Shiley Samuel G, Limonadi Farhad, Delashaw Johnny B, Barnwell Stanley L, Andersen Peter E, Hwang Peter H, Wax Mark K
Department of Otolaryngology-Head and neck Surgery, Orgon Health and Science University, Portland, 97239, USA.
Laryngoscope. 2003 Aug;113(8):1283-8. doi: 10.1097/00005537-200308000-00003.
OBJECTIVES/HYPOTHESIS: The incidence of cerebrospinal fluid (CSF) leak following trans-sphenoidal surgery ranges from 0.5% to 15.0%. Factors predicting which patients are likely to develop postoperative leaks and optimal management of these patients are poorly defined. The objective was to determine 1) the incidence of CSF leak following trans-sphenoidal surgery; 2) demographic or intraoperative factors associated with postoperative leaks; 3) techniques and efficacy of postoperative leak management at Oregon Health and Science University, (Portland, OR).
Retrospective chart review.
Two hundred thirty-five trans-sphenoidal surgeries were performed on 216 patients between 1994 and 2001. Follow-up data were available for 217 operations (92.3%) performed on 202 patients (93.5%).
Postoperative CSF leaks occurred in 6.0% (13 of 217) of patients. Leaks were more common in the setting of revision surgery versus primary surgery (14.6% vs. 4.0%, P =.0096), nonadenomatous disease versus pituitary adenoma (15.8% vs. 5.1%, P =.059), or if an intraoperative leak occurred (12.7% vs. 2.7%, P =.004). However, on multivariate analysis, only the presence of intraoperative leak (P =.008) and nonadenomatous disease (P =.047) were found to be independently associated with postoperative CSF leak. Size of adenoma was not associated with occurrence of postoperative CSF leak (6.4% for microadenoma vs. 4.2% for macroadenoma) on both univariate and multivariate analysis. There were 13 postoperative CSF leaks: 2 resolved with lumbar drainage and 11 required operative management (three required multiple procedures). Of the three patients who required multiple operations, two had hospital courses complicated by meningitis and postinfectious hydrocephalus and ultimately required ventriculoperitoneal shunts. Endoscopic re-exploration was successful in 87.5% (7 of 8) of cases.
Cerebrospinal fluid leaks following trans-sphenoidal surgery occurred in 6.0% of cases. Nonadenomatous disease and presence of an intraoperative leak were independent predictors of a postoperative leak. Endoscopic re-exploration combined with packing was an effective technique in managing uncomplicated postoperative leaks. In the setting of meningitis and postinfectious hydrocephalus, more invasive techniques such as ventriculoperitoneal shunt may be necessary.
目的/假设：经蝶窦手术后脑脊液漏的发生率为0.5%至15.0%。预测哪些患者可能发生术后漏以及对这些患者的最佳管理的因素尚不明确。目的是确定：1）经蝶窦手术后脑脊液漏的发生率；2）与术后漏相关的人口统计学或术中因素；3）俄勒冈健康与科学大学（波特兰，俄勒冈州）术后漏的管理技术及效果。
回顾性病历审查。
1994年至2001年间对216例患者进行了235次经蝶窦手术。202例患者（93.5%）的217次手术（92.3%）有随访数据。
6.0%（217例中的13例）患者发生术后脑脊液漏。与初次手术相比，翻修手术时漏更常见（14.6%对4.0%，P = 0.0096），非腺瘤性疾病与垂体腺瘤相比（15.8%对5.1%，P = 0.059），或术中发生漏时（12.7%对2.7%，P = 0.004）。然而，多因素分析显示，仅术中漏的存在（P = 0.008）和非腺瘤性疾病（P = 0.047）与术后脑脊液漏独立相关。单因素和多因素分析均显示腺瘤大小与术后脑脊液漏的发生无关（微腺瘤为6.4%，大腺瘤为4.2%）。共有13例术后脑脊液漏：2例通过腰大池引流治愈，11例需要手术治疗（3例需要多次手术）。在需要多次手术的3例患者中，2例患者的住院过程并发脑膜炎和感染后脑积水，最终需要脑室腹腔分流术。内镜再次探查在87.5%（8例中的7例）的病例中成功。
经蝶窦手术后脑脊液漏的发生率为6.0%。非腺瘤性疾病和术中漏的存在是术后漏的独立预测因素。内镜再次探查联合填塞是治疗单纯性术后漏的有效技术。在并发脑膜炎和感染后脑积水的情况下，可能需要更具侵入性的技术，如脑室腹腔分流术。
