Assessment of pituitary Assessment of pituitary function post pituitary function post pituitary

surgerysurgery

Rola Zamel, R5Rola Zamel, R5

OutlineOutline- CasesCases- Our current approachOur current approach- Preoperative evaluationPreoperative evaluation- Postoperative evaluationPostoperative evaluation- ConclusionConclusion

Case 1Case 1

Mr.ABMr.AB

45 YOM45 YOM

Presents with symptoms consistent with VF Presents with symptoms consistent with VF defectdefect

MRI: pituitary tumor 1.5 cmMRI: pituitary tumor 1.5 cm

Hormone evaluation NormalHormone evaluation Normal

Case 2Case 2

Mr.CDMr.CD

45 YOM45 YOM

Presents with symptoms consistent with VF defectPresents with symptoms consistent with VF defect

MRI: pituitary tumor 3.0 cmMRI: pituitary tumor 3.0 cm

Preoperative hormone evaluationPreoperative hormone evaluation

IGF-1 lowIGF-1 low

LH/ FSH/ S.testosterone lowLH/ FSH/ S.testosterone low

TSH 2.5 FT4 9 FT3 2TSH 2.5 FT4 9 FT3 2

AM cortisol 50 ACTH lowAM cortisol 50 ACTH low

PRL 35PRL 35

Protocol for managing patients after pituitary surgeryProtocol for managing patients after pituitary surgeryPre-operative:Pre-operative:

Solucortef 50-100 mg on call to the ORSolucortef 50-100 mg on call to the OR(Some like to give Decadron 4mg IV as well – check with consultant)(Some like to give Decadron 4mg IV as well – check with consultant)Post-operative:Post-operative:

Solucortef 50-100mg IV q6-8hSolucortef 50-100mg IV q6-8h- decrease by 25-50% each day when over major stress until down to 30 mg per day - decrease by 25-50% each day when over major stress until down to 30 mg per day - switch to equivalent dose of oral hydrocortisone and if stable gradually decrease to- switch to equivalent dose of oral hydrocortisone and if stable gradually decrease to

20 mg per day20 mg per day

- daily serum electrolytes and osmolality and urine osmolality- daily serum electrolytes and osmolality and urine osmolality- I&O hourly- I&O hourly - call if- call if >200/hr for 3 consecutive hours or>200/hr for 3 consecutive hours or

>300/hr for 2 consecutive hours or>300/hr for 2 consecutive hours or>400/hr for 1 hour>400/hr for 1 hour

- if output exceeds one of above calculate total I&O and if output exceeds intake order - if output exceeds one of above calculate total I&O and if output exceeds intake order serum electrolytes and osmolality and consider giving ddAVP intranasally or IVserum electrolytes and osmolality and consider giving ddAVP intranasally or IV

- if serum Na >150 or osmoality >300 and urine output >200 give ddAVP- if serum Na >150 or osmoality >300 and urine output >200 give ddAVPOn discharge:On discharge:

Give patient OHIP lab order form from Endocrinologist responsible for continuing care Give patient OHIP lab order form from Endocrinologist responsible for continuing care for:for:- electrolytes q 1 (if requiring ddAVP) to 4 weeks (if no ddAVP)- electrolytes q 1 (if requiring ddAVP) to 4 weeks (if no ddAVP)- serum free T4 and estradiol/testosterone in two, six and ten weeks- serum free T4 and estradiol/testosterone in two, six and ten weeks- serum cortisol monthly when down to hydrocortisone 20mg daily- serum cortisol monthly when down to hydrocortisone 20mg dailyInstructions given to patients on dischargeInstructions given to patients on discharge

Current Practice here:

Patient receives stress dosing peri-operatively

Hydrocortisone tapered to 20 mg OD (AM) only

8 AM cortisol level (48 hrs after last HC dose):– cortisol < 100 → pit-adrenal insufficiency– Cortisol > 500 (550) → sufficient function– Cortisol 100-500: unsure; need stimulation test

Stimulation tests can be:– Insulin tolerance test– ACTH stimulation test– (CRH test)

Preoperative assessment of pituitary functionPreoperative assessment of pituitary function

A minimum set of pre-operative endocrine tests A minimum set of pre-operative endocrine tests should include:should include:

1- Electrolytes1- Electrolytes

2- IGF-12- IGF-1

3- LH/FSH, Estradiol / testosterone 3- LH/FSH, Estradiol / testosterone

4- TSH, FT3,FT44- TSH, FT3,FT4

5- AM (8-9) Cortisol5- AM (8-9) Cortisol

6- Prolactin6- Prolactin

Interpretation of serum prolactin levelsInterpretation of serum prolactin levels

A- high PRLA- high PRL

1- R/O 21- R/O 2ndnd causes of high prolactin causes of high prolactin

Eg. Pregnancy, PRL- elevating drugs, Eg. Pregnancy, PRL- elevating drugs, primary hypothyroidism, PCOSprimary hypothyroidism, PCOS

2- if PRL >200 mcg/l is diagnostic of 2- if PRL >200 mcg/l is diagnostic of macroprolactinomamacroprolactinoma

3- <80 mcg/l in macroprolactinoma indicates 3- <80 mcg/l in macroprolactinoma indicates disconnectiondisconnection

4- R/O the hook effect and macroprolactin4- R/O the hook effect and macroprolactin

B- Low PRLB- Low PRL

Acquired PRL deficiency in a patient not Acquired PRL deficiency in a patient not taking PRL lowering medication is taking PRL lowering medication is associated with severe hypopituitarism associated with severe hypopituitarism and reduced IGF-1 levelsand reduced IGF-1 levels

HPAHPA

Precaution:Precaution:

1- Patient on glucocorticoids1- Patient on glucocorticoids

2- Patients on E2, need to hold E2 6 weeks 2- Patients on E2, need to hold E2 6 weeks prior to the testprior to the test

Several tests are available to help predict whether the HPA is able to respond to a significant stress;

1- Basal cortisol- Should be measured 8-9 AM since HPA

activity is maximal at this time- If am cortisol <100nmol/l replacement

should start- If >450 nmol/l adrenal insufficiency is

unlikely

100 < am cortisol< 450, then a provocative 100 < am cortisol< 450, then a provocative test:test:

- ITTITT- Glucagon stimulation testGlucagon stimulation test- ACTH stimulation test ( iv 250 mcg)ACTH stimulation test ( iv 250 mcg)- CRH test ( not recommended) CRH test ( not recommended)

GH IGF-1 axis- IGF1- GH provocative tests:

the gold standard is ITT

Arginine-GHRH test

Hypothalamus – pituitary – thyroid axisHypothalamus – pituitary – thyroid axis

- TSH, Free T4TSH, Free T4- NTI can cause a pattern of low T4, N/NTI can cause a pattern of low T4, N/↓/↑ ↓/↑

TSHTSH

Hypothalamus-pituitary-gonadal functionHypothalamus-pituitary-gonadal function- Gonadotropins/sex steroids ( E2 and AM Gonadotropins/sex steroids ( E2 and AM

testosterone)testosterone)

DIDI

- Uncommon preoperatively in setting of Uncommon preoperatively in setting of pituitary adenoma pituitary adenoma

- Occurs commonly in Craniopharyngioma Occurs commonly in Craniopharyngioma or other hypothalamic pathologyor other hypothalamic pathology

- S.Na, Osmol, U.OsmolS.Na, Osmol, U.Osmol

Postoperative assessment of the patient after Postoperative assessment of the patient after transsphenoidal pituitary surgerytranssphenoidal pituitary surgery

Early post-operative period ( 1st few weeks post OR):

1-Neurosurgical monitoring for:

- disturbances in vision or neurological function

- CSF leak (drainage of clear fluid from the nose, especially on bending over)

- meningitis: periop AB’s was shown to reduce incidence

- Nasal packs are removed 12–24 h after surgery- Nasal packs are removed 12–24 h after surgery

2-Monitoring for water imbalances2-Monitoring for water imbalances

DI DI

Can occur at any time, peaks in the 1Can occur at any time, peaks in the 1stst 48h 48h

- Monitoring of thirst (craving for cold - Monitoring of thirst (craving for cold liquids), volume statusliquids), volume status

- Ins/outs- Ins/outs

- specific gravities - specific gravities

- daily serum electrolyte measurements - daily serum electrolyte measurements

Diagnostic criteria:Diagnostic criteria: Urine specific gravity < Urine specific gravity < 1.005 and urine volume > 250 cc/hr for 2-3 1.005 and urine volume > 250 cc/hr for 2-3 hourshours

Indications for desmopressin therapy:Indications for desmopressin therapy: Patient unable to maintain adequate oral Patient unable to maintain adequate oral fluid intake, urine output >> fluid intake, fluid intake, urine output >> fluid intake, hypernatremia hypernatremia

SIADHSIADH

- Peaks in the 7Peaks in the 7thth postoperative day postoperative day- Home monitoring of fluid intake and urine Home monitoring of fluid intake and urine

output after discharge in patients with DI output after discharge in patients with DI postoperativelypostoperatively

- Measure serum sodium emergently if Measure serum sodium emergently if symptoms of hyponatremia (headache, symptoms of hyponatremia (headache, nausea and vomiting, mental status nausea and vomiting, mental status changes or seizure)changes or seizure)

- Measurement of serum sodium one week Measurement of serum sodium one week after surgery in all patients (isolated after surgery in all patients (isolated hypoNa after TS was reported)hypoNa after TS was reported)

- Fluid restriction (~ 800cc/d depending on Fluid restriction (~ 800cc/d depending on severity of hyponatremia)severity of hyponatremia)

3-What about Ant pituitary deficiency?3-What about Ant pituitary deficiency?

The development of new pituitary hormone The development of new pituitary hormone deficiencies after TS is uncommon when deficiencies after TS is uncommon when performed by an experienced pituitary performed by an experienced pituitary surgeon surgeon

Predictors of hypopituitarism post TSPredictors of hypopituitarism post TS

1-When the surgical procedure is more 1-When the surgical procedure is more extensive, hemorrhage or necrosis within extensive, hemorrhage or necrosis within the tumor are seen the tumor are seen

2- DI:the likelihood of postoperative AI was 2- DI:the likelihood of postoperative AI was found to be increased four-fold in patients found to be increased four-fold in patients who had post-operative DI who had post-operative DI

3-Type of pituitary lesion: non-pituitary 3-Type of pituitary lesion: non-pituitary lesions such as craniopharyngiomas are lesions such as craniopharyngiomas are more likely to be accompanied by more likely to be accompanied by hypopituitarism or DIhypopituitarism or DI

3-Pituitary–adrenal axis assessment3-Pituitary–adrenal axis assessment

No RCTsNo RCTs

Various strategies exist for ensuring the Various strategies exist for ensuring the integrity of this axisintegrity of this axis

1- IV HC 100 mg at time of surgery, this 1- IV HC 100 mg at time of surgery, this dose is tapered quickly over two to three dose is tapered quickly over two to three days days

2- dexamethasone at doses of 2 mg at the 2- dexamethasone at doses of 2 mg at the time of surgery and 1 mg bid on time of surgery and 1 mg bid on postoperative day 1 postoperative day 1 Postoperative assessment of the patient Postoperative assessment of the patient

after transsphenoidal pituitary surgery (Ausiello J et al. Pituitary 2008)after transsphenoidal pituitary surgery (Ausiello J et al. Pituitary 2008)

3- Some recommend administering these to 3- Some recommend administering these to patients with preoperative hypopituitarism patients with preoperative hypopituitarism but withholding them in those with normal but withholding them in those with normal preoperative pituitary–adrenal function preoperative pituitary–adrenal function [peak cortisol >496.8 nmol/l (18 μg/dl) post [peak cortisol >496.8 nmol/l (18 μg/dl) post 250 μg cosyntropin stimulation] in whom 250 μg cosyntropin stimulation] in whom only selective adenomectomy is planned only selective adenomectomy is planned Inder WJ, Hunt PJ (2002) Glucocorticoid replacement in pituitary surgery: guidelines for Inder WJ, Hunt PJ (2002) Glucocorticoid replacement in pituitary surgery: guidelines for perioperative assessment and management. J Clin Endocrinol Metab perioperative assessment and management. J Clin Endocrinol Metab

Inder WJ, Hunt PJ (2002) Glucocorticoid replacement in pituitary surgery: guidelines for perioperative Inder WJ, Hunt PJ (2002) Glucocorticoid replacement in pituitary surgery: guidelines for perioperative

assessmentassessment and management. J Clin Endocrinol Metaband management. J Clin Endocrinol Metab

Prior to hospital discharge after TS each Prior to hospital discharge after TS each patient needs an assessment of pituitary–patient needs an assessment of pituitary–adrenal axis integrityadrenal axis integrity

The 250 μg CST:The 250 μg CST: is not the test of choice for is not the test of choice for early post-operative assessment of early post-operative assessment of pituitary-adrenal function because of its pituitary-adrenal function because of its inability to detect recent onset secondary inability to detect recent onset secondary AI AI

ITT:ITT: not be clinically appropriate within the not be clinically appropriate within the first few days after surgery first few days after surgery

AM postoperative cortisol:AM postoperative cortisol:

the accuracy of this test for the prediction of the accuracy of this test for the prediction of secondary AI has been investigated secondary AI has been investigated

How early after surgery one may safely assess patients How early after surgery one may safely assess patients for adequacy of adrenal function?for adequacy of adrenal function?

Immediate postoperative cortisol levels accurately predict postoperative hypothalamic–pituitary–adrenal axis Immediate postoperative cortisol levels accurately predict postoperative hypothalamic–pituitary–adrenal axis function after transsphenoidal surgery for pituitary tumors . Pituitary March 26,2010function after transsphenoidal surgery for pituitary tumors . Pituitary March 26,2010

GoalGoal

to examine the ability of a normal preoperative to examine the ability of a normal preoperative ACTH stimulation test to predict an adequate ACTH stimulation test to predict an adequate postoperative stress response and normal HPA postoperative stress response and normal HPA axis function. Results of preop CST was axis function. Results of preop CST was compared to immediate post op DOS S.cortisol compared to immediate post op DOS S.cortisol and late post op CSTand late post op CST

-A prospective studyA prospective study

-100 patients ( pituitary adenoma (100 patients ( pituitary adenoma (nn = 99) or a  = 99) or a Rathke’s cleft cyst (Rathke’s cleft cyst (nn = 1) who underwent  = 1) who underwent transsphenoidal surgery by a single transsphenoidal surgery by a single neurosurgeon between October 2006 and neurosurgeon between October 2006 and March 2009)March 2009)

Cleveland ClinicCleveland Clinic

- Exclusion criteria:Exclusion criteria:

1- Patients undergoing surgery for Cushing’s disease1- Patients undergoing surgery for Cushing’s disease

2- patients who chronically received daily corticosteroids 2- patients who chronically received daily corticosteroids prior to surgeryprior to surgery

3- patients who did not have a preoperative ACTH 3- patients who did not have a preoperative ACTH stimulation test or who failed to follow up appropriately stimulation test or who failed to follow up appropriately

for postoperative testingfor postoperative testing

4- patients who failed preoperative ACTH stimulation test4- patients who failed preoperative ACTH stimulation test

MethodMethod

- All patients were tested preoperatively - All patients were tested preoperatively with a modified low-dose (25 μg) CST to with a modified low-dose (25 μg) CST to evaluate HPA axis function.evaluate HPA axis function.

- Serum total cortisol levels were assayed - Serum total cortisol levels were assayed at 0, 30 and 60 min post injection. An at 0, 30 and 60 min post injection. An adequate and sufficient response was adequate and sufficient response was defined as an absolute cortisol level of defined as an absolute cortisol level of ≥18 μg/dL (496.8 nmol/l) at either ≥18 μg/dL (496.8 nmol/l) at either tt 30 or 30 or tt 60. 60.

- Patients with normal pre-operative HPA axis Patients with normal pre-operative HPA axis function did not receive glucocorticoid coverage function did not receive glucocorticoid coverage during pituitary surgeryduring pituitary surgery

- All patients had:All patients had: * S.cortisol immediately post op,* S.cortisol immediately post op, * modified low-dose CST at 4–6 weeks * modified low-dose CST at 4–6 weeks

postoperatively postoperatively * F/U at 3 months, one year , and then at one * F/U at 3 months, one year , and then at one

year intervals thereafter. Laboratory assays of year intervals thereafter. Laboratory assays of HPA axis function were performed at these visits HPA axis function were performed at these visits if clinical symptoms suggestive of if clinical symptoms suggestive of hypocortisolemia were present, with a mean hypocortisolemia were present, with a mean follow-up of 22 months follow-up of 22 months

ResultsResults

- In patients in whom adequate pre-operative In patients in whom adequate pre-operative adrenal function is demonstrated, an immediate adrenal function is demonstrated, an immediate postoperative cortisol level ≥15 μg/dL has a postoperative cortisol level ≥15 μg/dL has a similar or greater ability to predict normal similar or greater ability to predict normal postoperative HPA axis function as does postoperative HPA axis function as does determination of cortisol levels on POD1 or later determination of cortisol levels on POD1 or later

In most centers, therefore, cortisol levels are In most centers, therefore, cortisol levels are measured the morning of the 2nd or 3rd measured the morning of the 2nd or 3rd postoperative day, 24 h after the last dose postoperative day, 24 h after the last dose of peri-operative hydrocortisone coverageof peri-operative hydrocortisone coverage

1- AM cortisol levels >17 μg/dl (460 nmol/L) 1- AM cortisol levels >17 μg/dl (460 nmol/L) do not require replacement on dischargedo not require replacement on discharge

2- level <10 ug/dl ( 270nmol/L) require2- level <10 ug/dl ( 270nmol/L) require3- AM cortisol levels between 10 and 17 3- AM cortisol levels between 10 and 17

debatable, some argue that these patients debatable, some argue that these patients should receive further therapy, some Rx if should receive further therapy, some Rx if symptoms of AI, some Rx if DI or symptoms of AI, some Rx if DI or complicated surgerycomplicated surgery

- In most centers; morning cortisol levels are In most centers; morning cortisol levels are reassessed 1 week postoperatively, 24 h after reassessed 1 week postoperatively, 24 h after the most recent dose of hydrocortisonethe most recent dose of hydrocortisone

…………………………………………………………………………………………………….. ..

Despite the many studies on this question, there is Despite the many studies on this question, there is still disagreement regarding the morning cortisol still disagreement regarding the morning cortisol level that best predicts normal HPA axis function level that best predicts normal HPA axis function in stressed and unstressed situations so some in stressed and unstressed situations so some centers treat all postoperative patients with oral centers treat all postoperative patients with oral glucocorticoid therapy on discharge and glucocorticoid therapy on discharge and continue this until at least the first postoperative continue this until at least the first postoperative visit visit

Other anterior pituitary hormone assessmentsOther anterior pituitary hormone assessments

- One report suggests measuring FT4 one week One report suggests measuring FT4 one week postoperatively in patients with:postoperatively in patients with:

1- other abnormalities of pituitary function 2- 1- other abnormalities of pituitary function 2- unknown preoperative thyroid functionunknown preoperative thyroid function

3- pituitary apoplexy3- pituitary apoplexy…………………………………………………………………………………………………………………………………………

In patients with prolactinomas, who may undergo In patients with prolactinomas, who may undergo TS because they are resistant to or intolerant of TS because they are resistant to or intolerant of dopamine agonists, early measurement of dopamine agonists, early measurement of prolactin levels can be undertaken as low levels prolactin levels can be undertaken as low levels may portend a better surgical outcomemay portend a better surgical outcome

…………………………………………………………………………………………………………………… Assessment of growth hormone and Assessment of growth hormone and

gonadotropins is reserved for a later gonadotropins is reserved for a later postoperative visitpostoperative visit

Late postoperative phaseLate postoperative phase - new hypopituitarism is very rare after TS in new hypopituitarism is very rare after TS in

patients with intact pituitary function patients with intact pituitary function preoperatively.preoperatively.

- In general, most cases of new In general, most cases of new hypopituitarism are detected very early hypopituitarism are detected very early post-operatively and almost always within post-operatively and almost always within the first 3 monthsthe first 3 months

- In one retrospective study of 71 patients - In one retrospective study of 71 patients 32 developed AI but none developed AI 32 developed AI but none developed AI after 3 months post OR. after 3 months post OR. Adrenocortical insufficiency after pituitary Adrenocortical insufficiency after pituitary

surgery: an audit of the reliability of the conventional short synacthen test Clin Endocrinol (Oxf). 2005 surgery: an audit of the reliability of the conventional short synacthen test Clin Endocrinol (Oxf). 2005 Nov;63(5):499-505.Nov;63(5):499-505.

Assessment of the pituitary–adrenal axisAssessment of the pituitary–adrenal axis

1-Measure morning cortisol at first postoperative visit 24-1-Measure morning cortisol at first postoperative visit 24-hrs after glucocorticoid dose if on therapy)hrs after glucocorticoid dose if on therapy)

2-Assess cortisol level and clinical status2-Assess cortisol level and clinical status

* If AM cortisol <100 nmol/L ( 3.7) likely to remain ACTH * If AM cortisol <100 nmol/L ( 3.7) likely to remain ACTH deficient, but late recovery was documenteddeficient, but late recovery was documented

* Some recommend D/C steroid if am.cortisol >10 and * Some recommend D/C steroid if am.cortisol >10 and no other hypopituitarism, others use >18no other hypopituitarism, others use >18

3-Consider further testing of pituitary-adrenal 3-Consider further testing of pituitary-adrenal function: function:

1- ITT1- ITT ( the gold standard for assessing HPA) ( the gold standard for assessing HPA)Normal response >500 nm Normal response >500 nm 2- Cosyntropin stimulation test2- Cosyntropin stimulation test (250 μg) (CST (250 μg) (CST

can be used 4 weeks post OR) can be used 4 weeks post OR) Normal response >550 nmNormal response >550 nm3- Glucagon stimulation test3- Glucagon stimulation testThe recommended dose is 1 mg IMThe recommended dose is 1 mg IMAdequate response is >500nmAdequate response is >500nm4- CRH test4- CRH testIs not recommended as it is inferior to 8AM Is not recommended as it is inferior to 8AM

s.cortisol for assessing HPA in pituitary diseases.cortisol for assessing HPA in pituitary diseaseIt doesn’t provided further info in the group with It doesn’t provided further info in the group with

intermediate cortisol level 200-400nMintermediate cortisol level 200-400nM

- Optimal timing of the tests to assess HPA Optimal timing of the tests to assess HPA is controversial is controversial

- Some recommend s.cortisol at d 7 Some recommend s.cortisol at d 7

and definitive testing 7-14 daysand definitive testing 7-14 days

then review in clinic at 3-4 weeksthen review in clinic at 3-4 weeks

- Other approach is to perform definitive test - Other approach is to perform definitive test between 4-6 weeks post opbetween 4-6 weeks post op

Thyroid axisThyroid axis

Thyroid function can be assessed by Thyroid function can be assessed by measuring free thyroxine levels at the first measuring free thyroxine levels at the first postoperative visit, again some time within postoperative visit, again some time within the first few months after surgery and on a the first few months after surgery and on a yearly basis thereafteryearly basis thereafter

Pituitary–gonadal axesPituitary–gonadal axes - In premenopausal women gonadal function can In premenopausal women gonadal function can

be assessed based on menstrual history and be assessed based on menstrual history and gonadotropin and estradiol levels if necessary gonadotropin and estradiol levels if necessary

- Male:Male:1- Assess for symptoms of hypogonadism1- Assess for symptoms of hypogonadism2- gonadotropin levels, and a morning total 2- gonadotropin levels, and a morning total

testosterone. A free testosterone may be testosterone. A free testosterone may be necessary in patients at risk for abnormal SHBG necessary in patients at risk for abnormal SHBG levels (elderly, obese, thyroid illness or other levels (elderly, obese, thyroid illness or other significant comorbidities)significant comorbidities)

Growth hormone axis Growth hormone axis

The optimal time postoperatively to assess The optimal time postoperatively to assess for and begin GHD therapy is not yet for and begin GHD therapy is not yet established established

MethodMethod

1- ITT1- ITT

2- arginine/GHRH test 2- arginine/GHRH test

Radiologic evaluationRadiologic evaluation

MRI 3 months post opMRI 3 months post op

Then q1yr X 5 yrs Then q1yr X 5 yrs

Then can lengthen interval if stableThen can lengthen interval if stable

Long term monitoring with assessments of Long term monitoring with assessments of visual, neurological and pituitary function visual, neurological and pituitary function coupled with pituitary imaging is necessary coupled with pituitary imaging is necessary for all patients who have undergone for all patients who have undergone surgery, irrespective of the hormone status surgery, irrespective of the hormone status of their tumors. of their tumors.

Assessments in patients with hormone Assessments in patients with hormone secreting pituitary tumorssecreting pituitary tumors

1- ACTH secreting tumors1- ACTH secreting tumors

a- administer stress glucocorticoids and taper to a- administer stress glucocorticoids and taper to about twice replacement doses postoperativelyabout twice replacement doses postoperatively

b- Other approach is to withhold peri-operative and b- Other approach is to withhold peri-operative and early postoperative glucocorticoids until early postoperative glucocorticoids until remission or persistent disease is documented. remission or persistent disease is documented. S.cortisol q6 h and monitor for signs and S.cortisol q6 h and monitor for signs and symptoms of AI symptoms of AI

If cortisol <55.2 nmol/l (2 μg/dl) and patients If cortisol <55.2 nmol/l (2 μg/dl) and patients have symptoms, remission is achieved and have symptoms, remission is achieved and replacement glucocorticoids are begun replacement glucocorticoids are begun

GH-secreting tumorsGH-secreting tumors

Preliminary assessment of recoveryPreliminary assessment of recovery

Can be done by measuring GH level on the Can be done by measuring GH level on the 3rd postoperative day. The lower the GH 3rd postoperative day. The lower the GH level, the better the evidence for remissionlevel, the better the evidence for remission

ConclusionConclusion

Do we need to change our protocol?Do we need to change our protocol?

ReferencesReferences

1-1-Preoperative assessment for pituitary surgery.Pereira O, Bevan Pereira O, Bevan JS.Pituitary. 2008;11(4):347-51. Review.JS.Pituitary. 2008;11(4):347-51. Review.

2-Postoperative assessment of the patient after transsphenoidal 2-Postoperative assessment of the patient after transsphenoidal pituitary surgery pituitary surgery Ausiello et alPituitary. 2008;11(4):391-401. et alPituitary. 2008;11(4):391-401.

3-Immediate postoperative cortisol levels accurately predict 3-Immediate postoperative cortisol levels accurately predict postoperative hypothalamic–pituitary–adrenal axis function postoperative hypothalamic–pituitary–adrenal axis function after transsphenoidal surgery for pituitary tumors . Pituitary after transsphenoidal surgery for pituitary tumors . Pituitary March 26,2010March 26,2010

4-4-Glucocorticoid replacement in pituitary surgery: guidelines for perioperative assessment and management. Inder WJ, Hunt PJ. Inder WJ, Hunt PJ.

J Clin Endocrinol Metab. 2002 Jun;87(6):2745-50. Review.J Clin Endocrinol Metab. 2002 Jun;87(6):2745-50. Review.5-Adrenocortical insufficiency after pituitary surgery: an audit of 5-Adrenocortical insufficiency after pituitary surgery: an audit of

the reliability of the conventional short synacthen test. Clin the reliability of the conventional short synacthen test. Clin Endocrinol (Oxf). 2005 Nov;63(5):499-505.Endocrinol (Oxf). 2005 Nov;63(5):499-505.