Standardized Protocols Reduce Length of Stay in Cushing Disease

Optimizing Surgical Outcomes in Cushing Disease

Transsphenoidal surgery remains the primary treatment for Cushing disease, offering high rates of biochemical remission when performed at experienced pituitary centers [1, 2]. However, the perioperative management of these patients is exceptionally complex due to the systemic effects of hypercortisolism, which increase the risk of venous thromboembolism, impaired wound healing, and metabolic instability [3, 4]. A particularly frequent challenge is delayed symptomatic hyponatremia (low serum sodium levels often caused by the syndrome of inappropriate antidiuretic hormone secretion), a complication that often leads to unplanned readmissions and prolonged hospitalizations [5]. While surgical techniques such as endoscopic and microscopic approaches have been refined to improve resection margins, the impact of standardized clinical pathways on recovery efficiency has remained less clear [6, 7]. A new multicenter study now examines how formalizing perioperative protocols can bridge these gaps in clinical care.

Quantifying the Impact of Formalized Care

The RAPID study (Registry of Adenomas of the Pituitary and Related Disorders) utilized a retrospective analysis to evaluate how standardized care affects surgical recovery in Cushing disease. This multicenter investigation leveraged data from the Registry of Adenomas of the Pituitary and Related Disorders consortium, involving 13 US academic pituitary centers and a total of 832 patients who met the inclusion criteria. The researchers surveyed these institutions to categorize their perioperative management strategies, finding that 10 institutions (76.9%) reported having a postoperative protocol in place. However, the level of formalization varied significantly across the cohort. While 9 institutions (69.2%) used a formal document to outline their clinical pathways, only 3 institutions (23.1%) had protocols implemented into hospital policy, representing the highest level of institutional integration where the protocol is mandated as a standard of care. The analysis demonstrated that the degree of protocol formalization directly correlated with hospital efficiency. The mean length of stay (LOS) was significantly reduced in centers with an established protocol compared to those without such frameworks, at 3.14 versus 3.42 days (P = .032). This benefit became more pronounced as the protocols became more structured. Specifically, centers utilizing a formal document saw a mean LOS of 3.10 days compared to 3.48 days in centers without one (P = .001). The most substantial reduction occurred in institutions where protocols were mandated by hospital policy, resulting in a mean LOS of 2.72 days versus 3.36 days in non-policy centers (P < .001). Furthermore, the researchers observed a temporal benefit within individual institutions, as patients treated after protocol implementation experienced shorter LOS (P < .001) compared to those treated prior to the adoption of standardized pathways.

Clinical Drivers of Early Discharge and Readmission

Beyond institutional policy, the researchers identified several granular clinical interventions that independently contributed to hospital efficiency. The presence of a separate Cushing disease pathway was associated with reduced length of stay (LOS), suggesting that the unique metabolic and endocrine requirements of these patients benefit from specialized management. Specific procedural steps also played a role; for instance, the use of an intraoperative checklist specific to pituitary surgery was associated with reduced LOS. Postoperative orders were equally influential, as a Foley removal order was associated with reduced LOS, likely by facilitating earlier patient mobilization and reducing the risk of catheter-associated infections. Furthermore, the study found that dedicated outpatient advanced practice provider follow-up (care managed by specialized physician assistants or nurse practitioners who provide continuity between the inpatient and outpatient settings) was associated with reduced LOS. Setting clear expectations for recovery also mattered, as a target discharge date of ≤2 days was associated with reduced LOS. The study also evaluated unplanned 90-day readmission (a return to the hospital within three months of discharge) as a primary clinical outcome to ensure that earlier discharge did not compromise patient safety. Several factors that shortened the initial stay also appeared to stabilize the patient's post-surgical course. Specifically, the use of intraoperative checklists was associated with reduced readmission (P = .045), and an aggressive 1-day target discharge date was associated with reduced readmission (P = .032). These findings suggest that highly structured care environments may better prepare patients for a safe transition to home by ensuring all critical surgical and safety steps are verified before the patient leaves the operating room. The choice of surgical technique presented a distinct trade-off in recovery metrics. The researchers found that endoscopic surgery was associated with shorter LOS compared with microscopic surgery, potentially due to the improved visualization and reduced nasal trauma associated with the endoscope. However, this benefit was tempered by the finding that endoscopic surgery was associated with increased readmission odds compared with microscopic surgery. This suggests that while endoscopic patients may meet discharge criteria sooner, they may require more intensive monitoring in the immediate postoperative period to prevent complications that lead to a return to the hospital.

Refining Postoperative Pain and Recovery

The management of postoperative pain and the stabilization of the nasal cavity emerged as critical determinants of both hospital efficiency and patient safety in this multicenter analysis. The researchers found that the use of a non-narcotic pain regimen was associated with reduced length of stay, suggesting that avoiding the sedative and gastrointestinal side effects of opioids may facilitate faster recovery and mobilization. Beyond merely shortening the initial hospitalization, the adoption of non-narcotic pain regimens was associated with reduced readmission (P = .048). This finding indicates that non-opioid analgesia provides sufficient pain control while potentially minimizing the risk of postoperative complications, such as respiratory depression or severe constipation, that might otherwise necessitate a return to the hospital. In addition to pharmacological choices, specific surgical finishing techniques significantly influenced the durability of the patient's recovery. The study demonstrated that the use of nasal packing was associated with reduced readmission (P = .005). While nasal packing is sometimes viewed as a source of patient discomfort, these data suggest its role in preventing postoperative epistaxis (nosebleeds) or cerebrospinal fluid leaks is vital for maintaining a stable course after discharge. For the practicing clinician, these results emphasize that standardized elements of the clinical pathway, particularly non-narcotic analgesia and meticulous local wound management, are essential for optimizing resource utilization without compromising the 90-day safety profile for patients undergoing surgery for Cushing disease.

References

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3. Kahn C, Weber T, Liu M, et al. Venous Thromboembolism and Bleeding in Endonasal Skull Base Surgery: A Systematic Review and Meta‐analysis. Otolaryngology. 2026. doi:10.1002/ohn.70105

4. Pelsma ICM, Faßnacht M, Tsagarakis S, et al. Comorbidities in mild autonomous cortisol secretion and the effect of treatment: systematic review and meta-analysis. European Journal of Endocrinology. 2023. doi:10.1093/ejendo/lvad134

5. Cote DJ, Alzarea A, Acosta MA, et al. Predictors and Rates of Delayed Symptomatic Hyponatremia after Transsphenoidal Surgery: A Systematic Review [corrected].. World neurosurgery. 2016. doi:10.1016/j.wneu.2016.01.022

6. Bastos RVS, Silva CMDM, Tagliarini JV, et al. Endoscopic versus microscopic transsphenoidal surgery in the treatment of pituitary tumors: systematic review and meta-analysis of randomized and non-randomized controlled trials. Archives of Endocrinology and Metabolism. 2016. doi:10.1590/2359-3997000000204

7. Broersen LHA, Biermasz NR, Furth WRV, et al. Endoscopic vs. microscopic transsphenoidal surgery for Cushing’s disease: a systematic review and meta-analysis. Pituitary. 2018. doi:10.1007/s11102-018-0893-3