Complications after TSP surgery:
- post-operative hematomas
- epistaxis
- ischemic events
- hydrocephalus
- CSF leaks
- meningitis
- diabetes insipidus
Nasal packing
- for intraoperative leaks requiring sellar floor reconstruction, Cushing’s Disease and acromegaly
- typically removed POD#1
Post-op Epistaxis
- common occurrence, routine nasal packing x 2-3days
- if refractory, reoperation or endovascular embolization of arterial bleeder
Electrolyte disturbances / DI / hyponatremia
- strict measurement of Is and Os, daily weight
- frequent sodium levels
- UO >250 cc/hr x 2-3 hours – check serum Na and USG
- DI is usually transient phenomenon
- DDAVP at bedtime (even if patient can drink to satiety) in clear-cut DI to allow patients to sleep comfortably
- SIADH and delayed hyponatremia 1 week after – check serum labs on POD#7
- mild hyponatremia, asymptomatic – manage at home with fluid restriction and f/u labs
- moderate to severe hyponatremia or symptomatic – admit for fluid restriction, Na checks and hypertonic saline
Hypopituitarism
- preoperative evidence of hypopituitarism
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- stress dose steroids perioperatively ad keep on physiological maintenance doses until appropriate to assess pituitary function in controlled manner
- evidence of hormonal excess
- lab testing during first few days after surgery to assess for endocrinological remission
- if Cushing’s – no steroids during operation unless necessary, check serum cortisol level post-op q6h until nadir, if <5ug/dL, esp if symptomatic hypocortisolemia, immediate glucocorticorticoid therapy IV then transition to physiologic oral maintenance doses until function can be reassessed in delayed and controlled setting
- normal cortisol function prior to surgery
- no intraoperative glucocorticoids
- assess post-op with AM fasting cortisol on POD#1 and POD#2
- if new hypocortisolemia (cortisol <10 ug/dL) – start glucocorticoid replacement until reassessed by endocrinologist in delayed fashion
- Acromegaly
- POD#1 serum GH level may predict early remission
- gold standard test is delayed IGF-1 level 6 weeks after surgery
- successful tumor resection – brisk fluid diuresis of third-spaced fluid, mimics DI – check serum Na and USG
- Prolactinomas
- POD1 or POD#2 am prolactin, typically normalizes in cases of remission
- Check cortisol POD#7 to rule out delayed hypocortisolemia
Discharge
- routine follow-up 1 week after surgery then 6 weeks post-op (for routine endocrine and post-op evaluation) [equilibration of PA axis and longer half-life of thyroid hormone]
- MRI 3 months after OR to allow resolution of post-op changes and assess extent of tumor resection
- routine imaging annually or more often as indicated (WOF delayed tumor recurrence up to several years) – continued endocrinological and imagnig surveillance even beyond a decade
REFERENCE:
Zada, G. et al. Asian J Neurosurg. 2010 Jan-Jun; 5(1): 1–6. PMCID: PMC3198670 Perioperative Management of Patients Undergoing Transsphenoidal Pituitary Surgery
