COVID-19 UK-Cambridge Protocol

Cambridge COVID-19 Protocol for Pituitary and Skull Base Surgery

Angelos Kolias¹, Thomas Santarius¹, Mark Gurnell², Peter Hutchinson¹, Richard J. Mannion¹

1. Division of Neurosurgery, Addenbrooke’s Hospital & University of Cambridge, Cambridge, United Kingdom
2. Department of Endocrinology, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, and National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, United Kingdom

Aerosol-generating procedures on COVID-19 patients or asymptomatic SARS-CoV-2 carriers have the potential for virus transmission to healthcare workers (HCWs). Given that SARS-CoV2 resides within the airway, surgery for pituitary / skull base lesions when access is via the nasal cavity, paranasal sinuses, or mastoid air cells has been flagged as high risk and caution recommended.

We have adopted a risk-mitigation approach for use during the COVID-19 pandemic (see table), as we believe that patients who require expedited surgery for a pituitary / skull base lesion due to progressive neurological or visual symptoms should still receive urgent treatment. In our unit, endoscopic transsphenoidal surgery for pituitary adenomas, translabyrinthine surgery for vestibular schwannomas, and endoscopic resection of malignant skull base tumours are the preferred surgical strategies.

Our paper, published in Acta Neurochirurgica, presents the data of 9 consecutive patients who had expedited surgery for a pituitary / skull base lesion with the use of this protocol during the peak of the pandemic in the UK [1]. No staff sickness related to a COVID-19 diagnosis was observed in any of the 57 HCWs involved in these 9 operations during the follow-up period. Since then, with the use of this protocol, we identified a patient who developed COVID-19 in the last few days prior to his expedited endoscopic endonasal surgery for a pituitary lesion. The patient had developed new onset symptoms and a nasopharyngeal swab was positive. As the patient’s bitemporal hemianopia was stable, we postponed the operation for 30 days and we counselled the patient regarding his vision, asking him to contact us urgently if it worsened in the meantime.

Caution is still needed as the number of cases is small. However, our report confirms that a risk mitigation approach is feasible and can enable timely pituitary and other skull base surgery to continue, and mitigate the burden of non-COVID morbidity for our patients, which is an evergrowing concern during this pandemic.

Reference

1. A safe approach to surgery for pituitary and skull base lesions during the COVID-19 pandemic. Kolias A, Tysome J, Donnelly N, Sharma R, Gkrania-Klotsas E, Budohoski K, Karcheva S, Adapa R, Lawes I, Gurnell M, Hutchinson P, Bance M, Axon P, Santarius T, Mannion RJ. Acta Neurochir (Wien). 2020 May 9:1-3. doi: 10.1007/s00701-020-04396-5