Road map to enhanced recovery protocol for endonasal endoscopic approach to pituitary adenomas: Surgical short-term outcome and experience of a single ENT/neurosurgery collaboration

Abstract

Background: The endoscopic endonasal transsphenoidal approach has become standard for the management of pituitary adenomas. This approach has been shown to facilitate early recovery and discharge from the hospital. The early recovery protocol has many advantages for both patients and the healthcare system in terms of patient satisfaction and cost-effectiveness.

Methods: Forty-seven patients with pituitary adenomas who underwent a trans-nasal endoscopic approach at our institution, operated by one neurosurgeon and one ENT surgeon, were retrospectively studied. Enhanced recovery protocols entailed preoperative, intraoperative, and postoperative protocols. The standard care included 1 day postoperative intensive care unit admission plus 1 or 2 days in the ward. Patient satisfaction was measured in terms of resolution of chief complaint, and a questionnaire survey was conducted at discharge and the 3-month follow-up.

Results: There was a significant decrease in the length of hospital stay with a mean of 2.7 days (standard deviation = 0.74). Patient satisfaction was better at the 3-month follow-up than in the early postoperative period. Most of our patients improved in terms of biochemical cure (18 out of 25 functioning adenomas [72%]) and experienced resolution of the chief complaint. The death occurred in only one patient due to pulmonary embolism.

Conclusion: Our study supports the benefits of early recovery protocols for endoscopic endonasal surgery for pituitary adenoma resection. The procedure is both safe and efficacious and improves overall patient satisfaction. Cerebrospinal fluid leaks remain a challenge but may improve with the use of fat, fascia lata, or middle turbinate flaps for large defects.

Keywords: Early recovery after surgery; Endonasal; Endoscopic; Outcome; Pituitary adenoma.

Figure 1:

Chart description of gender in relation to age in our study.

Figure 2:

Illustration of functional adenomas with secreting hormone percentages. PRL: Prolactin hormone, ACTH: Adrenocorticotropic hormone, GH: Growth hormone, NF: Non-Functioning adenoma

Figure 3:

Magnetic resonance imaging sella with contrast at the 3-month follow-up showing (a and b) Coronal and sagittal views of preoperative images with a tumor within the sella with homogenous enhancement characteristic of a pituitary adenoma. (c and d) Coronal and sagittal views of postoperative images show tumor removal within the Sella, but contrast enhancing pseudo-capsule is still present in spite of growth hormonal level control in this patient.

Figure 4:

Magnetic resonance imaging sella with contrast at the 3-month follow-up showing (a and b) Coronal and sagittal views of preoperative images with the tumor extending to the suprasellar region reaching the floor of the third ventricle. (c and d) Coronal and sagittal views of postoperative images showing gross total tumor.