Morbidity of repeat transsphenoidal surgery assessed in more than 1000 operations

Clinical article

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Object

While transsphenoidal surgery is associated with low morbidity, the degree to which morbidity increases after reoperation remains unclear. The authors determined the morbidity associated with repeat versus initial transsphenoidal surgery after 1015 consecutive operations.

Methods

The authors conducted a 5-year retrospective review of the first 916 patients undergoing transsphenoidal surgery at their institution after a pituitary center of expertise was established, and they analyzed morbidities.

Results

The authors analyzed 907 initial and 108 repeat transsphenoidal surgeries performed in 916 patients (9 initial surgeries performed outside the authors' center were excluded). The most common diagnoses were endocrine inactive (30%) or active (36%) adenomas, Rathke's cleft cysts (10%), and craniopharyngioma (3%). Morbidity of initial surgery versus reoperation included diabetes insipidus ([DI] 16% vs 26%; p = 0.03), postoperative hyponatremia (20% vs 16%; p = 0.3), new postoperative hypopituitarism (5% vs 8%; p = 0.3), CSF leak requiring repair (1% vs 4%; p = 0.04), meningitis (0.4% vs 3%; p = 0.02), and length of stay ([LOS] 2.8 vs 4.5 days; p = 0.006). Of intraoperative parameters and postoperative morbidities, 1) some (use of lumbar drain and new postoperative hypopituitarism) did not increase with second or subsequent reoperations (p = 0.3–0.9); 2) some (DI and meningitis) increased upon second surgery (p = 0.02–0.04) but did not continue to increase for subsequent reoperations (p = 0.3–0.9); 3) some (LOS) increased upon second surgery and increased again for subsequent reoperations (p < 0.001); and 4) some (postoperative hyponatremia and CSF leak requiring repair) did not increase upon second surgery (p = 0.3) but went on to increase upon subsequent reoperations (p = 0.001–0.02). Multivariate analysis revealed that operation number, but not sex, age, pathology, radiation therapy, or lesion size, increased the risk of CSF leak, meningitis, and increased LOS. Separate analysis of initial versus repeat transsphenoidal surgery on the 2 most common benign pituitary lesions, pituitary adenomas and Rathke's cleft cysts, revealed that the increased incidence of DI and CSF leak requiring repair seen when all pathologies were combined remained significant when analyzing only pituitary adenomas and Rathke's cleft cysts (DI, 13% vs 35% [p = 0.001]; and CSF leak, 0.3% vs 9% [p = 0.0009]).

Conclusions

Repeat transsphenoidal surgery was associated with somewhat more frequent postoperative DI, meningitis, CSF leak requiring repair, and greater LOS than the low morbidity characterizing initial transsphenoidal surgery. These results provide a framework for neurosurgeons in discussing reoperation for pituitary disease with their patients.

Abbreviations used in this paper:DI = diabetes insipidus; LOS = length of stay.
Article Information

Contributor Notes

Address correspondence to: Manish K. Aghi, M.D., Ph.D., University of California, San Francisco, 505 Parnassus Ave., Rm. M779, San Francisco, CA 94143. email: AghiM@neurosurg.ucsf.edu.Please include this information when citing this paper: published online May 16, 2014; DOI: 10.3171/2014.3.JNS131532.

© Copyright 1944-2019 American Association of Neurological Surgeons

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References
  • 1

    Aghi MK: Management of recurrent and refractory Cushing disease. Nat Clin Pract Endocrinol Metab 4:5605682008

  • 2

    Barker FG IIKlibanski ASwearingen B: Transsphenoidal surgery for pituitary tumors in the United States, 1996–2000: mortality, morbidity, and the effects of hospital and surgeon volume. J Clin Endocrinol Metab 88:470947192003

    • Search Google Scholar
    • Export Citation
  • 3

    Brada MRajan BTraish DAshley SHolmes-Sellors PJNussey S: The long-term efficacy of conservative surgery and radiotherapy in the control of pituitary adenomas. Clin Endocrinol (Oxf) 38:5715781993

    • Search Google Scholar
    • Export Citation
  • 4

    Cappabianca PAlfieri AColao ACavallo LMFusco MPeca C: Endoscopic endonasal transsphenoidal surgery in recurrent and residual pituitary adenomas: technical note. Minim Invasive Neurosurg 43:38432000

    • Search Google Scholar
    • Export Citation
  • 5

    Chang EFSughrue MEZada GWilson CBBlevins LS JrKunwar S: Long term outcome following repeat transsphenoidal surgery for recurrent endocrine-inactive pituitary adenomas. Pituitary 13:2232292010

    • Search Google Scholar
    • Export Citation
  • 6

    Chang SMParney IFMcDermott MBarker FG IISchmidt MHHuang W: Perioperative complications and neurological outcomes of first and second craniotomies among patients enrolled in the Glioma Outcome Project. J Neurosurg 98:117511812003

    • Search Google Scholar
    • Export Citation
  • 7

    Ciric IRagin ABaumgartner CPierce D: Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 40:2252371997

    • Search Google Scholar
    • Export Citation
  • 8

    Furtado SVThakar SHegde AS: The use of image guidance in avoiding vascular injury during trans-sphenoidal access and decompression of recurrent pituitary adenomas. J Craniomaxillofac Surg 40:6806842012

    • Search Google Scholar
    • Export Citation
  • 9

    Jahangiri AWagner JRPekmezci MHiniker AChang EFKunwar S: A comprehensive long-term retrospective analysis of silent corticotrophic adenomas versus hormonenegative adenomas. Neurosurgery [epub ahead of print]2013

    • Search Google Scholar
    • Export Citation
  • 10

    Laws ER Jr: Vascular complications of transsphenoidal surgery. Pituitary 2:1631701999

  • 11

    Laws ER JrFode NCRedmond MJ: Transsphenoidal surgery following unsuccessful prior therapy An assessment of benefits and risks in 158 patients. J Neurosurg 63:8238291985

    • Search Google Scholar
    • Export Citation
  • 12

    Liu JKDas KWeiss MHLaws ER JrCouldwell WT: The history and evolution of transsphenoidal surgery. J Neurosurg 95:108310962001

    • Search Google Scholar
    • Export Citation
  • 13

    McLaughlin NLaws EROyesiku NMKatznelson LKelly DF: Pituitary centers of excellence. Neurosurgery 71:9169262012

  • 14

    Patil CGVeeravagu APrevedello DMKatznelson LVance MLLaws ER Jr: Outcomes after repeat transsphenoidal surgery for recurrent Cushing's disease. Neurosurgery 63:2662712008

    • Search Google Scholar
    • Export Citation
  • 15

    Potts MBJahangiri ALamborn KRBlevins LSKunwar SAghi MK: Suprasellar Rathke cleft cysts: clinical presentation and treatment outcomes. Neurosurgery 69:105810692011

    • Search Google Scholar
    • Export Citation
  • 16

    Rudnik AZawadzki TGałuszka-Ignasiak BBazowski PDuda IWojtacha M: Endoscopic transsphenoidal treatment in recurrent and residual pituitary adenomas—first experience. Minim Invasive Neurosurg 49:10142006

    • Search Google Scholar
    • Export Citation
  • 17

    Schreckinger MSzerlip NMittal S: Diabetes insipidus following resection of pituitary tumors. Clin Neurol Neurosurg 115:1211262013

    • Search Google Scholar
    • Export Citation
  • 18

    Stefanidis DMalireddy KKuwada TPhillips RZoog EGersin KS: Revisional bariatric surgery: perioperative morbidity is determined by type of procedure. Surg Endosc 27:450445102013

    • Search Google Scholar
    • Export Citation
  • 19

    Tate MCJahangiri ABlevins LKunwar SAghi MK: Infected Rathke cleft cysts: distinguishing factors and factors predicting recurrence. Neurosurgery 67:7627692010

    • Search Google Scholar
    • Export Citation
  • 20

    Tsang RWBrierley JDPanzarella TGospodarowicz MKSutcliffe SBSimpson WJ: Radiation therapy for pituitary adenoma: treatment outcome and prognostic factors. Int J Radiat Oncol Biol Phys 30:5575651994

    • Search Google Scholar
    • Export Citation
  • 21

    Wilson TJMcKean ELBarkan ALChandler WFSullivan SE: Repeat endoscopic transsphenoidal surgery for acromegaly: remission and complications. Pituitary 16:4594642013

    • Search Google Scholar
    • Export Citation
  • 22

    Yamada SFukuhara NOyama KTakeshita ATakeuchi Y: Repeat transsphenoidal surgery for the treatment of remaining or recurring pituitary tumors in acromegaly. Neurosurgery 67:9499562010

    • Search Google Scholar
    • Export Citation
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