SURGICAL OUTCOME AFTER REPEATED TRANSSPHENOIDAL SURGERY IN ACROMEGALY

Transsphenoidal selective adenomectomy is the most efficient primary t reatment for acromegaly. However, management of persistent or recurren t disease remains controversial. The objective of the present study wa s to evaluate the early and long-term efficacy and safety of a second transsphenoidal surgery performed in those cases. The results of a ret rospective study of 16 patients undergoing reoperation by the senior a uthor (J.H.) between 1970 and 1991 are reported. Reoperation was perfo rmed for persistent or progressive acromegaly in 11 patients, visual i mpairment in four, and disease recurrence in one. Normalization of gro wth hormone (GH) was defined as a basal GH level of less than 5 mu g/L and suppression to less than 2 mu g/L during the oral glucose toleran ce test. Long-term follow-up data were available in 15 patients. The s econd transsphenoidal surgery induced a greater than 50% decrease of G H level in 11 patients. Three (19%) of 16 patients were cured accordin g to the authors' criteria and remained so after 2, 7, and 20 years. T wo more patients had a postoperative basal GH level of less than 5 mu g/L but incomplete suppression during the oral glucose tolerance test. Thus, a total of five patients (31%) achieved a basal GH of less than 5 mu g/L. One other patient who had no initial improvement after the second transsphenoidal surgery had spontaneous normalization of his GH level after 13 years. The following complications of the second surge ry occurred in three patients: one subarachnoid hemorrhage, two new vi sual field defects, one cranial nerve palsy, and one meningitis. Moreo ver, 10 patients (62.5%) developed one or more new pituitary hormone d eficiencies. In conclusion, reoperation for persistent or recurrent ac romegaly has low success and high complication rates. According to the authors' experience, this procedure should be reserved for patients u nresponsive to other forms of therapy or with progressive visual impai rment despite medical therapy.