Pilot Study on Early Postoperative Discharge in Pituitary Adenoma Patients: Effect of Socioeconomic Factors and Benefit of Specialized Pituitary Centers

Christopher A. Sarkiss; James Lee; Joseph A. Papin; Eliza B. Geer; Rudrani Banik; Janet C. Rucker; Barbara Oudheusden; Satish Govindaraj; Raj K. Shrivastava

doi:10.1055/s-0035-1549004

Journal of Neurological Surgery Part B: Skull Base, Table of Contents

J Neurol Surg B Skull Base 2015; 76(04): 323-330
DOI: 10.1055/s-0035-1549004

Original Article

Georg Thieme Verlag KG Stuttgart · New York

Pilot Study on Early Postoperative Discharge in Pituitary Adenoma Patients: Effect of Socioeconomic Factors and Benefit of Specialized Pituitary Centers

Authors

Christopher A. Sarkiss

¹Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
James Lee

¹Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
Joseph A. Papin

²Department of Neurosurgery, University of Michigan Medical School, Ann Arbor, Michigan, United States
Eliza B. Geer

³Department of Medicine-Endocrinology, Icahn School of Medicine at Mount Sinai, New York, New York, United States
Rudrani Banik

⁴Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York, United States
Janet C. Rucker

⁵Department of Neurology (Neuro-Ophthalmology), New York University School of Medicine, New York, New York, United States
Barbara Oudheusden

¹Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
Satish Govindaraj

⁶Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York, United States
Raj K. Shrivastava

¹Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States

Abstract

Introduction Pituitary neoplasms are benign entities that require distinct diagnostic and treatment considerations. Recent advances in endoscopic transsphenoidal surgery have resulted in shorter lengths of stay (LOS). We implemented a postoperative day (POD) 1 discharge paradigm involving a multidisciplinary approach and detailed preoperative evaluation and review of both medical and socioeconomic factors.

Methods The experience of a single neurosurgeon/ears, nose, throat (ENT) team was reviewed, generating a preliminary retrospective database of the first 30 patients who underwent resection of pituitary lesions under the POD 1 discharge paradigm. We assessed multiple axes from their preoperative, in-house, and postoperative care.

Results There were 14 men and 16 women with an average age of 53.8 years (range: 27–76 years). There were 22 nonsecretory and 8 secretory tumors with average size of 2.80 cm (range: 1.3–5.0 cm). All 30 patients underwent preoperative ENT evaluation. Average LOS was 1.5 ± 0.7 days. A total of 18 of 30 patients were discharged on POD 1. The insurance status included 15 with public insurance such as emergency Medicaid and 15 with private insurance. Four patients had transient diabetes insipidus (DI); none had permanent DI. Overall, 28 of 30 patients received postoperative steroids. Factors that contributed to LOS > 1 day included public insurance status, two or more medical comorbidities, diabetes mellitus, transient panhypopituitarism, and DI.

Conclusion The implementation of a POD 1 discharge plan for pituitary tumors is feasible and safe for elective patients. This implementation requires the establishment of a dedicated Pituitary Center model with experienced team members. The consistent limitation to early discharge was socioeconomic status. Efforts that incorporate the analysis of social disposition parameters with proper management of clinical sequelae are crucial to the maintenance of ideal LOS and optimal patient outcomes.

Keywords

pituitary adenoma - specialized pituitary centers - skull base surgery - endoscopic surgery - socioeconomics - early discharge

Full Text

References

References
1 Jane Jr JA, Laws Jr ER. The surgical management of pituitary adenomas in a series of 3,093 patients. J Am Coll Surg 2001; 193 (6) 651-659
2 Laws ER, Jane Jr JA. Pituitary tumors—long-term outcomes and expectations. Clin Neurosurg 2001; 48: 306-319
3 Laws ER, Jane Jr JA. Neurosurgical approach to treating pituitary adenomas. Growth Horm IGF Res 2005; 15 (Suppl A): S36-S41
4 Patil CG, Lad SP, Harsh GR, Laws Jr ER, Boakye M. National trends, complications, and outcomes following transsphenoidal surgery for Cushing's disease from 1993 to 2002. Neurosurg Focus 2007; 23 (3) E7
5 Liu JK, Weiss MH, Couldwell WT. Surgical approaches to pituitary tumors. Neurosurg Clin N Am 2003; 14 (1) 93-107
6 Gittleman H, Ostrom QT, Farah PD , et al. Descriptive epidemiology of pituitary tumors in the United States, 2004–2009. J Neurosurg 2014; 121 (3) 527-535
7 Dallapiazza RF, Grober Y, Starke RM, Laws Jr ER, Jane Jr JA. Long-term results of endonasal endoscopic transsphenoidal resection of nonfunctioning pituitary macroadenomas. Neurosurgery 2014; 76 (1) 42-52 ; discussion 52–53
8 Gao Y, Zhong C, Wang Y , et al. Endoscopic versus microscopic transsphenoidal pituitary adenoma surgery: a meta-analysis. World J Surg Oncol 2014; 12: 94
9 Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH. Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of giant pituitary adenomas. Pituitary 2012; 15 (2) 150-159
10 Paluzzi A, Fernandez-Miranda JC, Tonya Stefko S, Challinor S, Snyderman CH, Gardner PA. Endoscopic endonasal approach for pituitary adenomas: a series of 555 patients. Pituitary 2014; 17 (4) 307-319
11 Prevedello DM, Doglietto F, Jane Jr JA, Jagannathan J, Han J, Laws Jr ER. History of endoscopic skull base surgery: its evolution and current reality. J Neurosurg 2007; 107 (1) 206-213
12 Wang F, Zhou T, Wei S , et al. Endoscopic endonasal transsphenoidal surgery of 1,166 pituitary adenomas. Surg Endosc 2014;
13 Cho DY, Liau WR. Comparison of endonasal endoscopic surgery and sublabial microsurgery for prolactinomas. Surg Neurol 2002; 58 (6) 371-375 ; discussion 375–376
14 Kabil MS, Eby JB, Shahinian HK. Fully endoscopic endonasal vs. transseptal transsphenoidal pituitary surgery. Minim Invasive Neurosurg 2005; 48 (6) 348-354
15 White DR, Sonnenburg RE, Ewend MG, Senior BA. Safety of minimally invasive pituitary surgery (MIPS) compared with a traditional approach. Laryngoscope 2004; 114 (11) 1945-1948
16 O'Malley Jr BW, Grady MS, Gabel BC , et al. Comparison of endoscopic and microscopic removal of pituitary adenomas: single-surgeon experience and the learning curve. Neurosurg Focus 2008; 25 (6) E10
17 Juraschka K, Khan OH, Godoy BL , et al. Endoscopic endonasal transsphenoidal approach to large and giant pituitary adenomas: institutional experience and predictors of extent of resection. J Neurosurg 2014; 121 (1) 75-83
18 Dallapiazza R, Bond AE, Grober Y , et al. Retrospective analysis of a concurrent series of microscopic versus endoscopic transsphenoidal surgeries for Knosp Grades 0-2 nonfunctioning pituitary macroadenomas at a single institution. J Neurosurg 2014; 121 (3) 511-517
19 Tabaee A, Anand VK, Barrón Y , et al. Endoscopic pituitary surgery: a systematic review and meta-analysis. J Neurosurg 2009; 111 (3) 545-554
20 Cappabianca P, Alfieri A, Colao A, Ferone D, Lombardi G, de Divitiis E. Endoscopic endonasal transsphenoidal approach: an additional reason in support of surgery in the management of pituitary lesions. Skull Base Surg 1999; 9 (2) 109-117
21 Casler JD, Doolittle AM, Mair EA. Endoscopic surgery of the anterior skull base. Laryngoscope 2005; 115 (1) 16-24
22 Higgins TS, Courtemanche C, Karakla D , et al. Analysis of transnasal endoscopic versus transseptal microscopic approach for excision of pituitary tumors. Am J Rhinol 2008; 22 (6) 649-652
23 Neal JG, Patel SJ, Kulbersh JS, Osguthorpe JD, Schlosser RJ. Comparison of techniques for transsphenoidal pituitary surgery. Am J Rhinol 2007; 21 (2) 203-206
24 Rotenberg B, Tam S, Ryu WH, Duggal N. Microscopic versus endoscopic pituitary surgery: a systematic review. Laryngoscope 2010; 120 (7) 1292-1297
25 Barker II FG, Klibanski A, Swearingen B. Transsphenoidal surgery for pituitary tumors in the United States, 1996–2000: mortality, morbidity, and the effects of hospital and surgeon volume. J Clin Endocrinol Metab 2003; 88 (10) 4709-4719
26 Roddy SP, Estes JM, Kwoun MO, O'donnell Jr TF, Mackey WC. Factors predicting prolonged length of stay after carotid endarterectomy. J Vasc Surg 2000; 32 (3) 550-554
27 Millat B, Fingerhut A, Gignoux M, Hay JM ; French Associations for Surgical Research. Factors associated with early discharge after inguinal hernia repair in 500 consecutive unselected patients. Br J Surg 1993; 80 (9) 1158-1160
28 Thomas JG, Gadgil N, Samson SL, Takashima M, Yoshor D. Prospective trial of a short hospital stay protocol after endoscopic endonasal pituitary adenoma surgery. World Neurosurg 2014; 81 (3–4) 576-583
29 Childs BR, Vallier HA. Cost savings associated with a multidisciplinary protocol that expedites definitive fracture care. Am J Orthop 2014; 43 (7) 309-315
30 Fine MJ, Pratt HM, Obrosky DS , et al. Relation between length of hospital stay and costs of care for patients with community-acquired pneumonia. Am J Med 2000; 109 (5) 378-385
31 Osnabrugge RL, Speir AM, Head SJ , et al. Prediction of costs and length of stay in coronary artery bypass grafting. Ann Thorac Surg 2014; 98 (4) 1286-1293
32 El-Sayed IH, Roediger FC, Goldberg AN, Parsa AT, McDermott MW. Endoscopic reconstruction of skull base defects with the nasal septal flap. Skull Base 2008; 18 (6) 385-394
33 Joseph SP, Ho JT, Doogue MP, Burt MG. Perioperative management of the hypothalamic-pituitary-adrenal axis in patients with pituitary adenomas: an Australasian survey. Intern Med J 2012; 42 (10) 1120-1124
34 Loyo-Varela M, Herrada-Pineda T, Revilla-Pacheco F, Manrique-Guzman S. Pituitary tumor surgery: review of 3004 cases. World Neurosurg 2013; 79 (2) 331-336
35 Little AS, Chapple K. Predictors of resource utilization in transsphenoidal surgery for Cushing disease. J Neurosurg 2013; 119 (2) 504-511
36 Oosmanally N, Paul JE, Zanation AM , et al. Comparative analysis of cost of endoscopic endonasal minimally invasive and sublabial-transseptal approaches to the pituitary. Int Forum Allergy Rhinol 2011; 1 (4) 242-249
37 Little AS, Chapple K, Jahnke H, White WL. Comparative inpatient resource utilization for patients undergoing endoscopic or microscopic transsphenoidal surgery for pituitary lesions. J Neurosurg 2014; 121 (1) 84-90
38 Seaver MJ. Neurosurgical practice survey results. Am Assoc Neurol Surg Bull 2005; 14: 10-15
39 Shahlaie K, McLaughlin N, Kassam AB, Kelly DF. The role of outcomes data for assessing the expertise of a pituitary surgeon. Curr Opin Endocrinol Diabetes Obes 2010; 17 (4) 369-376
40 McLaughlin N, Laws ER, Oyesiku NM, Katznelson L, Kelly DF. Pituitary centers of excellence. Neurosurgery 2012; 71 (5) 916-924 ; discussion 924–926
41 Varshney S, Gupta C, Bansal KK, Bist SS, Bhagat S. Endoscopic trans-nasal trans-sphenoidal (TNTS) approach for pituitary adenomas: our experience. Indian J Otolaryngol Head Neck Surg 2013; 65 (2) (Suppl. 02) 308-313
42 Guthikonda B, Connor D, Clavenna M , et al. Endoscopic transsphenoidal surgery: a transition to neurosurgery-ENT collaboration producing better outcomes. J Neurol Surg B 2014; 75: A033
43 Little AS, Kelly D, Milligan J , et al. Prospective validation of a patient-reported nasal quality-of-life tool for endonasal skull base surgery: The Anterior Skull Base Nasal Inventory-12. J NeurosurgB Skull Base 2013; 119 (4) 1068-1074
44 McLaughlin N, Carrau RL, Kelly DF, Prevedello DM, Kassam AB. Teamwork in skull base surgery: an avenue for improvement in patient care. Surg Neurol Int 2013; 4: 36
45 Kripalani S, Henderson LE, Jacobson TA, Vaccarino V. Medication use among inner-city patients after hospital discharge: patient-reported barriers and solutions. Mayo Clin Proc 2008; 83 (5) 529-535
46 Bowles KH, Naylor MD, Foust JB. Patient characteristics at hospital discharge and a comparison of home care referral decisions. J Am Geriatr Soc 2002; 50 (2) 336-342