经蝶窦手术患者实施标准化多学科围手术期方案的效果：对患者结局的影响。

Implementation of a Standardized Interdisciplinary Perioperative Protocol for Patients Undergoing Transsphenoidal Surgery: Impact on Patient Outcomes.

机构信息

Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA.

Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Jacksonville, Florida, USA.

出版信息

World Neurosurg. 2024 Oct;190:e331-e340. doi: 10.1016/j.wneu.2024.07.128. Epub 2024 Jul 30.

DOI:10.1016/j.wneu.2024.07.128

PMID:39084288

Abstract

INTRODUCTION

Advances in endoscopic endonasal transsphenoidal surgery have led to improved postoperative outcomes after pituitary adenoma resection, including reduced length of stay, complications and readmission rates, without compromising safety and satisfaction.

METHODS

Our team implemented a perioperative protocol in January 2021 for patients undergoing endoscopic, transsphenoidal pituitary surgery. This study compares preoperative characteristics and postoperative outcomes in 279 patients between 2016 and 2022 (128 preprotocol and 151 postprotocol). Our protocol includes interdisciplinary preoperative evaluations, unified communication, cortisol thresholds for postoperative glucocorticoid replacement, and fluid restriction to prevent delayed hyponatremia.

RESULTS

Median age was 54 ± 17 years with 50.8% female patients. There were 229 (82.1%) macroadenomas (>1 cm) and 50 (17.9%) microadenomas/cysts (<1 cm). Mean diameter was 18 (transverse), 18 (craniocaudal), 16 (anteroposterior) mm. Tumor types included 125 (44.8%) gonadotroph, 46 (16.4%) adrenocorticotroph, 40 (14.3%) lactotroph, 26 (9.3%) Rathke cysts, 19 (6.8%) somatotroph, 13 (4.6%) nondiagnostic, 3 (1%) somatotroph-lactotroph, 3 (1%) mammosomatotroph, 2 (0.71%) null cell, and 2 (0.7%) thyrotroph adenomas. Postprotocol, 74.2% of patients were discharged on postoperative day 1 compared with 46.1% preprotocol (P < 0.0001). Transient arginine vasopressin deficiency decreased from 10.4% (preprotocol) to 4.6% postprotocol (P = 0.101). Hyponatremia occurred in 13.3% pre-protocol and 4.6% postprotocol. Emergency department visits dropped from 9.4% to 3.9%, and readmissions decreased from 7.8% to 2.6%. Persistent arginine vasopressin deficiency affected 2.3% preprotocol and 1.3% postprotocol patients. Cerebrospinal fluid leaks occurred in 8.5% preprotocol and 7.3% postprotocol.

CONCLUSIONS

Implementing an interdisciplinary, perioperative protocol for transsphenoidal endoscopic pituitary surgery improves length of stay while minimizing readmissions and surgery-related complications.

摘要

简介

内镜经鼻蝶窦入路垂体腺瘤切除术的进步，改善了垂体腺瘤切除术后的结果，包括减少住院时间、并发症和再入院率，同时不影响安全性和满意度。

方法

我们的团队在 2021 年 1 月为接受内镜、经蝶窦垂体手术的患者实施了围手术期方案。本研究比较了 2016 年至 2022 年间 279 例患者的术前特征和术后结果（128 例术前方案和 151 例术后方案）。我们的方案包括多学科术前评估、统一沟通、术后皮质醇替代的皮质醇阈值以及限制液体摄入以预防迟发性低钠血症。

结果

中位年龄为 54±17 岁，女性占 50.8%。有 229 例（82.1%）为大腺瘤（>1cm）和 50 例（17.9%）微腺瘤/囊肿（<1cm）。平均直径为 18（横向）、18（前后）、16（前后）mm。肿瘤类型包括 125 例（44.8%）促性腺激素腺瘤、46 例（16.4%）促肾上腺皮质激素腺瘤、40 例（14.3%）催乳素腺瘤、26 例（9.3%）Rathke 囊肿、19 例（6.8%）生长激素腺瘤、13 例（4.6%）无诊断价值腺瘤、3 例（1%）生长激素-催乳素腺瘤、3 例（1%）催乳素-生长激素腺瘤、2 例（0.71%）无功能细胞腺瘤和 2 例（0.7%）促甲状腺激素腺瘤。与术前方案相比，术后方案中 74.2%的患者在术后第 1 天出院（P<0.0001）。术后暂时性精氨酸加压素缺乏症从 10.4%（术前方案）下降到 4.6%（术后方案）（P=0.101）。术前低钠血症发生率为 13.3%，术后为 4.6%。急诊就诊率从 9.4%下降至 3.9%，再入院率从 7.8%下降至 2.6%。持续性精氨酸加压素缺乏症影响了 2.3%的术前方案和 1.3%的术后方案患者。术前脑脊液漏发生率为 8.5%，术后为 7.3%。