Prete Alessandro, Corsello Salvatore Maria, Salvatori Roberto
Unit of Endocrinology, Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, Rome, Italy.
Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University, 1830 East Monument Street #333, Baltimore, MD 21287, USA.
Ther Adv Endocrinol Metab. 2017 Mar;8(3):33-48. doi: 10.1177/2042018816687240. Epub 2017 Mar 1.
Sellar and parasellar masses are a common finding, and most of them are treated surgically transsphenoidal approach. This type of surgery has revolutionized the approach to several hypothalamic-pituitary diseases and is usually effective, and well-tolerated by the patient. However, given the complex anatomy and high density of glandular, neurological and vascular structures in a confined space, transsphenoidal surgery harbors a substantial risk of complications. Hypopituitarism is one of the most frequent sequelae, with central adrenal insufficiency being the deficit that requires a timely diagnosis and treatment. The perioperative management of AI is influenced by the preoperative status of the hypothalamic-pituitary-adrenal axis. Disorders of water metabolism are another common complication, and they can span from diabetes insipidus, to the syndrome of inappropriate antidiuretic hormone secretion, up to the rare cerebral salt-wasting syndrome. These abnormalities are often transient, but require careful monitoring and management in order to avoid abrupt variations of blood sodium levels. Cerebrospinal fluid leaks, damage to neurological structures such as the optic chiasm, and vascular complications can worsen the postoperative course after transsphenoidal surgery as well. Finally, long-term follow up after surgery varies depending on the underlying pathology, and is most challenging in patients with acromegaly and Cushing disease, in whom failure of primary pituitary surgery is a major concern. When these pituitary functioning adenomas persist or relapse after neurosurgery other treatment options are considered, including repeated surgery, radiotherapy, and medical therapy.
鞍区及鞍旁肿物很常见，其中大多数采用经蝶窦手术治疗。这类手术彻底改变了几种下丘脑 - 垂体疾病的治疗方法，通常效果良好，患者耐受性也较好。然而，鉴于有限空间内腺体、神经和血管结构的解剖复杂且密度高，经蝶窦手术存在相当大的并发症风险。垂体功能减退是最常见的后遗症之一，其中中枢性肾上腺功能不全是需要及时诊断和治疗的缺陷。肾上腺皮质功能减退的围手术期管理受下丘脑 - 垂体 - 肾上腺轴术前状态的影响。水代谢紊乱是另一种常见并发症，范围从尿崩症到抗利尿激素分泌不当综合征，甚至罕见的脑性盐耗综合征。这些异常通常是短暂的，但需要仔细监测和管理，以避免血钠水平突然变化。脑脊液漏、视交叉等神经结构损伤以及血管并发症也会使经蝶窦手术后的病程恶化。最后，术后长期随访因潜在病理情况而异，对于肢端肥大症和库欣病患者最具挑战性，在这些患者中，垂体初次手术失败是主要关注点。当这些垂体功能性腺瘤在神经外科手术后持续存在或复发时，会考虑其他治疗选择，包括再次手术、放疗和药物治疗。
