经蝶窦手术对生长激素型垂体腺瘤患者腺垂体功能的影响及相关因素分析

Effects of transsphenoidal surgery on anterior pituitary function in growth hormone-secreting pituitary adenomas and analysis of related factors

目的探讨经蝶窦手术对生长激素（GH）型垂体腺瘤患者腺垂体功能的影响及其相关因素。方法回顾性分析2013年1月至2014年12月复旦大学附属华山医院神经外科收治的173例肢端肥大症患者的临床资料，包括经蝶窦手术前后的生化指标及腺垂体功能。结果术前肾上腺轴、甲状腺轴、性腺轴功能减退的比例分别为15．0％（26／173）、18．5％（32／173）及60．8％（45／74）。手术导致上述3条轴的新发功能减退比例分别为3．2％（4／126）、0．8％（1／121）、12．5％（3／24）。术后上述3条轴功能减退的恢复率分别为85．7％（18／21）、92．3％（24／26）、52．8％（19／36）。单因素分析显示：术后肾上腺轴新发功能减退组的肿瘤体积明显大于保持正常组（10．3cm3对比1．3cm3，P=0．010）；术后男性性腺轴新发功能减退组的病程长于保持正常组（15年对比3年，P=0．039）；术后男性性腺轴功能改善组的GH达标率明显高于未改善组（78．9％对比47．1％，P=0．047）。多因素Logistic回归分析显示：肿瘤体积（OR=12．704，P=0．005，95％CI：2．115～76．323）是术后腺垂体功能减退的独立危险因素。结论经蝶窦手术能够显著改善GH型垂体腺瘤患者的肾上腺轴、甲状腺轴以及男性性腺轴的功能，且各轴的新发功能减退发生率较低。肿瘤体积越大则越易出现术后腺垂体功能减退，应注意加强随访及替代治疗。

Objective To investigate the effects of transsphenoidal surgery on anterior pituitary function in patients with growth hormone-secreting pituitary adenoma, and to explore the related factors. Methods A total of 173 patients with acromegaly were enrolled to this study who underwent transsphenoidal surgery from January 2013 to December 2014 at Department of Neurosurgery, Huashan Hospital, Fudan University. Their clinical data were retrospectively analyzed including preoperative and postoperative biochemical tests and the function of anterior pituitary. Results The preoperative prevalences of hypoadrenalisnl, hypothyroidism and male hypogonadism were 15.0% （26/173）, 18. 5% （32/173） and 60. 8% （45/74）, respectively. Post-operatively, the newly emerging hypoadrenalism, hypothyroidism and male hypogonadism were 3.2% （4/126）, 0. 8% （1/121） and 12.5% （3/24）, respectively. The recovery rates of hypoadrenalism, hypothyroidism and male hypogonadism were 85.7% （ 18/21 ）, 92. 3% （24/26） and 52. 8% （ 19/36）, respectively. Univariate analysis showed that the tumor volume in newly emerging hypoadrenalism group was significantly larger than that in normal group （ 10.3 cm3 vs. 1.3 cm3, P =0. 010）. As for male gonadal axis, the disease duration in the newly emerging hypogonadism group was longer than that in normal group （15 vs. 3 years, P = 0.039）. The percentage of GH remission in the group with improvement of sexual function was higher than that in deterioration group （78. 9% vs. 47.1%, P =0. 047）. By means of multivariate logistic analysis, tumor volume （OR = 12. 704, P = 0. 005, 95% CI： 2. 115 -76. 323 ） was decided to be the main risk factor for postoperative hypopituitarism. Conclusions Transsphenoidal surgery could help significantly improve the function of adrenal axis, thyroid axis and male gonadal axis in patients with GH-secreting adenomas, and the incidence of postoperatively anterior hypopituitarism is low. Tumor volume acts as an independent risk factor for postoperative hypopituitarism, and close follow-up and replacement therapy should be taken into consideration when necessary.