Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for the Role of Medical Perioperative Management for Patients With Functioning Pituitary Adenomas.

Background and objectives: Standardized perioperative management of patients with functioning pituitary adenomas is important for optimal medical and surgical outcomes. Review of the literature to evaluate the impacts of (1) postoperative fluid restriction and sodium level checks to prevent delayed hyponatremia and hospital-related readmissions, (2) preoperative somatostatin analog (SSA) medical treatment in patients with growth hormone-secreting tumors and its effects on surgical and medical outcomes, and (3) immediate postoperative pituitary hormone testing in patients with adrenocorticotropic hormone (ACTH)-secreting tumors to predict adrenal insufficiency and disease remission.

Methods: Systematic literature search using Embase and PubMed from 1946 to June 2021.

Results: A total of 1953 abstracts were identified for review: 124 studies were selected for full-text review, and 44 studies were included in the analyses. Overall, based on predominantly level III evidence, the literature supported the following: (1) fluid restriction (1000-1500 mL/day for ∼7 postoperative days), with/without a routine serum sodium check, to lower the risk of delayed hyponatremia and hospital-related readmission, and (2) basal morning serum cortisol (±ACTH levels), within the immediate postoperative period (≤72 h) for patients with ACTH-secreting tumors to predict adrenal insufficiency and disease remission. Conversely, perioperative treatment of patients with growth hormone-secreting tumors with a SSA is not recommended to improve surgical or medical outcomes.

Conclusion: Limited fluid restriction is recommended for all patients after trans-sphenoidal surgery (without diabetes insipidus), as is routine postoperative morning cortisol testing in patients with Cushing disease, but not somatostatin presurgical treatment in acromegalic patients.