Complications after Transsphenoidal Surgery for Cushing Disease

Introduction: The most common cause of the spontaneous Cushing syndrome is Cushing Disease (CD, 60–70% of Cushing syndrome patients). CD results from supraphysiologic levels of adrenocorticotropic hormone (ACTH) secreted by a pituitary corticotroph adenoma. The effects of elevated serum cortisol are manifold and poorly tolerated, and transsphenoidal pituitary surgery is the standard of treatment. The goals of surgery are to normalize serum ACTH levels, to restore a normal pituitary–adrenal axis, and eventually to reverse the peripheral manifestations and comorbidities of steroid excess. Reported complications related to transsphenoidal surgery for CD are rare, but it can be serious. We describe the complications of CD patients treated with endonasal endoscopic transsphenoidal surgery. Methods: Medical records from a single, large volume, academic center were retrospectively reviewed. A total of 82 consecutive CD patients who underwent transsphenoidal resection (with subsequent pathologic confirmation) from April 2008 to April 2014 were included in this study. In addition to demographic, patient, tumor, and surgery characteristics, complications were evaluated. Complications of interest included symptoms of inappropriate antidiuretic hormone secretion (SIADH), diabetes insipidus (DI), CSF leak, carotid artery injury, epistaxis, meningitis, and visual changes. Results: Overall, 82 patients were included in the study (55 women, 67.1%, 27 men, 32.9%). The majority of patients harbored macroadenomas ( n = 41, 50.0%), followed by those with microadenomas ( n = 35, 42.6%). Of the 82 patients, 28 patients (34.1%) were undergoing a reoperation. The median follow-up time was 14.1 months (range, 3–70 months). The most common histopathologic diagnosis was ACTH secreting ( n = 51, 62.2%), followed by “silent” ACTH ( n = 20, 24.4%), and null cell ( n = 1, 1.2%). Four patients were found to have ACTH hyperplasia (4.9%), and six patients were histopathologically nondiagnostic (7.3%). Seven patients had tumors with “atypical” features (8.5%), and two patients had tumors with markedly elevated tumor proliferation indices (2.4%). Overall, there were 10 complications (12.1%) in nine patients (11.0%). Two patients each developed permanent DI (2.4%) and transient symptomatic SIADH (2.4%). One patient experienced an intraoperative carotid injury requiring endovascular sacrifice of the injured carotid, but remained neurologically intact. One patient developed aseptic meningitis, and was treated effectively with steroids. One patient had major postoperative epistaxis requiring another operative procedure to achieve hemostasis. One patient had minor postoperative epistaxis that was treated effectively with topical vasoconstrictors and nasal packing. Another patient developed meningitis (treated with intravenous antibiotics), and went on to develop a transient pseudotumor cerebri syndrome. Conclusion: Transsphenoidal surgery is the treatment of choice for patients with CD. Recent advances in endoscopic technology, and increasing surgeon comfort with this technology are making transsphenoidal procedures safer, faster, and more effective. Serious complications are uncommon, and usually are managed successfully.