Key words
pituitary tumor - transsphenoidal surgery - postoperative recommendations
Introduction
For more than 40 years, transsphenoidal surgery (TSS) is the standard approach to
treat pituitary adenomas, most craniopharyngiomas, Rathke’s cleft cysts and other,
less frequent pathologies of the sellar and perisellar region [1]. Nowadays microsurgery as well as endoscopy is used with very good results in experienced
hands [2]
[3]
[4]. Although different complications of TSS have been reported, it is considered to
be a safe procedure, with the complication rate depending on the surgeons experience
[5]
[6] (6,9% major complication, 0,7% death). However, guidelines for patients` level of
activity following TSS do not exist. Therefore, the neurosurgeons of the pituitary
study group of the German Society of Endocrinology (DGE) started a nationwide survey
of the current practice in counselling their patients postoperatively. Stepwise they
came to a consensus statement. The focus of this report is on the advice related to
the surgical approach only. The recommendations, however, may differ considerably
in individual cases depending on the endocrinological, neurological, and ophthalmological
state given.
Subjects and Methods
The study was initiated by the speaker of the Pituitary Study Group of the German
Society of Endocrinology (DGE). A digital questionnaire was sent to 22 German neurosurgeons
who are known to be actively involved in pituitary surgery. Fourteen of 22 pituitary
surgeons returned the completed questionnaire (64%), 9 with microsurgical and 5 with
endoscopic focus.
The surgeons were asked about their personal experience with rules of conduct for
patients following TSS, namely how many transsphenoidal procedures they had performed
or supervised in the preceding year (2016), and how many such operations had been
performed in their institution in that period. Moreover, the participants were asked
to state whether they mainly use the microscope or the endoscope during TSS. Endoscopically
assisted microsurgical technique was assumed microscopic.
The queries addressed both a routine transsphenoidal approach and an extended transsphenoidal
approach (e. g. transtuberculum-sellae or transclival approach). The participants
were asked to provide the postoperative time interval after which specific activities
could be resumed by their patients. The questions addressed 3 topics: daily activities,
exertion of sports and work life.
Daily activities
washing the hair, nose blowing, sauna, playing wind instruments, flying on an airplane,
lifting heavy weights (about 12 kg, assumed equivalent to a crate of mineral water),
driving a car, using a CPAP (continuous positive airway pressure) -device, and having
sexual intercourse.
Recreation sports
Nordic walking, jogging, swimming (breaststroke – head above water, and crawl – head
under water), scuba diving (snorkeling at the surface assumed to be equivalent to
crawling), playing tennis, and playing soccer.
Performing competitive sports.
Work life
Occupation (for 8 h per day) with mental demands or physical labor.
Process of study
Initially, the project was presented and discussed at the meeting of the German pituitary
working group. The questionnaire was designed by JBH and UJK and send to the German
pituitary surgeons. The results were graphically presented and discussed at a following
meeting of the pituitary working group and a core group of pituitary surgeons (authors)
was constituted to screen the relevant literature (via PUBMED), and to elucidate related
scientific issues of the items. During 3 telephone conferences, joint recommendations
were elaborated. The results were brought together in a manuscript which was then
presented to all participating neurosurgeons and consultants, asking for approval,
to reach the highest possible grade of agreement. All participants and consultants
approved the recommendations as described in this manuscript. The manuscript was checked
following the AGREE reporting checklist [7] as far as applicable.
Results
Participants
Fourteen pituitary surgeons returned the completed questionnaire, 9 of them with microsurgical
focus and 5 of them with endoscopic focus. During one year (2016) these surgeons were
responsible for 1004 (range 8 to 270, mean 72, median 50) transsphenoidal procedures.
Of these, 846 operations have been performed using microscopic technique (range 38
to 270, mean 94, median 59), 158 using the endoscope (range 8 to 41, mean 32, median
40). In the institutions of the participants 1060 transsphenoidal operations had been
performed in 2016 (range 8 to 286), indicating that most procedures had been performed/supervised
by the participating individuals. Consequently, this report reflects the experience
with about 1000 transsphenoidal procedures per year.
There was no significant difference of times after which activities could be resumed
between surgeons with endoscopic or microsurgical focus (exemplary illustrated in
[Fig. 1]), however, independent from surgical technique used, some surgeons tended generally
to be more offensive, others more cautious.
Fig. 1 The expert opinions of 14 German pituitary surgeons about postoperative daily activities
following a routine transsphenoidal procedure are shown. The postoperative time interval
after which various daily activities can be resumed is depicted (• or ○ individual answer, — final consensus recommendation). There is no significant difference between recommendations
after microsurgical (N=9, •) or endoscopic (N=5, ○) procedures.
Recommendations after routine operations
Daily activities (see Fig. 1)
For nose blowing the answers varied between few days and 8 weeks (median 3 weeks).
The authors agreed to use the median of 3 weeks as a common recommendation ([Table 1]). In case of intraoperative CSF-leak, blowing the nose is allowed after 4 weeks.
Table 1 Instructions for patients` behavior after routine transsphenoidal pituitary surgery
or extended transsphenoidal approach for perisellar lesions created from statement
of 14 pituitary surgeons, who stand for about 1000 transphenoidal operations per year.
|
Activity
|
routine transsphenoidal operation [weeks]
|
extended transsphenoidal approach
|
|
range
|
median
|
recommendation
|
range
|
median
|
recommendation
|
|
daily activity
|
|
blow the nose
|
<1 – 8
|
3
|
3A
|
1 – 12
|
4
|
4A
|
|
wash hair
|
<1 – 1
|
<1
|
<1
|
<1 – 2
|
<1
|
<1
|
|
have a sauna
|
1 – 4
|
4
|
4
|
2 – 12
|
4
|
4
|
|
wind instrument
|
3 – 12
|
6
|
6B
|
3 – 26
|
8
|
6B
|
|
fly on airplane
|
<1 – 8
|
1.5
|
1C
|
<1 – 8
|
2.5
|
2C
|
|
lift heavy weight
|
<1 – 8
|
4
|
4
|
1 – 26
|
6
|
6
|
|
drive car
|
<1 – 12
|
1
|
<1D
|
<1 – 12
|
4
|
2G
|
|
use CPAP
|
<1 – 12
|
3.5
|
3A
|
<1 – 12
|
4
|
4A
|
|
have sex
|
<1 – 4
|
1
|
1
|
<1 – 8
|
3.5
|
2
|
|
sports
|
|
walking
|
<1 – 4
|
2
|
2
|
<1 – 6
|
3
|
3
|
|
jogging
|
<1 – 6
|
4
|
3
|
<1 – 12
|
5
|
4
|
|
breaststroke
|
1 – 8
|
4
|
4
|
2 – 12
|
6
|
6
|
|
crawl
|
1 – 8
|
4
|
4
|
2 – 12
|
6
|
6
|
|
dive
|
4 – 26
|
8
|
12E
|
6 – Ø
|
12
|
12E
|
|
tennis
|
<1 – 8
|
4
|
4
|
4 – 12
|
7
|
6
|
|
soccer
|
<1 – 8
|
4
|
4F
|
4 – 12
|
8
|
8F
|
|
competitive sp
|
4 – 12
|
6
|
6
|
6 – 12
|
12
|
10
|
|
occupation (8 h/d)
|
|
mental demands
|
<1 – 3
|
1.5
|
2
|
<1 – 4
|
2
|
3
|
|
physical work
|
<1 – 6
|
3.5
|
4A
|
2 – 12
|
6
|
6A
|
Alonger in case of intraoperative CSF leak (see text). Bstarting point for gradual increase in activity (see text). Cexclusion of intracranial air provided, e. g. by CT. Dprovided hyponatremia is ruled out and patient feels well (see text). Estatement of responsible surgeon mandatory. Fno headers. Gprovided brain surface not involved by tumor or resection. Ø=never; The recommendations
indicate the minimum time interval [weeks] after surgery, when a specific activity
may be resumed. The authors emphasize that the ability to resume such activities is
also dependent on endocrinological, neurological, ophthalmological, and mental state
postoperatively. For details see text.
Washing the hair was unanimously allowed in the first week after surgery. Discussion
between the authors revealed, that in case of intraoperative CSF-leak the patients
should refrain from bending the head downward during washing the hair for 3 weeks.
Having a sauna was permitted after 1 to 12 weeks (median 4 weeks). Recommendation
after discussion: 4 weeks ([Table 1]).
Playing wind instruments was permitted between 3 and 12 weeks postoperatively (median
6 weeks). After discussion with a consultant for music physiology and musician’s medicine
(EA), 6 weeks could be the starting point of gradual increase in activity (see below).
For flying on an airplane the primary statements varied between a few days and 8 weeks
(median 1.5 weeks after surgery). The recommendation of 1 week would allow patient`s
transfer to motherland after discharge by airplane. Discussion pointed out, that in
case of intraoperative CSF-leak absence of free intracranial air is obligatory (e. g.
proven by CT-scan).
Lifting a weight was defined as the equivalent to raise a crate of mineral water,
which would be at least 12 kg in Germany. The primary statements varied between a
few days and 8 weeks (median 4 weeks), a consensus of 4 weeks was found by the authors.
The majority of pituitary surgeons allowed driving a car early after operation (range
a few days to 12 weeks, median 1 week), after discussion between the authors the recommendation
was 5 days after surgery. This would allow the patient to drive home by car on discharge.
However, two surgeons opted for 12 weeks, following general guidelines of intracranial
surgery. For safety reasons, in routine cases also electrolyte imbalance (e. g. hyponatremia)
has to be ruled out prior to driving a car.
The results varied considerably concerning the use of a CPAP device (range immediately
to 12 weeks, median 3.5 weeks). The crucial point for this recommendation is whether
an intraoperative CSF-leak was evident or not (see discussion).
Having sexual intercourse was considered by the pituitary surgeons to be permissible
after a few days to 4 weeks postoperatively (median 1 week).
Sports (see [Fig. 2])
Most pituitary surgeons allow leisure sports approximately 4 weeks after surgery:
Nordic walking after a few days to 4 weeks (median 2 weeks). Jogging after a few days
to 6 weeks (median 4 weeks). Swimming (breaststroke) after 1 to 8 weeks (median 4
weeks). Crawling after 1 to 8 weeks (median 4 weeks). Playing tennis after a few days
to 8 weeks (median 4 weeks). Playing soccer after 1 to 8 weeks (median 4 weeks). This
median values were confirmed as recommendations during discussion, except for jogging
(recommendation 3 weeks). However, during soccer headers should be omitted for 12
weeks.
Fig. 2 The expert opinions of 14 German pituitary surgeons about postoperative sports activities
following a routine transsphenoidal procedure are shown. The postoperative time interval
after which sports activities can be resumed is depicted (• individual answer, — final consensus recommendation).
Heterogeneous opinions existed for scuba diving. Primary recommendations varied between
4 and 26 weeks (median 8 weeks). After interviews with experts for diving medicine,
evaluation of relevant literature, and discussion between the authors, it is recommended
not to dive earlier than12 weeks after surgery (see discussion below).
According to the surgeons, competitive sports are allowed between 4 and 12 weeks after
surgery (median 6 weeks). The final consent is to resume competitive sports not earlier
than 6 weeks after surgery.
Working life (see [Fig. 3])
Occupation (8 h per day) with mental demands was considered feasible immediately after
surgery to 3 weeks postoperatively (median 1.5 weeks). A consensus of 2 weeks was
worked out.
Fig. 3 The expert opinions of 14 German pituitary surgeons about work life following a routine
or extended transsphenoidal procedure are shown. The postoperative time interval after
which full-time work life can be resumed is depicted (• individual answer, — final consensus recommendation).
The postoperative time interval for continuation of an occupation with physical labor
varied between a few days and 6 weeks (median 3.5 weeks), recommendation is 4 weeks.
The authors want to emphasize that these recommendations consider the operative approach
only. Fitness for work is also dependent on endocrinological, neurological, ophthalmological,
and mental state postoperatively.
Recommendations after extended transsphenoidal approach (see [Fig. 3]
[4]
[5])
For an extended transsphenoidal approach, the time interval until activities can be
resumed was roughly twice as long compared to the routine approach.
Fig. 4 The expert opinions of 14 German pituitary surgeons about postoperative sports activities
following an extended transsphenoidal procedure are shown. The postoperative time
interval after which various daily activities can be resumed is depicted (• individual answer, — final consensus recommendation).
Fig. 5 The expert opinions of 14 German pituitary surgeons about postoperative sports activities
following a routine transsphenoidal procedure are shown. The postoperative time interval
after which sports activities can be resumed is depicted (• individual answer, — final consensus recommendation).
Driving a car was allowed within the first 4 weeks after surgery by some pituitary
surgeons, while other surgeons allow driving only after 3 months as it is recommended
for patients with intracranial surgery. Discussion revealed that involvement of the
brain (other than the optic nerves) is the crucial point to adjust the recommendations
to routine instructions after transcranial operations.
Scuba diving cannot be resumed earlier than 12 weeks after surgery. The risk of scuba
diving was considered particularly high as it is able to exert a tremendous increase
of pressure to the area of skull base closure. The estimation of this construct`s
stability provided by the responsible surgeon has to be the mainstay of recommendation
in these cases. If concerns regarding the stability of skull base reconstruction exist
scuba diving cannot be resumed.
The data and recommendations for both the routine and the extended approach are summarized
in [Table 1].
Discussion
So far, no generally accepted guidelines for patient behavior following TSS exist
in order to avoid postoperative complications. This survey aimed at giving an overview
of the current status quo of recommendations in Germany and to find a consensus between
pituitary surgeons after a focused literature review. This led to a proposal of guidelines.
Although a wide variance of individual statements, which can be explained by missing
guidelines, was observed initially, through the process described here a consensus
was suggested by the authors and approved by all participants.
Wound healing after TSS
Mucosal tissue healing is divided into four stages – exsudative (minutes to hours),
resorptive (up to 3 days), proliferative (up to 7 days), and regenerative (several
months) [8]. The extent of mucosal injury is crucial to the required time to heal. Xu and co-authors
[9] reported, that after functional endoscopic sinus surgery the re-epithelialization
is completed within 10 weeks in the majority of patients, however, few patients needed
longer than 15 weeks. Regarding mucociliary transport, Shaw et al. [10] reported a functional alteration of more than 3 months in an animal model. Injury
to the periost, which regularly happens in pituitary surgery, leads to osteoneogenesis.
In an animal model an increase of osteogenesis up to a year after surgery was reported
[11], therefore showing incomplete healing during that time. Taking this limited data
into account, most activities seem to be safe after a few weeks regarding potential
wound healing complications, except for scuba diving after extended approaches, which
have to be carefully evaluated.
Valsalva maneuver (raised intracranial pressure)
Performing valsalva maneuver means elevated intrathoracal pressure with closed vocal
cords and consecutive rise of intracranial pressure through reduction of intracranial
venous outflow [12]
[13]. Increased intracranial pressure raises the risk of CSF-fistula after TSS. Therefore,
careful consideration should be given to this issue in the postoperative period [14]
[15]
[16]. This mechanism seems to be relevant for recommendations concerning lifting heavy
weights, having sex, playing tennis and soccer.
Sexual intercourse
The advice concerning the resumption of sexual activity should address the avoidance
of valsava maneuver, straining, heavy lifting, and pressure on the abdomen in case
of intraoperative CSF leak, which implies advice concerning sexual practice [17].
Playing wind instruments
When playing wind instruments, valsava maneuver seems also to be applicable, as the
outflow resistance of the instrument will also elevate the thoracal pressure. The
pressure in the sphenoid sinus itself should not be a problem in this activity, as
the closure of soft palate permits a barrier against elevated pressure in the nasal
cavity and paranasal sinus. The recommendation of the consultant is to start playing
wind instruments not earlier than 6 weeks after transsphenoidal surgery with low pressure
for short playing periods (e. g. 10 min. 3 times a day), gradually intensifying the
activity by 30 to 60 min. per week, until full load is reached.
Concussion
In soccer, as in any other contact sports, concussion may also be a mechanism which
could lead to postoperative complications. For the same reason headers during playing
soccer should be omitted for at least 3 months after TSS.
Raised pressure in paranasal sinuses
Blowing one’s nose, using a CPAP-device, and scuba diving are associated with elevated
pressure in paranasal sinus and an inversed pressure gradient compared to the state
of valsalva maneuver. Air could be forced through the operative defect and cause tension
pneumencephalus [18]
[19], for which untreated obstructive sleep apnea, cerebrospinal fluid leaks, postoperative
positive-pressure mask ventilation, large pituitary tumors, and intraoperative lumbar
drainage catheters were reported as risk factors [20]. Therefore, recommendations to resume these activities not only depend on the extent
of the approach (routine vs. extended), but also on the occurrence of intraoperative
CSF-leak during routine procedures.
CPAP
Obstructive sleep apnea (OSA) is frequent in patients with pituitary disorder: Particularly
in acromegaly, OSA is a frequent presenting symptom, and can be resolved by successful
TSS [21]. Many patients with OSA are treated by using a CPAP-device. Affected patients benefit
from the use of CPAP or bilevel positive airway pressure (BiPAP) after any kind of
surgical procedures. However, both methods could cause pneumocephalus after TSS [22]
[23]. Unless contraindicated by the surgical procedure, the use of CPAP-device early
after surgery is generally recommended if it was already used by the patients preoperatively
[24]
[25]. However, currently no consensus exists for the management of OSA patients undergoing
transsphenoidal operations [26]. In a series of 469 patients undergoing TSS, 105 were at risk for OSA, and 10 of
them developed postoperative hypoxemia which was treated with low-flow oxygen using
face mask. However, three of them required a CPAP device not earlier than 2 days after
surgery. None of them had an intraoperative CSF-leak, and no complications occurred
after application of CPAP [27]. In another retrospective review the use of CPAP was re-initiated in 25 of 323 patients
undergoing 349 TSS early after surgery. The only 2 cases with postoperative pneumocephalus
in this series did not belong to the subgroup using CPAP postoperatively, leading
these authors to the assumption that resuming CPAP early after TSS might be less dangerous
than previously stated [28].
Diving
While pituitary surgeons are often faced with patients using a CPAP-device for treatment
of OSA, the question when to resume scuba diving after TSS is asked rarely. This may
explain the diversity of pituitary surgeons` primary statements in this survey. Moreover,
only one of the authors has personal experience with scuba diving. Therefore, the
authors included the advice of several consultants for diving medicine especially
for this topic. Diving at the surface using a snorkel is supposed to be equivalent
to crawling. In greater depth problems with pressure gradients may occur between solid
tissues and gas containing cavities, such as sinuses. Normal pressure at the sea level
is 1 bar. Air in a diver's body air spaces will be compressed as pressure increases
and expand as pressure decreases. During scuba dive descending leads to a linear pressure
increase (1 bar per 10 meter depth). Diving at 10 m depth means a pressure increase
of 1 bar and an absolute pressure of 2 bars (relative change of 100%). As a consequence,
any gas volume in the body is compressed to the half of its initial volume, thus producing
a negative pressure gradient in case of entrapment. In scuba diving any communicating
gas compartment is equilibrated to ambient pressure. Therefore, no pressure gradients
will develop. Thus, the problems with pressure gradients in scuba diving arise only
with trapped air compartments, wherever they may be. In apnea diving (breathhold diving)
by definition any air filled compartments are enclosed air compartments unless flooded
and therefore location of relevant pressure gradients.
The pressure in the paranasal sinus and middle ear rises if the gas cannot escape
properly. TSS is associated with swelling of the nasal mucosa and impairs ventilation
of the middle ear through the Eustachian tube and of the paranasal sinuses. In a retrospective
cohort of 306 divers, who were treated by otorhinolarnyngologists, 46% had problems
with the middle ear, 18% with the inner ear, and 17% with the nose and sinuses [29]. Sinus barotrauma from scuba diving is self-limiting in almost all cases, and frequently
results from nasal pathology [30]
[31]. Two of the consultants argued, that as long as a normal outflow of gas from the
paranasal sinuses is given, there should be no pressure gradient between this and
the sella or the cranial cavity, which would allow diving even with incomplete bony
closure after 3 months or 6 months, respectively. On the other hand it has been claimed
recently, that sphenoid sinus barotrauma may be underreported and misdiagnosed [32], and limitation of local ventilation may be overlooked. After sphenoid sinus barotrauma
sinusitis and abscess formation [33], intrasellar air collection [34] and even subarachnoid pneumatocephalus with severe persistent neurological deficit
[35] have been reported. The latter two cases showed spontaneous bony defects of the
sphenoidal wall, which may be equivalent to the postoperative state after TSS in many
cases. In conclusion, after surgeon`s statement on the stability of the skull base
scar, postoperative sinusitis especially of the sphenoid sinus and any trapped air
should be ruled out by ENT physicians before scuba diving is resumed after TSS. However,
ambitious apnoe diving with persistent bony defect of the skull base should be omitted
lifelong.
Flying on an airplane
Barometric changes also play a role in the question regarding the recommendation to
resume flying on an airplane [36]
[37]. At a height of 10.000 m, the air pressure is approximately ¼ of the pressure on
ground. However, the cabin pressure appears to be unproblematic. According to Lufthansa,
the maximum cabin pressure in an aircraft corresponds to the pressure in a height
of approximately 2500 m (depending on aircraft type cabin pressure can be lower).
Nasal swelling could impair ventilation of the paranasal sinuses and middle ear after
TSS and make flying painful. While air can more easily escape from the sinuses or
the middle ear during ascent of an aircraft even if the mucosa is swollen, the flow
of air into the paranasal sinuses during descent and landing is more problematic and
can cause heavy pain.
Our permission to resume flying in an aircraft as early as one week after surgery
definitely requires the exclusion of intracranial air by CT or MRI in order to prevent
space-occupying pneumatocephalus. Particular attention is required following an extended
transsphenoidal approach.
Risk of cerebral fits
Driving a motor vehicle
The recommendation to resume driving a car as early as 5 days after TSS in uncomplicated
cases without any involvement of brain surface by tumor or surgery seems to be applicable
when the patient feels well, has neither neurological nor ophthalmological deficit,
and hyponatremia is ruled out. One has to keep in mind and instruct the patient, that
the latter may also occur in the second week after TSS and even later, and may cause
seizures [38]
[39]
[40]
[41]. It is very important to instruct the patient that in case of secondary malaise
after discharge, driving a motor vehicle is prohibited. In case of postoperative seizures
fitness to drive is assessed according to neurological standards.
If extended TSS involves brain tissue, driving a car is not allowed for 3 months according
to the regulations following craniotomy.
Mental and physical condition
Work live
The recommendations concerning resumption of work life in this manuscript focus on
the operative approach and its consequences only. Any neurological and ophthalmological
problem may profoundly change the advices given. The same is true for the endocrinological
state. In Cushing’s disease or acromegaly, the co-morbidities could represent a limitation
to resume work after TSS.
Conclusions
Despite the diversity of opinions, the audit provides important information on expert
opinions and their customs in patients’ counselling with the power of about 1.000
transsphenoidal procedures performed per year. Together with information from the
meaningful literature the data of our survey provide a basis for elaboration of joint
recommendations for patients’ conduct and to minimize the approach-related postoperative
risks after TSS.
Funding
This research did not receive any specific grant from any funding agency in the public,
commercial or not-for-profit sector.
