Implementation of a Standardized Interdisciplinary Perioperative Protocol for Patients Undergoing Transsphenoidal Surgery: Impact on Patient Outcomes

• Published in: World neurosurgery Vol. 190; pp. e331 - e340
• Main Authors: Sanchez-Garavito, Jesus E., Perez-Vega, Carlos, Iyer, Harshvardhan, Rios-Zermeno, Jorge, Martinez, Guiselle Navarro, Navarro Garcia de Llano, Juan Pablo, Chang, Alice Y., Donaldson, Angela M., Olomu, Osarenoma U., Chaichana, Kaisorn L., Quiñones-Hinojosa, Alfredo, Almeida, Joao Paulo, Samson, Susan L.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.10.2024
• Subjects: Endoscopic endonasal; Hyponatremia; Length of stay; Patient outcomes; Pituitary adenoma; Protocol; Transsphenoidal surgery; RR; Hyponatremia; OR; POD; Transsphenoidal surgery; DI; MRI; Patient outcomes; CI; ACTH; IV; AVD; LOS; Pituitary adenoma; CSF; Protocol; Endoscopic endonasal; Length of stay
• ISSN: 1878-8750; 1878-8769; 1878-8769
• DOI: 10.1016/j.wneu.2024.07.128

Advances in endoscopic endonasal transsphenoidal surgery have led to improved postoperative outcomes after pituitary adenoma resection, including reduced length of stay, complications and readmission rates, without compromising safety and satisfaction. Our team implemented a perioperative protocol in January 2021 for patients undergoing endoscopic, transsphenoidal pituitary surgery. This study compares preoperative characteristics and postoperative outcomes in 279 patients between 2016 and 2022 (128 preprotocol and 151 postprotocol). Our protocol includes interdisciplinary preoperative evaluations, unified communication, cortisol thresholds for postoperative glucocorticoid replacement, and fluid restriction to prevent delayed hyponatremia. Median age was 54 ± 17 years with 50.8% female patients. There were 229 (82.1%) macroadenomas (>1 cm) and 50 (17.9%) microadenomas/cysts (<1 cm). Mean diameter was 18 (transverse), 18 (craniocaudal), 16 (anteroposterior) mm. Tumor types included 125 (44.8%) gonadotroph, 46 (16.4%) adrenocorticotroph, 40 (14.3%) lactotroph, 26 (9.3%) Rathke cysts, 19 (6.8%) somatotroph, 13 (4.6%) nondiagnostic, 3 (1%) somatotroph-lactotroph, 3 (1%) mammosomatotroph, 2 (0.71%) null cell, and 2 (0.7%) thyrotroph adenomas. Postprotocol, 74.2% of patients were discharged on postoperative day 1 compared with 46.1% preprotocol (P < 0.0001). Transient arginine vasopressin deficiency decreased from 10.4% (preprotocol) to 4.6% postprotocol (P = 0.101). Hyponatremia occurred in 13.3% pre-protocol and 4.6% postprotocol. Emergency department visits dropped from 9.4% to 3.9%, and readmissions decreased from 7.8% to 2.6%. Persistent arginine vasopressin deficiency affected 2.3% preprotocol and 1.3% postprotocol patients. Cerebrospinal fluid leaks occurred in 8.5% preprotocol and 7.3% postprotocol. Implementing an interdisciplinary, perioperative protocol for transsphenoidal endoscopic pituitary surgery improves length of stay while minimizing readmissions and surgery-related complications.