神经内镜经鼻蝶手术治疗垂体神经内分泌肿瘤术中发生脑脊液漏的影响因素分析及颅底重建策略

Analysis of influencing factors and skull base reconstruction strategies for cerebrospinal fluid leakage during neuroendoscopic transnasal transsphenoidal surgery for pituitary neuroendocrine tumor

目的探讨神经内镜经鼻蝶垂体神经内分泌肿瘤(PitNET)切除术中发生脑脊液漏的影响因素及分层颅底重建策略.方法回顾性分析2020年6月至2022年12月新疆维吾尔自治区人民医院神经外科收治的237例PitNET患者的临床资料,所有患者均行神经内镜经鼻蝶肿瘤切除术,依据术中是否发生脑脊液漏分为术中无脑脊液漏组(198例)和术中脑脊液漏组(39例),并依据脑脊液漏Kelly分级标准(术中无脑脊液漏组均为0级,术中脑脊液漏组为1~3级)采取分层颅底重建策略.分析两组患者的临床资料,采用多因素logistic回归分析判断术中发生脑脊液漏的影响因素.结果237例患者中,198例术中无脑脊液漏发生,39例术中发生脑脊液漏;其中Kelly分级0级198例,1级27例,2级9例,3级3例,所有患者均顺利完成颅底重建.术后2例患者发生颅内感染,无一例新发脑脊液漏.237例患者均获得临床随访,中位随访时间为7.5个月(3~12个月).至末次随访,均未见脑脊液漏和颅内感染等并发症.两组患者的年龄、性别、体质量指数、术前合并症的差异均无统计学意义(均P>0.05);而肿瘤最大径、肿瘤部位、肿瘤质地、手术次数及肿瘤切除程度的差异均有统计学意义(均P<0.05).多因素logistic回归分析结果显示,肿瘤最大径(OR=1.24,95%CI:1.13~1.36)、肿瘤部位(OR=0.17,95%CI:0.04~0.80)、肿瘤质地(OR=15.38,95%CI:4.61~51.28)、手术次数(OR=14.76,95%CI:2.44~89.19)是神经内镜经鼻蝶垂体腺瘤切除术中发生脑脊液漏的独立影响因素(均P<0.05).结论PitNET最大径较大且质韧、二次手术的患者采用神经内镜经鼻蝶肿瘤切除术中发生脑脊液漏的风险更高,而肿瘤位于鞍上是术中发生脑脊液漏的保护因素,依据脑脊液漏分级标准采取分层颅底重建策略安全、有效.

Objective To investigate the influencing factors and stratified skull base reconstruction strategies for cerebrospinal fluid leakage during endoscopic transnasal transsphenoidal resection of pituitary neuroendocrine tumor(PitNET).Methods A retrospective analysis was conducted on the clinical data of 237 patients with PitNET who were admtted to the Neurosurgery Department of People's Hospital of Xinjiang Uygur Autonomous Region from June 2020 to December 2022.All patients underwent endoscopic transnasal transsphenoidal tumor resection.According to whether cerebrospinal fluid leakage occurred during operation,the patients were divided into two groups:non-leakage group(198 cases)and leakage group(39 cases).In addition,according to the Kelly criteria for cerebrospinal fluid leakage(grade O for all patients in nonleakage group and grades 1-3 for those in leakage group),a stratified skull base reconstruction strategy was adopted.The clinical data of the two groups were analyzed and the influencing factors of cerebrospinal fluid leakage during operation were analyzed by multivariate logistic regression.Results Among 237 patients,198 had no cerebrospinal fluid leakage during operation and 39 had cerebrospinal fluid leakage during operation.Among them,Kelly grade 0 was reported in 198 cases,grade 1 in 27,grade 2 in 9,and grade 3 in 3.All patients successfully underwent skull base reconstruction.Intracranial infection occurred in 2 patients after operation,and no new cerebrospinal fluid leakage complication occurred.All 237 patients received clinical follow-up,with a median follow-up time of 7.5 months(3-12 months).As of the last follow-up,no complications such as cerebrospinal fluid leakage or intracranial infection were observed.There were significant differences in the maximum tumor diameter,tumor location,tumor texture,times of operation and tumor resection degree between the cerebrospinal fluid leakage group and non-leakage group(all P<0.05).Multivariate logistic regression analysis showed that maximum tumor diameter(OR=1.24,95%CI:1.13-1.36),tumor location(OR=0.17,95%CI:0.04-0.80),tumor texture(OR=15.38,95%CI:4.61-51.28)and operation times(0R=14.76,95%CI:2.44-89.19)were independent influencing factors for cerebrospinal fluid leakage during endoscopic transnasal sphenoidal resection of pituitary adenomas(all P<0.05).Conclusions Patients with PitNET with large maximum diameters and tough textures,and patients undergoing secondary surgery have a higher risk of cerebrospinal fluid leakage during neuroendoscopic transnasal sphenoidal tumor resection.The pituitary adenomas located on the sella is a protective factor for cerebrospinal fluid leakage during the operation.Stratified skull base reconstruction strategy,adopted based on the cerebrospinal fluid leakage grading standards,seems safe and effective.