I. Complications related to hypothalamic-pituitary axis
1. Acute cerebral swelling: The hypothalamus “vasodilatory and contractile regulating function” fails due to injury during surgery, resulting in cerebrovascular paralysis, cerebral blood volume increases dramatically, cerebral blood flow stagnation and acute cerebral swelling. Once it occurs, dehydrating agents are completely ineffective and difficult to save. Prevention should be the main focus. At the beginning of surgery, give drugs to promote hypothalamic vasodilatory function such as cytidylcholine (750mg), add mannitol into the IV, it can play a preventive role.
2, coma, hyperthermia: serious injury to the hypothalamus during surgery, or injury to the penetrating branch, postoperative patients deep coma, central hyperthermia, tracheotomy should be taken immediately to keep the airway open, cooling, maintaining water-electrolyte and acid-base balance.
3, hyponatremia syndrome: hypothalamic injury, postoperative will appear inappropriate secretion of antidiuretic hormone syndrome clinically, the severity of the disease varies, treatment to strictly control the amount of water intake: mild cases can be self-healing 1 to 2 d after water restriction, more serious cases can be supplemented with intramuscular injection of ACTH25mg. initial no salt supplementation, in the daily urinary sodium monitoring, to be urinary sodium <20mmol/24h, can start salt supplementation, severe cases In severe cases, 3% to 5% hypertonic saline may be given, but salt should not be given too quickly.
4, hypernatremia syndrome: intraoperative hypothalamic injury involving the thirst center. When the blood Na+>160mmol/L for more than 24h, the mortality rate can be as high as 60%-70%. Treatment and prognosis depend on early diagnosis and timely rehydration of glucose solution. But should not be rehydrated too fast.
5, urolithiasis: hypothalamic injury, postoperative patients appear polyuria, urine specific gravity <1.006, can be diagnosed as urolithiasis. Generally within 2-3d self-healing. In severe cases, posterior pituitary hormone can be given. If it is persistent, tannin can be given as an intramuscular injection, or as a micoagulation. If the pituitary stalk is cut off during the operation, serious intractable uremia will occur after the operation, and the urine volume can reach 10,000-15,000ml/d, which is difficult to control and requires long-term oral mydriatic therapy.
Anterior pituitary insufficiency
Anterior pituitary insufficiency is more likely to occur after pituitary macroadenoma surgery. In the early postoperative period, the treatment of ACTH-adrenal axis is the main problem
1, pituitary adenoma routine application of corticosteroids before surgery, postoperative application of corticosteroids, and decreasing dosage to a week to stop the drug. If the blood cortisol is rechecked and shows insufficient function, it is advisable to restart substitution therapy. Replacement therapy may last from 3 to 6 months. Even lifelong substitution is possible. In patients with preoperative anterior lobe insufficiency, prolonged replacement therapy is required for 3-7 days before surgery, and long-term replacement therapy is inevitable after surgery.
2, thyroid function: 3 months postoperative review, hypothyroidism (T3 ↓, T4 ↓), oral thyroxine tablets.
3, gonadal insufficiency: in the absence of pituitary gonadotropins (FSH, LH) excitement conditions, the surrounding target gland hormones such as testosterone, estradiol and other supplementation is difficult to play a role, become a blind spot in the pituitary adenoma postoperative replacement therapy. Combined replacement therapy with gonadotropin (FSH, LH) preparations and their surrounding target hormones such as testosterone and estradiol is expected to achieve satisfactory results.
III. Complications directly related to surgery
Cerebrospinal fluid nasal leakage: Cerebrospinal fluid nasal leakage is one of the more common complications of transsphenoidal pituitary tumor resection, and it is a fatal complication if combined with intracranial infection. Some scholars use autologous muscle block, autologous adipose tissue, autologous bone piece or artificial material to repair the saddle base. And mix with streptomycin powder to repair the saddle base.
2.Injury of internal carotid artery: Injury of internal carotid artery is a fatal complication of pituitary tumor transsphenoidal sinus surgery. Some patients die, some cause pseudoaneurysm or internal carotid artery cavernous sinus fistula, and another part leads to postoperative internal carotid artery spasm or thrombosis. In addition to intraoperative positioning devices and neuroendoscopic-assisted surgery, the most important thing is the surgeon’s experience, microsurgical skills and familiarity with anatomical structures.
Prevention of complications
1. Pay attention to the preoperative imaging evaluation.
2.Use the neurosurgical navigation system or C-arm X-ray machine to position the saddle bone window as much as possible under the premise of safety.
3, pay attention to the surgical technique and make full use of neuroendoscopic assisted surgery.
4.Master the midline well.
5.Judgment of the extent of tumor resection.
6.Protection of nasal mucosa.