Lopez Diana C, Almeida João Paulo, Momin Arbaz A, Andrade Erion Júnior de, Soni Pranay, Yogi-Morren Divya, Kshettry Varun R, Recinos Pablo F
1Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland.
2Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.
J Neurosurg. 2023 Feb 3;139(3):790-797. doi: 10.3171/2022.12.JNS221137. Print 2023 Sep 1.
Surgery is the primary treatment for craniopharyngioma with the preservation of hypothalamic function of paramount importance. Infundibular preservation is debated, as maximal resection decreases recurrence rates but causes hypopituitarism. A triphasic response of diabetes insipidus (DI), syndrome of inappropriate antidiuretic hormone secretion (SIADH), and recurrent DI has been described after pituitary surgery, but the impact of infundibular preservation on the triphasic response following craniopharyngioma resection has not been well established. The authors' objective was to assess postoperative fluid and sodium balance and differences in ADH imbalance management following endonasal craniopharyngioma resection based on infundibular transection status.
This is a retrospective cohort study of 19 patients with craniopharyngioma treated with endoscopic endonasal resection between 2014 and 2021. Resection was dichotomized into infundibular transection or preservation. Postoperative triphasic response, time to DI, and time to ADH replacement were compared using Fisher's exact test and Kaplan-Meier analysis.
Based on surgeon impression, 10 patients had infundibular transection and 9 had infundibular preservation. Overall, 16 patients experienced DI, 12 experienced persistent DI, and 6 experienced SIADH. A postoperative triphasic response occurred in 40% (n = 4) of transection patients without preoperative DI and 11% (n = 1) of preservation patients without preoperative DI. The median time to postoperative DI (0.5 vs 18.0 hours, p = 0.022) and median time to ADH replacement therapy (4.5 vs 24 hours, p = 0.0004) were significantly shorter in the transection group than in the preservation group.
Following endonasal craniopharyngioma resection, the triphasic response occurs in nearly half of infundibular transection cases. DI begins earlier with infundibular transection. On the basis of the study findings in which no patients met the criteria for SIADH or were endocrinologically unstable after postoperative day 6, it is reasonable to suggest that otherwise stable patients can be discharged at or before postoperative day 6 when ADH fluctuations have normalized and endocrinopathy is appropriately managed with oral desmopressin. Infundibular transection status may impact postoperative hormonal replacement strategies, but additional studies should evaluate their efficacies.
手术是颅咽管瘤的主要治疗方法，保留下丘脑功能至关重要。漏斗部保留存在争议，因为最大限度切除可降低复发率，但会导致垂体功能减退。垂体手术后已描述了尿崩症（DI）、抗利尿激素分泌不当综合征（SIADH）和复发性DI的三相反应，但漏斗部保留对颅咽管瘤切除术后三相反应的影响尚未明确。作者的目的是基于漏斗部横断状态评估鼻内镜下颅咽管瘤切除术后的液体和钠平衡以及抗利尿激素失衡管理的差异。
这是一项回顾性队列研究，纳入了2014年至2021年间接受内镜鼻内切除术治疗的19例颅咽管瘤患者。切除分为漏斗部横断或保留。使用Fisher精确检验和Kaplan-Meier分析比较术后三相反应、DI发生时间和抗利尿激素替代时间。
根据手术医生的判断，10例患者进行了漏斗部横断，9例进行了漏斗部保留。总体而言，16例患者出现DI，12例出现持续性DI，6例出现SIADH。在术前无DI的横断患者中，40%（n = 4）出现术后三相反应，在术前无DI的保留患者中，11%（n = 1）出现术后三相反应。横断组术后DI的中位时间（0.5 vs 18.0小时，p = 0.022）和抗利尿激素替代治疗的中位时间（4.5 vs 24小时，p = 0.0004）明显短于保留组。
鼻内镜下颅咽管瘤切除术后，近一半的漏斗部横断病例会出现三相反应。漏斗部横断时DI出现得更早。基于研究结果，即没有患者符合SIADH标准或术后第6天内分泌不稳定，合理的建议是，在抗利尿激素波动已恢复正常且通过口服去氨加压素适当管理内分泌病的情况下，其他情况稳定的患者可在术后第6天或之前出院。漏斗部横断状态可能影响术后激素替代策略，但需要更多研究评估其疗效。
