Covid-19 & Pituitary Surgery

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I am aware of a lot of interest in our pituitary community in regards to the situation with Covid-19, and in particular what this means for those with pituitary tumours awaiting surgery.

The Australian Prime Minister, Scott Morrison has just announced the cessation of non-urgent category 2 and all category 3 surgeries. What does that mean? Well category 1 surgeries are listed to require surgery within 30 days due to life or limb-threatening conditions, category 2 surgeries are listed to require surgery within 90 days, and category 3 surgeries within one year.

The majority of pituitary surgeries would come under the category 2 status UNLESS there is rapidly progressive visual loss and/or significant side-effects from functioning tumours that are unable to be controlled with medical therapy. These would be classified as category 1 surgeries. In short, based on our Prime Minister’s announcement, most pituitary surgeries would remain as urgent category 2 surgeries and continue to be performed at this stage.

Unfortunately there is a separate major factor that does however mean trans-sphenoidal pituitary surgeries are NOT proceeding during the Covid-19 crisis. It is known that the Covid-19 virus has high viral shedding within the nasal cavities. As such the testing swabs are performed using a swab inserted around 8cm into the nostril. International experienced has shown that surgery in the nasal passages, particular those that utilise debriders and drills to expand the nasal passage are prone to aerosolise the virus into air-borne particles. These particles remain active for hours and in one report, all fourteen medical, nursing and technical support theatre members of a Wuhan Hospital became infected by Covid-19 during a single endoscopic trans-sphenoidal surgery. There has also been a higher number of ENT (ear nose and throat) surgeon infected with Covid-19, presumedly during the same mechanism when performing endoscopic sinus surgery and the like.

How does this affect you, the pituitary patient? Well, across Australia all neurosurgical units have ceased performing trans-sphenoidal surgery for pituitary patients. The public health ramifications of operating inadvertently on a Covid-19 positive but asymptomatic patient is extreme. It has been recommended by the Neurosurgical Society of Australasia that any urgent pituitary patient who has deteriorating vision and/or apoplexy undergo a craniotomy as opposed to a trans-sphenoidal surgery. Non-urgent pituitary patients (ie those with slow growing tumours, with stable visual field defects, functioning tumours that can be controlled medically) are advised to postpone any pituitary surgery until the Covid-19 situation is controlled.

How long will this last? Until the Covid-19 pandemic is under control, which at this stage is looking like at least 3 months duration. I would recommend liaising with your specialist team with regards to this and any other treatment options.

Questions to ask include:
1. How often should I monitor my pituitary tumour?
2. Do I need regular MRI scans and/or visual field tests?
3. Is there any medications I can take to control the growth of my tumour?
4. Should I have a craniotomy to remove my tumour?
5. Can I start medical therapy for my functioning tumour?
6. What do I do if I suddenly develop a severe headache and loss of vision?

I will come back with more information when it comes to hand but for now, keep safe and remember to continue with social distancing. That is what will help us control things and that is what will allow us to recommence trans-sphenoidal surgeries as soon as possible.

Yi Yuen
Neurosurgeon and Chair (Australian Pituitary Foundation)