Can a 50‑year‑old man with a residual sellar‑suprasellar pituitary adenoma (~2‑3 cm) causing progressive bilateral visual loss, low‑normal free thyroxine, normal thyroid‑stimulating hormone, normal morning cortisol, normal adrenocorticotropic hormone, normal prolactin, controlled hypertension on amlodipine, and current medications (omeprazole, vitamin B complex, multivitamins, vitamin C with zinc, celecoxib, sultamicillin, paracetamol) be cleared for repeat endoscopic endonasal transsphenoidal resection, and what peri‑operative stress‑dose hydrocortisone regimen and postoperative monitoring should be employed?

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Last updated: February 17, 2026 • View editorial policy

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Clearance for Repeat Transsphenoidal Surgery

Yes, this patient can be cleared for repeat endoscopic endonasal transsphenoidal surgery with mandatory preoperative optimization, specifically discontinuation of celecoxib at least 7–10 days before surgery and completion of antibiotic therapy for otomastoiditis. 1

Absolute Surgical Indication

  • Progressive bilateral hemianopsia with severe visual acuity loss (counting fingers OD, 20/400 OS) and a residual 2.4 × 2.4 × 3.4 cm sellar-suprasellar mass constitute an absolute indication for repeat transsphenoidal surgery to prevent permanent visual loss. 1

  • Direct mass effect on the optic chiasm creates imminent risk of irreversible visual deterioration, making surgical decompression medically necessary. 1

  • Transsphenoidal microsurgery or endoscopic resection is recommended for symptomatic relief of patients with nonfunctioning pituitary adenomas, with endoscopic approaches providing better visualization of residual tumor. 2

  • Visual field defects improve in 67–95% of patients after transsphenoidal surgery, with 28% regaining completely normal vision. 3

Critical Preoperative Modifications Required

NSAID Discontinuation (Mandatory)

  • Celecoxib 200 mg twice daily must be discontinued at least 7–10 days before surgery because it markedly increases intraoperative bleeding risk in transsphenoidal procedures. 1

  • Fatal postoperative hemorrhage (internal carotid pseudoaneurysm rupture) has been reported when NSAIDs were continued during resection of vascularized sellar masses. 1

  • Switch to acetaminophen for analgesia, which can be used safely perioperatively. 1

Active Infection Resolution (Mandatory)

  • The ongoing right acute-on-chronic otomastoiditis is an active infectious focus that raises the risk of postoperative meningitis; complete the full course of sultamicillin and confirm clinical/radiographic resolution before proceeding. 1

  • Polysinus disease noted on imaging also requires optimization to minimize infectious complications. 1

Perioperative Stress-Dose Hydrocortisone Protocol

Proposed Regimen Assessment

The endocrinology team's proposed hydrocortisone protocol is appropriate and follows standard perioperative stress-dose guidelines:

  • Hydrocortisone 100 mg IV upon induction of anesthesia, then 50 mg IV every 8 hours on the day of surgery is appropriate initial stress-dose coverage. 4

  • Day 1 postoperative: decrease to 25 mg IV every 12 hours represents appropriate tapering. 4

  • Day 2 postoperative: decrease to once daily dosing at 8 PM continues appropriate taper. 4

  • Day 3 postoperative: extract 8 AM cortisol prior to giving hydrocortisone IM at 8 AM allows assessment of endogenous adrenal function. 4

Rationale for Stress-Dose Coverage

  • Although preoperative morning cortisol (11.07 µg/dL) and ACTH (36.29 pg/mL) are within normal range, the patient has low-normal free T4 (0.77, reference 0.78–2.19) suggesting evolving central hypothyroidism and potential hypothalamic-pituitary axis compromise. 1

  • Male gender, age greater than 50 years, and anticipated intraoperative CSF leak risk are associated with persistent postoperative adrenal insufficiency. 5

  • Early postoperative adrenal insufficiency occurs in 55% of patients after transsphenoidal surgery, though 79% of these patients do not require long-term replacement. 5

  • Adrenal axis impairment after pituitary surgery can lead to serious consequences if not identified and treated. 5

Mandatory Postoperative Monitoring

Diabetes Insipidus Surveillance

  • Monitor urine output for >200 mL/hr for 2 consecutive hours, as proposed by the endocrinology team. 1

  • Strict fluid input/output monitoring is essential, as arginine vasopressin deficiency (diabetes insipidus) occurs in 26% of cases after transsphenoidal surgery. 6

  • The patient's current polyuria (4800 mL urine output on the most recent 24-hour measurement) raises concern for developing diabetes insipidus and requires close perioperative monitoring. 1

  • Monitor for triphasic pattern: initial DI, followed by SIADH (syndrome of inappropriate antidiuretic hormone secretion), then potential return to permanent DI. 7

Electrolyte Monitoring

  • Check serum sodium and urinalysis postoperatively as proposed by the endocrinology team. 1

  • Monitor serum sodium every 6–12 hours during the first 48 hours postoperatively to detect both diabetes insipidus (hypernatremia) and SIADH (hyponatremia). 7

  • Current sodium is 140.24 mmol/L (normal), but close monitoring is required given polyuria. 1

Visual Function Assessment

  • Perform serial visual field and acuity examinations immediately postoperatively to assess surgical efficacy and detect any acute deterioration. 1

  • Visual field defects improve in most patients, with 28% regaining completely normal vision and 67% showing variable improvement after surgery. 3

Endocrine Reassessment

  • Repeat comprehensive endocrine evaluation at 6–12 weeks postoperatively to detect delayed hypopituitarism. 1

  • Of patients with preoperative hypopituitarism, 46% show variable improvement after surgery, while 54% have persistent deficits. 3

  • The presence of normal or slightly elevated prolactin and preserved TSH/LH responses predict possible recovery of pituitary function after surgery. 3

Hemodynamic and Hematologic Status

  • Blood pressure 110/90 mmHg, well-controlled on amlodipine 10 mg, may be continued perioperatively. 1

  • Mild anemia (hemoglobin 114 g/L, hematocrit 0.34) is acceptable for surgery. 1

  • Platelet count of 264 × 10⁹/L provides adequate hemostasis. 1

  • Neutrophil count has normalized (0.49, previously 0.85), indicating resolution of surgical stress response. 1

Metabolic and Renal Status

  • Blood glucose is adequately controlled (capillary values 120–147 mg/dL). 1

  • Renal function is preserved (creatinine 86.87 µmol/L). 1

  • Electrolytes are within normal limits (Na 140.24, K 3.46, Cl 105.15). 1

Neurologic Status

  • Glasgow Coma Scale 15, fully oriented, no focal deficits aside from visual field loss. 1

  • No signs of increased intracranial pressure or acute hydrocephalus on recent imaging. 1

  • Postoperative CT shows expected changes (reduced mass size, sphenoid sinus air locules, small hematoma) without acute hemorrhage or infarction. 1

Imaging Adequacy for Surgical Planning

  • Recent postoperative CT with contrast (performed after initial surgery) demonstrates residual tumor and expected postoperative changes. 1

  • High-resolution contrast-enhanced MRI is the gold standard for delineating residual sellar lesions and planning the surgical approach. 2, 1

  • Thin-slice CT of the sphenoid sinus should be obtained for navigation to evaluate septal anatomy and detect any bony dehiscence over the internal carotid arteries. 1

Common Pitfalls to Avoid

  • Do not proceed with surgery while the patient is taking celecoxib—this is a modifiable risk factor for catastrophic intraoperative hemorrhage. 1

  • Do not proceed with active otomastoiditis—complete antibiotic therapy and confirm resolution to prevent postoperative meningitis. 1

  • Do not underestimate the severity of postoperative water metabolism disturbances; failure to monitor closely can result in significant morbidity. 6

  • Do not assume normal preoperative cortisol excludes risk of postoperative adrenal insufficiency—stress-dose coverage is appropriate given borderline thyroid function and surgical stress. 5

  • CSF leak is a risk factor for diabetes insipidus development, indicating more extensive surgical manipulation; monitor closely if intraoperative CSF leak occurs. 7, 5

References

1
Guideline

Preoperative Optimization and Surgical Indications for Repeat Transsphenoidal Surgery

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

6
Guideline

Pituitary Adenoma Neurosurgery: Recommended Treatment Approach

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

7
Guideline

CSF Leakage and DI Recovery After Pituitary Macroadenoma Surgery

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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