30-Day Readmissions and Coordination of Care Following Endoscopic Transsphenoidal Pituitary Surgery: Experience with 409 Patients
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SUBMITTER: Ghiam M
PROVIDER: S-EPMC9272295 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundThe endoscopic transsphenoidal approach is an efficient minimally invasive procedure for removal of pituitary tumors that can be accomplished through a one-hand or two-hand approach. The one-hand procedure through one nostril is more intuitive for surgeons, but maneuvering the instruments can be restrictive. The two-hand procedure using a one-and-half nostril approach provides more precise manipulation. This study aimed to compare the surgical outcomes of one-hand/mono-nostril and two-hand/one-and-half nostril surgeries for resection of large pituitary tumors by a single neurosurgeon.Materials and methodsThe surgical data of 78 consecutive cases with pituitary macroadenoma (diameter >1 cm) were reviewed retrospectively. Altogether, 30 cases received one-hand/mono-nostril surgery, while 48 cases received two-hand/one-and-half nostril surgery. Postoperative outcomes of the two operations were compared.ResultsThe operative time, hospital stay, residual rate of pituitary macroadenoma, visual field, surgical complications, and re-operative rates were slightly improved in the two-hand/one-and-half nostril surgery group compared with that in the one-hand/mono-nostril surgery group (all p>0.05). However, postoperative hypopituitarism was less frequent (1/48; 2.0%) with the two-hand/one-and-half nostril approach than with the mono-nostril approach (p = 0.004). Similar surgical outcomes were found in all patients with either small or large pituitary tumors, except that the difference in postoperative improvement in visual field change reached statistical significance (p = 0.044).ConclusionA single-surgeon endoscopic endonasal transsphenoidal surgery with two-hand/one-and-half nostril approach is an effective and safe procedure for removal of large pituitary tumors.
| S-EPMC8345891 | biostudies-literature
Project description:Objectives Visual dysfunction in patients with pituitary adenomas is a clear indication for endoscopic endonasal transsphenoidal surgery (EETS). However, the visual outcomes vary greatly among patients and it remains unclear what tumor, patient, and surgical characteristics contribute to postoperative visual outcomes. Methods One hundred patients with pituitary adenomas who underwent EETS between January 2011 and June 2015 in a single institution were retrospectively reviewed. General patient characteristics, pre- and postoperative visual status, clinical presentation, tumor characteristics, hormone production, radiological features, and procedural characteristics were evaluated for association with presenting visual signs and visual outcomes postoperatively. Suprasellar tumor extension (SSE) was graded 0 to 4 following a grading system as formulated by Fujimoto et al. Results Sixty-six (66/100) of all patients showed visual field defects (VFD) at the time of surgery, of whom 18% (12/66) were asymptomatic. VFD improved in 35 (35%) patients and worsened in 4 (4%) patients postoperatively. Mean visual acuity (VA) improved from 0.67 preoperatively to 0.84 postoperatively ( p = 0.04). Nonfunctioning pituitary adenomas (NFPAs) and Fujimoto grade were independent predictors of preoperative VFD in the entire cohort ( p = 0.02 and p < 0.01 respectively). A higher grade of SSE was the only factor independently associated with postoperative improvement of VFD ( p = 0.03). NFPA and Fujimoto grade 3 were independent predictors of VA improvement (both p = 0.04). Conclusion EETS significantly improved both VA and VFD for most patients, although a few patients showed deterioration of visual deficits postoperatively. Higher degrees of SSE and NFPA were independent predictors of favorable visual outcomes.
| S-EPMC8289550 | biostudies-literature
Project description:BackgroundTo report the initial experience of surgery for non-functioning pituitary adenoma (NFPA) from a neurosurgeon in a dedicated residency training endoscopic transsphenoidal (ETS) program, and detail the surgical and clinical outcomes during this period.MethodsA prospective series of all patients operated for NFPA, using an ETS approach, during the three first years of experience of a newly board-certified neurosurgeon was analysed. Clinical, radiological and peri-operative data were collected. Extent of resection (EOR) was determined by formal volumetric analysis. Impact of the learning curve and predictive factors of gross total resection (GTR) were determined.ResultsFifty-three patients with NFPA were included in this prospective cohort which was divided in two periods of time ("First period": 30 first cases, and "second period": 23 following cases). Baseline characteristics of the patients in the two periods were similar. Overall occurrence of complication was 22% and was not significantly different in the two periods of time. No patient had severe neurological complication. Gross total resection was achieved in 70% of patients. Mean Extent of resection was 96%. In a multiple linear regression model, a higher EOR was positively correlated with experience (p = 0.018) and negatively correlated with Knosp Score equal to 4 (p < 0.001). Predictive factors for GTR were Higher Knosp grade (p = 0,01), higher pre-operative volume (p = 0.03), and second period of time (p = 0.01).ConclusionNFPA surgery can be safe and efficient during the learning period. Dedicated intensive learning, careful patient selection and multidisciplinary work are key to shorten the learning curve and achieve satisfactory results.
| S-EPMC9379140 | biostudies-literature
Project description:ObjectiveEarly descent of the diaphragm sellae (DS) during endoscopic endonasal transsphenoidal surgery (EETS) for pituitary macroadenoma surgery is occasionally a troublesome event by blocking the surgical field. Here we introduce an alternative technique with the new pituitary retractor and present our clinical experiences.MethodsWe designed a simple and rigid pituitary retractor with the least space occupation in the nasal cavity to be compatible in EETS. The pituitary retractor was held by external holder system to support the herniated DS stably. We retrospectively reviewed a clinical 22 cases of pituitary macroadenomas underwent EETS using the pituitary retractor.ResultsThe pituitary retractor stably pushed up the herniated DS in all cases, and the surgeon proceeded the procedure with bimanual maneuver. The pituitary retractor was helpful to remove tumors around the medial cavernous sinus and behind the DS in 16 and seven cases, respectively. In four cases, the meticulous hemostasis was completed with the direct visualization by the DS elevation with this retractor. Gross total tumor resection was performed in 20/22 patients (91%). The impaired visual function and hypopituitarism were improved in 18/20 (90%) and 7/14 (50%) patients after surgery, respectively. There was no complication related with the pituitary retractor.ConclusionDuring EETS for pituitary macroadenomas, the novel pituitary retractor reported in this study is a very useful technique when the herniated DS block the surgical field and bimanual maneuver. This pituitary retractor can help to result in the excellent surgical outcomes with minimal morbidity.
| S-EPMC8752885 | biostudies-literature
Project description:IntroductionNew financial incentives, such as reduced Medicare reimbursements, have led hospitals to closely monitor their readmission rates and initiate efforts aimed at reducing them. In this context, many surgical departments participate in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), which collects detailed demographic, laboratory, clinical, procedure and perioperative occurrence data. The availability of such data enables the development of data science methods which predict readmissions and, as done in this paper, offer specific recommendations aimed at preventing readmissions.Materials and methodsThis study leverages NSQIP data for 722,101 surgeries to develop predictive and prescriptive models, predicting readmissions and offering real-time, personalized treatment recommendations for surgical patients during their hospital stay, aimed at reducing the risk of a 30-day readmission. We applied a variety of classification methods to predict 30-day readmissions and developed two prescriptive methods to recommend pre-operative blood transfusions to increase the patient's hematocrit with the objective of preventing readmissions. The effect of these interventions was evaluated using several predictive models.ResultsPredictions of 30-day readmissions based on the entire collection of NSQIP variables achieve an out-of-sample accuracy of 87% (Area Under the Curve-AUC). Predictions based only on pre-operative variables have an accuracy of 74% AUC, out-of-sample. Personalized interventions, in the form of pre-operative blood transfusions identified by the prescriptive methods, reduce readmissions by 12%, on average, for patients considered as candidates for pre-operative transfusion (pre-operative hematoctic <30). The prediction accuracy of the proposed models exceeds results in the literature.ConclusionsThis study is among the first to develop a methodology for making specific, data-driven, personalized treatment recommendations to reduce the 30-day readmission rate. The reported predicted reduction in readmissions can lead to more than $20 million in savings in the U.S. annually.
| S-EPMC7480861 | biostudies-literature
Project description:BACKGROUND:Microscopic transsphenoidal surgery (mTSS) is a well-established method to address adenomas of the pituitary gland. Endoscopic transsphenoidal surgery (eTSS) has become a viable alternative, however. Advocates suggest that the greater illumination, panoramic visualization, and angled endoscopic views afforded by eTSS may allow for higher rates of gross total tumor resection (GTR). The aim of this meta-analysis was to determine the rate of GTR using mTSS and eTSS. METHODS:A meta-analysis of the literature was conducted using PubMed, EMBASE, and Cochrane databases through July 2017 in accordance with PRISMA guidelines. RESULTS:Seventy case series that reported GTR rate in 8257 pituitary adenoma patients were identified. For all pituitary adenomas, eTSS (GTR=74.0%; I2 =?92.1%) was associated with higher GTR as compared to mTSS (GTR=66.4%; I2 =?84.0%) in a fixed-effect model (P-interaction <?0.01). For functioning pituitary adenomas (FPAs) (n?=?1170 patients), there was no significant difference in GTR rate between eTSS (GTR=75.8%; I2 =?63.9%) and mTSS (GTR=75.5%; I2 =?79.0%); (P-interaction?=?0.92). For nonfunctioning pituitary adenomas (NFPAs) (n?=?2655 patients), eTSS (GTR=71.0%; I2 =?86.4%) was associated with higher GTR as compared to mTSS (GTR=60.7%; I2 =?87.5%) in a fixed-effect model (P-interaction <?0.01). None of the associations were significant in a random-effect model (all P-interaction >?0.05). No significant publication bias was identified for any of the outcomes. CONCLUSION:Among patients who were not randomly allocated to either approach, eTSS resulted in a higher rate of GTR as compared to mTSS for all patients and for NFPA patients alone, but only in a fixed-effect model. For FPA, however, eTSS did not seem to offer a significantly higher rate of GTR. These conclusions should be interpreted with caution because of the nature of the included non-comparative studies.
| S-EPMC5899014 | biostudies-literature
Project description:BackgroundIntraoperative low field MRI (iMRI, 0.15 T) during transsphenoidal surgery on pituitary adenomas (PAs) may significantly improve tumor removal. However, extensive surgery can lead to pituitary hormone deficiency. Furthermore, introduction of iMRI will prolong duration of surgery, which may elevate risk of postoperative infections.MethodsOverall, 180 transsphenoidal surgeries for PAs from 2007 to 2015 were included. IMRI was available from 2011 to 2015, during this period 67/78 (86%) surgeries were with iMRI (iMRI, n = 67). A total of 113 surgeries were performed without iMRI (controls). All surgical procedures were performed by microscopic technique. Tumor size, hormonal status and vision were assessed before surgery and 3-5 months postoperatively.ResultsGross total resection (GTR), mean tumor remnant volume and ∆-volumes were comparable between iMRI and controls: 15% (10/66) vs 23% (26/109) (P = 0.17), 2.97 cm3 (0.9-5) vs 2.1 cm3 (1.6-2.6) (P = 0.3) and 4.5 cm3 (3.6-5.5) vs 5.1 cm3 (4.2-6) (P = 0.4), respectively. Duration of surgery was significantly longer during iMRI vs controls: 126 min (117-135) vs 98 min (92-103) (P < 0.001). New pituitary-adrenal deficiency in iMRI vs controls was seen in 35% (17/48) and 35% (23/66) of surgeries, respectively (P = 0.95). New thyroid deficiency was found in 33% (13/29) and 41% (28/69) and visual field deficiencies improved in 44% (19/43) and 38% (23/60) in iMRI vs controls, respectively (P > 0.1).ConclusionTumor remnant after pituitary surgery was not significantly reduced using intraoperative low field MRI. Duration of surgery was increased in iMRI, but was not associated with increased infection rate. Pituitary hormonal function and vision were comparable between iMRI and controls.
| S-EPMC6063879 | biostudies-literature
Project description:BACKGROUND:General anesthesia with intravenous or inhalation anesthetics reduces respiratory functions. We investigated the effects of propofol, desflurane, and sevoflurane on postoperative respiratory function tests. METHODS:This single-center randomized controlled study was performed in a university hospital from October 2015 to February 2017. Ninety patients scheduled for endoscopic endonasal transsphenoidal pituitary surgery were randomly categorized into either of these three groups: propofol (n = 30, the Group TIVA), desflurane (n = 30, the Group D) or sevoflurane (n = 30, the Group S). We analyzed the patients before, after, and 24 h following surgery, to identify the following parameters: forced expiratory volume in 1 second (FEV1) %, forced vital capacity (FVC) %, FEV1/FVC, and arterial blood gases (ABG). Furthermore, we also recorded the intraoperative dynamic lung compliance and airway resistance values. RESULTS:We did not find any significant differences in FEV1 values (primary outcome) among the groups (P = 0.336). There was a remarkable reduction in the FEV1 and FVC values in all groups postoperatively relative to the baseline (P < 0.001). The FVC, FEV1/FVC, ABG analysis, compliance, and airway resistance were similar among the groups. Intraoperative dynamic compliance values were lower at the 1st and 2nd hours than those immediately after intubation (P < 0.001). CONCLUSIONS:We demonstrated that propofol, desflurane, and sevoflurane reduced FEV1 and FVC values postoperatively, without any significant differences among the drugs.
| S-EPMC6900426 | biostudies-literature
Project description:Objective:To compare patients' and providers' views on contributors to 30-day hospital readmissions. Design:Analysis of a qualitative interview survey between 18 May-30 June 2015. Setting:Interviews were conducted during the 30-day readmission hospitalisation at a single tertiary care academic hospital. Participants:We conducted 178 interviews of readmitted patients. Measures:We queried opinions of what factors patients believed contributed to their rehospitalisation and compared this with the perspective of the index admission provider. The primary outcome was the view that the readmission was preventable. A review by a RN (nurse) case manager also provided an assessment based on patient report, provider report and chart review. Results:Patients were more likely to view a readmission as preventable compared with physicians (p<0.0001). Patients identified system issues (defined as factors controlled by the hospital discharge process) as contributors to their readmission in 58% (103/178) of cases while providers identified system issues as the contributor to a patients' readmission in 2% (2/101) of cases. Patients with poor functional status were more likely to feel the cause of their readmission was due to system issues than patients with better functional status (p=0.03). A RN case manager review determined that in 48% (86/178) of cases the system had some amount of contribution to a patient's readmission. There was no significant difference in belief that the readmission was preventable between the RN case manager and the patient (p=0.47). Conclusions:Readmitted patients often feel that the hospital system contributed to their readmission. Providers did not recognise patient and RN case manager identified issues as contributors to hospital readmissions.
| S-EPMC6327873 | biostudies-literature
Project description:Differentiation of pituitary neuroendocrine tumor (PitNET) tissue from surrounding normal tissue during surgery is challenging. A number of fluorescent agents is available for visualization of tissue discrepancy, with the potential of improving total tumor resection. This review evaluates the availability, clinical and technical applicability of the various fluorescent agents within the field of pituitary surgery. According to PRISMA guidelines, a systematic review was performed to identify reports describing results of in vivo application of fluorescent agents. In this review, 15 publications were included. Sodium Fluorescein (FNa) was considered in two studies. The first study reported noticeable fluorescence in adenoma tissue, the second demonstrated the strongest fluorescence in non-functioning pituitary adenomas. 5-Aminolevulinic acid (5-ALA) was investigated in three studies. One study compared laser-based optical biopsy system (OBS) with photo-diagnostic filter (PD) and found that the OBS was able to detect all microadenomas, even when MRI was negative. The second study retrospectively analyzed twelve pituitary adenomas and found only one positive for fluorescence. The third investigated fifteen pituitary adenomas of which one displayed vague fluorescence. Indocyanine green (ICG) was researched in four studies with variable results. Second-Window ICG yielded no significant difference between functioning and non-functioning adenomas in one study, while a second study displayed 4 times higher fluorescence in tumor tissue than in normal tissue. In three studies, OTL38 showed potential in non-functioning pituitary adenomas. At present, evidence for fluorescent agents to benefit total resection of PitNETs is lacking. OTL38 can potentially serve as a selective fluorescent agent in non-functioning pituitary adenomas in the near future.
| S-EPMC9156450 | biostudies-literature