Abstract

Background: Endoscopic endonasal transsphenoidal approach (EETA) is a well-established technique for sellar tumor resection. However, this route causes aerosol dispersion from the nasal cavity. In the context of the coronavirus (COVID-19) pandemic, new measures were taken aiming at the safety and protection of patients and health-care professionals. Herein, we present a Brazilian experience with EETA during COVID-19 pandemic.

Methods: This study was based on the review of medical records and observation in the operating room of the patients undergoing endoscopic surgery in the period from May 2020 to July 2022. All patients were tested by real-time polymerase chain reaction (RT-PCR) COVID-19 before and after surgery. Since September 2021, it has been mandatory to present vaccination cards for adults (over 18 years old).

Results: This case series included 28 patients and 35 surgical procedures using the EETA, who presented of nonfunctioning macroadenomas (19 cases − 67.8%), GH-secreting tumor (three cases − 10.8%), ACTH-secreting tumor (three cases − 10.8%), meningiomas (two cases − 7.1%), and Rathke’s cleft cyst (one case – 3.5%). There were eight cases of diabetes insipidus (28.5%), five cases of cerebrospinal fluid leak (17.8%), and one case of meningitis (3.5%). Three patients died due to meningitis (one case), carotid occlusion (one case), and COVID-19 complications (one case).

Conclusion: A simple protocol was established to perform EETA during the COVID-19 pandemic. The pituitary surgeries were maintained to treat critical cases. To date, the protocol should be continually updated to improve the procedure’s safety.

Keywords: COVID-19, Pandemic, Pituitary, Transsphenoidal

INTRODUCTION

Endoscopic endonasal transsphenoidal technique is the main surgical approach for most types of sellar and suprasellar lesions. It is a less invasive procedure with less complications, when compared to other approaches.[ 21 ] Unfortunately, due to coronavirus (COVID-19) pandemic, there is a high risk of patient contamination with the virus and also staff contamination during airway manipulation procedures. Hence, the neurosurgery and skull base societies considered the open approach as an alternative solution.[ 9 ] Due to the severity of the complications and limitations of open approach, it is important to weigh the risks and benefits of endoscopic endonasal transsphenoidal approach (EETA).[ 13 ] Therefore, this article aims to describe the Brazilian experience with EETA during the COVID-19 pandemic.

MATERIALS AND METHODS

This case series described patients with pituitary lesions who underwent EETA from May 2020 to July 2022 in Pedro Ernesto University Hospital, Rio de Janeiro, Brazil. Because of the pandemic, only patients with a high risk of visual loss, severe hormonal dysfunction, apoplexy, or refractory headache were selected for surgery. The information used in this study was collected from the medical and surgical records, operating room (OR) observations, and pathology results.

A general safety protocol was established. The mandatory use of N95 for the professionals/patients inside the neurosurgery unit and the OR was implemented. In periods with increased COVID-19 cases, visits to hospitalized patients were suspended and all information were provided by video calls. Exceptions were made for hospital companions of patients under 18 s and over 65 s – with mandatory negative reverse transcriptase polymerase chain reaction (RT-PCR) for the COVID-19 test. The symptomatic or positive RT-PCR cases were isolated and transferred to internal COVID-19 units. Since September 2021, it has been mandatory to present vaccination cards for adults (over 18 years old). During the pandemic period, the staff and patients who presented respiratory symptoms or positive RT-PCR were submitted to a 10–14-day quarantine. It was possible to perform RT-PCR screening and avoid chest computed tomography (CT).

The surgical protocol was based on: (a) preoperative period: patient’s screening with RT-PCR at least 3 days before hospital admission for all patients. The surgical procedure was performed on the following day, (b) intraoperative period: preparation used a different anesthetic induction that was based on the rapid sequence intubation. It was constituted in a reduced dose of opioids (fentanyl or remifentanil) in the induction period, in addition to the lower doses of hypnotics (propofol and ketamine) and neuromuscular blockers (succinylcholine and rocuronium). Only the anesthesiologist was present in the OR during the intubation procedure. It was mandatory to use individual protection equipment, for example, gloves and cloak. A nasal drape (Steri-Drape, 3M, Minnesota, United States) was used to reduce the nostril entry area [ Figures 1a - d ], and (c) postoperative period: due to the risk of nasopharynx swab after skull base procedures, the suspected cases were tested with oropharynx swabs. All other patients in the intensive care unit were regularly tested with RT-PCR.

Figure 1:

(a) Overview of patient preparation. During the perioperative period, the patient was covered by the nasal and surgical drapes. (b) Nasal drape was used to reduce the nostril. (c) All team members used N95 and surgical cloak. (d) The instruments were inserted through the reduced nostril.

RESULTS

This study described 28 patients and 35 surgical procedures using the EETA between May 2020 and July 2022. Data are resumed in Table 1 . The age varied from 15 to 75 years old – average (56 years old)); 15 were male and 13 were female. The procedures included resection of (a) pituitary adenomas: nonfunctioning macroadenomas (19 cases − 67.8%), growth hormone-secreting tumor (three cases − 10.8%), ACTH hormone-secreting tumor (three cases − 10.8%); (b) meningiomas (two cases − 7.1%); and (c) Rathke’s cleft cyst (one case − 3.5%). Nonetheless, 5 patients (17.8%) had to be submitted to a second procedure due to cerebrospinal fluid (CSF) fistula: one patient developed fatal meningitis despite CSF leak closure and the other four were successfully treated after antibiotic therapy and skull base surgery reconstruction. One patient (3.5%) died due to a right internal carotid artery infarct. Furthermore, 8 patients (28.5%) presented diabetes insipidus in the postoperative period requiring desmopressin. Fifteen patients (53.5%) had no complications.

Table 1:

Detailed data of 28 patients that had endoscopic endonasal transsphenoidal approach during COVID-19 pandemic in Brazil.

There was one case of COVID-19-related complication: a 15-year-old boy diagnosed with Cushing disease (preoperative cortisol 63.4 µg/dL) was admitted and the magnetic resonance imaging of sella turcica exhibited a right nodular pituitary lesion, measuring 2.0 × 1.5 mm [ Figure 2a ]. His preoperative RT-PCR was negative. The patient underwent EETA and the postoperative basal serum cortisol was 9.0 µg/dL. On the 4^th postoperative day, he presented rhinorrhea, nasal congestion, and cough and his second RT-PCR was positive. The patient progressed with acute respiratory failure on the 10^th postoperative day requiring orotracheal intubation. He developed bacterial pneumonia, septic shock, and renal failure. After 1 month, the patient was with a coma and the absence of brain reflexes. The cranial CT exhibited a large right frontal intraparenchymal hemorrhage with subfalcine herniation [ Figure 2b ]. Cardiorespiratory arrest occurred on the 57^th postoperative day.

Figure 2:

(a) Coronal sellar MRI - red arrow shows a left microadenoma. (b) Postoperative cranial computed tomography exhibiting a large intracranial hemorrhage – right frontal lobe. There are multiple other frontoparietal hemorrhagic foci and signs of subfalcine herniation.

DISCUSSION

Some reference centers worldwide during the COVID-19 pandemic developed local protocols to perform ETTA safely. Most patients underwent urgent pituitary surgery due to chiasm compression, severe hormonal dysfunction, pituitary apoplexy, or refractory headache.[ 7 ] The centers used the clinical history and the following strategies to investigate COVID-19 in the preoperative period: (a) RTPCR alone,[ 3 , 17 , 20 ] (b) blood test (IgM/IgG) and RT-PCR,[ 14 , 24 ] (c) only chest CT,[ 2 , 22 ] and (d) RT-PCR and chest.[ 1 ] To reduce contamination in the OR, most groups used one surgical mask plus N95, face shields, eye protection, surgical gown, double surgical glove, and limited staff members presence.[ 6 ] The literature collected data is summarized in Table 2 .

Table 2:

Review of the literature data about endoscopic endonasal transsphenoidal approach during the COVID-19 pandemic: investigation, reported cases, complications, and staff contamination.

Different surgical strategies were implemented in COVID-19-negative patients. Arnaout et al. (Egypt)[ 2 ] prevented the dissemination of vapor or surgical debris using an extra suction tube inside the nostril. Barbosa et al. (Brazil)[ 3 ] sealed the patient’s head and trunk with a surgical microscope bag, leaving a small hole to insert the endoscopic instruments. Other groups used a negative pressure room (India and Japan)[ 16 , 1 ] and a flexible suction catheter in the nasopharynx for passive smoke evacuation (India).[ 16 ] The cranial consortium (United Kingdom and Ireland)[ 5 ] reported the following protocol: the patients were wrapped in a plastic cover and instruments sealed with plastic drapes. Solari et al. (Italy)[ 18 ] described the use of a latex endonasal surgery facial mask (namely, a nose lid) to seal the nostrils.

There were different protocols for COVID-19-positive patients: (a) simulation trainees before the skull base surgery;[ 14 ] (b) negative pressure rooms or exclusive OR;[ 23 ] (c) restricted personnel in the OR;[ 15 ] (d) powered air-purifying respirators (PAPRs) during the procedures;[ 11 , 4 ] (e) drapes on the patients head and face with an additional layer of transparent Steri-Drape;[ 23 ] and (f) tracheal suction in the nasopharynx throughout surgery with additional standard suction tips used during drilling to reduce contamination.[ 23 ] Our surgical protocol was based on the previous data.[ 3 , 5 , 6 ] There were applied different strategies for surgical procedures in the pre, peri, and postoperative period following previous guidelines.[ 3 , 5 , 6 , 9 ] The RT-PCR before admission, anesthetic procedures, use of personal protective equipment, and reduction of nostril size with plastic cover were some of the measures implemented. Unfortunately, due to institutional resources limitations, it was not possible to add some devices as negative pressure rooms and PAPR.

Regarding surgical complications[ 12 , 19 ] of endoscopic skull base surgery, we presented a higher rate of general complications compared to a prepandemic meta-analysis including 779 patients of 20 retrospective case series.[ 8 ] The following complications observed in this case series compared to the meta-analysis were as follows: CSF leak (17.8% vs. 11.7%); diabetes insipidus (28.5% vs. 11.5%); and meningitis (3.5% vs. 1.8%), respectively. There was also a higher surgical mortality rate compared to Halvorsen et al. series,[ 10 ] including 506 procedures (10.7% vs. 0.6%). Furthermore, there were no cases of postoperative hypopituitarism, increased visual defects, epistaxis, lower extremity deep vein thrombosis, or reoperation for hematoma.

To date, the surgical team implemented a recent aggressive strategy trying to achieve gross total resection. This includes an extended approach with a large sphenoid sinus/sellar floor opening; extensive tumor dissection raising the risk of sellar roof opening; and CSF fistula. To overcome these complications, especially the CSF leak, multiple layers for skull base reconstruction with nasoseptal flap and fat-fascia graft were used. Regarding the COVID-19 pandemic and skull base surgery, there are no definitive data about complications rates.

One patient suffered from COVID-19 4 days after the surgery. It was not possible to identify the infection source; however, as a pediatric patient, there was an obligation to have a companion during hospitalization increasing the patient exposure. To date, the companion admission RT-PCR was negative. On the 4^th postoperative day, the parent tested positive. The cause of the COVID-19-related death in this case series was not identified. It is possible that the hypercoagulability state of Cushing disease could have influenced the course of COVID-19 infection.

CONCLUSION

Our institutional protocol to perform EETA during COVID-19 pandemic was easy to implement and the pituitary surgeries were maintained during the pandemic only to treat critical cases. Nevertheless, the protocols should be continually updated for greater patient and health-care professional safety.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

The authors received financial support from FAPERJ – Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro and NIPNAC – Center of High Complexity Neurosurgery Intern Patients from Rio de Janeiro State Department of Health.

Conflicts of interest

There are no conflicts of interest.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

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