Bondugulapati L N Rao, Campbell Christopher, Chowdhury Sharmistha Roy, Goetz Pablo, Davies J Stephen, Rees D Aled, Hayhurst Caroline
a Department of Endocrinology , University Hospital of Wales , Cardiff , UK.
b Institute of Molecular and Experimental Medicine, Cardiff University , Cardiff , UK.
Br J Neurosurg. 2016;30(1):76-9. doi: 10.3109/02688697.2015.1071325. Epub 2015 Aug 24.
Assessment of adrenal reserve in patients who have undergone pituitary surgery is crucial. However, there is no clear consensus with regards to the type and timing of the test that should be used in the immediate post-operative period. Recently, there has been increased interest in measuring post-operative cortisol levels. We present our data utilising day 1 post-operative early morning cortisol as a tool to assess adrenal reserve in steroid-naive patients.
A retrospective analysis of endoscopic pituitary surgery undertaken over a 2-year period. 82 patients underwent 84 surgeries in total. Patients who were already on glucocorticoids pre-operatively and patients with Cushing's disease, pituitary apoplexy and those without follow-up data were excluded, leaving a study group of 44 patients with 45 operations. A 9am day 1 post-operative cortisol value of > 400 nmol/L was taken as an indicator of adequate adrenal reserve. All the patients were reassessed at 6 weeks with a standard short synacthen test (SST) using 250 micrograms of intravenous synacthen.
22 out of 45 patients had a cortisol value of > 400 nmol/L on day 1 post-operatively and were discharged without glucocorticoid supplementation. Of these, only 2 patients subsequently failed the SST when reassessed at 6-8 weeks. The remaining 23 patients had a cortisol value of < 400 nmol/L on day 1 post-operatively and were discharged on hydrocortisone 10 mg twice daily. At 6-8 weeks, nine continued to show suboptimal stimulated cortisol levels whereas the remaining fourteen patients showed adequate adrenal reserve. The 9 am cortisol value had high specificity (81.8%) and positive predictive value (90.9%) for integrity of the HPA axis. Sensitivity was 58.8% and negative predictive value was 39.1%.
A day 1 post-operative early morning cortisol is a useful tool to predict adrenal reserve post-pituitary surgery, enabling clinicians to avoid unnecessary blanket glucocorticoid replacement.
评估接受垂体手术患者的肾上腺储备至关重要。然而，关于术后即刻应使用的检测类型和时间，目前尚无明确共识。最近，人们对测量术后皮质醇水平的兴趣有所增加。我们展示了利用术后第1天清晨皮质醇作为评估未使用过类固醇患者肾上腺储备工具的数据。
对2年内进行的内镜垂体手术进行回顾性分析。共有82例患者接受了84次手术。术前已使用糖皮质激素的患者、库欣病患者、垂体卒中患者以及无随访数据的患者被排除，留下44例患者组成的研究组，共进行了45次手术。术后第1天上午9点皮质醇值>400 nmol/L被视为肾上腺储备充足的指标。所有患者在6周时使用250微克静脉注射促肾上腺皮质激素进行标准短程促肾上腺皮质激素试验（SST）重新评估。
45例患者中有22例术后第1天皮质醇值>400 nmol/L，未补充糖皮质激素即出院。其中，只有2例患者在6 - 8周重新评估时SST未通过。其余23例患者术后第1天皮质醇值<400 nmol/L，出院时接受每日两次10毫克氢化可的松治疗。在6 - 8周时，9例患者持续显示刺激后皮质醇水平欠佳，而其余14例患者肾上腺储备充足。上午9点皮质醇值对下丘脑 - 垂体 - 肾上腺（HPA）轴完整性具有高特异性（81.8%）和阳性预测值（90.9%）。敏感性为58.8%，阴性预测值为39.1%。
术后第1天清晨皮质醇是预测垂体手术后肾上腺储备的有用工具，使临床医生能够避免不必要的全面糖皮质激素替代治疗。
