Pituitary Surgery

 

 

Considerations

 

  • Mass effects:

    • Neurologic impairment (bitemporal hemianopsia, cranial nerve palsies)

    • Potential ↑ ICP (rare, secondary to obstructive hydrocephalus)

  • Neurohormonal effects/endocrinopathies:

    • Non-functional adenomas

    • Hypersecretory tumors (60%):  

      • Prolactin > GH > ACTH, TSH rare

      • Cushing’s, acromegaly

    • Endocrine deficiencies secondary to mass: 

      • Hormone production impaired in the following order

        • GH, LH, FSH, TSH, ACTH, prolactin ("Go Look For The Adenoma Please")

      • Panhypopituitarism

  • Surgical Issues/complications:

    • Shared airway

    • Head up positioning:

      • Poor patient & airway access 

      • Bleeding into pharynx (coroner's clot) 

      • Venous air embolism

    • Systemic absorption of cocaine from mucosa  HTN, arrhythmias

    • Neurologic injury

    • Massive, difficult to access hemorrhage (cavernous sinus or carotid) 

    • Post-operative endocrine dysfunction

    • CSF leak/meningitis risk 

    • Diabetes insipidus

  • Rapid smooth emergence 

 

 

Goals

 

  • Optimize perioperative endocrine function (stress dose steroids), consult endocrinology

  • Avoid further ↑ in ICP (if hydrocephalus)

  • Provide a still field for microscopic surgery

  • Minimize long acting sedatives (crisp emergence for neurological evaluation)

  • Controlled emergence (minimize bucking/coughing/vomiting to ↓ risk of bleeding and CSF leak)

  • Monitor for postoperative complications:

    • Diabetes insipidus (~40%)

    • SIADH (usually delayed)

    • Adrenal insufficiency & CV collapse (steroid coverage) 

    • Bleeding → ↑ ICP, brainstem compression, cranial nerve dysfunction 

    • CSF leak (risk of meningitis) 

    • Hypothalamic injury 

    • Cerebal ischemia

    • Stroke