Mr. Nijaguna Mathad

Consultant Neurosurgeon, Southampton, UK

Endoscopic Pituitary Surgery:  

Pituitary Gland

 Pituitary gland is situated at the base of the brain within pituitary fossa. Pituitary fossa is located at the roof of the sphenoid sinus, which is the largest air sinus at the back of the nose. Pituitary gland is of the size of a small broad bean, measuring 1.5cm X 1.0 cm. Its approximate weight is less than 0.75gm. 

Pituitary gland is called as the “master gland” of the body, as it regulates all other hormone producing (endocrine) glands. Pituitary has two lobes, the anterior pituitary (adenohypophysis) and the posterior pituitary (neurohypophysis). Posterior pituitary lobe is connected to hypothalamus by pituitary stalk. Hypothalamus decides which regulatory hormones the pituitary gland should release.

 

 Anterior pituitary releases the following hormones in response to hormonal signal from the hypothalamus-

· GH (Growth Hormone) – which regulates the muscle and bone

· TSH (Thyroid Stimulating Hormone)-stimulates  thyroid gland to release thyroxine, which regulates metabolism

· FSH (Follicle Stimulating Hormone) & LH (Luteinizing Hormone) -  in women it stimulates ovaries to produce estrogen and in men it stimulates sperm production

· Prolactin – stimulates breast tissue

· ACTH (AdrenoCorticoTropic Hormone)- stimulates adrenal to produce steroids

 

Posterior pituitary releases the following hormones in response to neural signal from the hypothalamus-

· ADH (AntiDiuretic Hormone)- stimulates kidneys to conserve water

· Oxytocin- stimulates uterine contractions in labor and milk ejection in mother.  More info..

 

Endoscopic Pituitary Surgery : 

Pituitary tumours

Pituitary tumours are almost always benign tumours. Pituitary Adenoma is a benign tumour, a non-cancerous tumour or growth and will not spread to other parts of the body.

Pituitary tumours fall into 2 categories:

 Non-secreting pituitary tumours do not release any hormones into the blood. They usually cause problems by pressing on the normal pituitary gland, preventing it from working effectively and /or become large enough to press on the optic nerves, which lie just above the pituitary gland. This affects your eyesight.

 Secreting pituitary tumours cause high hormone levels in the blood. They can also press on the optic nerves if they become large enough, but they are usually diagnosed before they get to that size.

The most common types are:

• Prolactin secreting tumour- this causes a condition called as a Prolactinoma (see Prolactinomas booklet by Pituitary Foundation)

• Growth Hormone secreting tumour- this causes a condition called Acromegaly. (See Acromegaly booklet by Pituitary Foundation)

• ACTH secreting tumour- this causes a condition called Cushing’s disease (see Cushing’s Syndrome booklet by Pituitary Foundation)

Pituitary adenoma may secrete many of the other hormones produced in the pituitary gland but the 3 listed above are the most common.

The type of tumour you have is determined by the blood test that your endocrinologist has done and/ or by the pathologist after your operation.

Pituitary tumour sized less than 1 cm is called “microadenoma”, sized 1cm to 4 cm is called “macroadenoma” and sized above 4cm is called “giant adenoma”.   

Endoscopic Pituitary Surgery :

Before operation

PITUITARY MULTIDISCIPLINARY TEAM MEETING (MDT)

As per the recommendations of NICE (National Institute of Clinical Excellence), all patients with pituitary tumour and craniopharyngioma are discussed in MDT to recommend best treatment. Pituitary MDT meeting takes place once a month where pituitary surgeons, endocrinologists, neuropathologists, oncologists and neuroradiologists plan optimal treatment. In clinically urgent cases, this discussion will take place after the necessary surgery.

AIMS OF SURGERY

In addition to trying to remove as much tumour as is possible and safe, surgery also aims to leave some of the normal pituitary gland behind (unless discussed before the operation). However, normal pituitary function may be disturbed by surgery. Immediately after the operation you will require hydrocortisone and occasionally a hormone to stop you passing too much water. These hormones can be easily taken if you require them.

All other hormones are assessed about 6-12 weeks after your operation by a hormone specialist (endocrinologist). All the hormones you are not producing yourself can be replaced but it can take time and patience for “fine tuning”. (See The Pituitary Gland and Hormone Replacement booklets by the Pituitary Foundation)

A biopsy (or sample) of the tumour will be taken at the time of the operation to be analyzed in the laboratory. This tells us what type of tumour you have. Ask the surgeon, if you would like more detail.

WILL MY EYESIGHT IMPROVE AFTER SURGERY?

Some tumours are so small that they do not threaten your eyesight at all.

If your eyesight has not been affected but the doctor can see from the scan that the pituitary tumour is growing close to the optic nerve, then a key aim of the operation is to prevent problems with your eyesight in the future.

Where surgery is for a problem with your eyesight, we usually see some improvement. Generally, we see the best results when the problems are mild and have been present only for a short time. The worse the eyesight and the longer it has been troublesome, the less improvement we see.

There are, however, some gratifying exceptions and on occasions we do see some excellent recovery of very poor vision.

Your surgeon will have discussed with you how close your tumour is to your optic nerve, in your consultation before operation. Do not hesitate to ask further questions.

HOW LONG WILL THE OPERATION TAKE?

The operation usually takes about two hours from when you are anaesthetised to when you wake up recovery. You will usually be in recovery for about one hour while you wake up from your operation. The surgeon will explain exactly what they hope to achieve by doing this operation. They will also outline the more common risks and complications. Please ask questions about anything which concerns you.

MRI SCANS

A MRI scan shows the size and shape of a pituitary tumour in great detail. In addition, the MRI scan shows the position of the surrounding structures such as arteries and nerves, especially the optic nerve, which controls your ability to see. Some people are quite anxious about having an MRI scan. If it helps, you can ask a member of your family, a friend or the pituitary nurse to go into the scan room with you. We still do CT scans of the pituitary gland but only when an MRI scan cannot be done, for example, if you have a pacemaker.

THE WARD DOCTOR

You will see a doctor who will make notes about your medical history and give you a physical examination. Some blood tests will be required. You will be asked to attend a pre-operative assessment to assess your fitness for surgery.

THE ANAESTHETIST

The anaesthetist will see you on the morning of operation. This gives you the opportunity to discuss any concerns you may have about having an anaesthetic. It is the anaesthetist who will ensure you enjoy a deep sleep during the operation and will continually monitor you throughout the operation.

THE WARD NURSE

The nurse will make a record of your personal details and take your blood pressure, temperature and pulse. The nurse will be there to look after your day-to-day needs and give both you and your family support during your hospital stay. The average time in hospital is 3-4 days.

Other important members of the team looking after you include:

ENT surgeon: may be involved in difficult tumours and will see you few times after the operation, if required, to make sure that wound inside the nose has healed well.

Endocrinologist: This doctor will carry out an assessment of your hormones. Everybody who has this operation will be referred to an endocrinologist at his or her local hospital, after the operation.

Ophthalmologist: to assess you visual function postoperatively and to monitor it by periodic review.

PREASSESSMENT CLINIC

Usually about 1-2 weeks before your scheduled operation,   you will be asked to attend pre assessment clinic. Your fitness for anaesthetic and surgery is assessed and if required necessary preparations for operation are undertaken.

RELATIVES ACCOMMODATION

Relatives’ accommodation on the premises is severely restricted and priority goes to the relatives of the most seriously ill.

However, a list of local Bed & Breakfast is available upon request, from Pituitary specialist nurse or any of the ward clerks based on the wards.

 

WHY DO I NEED AN OPERATION?

There are two main reasons:

  • Your pituitary tumour has grown and may be pressing on the optic nerve, which lies just above the pituitary gland. This may result in poor vision. Surgery is usually recommended to remove the pressure that the pituitary tumour is exerting on the optic nerve. If your vision is poor, you are likely to be offered an urgent treatment.

   And /or

  • If you have a tumour that is producing too much of a hormone, an operation may improve this overproduction. An example of this would be Cushing’s disease and acromegaly.

I will explain you the reason why you may need an operation. If there is anything you do not understand please do not hesitate to ask for further explanation.

 

WHY TEST FOR PROLACTIN BEFORE AN OPERATION ?

There is one type of pituitary tumour called Prolactinoma (prolactin secreting tumour), which can usually be treated with medications instead of an operation. A simple blood test can identify this.

Endoscopic Pituitary Surgery: 

Day of Operation

 

On the day of surgery you will be arriving in ‘C Neuro’ ward on level C  in Wessex Neurological Centre. The nurse will guide you to your place, complete all the necessary checklists and any necessary blood tests.

ALLERGY & MEDICATIONS

If you are allergic to any medications (like penicillin or iodine) or to any materials/substances (like latex or metal), you must tell the surgeon about it before the operation so that he can take adequate precautions.

If you are taking any regular medications please tell your surgeon about it. Some medications may make your blood thin and you may suffer excessive bleeding.

You will be able to take your blood pressure tablets on the day of surgery, please discuss this with the surgeon or any member of the staff.

CONSENT

Your surgeon or a member of his team will explain why and what operation you are going to have and all the potential risks involved (see below). Any alternatives to surgical treatment and expected benefits of the operation will also be discussed. Please ask the surgeon or the member of his team, if you are concerned about any aspects of your operation. It is important that you understand the benefits and risks involved in the operation before you sign your consent.

Increasingly the consent is being obtained in the clinic during your consultation. However, if you have any questions or concerns, please ask the surgeon or pituitary specialist nurse before your operation.

POTENTIAL RISKS

As with any other operation, there are potential risks with endoscopic transsphenoidal surgery. The most important risks are:

 Infection: Antibiotics are given at the beginning of the operation and continued for a week after the operation. Because sinuses are opened during surgery, sinus infection is a possibility. Occasionally infection can spread upwards, causing meninigitis, requiring antibiotics for longer time.

 Bleeding: Blood loss during surgery is minimal and is well tolerated by an adult. If you are on any blood thinning medications (like aspirin, warfarin or clopedigrol) excessive bleeding can occur. It is very important that you tell the surgeon if you are taking any of these medications, so that the surgeon can make adequate preparations for your operation. You may be asked to stop these medications a few days prior to the date of operation for the effect of these medications to wear off.

 Panhypopit: Pituitary gland is usually compressed by the adenoma and during the operation there is a risk that gland may get damaged, resulting in pituitary failure. In that case, an endocrinologist will replace all the required hormones.

 Daibetes insipidus: (Not sugar diabetes). If there is any disturbance to the posterior pituitary and pituitary stalk, diabetes insipidus sets in. You will feel very thirsty and drink excessive amount of water and pass excessive amount of urine. This can be controlled with medication.

 Cerebrospinal fluid (CSF) leak: There is a very thin membrane which separates the pituitary tumour from the brain fluid (CSF). During this operation, if there is any breach in that membrane CSF starts to leak into the nose. If this happens, the surgeon is able to identify the leak and repair with fat and or fascia taken from your tummy or thigh. Very rarely, CSF might leak after you are discharged.

 Vascular injury & Stroke: Very rarely the carotid artery (major blood vessel on either side of the pituitary gland) may get damaged. The risk is less than 1%. This will result in very severe bleeding and carotid artery may need to be sacrificed (or occluded internally by the radiologist) to control the bleeding. This may result in stroke and may risk your life.

CJD QUESTIONNAIRE

Everyone having the operation of the brain, spine and pituitary tumour will be asked about the risk factors for CJD (Creutzfeldt-Jakob disease). The questions need not alarm you. If you had previous operations on your brain, spinal cord or pituitary or you were treated with human growth hormone previously please tell the surgeon well before your operation. In that case, the surgeon may need more time to clarify the facts before your operation.

Once you are consented and all the checklists are completed you will be ready to go for your operation. When the theatre is ready, the porter will and nurse will escort you to the anaesthetic room.

ANAESTHETIC ROOM

This is the room adjacent to the theatre, where you are put to sleep by an anaesthetist. You will be anaesthetised and monitoring set up before you are moved into the operating room.

Endoscopic Pituitary Surgery :

After operation

DOS AND DONTS

 Sleep with head elevated by 2-3 pillows

 If constipated, take mild laxative or stool softner

 Avoid hot liquids and spicy food for few days

 Refrain from the activities, which raise your blood pressure like running, exercising, weight lifting or similar activities.

 Do not drink through tDhe straw

 Do not swim or fly for two weeks after surgery

 Do not blow your nose

CARE OF THE ABDOMINAL / THIGH WOUND

 You may remove the dressing on the second day after surgery

 You may shower, but do not soak in hot bath for 2 weeks

 Keep the wound dry.

 Clips or sutures need to come out 8-10 days after your operation. Please make appointment with your practice nurse. Ward nurse will give you necessary papers for the same.

WHAT SHOULD I EXPECT AFTER THE OPERATION

Immediately after the operation you will be taken to recovery room where you will be monitored carefully as you wake up. You will be made comfortable, given painkillers if required and allowed a little time to wake up from the anaesthetic. You will be asked to move your arms and legs. You will also be asked what may seem “daft” questions such as “what day is it?” or “where are you?” The nurse will also do some simple tests of your eyesight. This may seem strange or irritating but it is an assessment of how well you are recovering from the operation and is therefore very important. You will usually stay in recovery for about an hour, until you are awake

NASAL PACKS

You may have packs in your nose and a nasal dressing. These may feel uncomfortable but they are used to reduce bleeding after the operation. Your ears as well as nose may feel blocked. The packs are removed the day after the operation. Because you will be breathing through your mouth, it may feel quite dry. When the packs have been removed it is best not to blow your nose, if you sneeze do so with your mouth open and avoid prodding or poking the nasal area for 3-4 weeks. Heavy lifting should be avoided.

INTRAVENOUS INFUSION

After this operation you will have an intravenous infusion, commonly known as a drip. This is to replace the fluids you are unable to drink whilst “Nil by mouth”. Once you are drinking normally, this will be removed.

FLUID RESTRICTION

A strict record of how much you are drinking and passing will be kept for the first few days after your operation. You will be requested to use a bottle or bedpan (which will be placed over the toilet), in order to accurately measure your output. Catheters and commodes are not routinely used. You will be allowed to drink 2.4 litres of fluid (approximately 5 pints) over a 24-hour period, whilst in hospital. The reason is that occasionally, after the operation, your pituitary gland fails to control how much urine you pass. You can develop a condition called Diabetes Insipidus (not to be confused with sugar diabetes).

DIABETES INSIPIDUS

Diabetes Insipidus causes you to pass urine often, in large volumes and consequently, you feel thirsty and want to drink a lot. This can be treated quickly with a medication called Desmopressin.

The condition may only be temporary and will be carefully monitored by the doctors. It is important to note that the most common reason for feeling thirsty is being forced to breathe through your mouth because of the packs in your nose. (See Diabetes Insipidus booklet by the Pituitary Foundation).

UP AND ABOUT

The first day after the operation you will be encouraged to get up and out of bed, as much as you feel able. Gone are the days of complete bed-rest for weeks after an operation. Early mobilisation helps in preventing many postoperative complications, like pneumonia and blood clot in the legs.

CEREBRO-SPINAL FLUID (CSF) LEAK THROUGH NOSE

One of the complications of this operation is that occasionally a small tear occurs in a very thin layer of the brain’s “cling film” which lies over the pituitary gland. If you notice a constant leaking of clear fluid from your nose, perhaps worse when leaning forward, it is important to report this to your doctor or nurse so that appropriate treatment can be given.

This is called a CSF leak. Your surgeon will usually see this during the operation; if so, it is usually repaired with small amount fat and /or fascia taken from the thigh or tummy. Occasionally, you may need a second operation to repair the CSF leak.

In very unusual circumstances, a small drain may be put in your back through the lumbar puncture needle. This drain is usually removed  48-72 hours after the operation. This lumbar drain bypasses your brain fluid into a collection bag, giving the main wound a chance to heal. This collection bag will be placed at shoulder height and you will be able to walk around with it.  The height at which the bag is placed in relation to your body regulates the amount of fluid drained. You may get a headache, which is best relieved by bed rest, fluids and painkillers. This may prolong your hospital stay, usually only by 3-4 days.

MENINGITIS

This is rare complication of operations on the pituitary gland but without wishing to alarm you, it is a good idea to be aware of some of the symptoms of meningitis.

As you will already have been warned before the operation, if you develop a constant drip of clear fluid from your nose, this can be a CSF leak, which carries a small risk of meningitis. If you develop some or all of the symptoms described below contact your GP or the hospital immediately:

Violent or severe headaches

 High temperature

Stiff neck

Being sick

Dislike bright lights

Painful joints

Drowsiness & lack of energy

When diagnosed early, meningitis can usually be treated effectively. It is extremely unusual to develop meningitis after you leave the hospital.

STITCHES

With endoscopic techniques, we do not normally have to place stitches in and around the nose. If we have to obtain fat and or fascia from the thigh or tummy to repair CSF leak, you will have stitches or skin clips placed. These need to come out only after a week and a District Nurse can do this in your local practice.

SMELL AND TASTE

It is not unusual to experience a dulling of your sense of smell and taste but this will usually return to normal over time.

HEADACHES / BLOCKED UP FEELING

You may suffer from mild headaches for a few weeks after the operation. This is not unusual. Take some painkillers and allow yourself plenty of rest. Severe headaches or worsening headaches rarely occur but should be reported to your GP straight away. It is not unusual for your sinuses to feel blocked up after the operation. Sinusitis can cause pain and headaches around the forehead and around the eyes. You may or may not get a nasal discharge. The headaches are often worst first thing in the morning.

To promote healing inside the nose, we prescribe SINUS RINSE, a saline washout. It is a plastic bottle you fill with mildly warm water. Then you add salt, which comes a sachet. Bend forward over the sink and keep the bottle to one nostril and gently squeeze the bottle. The wash will go up that nostril and come out through the other nostril. Repeat the process from the other nostril. You may have to do this about 3-4 times a day for 6-8 weeks. Sinus rinse is freely available in pharmacies with or without prescription. If you have access to Internet, watch a video on its use by typing 'SinusRinse' in 'You Tube'.

HYDROCORTISONE

If you have been prescribed hydrocortisone tablets you must continue to take them as prescribed until the endocrinologist sees you. It is the endocrinologist who will tell you whether to continue or not, after few blood tests.

Take your morning dose first thing in the morning and your last dose around 5 pm. If you take it later than this, you may find it difficult to get off to sleep. This will endeavor to mimic your body’s natural rhythm. When you see the endocrinologist he / she may change the dose or time you take your hydrocortisone to suit your individual needs.

1. You must not stop taking hydrocortisone without discussing it with your endocrinologist because you may become very unwell.

2. Make sure you do not run out.

3. If you cannot take the tablets, for example, if you have a bout of diarrhoea and vomiting, you should inform your GP immediately, as you may need to be given the hydrocortisone by injection.

4. Finally, if you were unlucky enough to develop a serious illness such as a fever, pneumonia, or an injury such as a broken bone, you will need to take extra hydrocortisone. This should be brought to the attention of your doctor immediately.

5. If traveling abroad, you would need to consider taking your own injection kit, a letter for the customs from your GP, medic alert bracelet and taking extra tablets in case of illness. Advice can be sought from your endocrinologist.

6. Always carry your steroid card with you.

7. Do not pack your medication in check-in baggage.    More info...

PRESCRIPTION

You will be supplied with 1 month worth of hydrocortisone, when you are discharged from the hospital, plus a supply of the other medications you are prescribed. After this you will need to get a repeat prescription from your GP.

If you suffer from diabetes Insipidus or are on steroid replacement therapy (i.e. hydrocortisone tablets or thyroxin tablets) you are entitled to free prescriptions. You will have to claim an exemption certificate from your local health authority.

These can be claimed using form HC11, available from pharmacies or main post offices. For further information ring Free Prescriptions Advice Line on 0800 9177711.

You should be given a Blue Steroid Card with your prescription. Please contact the pituitary nurse if this does not happen.

ALCOHOL

When you are taking hydrocortisone as a replacement therapy as is the case after this operation, alcohol is not harmful, other medications permitting. However, some medications including some painkillers do not mix with alcohol. It is therefore wise to check with your GP or check with the pharmacist at your local chemist if you are not sure.

EYESIGHT TEST

To enable doctors to compare your eyesight before and after the operation you may have your eyesight checked formally before you are discharged home.

It is wise not to change you glass prescription immediately, as you may find your eyesight continues to improve over the next few weeks. Your optician will be able to advise you on this matter.

EMOTIONS

People can feel emotional ‘highs’ and ‘lows’after any big operation. One minute you feel happy and relieved, the next minute you feel tearful, tired and ‘low’. This is not unusual but should your ‘low’ mood continue for any length of time, you need to contact your GP, your endocrinologist or discuss it with the pituitary nurse. Read more

DRIVING

If you drive, you have a statutory obligation to inform the DVLA of any illness which may affect your ability to drive, within 3 months. If you fail to do this you may be breaking the law. Also if you have an accident, your insurance may be invalid. After the trans-sphenoidal operation the DVLA will want to know that your eyesight is safe to drive. A further eyesight test may be required.

You must inform the DVLA and your insurance company about your surgery, unless you were told before leaving the ward that you are permitted to drive once you have recovered.

 

You can contact the DVLA by telephone: 0870 0600 0301 or visit: www.dvla/medical.co.uk

TRAVEL EXPENSES

Anybody in receipt of income support, job seekers’ allowance, family credit or disability-working allowance is entitled to help with travel expenses to and from hospital. Public transport costs or mileage can be claimed. However, taxi fares and costs incurred by your escort can only be claimed if your GP or Consultant has written a letter stating that it is medically necessary. You will require proof of your entitlement such as a benefit award notice, your hospital appointment letter and receipts. Information about this can be found at the hospital’s Finance Office.

The nurses on the ward or the ward clerk will be able to direct you to the Finance Office.

RESEARCH

We are a large centre for pituitary surgery closely linked to the medical school at Southampton University. There are many research projects ongoing, all of which have received ethical approval, including ones on pituitary tumours. We may approach you about some of these projects. The research gives us information, which may change the way we treat people in the future. Your treatment will not be affected in any way if you don’t want to take part. No action will be taken without us discussing these projects with you (including giving you an information sheet) and without you signing a specific research consent form. Please ask if you want to know more.

 

Endoscopic Pituitary Surgery:

After Discharge

Your case will be reviewed in a MDT meeting in the light of histopathology report and postoperative MRI scan. Further follow ups and treatment are planned at this time.

If some tumour is left behind during your operation, it tends to grow back with time. Hence you will be given periodic MRI scan for long time.

FOLLOW UP

After your pituitary surgery you will be followed up by

 Endocrinologist: 4-6 weeks after the operation, for postoperative assessment of your pituitary hormones. Only he / she can tell you whether you can stop hydrocortisone or not.  If your pituitary does not wake up after the operation, endocrinologist will replace all necessary hormones

 Pituitary surgeon: usually 3-6 months after surgery with postoperative MRI scan. At this consultation, histology report, you scan findings and MDT recommendations are usually discussed.

 ENT Surgeon: if your nasal symptoms do not settle down in 6-8 weeks and if you needed extensive repair during your operation, you will be required to see the ENT surgeon (usually the one who works within pituitary surgery team). He will inspect your nose and clean inside the nose if required, taking care not to disturb the repair undertaken during your operation.

 Eye surgeon: If you have any ongoing visual problems after the operation, eye surgeon may be required to help you with your vision.

 Oncologist: Almost all pituitary tumours are benign. If your tumour is aggressive or you are left with residual tumour in a surgically inaccessible area, MDT might recommend additional treatment for you. This may be in the form of radiotherapy and or chemotherapy. Your doctor will explain all this in the follow up clinic.

If you do not understand anything in these pages or if you have any other questions, please ask.