The key point of transsphenoidal surgery for infradiaphragmatic craniopharyngioma：Better saddle diaphragm resection

Abstract Background Craniopharyngiomas have a high recurrence rate and a poor prognosis, and the key methods for reducing recurrences are unknown. The aim of this study was to explore the key points of microscopic or endoscopic transsphenoidal surgery used to treat infradiaphragmatic craniopharyngiomas. Methods We reviewed the medical records of patients with infradiaphragmatic craniopharyngiomas who were admitted to Peking Union Medical College Hospital between 2015 and 2018. Results The main symptoms of patients with infradiaphragmatic craniopharyngiomas included headache, endocrine disorders, decreased vision, or visual field defects. In terms of tumor location, nine patients were completely intrasellar and the remaining 11 patients were intrasuprasellar. Of the 20 patients, 16 patients underwent resection under the microscope and the remaining four patients underwent transsphenoidal endoscopic surgery. Gross total tumor resection was achieved in 12 patients. Six patients underwent saddle diaphragm resection, while the remaining 14 patients were not. Cerebrospinal fluid leaks occurred during surgery in six patients (6/6 saddle diaphragm resection group). Eleven patients with high PRL levels preoperatively all had decreased levels to varying degrees postoperatively and levels returned to normal in eight of these patients. Two patients with diabetes insipidus achieved resolution postoperative. Visual acuity improved in one patient. After an average follow-up of 26.4 months, eight patients experienced tumor recurrence. Recurrence did not occur in any of the six patients who underwent saddle diaphragm resection (0% vs 57.1%, P=0.0419). Conclusion The resection of the saddle diaphragm is pivotal in craniopharyngioma removal surgery and is related to tumor recurrence. In comparison to the saddle diaphragm protection group, the resection group is able to achieve a reduced recurrence rate while maintaining acceptable complications.