Aims: Hypophysitis is an inflammation of the pituitary gland or stalk. There are no standardized guidelines for diagnosis and treatment. The present study investigated the role of surgery in diagnosing and treating hypophysitis.

Patient and methods: A retrospective observational study was conducted in the University referral hospital of Marseille, France. Patients over 15 years of age diagnosed with histologically proven hypophysitis between January 1 ^st , 1994 and October 31 ^st , 2023 were included. Additionally, a literature review was performed, focusing on cases with surgical and/or medical management, during the same period. Immune checkpoint inhibitor-related hypophysitis was not included.

Results: In 9 of our 61 patients (14.5%), surgery was indicated mainly for visual disorder (75%). Four showed suspected adenoma. All patients recovered visual function. There was no endocrine improvement.

The literature review of surgical management, with 21 studies, included 289 operated patients (40% due to misdiagnosis of adenoma, and 40% for visual impairment). After surgery, 20% developed new endocrine deficits, while 13% showed hormonal improvement. Visual improvement was seen in 80-90% of cases. Non-endocrine complications were rare (5%).

The literature review of all forms of management included 661 patients from 22 studies. Glucocorticoids improved endocrine deficits in 30% of cases, and worsened pituitary function in 2%. Patients managed by monitoring had a lower incidence of new deficits than patients managed by surgery.

Conclusion: In hypophysitis not related to immune checkpoint inhibitors, surgery should not be performed systematically. It may be indicated in patients with severe visual impairment unresponsive to glucocorticoids or in situations of diagnostic uncertainty after complete medical assessment. In other cases, surgery seems to worsen pituitary function more than glucocorticoids or conservative follow-up, restricting its role to these specific cases after multidisciplinary discussion.