Artikel
Acromegaly: Repeat transsphenoidal surgery versus medical and radiation treatment in patients not achieving initial surgical remission. A study supporting early reoperation?
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Autoren
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Yawen Wang
- Klinik für Neurochirurgie, Vivantes Klinikum im Friedrichshain Berlin, Germany
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Stephanie Hammersen
- Klinik für Neurochirurgie, Vivantes Klinikum im Friedrichshain Berlin, Germany
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Dag Moskopp
- Klinik für Neurochirurgie, Vivantes Klinikum im Friedrichshain Berlin, Germany
| Veröffentlicht: | 8. Juni 2016 |
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Gliederung
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Objective: Acromegaly is associated with increased morbidity and mortality. Biochemical remission after surgery is reported to range from 35-90%. However, according to the latest survey based on the German Acromegaly Registry about 50% of patients fail to achieve disease control. Therefore early detection of persistent GH excess after surgery is essential to improve management strategies. There is a debate whether or not to offer early repeat surgery. We evaluated remission and complication rates in both - patients after revision and patients after medical and radiation therapy. Is repeat surgery a reasonable option when remission is not achieved in the initial operation?
Method: 43 patients with acromegaly underwent transsphenoidal surgery between 2007-2015. Oral glucose tolerance test was performed on POD2. Remission was defined as GH<1ng/ml. Patients with no remission underwent repeat surgery within 7 days. We evaluated our data with regard to complication and remission rate in long-term follow-up.
Results: 13/43 patients were not in remission after initial surgery. 9/13 underwent early revision. 4/9 patients achieved biochemical control after reoperation. CSF leakage occured in 1/9, diabetes insipidus in 4/9, hypopituitarism in 6/9 and hyposmia in 2/9 cases. No mortality occurred. 9 patients not achieving surgical remission were supposed to receive medical or radiation therapy. In 4 cases non-compliance was the reason for therapy stop. In total all patients who could not be defined as "cured" on POD2 were not in remission in median 4 months postoperative follow-up while in 4/9 patients disease activity had been controlled after early repeat surgery. Taking early revision into account we could achieve a total remission rate of 79% (34/43).
Conclusions: In our series none of those who received medical treatment or radiotherapy could achieve biochemical control. Non-compliance makes medical therapy difficult. Early repeat surgery was the only therapeutic option, which could achieve immediate GH regression. No mortality occured and the morbidity was moderate and in most cases transient while a persistent active acromegaly is associated with increased risk of developing life limiting diseases. We believe early repeat surgery should be considered as a reasonable option when remission cannot be achieved in the initial operation.
