Pituitary Surgery During Covid-19
see Precautions for endoscopic transnasal skull base surgery during the COVID-19 pandemic
During the Covid-19 pandemic, every hospital has had to change its internal organization. The nature of the transsphenoidal corridor exposes the pituitary surgery team to an increased risk of virus exposure 1).
It was reported that the aerosolization and mucosal involvement increase the risk of viral transmission during operation. Therefore, transcranial is a safer surgical approach during the COVID-19 pandemic.
Case series
Nine cases of pituitary neuroendocrine tumors have presented with urgent manifestations. The endoscopic endonasal approach was performed in eight patients, while a craniotomy was selected for a recurrent pituitary neuroendocrine tumor. Pre- and postoperative thorough clinical evaluations with chest CT scans were performed. Other strict infection control measures have been applied.
In 8 weeks duration starting from the past days of February 2020, we have operated on four females and five males of pituitary neuroendocrine tumors. Visual deterioration was the main presenting symptom. The driving factor for surgery was saving vision in eight patients. Fortunately, the postoperative course was uneventful for all patients. No suspected COVID-19 infection has been reported in any patient or health-care team except one patient. In our city, PCR test was routinely not available 2).
A retrospective cohort study was conducted of all patients who underwent high-priority endoscopic nasal surgery or anterior skull base surgery between 23rd March and 15th June 2020 at University Hospitals Birmingham NHS Trust.
Twenty-four patients underwent endonasal surgery during the study period, 12 were males and 12 were females. There was no coronavirus-related morbidity in any patient.
This observational study found that it is possible to safely undertake urgent endonasal surgery; the nosocomial risk of coronavirus disease 2019 can be mitigated with appropriate peri-operative precautions 3).
Case reports
A 21-year old male, who required urgent surgery because of progressive visual disturbance due to giant pituitary neuroendocrine tumor. On brain MRI with contrast, it was revealed an extra-axial tumor extending anteriorly over planum sphenoidal with the greatest diameter was 5.34 cm. A transcranial approach was chosen to resect the tumor. Near-total removal of the tumor was achieved without damaging the vital neurovascular structure. The visual acuity was improved and no significant postoperative complication. Pathology examination revealed pituitary neuroendocrine tumor.
Transcranial surgery for pituitary neuroendocrine tumor is still an armamentarium in neurosurgical practice, especially in the COVID-19 pandemic to provide a safer surgical approach 4).
The goal of a paper of Penner et al. is to illustrate the feasibility of pituitary region surgery during the SARS-CoV-2 pandemic.
After two negative COVID tests were obtained, three patients with macro GH-secreting tumors, and two patients with micro ACTH-secreting tumors resistant to medical treatment underwent surgery during the pandemic. During the surgery, every patient was treated as if they were positive.
Neither operator nor patient has developed COVID symptoms. The two neurosurgeons performing the operations underwent two COVID swabs, which resulted in negative.
Pituitary surgery is high-risk non-urgent surgery. However, the method described has so far been effective and is safe for both patients and healthcare providers 5).
The impact of COVID-19 on pituitary surgery. ANZ J Surg. 2020 Apr 25. doi: 10.1111/ans.15959. [Epub ahead of print] PubMed PMID: 32336017 6).
A 47-year-old male COVID-19 positive patient presented to the Emergency Department with a left frontal headache that culminated with diplopia, left eye ptosis, and left visual acuity loss after 5 days. Transsphenoidal hypophysectomy was uneventfully performed, and the patient was discharged from the hospital on postoperative day four. It additionally describes in detail the University of Mississippi Medical Center airway management algorithm for patients infected with the novel coronavirus who need emergent surgical attention 7).
A 72-year-old woman who required urgent endonasal transsphenoidal surgery (eTSS) because of progressive visual field disturbance due to pituitary neuroendocrine tumor, in whom we conducted reverse-transcriptase-polymerase-chain-reaction (RT-PCR) for COVID-19 and chest CT before eTSS. We took care of her by following the rule for suspected infection patient and safely completed her treatment without medical staff infection. Under COVID-19 pandemic state, essentially careful management including RT-PCR test and chest CT should be taken for the high infection risk surgeries to avoid the outbreak through the hospital. And the cost of the RT-PCR test for the patients should be covered by the government budget 8).