摘要：

目的 探讨内镜颅底肿瘤切除术中高流量脑脊液鼻漏修补失败原因及处理方法。方法 5 例患者均为 2012 年12月至 2016 年6月经鼻蝶和唇下-上颌窦入路行内镜颅底肿瘤切除术中发生高流量脑脊液鼻漏并首次颅底重建失败而行二次修补的病例，通过自体脂肪片 + 自体鼻中隔黏膜瓣、自体脂肪片 + 自体阔筋膜 + 自体鼻中隔黏膜瓣、自体脂肪片 + 自体阔筋膜等修补材料重建颅底。结果 二次修补术分别采用硬膜下覆盖自体脂肪片 + 自体鼻中隔黏膜瓣（1/5 例）、硬膜下覆盖自体脂肪片 + 硬膜外覆盖自体阔筋膜（1/5例），以及硬膜下覆盖自体脂肪片 + 硬膜外覆盖自体阔筋膜 + 自体鼻中隔黏膜瓣（3/5例）修补漏口，颅底创面愈合良好；平均随访20 个月，无脑脊液鼻漏复发。结论 高流量脑脊液鼻漏修补和颅底重建是内镜颅底肿瘤切除术成败之关键。修补失败原因包括人工硬膜完全吸收、未以脂肪组织封堵术区残腔或脂肪片液化、中鼻甲黏膜瓣与硬脑膜愈合不佳、未以阔筋膜封堵硬脑膜缺损、阔筋膜移位或鼻中隔黏膜瓣缺血坏死。多层组织重建联合带蒂组织瓣的修复方式安全、可靠，术前制定详细的手术方案、术中严格按照手术规程操作，可避免修补失败。

关键词: 颅底肿瘤, 内窥镜, 脑脊液鼻漏, 神经外科手术, 再手术

Abstract:

Objective To investigate the reasons and management of repair failure of high-flow cerebrospinal fluid rhinorrhea (HFCSFR) after endoscopic resection of skull base tumors. Methods We retrospectively reviewed 5 patients with repair failure of HFCSFR after endoscopic removal of skull base tumors in our center from December 2012 to June 2016. The patients underwent reoperations for skull base repair. The reasons of repair failure and management strategies were analyzed. Results The reconstruction methods of skull base in the reoperation for HFCSFR included autologous fat inlay and autologous pedicled nasal septal flap onlay in one patient, autologous fat inlay and autologous fascia lata onlay in one patient, and autologous fat inlay and autologous fascia lata onlay and autologous pedicled nasal septal flap in 3 patients. The skull base was reconstructed well in 5 patients. The mean follow-up period was 20 months, and no HFCSFR reoccurred in 5 patients. Conclusions Repair of HFCSFR and reconstruction of skull base are the key to endoscopic removal of skull base tumors. The reasons of repair failure included improperly employing synthetic dura mater, failing to obliterate the dead space left behind by removal of tumors with fat grafts or fat liquefaction, non-healing of middle turbinate and dura mater, failing to cover the dural defect onlay with fascia lata, displacement of the repair grafts, ischemia and necrosis of nasal septal flap. The surgeons should pay more attention to the repairment of HFCSFR after endoscopic removal of skull base tumors. Reconstruction with multilayer grafts and vascularized autologous flaps is an effective and safe strategy. Formulating detailed operation plan and strictly following surgical procedure could avoid repair failure.

Key words: Skull base neoplasms, Endoscopes, Cerebrospinal fluid rhinorrhea, Neurosurgical procedures, Reoperation