HYPOPHYSECTOMY AFTERCARE RISKS RESULTS
Category: Neurosurgery
Abstract : The operation takes about one to two hours, following which the patient is taken to the recovery area for about two hours before returning to the neurosurgical ward. The following postoperative measures are the normally taken: • The patients nose is packed to stop bleeding. • There may be a dressing on a site of incision in the abdominal wall or thigh if a graft was ne
The operation takes about one to two hours, following which the patient is taken to the recovery area for about two hours before returning to the neurosurgical ward.
The following postoperative measures are the normally taken:
• The patients nose is packed to stop bleeding.
• There may be a dressing on a site of incision in the abdominal wall or thigh if a graft was necessary.
• A drip is attached to the hand and foot and other lines are attached to monitor the heart and breathing.
• A urinary catheter is placed to monitor fluid output.
• The patient has an oxygen mask. Once in the ward, the patient is allowed to eat and drink the same night, after he or she has recovered from the anesthesia.
If fluid intake and output are in balance, the drip and urinary catheter are removed the next morning. The nurses continue to monitor the amount of fluid taken and the amount of urine passed by the patient for a few days. The blood is usually tested the day following surgery. The nasal pack stays for about four days. Once the nasal pack is removed, patients commonly experience moisture coming through the nose and bloodstained mucus occurs frequently. If all is well, patients are usually discharged the following day. There are no sutures to be removed. The sutures in the nose are degradable and the graft site is usually glued together. Patients are advised not to blow their nose or insert anything in the nose.
Risks
The risks associated with hypophysectomy are numerous. Procedures are painstakingly selected to minimize risk and maximize benefit. A special risk associated with surgery on the pituitary is the risk of destroying the entire gland and leaving the entire endocrine system without regulation. Historically, this was the purpose of hypophysectomy, when the procedure was performed tosuppress hormone production. After the procedure, the endocrinologist, a physician specializing in the study and care of the endocrine system, would provide the patient with all the hormones needed. Patients with no pituitary function did and still do quite well because of the available hormone replacements.
Other specific risks include;
• Hypopituitarism. Following surgery, if the pituitary gland has normal activity, it may become underactive and the patient may require hormone replacement therapy. Diabetes insipidus (DI) (excessive thirst and excessive urine) is not uncommon in the first few days following surgery. The vast majority of cases clear but a small number of individuals need hormone replacement.
• Cerebrospinal fluid (CSF) leakage. CSF leakage from the nose can occur following hypophysectomy. If it happens during surgery, the surgeon will repair the leak immediately. If it occurs after the nasal pack is removed, it may require diversion of the CSF away from the site of surgery or repair.
• Infection. Infection of the pituitary gland is a serious risk as it may result in abscess formation or meningitis. The risk is very small and the vast majority of cases are treatable by antibiotics. Patients are usually given antibiotics during surgery and until the nasal pack is removed.
• Bleeding. Nasal bleeding or bleeding in the cavity of the tumor after removal may occur. If the latter occurs it may lead to deterioration of vision as the visualnerves are very close to the pituitary region.
• Nasal septal perforation. This may also occur during surgery, although it is very uncommon.
• Visual impairment. A very rare occurrence, but still a risk.
• Incomplete tumor removal. Tumors may not be completely removed, due to their attachment to vital structures.
Normal results
In the past, complete removal of the pituitary was the goal for cancer treatment. Nowadays, removal of tumors with preservation of the gland is the goal of the surgery. Morbidity and mortality rates A follow-up study performed at the Massachusetts General Hospital and involving 349 patients who underwent surgery for pituitary adenomas between 1978 and 1985 documented 39 deaths over the 13 year follow-up. The primary cause of death was cardiovascular (27.5%) followed by non-pituitary cancer (20%) and pituitary-related deaths (20%). When compared to the population at large, the primary cause of death was also cardiovascular (40%), followed by cancers (at 24%).
Alternatives
Surgery is a common treatment for pituitary tumors. For patients in whom hypophysectomy has failed or who are not suitable candidates for surgery, radiotherapy is another possible treatment. Radiation therapy uses highenergy x rays to kill cancer cells and shrink tumors. Radiation to the pituitary gland is given over a six-week period, with improvement occurring in 40 - 50% of adults and up to 80% of children. It may take several months or years before patients feel better from radiation treatmentalone.
However, the combination of radiation and the drug mitotane (Lysodren) has been shown to help speed recovery. Mitotane suppresses cortisol production and lowers plasma and urine hormone levels. Treatment with mitotane alone can be successful in 30 - 40% of patients. Other drugs used alone or in combination to control the production of excess cortisol are aminoglutethimide, metyrapone, trilostane, and ketoconazole.
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