PNA Medical Corner: Endoscopic Endonasal Surgery Riskier in the Elderly
This month the PNA Medical Corner focuses on an article co-authored by PNA member and neurosurgeon Theodore Schwartz, a past recipient of the PNA’s highest honor, the Gentle Giant Award. The study compared surgical complication rates against two groups of patients, one 60-69 and another 70+, and found that the rate of complications were 7.4% and 18.5%, respectively. The authors conclude that the risk of complications rises significantly with advanced age.
J Neurosurg. 2017 Apr 7:1-8. doi: 10.3171/2016.11.JNS162286. [Epub ahead of print]
Endonasal endoscopic pituitary surgery in the elderly.
Wilson PJ1,2, Omay SB1, Kacker A3, Anand VK3, Schwartz TH1,3,4.
Pituitary adenomas are benign, slow-growing tumors that cause symptoms either through mass effect or hormone overproduction. The decision to operate on a healthy young person is relatively straightforward. In the elderly population, however, the risks of complications may increase, rendering the decision more complex. Few studies have documented the risks of surgery using the endonasal endoscopic approach in a large number of elderly patients. The purpose of this study was to audit a single center's data regarding outcomes of purely endoscopic endonasal transsphenoidal resection of pituitary adenomas in elderly patients and to compare them to the current literature. METHODS A retrospective review of a prospectively acquired database of all endonasal endoscopic surgeries done by the senior authors was queried for patients aged 60-69 years and for those aged 70 years or older. Demographic and radiographic preoperative data were reviewed. Outcomes with respect to extent of resection and complications were examined and compared with appropriate statistical tests. RESULTS A total of 135 patents were identified (81 aged 60-69 years and 54 aged 70 years or older [70+]). The average tumor diameter was slightly larger for the patients in the 70+ age group (mean [SD] 25.7 ± 9.2 mm) than for patients aged 60-69 years (23.1 ± 9.8 mm, p = 0.056). There was no significant difference in intraoperative blood loss (p > 0.99), length of stay (p = 0.22), or duration of follow-up (p = 0.21) between the 2 groups. There was a 7.4% complication rate in patients aged 60-69 years (3 nasal and 3 medical complications) and an 18.5% complication rate in patients older than 70 years (4 cranial, 3 nasal, 1 visual, and 2 medical complications; p = 0.05 overall and 0.013 for cranial complications). Cranial complications in the 70+ age category included 2 postoperative hematomas, 1 pseudoaneurysm formation, and 1 case of symptomatic subdural hygromas. CONCLUSIONS Endonasal endoscopic surgery in elderly patients is safe, but there is a graded increase in complication rates with increasing age. The decision to operate on an asymptomatic or mildly symptomatic patient in these age groups should take this increasing complication rate into account. The use of a lumbar drain or lumbar punctures should be weighed against the risk of subdural hematoma in patients with preexisting atrophy.
DDAVP = 1-desamino-8d-arginine vasopressin; GTR = gross-total resection; NTR = near-total resection; STR = subtotal resection; adenoma; elderly; endonasal; endoscopic; pituitary surgery; transsphenoidal