Department of Neurosurgery, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India.
Department of Neurosurgery, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India.
World Neurosurg. 2020 Feb;134:e46-e54. doi: 10.1016/j.wneu.2019.08.165. Epub 2019 Sep 3.
Cushing's disease (CD) is a spectrum of clinical manifestations due to adrenocorticotropic hormone-secreting pituitary adenoma. Transsphenoidal adenomectomy remains the standard treatment. There has been a paradigm shift from microscopic to endoscopic transsphenoidal surgery in recent years. However, the efficacy of endoscopic transsphenoidal surgery has not been established. Therefore, it is of interest to determine the superiority of endoscopic transsphenoidal surgery, if any, over microscopic surgery.
To assess the efficacy of endoscopic endonasal transsphenoidal surgery for the treatment of CD and to determine the factors affecting remission.
Patients undergoing surgery for CD from 2009 to 2017 were analyzed retrospectively. Transsphenoidal resection was the preferred treatment, with recent trends in favor of the endonasal endoscopic skull base approach. Postoperative cortisol level of <2 μg/dL was taken as remission and value between 2 and 5 μg/dL as possible remission.
In total, 104 patients operated primarily for CD were included for analysis; 47 patients underwent microscopic surgery, 55 endoscopic surgery, and 2 were operated transcranially. Remission was achieved in 76.47% of patients. In univariate analysis, factors significantly associated with remission were 1) type of surgery (P = 0.01); remission in endoscopy surgery (88.23%) is better than microscopy (56.6%); 2) postoperative day 1 morning cortisol (P = 0.004); and 3) postoperative day 1 morning ACTH (P = 0.015). In multivariate analysis, only postoperative day 1 cortisol was found to be significant predictor of remission (P = 0.02).
Postoperative plasma cortisol level is a strong independent predictor of remission. Remission provided by endoscopy is significantly better than the microscopic approach.
库欣病（CD）是由于促肾上腺皮质激素分泌的垂体腺瘤而导致的一系列临床表现。经蝶窦腺瘤切除术仍然是标准治疗方法。近年来，经蝶窦手术已从显微镜下手术转变为内镜下手术。然而，内镜经蝶窦手术的疗效尚未得到证实。因此，确定内镜经蝶窦手术是否优于显微镜手术具有重要意义。
评估内镜经鼻蝶窦入路手术治疗 CD 的疗效，并确定影响缓解的因素。
回顾性分析 2009 年至 2017 年期间因 CD 而行手术的患者。经蝶窦切除术是首选治疗方法，最近的趋势倾向于采用内镜经颅底入路。术后皮质醇水平<2μg/dL 被认为是缓解，2-5μg/dL 之间被认为是可能缓解。
共纳入 104 例因 CD 初次手术的患者进行分析；47 例行显微镜手术，55 例行内镜手术，2 例行经颅手术。76.47%的患者达到缓解。单因素分析显示，与缓解相关的因素有：1）手术类型（P=0.01）；内镜手术（88.23%）的缓解率优于显微镜手术（56.6%）；2）术后第 1 天早晨皮质醇（P=0.004）；3）术后第 1 天早晨 ACTH（P=0.015）。多因素分析显示，只有术后第 1 天皮质醇是缓解的独立预测因素（P=0.02）。
术后血浆皮质醇水平是缓解的强有力独立预测因素。内镜缓解效果明显优于显微镜手术。
