经蝶窦垂体腺瘤切除术围手术期糖皮质激素替代必要性的研究

Alternative necessity of perioperative glucocorticoid for resection of pituitary adenomas via sphenoid sinus

目的探究经蝶窦垂体腺瘤（促肾上腺皮质激素腺瘤除外）切除术患者围手术期糖皮质激素替代的必要性。方法纳入2013年9月至2014年7月入住复旦大学附属华山医院神经外科行经蝶窦手术的垂体腺瘤患者52例。患者均为下丘脑-垂体-肾上腺轴（HPA）功能完整者[以术前8：00空腹血浆皮质醇水平≥251nmol／L（9．1μg/dl）作为评估标准]，术前、术中均未给予糖皮质激素。观察患者术后血浆皮质醇的变化规律，评估术后糖皮质激素替代的必要性。结果52例中，40例皮质醇在手术当晚即达峰值，12例在术后1d达峰值。术后4例出现一过性皮质醇降低，其中1例给予甲强龙和醋酸可的松治疗。患者术前、术后当晚及术后连续3d的皮质醇水平分别为（412±132）、（934±256）、（733±376）、（471±205）、（457±217）nmol／L，与术前比较，术后当晚和术后1d的差异均有统计学意义（P〈0．05），术后2d和3d的差异均无统计学意义（P〉0．05）。术后一过性尿崩14例（均于出院前痊愈），均未发生慢性肾上腺皮质功能减退症、低血糖昏迷、低钠性昏迷、心血管衰竭等危象。结论术前HPA功能正常的垂体腺瘤患者，围手术期糖皮质激素的替代治疗并非必须。

Objective To explore the alternative necessity of perioperative glucoeortieoids for patients resection of pituitary adenoma （ except adrenocorticotropie hormone adenoma） via sphenoid sinus. Methods Fifty-two patients with pituitary adenoma operated with transsphenoidal surgery at the Department of Neurosurgery, Huashan Hospital, Fudan University from September 2013 to July 2014 were enrolled. All patients had complete hypothalamic-pituitary-drenal axis （HPA） function, the fasting plasma eortisol level ≥ 251 nmol/L （9. 1 μg/dl） as the evaluation criteria at 8 a. m. before procedure. The preoperative, intraoperative glucoeorticoids were given to the patients. The variation of plasma cortisol in patients was observed after procedure. The necessity of glueocortieoid replacement was assessed after procedure. Results Of the 52 patients, the eortisol of 40 patients reached the peak at the night of surgery. The cortisol of 12 patients reached the peak at 24 h after procedure. Four patients had transient decrease in serum eortisol after procedure, 1 of them was treated with methylprednisolone and cortisone acetate. The cortisol levels of the patients before operation, at the night after operation, and 3 consecutive days after procedure were 412 ±132,934 ±256,733 ±376,471 ±205,and 457 ±217 nmol/L, respectively. Compared with before procedure, there was no significant difference between the night after procedure and 1 day after procedure （ P 〈 0.05 ）. There was no significant difference between 2 clays and 3 days after procedure （ P 〉 0.05 ）. All 52 patients did not have Addison＇s disease, hypoglycemic coma, hyponatremia coma, cardiovascular failure, and other disease crises. Conclusion For the normal HPA function patients with pituitary adenoma before procedure, the pefioperative glueocortieoid replacement therapy is not necessary.