Tohti Mamatemin, Li Junyang, Zhou Yuan, Hu Yuebing, Yu Zhuang, Ma Chiyuan
Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China.
PLoS One. 2015 Mar 16;10(3):e0119621. doi: 10.1371/journal.pone.0119621. eCollection 2015.
Patients with pituitary adenomas usually receive "stress dose" steroids in the peri-operative peroids. Though randomized controlled trials(RCT) have not been performed to assess the necessity of steroid coverage, there are several studies that explained the changes of adrenal function during peri-operative peroids. The aim of the present study is to investigate whether it is necessary to employ conventional peri-operative glucocorticoid replacement therapy to all the patients undergoing surgery.
We searched studies addressing peri-operative steroids coverage for pituitary adenomas in the Web of Science, Medline and the Cochrane Library. Then we extracted studies about peri-operative morning serum cortisol(MSC) levels, morbidity of early postoperative adrenal insufficiency, postoperative diabetes insipidus, relationships between MSC levels and adrenal integrity. We used RevMan Software to combine the results for meta-analysis. We used fixed-effects models for there was no significant heterogeneity existed.
There are 18 studies from 11 countries published between 1987 and 2013 including 1224 patients. The postoperative serum cortisol levels were significantly increased compared with the preoperative one in hypothalamic-pituitary-adrenal axis(HPAA) functions preserved patients(P<0.00001). The morbidity of early postoperative adrenal insufficiency ranged from 0.96% to 12.90%, with the overall morbidity of 5.55%(41/739). There was no significant differences of early postoperative diabetes insipidus between no supplementation patients and in supplementation patients(P=0.82). Conversely, there may be some disadvantages of high levels of cortisols such as high incidence of osteopenia and bone derangement and even the increased mortality rate. The patients with MSC levels of less than 60 nmol/l at 3 days after operation is considered as adrenal insufficient and more than 270 nmol/l as adrenal sufficient. To patients with MSC levels of 60-270 nmol/l, we need more clinical data to establish further cortisol supplementation criteria.
垂体腺瘤患者通常在围手术期接受“应激剂量”的类固醇治疗。尽管尚未进行随机对照试验（RCT）来评估类固醇覆盖的必要性，但有几项研究解释了围手术期肾上腺功能的变化。本研究的目的是调查是否有必要对所有接受手术的患者采用传统的围手术期糖皮质激素替代疗法。
我们在科学网、医学数据库和考克兰图书馆中搜索了关于垂体腺瘤围手术期类固醇覆盖的研究。然后我们提取了关于围手术期早晨血清皮质醇（MSC）水平、术后早期肾上腺功能不全的发病率、术后尿崩症、MSC水平与肾上腺完整性之间关系的研究。我们使用RevMan软件合并结果进行荟萃分析。由于不存在显著异质性，我们使用固定效应模型。
1987年至2013年间，来自11个国家的18项研究共纳入1224例患者。下丘脑-垂体-肾上腺轴（HPAA）功能保留的患者术后血清皮质醇水平较术前显著升高（P<0.00001）。术后早期肾上腺功能不全的发病率在0.96%至12.90%之间，总体发病率为5.55%（41/739）。未补充患者和补充患者术后早期尿崩症无显著差异（P=0.82）。相反，高水平皮质醇可能存在一些缺点，如骨质疏松症和骨紊乱的高发生率，甚至死亡率增加。术后3天MSC水平低于60 nmol/l的患者被认为肾上腺功能不全，高于270 nmol/l则为肾上腺功能正常。对于MSC水平在60-270 nmol/l之间的患者，我们需要更多临床数据来建立进一步的皮质醇补充标准。
