Is peri-operative steroid replacement therapy necessary for the pituitary adenomas treated with surgery? A systematic review and meta analysis

Mamatemin Tohti, Junyang Li, Yuan Zhou, Yuebing Hu, Zhuang Yu, Chiyuan Ma, Mamatemin Tohti, Junyang Li, Yuan Zhou, Yuebing Hu, Zhuang Yu, Chiyuan Ma

Abstract

Background: Patients with pituitary adenomas usually receive "stress dose" steroids in the peri-operative peroids. Though randomized controlled trials(RCT) have not been performed to assess the necessity of steroid coverage, there are several studies that explained the changes of adrenal function during peri-operative peroids. The aim of the present study is to investigate whether it is necessary to employ conventional peri-operative glucocorticoid replacement therapy to all the patients undergoing surgery.

Methods: We searched studies addressing peri-operative steroids coverage for pituitary adenomas in the Web of Science, Medline and the Cochrane Library. Then we extracted studies about peri-operative morning serum cortisol(MSC) levels, morbidity of early postoperative adrenal insufficiency, postoperative diabetes insipidus, relationships between MSC levels and adrenal integrity. We used RevMan Software to combine the results for meta-analysis. We used fixed-effects models for there was no significant heterogeneity existed.

Findings: There are 18 studies from 11 countries published between 1987 and 2013 including 1224 patients. The postoperative serum cortisol levels were significantly increased compared with the preoperative one in hypothalamic-pituitary-adrenal axis(HPAA) functions preserved patients(P<0.00001). The morbidity of early postoperative adrenal insufficiency ranged from 0.96% to 12.90%, with the overall morbidity of 5.55%(41/739). There was no significant differences of early postoperative diabetes insipidus between no supplementation patients and in supplementation patients(P=0.82). Conversely, there may be some disadvantages of high levels of cortisols such as high incidence of osteopenia and bone derangement and even the increased mortality rate. The patients with MSC levels of less than 60 nmol/l at 3 days after operation is considered as adrenal insufficient and more than 270 nmol/l as adrenal sufficient. To patients with MSC levels of 60-270 nmol/l, we need more clinical data to establish further cortisol supplementation criteria.

Conflict of interest statement

Competing Interests: There're no conflicts of interest. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

References

    1. Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery. 1997;40(2):225–236; discussion 236–227.
    1. Salem M, Tainsh RE, Bromberg J, Loriaux DL, Chernow B. PERIOPERATIVE GLUCOCORTICOID COVERAGE—A REASSESSMENT 42 YEARS AFTER EMERGENCE OF A PROBLEM. Ann Surg. 1994;219(4):416–425.
    1. Inder WJ, Hunt PJ. Glucocorticoid replacement in pituitary surgery: guidelines for perioperative assessment and management. J Clin Endocrinol Metab. 2002;87(6):2745–2750.
    1. Hout WM, Arafah BM, Salazar R, Selman W. Evaluation of the hypothalamic-pituitary-adrenal axis immediately after pituitary adenomectomy: is perioperative steroid therapy necessary? J Clin Endocrinol Metab. 1988;66(6):1208–1212.
    1. Garcia-Luna PP, Leal-Cerro A, Rocha JL, Trujillo F, Garcia-Pesquera F, Astorga R. Evaluation of the pituitary-adrenal axis before, during and after pituitary adenomectomy. Is perioperative glucocorticoid therapy necessary? Acta Endocrinol (Copenh). 1990;122(1):83–88.
    1. Auchus RJ, Shewbridge RK, Shepherd MD. Which patients benefit from provocative adrenal testing after transsphenoidal pituitary surgery? Clin Endocrinol (Oxf). 1997;46(1):21–27.
    1. Courtney CH, McAllister AS, McCance DR, Bell PM, Hadden DR, Leslie H, et al. Comparison of one week 0900 h serum cortisol, low and standard dose synacthen tests with a 4 to 6 week insulin hypoglycaemia test after pituitary surgery in assessing HPA axis. Clinical endocrinology. 2000;53(4):431–436.
    1. Cozzi R, Lasio G, Cardia A, Felisati G, Montini M, Attanasio R. Perioperative cortisol can predict hypothalamus-pituitary-adrenal status in clinically non-functioning pituitary adenomas. J Endocrinol Invest. 2009;32(5):460–464. 10.3275/6237
    1. De Tommasi C, Goguen J, Cusimano MD. Transphenoidal surgery without steroid replacement in patients with morning serum cortisol below 9 mug/dl (250 Nmol/l). Acta neurochirurgica. 2012;154(10):1903–1915. 10.1007/s00701-012-1474-2
    1. Hagg E, Asplund K, Lithner F. Value of basal plasma cortisol assays in the assessment of pituitary-adrenal insufficiency. Clinical endocrinology. 1987;26(2):221–226.
    1. Jayasena CN, Gadhvi KA, Gohel B, Martin NM, Mendoza N, Meeran K, et al. Day 5 morning serum cortisol predicts hypothalamic-pituitary-adrenal function after transsphenoidal surgery for pituitary tumors. Clin Chem. 2009;55(5):972–977. 10.1373/clinchem.2008.117374
    1. Karaca Z, Tanriverdi F, Atmaca H, Gokce C, Elbuken G, Selcuklu A, et al. Can basal cortisol measurement be an alternative to the insulin tolerance test in the assessment of the hypothalamic-pituitary-adrenal axis before and after pituitary surgery? Eur J Endocrinol. 2010;163(3):377–382. 10.1530/EJE-10-0229
    1. Klose M, Lange M, Kosteljanetz M, Poulsgaard L, Feldt-Rasmussen U. Adrenocortical insufficiency after pituitary surgery: an audit of the reliability of the conventional short synacthen test. Clinical endocrinology. 2005;63(5):499–505.
    1. Kristof RA, Wichers M, Haun D, Redel L, Klingmüller D, Schramm J. Peri-operative glucocorticoid replacement therapy in transsphenoidal pituitary adenoma surgery: a prospective controlled study. Acta neurochirurgica [Internet]. 2008; 150(4):[329–335; discussion 335 pp.]. 10.1007/s00701-008-1517-x
    1. Marko NF, Gonugunta VA, Hamrahian AH, Usmani A, Mayberg MR, Weil RJ. Use of morning serum cortisol level after transsphenoidal resection of pituitary adenoma to predict the need for long-term glucocorticoid supplementation. Journal of neurosurgery. 2009;111(3):540–544. 10.3171/2008.12.JNS081265
    1. Marko NF, Hamrahian AH, Weil RJ. Immediate postoperative cortisol levels accurately predict postoperative hypothalamic-pituitary-adrenal axis function after transsphenoidal surgery for pituitary tumors. Pituitary. 2010;13(3):249–255. 10.1007/s11102-010-0227-6
    1. 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 neurosurgery. 2013;80(5):569–575. 10.1016/j.wneu.2012.07.034
    1. Page RCL, Ahlquist JAO, Adams CBT, Burke CW. Is routine steroid administration required for pituitary surgery? J Endocrinol. 1994;140(SUPPL.):P167–ABSTRACT P167.
    1. Rajaratnam S, Seshadri MS, Chandy MJ, Rajshekhar V. Hydrocortisone dose and postoperative diabetes insipidus in patients undergoing transsphenoidal pituitary surgery: a prospective randomized controlled study. British journal of neurosurgery [Internet]. 2003; 17(5):[437–442 pp.].
    1. Regan J, Watson J. Selective use of peri-operative steroids in pituitary tumor surgery: escape from dogma. Front Endocrinol (Lausanne). 2013;4:30 10.3389/fendo.2013.00030
    1. Wentworth JM, Gao N, Sumithran KP, Maartens NF, Kaye AH, Colman PG, et al. Prospective evaluation of a protocol for reduced glucocorticoid replacement in transsphenoidal pituitary adenomectomy: prophylactic glucocorticoid replacement is seldom necessary. Clin Endocrinol (Oxf). 2008;68(1):29–35.
    1. Aubry RH, Nankin HR, Moses AM, Streeten DH. Measurement of the osmotic threshold for vasopressin release in human subjects, and its modification by cortisol. The Journal of clinical endocrinology and metabolism. 1965;25(11):1481–1492.
    1. Udelsman R, Ramp J, Gallucci WT, Gordon A, Lipford E, Norton JA, et al. Adaptation during surgical stress. A reevaluation of the role of glucocorticoids. The Journal of clinical investigation. 1986;77(4):1377–1381.
    1. Okinaga H, Matsuno A, Okazaki R. High risk of osteopenia and bone derangement in postsurgical patients with craniopharyngiomas, pituitary adenomas and other parasellar lesions. Endocr J. 2005;52(6):751–756.
    1. Peacey SR, Guo CY, Robinson AM, Price A, Giles MA, Eastell R, et al. Glucocorticoid replacement therapy: are patients over treated and does it matter? Clin Endocrinol (Oxf). 1997;46(3):255–261.
    1. Zueger T, Kirchner P, Herren C, Fischli S, Zwahlen M, Christ E, et al. Glucocorticoid replacement and mortality in patients with nonfunctioning pituitary adenoma. J Clin Endocrinol Metab. 2012;97(10):E1938–1942. 10.1210/jc.2012-2432
    1. Filipsson H, Monson JP, Koltowska-Haggstrom M, Mattsson A, Johannsson G. The impact of glucocorticoid replacement regimens on metabolic outcome and comorbidity in hypopituitary patients. J Clin Endocrinol Metab. 2006;91(10):3954–3961.
    1. Li Voon Chong JS, Sen J, Johnson Z, Kyle G, MacFarlane IA. Hydrocortisone replacement dosage influences intraocular pressure in patients with primary and secondary hypocortisolism. Clinical endocrinology. 2001;54(2):267–271.
    1. Watts NB, Tindall GT. Rapid assessment of corticotropin reserve after pituitary surgery. JAMA. 1988;259(5):708–711.
    1. Courtney CH, McAllister AS, McCance DR, Hadden DR, Leslie H, Sheridan B, et al. The insulin hypoglycaemia and overnight metyrapone tests in the assessment of the hypothalamic-pituitary-adrenal axis following pituitary surgery. Clinical endocrinology. 2000;53(3):309–312.

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel