Consensus on Postoperative Recommendations After Transsphenoidal Surgery

Ulrich J. Knappe; Dag Moskopp; Rüdiger Gerlach; Jens Conrad; Jörg Flitsch; Jürgen B. Honegger

doi:10.1055/a-0664-7710

Experimental and Clinical Endocrinology & Diabetes, Table of Contents

Exp Clin Endocrinol Diabetes 2019; 127(01): 29-36
DOI: 10.1055/a-0664-7710

Article

Consensus on Postoperative Recommendations After Transsphenoidal Surgery

A Study Among Pituitary Surgeons in Germany and Review of Literature

Ulrich J. Knappe

¹Department of Neurosurgery, Johannes Wesling Klinikum, University Hospital of Ruhruniversität Bochum, Minden

,

Dag Moskopp

²Department of Neurosurgery, Vivantes Klinikum Friedrichshain, Berlin

,

Rüdiger Gerlach

³Department of Neurosurgery, Helios Kliniken, Erfurt

,

Jens Conrad

⁴Department of Neurosurgery, Johannes Gutenberg Universität, Mainz

,

Jörg Flitsch

⁵Department of Neurosurgery, Universitätskrankenhaus Eppendorf, Hamburg

,

Jürgen B. Honegger^*

⁶Department of Neurosurgery, Universitätsklinikum Tübingen, Germany

› Author Affiliations

Abstract

Background Guidelines for patient behavior following transsphenoidal surgery do not exist. To gain generally recommendations, the German pituitary working group conducted a study among pituitary surgeons to elucidate their opinions and customs of patients’ counselling.

Methods Questions concerning daily activities, exertion of sports and work life were addressed. It was asked to provide the postoperative time interval after which specific activities can be resumed both after a routine or an extended approach.

Results Fourteen pituitary surgeons returned the completed questionnaire. Following routine operations, washing the hair was allowed within one week, blowing the nose after 3, flying on an airplane and driving a car after one, lifting heavy weights after 4, playing wind instruments after 6, use of CPAP (continuous positive airway pressure) device after 3, permit leisure sports after 2 to 4 weeks (except for scuba diving). Competitive sports can be resumed after 6 weeks. Occupation with mental demands was considered feasible after 2 weeks, with physical labor after 4 weeks. After extended transsphenoidal surgery, the recommended time interval was roughly twice as long compared to the routine approach. Driving a car was allowed within the first 4 weeks after surgery by some pituitary surgeons, while others allow driving only after 3 months analogous to the regulations after craniotomy. The risk of scuba diving was considered high.

Conclusions The data of our study and the literature, and expert opinions from related scientific fields resulted in a consensus on recommendations for patients’ conduct to minimize risks after transsphenoidal surgery.

Key words

pituitary tumor - transsphenoidal surgery - postoperative recommendations

Full Text

References

References
1 Hardy J. Transsphenoidal microsurgery of the normal and pathological pituitary. Clin Neurosurg 1969; 16: 185-217
2 Cappabianca P, Cavallo LM, de Divitiis E. Endoscopic endonasal surgery. Neurosurgery 2004; 55: 933-941
3 Mortini P, Losa M, Barzaghi R. et al. Results of transsphenoidal surgery in a large series of patients with pituitary adenoma. Neurosurgery 2005; 56: 1222-1233
4 Honegger J, Schmalisch K, Beuschlein F. et al. Contemporary microsurgical concept for the treatment of Cushing`s disease: endocrine outcome in 83 consecutive patients. Clin Endocrinol (Oxf) 2012; 76: 560-567
5 Ciric I, Ragin A, Baumgartner C. et al. Complications of transsphenoidal surgery: results of a national survey, review of literature, and personal experience. Neurosurgery 1997; 40: 225-237
6 Cote DJ, Dasenbrock HH, Muskens IS. et al. Readmission and other adverse events after transsphenoidal surgery: Prevalence, timing, and predictive factors. J Am Coll Surg 2017; 224: 971-979
7 Brouwers MC, Kerkvliet K, Spithoff K. The AGREE reporting checklist: a tool to improve reporting of clinical practice guidelines. BMJ 2016; 352: i1152
8 Beule AG, Hosemann W. [Wound healing after endoscopic sinus surgery and postoperative management]. HNO 2009; 57: 763-771
9 Xu G, Jiang H, Li H. et al. Stages of nasal mucosal transitional course after functional endoscopic sinus surgery and their clinical indications. ORL J Otorhinolaryngol Relat Spec 2008; 70: 118-123
10 Shaw CK, Cowin A, Wormald PJ. A study of the normal temporal healing pattern and the mucociliary transport after endoscopic partial and full-thickness removal of nasal mucosa in sheep. Immunol Cell Biol 2001; 79: 145-148
11 Rajapaksa SP, Ananda A, Cain TM. et al. Frontal ostium neo-osteogenesis and restenosis after modified endoscopic Lothrop procedure in an animal model. Clin Otolaryngol Allied Sci 2004; 29: 386-388
12 Mousavi SR, Fehlner A, Streitberger KJ. et al. Measurement of in vivo cerebral volumetric strain induced by Valsalva maneuver. J Biomech 2014; 47: 1652-1657
13 Zhang Z, Wang X, Jonas JB. et al. Valsalva maneuver, intra-ocular pressure, cerebrospinal fluid pressure, optic disc topography: Beijing intracranial and intra-ocular pressure study. Acta Opthalmol 2014; 92: e475-e480
14 Nath G, Korula G, Chandy MJ. Effect of intrathecal saline injection and Valsalva maneuver on cerebral perfusion pressure during transsphenoidal surgery for pituitary macroadenoma. J Neurosurg Anesthesiol 1995; 7: 1-6
15 Neville L, Egan RA. Frequency and amplitude of elevation of cerebrospinal fluid resting pressure by Valsalva maneuver. Can J Ophthalmol 2005; 40: 775-777
16 Mishra SK, Mathew GA, Paul RR. et al. Endoscopic repair of CSF rhinorrhea: an institutional experience. Iran J Otorhinolaryngol 2016; 28: 39-43
17 De Boisanger L, Kaliaperumal C. Sex after neurosurgery – is it safe?. Neurosurgery 2018; 82: E67-E68
18 Haran RP, Chandy MJ. Symptomatic pneumencephalus after transsphenoidal surgery. Surg Neurol 1997; 48: 575-578
19 Satyarthee GD, Mahapatra AK. Tension pneumocephalus following transsphenoidal surgery for pituitary adenoma – report of two cases. J Clin Neurosci 2003; 10: 495-497
20 Sawka AM, Aniszewski JP, Youn Jr WF. et al. Tension pneomocranium, ar rare complication of transsphenoidal pituitary surgery: Mayo Clinic experience 1976 – 1998. J Clin Endocrinol Metab 1999; 84: 4731-4734
21 Sze L, Schmid C, Bloch KE. et al. Effect of transsphenoidal surgery on sleep apnea in acromegaly. Eur J Endocrinol 2007; 156: 321-329
22 Jarjour NN, Wilson P. Pneumocephalus associated with nasal continuous positive airway pressure in a patient with sleep apnea syndrome. Chest 1989; 96: 1425-1426
23 Kopelovic JC, de la Garza G, Greenlee JDW. et al. Pneumocephalus with BiPAP use after transsphenoidal surgery. J Clin Anesthesiol 2012; 24: 415-418
24 American Society of Anesthesiologists. Practice guidelines for the perioperative management of patients with obstructive sleep apnea. A report by the American Society of Anesthesiologists Task Force on perioperative management of patients with obstructive sleep apnea. Anesthesiology 2006; 104: 1081-1093
25 American Society of Anesthesiologists. Practice guidelines for the perioperative management of patients with obstructive sleep apnea. An update report by the American Society of Anesthesiologists task force on perioperative management of patients with obstructive sleep apnea. Anesthesiology 2014; 120: 268-286
26 Venkatraghavan L, Perks A. Postoperative management of obstructive sleep apnea after transsphenoidal pituitary surgery. J Neurosurg Anesthesiol 2009; 21: 179-180
27 Rahimi E, Mariappan R, Tharmaradinam S. et al. Perioperative management and complications in patients with obstructive sleep apnea undergoing transsphenoidal surgery: Our institutional experience. J Anaesthesiol Clin Pharmacol 2014; 30: 351-354
28 White-Dzuro GA, Maynard K, Zuckerman SL. et al. Risk of post-operative in patients with obstructive sleep apnea undergoing transsphenoidal surgery. J Clin Neurosci 2016; 29: 25-28
29 Klingmann C, Praetorius M, Baumann I. et al. Otorhinolaryngologic disorder and diving accidents: an analysis of 306 divers. Eur Arch Otorhinolaryngol 2007; 264: 1243-1251
30 Parell GJ, Becker GD. Neurological consequences of scuba diving with chronic sinusitis. Laryngoscope 2000; 110: 1358-1360
31 Pennell DJ, Asimakopoulos P, Ram B. et al. Periorbital emphysema after dive barotrauma without radiological evidence of paranasal sinus injury. Aviat Space Environ Med 2014; 85: 863-866
32 Schipke JD, Cleveland S, Drees M. Sphenoid sinus barotrauma in diving: case series and review of the literature. Res Sports Med 2018; 26: 124-137
33 Jeong JH, Kim K, Cho SH. et al. Sphenoid sinus barotrauma after scuba diving. Am J Otolaryngol 2012; 33: 477-480
34 Tryggvason G, Briem B, Guđmundsson Ó. et al. Sphenoid sinus barotrauma with intracranial air in sella turcica after diving. Acta Radiol 2006; 8: 872-874
35 Budal O, Risberg J, Troland K. et al. Pneumocephalus, a rare complication of diving. Undersea Hyperb Med 2011; 38: 73-79
36 Andersson N, Grip H, Lindvall P. Air transport of patients with intracranial air. computer model of pressure effects. Aviat Space Environ Med 2003; 74: 138-144
37 Perin A, Larosa F, Longatti P. Barometric changes in patients with intracranial lesions: can they dive and fly?. Surg Neurol 2009; 71: 368-371
38 Taylor SL, Tyrell JB, Wilson CB. Delayed onset hyponatremia after transsphenoidal surgery for pituitary adenomas. Neurosurgery 1995; 37: 649-653
39 Atkin SL, Coady AM, White MC. et al. Hyponatraemia secondary to cerebral salt wasting syndrome following routine pituitary surgery. Eur J Endocrinol 1996; 135: 245-247
40 Boehnert M, Hensen J, Henig A. et al. Severe hyponatremia after transsphenoidal surgery for pituitary adenoamas. Kidney Int Suppl 1998; 64: 12-14
41 Cuesta M, Hannon MJ, Thompson CJ. Diagnosis and treatment of hyponatraemia in neurosurgical patients. Endocrinol Nutr 2016; 63: 230-238

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