OBJECT The purpose of this study was to describe complications associated with the endonasal, transsphenoidal approach for the treatment of
adrenocorticotropic hormone (
ACTH)-positive staining
tumors (
Cushing's disease [CD] and silent
corticotroph adenomas [SCAs]) performed by 1 surgeon at a high-volume academic medical center. METHODS Medical records from Brigham and Women's Hospital were retrospectively reviewed. Selected for study were 82 patients with CD who during April 2008-April 2014 had consecutively undergone transsphenoidal resection or who had subsequent pathological confirmation of
ACTH-positive
tumor staining. In addition to demographic, patient,
tumor, and surgery characteristics, complications were evaluated. Complications of interest included syndrome of inappropriate
antidiuretic hormone secretion,
diabetes insipidus (DI), CSF leakage,
carotid artery injury,
epistaxis,
meningitis, and vision changes. RESULTS Of the 82 patients, 68 (82.9%) had CD and 14 (17.1%) had SCAs; 55 patients were female and 27 were male. Most common (n = 62 patients, 82.7%) were microadenomas, followed by macroadenomas (n = 13, 14.7%). A total of 31 (37.8%) patients underwent reoperation. Median follow-up time was 12.0 months (range 3-69 months). The most common diagnosis was
ACTH-secreting (n = 68, 82.9%), followed by silent
tumors/
adenomas (n = 14, 17.1%).
ACTH hyperplasia was found in 8 patients (9.8%). Of the 74 patients who had verified
tumors, 12 (16.2%) had
tumors with atypical features. The overall (CD and SCA) rate of minor complications was 35.4%; the rate of major complications was 8.5% (n = 7). All permanent morbidity was associated with DI (n = 5, 6.1%). In 16 CD patients (23.5%), transient DI developed. Transient DI was more likely to develop in CD patients who had undergone a second operation (37.9%) than in those who had undergone a first operation only (12.8%, p < 0.05). Permanent DI developed in 4 CD patients (5.9%) and 1 SCA patient (7.1%). For 1 CD patient, intraoperative
carotid artery injury required endovascular sacrifice of the injured artery, but the patient remained neurologically intact. For another CD patient,
aseptic meningitis developed and was treated effectively with
corticosteroids. One CD patient experienced major postoperative
epistaxis requiring another operative procedure to achieve hemostasis. For 2 CD patients, development of sinus
mucoceles was managed conservatively. For 1 SCA patient, an abdominal
wound dehisced at the fat graft site. No patients experienced postoperative CSF leakage,
visual impairment, or
deep vein thrombosis. CONCLUSIONS Transsphenoidal surgery is the treatment of choice for patients with CD and other
ACTH-positive staining
tumors. Recent advances in endoscopic technology and increasing surgeon comfort with this technology are making transsphenoidal procedures safer, faster, and more effective. Serious complications are uncommon and can be managed successfully.