 5 mg. Thirty-nine patients (27.1%) did not require prescriptions. Only 10 patients (6.9%) required opiate refill(s) within 30 days after surgery. Conclusion Patients undergoing EETS have higher opiate needs compared to those undergoing endoscopic sinus surgery, although the overall requirements are still considered low. Independent risk factors associated with higher opiate use in the immediate postoperative period included current smokers and grade 3 intraoperative cerebrospinal fluid leaks.

Perioperative Antibiotic Use in Endoscopic Endonasal Skull Base Surgery

Background Improved evidence-based guidelines on the optimal type and duration of antibiotics for patients undergoing endoscopic endonasal transsphenoidal surgery (EETS) are needed. We analyze the infectious complications among a large cohort of EETS patients undergoing a standardized regimen of cefazolin for 24 hours, followed by cephalexin for 7 days after surgery (clindamycin if penicillin/cephalosporin allergic). Methods A retrospective review of 132 EETS patients from 2018 to 2020 was conducted. Patient, tumor, and surgical characteristics were collected, along with infection rates. Multivariate logistic regression determined the variable(s) independently associated with infectious outcomes. Results Nearly all patients (99%) received postoperative antibiotics with 78% receiving cefazolin, 17% receiving cephalexin, 3% receiving clindamycin, and 2% receiving other antibiotics. Fifty-three patients (40%) had an intraoperative cerebrospinal fluid (CSF) leak, and three patients (2%) developed a postoperative CSF leak requiring surgical repair. Within 30 days, no patients developed meningitis. Five patients (4%) developed sinusitis, two patients (3%) developed pneumonia, and one patient (1%) developed cellulitis at a peripheral intravenous line. Two patients (2%) developed an allergy to cephalexin, requiring conservative management. After adjustment for comorbidities and operative factors, presence of postoperative infectious complications was independently associated with increased LOS (β = 3.7 days; p = 0.001). Conclusion Compared with reported findings in the literature, we report low rates of infectious complications and antibiotic intolerance, despite presence of a heavy burden of comorbidities and high intraoperative CSF leak rates among our cohort. These findings support our standardized 7-day perioperative antibiotic regimen.

The development of a virtual simulator for a novel design surgical tool in endoscopic endonasal transsphenoidal surgery

Endoscopic endonasal transsphenoidal surgery (EETS) is a standard procedure to treat the pituitary adenoma, a tumor in the pituitary gland that causes malfunction of hormones. Although the method is substantially minimal invasive, the surgeon may encounter intricacies. The major challenges are narrow surgery pathway, limited working area, lack of case studies for practicing, steep learning curve owing to the intricate steps, and the tool insertion risk. To ease the neurosurgeons, this research focuses on the development and testing of the surgical simulator based on the pathway guidance and the interchangeable surgical instrument tooltip. The system was tested in human cadaver-based experiments with interchangeability in terms of function and the performance of the simulator in terms of the benefits. The experiments demonstrate the augmentation in the learning skill of the user through the simulator based on the completion time assessment and the error reduction. Furthermore, the satisfaction level of the interchangeable surgical tool, which was found using sliding switch and gripper scored 71.40%, the interchangeable tooltip function, which is a novel function to participants scored 85.6% and the practical use had 77%. The geometric aspect of the interchangeable tool scored lowest (62.80%) and was found to be moderate among the neurosurgeons.

Self-Inflicted Craniofacial Impalement Injury with a Screwdriver During the COVID-19 Pandemic: A Case Report

ABSTRACT Objective: To present a case of a 37-year-old man presenting with craniofacial impalement injury from a screwdriver that happened during the early stages of the COVID-19 pandemic. Methods: Design: Case Report Setting: Tertiary Government Training Hospital Patient: One Results: During the early stages of COVID-19 pandemic a 37-year-old man was brought to the emergency room with a screwdriver embedded in his right eye. A multidisciplinary team observing available recommendations (level IV PPE, carefully planned operative directives) successfully performed endoscopic endonasal transsphenoidal surgery with application of a nasoseptal Hadad flap and abdominal fat obliteration. Aside from medial gaze limitations of the right eye, there was no CSF leak or rhinorrhea and no neurologic sequelae on follow up. Conclusion: Endoscopic skull base surgery for such an impalement injury as this is a formidable multidisciplinary challenge, even in normal times. The early stages of the COVID-19 pandemic presented additional challenges. Observing evolving guidelines minimized the high risk of exposure for health care workers while maximizing care for the patient.

Application of 3D printed model for planning the endoscopic endonasal transsphenoidal surgery

The application of 3D printing in planning endoscopic endonasal transsphenoidal surgery is illustrated based on the analysis of patients with intracranial skull base diseases who received treatment in our department. Cranial computed tomography/magnetic resonance imaging data are attained preoperatively, and three-dimensional reconstruction is performed using MIMICS (Materialise, Leuven, Belgium). Models of intracranial skull base diseases are printed using a 3D printer before surgery. The models clearly demonstrate the morphologies of the intracranial skull base diseases and the spatial relationship with adjacent large vessels and bones. The printing time of each model is 12.52–15.32 h, and the cost ranges from 900 to 1500 RMB. The operative approach was planned in vitro, and patients recovered postoperatively well without severe complications or death. In a questionnaire about the application of 3D printing, experienced neurosurgeons achieved scores of 7.8–8.8 out of 10, while unexperienced neurosurgeons achieved scores of 9.2–9.8. Resection of intracranial skull base lesions is demonstrated to be well assisted by 3D printing technique, which has great potential in disclosing adjacent anatomical relationships and providing the required help to clinical doctors in preoperative planning.

Cushing’s Disease due to ACTH Secreting Pituitary Microadenoma: A Single Institutional Experience of Four Cases

ACTH secreting pituitary adenomas are rare occurrences in autoptical, surgical and neuroradiological series. We herewith describe a series of four patients of Cushing’s disease due to ACTH secreting pituitary microadenoma. All patients presented with signs and symptoms of hypercortisolism. Hormonal testing and bilateral inferior petrosal sinus sampling were indicative of pituitary-dependent Cushing`s syndrome. Dynamic sellar MRI was suggestive of asymmetric pituitary, with suspect pituitary microadenoma in all cases. Three patients were operated for endoscopic endonasal transsphenoidal surgery, while one patient refused surgery and was managed with ketoconazole. During postoperative period, remission of hypercortisolism was ensured in two patients, while one patient continued to have raised levels of cortisol. One patient with raised levels of cortisol during postoperative period was prescribed Ketoconazole for 6 months. Histopathology confirmed the presence of pituitary adenoma. Adenoma displayed ACTH immunoreactivity. Our cases indicate that ACTH secreting pituitary microadenoma may occur in patients with Cushing̓s disease. Careful radiological, surgical and pathological examination is necessary to recognize this condition and avoid surgical failure.