Difference between revisions of "Transphenoidal resection of pituitary tumor"

From WikiAnesthesia
VisualWikitext
m
 
(10 intermediate revisions by 3 users not shown)
Line 2: Line 2:
| anesthesia_type = General
| anesthesia_type = General
| airway = ETT
| airway = ETT
| lines_access = PIV x 2<Br>Art line
| lines_access = PIV x 2
| monitors = Standard ASA<Br>5-lead EKG<Br>Core temp<Br>UOP<Br>EEG (optional)
Arterial line
| considerations_preoperative = Characterize baseline neurologic deficits (i.e., visual field defects)<Br>Characterize type of adenoma (secreting vs non-secreting) and which type of hormone secreted
| monitors = Standard ASA
| considerations_intraoperative = Avoidance of hypertension as it can worsen visual of endoscopic surgical field due to bleeding<Br>Avoid turbulent emergence; avoid positive pressure mask ventilation on extubation
5-lead EKG
| considerations_postoperative = PONV prophylaxis<Br>Iatrogenic diabetes insipidus (monitor intraop and post-op urinary output)
Core temp
UOP
± EEG
| considerations_preoperative = Characterize baseline neurologic deficits (i.e., visual field defects)
Characterize type of adenoma (secreting vs non-secreting) and which type of hormone secreted
| considerations_intraoperative = Avoidance of hypertension as it can worsen visual of endoscopic surgical field due to bleeding
Avoid turbulent emergence; avoid positive pressure mask ventilation on extubation
| considerations_postoperative = PONV prophylaxis
Iatrogenic diabetes insipidus (monitor intraop and post-op urinary output)
}}
}}


Provide a brief summary of this surgical procedure and its indications here.
A '''transphenoidal resection of pituitary tumor''' is a neurosurgical procedure performed through an intranasal exposure to remove tissue from the sella turica.  


== Preoperative management ==
==Overview==


=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
* Most pituitary tumors are benign adenomas<ref>{{Cite web|date=2022-05-23|title=Pituitary Tumors Treatment (PDQ®)–Health Professional Version - NCI|url=https://www.cancer.gov/types/pituitary/hp/pituitary-treatment-pdq|access-date=2022-09-19|website=www.cancer.gov|language=en}}</ref>
** Only 0.1-0.2% malignant carcinomas
* Approximately 35% are invasive into adjacent bony and/or vascular structures
* Approximately 75% of tumors are functional (hormone-secreting)<ref name=":0">{{Cite book|last=Reddy|first=SS|url=https://www.worldcat.org/oclc/234428919|title=The Cleveland Clinic Foundation intensive review of internal medicine|last2=Hamrahian|first2=AH|date=2009|publisher=Wolters Kluwer Health/Lippincott Williams & Wilkins|others=James K. Stoller, Franklin A. Michota, Brian F. Mandell, Cleveland Clinic Foundation|isbn=978-0-7817-9079-6|edition=5|location=Philadelphia|chapter=Pituitary Disorders and Multiple Endocrine Neoplasia Syndromes|oclc=234428919}}</ref>
* Mass effect of tumor can lead to decreased secretion of one or more pituitary hormones and other neurologic deficiencies
 
===Indications<!-- List and/or describe the indications for this surgical procedure. -->===
*Resection of pituitary tumor
===Surgical procedure<!-- Briefly describe the major steps of this surgical procedure. -->===
 
* Performed via a transphenoidal approach through the nares
 
==Preoperative management==
 
===Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. -->===
{| class="wikitable"
{| class="wikitable"
|+
|+
!System
!System
!Considerations
!Considerations
|-
|Airway
|
*ACTH or GH secreting tumors may lead to airway abnormalities
*GH: macroglossia, enlarged epiglottis, RLN palsy, subglottic stenosis, enlarged nasal turbinates
|-
|-
|Neurologic
|Neurologic
|
|
*Baseline neuro exam
*GH prone to peripheral neuropathies.
|-
|-
|Cardiovascular
|Cardiovascular
|
|
|-
*Hyperthyroid patients may have ECG abnormalities
|Respiratory
*GH pts may have HTN, LVH, diastolic dysfunction, arrhythmias, CAD
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|-
|Renal
|Renal
|
|
*Preoperative diabetes insipidus
|-
|-
|Endocrine
|Endocrine
|
|
|-
*Identify and treat (if needed) pituitary hormone abnormalities (see below)
|Other
|
|}
|}


=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
====Tumor anatomy====
 
*Classified based upon size/structural invasion<ref>{{Cite journal|last=Asa|first=S. L.|last2=Ezzat|first2=S.|date=1998|title=The cytogenesis and pathogenesis of pituitary adenomas|url=https://pubmed.ncbi.nlm.nih.gov/9861546|journal=Endocrine Reviews|volume=19|issue=6|pages=798–827|doi=10.1210/edrv.19.6.0350|issn=0163-769X|pmid=9861546}}</ref>
**Stage I: Microadenoma (<1 cm)
**Stage II: Macroadenoma (≥1 cm)
**Stage III: Macroadenoma with invasion
**Stage IV: Destruction of the sella
*Mass effect can directly compress neurologic structures
**Visual field defects (classically bitemporal hemianopsia)
**Eye movement deficits (CN III more common than CN VI)
**Elevated ICP rare (secondary to obstructive hydrocephalus)
*Invasion into adjacent structures
**Bone
***Skull base
***Sphenoid
**Vascular
***Cavernous sinus
***Carotid artery
*Tumor can be hemorrhagic and/or necrotic
 
====Endocrine abnormalities====
 
*Pituitary tumors can be classified as functional (hormone-secreting) or nonfunctional (not hormone-secreting)
**Prolactin > GH > ACTH > LH/FSH > TSH<ref name=":0" />
*Endocrine deficiencies from mass effect
**GH > LH/FSH > TSH > ACTH > Prolactin
**Panhypopituitarism possible
**Posterior pituitary deficiencies less common (ADH, oxytocin)


=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. -->===


=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
* Brain MRI
** Review imaging to evaluate structural invasion
*** Invasion into cavernous sinus and/or enveloping carotid artery higher risk for bleeding


* Versed
===Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. -->===


=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
===Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->===


* N/A
*Versed
*Consider aprepitant 40 mg PO for PONV prophylaxis


== Intraoperative management ==
==Intraoperative management==


=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
===Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->===


* PIV x 2 (20g for drips, 18g+ for bolus)
*PIV x 2 (20g for drips, 18g+ for bolus)
* Art line
*Arterial line  


* If patient is hemodynamically stable, consider placing art line after the 180 spin as surgical team can prep simultaneously. It also reduces the chance of inadvertent line dislodgment while spinning.
*If patient is hemodynamically stable, consider placing art line after the 180 spin as surgical team can prep simultaneously. It also reduces the chance of inadvertent line dislodgment while spinning.


=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->===


* Standard induction
* Standard induction  
** Propofol
**Propofol
** Short acting opioid vs beta blocker
**Short acting opioid vs beta blocker
*** Can even use remifentanil bolus as induction agent, but consider risk of chest rigidity on induction
***Can even use remifentanil bolus as induction agent, but consider risk of chest rigidity on induction
** Rocuronium
**Rocuronium
*** Induction dose should be sufficient for the entire case as you are also running a remifentanil gtt, which should blunt movement
***Induction dose should be sufficient for the entire case as you are also running a remifentanil gtt, which should blunt movement
* ETT with straight connector
*ETT with straight connector
** Consider mastisol and tegaderm reinforcement of the ETT as you will not have access to the airway.
**Consider mastisol and tegaderm reinforcement of the ETT as you will not have access to the airway.
**GH: glottic opening may be very distal, traditional ETT may not be long enough, consider MLT 6.0mm


=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->===


* 180 - place all leads and wiring on one side of the body prior to induction to facilitate an easier spin
*180 - place all leads and wiring on one side of the body prior to induction to facilitate an easier spin
* Supine
*Supine
* Arms tucked
*Arms tucked
** Additional IV access site options: saphenous veins
** Additional IV access site options: saphenous veins


=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->===


* Propofol gtt (if TIVA, start at 100-150 mcg/kg/min and consider EEG monitoring/Sedline/BISl; titrate to effect)
*Propofol gtt (if TIVA, start at 100-150 mcg/kg/min and consider EEG monitoring/Sedline/BISl; titrate to effect)
* Remifentanil gtt (start with 0.1mcg/kg/min and titrate normal hemodynamic parameters)
* Remifentanil gtt (start with 0.1mcg/kg/min and titrate normal hemodynamic parameters)
* +/- Volatile (can use 0.5 MAC of Sevoflurane requiring less propofol; useful for longer cases when propofol begins to accumulate)
*± Volatile (can use 0.5 MAC of Sevoflurane requiring less propofol; useful for longer cases when propofol begins to accumulate)
* No steroids unless specifically asked; may interfere with AM cortisol measurement the next day
*No steroids unless specifically asked; may interfere with AM cortisol measurement the next day
* Pinning of the head using Mayfield pins by neurosurgery will cause a pain/sympathetic surge. Prepare to bolus 1-2 mcg/kg of remi 2-3 minutes prior to pinning; coordinate with surgeons.
*Pinning of the head using Mayfield pins by neurosurgery will cause a pain/sympathetic surge. Prepare to bolus 1-2 mcg/kg of remi 2-3 minutes prior to pinning; coordinate with surgeons.
* ENT will inject lidocaine with epinephrine, watch for inadvertent IV injection or mucosal absorption→ transient tachycardia, hypertension
* ENT will inject lidocaine with epinephrine, watch for inadvertent IV injection or mucosal absorption→ transient tachycardia, hypertension
* Combined ENT/Neurosurgery case - ENT for exposure, neurosurgery for tumor resection
*Combined ENT/Neurosurgery case - ENT for exposure, neurosurgery for tumor resection
* As with many ENT cases in the nasopharynx, can be very stimulating, hence the suggested remi gtt. However, once the stimulation is over, it is typically not very painful so do not overdo it with long-acting opioids.
*As with many ENT cases in the nasopharynx, can be very stimulating, hence the suggested remifentanil gtt. However, once the stimulation is over, it is typically not very painful so do not overdo it with long-acting opioids.
* Consider short-to-intermediate acting BB (i.e, esmolol, labelol) for HTN/stimulation not controlled by remi bolus/gtt. HTN will worsen bleeding during ENT portion.
*Consider short-to-intermediate acting BB (i.e, esmolol, labetalol) for HTN/stimulation not controlled by remifentanil bolus/gtt. HTN will worsen bleeding during ENT portion.
* Surgeons will ask for Valsava during the case.
*Surgeons will ask for Valsalva during the case.
* Foley: yes, for duration of case and to monitor iatrogenic DI caused by the tumor resection
*Note down when throat pack is placed in and taken out during case.
*Foley: yes, for duration of case and to monitor iatrogenic DI caused by the tumor resection


=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===  


*Pass OGT to ENT at end of case prior to extubation to suction out any blood that may have dripped down the esophagus and into the stomach.
* Paralytic reversal (if used).
* Paralytic reversal (if used).
* Spin back to neutral (particularly, if solo).
*Spin back to neutral (particularly, if solo).
* Smooth awake extubation (i.e., remi wake-up: decrease gtt to 0.03-0.05 mcg/kg/min for extubation). Patients may not spontaneously breath initially even if all volatile/propofol if out of the system, but if gently encouraged, will open their eyes and follow commands.  
*Smooth awake extubation (i.e., remifentanil wake-up: decrease gtt to 0.03-0.05 mcg/kg/min for extubation). Patients may not spontaneously breath initially even if all volatile/propofol if out of the system, but if gently encouraged, will open their eyes and follow commands.
* Avoid positive pressure masking after extubation.
*Avoid positive pressure masking after extubation.
 
=== Potential Modalities of Neuromonitoring<ref>{{Cite journal|last=Singh|first=Harminder|last2=Vogel|first2=Richard W.|last3=Lober|first3=Robert M.|last4=Doan|first4=Adam T.|last5=Matsumoto|first5=Craig I.|last6=Kenning|first6=Tyler J.|last7=Evans|first7=James J.|date=2016|title=Intraoperative Neurophysiological Monitoring for Endoscopic Endonasal Approaches to the Skull Base: A Technical Guide|url=https://pubmed.ncbi.nlm.nih.gov/27293965|journal=Scientifica|volume=2016|pages=1751245|doi=10.1155/2016/1751245|issn=2090-908X|pmc=4886091|pmid=27293965}}</ref> ===
{| class="wikitable"
|+
!Surgical Approach
!Potential IONM Modalities
!Common Pathologies
|-
|Transsphenoidal to sella
|None
|Adenoma, Rathke's cleft cyst
|-
|Transsphenoidal, transplanum, transtuberculum to suprasellar region
|EEG, SSEPs, MEPs
|Meningioma, craniopharyngioma, giant piutitary adenomas
|-
|Transsphenoidal to orbital apex
|EEG, SSEPs, MEPs, EMG (CN III, IV, VI)
|Hemangioma, meningioma, neoplasm
|}


== Postoperative management ==
==Postoperative management ==


=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->===


* PACU
*PACU


=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===


* Tylenol IV
* Tylenol IV
* Fentanyl (be judicious) as surgeons will likely want a good neuro exam post-op.  
*Fentanyl (be judicious) as surgeons will likely want a good neuro exam post-op.


=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===


* Iatrogenic diabetes insipidus if vasopressin secreting cells are affected.
*Iatrogenic diabetes insipidus if vasopressin secreting cells are affected.
** Importing to monitor intraop and post-op urinary output.
**Important to monitor intraop and post-op urinary output.


== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->==


{| class="wikitable"
{| class="wikitable"
Line 157: Line 231:
|}
|}


== References ==
==References==


[[Category:Surgical procedures]]
[[Category:Surgical procedures]]
[[Category:Neurosurgery]]
<references />

Latest revision as of 16:53, 7 September 2023

Transphenoidal resection of pituitary tumor
Anesthesia type

General

Airway

ETT

Lines and access

PIV x 2 Arterial line

Monitors

Standard ASA 5-lead EKG Core temp UOP ± EEG

Primary anesthetic considerations
Preoperative

Characterize baseline neurologic deficits (i.e., visual field defects) Characterize type of adenoma (secreting vs non-secreting) and which type of hormone secreted

Intraoperative

Avoidance of hypertension as it can worsen visual of endoscopic surgical field due to bleeding Avoid turbulent emergence; avoid positive pressure mask ventilation on extubation

Postoperative

PONV prophylaxis Iatrogenic diabetes insipidus (monitor intraop and post-op urinary output)

Article quality
Editor rating
In development
User likes
0

A transphenoidal resection of pituitary tumor is a neurosurgical procedure performed through an intranasal exposure to remove tissue from the sella turica.

Overview

  • Most pituitary tumors are benign adenomas[1]
    • Only 0.1-0.2% malignant carcinomas
  • Approximately 35% are invasive into adjacent bony and/or vascular structures
  • Approximately 75% of tumors are functional (hormone-secreting)[2]
  • Mass effect of tumor can lead to decreased secretion of one or more pituitary hormones and other neurologic deficiencies

Indications

  • Resection of pituitary tumor

Surgical procedure

  • Performed via a transphenoidal approach through the nares

Preoperative management

Patient evaluation

System Considerations
Airway
  • ACTH or GH secreting tumors may lead to airway abnormalities
  • GH: macroglossia, enlarged epiglottis, RLN palsy, subglottic stenosis, enlarged nasal turbinates
Neurologic
  • Baseline neuro exam
  • GH prone to peripheral neuropathies.
Cardiovascular
  • Hyperthyroid patients may have ECG abnormalities
  • GH pts may have HTN, LVH, diastolic dysfunction, arrhythmias, CAD
Renal
  • Preoperative diabetes insipidus
Endocrine
  • Identify and treat (if needed) pituitary hormone abnormalities (see below)

Tumor anatomy

  • Classified based upon size/structural invasion[3]
    • Stage I: Microadenoma (<1 cm)
    • Stage II: Macroadenoma (≥1 cm)
    • Stage III: Macroadenoma with invasion
    • Stage IV: Destruction of the sella
  • Mass effect can directly compress neurologic structures
    • Visual field defects (classically bitemporal hemianopsia)
    • Eye movement deficits (CN III more common than CN VI)
    • Elevated ICP rare (secondary to obstructive hydrocephalus)
  • Invasion into adjacent structures
    • Bone
      • Skull base
      • Sphenoid
    • Vascular
      • Cavernous sinus
      • Carotid artery
  • Tumor can be hemorrhagic and/or necrotic

Endocrine abnormalities

  • Pituitary tumors can be classified as functional (hormone-secreting) or nonfunctional (not hormone-secreting)
    • Prolactin > GH > ACTH > LH/FSH > TSH[2]
  • Endocrine deficiencies from mass effect
    • GH > LH/FSH > TSH > ACTH > Prolactin
    • Panhypopituitarism possible
    • Posterior pituitary deficiencies less common (ADH, oxytocin)

Labs and studies

  • Brain MRI
    • Review imaging to evaluate structural invasion
      • Invasion into cavernous sinus and/or enveloping carotid artery higher risk for bleeding

Operating room setup

Patient preparation and premedication

  • Versed
  • Consider aprepitant 40 mg PO for PONV prophylaxis

Intraoperative management

Monitoring and access

  • PIV x 2 (20g for drips, 18g+ for bolus)
  • Arterial line
  • If patient is hemodynamically stable, consider placing art line after the 180 spin as surgical team can prep simultaneously. It also reduces the chance of inadvertent line dislodgment while spinning.

Induction and airway management

  • Standard induction
    • Propofol
    • Short acting opioid vs beta blocker
      • Can even use remifentanil bolus as induction agent, but consider risk of chest rigidity on induction
    • Rocuronium
      • Induction dose should be sufficient for the entire case as you are also running a remifentanil gtt, which should blunt movement
  • ETT with straight connector
    • Consider mastisol and tegaderm reinforcement of the ETT as you will not have access to the airway.
    • GH: glottic opening may be very distal, traditional ETT may not be long enough, consider MLT 6.0mm

Positioning

  • 180 - place all leads and wiring on one side of the body prior to induction to facilitate an easier spin
  • Supine
  • Arms tucked
    • Additional IV access site options: saphenous veins

Maintenance and surgical considerations

  • Propofol gtt (if TIVA, start at 100-150 mcg/kg/min and consider EEG monitoring/Sedline/BISl; titrate to effect)
  • Remifentanil gtt (start with 0.1mcg/kg/min and titrate normal hemodynamic parameters)
  • ± Volatile (can use 0.5 MAC of Sevoflurane requiring less propofol; useful for longer cases when propofol begins to accumulate)
  • No steroids unless specifically asked; may interfere with AM cortisol measurement the next day
  • Pinning of the head using Mayfield pins by neurosurgery will cause a pain/sympathetic surge. Prepare to bolus 1-2 mcg/kg of remi 2-3 minutes prior to pinning; coordinate with surgeons.
  • ENT will inject lidocaine with epinephrine, watch for inadvertent IV injection or mucosal absorption→ transient tachycardia, hypertension
  • Combined ENT/Neurosurgery case - ENT for exposure, neurosurgery for tumor resection
  • As with many ENT cases in the nasopharynx, can be very stimulating, hence the suggested remifentanil gtt. However, once the stimulation is over, it is typically not very painful so do not overdo it with long-acting opioids.
  • Consider short-to-intermediate acting BB (i.e, esmolol, labetalol) for HTN/stimulation not controlled by remifentanil bolus/gtt. HTN will worsen bleeding during ENT portion.
  • Surgeons will ask for Valsalva during the case.
  • Note down when throat pack is placed in and taken out during case.
  • Foley: yes, for duration of case and to monitor iatrogenic DI caused by the tumor resection

Emergence

  • Pass OGT to ENT at end of case prior to extubation to suction out any blood that may have dripped down the esophagus and into the stomach.
  • Paralytic reversal (if used).
  • Spin back to neutral (particularly, if solo).
  • Smooth awake extubation (i.e., remifentanil wake-up: decrease gtt to 0.03-0.05 mcg/kg/min for extubation). Patients may not spontaneously breath initially even if all volatile/propofol if out of the system, but if gently encouraged, will open their eyes and follow commands.
  • Avoid positive pressure masking after extubation.

Potential Modalities of Neuromonitoring[4]

Surgical Approach Potential IONM Modalities Common Pathologies
Transsphenoidal to sella None Adenoma, Rathke's cleft cyst
Transsphenoidal, transplanum, transtuberculum to suprasellar region EEG, SSEPs, MEPs Meningioma, craniopharyngioma, giant piutitary adenomas
Transsphenoidal to orbital apex EEG, SSEPs, MEPs, EMG (CN III, IV, VI) Hemangioma, meningioma, neoplasm

Postoperative management

Disposition

  • PACU

Pain management

  • Tylenol IV
  • Fentanyl (be judicious) as surgeons will likely want a good neuro exam post-op.

Potential complications

  • Iatrogenic diabetes insipidus if vasopressin secreting cells are affected.
    • Important to monitor intraop and post-op urinary output.

Procedure variants

Variant 1 Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

  1. ↑ "Pituitary Tumors Treatment (PDQ®)–Health Professional Version - NCI". www.cancer.gov. 2022-05-23. Retrieved 2022-09-19.
  2. ↑ 2.0 2.1 Reddy, SS; Hamrahian, AH (2009). "Pituitary Disorders and Multiple Endocrine Neoplasia Syndromes". The Cleveland Clinic Foundation intensive review of internal medicine. James K. Stoller, Franklin A. Michota, Brian F. Mandell, Cleveland Clinic Foundation (5 ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. ISBN 978-0-7817-9079-6. OCLC 234428919.
  3. ↑ Asa, S. L.; Ezzat, S. (1998). "The cytogenesis and pathogenesis of pituitary adenomas". Endocrine Reviews. 19 (6): 798–827. doi:10.1210/edrv.19.6.0350. ISSN 0163-769X. PMID 9861546.
  4. ↑ Singh, Harminder; Vogel, Richard W.; Lober, Robert M.; Doan, Adam T.; Matsumoto, Craig I.; Kenning, Tyler J.; Evans, James J. (2016). "Intraoperative Neurophysiological Monitoring for Endoscopic Endonasal Approaches to the Skull Base: A Technical Guide". Scientifica. 2016: 1751245. doi:10.1155/2016/1751245. ISSN 2090-908X. PMC 4886091. PMID 27293965.

Top contributors: Chetra Yean, Chris Rishel, Gang Chen and Daniel Diaczok

Retrieved from "https://wikianesthesia.org/w/index.php?title=Transphenoidal_resection_of_pituitary_tumor&oldid=15694"