What preoperative clearance recommendations are needed for a 72-year-old female patient with a history of pituitary adenoma undergoing endoscopic endonasal transsphenoidal pituitary adenoma resection?

From the Guidelines

For a 72-year-old female with a history of pituitary adenoma undergoing endoscopic endonasal transsphenoidal pituitary adenoma resection, comprehensive preoperative clearance is crucial to minimize morbidity and mortality, and improve quality of life. This should include a thorough endocrine evaluation, cardiovascular assessment, and medication management, as suggested by recent guidelines 1. The patient should undergo complete pituitary hormone panel testing including cortisol, thyroid function tests, prolactin, growth hormone, IGF-1, gonadotropins, and electrolytes to assess for hormonal imbalances.

Key Preoperative Considerations

• Cortisol deficiency is particularly important to identify, as patients may require stress-dose steroids (typically hydrocortisone 100mg IV before induction, followed by 50mg every 8 hours for 24 hours, then tapering) 1.
• Cardiovascular clearance with ECG and possibly echocardiography is essential given the patient's advanced age.
• Anesthesia consultation should address airway concerns specific to this procedure.
• The patient should discontinue antiplatelet medications and anticoagulants 5-7 days before surgery if medically safe.
• Preoperative nasal preparation with saline irrigations and potentially antibiotics may be recommended.

Postoperative Care

A detailed discussion about the need for postoperative hormone replacement therapy is crucial, as many patients require temporary or permanent hormone supplementation following surgery. This comprehensive approach addresses both the specific risks of pituitary surgery and the general perioperative concerns for an elderly patient. Strict fluid and electrolyte balance monitoring peri-operatively and post-operatively is also recommended, as changes in water metabolism and regulation of arginine vasopressin (AVP) are common complications of pituitary surgery 1.

Additional Recommendations

Consideration should be given to the potential benefits of endoscopic over microscopic transsphenoidal techniques, which are increasingly used in pituitary surgery and are perceived as providing better operative visualization and fewer perioperative complications and hormone deficiencies 1. However, the choice of surgical technique should be based on the surgeon's experience and the individual patient's needs.

Given the limited evidence on pituitary apoplexy in children and adolescents, the guidelines suggest adopting the recommendations of available adult guidelines 1, but this may not be directly applicable to a 72-year-old patient. Nonetheless, the principles of careful preoperative evaluation and postoperative monitoring remain essential.

In summary, a comprehensive preoperative evaluation and careful postoperative monitoring are essential to minimize morbidity and mortality, and improve quality of life for a 72-year-old female with a history of pituitary adenoma undergoing endoscopic endonasal transsphenoidal pituitary adenoma resection.

From the Research

Preoperative Clearance Recommendations

For a 72-year-old female patient with a history of pituitary adenoma undergoing endoscopic endonasal transsphenoidal pituitary adenoma resection, the following preoperative clearance recommendations are suggested:

• Evaluation of pituitary function, including assessment of adrenal axis, thyroid function, and gonadal function 2, 3
• Measurement of basal morning cortisol as a predictor of adrenal insufficiency 3
• Assessment of tumor size, invasiveness, and hormone levels, such as growth hormone and insulin-like growth factor-1 (IGF-1) levels, to predict postoperative hormonal remission 4
• Consideration of the patient's overall health status, including any comorbidities, to determine the risk of surgery and the need for perioperative glucocorticoid treatment 2, 3

Predictors of Extent of Resection

The following factors have been identified as predictors of extent of resection in patients undergoing endoscopic endonasal transsphenoidal surgery for pituitary adenomas:

• Tumor size and volume 5, 4
• Invasiveness of the tumor, including Knosp grade and extrasellar extension 5, 4
• Presence of a hemorrhagic component or posterior extension 5
• Sphenoid sinus invasion 5

Perioperative Management

Perioperative management of patients undergoing endoscopic endonasal transsphenoidal pituitary adenoma resection should include:

• Perioperative glucocorticoid treatment to prevent adrenal insufficiency 2, 3
• Monitoring of pituitary function, including assessment of adrenal axis, thyroid function, and gonadal function, to detect any postoperative deficiencies 2, 3
• Measurement of basal morning cortisol to predict adrenal insufficiency 3
• Consideration of postoperative medical therapy, such as dopamine agonists or somatostatin analogues, to manage hormonal deficiencies or excesses 6, 4