Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Acta Neurochirurgica
Published in: Acta Neurochirurgica 10/2012

01-10-2012 | Clinical Article

Transphenoidal surgery without steroid replacement in patients with morning serum cortisol below 9 μg/dl (250 Nmol/l)

Authors: Claudio De Tommasi, Jeannette Goguen, Michael D. Cusimano

Published in: Acta Neurochirurgica | Issue 10/2012

Login to get access

Abstract

Background

Adrenal insufficiency is a feared complication in patients undergoing transphenoidal surgery (TSS). Using the insulin tolerance test (ITT) for the preoperative assessment of hypothalamic-pituitary-adrenal (HPA) status is less than ideal, and the morning serum cortisol (MSC) is often used as a proxy for ITT. However, neither the ITT nor the MSC level has been validated to indicate HPA sufficiency compared to a physiological gold standard such as patients’ ability to withstand transphenoidal surgery.

Objective

To evaluate the intraoperative and postoperative course of nine patients with non-ACTH-secreting pituitary adenomas who did not receive intraoperative cortisol replacement despite having a preoperative MSC below 9 μg/dl (250 nmol/l) and to compare this with a set of patients with a preoperative MSC greater than 14.5 μg/dl (400 nmol/l) and another set of patients with MSC below 9 μg/dl (250 nmol/l) who received intraoperative cortisol administration.

Methods

Preoperative and day 1 and day 2 postoperative MSC, intraoperative anesthetic record, vital signs, fluid balance, medications, and complications were recorded.

Results

None of the patients experienced the full syndrome of adrenal insufficiency. One patient with a preoperative MSC <9 μg/dl (250 mol/l) had isolated postoperative fatigue and required cortisol replacement. No patient suffered any life-threatening complications. There were no differences among the three groups in their intraoperative or postoperative courses when compared for intraoperative hypotension, acute blood pressure drop, and administration of vasopressors.

Conclusion

This study suggests that TSS can be performed safely in patients with preoperative MSC less than 9 μg/dl (250 nmol/l) in closely monitored settings without intraoperative cortisol administration. Further studies are warranted.
Literature
1.
Fraser CG, Preuss FS, Bigford WD (1952) Adrenal atrophy and irreversible shock associated with cortisone therapy. J Am Med Assoc 149:1542–1543PubMedCrossRef
2.
Lewis L, Robinson RF, Yee J, Hacker LA, Eisen G (1953) Fatal adrenal cortical insufficiency precipitated by surgery during prolonged continuous cortisone treatment. Ann Intern Med 39:116–126PubMed
3.
Auchus RJ, Shewbridge RK, Shepherd MD (1997) Which patients benefit from provocative adrenal testing after transsphenoidal pituitary surgery? Clin Endocrinol (Oxf) 46:21–27CrossRef
4.
Marko NF, Gonugunta VA, Hamrahian AH, Usmani A, Mayberg MR, Weil RJ (2009) Use of morning serum cortisol level after transsphenoidal resection of pituitary adenoma to predict the need for long-term glucocorticoid supplementation. J Neurosurg 111:540–544PubMedCrossRef
5.
Rajasekaran S, Vanderpump M, Baldeweg S, Drake W, Reddy N, Lanyon M, Markey A, Plant G, Powell M, Sinha S, Wass J (2011) UK guidelines for the management of pituitary apoplexy. Clin Endocrinol 74:9–20CrossRef
6.
Salem M, Tainsh RE Jr, Bromberg J, Loriaux DL, Chernow B (1994) Perioperative glucocorticoid coverage. A reassessment 42 years after emergence of a problem. Ann Surg 219:416–425PubMedCrossRef
7.
Fish HR, Chernow B, O’Brian JT (1986) Endocrine and neurophysiologic responses of the pituitary to insulin-induced hypoglycemia: a review. Metabolism 35:763–780PubMedCrossRef
8.
Karaca Z, Tanriverdi F, Atmaca H, Gokce C, Elbuken G, Selcuklu A, Unluhizarci K, Kelestimur F (2010) 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 163:377–382
9.
Plumpton FS, Besser GM (1969) The adrenocortical response to surgery and insulin-induced hypoglycaemia in corticosteroid-treated and normal subjects. Br J Surg 56:216–219PubMedCrossRef
10.
Pfeifer M, Kanc K, Verhovec R, Kocijancic A (2001) Reproducibility of the insulin tolerance test (ITT) for assessment of growth hormone and cortisol secretion in normal and hypopituitary adult men. Clin Endocrinol (Oxf) 54:17–22CrossRef
11.
Bhansali A, Dutta P, Bhat MH, Mukherjee KK, Rajput R, Bhadada S (2008) Rational use of glucocorticoid during pituitary surgery–a pilot study. Indian J Med Res 128:294–299PubMed
12.
Hagg E, Asplund K, Lithner F (1987) Value of basal plasma cortisol assays in the assessment of pituitary-adrenal insufficiency. Clin Endocrinol (Oxf) 26:221–226CrossRef
13.
Jayasena CN, Gadhvi KA, Gohel B, Martin NM, Mendoza N, Meeran K, Dhillo WS (2009) Day 5 morning serum cortisol predicts hypothalamic-pituitary-adrenal function after transsphenoidal surgery for pituitary tumors. Clin Chem 55:972–977PubMedCrossRef
14.
Abdu TA, Elhadd TA, Neary R, Clayton RN (1999) Comparison of the low dose short synacthen test (1 microg), the conventional dose short synacthen test (250 microg), and the insulin tolerance test for assessment of the hypothalamo-pituitary-adrenal axis in patients with pituitary disease. J Clin Endocrinol Metab 84:838–843PubMedCrossRef
15.
Cozzi R, Lasio G, Cardia A, Felisati G, Montini M, Attanasio R (2009) Perioperative cortisol can predict hypothalamus-pituitary-adrenal status in clinically non-functioning pituitary adenomas. J Endocrinol Invest 32:460–464PubMed
16.
Avgerinos PC, Schurmeyer TH, Gold PW, Tomai TP, Loriaux DL, Sherins RJ, Cutler GB Jr, Chrousos GP (1986) Pulsatile administration of human corticotropin-releasing hormone in patients with secondary adrenal insufficiency: restoration of the normal cortisol secretory pattern. J Clin Endocrinol Metab 62:816–821PubMedCrossRef
17.
Kehlet (1976) Clinical course and hypothalamic-pituitary-adreno-cortical function in glucocorticoid-treated surgical patients. FADL’s Forlag, Copenhagen
18.
Masala A, Satta G, Alagna S, Anania V, Frassetto GA, Rovasio PP, Semiani A (1985) Effect of clonidine on stress-induced cortisol release in man during surgery. Pharmacol Res Commun 17:293–298PubMedCrossRef
19.
Reincke M, Allolio B, Wurth G, Winkelmann W (1993) The hypothalamic-pituitary-adrenal axis in critical illness: response to dexamethasone and corticotropin-releasing hormone. J Clin Endocrinol Metab 77:151–156PubMedCrossRef
20.
Schlaghecke R, Kornely E, Santen RT, Ridderskamp P (1992) The effect of long-term glucocorticoid therapy on pituitary-adrenal responses to exogenous corticotropin-releasing hormone. N Engl J Med 326:226–230PubMedCrossRef
21.
Wand GS, Ney RL (1985) Disorders of the hypothalamic-pituitary-adrenal axis. Clin Endocrinol Metab 14:33–53PubMedCrossRef
22.
Mathes DD, Assimos DG, Donofrio PD (1996) Rhabdomyolysis and myonecrosis in a patient in the lateral decubitus position. Anesthesiology 84:727–729PubMedCrossRef
23.
Chernow B, Alexander HR, Smallridge RC, Thompson WR, Cook D, Beardsley D, Fink MP, Lake CR, Fletcher JR (1987) Hormonal responses to graded surgical stress. Arch Intern Med 147:1273–1278PubMedCrossRef
24.
Carey LC, Lowery BD, Cloutier CT (1970) Blood sugar and insulin response of humans in shock. Ann Surg 172:342–350PubMedCrossRef
25.
Nieman LK (2009) ACTH and cortisol secretion in health and disease.
26.
Carey LC, Cloutier CT, Lowery BD (1971) Growth hormone and adrenal cortical response to shock and trauma in the human. Ann Surg 174:451–460PubMedCrossRef
27.
Meguid MM, Brennan MF, Aoki TT, Muller WA, Ball MR, Moore FD (1974) Hormone-substrate interrelationships following trauma. Arch Surg 109:776–783PubMedCrossRef
28.
Udelsman R, Goldstein DS, Loriaux DL, Chrousos GP (1987) Catecholamine-glucocorticoid interactions during surgical stress. J Surg Res 43:539–545PubMedCrossRef
29.
Udelsman R, Ramp J, Gallucci WT, Gordon A, Lipford E, Norton JA, Loriaux DL, Chrousos GP (1986) Adaptation during surgical stress. A reevaluation of the role of glucocorticoids. J Clin Invest 77:1377–1381PubMedCrossRef
30.
Aizawa T, Yasuda N, Greer MA (1981) Hypoglycemia stimulates ACTH secretion through a direct effect on the basal hypothalamus. Metabolism 30:996–1000PubMedCrossRef
31.
Udelsman R, Norton JA, Jelenich SE, Goldstein DS, Linehan WM, Loriaux DL, Chrousos GP (1987) Responses of the hypothalamic-pituitary-adrenal and renin-angiotensin axes and the sympathetic system during controlled surgical and anesthetic stress. J Clin Endocrinol Metab 64:986–994PubMedCrossRef
32.
Alford WC Jr, Meador CK, Mihalevich J, Burrus GR, Glassford DM Jr, Stoney SW, Thomas CS Jr (1979) Acute adrenal insufficiency following cardiac surgical procedures. J Thorac Cardiovasc Surg 78:489–493PubMed
33.
Mohler JL, Michael KA, Freedman AM, McRoberts JW, Griffen WO Jr (1985) The evaluation of postoperative function of the adrenal gland. Surg Gynecol Obstet 161:551–556PubMed
34.
Christy NP (1992) Pituitary-adrenal function during corticosteroid therapy. Learning to live with uncertainty. N Engl J Med 326:266–267PubMedCrossRef
35.
Glowniak JV, Loriaux DL (1997) A double-blind study of perioperative steroid requirements in secondary adrenal insufficiency. Surgery 121:123–129PubMedCrossRef
36.
Fraser RAF, Smith PH (1941) The value of the glucose tolerance test, the insulin tolerance test, and the glucose-insulin tolerance test in the diagnosis of endocrinologic disorders of glucose metabolism. J Clin Endocrinol Metab 1:297–306CrossRef
37.
Schaffranietz L, Wolfel H, Fritz H, Rudolph C (2003) Is the combination of remifentanil and propopfol suitable for transsphenoid resection of the hypophysis? Anaesthesiol Reanim 28:45–49PubMed
38.
Liddle GW (1981) The adrenals. In: Williams RH (ed). Textbook of Endocrinology, 6th ed. W.B. Saunders & Co. Philadelphia, pp 249–292
39.
Kehlet H (1975) A rational approach to dosage and preparation of parenteral glucocorticoid substitution therapy during surgical procedures. A short review. Acta Anaesthesiol Scand 19:260–264PubMedCrossRef
Metadata
Title
Transphenoidal surgery without steroid replacement in patients with morning serum cortisol below 9 μg/dl (250 Nmol/l)
Authors
Claudio De Tommasi
Jeannette Goguen
Michael D. Cusimano
Publication date
01-10-2012
Publisher
Springer Vienna
Published in
Acta Neurochirurgica / Issue 10/2012
Print ISSN: 0001-6268
Electronic ISSN: 0942-0940
DOI
https://doi.org/10.1007/s00701-012-1474-2

Other articles of this Issue 10/2012

Acta Neurochirurgica 10/2012 Go to the issue

Clinical Article

Endovascular treatment for saccular aneurysms of the proximal (M1) segment of the middle cerebral artery

Technical Note

Transvertebral anterior key hole foraminotomy without fusion for the cervicothoracic junction

Clinical Article

Quality of life in nonfunctioning pituitary macroadenoma patients before and after surgical treatment

Book Review

Pickard J, Akalan N, Benes V: Advances and technical standards in neurosurgery

Letter to the editor

Allergy to implants in lumbar screw fixation mimics postsurgical wound infection

Clinical Article

Morphometric comparison of foramen magnum in non-syndromic craniosynostosis patients with or without Chiari I malformation