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Evaluation of different hydrocortisone treatment strategies in transsphenoidal pituitary surgery. Acta Neurochir (Wien) 2019; 161:1715-1721. [PMID: 31065892 PMCID: PMC6616203 DOI: 10.1007/s00701-019-03885-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 03/20/2019] [Indexed: 12/26/2022]
Abstract
Background Hydrocortisone treatment in transsphenoidal pituitary surgery has been debated. Although several publications advocate restrictive treatment, centers around the world administer stress doses of hydrocortisone in patients with presumed intact cortisol production. Our aim with this analysis was to compare postoperative hypocortisolism in patients who received three different protocols of hydrocortisone therapy during and after surgery. Method This was a retrospective observational study. Based on perioperative hydrocortisone dose given, patients were divided in three groups: high dose (HD), intermediate dose (ID), and low dose (LD). Postoperative evaluation of the pituitary function was performed using S-cortisol at day 4 and short Synacthen test (SST) at 6–8 weeks. Patients with ACTH-producing adenomas or preoperative hydrocortisone treatment were excluded. Result There was no difference between the groups regarding failure rate of SST. The rate of failed SST (all groups) was 51/186 (27%), 24/74 (32%) in the HD group and 26/74 (35%) and 11/38 (29%) in the ID and LD groups respectively. There was no significant difference between the ID and LD groups regarding S-cortisol at postoperative day 4 regarding serum cortisol level below 200 nmol/L. There was a significant but weak correlation, rs 0.330 (P < 0.01) between S-cortisol day 4 and SST at 4–6 weeks. Conclusions Peri and postoperative hydrocortisone treatment did not affect SST response 6–8 weeks postoperatively, whereas the rate of patients with S-cortisol below 200 nmol/L at postoperative day 4 did. LD hydrocortisone therapy seems to favor a better endogenous production in the early postoperative phase.
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Pecoraro NC, Heiferman DM, Martin B, Li D, Johans SJ, Patel CR, Germanwala AV. Lower-dose perioperative steroid protocol during endoscopic endonasal pituitary adenoma resection. Surg Neurol Int 2019; 10:52. [PMID: 31528390 PMCID: PMC6743680 DOI: 10.25259/sni-68-2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 01/30/2019] [Indexed: 11/30/2022] Open
Abstract
Background: Perioperative steroid management for pituitary adenoma resections is multifaceted due to possible hypothalamic–pituitary–adrenal (HPA) axis disruption. Although many different strategies have been proposed, there is no standard protocol for prophylaxis of potential hypocortisolemia. Methods: We performed a retrospective analysis of consecutive endoscopic endonasal pituitary adenoma resections. Before March 2016, patients received ≥100 mg of hydrocortisone intraoperatively followed by 2 mg of dexamethasone immediately postoperatively in most of the patients. Subsequently, patients received only 50 mg of hydrocortisone intraoperatively. A morning cortisol level was checked on postoperative day (POD) 2, and if it was <10 mcg/dL, patients remained on maintenance hydrocortisone. At 6 weeks, serum cortisol was redrawn and low-dose therapy was weaned when indicated. Results: Of those who received ≥100 mg of hydrocortisone, 8 of 24 (33.3%) were discharged on hydrocortisone compared to 1 of 14 (7.1%) who received 50 mg. 18 of 24 (75%) of ≥100 mg group received dexamethasone on POD 1, and of those, 8 (44.4%) were discharged on hydrocortisone. Of those who received ≥100 mg and were on outpatient steroid therapy initially, 3 of 8 (37.5%) required continuation after 6 weeks compared to none who received 50 mg. There was an association between patient’s intraoperative/immediate postoperative steroid use and steroid continuation at discharge. Conclusion: Through our experience, we hypothesize that ≥100 mg of hydrocortisone intraoperatively followed by postoperative dexamethasone may be overly suppressive in patients with otherwise normally functioning HPA. A 50 mg intraoperative dose alone may be considered to lower rates of unnecessary steroid regimens postoperatively.
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Affiliation(s)
- Nathan C Pecoraro
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois
| | - Daniel M Heiferman
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois.,Department of Surgery, Edward Hines, Jr. VA Medical Center, Hines, Illinois, USA
| | - Brendan Martin
- Department of Clinical Research Office Stritch School of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Daphne Li
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois.,Department of Surgery, Edward Hines, Jr. VA Medical Center, Hines, Illinois, USA
| | - Stephen J Johans
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois.,Department of Surgery, Edward Hines, Jr. VA Medical Center, Hines, Illinois, USA
| | - Chirag R Patel
- Department of Otolaryngology, Loyola University Medical Center, Maywood, Illinois.,Department of Surgery, Edward Hines, Jr. VA Medical Center, Hines, Illinois, USA
| | - Anand V Germanwala
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois.,Department of Otolaryngology, Loyola University Medical Center, Maywood, Illinois.,Department of Surgery, Edward Hines, Jr. VA Medical Center, Hines, Illinois, USA
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Borg H, Siesjö P, Kahlon B, Fjalldal S, Erfurth EM. Perioperative serum cortisol levels in ACTH sufficient and ACTH deficient patients during transsphenoidal surgery of pituitary adenoma. Endocrine 2018; 62:83-89. [PMID: 29968225 PMCID: PMC6153577 DOI: 10.1007/s12020-018-1655-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 06/12/2018] [Indexed: 01/09/2023]
Abstract
PURPOSE No previous study has analyzed serum cortisol levels during transsphenoidal endoscopic pituitary surgery in patients with and without hydrocortisone (HC) substitution. METHODS A total of 15 patients undergoing surgery for a pituitary adenoma were studied. Those with normal ACTH function were either not given HC (n = 7) or received 50 mg intravenous HC at the start of surgery (n = 4). Patients with ACTH deficiency received intravenous HC of 100 mg in the morning before surgery (n = 4) with the additional 50 mg for an afternoon operation (n = 2). Propofol and remifentanil were used as anesthetics. Serum cortisol was measured at the start of and every 30 min during surgery. RESULTS Among 7 patients with normal ACTH function without HC substitution, cortisol levels before surgery were 126-244 nmol/L, among the 4 patients undergoing surgery in the morning, whereas the 3 who underwent surgery in the afternoon had lower levels, 38-76 nmol/L. During nose/sinus surgery cortisol levels decreased to 79-139 and 24-54 nmol/L, respectively. At intrasellar manipulation a distinct rise was noted. Also, in the 4 ACTH sufficient patients receiving HC, cortisol levels decreased during nose/sinus surgery, but only with a slight increase during intrasellar surgery. In the 4 ACTH deficient patients cortisol peaked at 1914-2582 nmol/L. CONCLUSIONS Patients with normal ACTH function without HC substitution had very low cortisol levels during the first part of surgery, likely suppressed by the anesthetics. After mechanical impact in the sella, a marked increase in cortisol was noted. Supraphysiological cortisol levels were achieved with our routine HC substitution, advising us to reduce the supplementation.
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Affiliation(s)
- Henrik Borg
- Department of Endocrinology, Skåne University Hospital, Lund, S-221 85, Sweden.
| | - Peter Siesjö
- Department of Neurosurgery, Skåne University Hospital, Lund, S-221 85, Sweden
| | - Babar Kahlon
- Department of Neurosurgery, Skåne University Hospital, Lund, S-221 85, Sweden
| | - Sigridur Fjalldal
- Department of Endocrinology, Skåne University Hospital, Lund, S-221 85, Sweden
| | - Eva Marie Erfurth
- Department of Endocrinology, Skåne University Hospital, Lund, S-221 85, Sweden
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McCormack AI, Burt MG. Optimising pituitary surgery outcomes in Australia: how much does size matter? Intern Med J 2017; 47:1225-1227. [PMID: 29105260 DOI: 10.1111/imj.13610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 08/20/2017] [Accepted: 08/23/2017] [Indexed: 01/02/2023]
Affiliation(s)
- Ann I McCormack
- Department of Endocrinology, St Vincent's Hospital, Sydney, New South Wales, Australia.,Hormones and Cancer Group, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | - Morton G Burt
- Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, South Australia, Australia.,School of Medicine, Flinders University, Adelaide, South Australia, Australia
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Sarkiss CA, Lee J, Papin JA, Geer EB, Banik R, Rucker JC, Oudheusden B, Govindaraj S, Shrivastava RK. Pilot Study on Early Postoperative Discharge in Pituitary Adenoma Patients: Effect of Socioeconomic Factors and Benefit of Specialized Pituitary Centers. J Neurol Surg B Skull Base 2015. [PMID: 26225324 DOI: 10.1055/s-0035-1549004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Introduction Pituitary neoplasms are benign entities that require distinct diagnostic and treatment considerations. Recent advances in endoscopic transsphenoidal surgery have resulted in shorter lengths of stay (LOS). We implemented a postoperative day (POD) 1 discharge paradigm involving a multidisciplinary approach and detailed preoperative evaluation and review of both medical and socioeconomic factors. Methods The experience of a single neurosurgeon/ears, nose, throat (ENT) team was reviewed, generating a preliminary retrospective database of the first 30 patients who underwent resection of pituitary lesions under the POD 1 discharge paradigm. We assessed multiple axes from their preoperative, in-house, and postoperative care. Results There were 14 men and 16 women with an average age of 53.8 years (range: 27-76 years). There were 22 nonsecretory and 8 secretory tumors with average size of 2.80 cm (range: 1.3-5.0 cm). All 30 patients underwent preoperative ENT evaluation. Average LOS was 1.5 ± 0.7 days. A total of 18 of 30 patients were discharged on POD 1. The insurance status included 15 with public insurance such as emergency Medicaid and 15 with private insurance. Four patients had transient diabetes insipidus (DI); none had permanent DI. Overall, 28 of 30 patients received postoperative steroids. Factors that contributed to LOS > 1 day included public insurance status, two or more medical comorbidities, diabetes mellitus, transient panhypopituitarism, and DI. Conclusion The implementation of a POD 1 discharge plan for pituitary tumors is feasible and safe for elective patients. This implementation requires the establishment of a dedicated Pituitary Center model with experienced team members. The consistent limitation to early discharge was socioeconomic status. Efforts that incorporate the analysis of social disposition parameters with proper management of clinical sequelae are crucial to the maintenance of ideal LOS and optimal patient outcomes.
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Affiliation(s)
- Christopher A Sarkiss
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - James Lee
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Joseph A Papin
- Department of Neurosurgery, University of Michigan Medical School, Ann Arbor, Michigan, United States
| | - Eliza B Geer
- Department of Medicine-Endocrinology, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Rudrani Banik
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Janet C Rucker
- Department of Neurology (Neuro-Ophthalmology), New York University School of Medicine, New York, New York, United States
| | - Barbara Oudheusden
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Satish Govindaraj
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Raj K Shrivastava
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
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Burt MG, Mangelsdorf BL, Rogers A, Ho JT, Lewis JG, Inder WJ, Doogue MP. Free and total plasma cortisol measured by immunoassay and mass spectrometry following ACTH₁₋₂₄ stimulation in the assessment of pituitary patients. J Clin Endocrinol Metab 2013; 98:1883-90. [PMID: 23539724 DOI: 10.1210/jc.2012-3576] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
CONTEXT Measurement of plasma cortisol by immunoassay after ACTH₁₋₂₄ stimulation is used to assess the hypothalamic-pituitary-adrenal (HPA) axis. Liquid chromatography-tandem mass spectrometry (LCMS) has greater analytical specificity than immunoassay and equilibrium dialysis allows measurement of free plasma cortisol. OBJECTIVE We investigated the use of measuring total and free plasma cortisol by LCMS and total cortisol by immunoassay during an ACTH₁₋₂₄ stimulation test to define HPA status in pituitary patients. DESIGN AND SETTING This was a case control study conducted in a clinical research facility. PARTICIPANTS We studied 60 controls and 21 patients with pituitary disease in whom HPA sufficiency (n = 8) or deficiency (n = 13) had been previously defined. INTERVENTION Participants underwent 1 μg ACTH(1-24) intravenous and 250 μg ACTH₁₋₂₄ intramuscular ACTH₁₋₂₄ stimulation tests. MAIN OUTCOME MEASURES Concordance of ACTH₁₋₂₄-stimulated total and free plasma cortisol with previous HPA assessment. RESULTS Total cortisol was 12% lower when measured by immunoassay than by LCMS. Female sex and older age were positively correlated with ACTH₁₋₂₄-stimulated total and free cortisol, respectively. Measurements of total cortisol by immunoassay and LCMS and free cortisol 30 minutes after 1 μg and 30 and 60 minutes after 250 μg ACTH₁₋₂₄ were concordant with previous HPA axis assessment in most pituitary patients. However, free cortisol had greater separation from the diagnostic cutoff than total cortisol. CONCLUSIONS Categorization of HPA status by immunoassay and LCMS after ACTH₁₋₂₄ stimulation was concordant with previous assessment in most pituitary patients. Free cortisol may have greater clinical use in patients near the diagnostic threshold.
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Affiliation(s)
- Morton G Burt
- Southern Adelaide Diabetes and Endocrine Services, Repatriation General Hospital, Daw Park, Adelaide 5041, Australia.
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