Huang Jinxiang, Hong Xinjie, Cai Zheng, Lv Qian, Jiang Ying, Dai Wei, Hu Guohan, Yan Yong, Chen Juxiang, Ding Xuehua
Department of Neurosurgery, Shanghai Institute of Neurosurgery, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China.
Department of Endocrinology, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China.
Front Surg. 2023 Mar 21;10:1117766. doi: 10.3389/fsurg.2023.1117766. eCollection 2023.
To investigate the learning curve under different surgical complexity in endoscopic transsphenoidal approach for pituitary adenoma.
273 patients undergoing endoscopic transsphenoidal surgery for pituitary adenoma were collected retrospectively and divided into three groups chronologically (early, middle, and late periods). Surgical complexity was differentiated based on Knosp classification (Knsop grade 0-2 vs. Knosp grade 3-4), tumor maximum diameter (MD) (macroadenomas vs. giant adenomas), and history of previous surgery for pituitary adenoma (first operation vs. reoperation). Then the temporal trends in operative time, surgical outcomes, and postoperative complications were evaluated from early to late.
The median operative time decrease from 169 to 147 min across the three periods ( = 0.001). A significant decrease in operative time was seen in the simple groups [Knosp grade 0-2 adenoma (169 to 137 min, < 0.001), macroadenoma (166 to 140 min, < 0.001), and first operation (170.5 to 134 min, < 0.001)] but not in their complex counterparts ( > 0.05). The GTR rate increased from 51.6% to 69.2% ( = 0.04). The surgical period was an independent factor for GTR in the simple groups [Knosp grade 0-2 adenoma: OR 2.076 (95%CI 1.118-3.858, = 0.021); macroadenoma: OR = 2.090 (95%CI 1.287-3.393, = 0.003); first operation: OR = 1.809 (95%CI 1.104-2.966, = 0.019)] but not in the complex groups. The biochemical cure rate increased over periods without statistical significance (from 37.5% to 56.3%, = 0.181). Although intraoperative CSF leakage rose (from 20.9% to 35.2%) and postoperative CSF leakage reduced (from 12.1% to 5.5%), there was no statistically significant trend across the three time periods ( > 0.05).
This study showed that complex operations might have a prolonged learning curve. Differentiating surgical difficulty and using multivariate combined analysis may be more helpful in clinical practice.
探讨垂体腺瘤经鼻内镜经蝶窦入路在不同手术复杂程度下的学习曲线。
回顾性收集273例行垂体腺瘤经鼻内镜经蝶窦手术的患者，并按时间顺序分为三组（早期、中期和晚期）。根据克诺斯普分类（克诺斯普0-2级与克诺斯普3-4级）、肿瘤最大直径（MD）（大腺瘤与巨大腺瘤）以及垂体腺瘤既往手术史（首次手术与再次手术）区分手术复杂程度。然后评估从早期到晚期手术时间、手术结果及术后并发症的时间趋势。
三个时期的中位手术时间从169分钟降至147分钟（P = 0.001）。简单组手术时间显著缩短[克诺斯普0-2级腺瘤（169至137分钟，P < 0.001）、大腺瘤（166至140分钟，P < 0.001）及首次手术（170.5至134分钟，P < 0.001）]，而复杂组无显著变化（P > 0.05）。全切除率从51.6%升至69.2%（P = 0.04）。手术时期是简单组全切除的独立因素[克诺斯普0-2级腺瘤：比值比2.076（95%可信区间1.118-3.858，P = 0.021）；大腺瘤：比值比 = 2.090（95%可信区间1.287-3.393，P = 0.003）；首次手术：比值比 = 1.809（95%可信区间1.104-2.966，P = 0.019）]，复杂组则不然。生化治愈率随时间增加但无统计学意义（从37.5%至56.3%，P = 0.181）。尽管术中脑脊液漏增加（从20.9%至35.2%）且术后脑脊液漏减少（从12.1%至5.5%），但三个时间段无统计学显著趋势（P > 0.05）。
本研究表明复杂手术可能有较长的学习曲线。区分手术难度并采用多因素综合分析在临床实践中可能更有帮助。
