Surgery & Radiation
In many cases surgery may be necessary as a treatment. At Henry Ford Hospital, the surgical procedure used to remove a pituitary tumor is usually a transsphenoidal (“through the nose”) microsurgical (under the microscope) approach. For fewer than 5% of patients, transcranial surgery (through the skull, also done under the microscope) will be necessary. The transcranial technique is often needed for patients with very large, unevenly shaped tumors.
Transsphenoidal surgery requires the patient to be under general anesthesia for about 3 hours while the surgeon approaches the tumor through the nasal passage and microscopically removes it. In many instances the entire tumor will be removed. In other cases it will be possible to remove most, but not all, of the tumor. The outcome of the surgical procedure depends on several factors, including the surgeon’s experience and the anatomical features of the tumor (size, shape, location). There is generally only a small amount of bleeding during the procedure and therefore blood transfusions are rarely required. After the tumor has been removed and the incisions closed, nasal packing is left in the nose for approximately 24-48 hours and then removed.
As a result of the tumor removal and manipulation of the normal pituitary gland (which is generally not removed), a condition called diabetes insipidus may result. This is a temporary condition that causes increased loss of water from the body by way of the kidneys. Symptoms include increased thirst and frequent urination which may last from several days to several weeks and is rarely permanent. The symptoms can be controlled with a hormone that is administered as a nasal spray.
Some blood-tinged nasal drainage may occur for the first 2-3 days after removal of the nasal packing and may occasionally occur on and off for the first 2-3 weeks after surgery. A more rare, although sometimes expected, result of surgery is drainage from the nose of a clear, watery liquid called cerebrospinal fluid (CSF), which is a normal fluid that surrounds the brain. Large pituitary tumors lean up against a membrane that separates this fluid space from the nose, and a CSF leak may occur if this membrane is absent or opened during surgery. The surgeon will generally recognize a CSF leak when it occurs and will “repair” the leak by placing a small amount of abdominal fat over the leak. The patient may awake from surgery and find that it was necessary for the surgeon to place a small tube in the lower back to allow CSF to drain into a bag and help the leak to seal. The tube is placed while the patient is still under anesthesia, and it is not painful while in place. The tube (about 3 millimeters in diameter) will remain in the lower back for 3-5 days and the patient will be kept in the hospital during this period. After the tube is removed (a painless, approximately 15-second procedure), the patient usually will be able to leave the hospital later the same day with the leak sealed. In most cases, CSF leakage does not occur and the patient may expect to go home 2 to 4 days after surgery.
Other risks of the transsphenoidal procedure are uncommon and generally involve the lining of the nose. The risk of stroke is less than 1%.
HOSPITAL COURSE FOR THE SURGICAL PATIENT
Preparing for Surgery
After thorough endocrinologic and surgical evaluation followed by the recommendation for surgical treatment, the patient will be seen by the nurse clinician in the outpatient clinic before the scheduled surgical date. The purpose of this visit is to prepare the patient for the surgery, hospitalization, and for recovery at home after being discharged from the hospital.
Patients will be asked to take nothing by mouth (no liquids, no food) starting at midnight the night before the surgery, to allow enough time for the stomach to become empty. In some cases, such as when the patient is taking medications for diabetes or heart problems, the patient will receive special instructions regarding when and how to take their medications.
The time to arrive at the hospital on the day of surgery, where to go and the events to occur are also discussed. Patients usually do not come to the hospital until the morning of the surgery and are admitted to the hospital following the procedure. Patients usually are asked to be at the hospital 2 hours before the scheduled time of surgery. Patients are prepared for surgery in the preoperative area on the surgery floor. Family members wait in the surgical waiting room during the surgery, which is where the doctor will talk to them when the surgery is finished.
Another area of discussion with the nurse clinician will be the amount of assistance the patient will need at home following the surgery. In general, patients will be able to provide for their own personal care, but assistance with some household chores will be recommended due to restrictions on lifting, and to allow time to regain tolerance for activity and normal energy levels. Patients should avoid strenuous activities, and exercise should be limited to walking for the first month after surgery. Driving is permitted when patients feel able, presuming vision is adequate and narcotic pain medications are no longer required. Patients can resume social activities as they feel able.
Returning to work is individualized depending on the patient’s condition and the amount of physical activity required. Patients with less physically active jobs sometimes return to work as early as 2-3 weeks after surgery. Those whose jobs require more physical activity may not return to work for 4-8 weeks after surgery, while those whose endocrine status has not stabilized or whose vision is affected may require a longer time.
In addition to meeting with the nurse clinician, the patient may need certain tests to be done before the surgery, such as blood tests, a chest x-ray and an electrocardiogram (EKG).
The Day of Surgery
On the day of surgery when patients arrive at the preoperative area, they change into a hospital gown, have an intravenous (IV) line started, and receive medications such as sedatives to promote relaxation and other medications to prepare for surgery. Although sleepy or groggy, most patients are still awake when they are taken to the operating room.
In the operating room the patient is given IV medication that puts them to sleep. When they are completely asleep, the anesthesiologist places a tube (endotracheal tube) through the mouth into the trachea (breathing tube) so that oxygen and anesthetics can be given during the surgery. This tube is removed when the surgery is finished, before the patient is awake. Sometimes there is a slight scratchy or sore feeling in the throat for a few days related to the use of the endotracheal tube. This usually goes away on its own and requires no treatment.
In addition, a tube called a foley catheter will be placed into the patient’s bladder; this tube drains the patient’s urine into a bag connected to the catheter. The catheter will remain in place at least for the first night after surgery or possibly for a few days if diabetes insipidus (DI) occurs. The catheter allows the doctors and nurses to accurately monitor the amount of urine produced so that DI can be diagnosed and treated. Removal of the tube takes only a few seconds and causes only minor, if any, discomfort. After the tube is removed, the patient resumes passing urine normally. If it is still necessary to monitor the urine output, patients will be instructed to collect their urine each time they void in containers provided.
After the surgical procedure the patient will stay in the recovery room for 1 to 3 hours. After recovering from the anesthesia sufficiently, the patient is transferred to the neurosurgical general practice unit in the hospital.
The nurses on the neurosurgical general practice unit at Henry Ford Hospital know how to detect the significant neurologic and physiologic features of the pituitary patient’s status. It is important for patients to cooperate with the nurses as they do their assessments and provide the required care. Nurses will be especially concerned with any changes in vision, the amounts of fluids taken and the urine produced, and the presence of clear, watery drainage from the nose. Patients will be asked to help keep accurate accounts of the amounts of fluids taken and the amounts of urine voided.
Activity begins as soon as possible after surgery once the patient has recovered from the anesthesia. First the patient will sit in a chair, then walk in the room and then in the hallway. This type of activity helps to prevent complications such as pneumonia and blood clots in the legs. The patient will be given a device called an incentive spirometer which is used to help clear the lungs and prevent pneumonia. The nurse will teach the patient how to use this device and encourage its use each hour that the patient is awake. During the operation and until the patient is up out of bed, the patient’s legs will be wrapped in sequential compression boots to lower the risk of blood clots developing in the legs. Attached to a machine, the boots periodically fill with air which compresses the legs enough to improve blood circulation. The boots are removed once physical activity can be increased.
If a spinal drain is left in place after the surgery to prevent a CSF leak, the patient may be required to stay in bed and not sit up higher than at a 30 degree angle. Once the drain is removed the patient will be allowed out of bed.
During the time that the nasal packing is in place, the patient will not be able to breathe through the nose and will have to breathe through the mouth instead. As a result, dryness of the mouth and throat may occur. Drinking liquids and using throat lozenges can help, but if the discomfort persists humidified air can be given by a face mask to help relieve this problem. The nasal packing stays in place for 24-48 hours and is removed at the bedside by the doctor or nurse clinician. It takes only a moment and causes brief minor discomfort. Once the packs are out, there may be a minute or two of bloody drainage from the nose or in the back of the throat. Once this has drained there will be only small amounts of drainage. To help the patient contain any drainage, a dressing (called a snuffer dressing) may be taped over the front of the nose. This dressing is only used until the patient is able to handle any secretions with a tissue as needed. However, the patient must not try to blow his/her nose during the first few weeks following the surgery to allow the surgical site time to heal.
Patients may begin drinking liquids once they have recovered from the anesthesia. Once liquids are tolerated, patients may eat a regular diet. Because of the incision under the upper lip inside the mouth, patients may find this area somewhat sore and may wish to eat softer types of food for a few days. Those who wear dentures may choose not to wear them until the lip area has had time to heal. This incision is closed with sutures that dissolve as the wound heals. Therefore, the sutures do not have to be removed by the doctor. Also, most patients experience some headache or discomfort during the days after surgery. Although medication such as Tylenol with codeine or Darvocet will be prescribed, many patients find that by the time they go home from the hospital regular Tylenol will alleviate their symptoms.
Before the patient is discharged from the hospital, the nurse will review important issues that the patient and family need to be aware of, such as the symptoms of DI (increased thirst and urine output). It is important for patients to realize that they should drink fluids as they feel thirsty. Reducing the amount of fluids will not prevent or control DI and may contribute to dehydration. Patients should drink water and fruit and vegetable juices to help maintain the body’s normal electrolyte levels. Patients may be asked to monitor their urine output at home for a few days after hospital discharge. Arrangements are made to report this information to the nurse clinician by telephone, allowing medication to be ordered or adjusted as needed to treat DI. Patients will be taught how to take the medication for DI before they leave the hospital. Called DDAVP, the medication is a synthetic hormone replacement given in the form of a nasal spray. Pituitary patients with DI usually only need to take one spray in one nostril one time each day. This condition is usually temporary and the medication is stopped when it is no longer needed.
Patients are also taught to watch for the signs of a CSF leak (clear, watery drainage from the nose, a salty taste in the mouth, or a feeling of fluid draining in the back of the throat). If there is a question of a CSF leak, the patient should call and report this to the doctor or nurse clinician as this condition could lead to an infection around the brain (called meningitis) if left untreated.
Patients need to restrict their activity by avoiding any heavy lifting (no more than 10-15 pounds) for one month after surgery. They should not blow their nose and should sneeze through their mouth instead of through their nose. They should avoid straining or the Valsalva maneuver (internal pressure that occurs with expiratory effort against a closed mouth and nose). Patients will be instructed to use a saline nasal spray two to three times a day to keep the nasal surface moist and to decrease crusting of the secretions and drainage. Patients should not pick at any crusting that might develop.
Many patients will be placed on a steroid medication called Prednisone to replace the cortisol usually produced in the adrenal gland but possibly deficient after surgery. It is important for patients to continue this medication until their doctor tapers them off of it. Suddenly stopping the medication can cause symptoms of nausea, headache, a general aching feeling or flu-like symptoms, and fatigue. Gradually reducing the amount of this medication usually avoids these symptoms. However, patients should call the doctor if they experience any such symptoms as they reduce the amounts of Prednisone taken so that the tapering schedule can be adjusted.
Before leaving the hospital patients will be told when to see their doctors for a followup appointment. Generally, they will see the endocrinologist in 1-2 weeks, the otolaryngologist in 1 week, and the neurosurgeon 6 weeks after the surgery.
Radiation therapy is usually considered for patients who require treatment but for whom surgery is too risky, for patients whose medications are not useful, or for those patients whose tumors have grown back after surgery and for whom further surgery is not felt to be appropriate.
Two standard types of radiation therapy are considered: standard radiation therapy and stereotactic radiosurgery. Radiosurgery is a special way to deliver radiation; it is not a surgical procedure. Although no form of therapy can guarantee that a tumor will disappear or shrink, radiation therapy may help to stop the tumor from growing any larger and in certain cases may actually shrink or dissolve the tumor. Standard radiation therapy is the most commonly offered form, but radiosurgery has been used more often in recent years.
Even if initial treatment with drug therapy and/or surgery results in persistent hormonal over-secretion and/or tumor, radiation therapy may not be immediately recommended. If over-secretion of hormones persists, further medication trials may be considered before radiation therapy is recommended. If the tumor mass persists, the surgeon will recommend observation for 3 months and then use MRI to verify the final result of surgery. If the tumor has shrunken significantly after 3 months, the surgeon may recommend observation for the next 6-12 months and may recommend radiation therapy only if the tumor continues to grow. These decisions require careful explanation by the physician and understanding by the patient.
Endoscopic Transsphenoidal Pituitary Surgery after clicking on this link you will leave the PDES website and will have to use the Back arrow to return. This site contains acual photos of this type of surgery.