Complication avoidance protocols in endoscopic pituitary adenoma surgery: a retrospective cohort study in 514 patients

Avoidance of Major Vascular Injury in Transcranial Brain Tumor Surgery Using Real-Time Doppler Navigation: Technical Note and Case Series

BACKGROUND AND OBJECTIVES

In endoscopic endonasal surgery, the Doppler probe has proven useful for localizing the paraclival and cavernous internal carotid arteries (ICA) and avoiding ICA injury. Similarly, during transcranial brain tumor removal, the Doppler probe may help avoid major vascular injury, particularly for tumors encasing or adherent to Circle of Willis branches. In this study, we describe the technique, outcomes, and potential neurovascular benefits of real-time navigation using the Doppler probe during craniotomy for brain tumor removal.

METHODS

Patients from 2015 to 2022 who underwent craniotomy for brain tumor resection and the Doppler probe was used were retrospectively analyzed. Data collection included demographics, tumor pathology, incidence of major/minor vascular injury, MRI-confirmed stroke/infarction, and extent of tumor resection.

RESULTS

In total, 695 patients underwent 840 craniotomies for brain tumor resection; in 501 craniotomies (59.6%), the Doppler was used. One major vascular injury (0.2%) of a supraclinoid ICA was directly attributed to non-Doppler probe use immediately before vessel injury, leading to stroke and severe neurological decline. There were 7 strokes (1.4%) leading to permanent neurological deficit attributable to vasospasm or small vessel injury and 26 asymptomatic infarctions/strokes (5.2%) attributable to unrecognized vascular injury or spasm at the time of surgery.

CONCLUSION

In this series of 501 craniotomies for brain tumor removal where the Doppler probe was used, the rate of direct large vessel injury was under 1%. Although our data show that smaller vessel injuries can still occur and may lead to permanent neurological deficits, routine Doppler probe use may help guide tumor dissection and aggressiveness of removal, avoiding inadvertent major arterial injury. Our experience suggests that it is most useful as tumor dissection progresses as the resulting brain shift makes stereotactic neuronavigation less reliable. We recommend routine Doppler probe use during transcranial brain tumor removal, particularly for tumors encasing or adherent to major arteries.

Impact of Frailty on Surgical Outcomes of Patients With Cushing Disease Using the Multicenter Registry of Adenomas of the Pituitary and Related Disorders Registry

BACKGROUND AND OBJECTIVES

Despite growing interest in how patient frailty affects outcomes (eg, in neuro-oncology), its role after transsphenoidal surgery for Cushing disease (CD) remains unclear. We evaluated the effect of frailty on CD outcomes using the Registry of Adenomas of the Pituitary and Related Disorders (RAPID) data set from a collaboration of US academic pituitary centers.

METHODS

Data on consecutive surgically treated patients with CD (2011-2023) were compiled using the 11-factor modified frailty index. Patients were classified as fit (score, 0-1), managing well (score, 2-3), and mildly frail (score, 4-5). Univariable and multivariable analyses were conducted to examine outcomes.

RESULTS

Data were analyzed for 318 patients (193 fit, 113 managing well, 12 mildly frail). Compared with fit and managing well patients, mildly frail patients were older (mean ± SD 39.7 ± 14.2 and 48.9 ± 12.2 vs 49.4 ± 8.9 years, P < .001) but did not different by sex, race, and other factors. They had significantly longer hospitalizations (3.7 ± 2.0 and 4.5 ± 3.5 vs 5.3 ± 3.5 days, P = .02), even after multivariable analysis (β = 1.01, P = .007) adjusted for known predictors of prolonged hospitalization (age, Knosp grade, surgeon experience, American Society of Anesthesiologists grade, complications, frailty). Patients with mild frailty were more commonly discharged to skilled nursing facilities (0.5% [1/192] and 4.5% [5/112] vs 25% [3/12], P < .001). Most patients underwent gross total resection (84.4% [163/193] and 79.6% [90/113] vs 83% [10/12]). No difference in overall complications was observed; however, venous thromboembolism was more common in mildly frail (8%, 1/12) than in fit (0.5%, 1/193) and managing well (2.7%, 3/113) patients ( P = .04). No difference was found in 90-day readmission rates.

CONCLUSION

These results demonstrate that mild frailty predicts CD surgical outcomes and may inform preoperative risk stratification. Frailty-influenced outcomes other than age and tumor characteristics may be useful for prognostication. Future studies can help identify strategies to reduce disease burden for frail patients with hypercortisolemia.

Socioeconomic Disparities in the Utilization of Endoscopic Transsphenoidal Pituitary Surgery: A Retrospective Analysis of the National Inpatient Sample

BACKGROUND

Pituitary neoplasms account for 15% of all intracranial neoplasms and affect 20% of the population. Disparities in treatment and outcomes may exist across racial, socioeconomic, and insurance groups, warranting further investigation.

METHODS

The National Inpatient Sample was analyzed from 2010 to 2020. Pearson's χ2 test, Fisher's exact test, and independent 2-tailed t-test were used to assess patient characteristics and outcomes. Common complications such as cerebrospinal fluid leak, diabetes insipidus, iatrogenic pituitary disorder, fluid and electrolyte disorders, neurological disorders, pulmonary disorders, and less common complications were assessed. A logistic regression model was used to compare in-hospital mortality and postoperative complications between racial groups. Statistically significant postoperative complications were analyzed with a multivariable logistic regression to determine the independent impact of obesity on postoperative outcomes.

RESULTS

Hospitalization rates for this procedure declined significantly over the decade, from 10,279 in 2010 to 5875 in 2020 (trend P value < 0.001). The majority of patients were aged between 25 and 64 years (72.16%), with 60.73% having no comorbidities. While the gender distribution was nearly even, disparities emerged across racial and socioeconomic groups. Black and Hispanic patients were more likely to reside in lower income zip codes and depend on Medicaid compared to White patients. Black patients had higher odds of any postoperative complication (adjusted odds ratio [aOR]: 1.14, P = 0.003) and specific complications like diabetes insipidus, fluid/electrolyte disorders, and renal/urinary issues compared to White patients. Both Black and Hispanic patients faced higher mortality risks postsurgery compared to White patients (aOR: 2.62 and 2.44, respectively, P < 0.05).Medicaid coverage was associated with higher odds of any complication (aOR: 1.18, P = 0.016), while private insurance was linked to lower odds (adjusted OR: 0.88, P = 0.015). Patients in the lowest income quartile had higher odds of complications compared to those in higher quartiles. Obesity independently predicted increased odds of pulmonary, renal, and hemorrhagic complications.

CONCLUSIONS

Despite advancements in endoscopic endonasal pituitary surgery, disparities in access and outcomes persist across racial, socioeconomic, and insurance groups. These findings underscore the need for targeted interventions to address these inequalities and ensure equitable access to quality care.

Endoscopic Occipital Transtentorial Approach for Dorsal Midbrain Cavernous Malformation: Technical Notes With Illustrative Case

BACKGROUND

The dorsal midbrain, an anatomically intricate region, presents significant challenges for traditional surgical interventions due to the heightened risk of vascular and neurological injury, and the necessity of brain tissue retraction.

METHODS

This study retrospectively reviewed the case of a 29-year-old male diagnosed with a cavernous malformation located in the dorsal aspect of the left midbrain. The patient underwent resection via the endoscopic occipital transtentorial approach (EOTA) in July 2024. Comprehensive records were analyzed, including preoperative magnetic resonance imaging and computed tomography imaging, detailed surgical notes, and postoperative outcomes.

RESULTS

The patient initially presented with headaches and diplopia. Imaging revealed a 17 × 13 mm tumor in the dorsal aspect of the left midbrain, associated with obstructive hydrocephalus. The 2.5-hour EOTA surgery resulted in complete resection of the tumor, with the resolution of headache symptoms and improvement of diplopia. No new complications were reported postoperatively. The patient was discharged 7 days postsurgery without the need for intensive care unit admission. Pathological examination confirmed the diagnosis of a cavernous malformation. Additionally, the EOTA facilitated a concurrent endoscopic third ventriculostomy, and no evidence of hydrocephalus was observed during the 3-month follow-up period.

CONCLUSIONS

The EOTA constitutes a significant advancement in neurosurgical techniques for the resection of dorsal midbrain tumors, enhancing surgical precision and safety. This approach contributes to improved patient outcomes and a reduction in complication rates. Further studies are warranted to validate these findings and to establish standardized protocols for the application of EOTA in midbrain tumor resection.

Contributing factors to postoperative surgical site infections in pituitary neuroendocrine tumors undergoing endonasal transsphenoidal resection

Pituitary Neuroendocrine Tumors (PitNETs), often treated via endonasal transsphenoidal resection, present a risk for postoperative surgical site infections (SSIs), including intracranial infections such as meningitis. Identifying the risk factors associated with these infections is crucial for improving surgical outcomes and patient care. A retrospective study was conducted at a medical center from June 2020 to June 2023. The study included 20 patients with postoperative intracranial infections and 50 controls without infections. Inclusion criteria involved adult patients diagnosed with PitNETs who underwent standard endonasal transsphenoidal surgery and provided informed consent. Exclusion criteria included previous neurosurgical procedures, preoperative infections, concurrent severe diseases, or alternative surgical approaches. Diagnostic criteria for intracranial infections were based on clinical, hematological, cerebrospinal fluid, radiological, and microbiological findings. Statistical analyses were performed using IBM SPSS, focusing on univariate and multivariate logistic regression analyses. Univariate analysis showed no significant association of intracranial infections with factors like smoking history, previous craniotomy, operation time, hypertension, preoperative sphenoid sinusitis, BMI, and age. However, postoperative CSF leaks, intracranial pneumocephalus, diabetes mellitus, and tumor extension to the third ventricle were significantly associated with infections. Multivariate logistic regression further confirmed these findings, with significant odds ratios for these factors. The study reveals a significant correlation between postoperative CSF leaks, intracranial pneumocephalus, diabetes mellitus, and tumor extension to the third ventricle with the occurrence of SSIs following endonasal transsphenoidal resection of PitNETs. Microbial analysis revealed Escherichia coli as the most prevalent pathogen in post-surgery infections, with notable antibiotic resistance patterns observed in key bacteria, necessitating careful antibiotic selection. Tailored clinical treatment strategies addressing these risk factors are essential to reduce the incidence of postoperative SSIs and enhance patient safety.

Cushing's Syndrome in the Elderly

Management of Cushing's syndrome (CS) can be particularly challenging in older patients, compared with younger individuals, due to the lack of several clinical features associated with cortisol excess along with a greater burden of associated comorbidities. Moreover, the interpretation of diagnostic tests could be influenced by age-related physiological changes in cortisol secretion. While mortality is higher and quality of life is more impaired in the elderly with CS as compared with the younger, there is currently no agreement on the most effective therapeutic options in aged individuals, and safety data concerning medical treatment are scanty. In this review, we summarize the current knowledge about age-related differences in CS etiology, clinical presentation, treatment, and outcomes and describe the potential underlying mechanisms.

Endonasal surgery high-risk carotid injury timeout checklist: implementation, institutional protocol and experience

OBJECTIVE

Carotid artery injury is a rare, but major complication of endonasal operations. The morbidity and mortality of such a complication can be mitigated by preparedness and a clear plan set in place to address the hemorrhage expeditiously. This study examines the implementation of such a carotid injury timeout checklist and demonstrates its effectiveness in a patient with possible arterial injury.

METHODS

A carotid injury timeout checklist was implemented for high risk endonasal procedures. The case selection was left to the surgeon, with guidelines including prior surgery, prior radiation, invasive tumors, and certain pathologies such as meningioma or chordoma. Factors affecting implementation were analyzed including tumor characteristics and patient history.

RESULTS

Over a 12-month period, 103 endonasal operations were performed since the carotid artery injury timeout checklist was implemented, with 21 (20.4%) having a carotid artery injury timeout performed. Tumor characteristics that were associated with performing this timeout included Knosp grade (for pituitary adenomas, p = 0.002), carotid artery encasement (p < 0.001), extended approach (p < 0.001), tumor size (p = 0.05) and diagnosis (p < 0.001). Re-operation and prior radiation were not factors for this cohort. The single carotid artery branch (hypertrophic vidian artery) injury that was sustained was easily and successfully managed, aided by preparation established via this protocol. The additional time necessary for this timeout to be performed was negligible with respect to the overall surgery length.

CONCLUSION

A carotid artery injury timeout can and should be successfully implemented for extended endonasal operations for pituitary and parasellar tumors with high risk factors including, but not limited to, carotid injury encasement, large tumor size and non-adenomatous diagnoses. A comprehensive plan for both intraoperative and perioperative management of the carotid injury is necessary to minimize the risk of morbidity and to deliver care expeditiously.

Central diabetes insipidus (vasopressin deficiency) after surgery for pituitary tumours: a systematic review and meta-analysis

OBJECTIVE

Central diabetes insipidus or vasopressin deficiency (AVP-D) is the most frequent water balance disorder after transsphenoidal surgery (TSS) with variable prevalence amongst studies. We aimed to determine rates of newly developed transient or permanent AVP-D in patients with pituitary tumours treated with TSS.

DESIGN AND METHODS

We performed systematic review of Medline, Embase, and Cochrane Library between January 1, 2000 and January 31, 2021 for studies reporting on outcomes for pituitary adenoma, craniopharyngioma, and Rathke's cleft cyst (RCC) after TSS and providing definition of post-operative AVP-D. We pooled the results as proportions with 95% confidence intervals (CIs) using Freeman-Tukey transformation random effects meta-analysis.

RESULTS

From 11 694 studies, 51 were included. Rates of transient or permanent AVP-D were: 17% (95% CI, 13-21) and 3% (95% CI, 2-5) in total group, 16% (95% CI, 12-21) and 2% (95% CI, 2-3) in pituitary adenomas, 31% (95% CI, 24-39) and 30% (95% CI, 22-39) in craniopharyngiomas, and 35% (95% CI, 16-57) and 14% (95% CI, 6-23) in RCCs, respectively. Based on diagnostic criteria, rates of transient or permanent AVP-D were: For hypotonic polyuria, 14% (95% CI, 8-22) and 3% (95% CI, 1-4), for hypotonic polyuria and hypernatraemia, 21% (95% CI, 13-29) and 5% (95% CI, 2-11), and for desmopressin administration, 22% (95% CI, 15-29) and 9% (95% CI, 0-30), respectively.

CONCLUSIONS

Following TSS, a small proportion of patients with pituitary adenoma have permanent AVP-D (2%), but prevalence reaches 30% in ones with craniopharyngioma and 14% in those with RCC. Diagnostic criteria for post-operative AVP-D remain variable affecting reported rates of this condition.

Endoscopic Endonasal Transsphenoidal Surgery for the Resection of Pituitary Adenomas: A Prime Candidate for a Shortened Length of Stay Enhanced Recovery after Surgery Protocol? A Systematic Review

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a perioperative model of care aimed at optimizing postoperative rehabilitation and reducing hospital length of stay (LOS). Decreasing LOS avoids hospital-acquired complications, reduces cost of care, and improves patient satisfaction. Given the lack of ERAS protocols for endoscopic endonasal transsphenoidal surgery (EETS) resection of pituitary adenomas, a systematic review of EETS was performed to compile patient outcomes and analyze factors that may lead to increased LOS, reoperation, and readmission rates with the intention to contribute to the development of a successful ERAS protocol for EETS.

METHODS

The authors performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines-based systematic review of the literature. Information was extracted regarding patient LOS, surgery complications, and readmission/reoperation rates. Pearson's correlations to LOS and reoperation/readmission rates were performed with variables normalized to the number of participants. Statistical significance was set at P value <0.05.

RESULTS

Fourteen studies were included, consisting of 2083 patients. The most common complications were cerebrospinal fluid leaks (37%) and postoperative diabetes insipidus (DI) (9%). Transient DI was significantly correlated with shorter LOS. Functional pituitary adenomas were significantly correlated with lower readmission rates while nonfunctional pituitary adenomas were correlated with higher readmission rates. No other factor was found to be significantly correlated with a change in LOS or reoperation rate.

CONCLUSIONS

EETS may be an ideal candidate for the development of ERAS cranial protocols. While our data largely supports the safe implementation of shortened LOS protocols in EETS, our findings highlight the importance of transient DI and nonfunctional pituitary adenomas management when formulating ERAS protocols.

Visual outcomes and optimal timing for repeat surgery in cases of postoperative hematoma following transsphenoidal surgery for pituitary neuroendocrine tumors: A retrospective cohort study

OBJECTIVE

To investigate the visual outcomes and optimal timing for repeat surgery in cases of postoperative hematoma following transsphenoidal surgery for pituitary neuroendocrine tumors (PitNETs).

METHODS

A retrospective study was conducted on 28 patients who developed evident postoperative hematoma out of a total of 9,010 patients. The hematomas were classified into three types based on their CT appearance. Type 1a - mild high density with no tension, Type 1b - thin-layer high density; Type 2a - solid high density with large empty cavities, Type 2b - solid high density with small empty cavities; Type 3 -solid high density with no cavity showing high tension. Patient data were collected for analysis.

RESULTS

The study cohort comprised 10 female and 18 male patients, with a mean age of 51.5±11.9 years. Most patients presented with large adenomas (median diameter 36mm). Postoperative visual sight improved in 12 patients, remained stable in 11 patients, and worsened in 5 patients. Notably, no patients experienced worsened visual sight beyond twenty-four hours after the operation. Among the five patients with visual deterioration, four had CT type 3 hematoma (4/6, 66.7%), and one had CT type 2b hematoma (1/9, 11.1%). Patients in the type 3 CT group were significantly more prone to experience visual deterioration compared to those in the type 2 group (odds ratio [OR] 2.154 [95% CI 1.858-611.014], P=.027). Four patients underwent repeat surgery after visual deterioration, resulting in visual improvement following a prolonged recovery period. Postoperative hematoma had limited impact on pituitary dysfunction and hyponatremia.

CONCLUSION

Our study reveals a significant association between postoperative hematoma CT types and visual deterioration. For patients with stable visual sight and type 1 or 2a hematoma, conservative strategies may be considered. Conversely, type 2b and 3 patients are at higher risk of visual deterioration, especially within the first 24 hours after the operation. Consequently, early reoperation before vision worsens may be a prudent approach to reduce risks and improve visual outcomes, particularly in type 3 patients.

The RAPID Consortium: A Platform for Clinical and Translational Pituitary Tumor Research

Objectives  Pituitary tumor treatment is hampered by the relative rarity of the disease, absence of a multicenter collaborative platform, and limited translational-clinical research partnerships. Prior studies offer limited insight into the formation of a multicenter consortium. Design  The authors describe the establishment of a multicenter research initiative, Registry of Adenomas of the Pituitary and Related Disorders (RAPID), to encourage quality improvement and research, promote scholarship, and apply innovative solutions in outcomes research. Methods  The challenges encountered during the formation of other research registries were reviewed with those lessons applied to the development of RAPID. Setting/Participants  RAPID was formed by 11 academic U.S. pituitary centers. Results  A Steering Committee, bylaws, data coordination center, and leadership team have been established. Clinical modules with standardized data fields for nonfunctioning adenoma, prolactinoma, acromegaly, Cushing's disease, craniopharyngioma, and Rathke's cleft cyst were created using a Health Insurance Portability and Accountability Act-compliant cloud-based platform. Currently, RAPID has received institutional review board approval at all centers, compiled retrospective data and agreements from most centers, and begun prospective data collection at one site. Existing institutional databases are being mapped to one central repository. Conclusion  The RAPID consortium has laid the foundation for a multicenter collaboration to facilitate pituitary tumor and surgical research. We sought to share our experiences so that other groups also contemplating this approach may benefit. Future studies may include outcomes benchmarking, clinically annotated biobank tissue, multicenter outcomes studies, prospective intervention studies, translational research, and health economics studies focused on value-based care questions.

Intraoperative cerebrospinal fluid leakage and residual tumors in endoscopic transsphenoidal surgery for pituitary adenoma: risk analysis and nomogram development

BACKGROUND

Endoscopic transsphenoidal surgery is the primary method used to treat pituitary adenomas (PAs) at present; however, this technique is associated with certain risks, including cerebrospinal fluid leakage (CFL) and residual tumors (RTs). In this study, we aimed to identify specific risk factors for intraoperative CFL (ioCFL) and postoperative RT in patients with pituitary adenoma and construct a corresponding nomogram for risk assessment.

METHODS

We collected a range of information from 782 patients who underwent endoscopic transsphenoidal PA resection in the Department of Neurosurgery at Beijing Tiantan Hospital between 2019 and 2021. Patients were then randomly assigned to training and validation groups (in a 8:2 ratio) with R software. Univariate and multivariable logistic regression models were then used to screen variables related to ioCFL and RT. These variables were then used to construct a predictive nomogram. Finally, the accuracy of the nomogram was validated by receiver operating characteristic curve (ROC) analysis, calibration plots, and decision curve analysis (DCA).

RESULTS

Univariate and multivariable logistic regression models identified four risk factors for ioCFL (Hardy grade, tumor size, position, and consistency) and five risk factors for RT (operation time, tumor size, consistency, Knosp grade, and primary/recurrence type). The area under the ROC curve (AUC) for the ioCFL risk model was 0.666 and 0.697 for the training and validation groups, respectively. For RT, the AUCs for the two groups were 0.788 and 0.754, respectively. The calibration plots for the ioCFL and RT models showed high calibration quality and DCA analysis yielded excellent efficiency with regards to clinical decision making.

CONCLUSION

Tumor size, growth characteristics, and invasion location were identified as the main factors affecting intraoperative CFL and RT. With our novel nomogram, surgeons can identify high-risk patients according to preoperative and intraoperative tumor performance and reduce the probability of complications.

Endoscopic Transsphenoidal Surgery with a Layered Peel Strategy for Cushing's Disease Treatment: A Case Series

Patients with Cushing's disease (CD) who underwent endoscopic transsphenoidal surgery (ETS) with a layered peel strategy at our center were retrospectively analyzed. Records on patients' basic characteristics, preoperative and early postoperative evaluations, perioperative complications, and follow-up were collected. A total of 12 unselected, consecutive patients with CD were identified. Ten of the twelve patients were female. All tumors were confirmed by magnetic resonance imaging, with a maximum tumor diameter ranging from 5 mm to 11 mm. A lower rate of surgical complications was identified postoperatively, with no cases of carotid artery injury, epistaxis, hematoma, visual disturbance, or intracranial infection, but with one case of cerebrospinal fluid rhinorrhea. Ten patients experienced immediate remission, and two had delayed remission. No recurrence events were observed during a median follow-up of 51 months. In conclusion, our preliminary experience indicated that ETS with a layered peel strategy provided a perfect remission rate, low complication rate, and no recurrence in a case series of CD patients. Given the limited number of cases, future studies are warranted to confirm its effectiveness and safety.

Comparison of Endoscopic and Microscopic Transsphenoidal Approaches for the Resection of Pituitary Adenoma

Background: The comparative outcomes between endoscopic and microscopic transsphenoidal approaches (ETSA and MTSA) for pituitary adenomas (PAs) remain controversial; however, the numerous literatures have been investigated for decades. This study evaluated the effectiveness of these two techniques using comprehensive measurements and rigorous statistical methods. Methods: A retrospective review of patients who underwent transsphenoidal surgery for PAs at our institution between January 2010 and December 2019 was performed. We included only cases treated by surgeons who have independently performed more than 30 transsphenoidal surgeries. Patients’ characteristics, surgical outcomes, complications, and recurrence were collected for statistical analysis Results: A total of 210 patients, including 138 ETSA patients, and 72 MTSA patients, were analyzed. The baseline characteristics of the two groups were comparable. ETSA patients showed less intraoperative blood loss (191.9 mL vs. 369.9 mL, P < 0.01), a higher rate of gross total resection (GTR) (84.1% vs. 72.2%, P = 0.04), a higher rate of extent of resection (EOR) (95.1% vs. 87.4%, P < 0.01), and shorter hospital stay (10 days vs. 13.5 days, P < 0.01). These better outcomes of ETSA persisted in multivariable regression analysis. Complications were not significantly different between groups. There was no statistical difference between recurrence-free survival of the two groups (P = 0.06, log-rank test) Conclusions: Our study showed that ETSA provided better outcomes and attained similar complications compared to MTSA for the resection of PAs.