Endocrine Evaluation Following Aggressive Surgical Resection of Craniopharyngiomas in Children（Report of 782 cases)

Endocrine Evaluation Following Aggressive Surgical Resection of Craniopharyngiomas in Children（Report of 782 cases) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Endocrine Evaluation Following Aggressive Surgical Resection of Craniopharyngiomas in Children（Report of 782 cases) Yang Yang, Zaitao Yu, Xiangen Shi, Zhongqing Zhou, Fangjun Liu, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7787534/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: A retrospective study assessed the endocrinological outcomes of aggressive surgical tumor resection in pediatric patients, focusing on the treatment's efficacy and safety. Patients and methods: 782 craniopharyngioma pediatric patients were treated surgically from January 2004 to May 2023. There were 62.9% boys and 37.1% girls, with mean ages of 8.09±3.67 years ranging from 8 months to 15 years old. The tumor size in pediatric patients ranged from 1.1cm to 16cm in maximal diameter, with an average diameter of 3.84±1.47 cm. 82.1% of the tumors had calcified tumors with 6.3% huge calcified masses of 1.5 cm diameter. Results : Total removal of tumors were achieved in 90.2%. The pituitary stalk was intentionally preserved in 87.1% cases despite partial injury or remains intact with peeling off the residual tumor. Within the perioperative period, there were 2.7% deaths. Of the remaining patients, 77.6% were followed up for an average of 3.9 years. Out of 607 patients, 92.3% had total tumor removal and other had a subtotal or partial resection. At a 1.5-year follow-up after surgery, hormone levels showed no improvement compared to the deficits observed during the perioperative period. A total of 71.3% patients with an endocrine disturbance required postoperative substitution of the deficient hormone. 11.6% of the patients with total tumor removal experienced recurrence in an average of 3.3 years, while 91.5 % of patients with subtotal or partial resection had tumor progression within an average of 0.5 years. Conclusion: Transcranial surgery allows for gross total removal of the tumor to achieve free survival in most pediatric patients, which enables precise targeting of the tumor while minimizing interference from its specific characteristics.The morbidity of hormone deficits and hypothalamic obesity presents a challenge to the surgical aggressive resection of the tumor. Craniopharyngioma Hormone deficits Open surgery Aggressive resection Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Craniopharyngiomas(CPs) develop along the hypothalamic-pituitary axis, posing a significant challenge for complete resection and the restoration of hypothalamic and pituitary function. The surgical approach for craniopharyngioma has evolved from radical resection, which often leads to high functional morbidity, to a strategy that focuses on tailored resection under neuromonitoring. This change aims to enhance functional outcomes, followed by supplemental treatment of any suspicious residual lesions using stereotactic radiosurgery and radiotherapy. Endonasal endoscopic surgery is a well-established technique for removing tumors, even when they extend near major arteries in the anterior or posterior circulation, which can complicate complete removal. The use of expanded endonasal endoscopic corridors and angled endoscopes enables surgeons to access tumors more effectively[ 1 , 2 ]. While the endonasal approach can effectively treat challenging conditions, many pediatric patients in the CPs receive inadequate treatment through poorly tailored resections and ineffective irradiation methods[ 3 – 5 ]. Further evaluation is necessary to assess the balance between tumor resection and post-operative hormonal stability, visual outcomes, and hypothalamic function. Complete surgical resection is associated with improved overall survival and progression-free survival compared to conservative management alone. Choosing the right open surgical method ensures complete tumor removal while preserving hypothalamic-pituitary function in pediatric patients, resulting in minimal hormone replacement[ 6 , 7 ]. This approach reduces the necessity for retreatments that can occur due to insufficient sensitivity to radiotherapy in cases of recurrent tumors. Traditionally, the surgical treatment of CPs in pediatric patients has involved open surgery, employing various techniques such as subfrontal, interhemispheric, and pterional approaches, along with their modifications. This open surgery to remove the CP has a lower risk of cerebrospinal fluid leakage without limiting tumor features, compared to endoscopic surgery[ 8 – 10 ]. In open surgery, the tumor is accessed directly, which allows for better exposure of its lateral growth and the encirclement of surrounding structures without requiring a large transsphenoidal approach through the nasal floor[ 11 – 12 ]. At present, there is a lack of large randomized studies comparing this technique to the established standards, which include options such as open surgery, endoscopic endonasal surgery, and radiotherapy[ 13 – 15 ].This results in variability in the selection of surgical approaches. This report reviews the open surgical management of pediatric CPs and their endocrine outcomes. It emphasizes the protection of nearby blood vessels, the optic apparatus, and hypothalamic areas, while also assessing long-term hormone status and quality of life following surgery. Methods Participants A total of 782 pediatric cases of CP were surgically treated between January 2004 and May 2023. Among the pediatric patients, 62.9% were boys and 37.1% were girls, with an average age of 8.09 ± 3.67 years. The ages of the patients ranged from 8 months to 15 years old. In 86.6% of cases, patients exhibit persistent headaches, blurred vision, diabetes insipidus, and growth failure as their initial clinical manifestations. The visual acuity and field test were not gained due to young age not to cooperative examination in 101 less than 3-year-old baby patients. Conversely, 13.4% of patients had manifestations uncertain related to hypothalamic-pituitary area invasion. In this series, 185 (23.7%) patients experienced tumor recurrence following previous surgical procedures. This included 146 (78.9%) cases of recurrent tumors after the initial surgical procedure, 24 (13.0%) after a secondary surgery, and 15 (8.1%) after a third surgery. One pediatric patient underwent ten open surgeries after experiencing nine surgical procedures, including three endoscopic surgeries, two open surgeries, two interstitial brachytherapy, and two ventriculoperitoneal shunt shunts. On MR images, the tumors were identified within the suprasellar region in 346 cases (44.2%), with upward extension to the third ventricular floor in 251 cases (32.1%), lateral extension to the parasellar region in 56 cases (7.2%), downward invasion to the intrasellar region in 50 cases (6.4%), passing over the dorsum sellae to the posterior cranial fossa in 6 cases (0.7%), located solely within the third ventricular floor in 63 cases (8.1%), and restricted to the intrasellar region in 10 cases (1.3%). Concurrently, obstructive hydrocephalus manifested in 296 patients (37.8%) with concurrent lateral ventricle enlargement. The tumor size in pediatric patients ranged from 1.1 cm to 16 cm in maximal diameter, with an average diameter of 3.84 ± 1.47 cm. 46.4% of tumors were pure cystic, 48.3% were mixed cystic and solid, and 5.3% were completely solid. 82.1% of the tumors on CT scans had calcifications, with 6.3% showing huge calcified masses of more than 1.5 cm in diameter. Surgical Procedures An aggressive surgical resection plan was executed for all patients to achieve the best overall outcome and recurrence-free survival independent of radiotherapy whenever possible. A unifrontal basal interhemispheric approach (UBIA) approach was used for midline tumors in 647(82.8%) of the patients(Fig. 1and 2)[ 16 , 17 ]. Total removal of the tumor is ensured in the absence of tumor residual under microscopic procedures. Subtotal removal refers to the residual small tumor under a surgical microscopic procedure due to the tumor's attachment to vital vascular or neural structures. Tumor partial removal refers to a larger portion remaining by way of the surgical microscope procedure. The entire extent of the surgical procedure was confirmed on postoperative enhanced MR images. A pterional craniotomy in 99 (12.7%) patients was elected for the suprasellar tumor extending to the parasellar region, middle cranial fossa, and Sylvian fissure, which minimally retracts the optic nerve to access the suprasellar region through the enlarged space between the optic nerve and internal carotid artery (ICA) followed by the tumor of the parasellar region removal (Fig. 3 ). The combination of the UBIA and pterional craniotomy in 33(4.2%) patients was used for the huge suprasellar tumors extensive to the sylvian fissure, and middle cranial fossa,(Fig. 4 ). Results Tumor resection In 688 cases (88%), a senior neurosurgeon definitively confirmed intraoperatively the complete removal of the tumor, a result later validated by a postoperative MR image. In 147 of the cases (18.8%) where patients underwent subtotal tumor removal or residual tumor on postoperative MR image. 9 cases (1.2%) had low tolerance for surgical intervention due to prior radiation treatment for recurrent tumors and long-term hormone deficits. A mark of the pituitary stalk served to preserve hypothalamic structures. There was preservation in 464 cases (59.3%), failure or no visible pituitary stalk in 318 cases (40.7%). Visual Function In 213(27.2%) patients with visual acuity and visual field deficits before surgery, there were visual acuity deficits in 49 (23%) of the patients and visual field deficits in 164 (77%) of the patients. Of those with visual field deficits, 106 (64.6%) had bitemporal hemianopia, and the remaining 58 (35.4%) had pleomorphic hemianopia. Postoperative visual acuity and field defects improve in 150 patients (70.4%). Of patients with deteriorated visual acuity and visual defect, one patient with UBIA lost all vision of both eyes, likely due to optic pathway ischemia, and either had unilateral eye blindness resulting from retracting optic nerve due to tumor calcification removal with pterional approach. These two patients still could not perceive light 6 months after surgery. Among 569 patients without visual deficits before surgery, new acuity or field impairment occurred in 8 (1.4%) patients (10 eyes), consisting of pterional approaches in 6 patients and UBIA in 2 patients. Endocrine Morbidity Following surgery, various hypothalamic-pituitary hormones were assessed during the perioperative period, outpatient follow-up, and through WeChat inquiries. A significant difference was noted between preoperative and postoperative hormone deficiencies, including thyroid-stimulating hormone (TSH), growth hormone (GH), adrenocorticotropic hormone (ACTH), hyperprolactinemia (hyper PRL), and cortisol. This suggests that existing hormone deficiencies worsened, and new deficiencies emerged after the surgery (Table 1 ). At a 1.5-year follow-up, there was no significant difference in deficits of pituitary-hypothalamic hormones after surgery (Table 2 ).Obesity and eating disorders at a two-year follow-up after surgery were observed in 266 children, representing 34.0% of those with a BMI greater than 25 kg/m². In Table 3 , the distribution of patient ages concerning the incidence of hypothalamic obesity was analyzed. There was a statistically significant difference in hypothalamic obesity rates before and after surgery (X = 161.282, P < 0.005). After surgery, patients tended to experience higher rates of morbidity associated with hypothalamic obesity as they aged. Table 1 Hormone deficits from the anterior pituitary were compared before surgery and three months after the procedure. Hormone Deficits Total cases Before surgery After surgery Wilcoxon Signed Ranks Test GH 751 180 (24.0%) 591 (78.7%) u = 4.498, p < 0.05 TSH 751 161 (21.4%) 344 (45.8%) u = 6.979, p < 0.05 ACTH 706 25 (3.4%) 278 (39.4%) u = 5.570, p < 0.05 Cortisol 715 154 (21.5%) 351 (49.1%) u = 6.254, p < 0.05 Hyper-PRL 716 182 (25.4%) 134 (18.7%) u = 5.141, p < 0.05 Table 2 Endocrine outcome comparison of 1.5 years after surgery with 3 months after surgery Hormone Deficits 3 months after surgery 1.5 years(%) after surgery X2 test P Value GH 591/749 (78.9%) 306/398 (76.9%) 0.50972 P > 0.5 TSH 344/751 (45.8%) 187/472 (39.6%) 4.2677 P 0.5 Cortisol 351/715 (49.1%) 219/472(46.4%) 0.7138 P > 0.5 Hyper-PRL 134/716 (18.7%) 75/432(17.4%) 0.2470 P > 0.5 Table 3 The age distribution of patients with hypothalamic obesity at a six-month follow-up. Age Case number Hypothalamic Obesity (%) Before surgery After surgery < 3 95 4(4.2) 8 (8.4) 4–6 190 24 (12.6) 30 (15.8) 7–9 190 32 (16.8) 75 (39.5) 10–12 176 42 (23.9) 85 (48.3) 13–15 131 55 (42.0) 68 (51.9) Total 782 157 (20.1) 266 (34.0) In this series, diabetes insipidus (DI) was identified as a potential diagnosis for patients exhibiting a urine output exceeding 3 cc/kg/hour, urine osmolality lower than 200 mosm/L, and elevated serum sodium levels over 150 mEq/L. Before the surgical procedure, 103 patients exhibited symptoms of polyuria/polydipsia. After surgery, 69.6% of the patients experienced their DI symptoms, and 29.7% of the patients developed new cases of DI following surgery. The patients with DI after surgery disclosed a remarkable deterioration in their symptoms compared to patients with non-DI before surgery, while patients with non-DI developed a new high rate of DI complications after surgery. There was a higher DI complication after surgery compared to before surgery, X 2 = 105.158, P < 0.005, as seen in Table 4 . Table 4 Comparison of preoperative and postoperative diabetes insipidus in 782 patients with CP DI Non-DI (%) DI Before surgery (%) Deteriorate DI New DI Before surgery 679 (86.8) 103 (13.2) After surgery 477 (61.0) 305 (39.0) 93(90.3) 212(44.4) Related Complications Postoperative intracranial infection typically indicates bacterial infection, referred to as bacterial meningitis, which is shown by CSF with elevated protein and WBC counts, along with low glucose levels. Gram stains of the CSF organisms may be positive or negative. Aseptic or chemical meningitis was characterized by merely elevated protein and WBC count with no organisms in CSF, which showed negative results from Gram stains or CSF cultures. There occurred in 68 patients (8.7%) due to the body's inability to ward off intracranial infections, associated with the cyst fluid triggering inflammatory responses and hypothalamic involvement[ 18 , 19 ]. This rate was higher than that reported in other craniotomies[ 20 ]. In 7 out of 73 cases (9.6%), cerebrospinal fluid (CSF) leaks developed during specific procedures involved in the surgical process, including drilling out the planum sphenoidale, anterior clinoid process, unroofing the optic canal, and frontal sinus opening. After surgery, 19 of the 305 cases(6.2%) of DI resulted in deep-vein thrombosis leading to pulmonary emboli (PE) on helical CT pulmonary angiography. 14 of the 19 affected patients died from PE. In 3 to 6 days after surgery, 4 out of 647 cases༈0.62%༉ of UBIA experienced central herniation. This was due to swelling on the bilateral medial surface of the frontal face, causing downward displacement of the bilateral hypothalamus and diencephalic dysfunction resulting in Cheyne-Stokes respiration, bilateral small reactive pupils, and rapid loss of consciousness. Two patients underwent bilateral frontal decompression with bone flaps removal to relieve their herniations, while two others died. Histopathology Our histopathological bank currently contains 917 pediatric cases of CPs in patients aged 15 and younger. Among these, 909 cases (99.2%) exhibit adamantinomatous features, making it the predominant type. Additionally, 8 cases (0.8%) show papillary features, representing an alternative presentation. Notably, we have documented 2 cases that experienced malignant transformations of adamantinomatous features, which necessitated a second surgery to address recurrent tumors following initial radiotherapy(Fig. 5 ). Follow-Up and Patient Outcome A total of 601/782 patients (76.8%) were followed up for an average of 3.6 ± 10.03 years (range, 1.9 ± 20 years) (Figs. 4 and 5 ). Of the 601 follow-up patients with complete tumor removal, 88 (12.4%) compromised tumor recurrence within an average of 3.4 ± 1.64 years (range, 2.1 months to 20 years). Among the 70 follow-up patients with subtotal or partial resection, 67 patients (95.7%) experienced tumor recurrence within an average of 4.3 months (range, 2.1 months to 2.1 years), including 23 of 53 patients (47.3%) who received postoperative stereotactic radiation and Gamma Knife treatment (Elekta, Stockholm, Sweden) at a mean of 5.4 months after surgery (range, 3–21 months). Most patients with tumor free or tumor control, 601 (82.3%) with a Karnofsky Scale (KPS) mean 88 ± 8.81 returned to their normal life or school responsibilities without special care; 56 patients (6.6%) with a KPS mean 67 ± 8.91 were able to live at home and complete daily activities independently with minor neurologic or endocrinologic deficits; and 31 patients (5.1%) with a KPS mean 31 ± 5.72 needed local clinical care and variable assistance for daily living. Out of all the patients, 78.7% (610) required hormone replacement therapy for over two years due to endocrine disturbances. 507 patients (47.1%) needed ADH prescription, 206 patients (26.3%) required cortisol and thyroxine replacement, and 149 children (19.3%) needed growth hormone (GH) replacement to improve their short stature. A total of 91 patients (17.9%) experienced permanent polydipsia or polyuria, requiring antidiuretic medication for over 3 years to manage urine output. Out of 193 pediatric patients over 25 years old, 151 (78.2%) did not achieve normal sexual function and fertility. Only 5 patients married and had children during the 10-year follow-up period, consisting of 4 female and 1 male patients. Discussion transcranial and endoscopic endonasal approach This report outlines our perspectives on the outcomes of transcranial approaches based on our single-center experience. Our views stem from our knowledge and expertise in the field. However, it's suggestive to note that these outcomes may differ when compared to endoscopic approaches used at other centers or in cases involving partial resection followed by radiation treatment. Recent advances in the transcranial approach to treating CPs are not significantly limited by the characteristics of the tumor. This method enables minimal enlargement of the sella while effectively addressing large suprasellar masses and any extensions into the parasellar region and the middle fossa. The appropriate selection of transcranial modalities is essential for ensuring that patients with complex tumors receive aggressive surgical treatment. This approach aims to achieve complete tumor removal and prevent the need for unnecessary retreatment or radiation therapy following tumor recurrence. There is a need to investigate tumor recurrence rates after endoscopic surgery and compare them with those following transcranial surgery[ 21 , 22 ]. In this study, a 12.4% rate of recurrent gross total tumor removal was observed after more than three years of follow-up. The transcranial method provides effective tumor dissection through maximal exposure while minimizing invasion of vital neural and vascular structures. This is especially important given the challenges posed by difficult tumor locations, large calcified masses, and extensive involvement of surrounding tissues. A trend in neurosurgery is the shift to endoscopic surgery, driven by advancements in artificial intelligence, machine learning, and virtual reality. There exists an essential distinction between endoscopic and transcranial surgery for treating CPs. The effectiveness of each technique depends on a maximal safe resection or near-total resection tailored specifically to the individual patient, rather than the limitations of each surgical corridor. Yasargil initially preferred to use subfrontal or frontotemporal approaches for treating extra-axial tumors[ 10 ]. In our series, a unifrontal approach to the basal interhemispheric fissure, without the opening of other lateral dural layers, allows for minimal retraction of the bilateral frontal medial surfaces. This technique provides wider exposure of the laminal terminal and prechiasmatic spaces while minimally invading the frontal medial surface. Additionally, the shelter provided by the frontal portion of the falx cerebri may help alleviate concerns about central herniation caused by edema in the bilateral frontal medial surfaces, which can result from excessive retraction[ 16 – 23 ]. Central herniation during the perioperative period results from bilateral frontal edema caused by excessive retraction of the frontal medial surface during surgery. Intraoperative accidental bleeding from a tear in the ACoA may necessitate a microsuture to effectively close any portions of the tear that are difficult to control. Endocrinological Complications In pediatric patients, one of the most serious complications following aggressive resection of CPs is hypothalamic injury. Endocrinopathies resulting from injury to the hypothalamic structures can be particularly challenging to treat through aggressive resection of the tumor with minimal hormone morbidity. The normal endocrine function may be impaired, and hormone deficiencies are likely exacerbated after aggressive surgical resection. Currently, endoscopic surgery, as some reports suggest, has achieved a lower rate of hormone deficiencies in a select group of cases due to minimal surgical invasion, but may be limited to tumor location and features[ 24 , 25 ]. In this series, 44% pediatric patients developed new DI, 34.4% hypothalamic obesity in the total series, but 51.9% hypothalamic obesity occurred in more than 13-year-old pediatric patients while undergoing gross complete tumor removals, which presented a challenge for the transcranial approach at a six-month follow-up. Surgical dissecting procedures remain essential for preventing all hypothalamic structure injuries, including those involving its small perforators and the preservation of a remnant of the pituitary stalk, as well as the use of minimal or rare bipolar cautery. In the future, manual dexterity and technical skills still matter for the surgical treatment of CPs when cutting-edge devices fail. Hypothalamic obesity is the most serious and intractable complication for either transcranial or endoscopic surgery, which involves and damages the hypothalamic satiety center. A normal appetite inhibition fails to be active in the hypothalamic receptors that regulate the negative feedback loop in which leptin, formed in adipocytes, binds to hypothalamic leptin receptors[ 26 , 27 ]. All neural structures in the floor of the hypothalamus produce hormones that regulate the anterior pituitary gland. Hormone replacement therapy may inhibit endogenous hormone secretion related to the presence of exogenous hormones. Specifically, thyroid hormone replacement can lead to dysfunction of the thyroid gland cells and worsen hypothyroidism. The therapy disrupts the negative feedback mechanisms for thyroid hormone secretion, including thyroxine (T4) and triiodothyronine (T3)[ 22 , 23 ]. ACTH is essential for adrenal cortex function and cortisol secretion. Prolonged use of exogenous glucocorticoids can lead to secondary adrenal insufficiency and atrophy of the adrenal cortex. This occurs because the glucocorticoids interfere with the regulation of the hypothalamic-pituitary axis, disrupting the normal feedback mechanisms that control cortisol levels. As a result, the basic functions of negative feedback, diurnal rhythms, and stress-activated responses are affected, which can influence neuroendocrine, autonomic, and hemostatic regulation[ 28 – 29 ]. The primary goal of surgical treatment for CP is to aggressively remove the tumor while minimizing damage to crucial hypothalamic structures without relying solely on hormone replacement therapy after surgery. An appropriate surgical procedure to treat pediatric CP can lead to optimal outcomes with the complete removal of the tumor. The endocrine deficits that may arise after total tumor removal are not more severe than those that occur following a partial removal. When the largest portion of the tumor is accessible via a suitable approach, there is usually a clear dissection plane between the tumor and the hypothalamus. In such cases, an attempt should be made to achieve complete removal of the tumor to reduce the potential risk of recurrence. During a surgical procedure, it is crucial to handle the pituitary stalk carefully, as preserving it can help minimize the risk of postoperative endocrine deficits and diabetes insipidus. High-magnification microscopy aids in identifying tumor tissue within pituitary stalk structures, facilitating the resection of tumors that invade the stalk[ 30 , 31 ]. Conformal radiation and γ-knife probably benefit from preventing regrowth when a residual tumor was left behind or tumor recurrence[ 32 , 33 ]. Reoperation was usually considered for tumor recurrence; the reason for this was that radiation therapy potentially decreased cognition and increased the risk of visual and endocrine morbidities[ 34 , 35 ]. Histopathological Features and Surgical Resection The adamantinomatous type of CP in pediatric patients poses a significantly higher risk of recurrence and progressive growth. This increased risk is largely due to challenges in identifying the surgical plane during surgical dissection. In contrast, the papillary type of CP, which is more commonly found in adult patients, tends to have better outcomes following surgical resection[ 36 , 37 ]. Nearly all CPs exhibit cystic changes and calcifications that are often associated with adamantinomatous features in pediatric cases[ 38 ]. The tumor's adhesion to suprasellar and hypothalamic structures, along with vascular invasion, significantly increases the risk of recurrence and endocrine complications; this was similar to atypical tumors in some cases of the series. However, this rarely indicates a malignant grade that would signify a higher risk of recurrence. Aggressive resection of pediatric CP involves several considerations: 1) It is essential to establish a dissection plane between the tumor and the hypothalamus to manage the long-term risk of recurrence. 2) Achieving complete tumor removal requires excising any dural attachments in the sellar region and the medial wall of the cavernous sinus. Alternatively, endothermic coagulation can be applied to the dural attachments beneath the pituitary stalk and the floor of the hypothalamus, ensuring that the gland's function remains intact. 3) Aggressive resection should aim for freedom from CP recurrence while minimizing postoperative endocrine deficits and diabetes insipidus. In contrast to the pediatric cases in this series, 21.9% of the papillary cystic pancreatic tumors (CP) identified in our study of 2,103 adult cases are included in the histologic bank. These adult CP cases frequently result in anatomical distortion and functional impairment of the hypothalamus. There is no evidence of malignant attachment to the dural and hypothalamic structures following tumor recurrence after aggressive resection without multiple rounds of radiotherapy in most patients[ 39 – 40 ]. Conclusion Transcranial surgery allows for gross total removal of the tumor to achieve free survival in most pediatric patients, which enables precise targeting of the tumor while minimizing interference from its specific characteristics. The morbidity of hormone deficits and hypothalamic obesity presents a serious challenge to the surgical aggressive resection of the tumor. Preserving the hypothalamic structures around the tumor remains a matter for surgical treatment, requiring manual dexterity and technical skills rather than cutting-edge devices. Declarations Acknowledgements Thanks to all our department members. Author contribution Yang Yang and Zaitao Yu wrote the manuscript . Xiangen Shi and Zhongqing Zhou designed the study. Fangjun Liu and Yuming Sun performed Data Collection and Analysis. Xianghua Zhang and Guangkui Han was responsible for Literature Review. Mengqing Hu , Ting Lei, Xin Xiang and Jie Zhang were responsible for Tables and Figures. Funding No Data Availability All data that support the findings of this study are available from the Neurosurgery Department at Capital medical University Sanbo Brain Hospital. Data are however available from the author when requested with permission. Ethical approval The study was approved by our Institutional Review Board (IRB) [IRB#:5782–01–2004] in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for studies involving humans. Consent to participate Received for participation. Conflict of interest The authors have no relevant financial or non-financial interests to disclose. References Bakhsheshian J, Jin DL, Chang KE, Strickland BA, Donoho DA, Cen S, et al (2016) Risk factors associated with the surgical management of craniopharyngiomas in pediatric patients: analysis of 1961 patients from a national registry database. 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J Neurosurg Pediatr 15:499-505. Erin N. Kiehna EN, Merchant TE(2010)Radiation therapy for pediatric craniopharyngioma. Neurosurg Focus 28:E10 Gan HW, Morillon P, Albanese A, Aquilina K, Chandler C, Chang YC, et al(2023)National UK guidelines for the management of paediatric craniopharyngioma. Lancet Diabetes Endocrinol 11(9):694-706. Aldave G, Okcu F, Chintagumpala M, Ruggieri L, Minard CG, Malbari F, et al(2023)Comparison of neurocognitive and quality-of-life outcomes in pediatric craniopharyngioma patients treated with partial resection and radiotherapy versus gross-total resection only. J Neurosurg Pediatr 31:453-462. Chang KE, Strickland BA, Donoho DA, Cen S, Mack WJ, Attenello,et al(2016)Risk factors associated with the surgical management of craniopharyngiomas in pediatric patients: analysis of 1961 patients from a national registry database. Neurosurg Focus 41 (6):E8. Karavitaki N, Cudlip S, Adams CBT, Wass AJ(2006)Craniopharyngiomas. Endocr Rev 27(4):371-397. Zhang YQ, Wang CC, Ma ZY(2002)Pediatric craniopharyngiomas: clinicomorphological study of 189 cases. Pediatr Neurosurg 36: 80–84. Prieto R, Juratli TA, Bander ED, Santagata S, Barrios L, Brastianos PK, et al(2025) Papillary craniopharyngioma: An integrative and comprehensive review. Endocr Rev 46(2):151-213. Shuzi Gao, Xiangen Shi, Yanxia Wang, Hai Qian, Chengyin Liu(2011) Malignant transformation of craniopharyngioma: case report and review of the literature. J Neurooncol 103(3):719-725. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7787534","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":546729109,"identity":"caaf8d0b-e4b9-457e-87b0-748e4a0f1a9d","order_by":0,"name":"Yang Yang","email":"","orcid":"","institution":"Sanbo Brain Hospital Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Yang","suffix":""},{"id":546729110,"identity":"7dd3346f-634b-41e0-8dbd-36f187d13f98","order_by":1,"name":"Zaitao Yu","email":"","orcid":"","institution":"Sanbo Brain Hospital Capital Medical 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Preoperative sagittal (A), coronal (B), and axial (C) enhanced MR imaging revealed a large cystic mixed solid tumor (arrowhead) in the suprasellar region, with significant extension into the third ventricle; the head arrow indicates the direction of the tumor. (D) The drawing illustrated a sagittal view of a supra-sellar tumor with prefixed chiasm, with a short pituitary stalk forward to the tuberculum sellae and enlarged lamina terminalis space. (E) The intraoperative picture of the tumor with compression of the optic chiasm forward to tuberculum sellae and enlarged laminal terminalis spaces through a unifrontal basal interhemispheric approach and (F) visualization of prechiamatic and laminal terminalis region with preservation of the pituitary stalk and perforator after tumor removal. An 8-year follow-up sagittal(H), coronal (I), and axial (J) enhanced MR images showed no tumor growth, the sagittal image arrowhead directing the pituitary stalk, and the coronal image arrowhead directing the irregular mammillary body.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7787534/v1/23f1bc96feebc62d1da79353.jpg"},{"id":96845869,"identity":"e7dea0c5-0ab0-4db1-8e1d-3bc83d6f7c09","added_by":"auto","created_at":"2025-11-26 16:36:45","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":262318,"visible":true,"origin":"","legend":"\u003cp\u003eA 5.4-year-old boy presented with a year's history of visual blur of both eyes and headache for 3 months. Preoperative sagittal(A) and coronal (B) axial (C) enhanced MR imaging showed a large cystic tumor (arrowhead) in the intra-suprasellar region with a large extension into the third ventricle and Sylvian fissure, head arrow directing the tumor. (D) The drawing illustrated a sagittal view of an intrasellar tumor with an enlarged prechiasmatic space, characterized by a longer and thinner pituitary stalk extending upward to the infundibulum, tending to close the lamina terminalis space due to the optic chiasm and third ventricular floor being elevated. (E) The intraoperative picture showed the tumor with compression of the optic chiasm with enlarged prechiasmatic spaces through a unifrontal basal interhemispheric approach, and (F) visualization of the sellar turcica and peduncular fossa structures after tumor removal. An 8-year follow-up sagittal(G), coronal (H), and axial(I) enhanced MR images showed no tumor growth, a sagittal image arrowhead directing the pituitary stalk, and coronal image arrowhead directing the irregular mammillary body, and an axial image arrowhead tending a residual infundibulum.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7787534/v1/45096d7c13f0f1ebfb90ca8d.jpg"},{"id":96917961,"identity":"92e4c669-9d68-4b26-98da-dcedb4614448","added_by":"auto","created_at":"2025-11-27 14:10:52","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":271278,"visible":true,"origin":"","legend":"\u003cp\u003eA 13-year-old boy had compromised ptosis of the right eye due to tumor recurrence 9 months after surgical treatment of the intracranial tumor. Preoperative sagittal(A) and coronal (B) enhanced MR imaging showed a cystic mixed solid tumor of the suprasellar region with the extension of the third ventricle and lateral to the right parasellar region, arrowhead pointing to the tumor. (C) \u0026nbsp;The intraoperative picture showed the tumor extending into the right space between the optic nerve and internal carotid artery through a right pterional approach, and (D) visualization of a clear suprasellar region with preservation of the surrounding tumor structure, including the pituitary stalk, after the tumor removal. \u0026nbsp;Postoperative sagittal(E) and coronal (F) enhanced MR images showed tumor disappearance with basic surrounding tumor structures, including the sagittal image arrowhead pointing to the pituitary gland, and the coronal image arrowhead pointing to the mamillary body. At a 19-year follow-up, a sagittal (G) and coronal (H) showed no tumor growth with preservation of the pituitary stalk and gland, arrowheads directing the pituitary stalk.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7787534/v1/ba22a737a73ec613ab8e18ef.jpg"},{"id":96845874,"identity":"f046ace3-cdc0-4f7a-87e2-07c0162af62d","added_by":"auto","created_at":"2025-11-26 16:36:45","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":455433,"visible":true,"origin":"","legend":"\u003cp\u003eA 14-year-old boy had about a half-year history of decreasing visual acuity. Preoperative sagittal(A) and coronal (B) enhanced MR imaging showed a large solid tumor mass of the intra-suprasellar region with extension into the third ventricle, and right anterior frontal lobe, arrowhead arrow pointing to the tumor. (C) \u0026nbsp;The intraoperative picture showed the tumor mass of the anterior frontal interhemispheric fissure through a combination of frontal and temporal fossa craniotomies, and (D) a clear sellar turcica, prechiasmatic space, and a portion of the parasellar area after the tumor removal. Three months after surgery, sagittal(E) and coronal (F) enhanced MR images showed total tumor removal and generally preserved hypothalamic floor, sagittal image arrowhead pointing pituitary stalk, coronal image arrowhead pointing hypothalamic floor, and axial images arrowhead indicating the sellar turcica.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7787534/v1/707631cce252b60335bfc4fc.jpg"},{"id":96845872,"identity":"062a4952-c40f-43be-a5dd-5904c3887888","added_by":"auto","created_at":"2025-11-26 16:36:45","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":970911,"visible":true,"origin":"","legend":"\u003cp\u003eA.A histopathology slide stained with Hematoxylin and eosin (H\u0026amp;E) from a tumor removed from the suprasellar region of a 7-year-old exhibited cords of squamous epithelium, palisaded columnar epithelium, wet keratin, and focal keratin consistent with the adamantinomatous type of craniopharyngioma, at a magnification of 100×.\u003cstrong\u003e \u003c/strong\u003eB. A microscopic slide stained with H\u0026amp;E from a tumor removed from the floor of the third ventricle of a 4-year-old boy revealed a pseudopapillary type of craionpharyngioma. The slide featured well-differentiated, non-keratinizing stratified squamous epithelium. A prominent layer of palisaded basal cells rested on fibrovascular cores made up of loose stroma, at a magnification of 100×. C and D. \u0026nbsp;A microscopic slide stained with H\u0026amp;E was obtained from a recurrent tumor after three-time surgeries in the parasellar region of a 14-year-old boy. He had undergone three surgeries, along with radiotherapy and gamma knife treatment for his tumor, which displayed typical features of adamantinomatous craniopharyngioma transforming into ameloblastic carcinoma. The tumor destroyed the basement membrane (C) at a magnification of ×200. The tumor cells exhibited round-to-oval nuclei, pleomorphism, hyperchromasia, and a higher nuclear-to-cytoplasmic ratio (D) at a magnification of ×400.\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7787534/v1/e446887d480ae3c6d6daebac.jpg"},{"id":97139777,"identity":"be50f527-0994-48ba-b807-deec78f53425","added_by":"auto","created_at":"2025-12-01 10:02:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2866812,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7787534/v1/e6c2da8a-b62f-4c00-b7ed-6be263c3608e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Endocrine Evaluation Following Aggressive Surgical Resection of Craniopharyngiomas in Children（Report of 782 cases) ","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCraniopharyngiomas(CPs) develop along the hypothalamic-pituitary axis, posing a significant challenge for complete resection and the restoration of hypothalamic and pituitary function. The surgical approach for craniopharyngioma has evolved from radical resection, which often leads to high functional morbidity, to a strategy that focuses on tailored resection under neuromonitoring. This change aims to enhance functional outcomes, followed by supplemental treatment of any suspicious residual lesions using stereotactic radiosurgery and radiotherapy. Endonasal endoscopic surgery is a well-established technique for removing tumors, even when they extend near major arteries in the anterior or posterior circulation, which can complicate complete removal. The use of expanded endonasal endoscopic corridors and angled endoscopes enables surgeons to access tumors more effectively[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While the endonasal approach can effectively treat challenging conditions, many pediatric patients in the CPs receive inadequate treatment through poorly tailored resections and ineffective irradiation methods[\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Further evaluation is necessary to assess the balance between tumor resection and post-operative hormonal stability, visual outcomes, and hypothalamic function. Complete surgical resection is associated with improved overall survival and progression-free survival compared to conservative management alone. Choosing the right open surgical method ensures complete tumor removal while preserving hypothalamic-pituitary function in pediatric patients, resulting in minimal hormone replacement[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This approach reduces the necessity for retreatments that can occur due to insufficient sensitivity to radiotherapy in cases of recurrent tumors. Traditionally, the surgical treatment of CPs in pediatric patients has involved open surgery, employing various techniques such as subfrontal, interhemispheric, and pterional approaches, along with their modifications. This open surgery to remove the CP has a lower risk of cerebrospinal fluid leakage without limiting tumor features, compared to endoscopic surgery[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In open surgery, the tumor is accessed directly, which allows for better exposure of its lateral growth and the encirclement of surrounding structures without requiring a large transsphenoidal approach through the nasal floor[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. At present, there is a lack of large randomized studies comparing this technique to the established standards, which include options such as open surgery, endoscopic endonasal surgery, and radiotherapy[\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].This results in variability in the selection of surgical approaches. This report reviews the open surgical management of pediatric CPs and their endocrine outcomes. It emphasizes the protection of nearby blood vessels, the optic apparatus, and hypothalamic areas, while also assessing long-term hormone status and quality of life following surgery.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eA total of 782 pediatric cases of CP were surgically treated between January 2004 and May 2023. Among the pediatric patients, 62.9% were boys and 37.1% were girls, with an average age of 8.09\u0026thinsp;\u0026plusmn;\u0026thinsp;3.67 years. The ages of the patients ranged from 8 months to 15 years old. In 86.6% of cases, patients exhibit persistent headaches, blurred vision, diabetes insipidus, and growth failure as their initial clinical manifestations. The visual acuity and field test were not gained due to young age not to cooperative examination in 101 less than 3-year-old baby patients. Conversely, 13.4% of patients had manifestations uncertain related to hypothalamic-pituitary area invasion. In this series, 185 (23.7%) patients experienced tumor recurrence following previous surgical procedures. This included 146 (78.9%) cases of recurrent tumors after the initial surgical procedure, 24 (13.0%) after a secondary surgery, and 15 (8.1%) after a third surgery. One pediatric patient underwent ten open surgeries after experiencing nine surgical procedures, including three endoscopic surgeries, two open surgeries, two interstitial brachytherapy, and two ventriculoperitoneal shunt shunts.\u003c/p\u003e\u003cp\u003eOn MR images, the tumors were identified within the suprasellar region in 346 cases (44.2%), with upward extension to the third ventricular floor in 251 cases (32.1%), lateral extension to the parasellar region in 56 cases (7.2%), downward invasion to the intrasellar region in 50 cases (6.4%), passing over the dorsum sellae to the posterior cranial fossa in 6 cases (0.7%), located solely within the third ventricular floor in 63 cases (8.1%), and restricted to the intrasellar region in 10 cases (1.3%). Concurrently, obstructive hydrocephalus manifested in 296 patients (37.8%) with concurrent lateral ventricle enlargement.\u003c/p\u003e\u003cp\u003eThe tumor size in pediatric patients ranged from 1.1 cm to 16 cm in maximal diameter, with an average diameter of 3.84\u0026thinsp;\u0026plusmn;\u0026thinsp;1.47 cm. 46.4% of tumors were pure cystic, 48.3% were mixed cystic and solid, and 5.3% were completely solid. 82.1% of the tumors on CT scans had calcifications, with 6.3% showing huge calcified masses of more than 1.5 cm in diameter.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSurgical Procedures\u003c/h3\u003e\n\u003cp\u003eAn aggressive surgical resection plan was executed for all patients to achieve the best overall outcome and recurrence-free survival independent of radiotherapy whenever possible. A unifrontal basal interhemispheric approach (UBIA) approach was used for midline tumors in 647(82.8%) of the patients(Fig.\u0026nbsp;1and 2)[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Total removal of the tumor is ensured in the absence of tumor residual under microscopic procedures. Subtotal removal refers to the residual small tumor under a surgical microscopic procedure due to the tumor's attachment to vital vascular or neural structures. Tumor partial removal refers to a larger portion remaining by way of the surgical microscope procedure. The entire extent of the surgical procedure was confirmed on postoperative enhanced MR images.\u003c/p\u003e\u003cp\u003eA pterional craniotomy in 99 (12.7%) patients was elected for the suprasellar tumor extending to the parasellar region, middle cranial fossa, and Sylvian fissure, which minimally retracts the optic nerve to access the suprasellar region through the enlarged space between the optic nerve and internal carotid artery (ICA) followed by the tumor of the parasellar region removal (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The combination of the UBIA and pterional craniotomy in 33(4.2%) patients was used for the huge suprasellar tumors extensive to the sylvian fissure, and middle cranial fossa,(Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eTumor resection\u003c/strong\u003e\u003cp\u003eIn 688 cases (88%), a senior neurosurgeon definitively confirmed intraoperatively the complete removal of the tumor, a result later validated by a postoperative MR image. In 147 of the cases (18.8%) where patients underwent subtotal tumor removal or residual tumor on postoperative MR image. 9 cases (1.2%) had low tolerance for surgical intervention due to prior radiation treatment for recurrent tumors and long-term hormone deficits. A mark of the pituitary stalk served to preserve hypothalamic structures. There was preservation in 464 cases (59.3%), failure or no visible pituitary stalk in 318 cases (40.7%).\u003c/p\u003e\u003c/p\u003e\n\u003ch3\u003eVisual Function\u003c/h3\u003e\n\u003cp\u003eIn 213(27.2%) patients with visual acuity and visual field deficits before surgery, there were visual acuity deficits in 49 (23%) of the patients and visual field deficits in 164 (77%) of the patients. Of those with visual field deficits, 106 (64.6%) had bitemporal hemianopia, and the remaining 58 (35.4%) had pleomorphic hemianopia. Postoperative visual acuity and field defects improve in 150 patients (70.4%). Of patients with deteriorated visual acuity and visual defect, one patient with UBIA lost all vision of both eyes, likely due to optic pathway ischemia, and either had unilateral eye blindness resulting from retracting optic nerve due to tumor calcification removal with pterional approach. These two patients still could not perceive light 6 months after surgery. Among 569 patients without visual deficits before surgery, new acuity or field impairment occurred in 8 (1.4%) patients (10 eyes), consisting of pterional approaches in 6 patients and UBIA in 2 patients.\u003c/p\u003e\n\u003ch3\u003eEndocrine Morbidity\u003c/h3\u003e\n\u003cp\u003eFollowing surgery, various hypothalamic-pituitary hormones were assessed during the perioperative period, outpatient follow-up, and through WeChat inquiries. A significant difference was noted between preoperative and postoperative hormone deficiencies, including thyroid-stimulating hormone (TSH), growth hormone (GH), adrenocorticotropic hormone (ACTH), hyperprolactinemia (hyper PRL), and cortisol. This suggests that existing hormone deficiencies worsened, and new deficiencies emerged after the surgery (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). At a 1.5-year follow-up, there was no significant difference in deficits of pituitary-hypothalamic hormones after surgery (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).Obesity and eating disorders at a two-year follow-up after surgery were observed in 266 children, representing 34.0% of those with a BMI greater than 25 kg/m\u0026sup2;. In Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, the distribution of patient ages concerning the incidence of hypothalamic obesity was analyzed. There was a statistically significant difference in hypothalamic obesity rates before and after surgery (X\u0026thinsp;=\u0026thinsp;161.282, P\u0026thinsp;\u0026lt;\u0026thinsp;0.005). After surgery, patients tended to experience higher rates of morbidity associated with hypothalamic obesity as they aged.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eHormone deficits from the anterior pituitary were compared before surgery and three months after the procedure.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHormone Deficits\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal cases\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBefore surgery\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAfter surgery\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eWilcoxon Signed Ranks Test\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e751\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e180 (24.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e591 (78.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eu\u0026thinsp;=\u0026thinsp;4.498, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTSH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e751\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e161 (21.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e344 (45.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eu\u0026thinsp;=\u0026thinsp;6.979, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eACTH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e706\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e25 (3.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e278 (39.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eu\u0026thinsp;=\u0026thinsp;5.570, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCortisol\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e715\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e154 (21.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e351 (49.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eu\u0026thinsp;=\u0026thinsp;6.254, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHyper-PRL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e716\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e182 (25.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e134 (18.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eu\u0026thinsp;=\u0026thinsp;5.141, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eEndocrine outcome comparison of 1.5 years after surgery with 3 months after surgery\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHormone Deficits\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 months after surgery\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.5 years(%) after surgery\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eX2 test\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e591/749 (78.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e306/398 (76.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.50972\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTSH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e344/751 (45.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e187/472 (39.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.2677\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eACTH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e278/706 (39.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e135/363 (37.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.3956\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCortisol\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e351/715 (49.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e219/472(46.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.7138\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHyper-PRL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e134/716 (18.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e75/432(17.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.2470\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe age distribution of patients with hypothalamic obesity at a six-month follow-up.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCase number\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eHypothalamic Obesity (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBefore surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAfter surgery\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4(4.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8 (8.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u0026ndash;6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e190\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (12.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30 (15.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u0026ndash;9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e190\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32 (16.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e75 (39.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u0026ndash;12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e176\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42 (23.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e85 (48.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u0026ndash;15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e131\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55 (42.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e68 (51.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e782\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e157 (20.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e266 (34.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn this series, diabetes insipidus (DI) was identified as a potential diagnosis for patients exhibiting a urine output exceeding 3 cc/kg/hour, urine osmolality lower than 200 mosm/L, and elevated serum sodium levels over 150 mEq/L. Before the surgical procedure, 103 patients exhibited symptoms of polyuria/polydipsia. After surgery, 69.6% of the patients experienced their DI symptoms, and 29.7% of the patients developed new cases of DI following surgery. The patients with DI after surgery disclosed a remarkable deterioration in their symptoms compared to patients with non-DI before surgery, while patients with non-DI developed a new high rate of DI complications after surgery. There was a higher DI complication after surgery compared to before surgery, X\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;105.158, P\u0026thinsp;\u0026lt;\u0026thinsp;0.005, as seen in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of preoperative and postoperative diabetes insipidus in 782 patients with CP\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon-DI (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDI Before surgery (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDeteriorate DI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNew DI\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBefore surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e679 (86.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e103 (13.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAfter surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e477 (61.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e305 (39.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e93(90.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e212(44.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eRelated Complications\u003c/h2\u003e\u003cp\u003ePostoperative intracranial infection typically indicates bacterial infection, referred to as bacterial meningitis, which is shown by CSF with elevated protein and WBC counts, along with low glucose levels. Gram stains of the CSF organisms may be positive or negative. Aseptic or chemical meningitis was characterized by merely elevated protein and WBC count with no organisms in CSF, which showed negative results from Gram stains or CSF cultures. There occurred in 68 patients (8.7%) due to the body's inability to ward off intracranial infections, associated with the cyst fluid triggering inflammatory responses and hypothalamic involvement[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This rate was higher than that reported in other craniotomies[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In 7 out of 73 cases (9.6%), cerebrospinal fluid (CSF) leaks developed during specific procedures involved in the surgical process, including drilling out the planum sphenoidale, anterior clinoid process, unroofing the optic canal, and frontal sinus opening. After surgery, 19 of the 305 cases(6.2%) of DI resulted in deep-vein thrombosis leading to pulmonary emboli (PE) on helical CT pulmonary angiography. 14 of the 19 affected patients died from PE. In 3 to 6 days after surgery, 4 out of 647 cases༈0.62%༉ of UBIA experienced central herniation. This was due to swelling on the bilateral medial surface of the frontal face, causing downward displacement of the bilateral hypothalamus and diencephalic dysfunction resulting in Cheyne-Stokes respiration, bilateral small reactive pupils, and rapid loss of consciousness. Two patients underwent bilateral frontal decompression with bone flaps removal to relieve their herniations, while two others died.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eHistopathology\u003c/h3\u003e\n\u003cp\u003eOur histopathological bank currently contains 917 pediatric cases of CPs in patients aged 15 and younger. Among these, 909 cases (99.2%) exhibit adamantinomatous features, making it the predominant type. Additionally, 8 cases (0.8%) show papillary features, representing an alternative presentation. Notably, we have documented 2 cases that experienced malignant transformations of adamantinomatous features, which necessitated a second surgery to address recurrent tumors following initial radiotherapy(Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eFollow-Up and Patient Outcome\u003c/h3\u003e\n\u003cp\u003eA total of 601/782 patients (76.8%) were followed up for an average of 3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.03 years (range, 1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;20 years) (Figs.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Of the 601 follow-up patients with complete tumor removal, 88 (12.4%) compromised tumor recurrence within an average of 3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.64 years (range, 2.1 months to 20 years). Among the 70 follow-up patients with subtotal or partial resection, 67 patients (95.7%) experienced tumor recurrence within an average of 4.3 months (range, 2.1 months to 2.1 years), including 23 of 53 patients (47.3%) who received postoperative stereotactic radiation and Gamma Knife treatment (Elekta, Stockholm, Sweden) at a mean of 5.4 months after surgery (range, 3\u0026ndash;21 months). Most patients with tumor free or tumor control, 601 (82.3%) with a Karnofsky Scale (KPS) mean 88\u0026thinsp;\u0026plusmn;\u0026thinsp;8.81 returned to their normal life or school responsibilities without special care; 56 patients (6.6%) with a KPS mean 67\u0026thinsp;\u0026plusmn;\u0026thinsp;8.91 were able to live at home and complete daily activities independently with minor neurologic or endocrinologic deficits; and 31 patients (5.1%) with a KPS mean 31\u0026thinsp;\u0026plusmn;\u0026thinsp;5.72 needed local clinical care and variable assistance for daily living. Out of all the patients, 78.7% (610) required hormone replacement therapy for over two years due to endocrine disturbances. 507 patients (47.1%) needed ADH prescription, 206 patients (26.3%) required cortisol and thyroxine replacement, and 149 children (19.3%) needed growth hormone (GH) replacement to improve their short stature. A total of 91 patients (17.9%) experienced permanent polydipsia or polyuria, requiring antidiuretic medication for over 3 years to manage urine output. Out of 193 pediatric patients over 25 years old, 151 (78.2%) did not achieve normal sexual function and fertility. Only 5 patients married and had children during the 10-year follow-up period, consisting of 4 female and 1 male patients.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003etranscranial and endoscopic endonasal approach\u003c/h2\u003e\u003cp\u003eThis report outlines our perspectives on the outcomes of transcranial approaches based on our single-center experience. Our views stem from our knowledge and expertise in the field. However, it's suggestive to note that these outcomes may differ when compared to endoscopic approaches used at other centers or in cases involving partial resection followed by radiation treatment. Recent advances in the transcranial approach to treating CPs are not significantly limited by the characteristics of the tumor. This method enables minimal enlargement of the sella while effectively addressing large suprasellar masses and any extensions into the parasellar region and the middle fossa. The appropriate selection of transcranial modalities is essential for ensuring that patients with complex tumors receive aggressive surgical treatment. This approach aims to achieve complete tumor removal and prevent the need for unnecessary retreatment or radiation therapy following tumor recurrence. There is a need to investigate tumor recurrence rates after endoscopic surgery and compare them with those following transcranial surgery[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In this study, a 12.4% rate of recurrent gross total tumor removal was observed after more than three years of follow-up. The transcranial method provides effective tumor dissection through maximal exposure while minimizing invasion of vital neural and vascular structures. This is especially important given the challenges posed by difficult tumor locations, large calcified masses, and extensive involvement of surrounding tissues. A trend in neurosurgery is the shift to endoscopic surgery, driven by advancements in artificial intelligence, machine learning, and virtual reality. There exists an essential distinction between endoscopic and transcranial surgery for treating CPs. The effectiveness of each technique depends on a maximal safe resection or near-total resection tailored specifically to the individual patient, rather than the limitations of each surgical corridor. Yasargil initially preferred to use subfrontal or frontotemporal approaches for treating extra-axial tumors[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In our series, a unifrontal approach to the basal interhemispheric fissure, without the opening of other lateral dural layers, allows for minimal retraction of the bilateral frontal medial surfaces. This technique provides wider exposure of the laminal terminal and prechiasmatic spaces while minimally invading the frontal medial surface. Additionally, the shelter provided by the frontal portion of the falx cerebri may help alleviate concerns about central herniation caused by edema in the bilateral frontal medial surfaces, which can result from excessive retraction[\u003cspan additionalcitationids=\"CR17 CR18 CR19 CR20 CR21 CR22\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e–\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Central herniation during the perioperative period results from bilateral frontal edema caused by excessive retraction of the frontal medial surface during surgery. Intraoperative accidental bleeding from a tear in the ACoA may necessitate a microsuture to effectively close any portions of the tear that are difficult to control.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eEndocrinological Complications\u003c/h2\u003e\u003cp\u003eIn pediatric patients, one of the most serious complications following aggressive resection of CPs is hypothalamic injury. Endocrinopathies resulting from injury to the hypothalamic structures can be particularly challenging to treat through aggressive resection of the tumor with minimal hormone morbidity. The normal endocrine function may be impaired, and hormone deficiencies are likely exacerbated after aggressive surgical resection. Currently, endoscopic surgery, as some reports suggest, has achieved a lower rate of hormone deficiencies in a select group of cases due to minimal surgical invasion, but may be limited to tumor location and features[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In this series, 44% pediatric patients developed new DI, 34.4% hypothalamic obesity in the total series, but 51.9% hypothalamic obesity occurred in more than 13-year-old pediatric patients while undergoing gross complete tumor removals, which presented a challenge for the transcranial approach at a six-month follow-up. Surgical dissecting procedures remain essential for preventing all hypothalamic structure injuries, including those involving its small perforators and the preservation of a remnant of the pituitary stalk, as well as the use of minimal or rare bipolar cautery. In the future, manual dexterity and technical skills still matter for the surgical treatment of CPs when cutting-edge devices fail. Hypothalamic obesity is the most serious and intractable complication for either transcranial or endoscopic surgery, which involves and damages the hypothalamic satiety center. A normal appetite inhibition fails to be active in the hypothalamic receptors that regulate the negative feedback loop in which leptin, formed in adipocytes, binds to hypothalamic leptin receptors[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. All neural structures in the floor of the hypothalamus produce hormones that regulate the anterior pituitary gland. Hormone replacement therapy may inhibit endogenous hormone secretion related to the presence of exogenous hormones. Specifically, thyroid hormone replacement can lead to dysfunction of the thyroid gland cells and worsen hypothyroidism. The therapy disrupts the negative feedback mechanisms for thyroid hormone secretion, including thyroxine (T4) and triiodothyronine (T3)[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. ACTH is essential for adrenal cortex function and cortisol secretion. Prolonged use of exogenous glucocorticoids can lead to secondary adrenal insufficiency and atrophy of the adrenal cortex. This occurs because the glucocorticoids interfere with the regulation of the hypothalamic-pituitary axis, disrupting the normal feedback mechanisms that control cortisol levels. As a result, the basic functions of negative feedback, diurnal rhythms, and stress-activated responses are affected, which can influence neuroendocrine, autonomic, and hemostatic regulation[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e–\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The primary goal of surgical treatment for CP is to aggressively remove the tumor while minimizing damage to crucial hypothalamic structures without relying solely on hormone replacement therapy after surgery. An appropriate surgical procedure to treat pediatric CP can lead to optimal outcomes with the complete removal of the tumor. The endocrine deficits that may arise after total tumor removal are not more severe than those that occur following a partial removal. When the largest portion of the tumor is accessible via a suitable approach, there is usually a clear dissection plane between the tumor and the hypothalamus. In such cases, an attempt should be made to achieve complete removal of the tumor to reduce the potential risk of recurrence. During a surgical procedure, it is crucial to handle the pituitary stalk carefully, as preserving it can help minimize the risk of postoperative endocrine deficits and diabetes insipidus. High-magnification microscopy aids in identifying tumor tissue within pituitary stalk structures, facilitating the resection of tumors that invade the stalk[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Conformal radiation and γ-knife probably benefit from preventing regrowth when a residual tumor was left behind or tumor recurrence[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Reoperation was usually considered for tumor recurrence; the reason for this was that radiation therapy potentially decreased cognition and increased the risk of visual and endocrine morbidities[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eHistopathological Features and Surgical Resection\u003c/h2\u003e\u003cp\u003eThe adamantinomatous type of CP in pediatric patients poses a significantly higher risk of recurrence and progressive growth. This increased risk is largely due to challenges in identifying the surgical plane during surgical dissection. In contrast, the papillary type of CP, which is more commonly found in adult patients, tends to have better outcomes following surgical resection[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Nearly all CPs exhibit cystic changes and calcifications that are often associated with adamantinomatous features in pediatric cases[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. The tumor's adhesion to suprasellar and hypothalamic structures, along with vascular invasion, significantly increases the risk of recurrence and endocrine complications; this was similar to atypical tumors in some cases of the series. However, this rarely indicates a malignant grade that would signify a higher risk of recurrence. Aggressive resection of pediatric CP involves several considerations: 1) It is essential to establish a dissection plane between the tumor and the hypothalamus to manage the long-term risk of recurrence. 2) Achieving complete tumor removal requires excising any dural attachments in the sellar region and the medial wall of the cavernous sinus. Alternatively, endothermic coagulation can be applied to the dural attachments beneath the pituitary stalk and the floor of the hypothalamus, ensuring that the gland's function remains intact. 3) Aggressive resection should aim for freedom from CP recurrence while minimizing postoperative endocrine deficits and diabetes insipidus. In contrast to the pediatric cases in this series, 21.9% of the papillary cystic pancreatic tumors (CP) identified in our study of 2,103 adult cases are included in the histologic bank. These adult CP cases frequently result in anatomical distortion and functional impairment of the hypothalamus. There is no evidence of malignant attachment to the dural and hypothalamic structures following tumor recurrence after aggressive resection without multiple rounds of radiotherapy in most patients[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e–\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTranscranial surgery allows for gross total removal of the tumor to achieve free survival in most pediatric patients, which enables precise targeting of the tumor while minimizing interference from its specific characteristics. The morbidity of hormone deficits and hypothalamic obesity presents a serious challenge to the surgical aggressive resection of the tumor. Preserving the hypothalamic structures around the tumor remains a matter for surgical treatment, requiring manual dexterity and technical skills rather than cutting-edge devices.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003eThanks to all our department members.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u0026nbsp;\u003c/strong\u003eYang Yang and Zaitao Yu wrote the manuscript . Xiangen Shi and Zhongqing Zhou designed the study. Fangjun Liu and Yuming Sun performed Data Collection and Analysis. Xianghua Zhang and Guangkui Han was responsible for Literature Review. Mengqing Hu , Ting Lei, Xin Xiang and Jie Zhang were \u0026nbsp;responsible for Tables and Figures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp; No\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u0026nbsp; All data that support the findings of this study are available from the Neurosurgery Department at Capital medical University Sanbo Brain Hospital. Data are however available from the author when requested with permission.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u0026nbsp;\u003c/strong\u003eThe study was approved by our Institutional Review Board (IRB) [IRB#:5782\u0026ndash;01\u0026ndash;2004] in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for studies involving humans.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u0026nbsp;\u003c/strong\u003eReceived for participation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e The authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBakhsheshian J, Jin DL, Chang KE, Strickland BA, Donoho DA, Cen S, et al (2016) Risk factors associated with the surgical management of craniopharyngiomas in pediatric patients: analysis of 1961 patients from a national registry database. Neurosurg Focus 41 (6):E8\u003c/li\u003e\n\u003cli\u003eKaravitaki N, Cudlip S, Adams CBT, Wass JAH(2006) Craniopharyngiomas.Endocr Rev 27(4):371\u0026ndash;397.\u003c/li\u003e\n\u003cli\u003eLiubinas SV, Munshey AS, Kaye AH(2011)Management of recurrent craniopharyngioma. J Clin Neurosci 18: 451\u0026ndash;457.\u003c/li\u003e\n\u003cli\u003eChibbaro S, Signorelli F, Milani D, Cebula H, Scibilia A, Bozzi MT(2021)Primary endoscopic endonasal management of giant pituitary adenomas: outcome and pitfalls from a large prospective multicenter experience. Cancers (Basel)13:3603. \u003c/li\u003e\n\u003cli\u003eMadsen PJ, Buch VP, Douglas, Parasher AK, Lerner DK, Alexander E, et al(2019)Endoscopic endonasal resection versus open surgery for pediatric craniopharyngiomas: comparison of outcome and complication. J Neurosurg Pediatr 24(3):236-245. \u003c/li\u003e\n\u003cli\u003eGan HW, Morillon P, Albanese A, Aquilina K, Chandler C, Chang YC, et al(2023)National UK guidelines for the management of pediatric craniopharyngioma. Lancet Diabetes Endocrinol Sep 11(9):694-706. \u003c/li\u003e\n\u003cli\u003eRobert E. Elliott RE, Jane JA Jr., Wisoff JH (2011)Surgical Management of Craniopharyngiomas in Children: Meta-analysis and Comparison of Transcranial and Transsphenoidal Approaches. Neurosurgery 69:630\u0026ndash;643.\u003c/li\u003e\n\u003cli\u003eKaptain, G.J., Vincent, D.A., Sheehan, J.P. ,Laws, E.R. (2001)Transsphenoidal Approaches for the Extracapsular Resection of Midline Suprasellar and Anterior Cranial Base Lesions. Neurosurgery 49: 94-101. \u003c/li\u003e\n\u003cli\u003eHoffman H J(1994) Surgical management of craniopharyngioma. Pediatr Neurosurg21 Suppl 1:44-9.\u003c/li\u003e\n\u003cli\u003eYasargil, M.G., Curcic, M., Kis, M., Siegenthaler, G., Teddy, P.J. Roth, P.(1990)Total Removal of Craniopharyngiomas.J Neurosurg 73: 3-11. \u003c/li\u003e\n\u003cli\u003ePrieto R, Barrios L, Pascual JM(2022)Strictly third ventricle craniopharyngiomas: pathological verification, anatomo‑clinical characterization and surgical results from a comprehensive overview of 245 cases. Neurosurg Rev 45(1):375-394.\u003c/li\u003e\n\u003cli\u003eJeswani S, Nu\u0026ntilde;o M, Wu A, Bonert V, Carmichael JD, Black KL, et al(2016)Comparative analysis of outcomes following craniotomy and expanded endoscopic endonasal transsphenoidal resection of craniopharyngioma and related tumors: a single-institution study. J Neurosurg 124:627\u0026ndash;638.\u003c/li\u003e\n\u003cli\u003eCalandrelli R, D\u0026rsquo;Apolito G, Martucci M, Giordano C, Schiarelli C, Marziali G, et al(2024)Topography and Radiological Variables as Ancillary Parameters for Evaluating Tissue Adherence, Hypothalamic\u0026ndash;Pituitary Dysfunction, and Recurrence in Craniopharyngioma: An Integrated Multidisciplinary Overview.\u003cem\u003e Cancers\u003c/em\u003e \u003cem\u003e16\u003c/em\u003e(14):2532.\u003c/li\u003e\n\u003cli\u003eMoussazadeh N, Prabhu V, Bander ED, Cusic RC, Tsiouris AJ，Anand VK, et al(2016) Endoscopic endonasal versus open transcranial resection of craniopharyngiomas: a case-matched single-institution analysis. Neurosurg Focus 41 (6):E7.\u003c/li\u003e\n\u003cli\u003eCaklili M, Uzuner A, Yilmaz E, Ozkurk SD, Jones FMC, Balci S, et al(2024)Surgical outcome and follow-up results of 53 pediatric craniopharyngioma cases: a single-center study. J Neurosurg Pediatr 33:223-235.\u003c/li\u003e\n\u003cli\u003eShi X, Zhou Z\u003csup\u003e \u003c/sup\u003e, Wu B\u003csup\u003e \u003c/sup\u003e, Zhang Y\u003csup\u003e \u003c/sup\u003e, Qian H\u003csup\u003e \u003c/sup\u003e, Sun Y\u003csup\u003e \u003c/sup\u003e, et al(2017)Outcome of Radical Surgical Resection for Craniopharyngioma with Hypothalamic Preservation: A Single-Center, Retrospective Study of 1054 Patients. World Neurosurg 102:167-180.\u003c/li\u003e\n\u003cli\u003eZheng X, Chen Y, Zhang X, Yang H, Li S(2025)Risk Factors for Intracranial Infection in Surgical Patients with Suprasellar Craniopharyngiomas by an Expanded Endoscopic Endonasal Approach: A Single-Center Initial Experience. World Neurosurg 197:123902.\u003c/li\u003e\n\u003cli\u003eChen JX, Alkire BC, Lam AC, Curry WT, Holbrook EH(2016) Aseptic Meningitis with Craniopharyngioma Resection: Consideration after Endoscopic Surgery. J Neurol Surg Rep 77:e151\u0026ndash;e155.\u003c/li\u003e\n\u003cli\u003eVillani RM, Tomei G, Bello L, Sganzerla E, Re T, Barilari MG(1997) Long-term results of treatment for craniopharyngioma in Children, Child\u0026rsquo;s Nerv Syst 13:397-405.\u003c/li\u003e\n\u003cli\u003ePralea A, Walek K, Auld D, and Mermel LA(2024)Differences in microorganisms causing infection after cranial and spinal surgeries. J Neurosurg 140:892-899.\u003c/li\u003e\n\u003cli\u003eShibuya M, Takayasu M, Suzuki Y, Saito K, Sugita K(1996) Bifrontal basal interhemispheric approach to craniopharyngioma resection with or without division of the anterior communicating artery. J Neurosurg 84:951-956.\u003c/li\u003e\n\u003cli\u003eAranda A(2025)Thyroid hormone action by genomic and nongenomic molecular mechanisms. Methods Mol Biol 2876:17\u0026ndash;34. \u003c/li\u003e\n\u003cli\u003eMandell BF(2025)Treating the thyroid: Trust the feedback loop. Cleve Clin J Med. 92(2): 71-72.\u003c/li\u003e\n\u003cli\u003eOzgural O, Kahllogullarl G, Dogan I, Al-Beyati G, Bozkurt M, Tertik B, et al(2018)Single-center surgical experience of the treatment of craniopharyngiomas with emphasis on the operative approach: Endoscopic endonasal and open microscopic transcranial approached. J Craniofac Surg 29:e572-e578.\u003c/li\u003e\n\u003cli\u003eNa MK, Jang B, Choi K-S, Lim TH, Kim W, Cho Y, et al(2022)Craniopharyngioma resection by endoscopic endonasal approach versus transcranial approach: A systematic review and meta-analysis of comparative studies. Front. Oncol 12:1058329.\u003c/li\u003e\n\u003cli\u003eSughrue ME, Yang I, Kane AJ, Fang S, Clar AJ, Aranda D, et al(2011)Endocrinologic, neurologic and visual morbidity after treatment for craniopharyngioma. J Neurooncol 101:463-476\u003c/li\u003e\n\u003cli\u003eSterkenburg AS, Hoffmann A, Gebhardt U, Warmuth-Metz M, Daubenb\u0026uuml;chel AMM, M\u0026uuml;ller HL(2015)Survival, hypothalamic obesity, and neuropsychological/psychosocial status after childhood-onset craniopharyngioma: newly reported long-term outcomes. Neuro-Oncology 17(7):1029\u0026ndash;1038.\u003c/li\u003e\n\u003cli\u003eBroersen LHA, Pereira AM, J\u0026oslash;rgensen JOL, Dekkers OM(2015)Adrenal Insufficiency in Corticosteroids Use: Systematic Review and Meta-Analysis. J. Clin. Endocrinol. Metab 100:2171\u0026ndash;2180. \u003c/li\u003e\n\u003cli\u003ePelewicz K, and Miśkiewicz P(2021)Glucocorticoid Withdrawal-An Overview on When and How to Diagnose Adrenal Insufficiency in Clinical Practice. Diagnostics (Basel) 11(4):728.\u003c/li\u003e\n\u003cli\u003eLi K, Lu X, Yang N, Zheng J, Huang B, Li L(2015)Association of pituitary stalk management with endocrine outcomes and recurrence in microsurgery of craniopharyngiomas: a meta-analysis. Clin Neurol Neurosurg 136:20-24.\u003c/li\u003e\n\u003cli\u003eCossu G, Jouanneau E, Cavallo LM, Giulia Cossu1, Elbabaa SK, Giammattei1 L, et al(2020)Surgical management of craniopharyngiomas in adult patients: a systematic review and consensus statement on behalf of the EANS skull base section. Acta Neurochir 162: 1159\u0026ndash;1177. \u003c/li\u003e\n\u003cli\u003eKlimo Jr. P, Venable GV, Boop FK, and Merchant E(2015)Recurrent craniopharyngioma after conformal radiation an children and the burden of treatment. J Neurosurg Pediatr 15:499-505.\u003c/li\u003e\n\u003cli\u003eErin N. Kiehna EN, Merchant TE(2010)Radiation therapy for pediatric craniopharyngioma. Neurosurg Focus 28:E10\u003c/li\u003e\n\u003cli\u003eGan HW, Morillon P, Albanese A, Aquilina K, Chandler C, Chang YC, et al(2023)National UK guidelines for the management of paediatric craniopharyngioma. Lancet Diabetes Endocrinol 11(9):694-706.\u003c/li\u003e\n\u003cli\u003eAldave G, Okcu F, Chintagumpala M, Ruggieri L, Minard CG, Malbari F, et al(2023)Comparison of neurocognitive and quality-of-life outcomes in pediatric craniopharyngioma patients treated with partial resection and radiotherapy versus gross-total resection only. J Neurosurg Pediatr 31:453-462.\u003c/li\u003e\n\u003cli\u003eChang KE, Strickland BA, Donoho DA, Cen S, Mack WJ, Attenello,et al(2016)Risk factors associated with the surgical management of craniopharyngiomas in pediatric patients: analysis of 1961 patients from a national registry database. Neurosurg Focus 41 (6):E8.\u003c/li\u003e\n\u003cli\u003eKaravitaki N, Cudlip S, Adams CBT, Wass AJ(2006)Craniopharyngiomas. Endocr Rev 27(4):371-397.\u003c/li\u003e\n\u003cli\u003eZhang YQ, Wang CC, Ma ZY(2002)Pediatric craniopharyngiomas: clinicomorphological study of 189 cases. Pediatr Neurosurg \u003cstrong\u003e36: \u003c/strong\u003e80\u0026ndash;84.\u003c/li\u003e\n\u003cli\u003ePrieto R, Juratli TA, Bander ED, Santagata S, Barrios L, Brastianos PK, et al(2025) Papillary craniopharyngioma: An integrative and comprehensive review. Endocr Rev 46(2):151-213. \u003c/li\u003e\n\u003cli\u003eShuzi Gao, Xiangen Shi, Yanxia Wang, Hai Qian, Chengyin Liu(2011) Malignant transformation of craniopharyngioma: case report and review of the literature. J Neurooncol 103(3):719-725.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Craniopharyngioma, Hormone deficits, Open surgery, Aggressive resection","lastPublishedDoi":"10.21203/rs.3.rs-7787534/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7787534/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eA retrospective study assessed the endocrinological outcomes of aggressive surgical tumor resection in pediatric patients, focusing on the treatment's efficacy and safety.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients and methods:\u003c/strong\u003e 782 craniopharyngioma pediatric patients were treated surgically from January 2004 to May 2023. There were 62.9% boys and 37.1% girls, with mean ages of 8.09±3.67 years ranging from 8 months to 15 years old. The tumor size in pediatric patients ranged from 1.1cm to 16cm in maximal diameter, with an average diameter of 3.84±1.47 cm. 82.1% of the tumors had calcified tumors with 6.3% huge calcified masses of 1.5 cm diameter.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Total removal of tumors were achieved in 90.2%. The pituitary stalk was intentionally preserved in 87.1% cases despite partial injury or remains intact with peeling off the residual tumor. Within the perioperative period, there were 2.7% deaths. Of the remaining patients, 77.6% were followed up for an average of 3.9 years. Out of 607 patients, 92.3% had total tumor removal and other had a subtotal or partial resection. At a 1.5-year follow-up after surgery, hormone levels showed no improvement compared to the deficits observed during the perioperative period. A total of 71.3% patients with an endocrine disturbance required postoperative substitution of the deficient hormone. 11.6% of the patients with total tumor removal experienced recurrence in an average of 3.3 years, while 91.5 % of patients with subtotal or partial resection had tumor progression within an average of 0.5 years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Transcranial surgery allows for gross total removal of the tumor to achieve free survival in most pediatric patients, which enables precise targeting of the tumor while minimizing interference from its specific characteristics.The morbidity of hormone deficits and hypothalamic obesity presents a challenge to the surgical aggressive resection of the tumor.\u003c/p\u003e","manuscriptTitle":"Endocrine Evaluation Following Aggressive Surgical Resection of Craniopharyngiomas in Children（Report of 782 cases)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-26 16:36:40","doi":"10.21203/rs.3.rs-7787534/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6dfcbb33-fa01-4029-b4fe-7b88eddf38c1","owner":[],"postedDate":"November 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-30T19:53:35+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-26 16:36:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7787534","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7787534","identity":"rs-7787534","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}