Azad Tej D, Lee Yu-Jin, Vail Daniel, Veeravagu Anand, Hwang Peter H, Ratliff John K, Li Gordon
Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States.
Department of Otolaryngology, Stanford University School of Medicine, Stanford, CA, United States.
Front Surg. 2017 Jun 22;4:33. doi: 10.3389/fsurg.2017.00033. eCollection 2017.
Direct comparisons of microscopic and endoscopic resection of sellar lesions are scarce, with conflicting reports of cost and clinical outcome advantages.
To determine if the proposed benefits of endoscopic resection are realized on a population level.
We performed a matched cohort study of 9,670 adult patients in the MarketScan database who underwent either endoscopic or microscopic surgery for sellar lesions. Coarsened matching was applied to estimate the effects of surgical approach on complication rates, length of stay (LOS), costs, and likelihood of postoperative radiation.
We found that LOS, readmission, and revision rates did not differ significantly between approaches. The overall complication rate was higher for endoscopy (47% compared to 39%, OR 1.37, 95% CI 1.22-1.53). Endoscopic approach was associated with greater risk of neurological complications (OR 1.32, 95% CI 1.11-1.55), diabetes insipidus (OR 1.65, 95% CI 1.37-2.00), and cerebrospinal fluid rhinorrhea (OR 1.83, 95% CI 1.07-3.13) compared to the microscopic approach. Although the total index payment was higher for patients receiving endoscopic resection ($32,959 compared to $29,977 for microscopic resection), there was no difference in long-term payments. Endoscopic surgery was associated with decreased likelihood of receiving post-resection stereotactic radiosurgery (OR 0.67, 95% CI 0.49-0.90) and intensity-modulated radiation therapy (OR 0.78, 95% CI 0.65-0.93).
Our results suggest that the transition from a microscopic to endoscopic approach to sellar lesions must be subject to careful evaluation. Although there are evident advantages to transsphenoidal endoscopy, our analysis suggests that the benefits of the endoscopic approach are yet to be materialized.
关于蝶鞍区病变的显微镜下切除术和内镜下切除术的直接比较很少，关于成本和临床结果优势的报道相互矛盾。
确定内镜下切除术的预期益处是否在总体人群水平上得以实现。
我们在MarketScan数据库中对9670例接受蝶鞍区病变内镜手术或显微镜手术的成年患者进行了一项匹配队列研究。采用粗匹配来估计手术方式对并发症发生率、住院时间（LOS）、成本以及术后放疗可能性的影响。
我们发现两种手术方式在住院时间、再入院率和翻修率方面无显著差异。内镜手术的总体并发症发生率更高（47%，而显微镜手术为39%，比值比1.37，95%置信区间1.22 - 1.53）。与显微镜手术相比，内镜手术发生神经并发症（比值比1.32，95%置信区间1.11 - 1.55）、尿崩症（比值比1.65，95%置信区间1.37 - 2.00）和脑脊液鼻漏（比值比1.83，95%置信区间1.07 - 3.13）的风险更高。虽然接受内镜切除术的患者的总指数支付更高（32959美元，而显微镜切除术为29977美元），但长期支付并无差异。内镜手术与切除后接受立体定向放射外科治疗（比值比0.67，95%置信区间0.49 - 0.90）和调强放射治疗（比值比0.78，95%置信区间0.65 - 0.93）可能性降低相关。
我们的结果表明，从显微镜手术方式向蝶鞍区病变内镜手术方式的转变必须经过仔细评估。虽然经蝶窦内镜手术有明显优势，但我们的分析表明内镜手术方式的益处尚未实现。
