内镜下扩大经鼻入路手术切除鞍上侵袭性垂体腺瘤

doi:10.3969/j.issn.1672-6731.2023.07.004

摘要/Abstract

摘要：

目的: 分析内镜下扩大经鼻入路手术切除鞍上侵袭性垂体腺瘤的疗效及安全性。方法与结果: 以2019年6月至2022年6月河北医科大学第二医院收治的68例鞍上侵袭性垂体腺瘤患者为研究对象, 于内镜下扩大经鼻入路手术切除肿瘤, 73.53%(50/68)实现全切除, 17.65%(12/68)次全切除, 8.82%(6/68)部分切除; 巨大型腺瘤全切除率达37.40%(10/27)。平均随访(12 ± 6)个月, 视力改善者占75.81%(47/62)、无变化19.35%(12/62)、恶化4.84%(3/62); 视野缺损改善占74.14%(43/58)、无变化15.52%(9/58)、加重10.34%(6/58); 动眼神经麻痹患者末次随访复视消失(3例)。术后并发症包括脑脊液漏[1.47%(1/68)]、中枢性尿崩症[16.18%(11/68)]、术区血肿[4.41%(3/68)]、迟发性鼻腔出血[4.41%(3/68)]和颅内感染[7.35%(5/68)], 无死亡病例。结论: 于内镜下扩大经鼻入路手术切除向前颅底、鞍上区域、第三脑室方向侵袭的大型或巨大型垂体腺瘤, 全切除率高、创伤小、并发症少, 值得临床推广。

关键词: 垂体肿瘤, 蝶鞍, 内窥镜检查, 手术后并发症

Abstract:

Objective: To analyze the clinical efficacy and safety of the extended endoscopic endonasal approach (EEEA) in the resection of suprasellar invasive pituitary adenoma. Methods and Results: A total of 68 patients with suprasellar invasive pituitary adenoma admitted to The Second Hospital of Hebei Medical University from June 2019 to June 2022 were treated with EEEA for tumor resection, of whom 73.53% (50/68) achieved gross total resection (GTR), 17.65% (12/68) achieved subtotal resection, and 8.82% (6/68) achieved partial resection. The GTR rate of giant adenoma was 37.40% (10/27). The average follow-up was (12 ±6) months, 75.81% (47/62) improved visual acuity, 19.35% (12/62) had no change after surgery, 4.84% (3/62) deteriorated visual acuity. The improvement rate of visual field defect was 74.14% (43/58), no change was 15.52% (9/58), and symptom aggravation was 10.34% (6/58). The symptoms of diplopia disappeared completely in the patients with oculomotor nerve palsy at the last follow-up (3 cases). Postoperative complications included cerebrospinal fluid leakage[1.47% (1/68)], central diabetes insipidus[16.18% (1/68)], intraoperative hematoma[4.41% (3/68)], delayed nasal hemorrhage[4.41% (3/68)] and intracranial infection[7.35% (5/68)], with no death. Conclusions: EEEA for large or giant pituitary adenomas invading the anterior skull base, suprasellar region and the third ventricle has a high GTR rate, less trauma and fewer complications, and is worthy of clinical promotion.

Key words: Pituitary neoplasms, Sella turcica, Endoscopy, Postoperative complications

贾亮, 周航, 张晓炜, 张庆九, 吕中强. 内镜下扩大经鼻入路手术切除鞍上侵袭性垂体腺瘤[J]. 中国现代神经疾病杂志, 2023, 23(7): 586-590.

Liang JIA, Hang ZHOU, Xiao-wei ZHANG, Qing-jiu ZHANG, Zhong-qiang LÜ. Extended endoscopic endonasal approach in resection of suprasellar invasive pituitary adenoma[J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2023, 23(7): 586-590.

https://journal11.magtechjournal.com/cjcnn/CN/Y2023/V23/I7/586

图/表 2

图 1 女性患者，63岁。于内镜下扩大经鼻入路行侵袭性垂体大腺瘤切除术，手术前后MRI检查所见 1a 术前矢状位增强T₁WI显示肿瘤自鞍内向鞍上侵袭性生长，强化明显(箭头所示) 1b 术前冠状位增强T1WI显示肿瘤向鞍上右上方生长(箭头所示) 1c，1d 术后72 h矢状位和冠状位增强T₁WI显示肿瘤全切除(箭头所示)

Figure 1 A 63-year-old female underwent endoscopic resection of invasive pituitary macroadenomas via EEEA approach. Pre- and post-operative MRI findings Preoperative sagittal enhanced T₁WI showed invasive growth of the tumor from sellar to suprasellar, and the enhancement was obvious (arrow indicates, Panel 1a). Preoperative coronal enhanced T₁WI showed tumor growth toward the upper right suprasellar (arrow indicates, Panel 1b). Postoperative sagittal (Panel 1c) and coronal (Panel 1d) enhanced T₁WI showed GTR of tumor at 72 hours after surgery (arrows indicate).

图 2 女性患者，51岁。于内镜下扩大经鼻入路行侵袭性异位垂体大腺瘤切除术，手术前后MRI检查与术中所见 2a 术前矢状位增强T₁WI显示，肿瘤位于鞍上凸向第三脑室，呈不均匀明显强化(箭头所示) 2b 术前冠状位增强T₁WI可见第三脑室受压，幕上脑室轻度扩张(箭头所示) 2c 肿瘤全切除后于显微镜下第三脑室内结构(双侧室间孔、侧脑室脉络丛、中脑导水管上口、丘脑中间块)清晰可见 2d，2e 术后72 h矢状位和冠状位增强T₁WI显示肿瘤全切除(箭头所示)

Figure 2 A 51-year-old female underwent endoscopic resection of invasive dystopia pituitary macroadenomas via EEEA approach. Pre - and post - operative MRI findings and intraoperative findings Preoperative sagittal enhanced T₁WI showed the tumor was located in the suprasellar convexity toward the third ventricle, with significant uneven enhancement (arrow indicates, Panel 2a). Preoperative coronal enhanced T₁WI showed compression of the third ventricle and mild dilation of the supratentorial ventricle (arrow indicates, Panel 2b). Intraoperative finding showed after GTR of the tumor, the structure of the third ventricle could be seen, including bilateral ventricular foramen, choroid plexus of lateral ventricle, superior orifice of midbrain aquifer, and middle mass of thalamus (Panel 2c). Postoperative sagittal (Panel 2d) and coronal (Panel 2e) enhanced T₁WI showed GTR of tumor at 72 hours after surgery (arrows indicate).

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