Morbidity of repeat transsphenoidal surgery assessed in more than 1000 operations

Clinical article

Arman JahangiriDepartment of Neurosurgery and The California Center for Pituitary Disorders, University of California, San Francisco, California

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Jeffrey WagnerDepartment of Neurosurgery and The California Center for Pituitary Disorders, University of California, San Francisco, California

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Sung Won HanDepartment of Neurosurgery and The California Center for Pituitary Disorders, University of California, San Francisco, California

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Corinna C. ZygourakisDepartment of Neurosurgery and The California Center for Pituitary Disorders, University of California, San Francisco, California

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Seunggu J. HanDepartment of Neurosurgery and The California Center for Pituitary Disorders, University of California, San Francisco, California

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Mai T. TranDepartment of Neurosurgery and The California Center for Pituitary Disorders, University of California, San Francisco, California

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Liane M. MillerDepartment of Neurosurgery and The California Center for Pituitary Disorders, University of California, San Francisco, California

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Maxwell W. TomDepartment of Neurosurgery and The California Center for Pituitary Disorders, University of California, San Francisco, California

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Sandeep KunwarDepartment of Neurosurgery and The California Center for Pituitary Disorders, University of California, San Francisco, California

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Lewis S. Blevins Jr.Department of Neurosurgery and The California Center for Pituitary Disorders, University of California, San Francisco, California

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Manish K. AghiDepartment of Neurosurgery and The California Center for Pituitary Disorders, University of California, San Francisco, California

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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.
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