Can a 50‑year‑old man with a sellar‑suprasellar pituitary adenoma, progressive bilateral visual loss, mild anemia, controlled hypertension on amlodipine, currently taking celecoxib (COX‑2 inhibitor) and sultamicillin, stable vital signs and normal endocrine labs be cleared for repeat endoscopic endonasal transsphenoidal surgery?

Can This Patient Be Cleared for Repeat Endoscopic Endonasal Transsphenoidal Surgery?

Yes, this patient should be cleared for repeat endoscopic endonasal transsphenoidal surgery given the progressive bilateral visual loss (counting fingers OD, 20/400 OS with bilateral hemianopsia), stable hemodynamics, controlled hypertension, normal endocrine function, and acceptable hematologic parameters. The progressive visual deterioration with documented optic chiasm compression represents an urgent surgical indication that outweighs the modest perioperative risks. 1, 2

Primary Surgical Indication: Progressive Visual Loss

The patient's severe bilateral visual impairment (counting fingers OD, 20/400 OS) with bilateral hemianopsia constitutes an urgent indication for surgical decompression. The Congress of Neurological Surgeons explicitly recommends transsphenoidal surgery for symptomatic relief in patients with nonfunctioning pituitary adenomas causing visual deficits. 1 Progressive neurological deterioration—including worsening visual acuity or visual field deficits—mandates urgent endoscopic transsphenoidal decompression to prevent permanent optic nerve damage. 2

• Visual recovery is time-sensitive: further improvement of visual field deficits is unlikely after the first postoperative month, making early intervention critical for preserving any remaining visual function. 1
• The patient's documented bilateral hemianopsia indicates direct optic chiasm compression requiring immediate surgical relief. 1
• Delayed visual deterioration after pituitary surgery can occur (0.8% incidence), but in this case the patient has active, progressive symptoms requiring intervention rather than observation. 3

Anesthetic and Medical Risk Assessment

Cardiovascular Status

The patient's controlled hypertension (BP 110/90 mmHg on amlodipine 10 mg daily) and stable vital signs (HR 80 bpm, RR 21/min, SpO₂ 96%) indicate acceptable cardiovascular risk for surgery. 1 The Congress of Neurological Surgeons supports transsphenoidal surgery in American Society of Anesthesiologists grade 1 to 3 patients, and this 50-year-old with controlled hypertension and no other significant comorbidities falls well within this range. 1

Hematologic Parameters

• Hemoglobin 114 g/L (11.4 g/dL) represents mild anemia but is above the typical transfusion threshold and adequate for elective surgery. 4
• Platelet count 237 × 10⁹/L is normal and sufficient for hemostasis. 4
• The elevated WBC 11.5 × 10⁹/L with neutrophil predominance (85%) likely reflects surgical stress from the recent procedure rather than active infection, given normal temperature (36.3°C) and low CRP (0.8 mg/L). 4

Renal and Electrolyte Status

Normal electrolytes (Na 140 mmol/L, K 4 mmol/L), BUN 7.03 mmol/L, and creatinine 78.14 µmol/L indicate preserved renal function and appropriate fluid balance. 2, 4 The urinalysis showing specific gravity 1.01 with concentrated urine suggests intact posterior pituitary function without diabetes insipidus at present. 2

Endocrine Function

The patient's normal thyroid function (FT3 2.31 pg/mL, FT4 0.77 ng/dL, TSH 1.11 µIU/mL) and adequate cortisol (11.07 µg/dL) indicate no immediate endocrine contraindication to surgery. 2, 5 However, perioperative stress-dose corticosteroids (hydrocortisone 50-100 mg IV every 6-8 hours) should be initiated immediately upon induction to prevent secondary adrenal insufficiency, as recommended by the Endocrine Society. 2, 5

Medication Management

Celecoxib (COX-2 Inhibitor)

Celecoxib 200 mg BID should be discontinued at least 5-7 days before surgery to minimize bleeding risk, despite its more selective COX-2 inhibition compared to traditional NSAIDs. While not explicitly addressed in pituitary surgery guidelines, standard perioperative practice dictates stopping NSAIDs to reduce hemorrhagic complications during intracranial procedures.

Sultamicillin (Antibiotic)

The current sultamicillin 750 mg TID can be continued through surgery as prophylactic antibiotic coverage for the transsphenoidal approach, which violates the sphenoid sinus. 4

Amlodipine

Continue amlodipine 10 mg daily through the morning of surgery to maintain blood pressure control. 4

Critical Perioperative Monitoring Requirements

Mandatory Fluid and Electrolyte Surveillance

Strict fluid and electrolyte balance monitoring is essential perioperatively and postoperatively, with serum sodium and osmolality checked every 4-6 hours initially. 2, 5 This patient faces significant risk for:

• Diabetes insipidus (26% incidence): Monitor hourly urine output and watch for polyuria (>200-300 mL/hour for 2-3 consecutive hours). 2, 5
• SIADH (14% incidence): Watch for oliguria with hyponatremia and clinical euvolemia. 2, 5
• Biphasic or triphasic patterns: Initial diabetes insipidus followed by SIADH, or diabetes insipidus → SIADH → permanent diabetes insipidus. 2, 5

Risk Factors Present in This Patient

This patient has no identified high-risk factors for postoperative AVP deficiency or SIADH (not female sex, no planned CSF leak or drain placement documented). 2, 5 However, any manipulation of the posterior pituitary during tumor resection increases risk and mandates vigilant monitoring. 2, 5

Surgical Approach and Technique

Endoscopic transsphenoidal surgery is the preferred approach over microscopic technique because it provides superior visualization and better preservation of residual pituitary function. 2, 4 The Congress of Neurological Surgeons confirms that both endoscopic and microscopic transsphenoidal approaches achieve symptom relief, but endoscopic visualization reveals residual tumor tissue missed by microscopy alone. 1

• Optimal bony exposure of the sphenoid and sellar regions improves extent of resection. 1
• For this recurrent/residual tumor with suprasellar extension, endoscopic approach allows better visualization of residual disease. 1
• The procedure should be performed by experienced pituitary surgeons in high-volume centers (≥50 pituitary operations/year). 2

Postoperative Endocrine Management Protocol

Immediate Postoperative Period

• Continue stress-dose hydrocortisone 50-100 mg IV every 6-8 hours until hemodynamically stable, then taper to oral maintenance over 5-7 days. 2
• Never start thyroid hormone replacement before adequate corticosteroid coverage if both deficiencies coexist, as this can precipitate adrenal crisis. 2, 5

Scheduled Endocrine Assessments

• Postoperative day 2: Evaluate adrenal function (morning cortisol and ACTH). 5
• 6 weeks postoperatively: Repeat adrenal function testing and assess other pituitary axes. 5
• 12 months postoperatively: Complete endocrine evaluation for all pituitary axes. 5

Visual Follow-Up

Formal visual field testing should be performed within 3 months of surgery to document improvement or identify any delayed deterioration. 1 Ongoing visual follow-up should continue based on individual response. 1

Common Pitfalls to Avoid

1. Delaying surgery for "optimization": The progressive visual loss makes this an urgent case; further delay risks permanent blindness. 2

2. Inadequate perioperative steroid coverage: Failure to provide stress-dose corticosteroids can result in life-threatening adrenal crisis. 2, 5

3. Insufficient fluid/electrolyte monitoring: Missing early diabetes insipidus or SIADH can lead to severe hyponatremia or hypernatremia with neurological sequelae. 2, 5

4. Premature discharge: A minimum 3-day inpatient stay is medically necessary for monitoring fluid/electrolyte disturbances, which commonly manifest 24-72 hours postoperatively. 4

5. Starting thyroid hormone before steroids: If postoperative hypothyroidism develops, always initiate corticosteroids first and delay levothyroxine for at least one week. 2, 5