ACM  >> Vol. 10 No. 3 (March 2020)

    导航下经蝶鞍底小骨窗硬脑膜小切口切除垂体微小病变
    Under the Guidance of Transsphenoidal Sellar Dura Small Incision and Small Bone Window Resection of Pituitary Lesions

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作者:  

李首春,魏少波,张志文,焦永成,高兵兵,丁雪虎:解放军总医院第四医学中心神经外科,北京

关键词:
导航垂体微小腺瘤鞍底小骨窗硬膜小切口Navigation Pituitary Microadenomas Sellar Durasmall Incision Small Bone Window

摘要:

导航的精准定位让经鼻蝶入路切除鞍区微小病变手术变得更加方便。我们在导航导引下尝试着经蝶鞍底小骨窗硬脑膜小切口切除垂体微小病变,取得了良好的效果。方法:自2015年9月至2016年7月间收治的垂体微小腺瘤病例30例,其中男性8例,女性22例,年龄从13~65岁。术前均进行内分泌功能检查,鞍区MRI平扫加薄层动态增强、MRV、冠状位CT加骨窗。病灶直径均小于10 mm。均采用右侧单鼻孔经蝶入路,行鞍底小骨窗硬脑膜小切口切除术。术后复查垂体相关激素水平,第三天复查蝶鞍MRI。结果:本组30例患者中促肾上腺皮质激素腺瘤5例,泌乳素腺瘤12例,生长激素腺瘤7例,Rathke囊肿6例。术中出血均在50 ml以下,均未输血。术中导航定位精确,准确发现肿瘤。术后复查内分泌功能指标均在正常值内。所有患者术后72 h内复查鞍区增强MRI,证实所有病灶均为全切。术后一过性尿崩5例,无脑脊液漏、视力下降、出血等其它并发症。平均术后住院日期为4天。所有患者随访3~13个月,平均8个月。随访内容为复查鞍区增强MRI,查血内分泌指标。所有患者均未见肿瘤残留或复发,术后内分泌指标均在正常范围内。结论:导航下经蝶鞍底小骨窗硬脑膜小切口切除垂体微小病变,能显著减少海绵窦、海绵间窦及颈内动脉的损伤,减少术中出血,更有利于垂体的功能保护,患者术后康复快,明显减少患者住院日期。

The precise positioning of navigation makes it easier to operate via transsphenoidal approach for the removal of minor lesions in the saddle area. We tried to remove the pituitary microdisease through the small dural incision of the small bone window of the bottom of the sella under the guidance of navigation. Methods: From September 2015 to July 2016, 30 cases of pituitary microadenoma admitted in our department were treated, including 8 cases of male and 22 cases of female, aged from 13 - 65 years. The endocrine function was examined before operation, and the saddle area MRI plain scan with thin layer dynamic enhancement, MRV, coronal position CT plus bone window. All lesions were less than 10 mm in diameter. All of them were operated through right single nostril transsphenoidal approach with parsellar floor small bone window and dural small incision. After operation, the pituitary-related hormone levels were reviewed and by the third day, the MRI of the sella area was scanned. RESULTS: There were 5 cases of corticotropin adenoma, 12 cases of prolactin adenoma, 7 cases of growth hormone adenoma and 6 cases of Rathke cyst. All intraoperative bleeding was below 50 ml and no transfusion. During the operation, navigation helps us detect and position tumors accurately. After operation, the endocrine function indexes were all within the normal value. The enhancement MRI of the saddle area was re-examined within 72 h after operation in all patients, confirming that all lesions were fully cut. There were 5 cases of transient diabetes insipidus after operation, no cerebrospinal fluid leakage, visual acuity decline, bleeding and other complications. The average postoperative hospitalization date was 4 days. All patients were followed up for 3 - 13 months, with an average of 8 months. Follow-up content included saddle area enhancement MRI, blood endocrine index. All patients did not find tumor residue or recurrence, and the postoperative endocrine indexes were within the normal range. Conclusion: the new way of operation navigated by MRI can significantly reduce probability about the injury of the cavernous sinus, intercavernous sinuses and the internal carotid artery, reduce the intraoperative bleeding, and be more conducive to the functional protection of the pituitary gland.

1. 引言

导航的精准定位给神经外科手术带来新的飞跃,让垂体微小腺瘤的术中定位变得容易,让经鼻蝶入路切除鞍区微小病变手术变得更加方便,且比内镜效果更好 [1]。我们在导航导引下尝试着经蝶鞍底小骨窗硬脑膜小切口切除垂体微小病变,取得了良好的效果。本研究得到我院医学伦理委员会许可。

2. 对象与方法

2.1. 临床资料

2.1.1. 一般资料

自2015年9月至2016年7月间收治的垂体微小腺瘤病例30例,其中男性8例,女性22例,年龄从13~65岁。诊断依据:1、垂体MRI平扫加增强检查明确肿瘤存在,肿瘤最大径 < 1 cm;2、垂体相关激素水平检查。纳入入组标准:1、有明显症状;2、泌乳素型垂体腺瘤服药无效或难以耐受药物副作用。排除入组标准:1、心肺等功能损伤不能接受手术治疗的患者;2、经一次手术后垂体腺瘤复发者。

2.1.2. 术前症状

头痛6例,Cushing综合征5例,停经溢乳12例,肢端肥大5例,巨人症2例。

2.1.3. 术前检查

每位患者术前均进行内分泌功能检查,鞍区MRI平扫加薄层动态增强,冠状位CT加骨窗。所有30例均发现鞍区垂体微腺瘤,病灶直径均小于10 mm。

3. 手术要点

3.1. 术前准备

术前全部行CE-MRV扫描,评估海绵窦,特别是海绵间窦的发育状况。术前1 d行MRI导航定位扫描,均行MRI增强定位扫描,层厚2 mm。手术前将导航影像资料及MRV数据,输入导航系统计算机,进行三维重建,寻找最佳鞍底骨质切口处,并在导航系统上显示模拟手术入路方向。

患者全麻后,头部后仰15˚,Mayfield头架固定,并将参考弧形架与头架固定。所有患者均采用头面部解剖点注册。即利用鼻根、双眼内外眦、双侧外耳道、耳廓等解剖点进行配准注册,直至系统提示系统误差小于4 mm为止。

3.2. 手术方法

30例患者均采用右侧单鼻孔经蝶入路,手术过程中根据导航指示方向,依次确定鼻中隔、蝶窦前壁、蝶窦开口、后组筛窦、斜坡,显露鞍底,根据术前导航及MRV确定的鞍底骨质切口处,微型长头磨钻切开鞍底骨质约5 mm类圆形骨窗,穿刺骨窗硬膜,如明显出血,则采用微小电凝变电灼边缓慢逐渐扩大硬膜切口达骨窗边缘,电灼硬膜两侧扩大切口,显微剥离子探索鞍内,直至暴露肿瘤。用最小号刮匙及取瘤钳取尽肿瘤后再次用导航确认正常垂体后叶、鞍膈及肿瘤边界以保证肿瘤全切。

4. 统计分析

各组数据用均数 ± 标准误( x ¯ ± s )表示,采用SPSS13.0软件包进行分析;显著差异水平为P < 0.05。

Table 1. Descriptive data for various variables

表1. 各种变量的描述性数据

5. 结果

本组30例患者中促肾上腺皮质激素(adrenocorticotropic hormone, ACTH)腺瘤5例,泌乳素(prolactin, PRL)腺瘤12例,生长激素(growthhormone, GH)腺瘤7例,Rathke囊肿6例。所有手术过程中均达到显微镜下全切肿瘤。术中出血均在50 ml以下,均未输血。术中导航定位精确,系统误差为(2.3 ± 0.3) mm。术后复查内分泌功能指标,均见明显降低。所有患者术后72 h内复查鞍区增强MRI,再次证实所有病灶均为全切。术后一过性尿崩5例,无脑脊液漏、视力下降、出血等其它并发症。平均术后住院日期为4天(如表1)。所有患者随访3~13个月,平均8个月。随访内容为复查鞍区增强MRI,查血内分泌指标。所有患者均未见肿瘤残留或复发,术后内分泌指标均在正常范围内(如表2)。

Table 2. Comparison of preoperative and postoperative hormones in each group

表2. 各组激素术前与术后比较

6. 讨论

垂体微小腺瘤的手术治疗相对于大腺瘤而言更为困难 [2],主要原因是由于鞍底扁平、骨质厚、肿瘤小而导致术中发现肿瘤存在困难,但随着导航的应用这些困难被完全解决。神经导航具有手术中实时跟踪指示的特点,能使术者随时了解手术方向、肿瘤位置、肿瘤范围、周边重要神经血管等重要情况 [3]。且由于垂体微腺瘤位于鞍内且体积微小,故在手术整个进程中病灶位置会相对比较固定,这个特点使得神经导航的精度很高而误差很小。而不会出现明显脑移位,造成导航误差加大,或误导手术 [4]。导航的实用性给我们经蝶小骨窗、硬膜小切口切除肿瘤提供了良好的基础。

我们认为海绵间窦的发育状况是这个手术中需要明确的最大障碍,因为海绵间窦太发达,尤其是下海绵间窦充满整个鞍底时,将为手术的进行带来很大的困难,有时不得不中止手术。Cooke and Jones报道在经蝶手术中因为海绵间窦导致大出血并被迫中止手术达8% [5],Orozco LD报道对一例ACTH型微腺瘤术中因为下海绵间窦大出血,中止手术,行血管内介入术栓塞海绵间窦后再行经蝶入路完全切除肿瘤 [6]。我们建议行术前MRV检查,MRV可以360度旋转将海绵间窦、海绵窦完好的显示 [7],我们30例患者术前均行MRV检查,其中1例可见肿瘤最近处下海绵间窦异常发达,采取避开此处硬膜,选择下海绵间窦发育欠佳的部位进行手术,最终顺利完整切除肿瘤,且出血量很少。

本组病例我们均采用鞍底小骨窗,有效地避免了海绵间窦、海绵窦的暴露性损伤,在硬脑膜切开前,细针穿刺硬膜,逐渐扩大,小功率电凝止血,同样解决了因硬膜切开时牵张力过高诱发的海绵间窦出血,运用显微剥离子探查鞍内发现肿瘤,用最小刮圈反复轻柔切除肿瘤,有效地保护了垂体,减少了并发症的发生。术后增强MRI检查证实肿瘤均完全切除,垂体相关激素水平复查均恢复正常。本组病例中肿瘤质地均较软,未见明显质地极硬且韧的改变。如遇肿瘤质地硬韧,难以达到全切时,可考虑扩大切口,直视下全切。

通过导航导引下经蝶鞍底小骨窗及硬膜小切口切除垂体微小腺瘤,效率高,并发症少,我们认为,针对微小腺瘤,即使是泌乳素腺瘤,也可以首选此种手术治疗,做到早发现早治疗,完整切除,避免终身服药,尤其是女性未孕患者,避免孕期因垂体瘤导致的流产,或肿瘤急性增大、卒中引起的风险。

文章引用:
李首春, 魏少波, 张志文, 焦永成, 高兵兵, 丁雪虎. 导航下经蝶鞍底小骨窗硬脑膜小切口切除垂体微小病变[J]. 临床医学进展, 2020, 10(3): 265-269. https://doi.org/10.12677/ACM.2020.103042

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