Perioperative management of patients with acromegaly-a retrospective analysis


  • Nethra H. Nanjundaswamy Department of Anesthesiology, Bangalore Medical College and Research Institute, Bangalore, Karnataka, India
  • Raghavendra Biligiri Sridhara Department of Anesthesiology, Bangalore Medical College and Research Institute, Bangalore, Karnataka, India



Acromegaly, Growth Hormone, Pituitary, Perioperative, Retrospective, Surgery


Background: Acromegaly poses several challenges to the anesthetists, neurosurgeons, endocrinologists and intensivists, mandating a careful, coordinated multidisciplinary approach for a successful surgical outcome. An emphasis is required on a thorough preoperative evaluation of airway, neurological and endocrine and metabolic status so as to formulate a suitable perioperative management plan.

Methods: The rates of various perioperative complications, both surgical and anesthesia related, during pituitary surgeries in acromegaly patients were studied. Data collected included demographics, patient’s medical history and any associated comorbid conditions, diagnosis, procedure performed, anesthetic management, intraoperative and postoperative complications.

Results: This is a retrospective analysis of 22 patients of acromegaly who underwent excision of a growth hormone (GH) secreting pituitary adenoma from October 2012 to December 2017. Male: female, 14:8 with a mean age of 32±9.5 years. The common presenting symptoms were somatic dysmorphism, headache, visual field defects and menstrual irregularities. Preoperative associated co-morbidities were hypertension (4), diabetes mellitus (6), Ischemic Heart Disease (1), hypothyroidism (3), situs solitus (1), lumbar and cervical disc prolapse (1), nephropathy (1) and poliomyelitis (1). One patient had difficult tracheal intubation with repeated attempts at direct laryngoscopy and surgery was deferred to a later date where awake fibreoptic bronchoscopic intubation was done. Two more patients with anticipated difficult airway, trachea was intubated using a fibreoptic bronchoscope. Out of 22 Transsphenoidal surgical approach (transnasal or sublabial) and pterional craniotomy in 18 and 4. Inhalational anaesthetic was used in the majority of patients (isoflurane, 18 and sevoflurane, 03) propofol infusion was used in 1 patient. Intraoperative cardiac complications like hypertension, ventricular ectopics was seen. Postoperatively metabolic, water and electrolyte imbalance were common occurance. CSF rhinorrhoea in 4 patients and one developed meningitis.

Conclusions: The present data shows that patients undergoing pituitary surgery for acromegaly have many airway issues, cardiac and metabolic risk factors.


Aiketerini L, Alessandro P, John A, Wass H, Niki K. Pituitary. 2017;20(1):4-9.

Abraham M. Perioperative management of patients with pituitary tumours. J Neuroanaesthesiol Crit Care. 2016;3:211-8.

Marulasiddappa V, Raghavendra. Anaesthetic management of a patient with extreme Gigantism for endoscopic transsphenoidal removal of pituitary adenoma. Int J Res Health Sci. 2015;3(1):62-5.

Vasu TS, Grewal R, Doghramji K. Obstructive sleep apnea syndrome and perioperative complications: A systematic review of the literature. J Clin Sleep Med. 2012;8:199-207.

Bottini P, Tantucci C. Sleep apnea syndrome in endocrine diseases. Respiration. 2003;70:320-7.

Colao A, Ferone D, Marzullo P, Lombardi G. Systemic complications of acromegaly: Epidemiology, pathogenesis, and management. Endocr Rev. 2004;25:102-52.

Sze L, Schmid C, Bloch KE, Bernays R, Brändle M. Effect of transsphenoidal surgery on sleep apnoea in acromegaly. Eur J Endocrinol. 2007;156:321-9.

Adesanya AO, Lee W, Greilich NB, Joshi GP. Perioperative management of obstructive sleep apnea. Chest. 2010;138:1489-98.

Rahimi E, Mariappan R, Tharmaradinam S, Manninen P, Venkatraghavan L. Perioperative management and complications in patients with obstructive sleep apnea undergoing transsphenoidal surgery: Our institutional experience. J Anaesthesiol Clin Pharmacol. 2014;30:351-4.

Melmed S, Casanueva FF, Cavagnini F, Chanson P, Frohman L, Grossman A, et al. Guidelines for acromegaly management. J Clin Endocrinol Meta. 2002;87:4054-8.

Han ZL, He DS, Mao ZG, Wang HJ. Cerebrospinal fluid rhinorrhea following trans-sphenoidal pituitary macroadenoma surgery: Experience from 592 patients. Clin Neurol Neurosurg. 2008;110:570-9.

Shiley SG, Limonadi F, Delashaw JB, Barnwell SL, Andersen PE, Hwang PH, et al. Incidence, etiology, and management of cerebrospinal fluid leaks following transsphenoidal surgery. Laryngoscope. 2003;113:1283-8.

Gondim JA, Almeida JP, Albuquerque LA, Schops M, Gomes E, Ferraz T, et al. Endoscopic endonasal approach for pituitary adenoma: surgical complications in 301 patients. Pituitary. 2011;14:174‑83.

Ali Z, Bithal PK, Prabhakar H, Rath GP, Dash HH. An assessment of the predictors of difficult intubation in patients with acromegaly. J Clin Neurosci. 2009;16:1043-45.

Messick JM Jr, Cucchiara RF, Faust RJ. Airway management in patients with acromegaly. Anesthesiol. 1982;56:157.

Schmitt H, Buchfelder M, Radespiel‑Troger M, Fahlbusch R. Difficult intubation in acromegalic patients: incidence and predictability. Anesthesiol. 2000;93:110‑4.

Nemergut EC, Zuo Z. Airway management in patients with pituitary disease: A review of 746 patients. J Neurosurg Anesthesiol. 2006;18:73‑7.

Law‑Koune JD, Liu N, Szekely B, Fischler M. Using the intubating laryngeal mask airway for ventilation and endotracheal intubation in anesthetized and unparalyzed acromegalic patients. J Neurosurg Anesthesiol. 2004;16:11‑3.

Hakala P, Randell T, Valli H. Laryngoscopy and fibreoptic intubation in acromegalic patients. Br J Anaesth. 1998;80:345‑7.

Fabregas N, Lopez A, Valero R, Carrero E, Caral L, Ferrer E. Anesthetic management of surgical neuroendoscopies: Usefulness of monitoring the pressure inside the neuroendoscope. J Neurosurg Anesthesiol. 2000;12:21-8.

Chowdhury T, Prabhakar H, Bithal PK, Schaller B, Dash HH. Immediate postoperative complications in transsphenoidal pituitary surgery: A prospective study. Saudi J Anaesth. 2014;8:335-41.

Lie JT, Grossman SJ. Pathology of the heart in acromegaly: Anatomic findings in 27 autopsied patients. Am Heart J. 1980;100:41-51.

Rajasoorya C, Holdaway IM, Wrightson P, Scott DJ, Ibbertson HK. Determinants of clinical outcome and survival in acromegaly. Clin Endocrinol (Oxf). 1994;41:95‑102.

Lopez‑Velasco R, Escobar‑Morreale HF, Vega B, Villa E, Sancho JM, Moya‑Mur JL, et al. Cardiac involvement in acromegaly: specific myocardiopathy or consequence of systemic hypertension? J Clin Endocrinol Metab. 1997;82:1047‑53.

Herrmann BL, Bruch C, Saller B, Bartel T, Ferdin S, Erbel R, et al. Acromegaly: Evidence for a direct relation between disease activity and cardiac dysfunction in patients without ventricular hypertrophy. Clin Endocrinol (Oxf). 2002;56:595‑602.

Fazio S, Cittadini A, Sabatini D, Merola B, Colao AM, Biondi B, et al. Evidence for biventricular involvement in acromegaly: a doppler echocardiographic study. Eur Heart J. 1993;14:26‑33.

Dunn LK, Nemergut EC. Anesthesia for transsphenoidal pituitary surgery. Curr Opin Anaesthesiol. 2013;26:549‑54.

Singer PA, Sevilla LJ. Postoperative endocrine management of pituitary tumors. Neurosurg Clin N Am. 2003;14:123‑38.

Hensen J, Buchfelder M, Henig A, Fahlbusch R. Disturbances of osmoregulation in the neurosurgical setting-with special emphasis on the situation after surgery for pituitary adenomas. Werder K, Fahlbusch R: Pituitary adenomas-from basic research to diagnosis and therapy. Elsevier Excerpta Medica, Amsterdam. 1996:255-68.

Van Aken MO, de Marie S, van der Lely AJ, Singh R, de Marie S, van den Berge JH, et al. Risk factors for meningitis after transsphenoidal surgery. Clinical infectious diseases. 1997;25(4):852-6.




How to Cite

Nanjundaswamy, N. H., & Sridhara, R. B. (2018). Perioperative management of patients with acromegaly-a retrospective analysis. International Journal of Research in Medical Sciences, 6(2), 515–520.



Original Research Articles