Ordóñez-Rubiano Edgar G, Forbes Jonathan A, Morgenstern Peter F, Arko Leopold, Dobri Georgiana A, Greenfield Jeffrey P, Souweidane Mark M, Tsiouris Apostolos John, Anand Vijay K, Kacker Ashutosh, Schwartz Theodore H
Departments of1Neurological Surgery.
6Department of Neurological Surgery, Fundación Universitaria de Ciencias de la Salud (FUCS), Hospital de San José, Bogotá, Colombia; and.
J Neurosurg. 2018 Nov 23;131(4):1163-1171. doi: 10.3171/2018.6.JNS18901. Print 2019 Oct 1.
Gross-total resection (GTR) of craniopharyngiomas (CPs) is potentially curative and is often the goal of surgery, but endocrinopathy generally results if the stalk is sacrificed. In some cases, GTR can be attempted while still preserving the stalk; however, stalk manipulation or devascularization may cause endocrinopathy and this strategy risks leaving behind small tumor remnants that can recur.
A retrospective review of a prospective cohort of patients who underwent initial resection of CP using the endoscopic endonasal approach over a period of 12 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital, was performed. Postresection integrity of the stalk was retrospectively assessed using operative notes, videos, and postoperative MRI. Tumors were classified based on location into type I (sellar), type II (sellar-suprasellar), and type III (purely suprasellar). Pre- and postoperative endocrine function, tumor location, body mass index, rate of GTR, radiation therapy, and complications were reviewed.
A total of 54 patients who had undergone endoscopic endonasal procedures for first-time resection of CP were identified. The stalk was preserved in 33 (61%) and sacrificed in 21 (39%) patients. GTR was achieved in 24 patients (73%) with stalk preservation and 21 patients (100%) with stalk sacrifice (p = 0.007). Stalk-preservation surgery achieved GTR and maintained completely normal pituitary function in only 4 (12%) of 33 patients. Permanent postoperative diabetes insipidus was present in 16 patients (49%) with stalk preservation and in 20 patients (95%) following stalk sacrifice (p = 0.002). In the stalk-preservation group, rates of progression and radiation were higher with intentional subtotal resection or near-total resection compared to GTR (67% vs 0%, p < 0.001, and 100% vs 12.5%, p < 0.001, respectively). However, for the subgroup of patients in whom GTR was achieved, stalk preservation did not lead to significantly higher rates of recurrence (12.5%) compared with those in whom it was sacrificed (5%, p = 0.61), and stalk preservation prevented anterior pituitary insufficiency in 33% and diabetes insipidus in 50%.
While the decision to preserve the stalk reduces the rate of postoperative endocrinopathy by roughly 50%, nevertheless significant dysfunction of the anterior and posterior pituitary often ensues. The decision to preserve the stalk does not guarantee preserved endocrine function and comes with a higher risk of progression and need for adjuvant therapy. Nevertheless, to reduce postoperative endocrinopathy attempts should be made to preserve the stalk if GTR can be achieved.
颅咽管瘤（CP）的全切除（GTR）可能治愈疾病，通常是手术的目标，但如果垂体柄被牺牲，内分泌病通常会出现。在某些情况下，可以尝试全切除同时保留垂体柄；然而，垂体柄的操作或血运阻断可能导致内分泌病，并且这种策略有残留小肿瘤残余灶并复发的风险。
对纽约长老会医院威尔康奈尔医学院12年间采用鼻内镜经鼻入路首次切除CP的前瞻性队列患者进行回顾性研究。通过手术记录、视频和术后MRI对术后垂体柄的完整性进行回顾性评估。根据肿瘤位置将肿瘤分为I型（鞍内）、II型（鞍内-鞍上）和III型（纯鞍上）。回顾术前和术后的内分泌功能、肿瘤位置、体重指数、全切除率、放射治疗和并发症。
共确定54例接受鼻内镜经鼻手术首次切除CP的患者。33例（61%）患者的垂体柄得以保留，21例（39%）患者的垂体柄被牺牲。保留垂体柄的24例患者（73%）和牺牲垂体柄的21例患者（100%）实现了全切除（p = 0.007）。保留垂体柄手术实现全切除且垂体功能完全正常的患者仅33例中的4例（12%）。术后永久性尿崩症在保留垂体柄的16例患者（49%）和牺牲垂体柄后的20例患者（95%）中出现（p = 0.002）。在保留垂体柄组中，与全切除相比，有意次全切除或近全切除的进展率和放射治疗率更高（分别为67%对0%，p < 0.001，以及100%对12.5%，p < 0.001）。然而，对于实现全切除的患者亚组，保留垂体柄与牺牲垂体柄的患者相比，复发率没有显著更高（12.5%对5%，p = 0.61），并且保留垂体柄预防了33%的垂体前叶功能减退和50%的尿崩症。
虽然保留垂体柄的决定可使术后内分泌病发生率降低约50%，但垂体前叶和后叶仍常出现明显功能障碍。保留垂体柄的决定并不能保证保留内分泌功能，且有更高的进展风险和辅助治疗需求。尽管如此，为减少术后内分泌病，如果能实现全切除，应尝试保留垂体柄。
