Endoscopic Pituitary Surgery
What Happens When You Get Referred to Me?
Firstly, try not to panic. I see patients with a multitude of pituitary abnormalities, but invariably more than 99% of these are BENIGN and not in any way cancerous.
Patients are referred to Oxford from a huge variety of doctors and specialists. Many have seen their own endocrinologist in a district general hospital or teaching hospital before being referred on. Many patients come directly from their GP, neurologist, ophthalmologist, gynaecologist and sometimes via a high street optician.
On every occasion, you will be seen in a clinic jointly with my endocrinology colleagues Professor Ashley Grossman and Dr Niki Karavitaki. As it is often quite a distance to come for an appointment we combine this clinic with a day assessment in the endocrine unit where you will have blood tests, an eye test, and some pre-operative tests such as a heart trace and a chest X-Ray if needed.
The Joint Pituitary Clinic
This is held weekly at 1.30 pm every Tuesday at the Oxford Centre for Diabetes Endocrinology and Metabolism next to Sobell house and opposite the Fulbrook Centre. This is in the grounds of the Churchill Hospital in Headington, Oxford.
An appointment at this clinic usually starts in the morning with a full assessment including a visual field test, blood tests and examination by a doctor.
After these tests the appointment with the pituitary team will be in the afternoon. Its quite a big team of people you’ll meet, there will be myself and my fellow (training to be a pituitary surgeon), one or two consultant endocrinologists, some endocrinologists in training, a specialist endocrine nurse, and often some visiting doctors and medical students. We completely understand that it can feel a little overwhelming, but rest assured everyone is there to try and help, and also answer any questions you might have.
If its felt that you need an operation then we can also fix a date at this time, there isn’t a very long waiting list for this type of surgery and so we can often work around patients’ preferred dates.
If You Need Surgery
Part of the function of the joint pituitary clinic is to arrange any investigations, including blood tests prior to an operation. Occasionally we need specialised tests such as a specialised MRI scan, or an ultrasound test of the heart. These can be organised via our clinic, but it does mean that we’ll have to wait for the results before proceeding with an operation.
All NHS pituitary surgery is performed at the John Radcliffe Hospital Department of Neurosurgery situated on Level 2 of the West Wing of the JR. This is the new building you see straight ahead as you enter the grounds of the John Radcliffe Hospital.
My operating list is every Monday, and we usually operate on two patients with pituitary tumours every week. This means that all of the medical staff, nursing staff and operating theatre staff are very familiar with looking after patients with pituitary tumours. The vast majority of patients are admitted to hospital on the evening before surgery on the Sunday, you will usually be asked to come into hospital at about 5pm, if you haven’t heard anything by about 2pm please call the JR switchboard on:
01865 741166 and ask for the neurosciences floor co-ordinator
All operations are performed using a keyhole surgical technique via the nose using an endoscope (telescope)
I have now performed over 1000 of these operations and overall it is a very safe operation with a low complication rate and a very very low rate of serious or life-changing complications.
Every pituitary tumour is different and thus the aims of the operation and the risks of complications are different for all patients. For instance where fertility is important and patients wish to have children, we may need to set the goalposts such that we do the most possible to protect the pituitary gland, sometimes at the risk of leaving a small amount of tumour behind. Any tumour left behind can be monitored perhaps until a patient has successfully had children, and then more definitive treatment given.
Occasionally, we have to treat pituitary tumours more aggressively as the consequences of incomplete treatment are risky. An example of this is Cushing’s disease where the pituitary tumour produces a hormone that can lead to severe effects on the patient’s health, which can ultimately be life threatening. Here we have to balance the risks of not ‘curing’ the Cushing’s disease against fertility and missing other hormones. Overall the safest option is removal of the tumour and risking damage to the normal pituitary gland as all of the hormones can be safely replaced with simple medication.
Most operations take 1-2 hours and are performed by myself and my fellow. We have a specialised anaesthetist who is very used to patients with pituitary problems.
Occasionally we ask your permission to take a small piece of fat from your abdomen or thigh to repair the hole in the bone at the back of your nose, and very occasionally we ask to place a drain in your back called a lumbar drain as part of the operation. This will be performed whilst you are under the same anaesthetic.
After the operation
When you wake up from your anaesthetic you will most likely be in the recovery ward. The operation does not tend to be painful but most patients are given pain relief just in case. there will be no external bruising and you will not have any packs in your nose. Most patients feel their nose is stuffy or partly blocked and this tends to persist for a few days. Occasionally you may experience a small amount of bleeding from the nose, this is very common after an nasal surgery and generally settles quickly, sometimes sitting upright in bed can help with this. You can get out of bed when you feel up to it the same day of the operation to eat / during and use the bathroom etc.
There is a standardised protocol after pituitary surgery for most patients with the plan to discharge you home 48hrs after the operation on the Wednesday afternoon
Tuesday: Restrict drinking to 2 litres, blood tests and urine tests, start hydrocortisone medication
Wednesday: Restrict drinking to 2 litres until blood tests back, blood tests and urine tests, continue hydrocortisone
The Endocrine Drs will review all of you blood and urine tests, we’ll also check you over generally including whether you have any ongoing bleeding or nasal discharge, and if all is well you’ll be able to go home later on the Wednesday.
Prior to going home an appointment will be made for you to come back to the endocrine department (where you where seen in the joint pituitary clinic) on the Monday 1 week after surgery for some blood tests and a visual test. You will remain on the hydrocortisone until this appointment, when we get the blood test results back from the Monday followup appointment it may be possible to stop the hydrocortisone.
At 6 weeks you’ll come back to the Churchill hospital for a more complete assessment of your pituitary gland
At 3 Months you will have an MRI scan
After the MRI scan we’ll review all of your blood tests, scans, and the analysis of the tumour removed at a meeting called an MDT, and determine the long-term plan for scans / blood tests and ay further treatment