Baussart Bertrand, Venier Alice, Jouinot Anne, Reuter Gilles, Gaillard Stephan
Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.
Université Paris Cité, Institut Cochin, CNRS, INSERM, Paris, France.
Front Oncol. 2023 Jan 4;12:1067312. doi: 10.3389/fonc.2022.1067312. eCollection 2022.
Effective strategies are required to ensure optimal management of the crucial closure step in endoscopic pituitary surgery. Many surgical techniques have been reported but no significant consensus has been defined.
Between January 2006 and March 2022, 3015 adult patients with pituitary adenomas were operated on by a single expert neurosurgical team, using a mononostril endoscopic endonasal approach. Based of preoperative risk factors of and operative findings, a detailed closure strategy was used. Body mass index >40, sellar floor lysis, number of surgeries>2, large skull base destruction, prior radiotherapy were considered as preoperative risk factors for closure failure. All patients treated with an expanded endonasal approach were excluded.
Patients were mostly women (F/M ratio: 1.4) with a median age of 50 (range: 18 -89). Intraoperative CSF leak requiring specific surgical management was observed in 319/3015 (10.6%) of patients. If intraoperative leak occurred, patients with predictive risk factors were managed using a Foley balloon catheter in case of sellar floor lysis or BMI>40 and a multilayer repair strategy with a vascularized nasoseptal flap in other cases. Postoperative CSF leak occurred in 29/3015 (1%) of patients, while meningitis occurred in 24/3015 (0.8%) of patients. In patients with intraoperative leak, closure management failed in 11/319 (3.4%) of cases.
Based on our significant 16-year experience, our surgical management is reliable and easy to follow. With a planned and stepwise strategy, the closure step can be optimized and tailored to each patient with a very low failure rate.
需要有效的策略来确保垂体内镜手术关键闭合步骤的最佳管理。已报道了多种手术技术，但尚未达成显著共识。
2006年1月至2022年3月期间，由一个专家神经外科团队对3015例成年垂体腺瘤患者采用单鼻孔内镜鼻内入路进行手术。根据术前危险因素和手术结果，采用详细的闭合策略。体重指数>40、鞍底溶解、手术次数>2、巨大颅底破坏、既往放疗被视为闭合失败的术前危险因素。所有采用扩大鼻内入路治疗的患者均被排除。
患者大多为女性（女/男比例：1.4），中位年龄为50岁（范围：18 - 89岁）。3015例患者中有319例（10.6%）术中出现脑脊液漏，需要进行特殊手术处理。如果术中出现脑脊液漏，对于有预测危险因素的患者，若存在鞍底溶解或体重指数>40，则使用Foley气囊导管处理，其他情况则采用带血管蒂鼻中隔瓣的多层修复策略。29例（1%）患者术后出现脑脊液漏，24例（0.8%）患者发生脑膜炎。在术中出现脑脊液漏的患者中，11例（3.4%）闭合处理失败。
基于我们16年的丰富经验，我们的手术管理可靠且易于遵循。通过有计划的逐步策略，可以优化闭合步骤，并根据每位患者的情况进行调整，失败率非常低。
