Hypophysectomy

Surgical treatment of Pituitary Adenomas via the Trans-sphenoidal Route:

The following information is for patients undergoing surgery for pituitary adenoma by the Trans-sphenoidal Route.

You will be seen and your pituitary functions will be assessed by the endocrine team. You will have undergone an MRI scan of the pituitary gland. You will be seen by the neurosurgeon in the outpatient clinic or the hospital ward to assess whether this kind of surgery is suitable for you. The neurosurgeon will discuss with you the options of treatment, the benefits and potential risks of each option available to you.

You will come in the day before surgery and meet the junior doctors and nurses who will be looking after you. You will have blood tests, chest X-ray or Electrocardiogram to assess your fitness for anaesthetic. One of the staff will attach 4-5 stick on buttons on your forehead and mark them before you go for a special MRI scan. These buttons and scan will help the neurosurgeon to accurately remove the adenoma using sophisticated navigation computers (Please leave the buttons attached and the marks in place, do not rub the mark and do not reattach a button if it has fallen off, the buttons will be removed during the operation). You will be visited by the anaesthetist (the doctor who will put you to sleep for the operation). You will also be visited by the operating theatre nursing staff to discuss with you your journey in theatre and answer any questions you may have. You need to be fasted (nothing to eat or drink) from midnight before the day of surgery. It is also advisable to practice breathing through your mouth as your nose will be packed after the surgery. (if you have any difficulty breathing through your mouth you should inform the nurse in charge).

If your pituitary gland is hyperactive and you are on medicines to reduce the effect of the hyperactivity (e.g. Bromocriptine, metyrapone, etc) you should continue these medicines. Similarly if you pituitary gland is underactive and you are receiving hormone replacement (e.g. hydrocortisone, thyroxine) you should continue these medicines.

You will be given hydrocortisone 100 mg four times a day just before the surgery and it will be continued for few days after surgery as your body needs this hormone and your gland may not be able to produce it sufficiently.

Some medicines increase the risk of bleeding during the operation and need to be stopped, these medicines are called Non-steroidal anti-inflammatory medicines (NSAID for short), e.g. Asprin need to be stopped for at least 10 days before surgery, similarly Ibuprofen, indomethacin & voltral group of medicines need to be discontinued for few days before surgery (You may use paracetamol [Panadol] or dihydrocodeine or Tramadol (Zydol) for pain instead).

The operation is called trans-sphenoidal pituitary hypophysectomy. You will have a general anaesthetic. The operation is done through the right nostril by making an incision at the junction of the skin and the nasal mucosa. This allows the surgeon to reach the sphenoid sinus which separates the nose from the pituitary fossa where the adenoma lies. The surgeon will be using a combination of minimally invasive equipment (key-hole surgery) such as the surgical microscope navigator and the neuro-endoscopes. The neurosurgeon will remove the adenoma or part/whole of the pituitary gland. At the end of the operation the neurosurgeon will make a decision about the need to insert a fat graft to stop fluid leakage (one of the potential complications of trans-sphenoidal surgery). Fat grafs can be obtained from either the abdominal wall (through a small incision just below and to the right of the umbilicus) or from the outer side of the right thigh.

The operation takes about 1-2 hours, following which you will stay in the recovery area for about 2 hours before returning to the neurosurgical ward. When you wake up, you notice the following:

- Your nose will be packed to stop bleeding and you have to breath through your mouth.
- You may feel the site of incision in your abdominal wall or thigh if a graft was necessary.
- You will have a drip attached to your hand and foot and other lines to monitor your heart and breathing.
- You will have a urinary catheter to monitor your fluid output.
- You will have an oxygen mask to give you Oxygen.

Once you are in the ward, you will be allowed to eat and drink the same night, once you have recovered from the anaesthesia. If your fluid intake and output are in balance, the following morning the drip and urinary catheter will be taken down. You still need to let the nurses know the amount of fluid you drink and the amount of urine you pass for few days. Your blood will be tested the day following surgery. The nasal pack stays for about 4 days. Once the nasal pack is removed you will feel moist coming through your nose (blood stained mucus is common). If all well you will be discharged home the following day. There are no sutures to be removed. The sutures in the nose are absorbable and the graft site usually glued together. Do not blow your nose or insert anything in the nose.

Before you leave the neurosurgical ward, arrangement will be made for you to be reviewed in the neurosurgical outpatient clinic in 8 weeks and the endocrine department for pituitary function tests. After the first visit the endocrine team and the neurosurgeon will review you regularly usually at 3 or 6 monthly intervals initially.
You may need radiotherapy if you condition requires it.
You may need follow up in the eye department to chart you visual fields.
You may need further MRI scans to assess the pituitary gland.
Your outpatient visits to Ninewells hospital can be coordinated so that you can see the endocrinologist and the neurosurgeon on the same day.

There are potential risks for every thing we do including operations, these include;

- Hypopituitarism: following surgery if the pituitary gland has normal activity it may become under active and you need hormone replacement therapy. Diabetes insipidus (DI) (excessive thirst and excessive urine) is not uncommon in the first few days following surgery. The vast majority will settle but a small number will need hormone replacement (DDAVP).

- CSF leakage: fluid leakage from the nose can occur in 3.5% following this surgery. If it happens during surgery the surgeon will repair at the spot. If it occurs after the nasal pack is removed, it may require diversion of the CSF away from the site of surgery or repair.

- Infection: which can include infection of the pituitary gland forming an abscess or meningitis. The risk is very small and the vast majority are treatable by antibiotics. You will be given antibiotics during surgery and till the nasal pack is removed.

- Bleeding: rarely nasal bleeding can occur or bleeding in the cavity of the adenoma. If the latter occurs it may lead to deterioration of vision as the visual nerves are very close bye.

- Nasal septal perforation may occur: uncommon.

- Visual impairment: very rare.

DVLA recommend that provided there is no visual defect then you may drive following recovery. If there is a visual defect then driving is only permissible if certain requirements are met which will require examination by an ophthalmic expert in such matters. For details why not contact the website of the DVLA on www.dvla.gov.uk

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Ó NHS Tayside; 2006; version 1.0

Disclaimer; no liability whatsoever is accepted for information given and all such information, especially with regard to drug usage (UK version provided), must be checked with a person’s health provider.