Ausiello John C, Bruce Jeffrey N, Freda Pamela U
Department of Medicine, Columbia University, College of Physicians & Surgeons, New York, NY 10032, USA.
Pituitary. 2008;11(4):391-401. doi: 10.1007/s11102-008-0086-6.
While most transsphenoidal pituitary surgery is accomplished without complication, monitoring is required postoperatively for a set of disorders that are specific to this surgery. Postoperative assessments are tailored to the early and later postoperative periods. In the early period, which spans the first few weeks after surgery, both monitoring of anterior and posterior pituitary function and managing neurosurgical issues are the focus of care. Potential disruption of pituitary-adrenal function is covered with perioperative glucocorticoids. Various strategies exist for ensuring the integrity of this axis, but typically this is done by measuring a morning cortisol on the 2nd or 3rd postoperative days. Patients with levels <10 microg/l should continue therapy with reassessment in the later postoperative period. Monitoring for water imbalances, which are due to deficiency or excess of ADH (DI or SIADH, respectively), is accomplished by continuous accounting of fluid intake, urine output and specific gravities coupled with daily serum electrolyte measurements. DI is characterized by excess volumes of inappropriately dilute urine, which can lead to hypernatremia. Most patients maintain adequate fluid intake and euvolemia, but desmopressin therapy is required for some. SIADH, which peaks in incidence on 7th postoperative day, presents with hyponatremia that can be severe and symptomatic. Management consists of fluid restriction. Neurosurgical monitoring is primarily for disturbances in vision or neurological function, and although uncommon, for CSF leak and infections such as meningitis. In the later postoperative period, the adrenal, thyroid and gonadal axes are assessed. New persistent hypopituitarism is rare when transsphenoidal surgery is performed by an experienced surgeon. Various strategies are available for assessing each axis and for providing replacement therapy in patients with deficiencies. Long term monitoring with assessments of visual, neurological and pituitary function coupled with pituitary imaging is necessary for all patients who have undergone surgery, irrespective of the hormone status of their tumors.
虽然大多数经蝶窦垂体手术都能顺利完成且无并发症，但术后仍需对该手术特有的一系列病症进行监测。术后评估针对术后早期和后期进行了调整。在术后早期，即术后的头几周，垂体前叶和后叶功能的监测以及神经外科问题的处理是护理的重点。围手术期使用糖皮质激素可预防垂体 - 肾上腺功能的潜在紊乱。确保该轴完整性有多种策略，但通常是在术后第2天或第3天测量清晨皮质醇水平来实现。皮质醇水平<10μg/l的患者应继续治疗，并在术后后期重新评估。通过持续记录液体摄入量、尿量和比重，以及每日血清电解质测量来监测因抗利尿激素缺乏或过量导致的水代谢失衡（分别为尿崩症或抗利尿激素分泌异常综合征）。尿崩症的特征是排出大量稀释不当的尿液，可导致高钠血症。大多数患者能维持足够的液体摄入和血容量正常，但部分患者需要去氨加压素治疗。抗利尿激素分泌异常综合征在术后第7天发病率最高，表现为低钠血症，可能很严重且有症状。治疗方法是限制液体摄入。神经外科监测主要针对视力或神经功能障碍，虽然不常见，但也针对脑脊液漏和脑膜炎等感染。在术后后期，评估肾上腺、甲状腺和性腺轴。由经验丰富的外科医生进行经蝶窦手术时，新出现的持续性垂体功能减退很少见。有多种策略可用于评估每个轴，并为有缺陷的患者提供替代疗法。所有接受手术的患者，无论其肿瘤的激素状态如何，都需要长期进行视觉、神经和垂体功能评估以及垂体成像监测。
