Quality Improvement in Endoscopic Endonasal Surgery

Background: Surgical resection of pituitary adenomas is associated with a 10 to 30% rate of temporary diabetes insipidus with ~50% resolving within 1 week and 80% resolving at 3 months.[1] Adrenal insufficiency occurs in ~5% of patients and can result in an Addisonian crisis if left undiagnosed postoperatively.[1] [2] Many studies have been performed looking at readmission rates after pituitary surgery. A review of over 1,200 cases demonstrated a readmission rate of 8.5% with the most common cause being hyponatremia (29.5%).[3] To reduce the rate of readmission for hyponatremia, some groups have demonstrated the effective use of outpatient fluid restriction criteria during the first week post-op.[4]

These guidelines are intended for the management of standard postoperative hormonal fluctuations which do not necessitate endocrine consultation during hospitalization.

Objective: Retrospectively evaluate patients undergoing endoscopic endonasal resection of pituitary adenomas to identify areas for quality improvement through the development of more standardized postoperative guidelines.

Method: A retrospective review of 75 patients who underwent endoscopic endonasal resection of pituitary adenomas at a single academic center from 2013 to 2018. We evaluated the average length of stay, number of laboratory studies performed, need for hormone supplementation long term and short term, rate of gross-total resection, rate of cerebrospinal fluid leak, rate of infection, and 30-day readmission rate ([Table 1]). From this, we have developed a change in guidelines aimed at reducing length of stay, redundant laboratory studies, and reduced rate of readmission.

Conclusion: Although our current outcomes for resection of pituitary adenoma are on par with published data, we have identified areas of possible quality improvement which have since been implemented.

• References

• 1 Prete A, Corsello SM, Salvatori R. Current best practice in the management of patients after pituitary surgery. Ther Adv Endocrinol Metab 2017; 8 (03) 33-48
• 2 McLaughlin N, Cohan P, Barnett P, Eisenberg A, Chaloner C, Kelly DF. Early morning cortisol levels as predictors of short-term and long-term adrenal function after endonasal transsphenoidal surgery for pituitary adenomas and Rathke’s cleft cysts. World Neurosurg 2013; 80 (05) 569-575
• 3 Cote DJ, Dasenbrock HH, Muskens IS. , et al. Readmission and other adverse events after transsphenoidal surgery: prevalence, timing, and predictive factors. J Am Coll Surg 2017; 224 (05) 971-979
• 4 Burke WT, Cote DJ, Iuliano SI, Zaidi HA, Laws ER. A practical method for prevention of readmission for symptomatic hyponatremia following transsphenoidal surgery. Pituitary 2018; 21 (01) 25-31