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Table of Contents    
REVIEW ARTICLE
Year : 2020  |  Volume : 68  |  Issue : 7  |  Page : 134-136

Status of Pituitary Surgery During the COVID-19 Pandemic


Department of Neurosurgery, Emory University, USA

Date of Web Publication24-Jun-2020

Correspondence Address:
Dr. Joseph W Quillin
Department of Neurosurgery, Emory University
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.287685

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 » Abstract 


Even in ideal circumstances, the performance of safe and effective endoscopic transsphenoidal pituitary surgery requires complicated orchestration of care amongst multiple medical and surgical teams in the preoperative, intraoperative, and postoperative settings. The current COVID-19 pandemic further complicates this highly orchestrated effort. Healthcare systems around the globe are working to adapt to the rapidly changing healthcare landscape as information about the SARS-CoV-2 virus is discovered and disseminated. The nature of the transsphenoidal corridor exposes the pituitary surgery team to increased risk of virus exposure.


Keywords: COVID-19, endoscopic surgery, pituitary, surgery, transsphenoidal, TSA
Key Message: Pituitary surgery is possible and safe as long as the proper precautions are observed during the COVID-19 pandemic. A coordinated interdisciplinary approach from our collected international experience is required to maintain a high quality of patient care and the safety of health care workers. Patients with pituitary tumors have an endocrinological disposition to secondary adrenal insufficiency and may require steroid supplementation during acute illness.


How to cite this article:
Quillin JW, Oyesiku NM. Status of Pituitary Surgery During the COVID-19 Pandemic. Neurol India 2020;68, Suppl S1:134-6

How to cite this URL:
Quillin JW, Oyesiku NM. Status of Pituitary Surgery During the COVID-19 Pandemic. Neurol India [serial online] 2020 [cited 2020 Oct 28];68, Suppl S1:134-6. Available from: https://www.neurologyindia.com/text.asp?2020/68/7/134/287685




Endoscopic transsphenoidal pituitary surgery is a complicated endeavor. Apart from the usual intraoperative challenges, such as endless anatomical variation, the difficulty of precise tumor localization, the nuances for complete tumor excision, and the harrowing avoidance of nearby neurovascular structures, a pituitary patient's preoperative and postoperative care is complex. These tumors are frequently identified by endocrinologists, ophthalmologists, obstetricians, emergency physicians, and primary care physicians, who all bring different levels of familiarity with the disease process and its management. Patient care must be coordinated amongst neurosurgeons, otolaryngologists, ophthalmologists, and endocrinologists.

The current COVID-19 pandemic has wrought havoc on unprepared healthcare systems worldwide.[1] According to the World Health Organization (WHO), there are over 5.4 million confirmed cases of the virus and over 343,000 deaths attributed to it worldwide to date.[2] The otolaryngology and neurosurgery teams at Stanford University alerted the endoscopic skull base surgery community to the elevated risks of transsphenoidal approaches based on the early anecdotal reports of widespread surgical team infection from pituitary surgery teams in China and Italy.[3] While the veracity of this warning was refuted by sources in Wuhan, it raised the specter of increased transmission risk that must be addressed by pituitary surgery teams.[4],[5] As we continue to provide care to these patients, it is clear that precautions must be taken during every step of the diagnostic and therapeutic journey by care teams and patients alike.

Existing pituitary tumor patients with varying levels of hypopituitarism must be made aware of the elevated risk during the pandemic. Frequently, these patients are encountered with nonfunctional macroadenomas that have interfered with the proper functioning of their hypothalamic-pituitary axis. After basic preventative measures are observed such as social distancing, hand washing, and the donning of a face mask in public, these patients should be counselled that they may require additional supportive glucocorticoid supplementation in the event of a dry continuous cough and fever.[6] Oftentimes, life threatening adrenal crisis can be avoided by this simple educational point. Patients with secondary adrenal insufficiency have proven to be more susceptible to hospitalization for infection prior to the emergence of SARS- CoV-2.[7] The baseline increased mortality of patients with primary adrenal insufficiency compared to the general population is frequently attributed to severe respiratory infections due to their relative lack of effective natural killer cell function.[8] It is clear these patients must take every reasonable precaution to avoid exposure to the virus.

In addition to patients with secondary adrenal insufficiency due to large nonfunctional tumors, those with small functional tumors bear their own burdens. Patients with acromegaly have a higher incidence of more routine medical comorbidities than the general population.

These patients are at higher risk of developing diabetes, hypertension, cardiovascular disease, and respiratory disease.[9] Indeed, the respiratory disease can be threefold higher in this population.[10] Given their elevated baseline mortality, they must be counseled as to their risks compared to the general public to effectively protect themselves. Patients with Cushing's disease have a similarly startling increase in general mortality compared the general population—double—even without the complication of a worldwide pandemic.[11]

Intraoperatively, multiple considerations must be made to the healthcare teams caring for these patients. At our institution, we are preoperatively testing for COVID-19 using batch testing within 48 hours of the procedure. This of course limits the potential exposure of healthcare workers and operating room staff to the virus. Emergent procedures require a “rapid” RT-PCR test that takes approximately 30 minutes to return. Ever since the risks regarding transsphenoidal approach has been raised, we have been mindful of the urgency and order of our case selection. We have delayed cases where possible, and we have restricted our operations to those individuals with apoplexy, new symptomatic compression of the anterior visual pathways, or biochemically functional tumors with severe presentation not amenable to medical therapy.

SARS-CoV-2 has been demonstrated to shed from the nasal mucosa, and the virus may be spread by asymptomatic carriers.[12] SARS-CoV-2 is also viable for hours in aerosols.[13] Furthermore, the hospital environment will certainly become infected with SARS-CoV-2 while caring for patients with COVID-19.[14] Standard use of personal protective equipment (PPE) is observed throughout the hospital, including the regular and widespread use of surgical masks by all staff. Visitors have been greatly restricted, and overall foot traffic is drastically reduced. We have instituted the requirement for N95 masks and eye protection for all members of the intraoperative pituitary surgery team to even enter the operating room. For those that fail their N95 fit test, a powered air-purifying respirator (PAPR) is provided for their use during the case. Following the presumed production of aerosols during endotracheal intubation, we observe a 15- minute waiting period to allow for adequate room ventilation and air turnover as an institutional policy.[15] During this time, anesthesia can finalize their line placement and patient monitoring devices, a Foley catheter may be placed, and the head of bed turned 90 degrees with the right side facing out. The right arm is padded and tucked to the patient's side with a bed sheet. A head clamp is applied to the patient's head, which is then rigidly fixed to the bed. A closed system suction device with a HEPA filter is used along with active smoke evacuation to avoid further environmental contamination. A flexible suction catheter can be placed in the nasopharynx for additional passive smoke evacuation.

Drilling and the use of cautery in the nasopharynx have been demonstrated to produce aerosols in the 1-10 micron range.[16] All aforementioned measures as well as bimanual technique with surgeon-guided Frazier suction is utilized. We do not use a camera holder, though this could be considered to minimize the necessary surgical personnel entering the room such as neurosurgical or otolaryngology residents. We believe that dynamic endoscopic visualization provided by a trained assistant holding the camera contributes to superior patient safety and operational efficiency, outweighing the risk of the additional surgeon's presence. If only one surgeon is available, a self-suctioning ultrasonic aspirator is utilized for removal of sphenoid sinus septations and other bony obstacles. Tumor resection techniques have not been altered, nor have our reconstructions.

Postoperatively, special precautions must be taken for patients who are required to undergo investigation for SARS-CoV-2 infection. As is well-recognized, there can be disastrous complications with introduction of foreign bodies into the nasopharynx after transsphenoidal surgery.[17] In observance of this, we are promoting the use of oropharyngeal swabs in our patients. Due to their slightly lower sensitivity, we are requesting two consecutive tests be run per patient. Additionally, a chest CT can help identify early infection in this susceptible population.

In aggregate, we have become more selective and more cautious. We respect the risk to the hospital environment poses to the patient, but simultaneously must protect our teams as vital resources.[18],[19] All of this rapidly emerging data is incomplete, but has significant implications for the safe practice of surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Patel ZM, Fernandez-Miranda J, Hwang PH, Nayak JV, Dodd RL, Sajjadi H, et al. In reply: Precautions for endoscopic transnasal skull base surgery during the COVID-19 pandemic. Neurosurgery 2020:nyaa156. Published online 2020. doi: 10.1093/neuros/nyaa156.  Back to cited text no. 5
    
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Arlt W, Baldeweg SE, Pearce SHS, Simpson HL. Endocrinology in the time of COVID- 19: Management of adrenal insufficiency. Eur J Endocrinol 2020;EJE-20-0361. doi: 10.1530/EJE-20-0361. Online ahead of print.  Back to cited text no. 6
    
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Stewart PM, Biller BM, Marelli C, Gunnarsson C, Ryan MP, Johannsson G. Exploring inpatient hospitalizations and morbidity in patients with adrenal insufficiency. J Clin Endocrinol Metab 2016;101:4843-50.  Back to cited text no. 7
    
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Bancos I, Hazeldine J, Chortis V, Hampson P, Taylor AE, Lord JM, et al. Primary adrenal insufficiency is associated with impaired natural killer cell function: A potential link to increased mortality. Eur J Endocrinol 2017;176:471-80.  Back to cited text no. 8
    
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Pivonello R, Auriemma RS, Grasso LF, Pivonello C, Simeoli C, Patalano R, et al. Complications of acromegaly: Cardiovascular, respiratory and metabolic comorbidities. Pituitary 2017;20:46-62.  Back to cited text no. 9
    
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Colao A, Ferone D, Marzullo P, Lombardi G. Systemic complications of acromegaly: Epidemiology, pathogenesis, and management. Endocr Rev 2004;25:102-52.  Back to cited text no. 10
    
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Ye G, Lin H, Chen L, Wang S, Zeng Z, Wang W, et al. Environmental contamination of the SARS-CoV-2 in healthcare premises: An urgent call for protection for healthcare workers. Epub medRxiv 2020.03.11.20034546; doi: https://doi.org/10.1101/2020.03.11.20034546.  Back to cited text no. 14
    
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Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: A systematic review. PLoS One 2012;7:e35797.  Back to cited text no. 15
    
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Workman AD, Welling DB, Carter BS, Curry WT, Holbrook EH, Gray ST, et al. Endonasal instrumentation and aerosolization risk in the era of COVID-19: Simulation, literature review, and proposed mitigation strategies. Int Forum Allergy Rhinol 2020. doi: 10.1002/alr. 22577. Online ahead of print.  Back to cited text no. 16
    
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Hanna AS, Grindle CR, Patel AA, Rosen MR, Evans JJ. Inadvertent insertion of nasogastric tube into the brain stem and spinal cord after endoscopic skull base surgery. Am J Otolaryngol 2012;33:178-80.  Back to cited text no. 17
    
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Sankhla SK, Jayashankar N, Khan GM. Surgical management of selected pituitary macroadenomas using extended endoscopic endonasal transsphenoidal approach: early experience. Neurol India 2013;61:122-30.  Back to cited text no. 18
[PUBMED]  [Full text]  
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Rajaratnam S, Jeyaseelan L, Rajshekhar V. Delayed Hyponatremia Following Surgery for Pituitary Adenomas: An Under-recognized Complication. Neurol India 2020;68:340-5.  Back to cited text no. 19
[PUBMED]  [Full text]  




 

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