鞍隔重建技术对垂体瘤经鼻内镜术中中等流量脑脊液漏的应用分析

Analysis of the Application of Diaphragma Sellae Reconstruction Technology for Moderate Cerebrospinal Fluid Leakage during Endoscopic Transnasal Surgery for Pituitary Tumors

摘要: 目的：旨在解决垂体瘤经鼻内镜手术中出现中等量脑脊液漏的颅底重建问题，以减少术后脑脊液漏及感染风险，本研究引入了一种创新性重建方法，即针对于鞍隔本身的直接修复与重建，不再仅仅局限于鞍底层面。该策略结合了我们既有的成熟技术，如鞍底硬膜缝合及交叉镶嵌骨筋膜瓣技术，旨在实现更加可靠稳定的颅底重建。为进一步验证其效用，我们将此新方法与传统多层重建方法进行对比，以评估鞍隔重建的重建效果。方法：本研究方法收集了本院2016年9月至2022年6月行标准经蝶入路垂体瘤切除术，并在术中发生了中等流量脑脊液漏病例。依据手术中采用的颅底重建策略的差异，将病例划为鞍隔缝合组(术中直接将破损的鞍隔缝合于临近的鞍底硬膜缘上，同时鞍底层面采用骨瓣筋膜交叉嵌入法(CBEF法))和传统多层重建组(组合运用自体脂肪、自体阔筋膜以及鼻中隔带蒂黏膜瓣，简称传统组)。对两组临床资料(脑脊液漏、颅内感染、腰大池引流、鼻出血、平均卧床时间及平均住院时间等)进行统计学分析。结果：研究结果显示，鞍隔缝合组收纳了33例病例，而传统重建组则纳入了40例病例。两组在性别构成、患者基础健康状况、肿瘤最大直径以及其侵袭程度等方面的基线数据呈现出均衡态势，无统计学差异。就重建效果而言，鞍隔缝合技术组与传统技术组相当，其中鞍隔重建术后脑脊液漏情况(0/33)和颅内感染比率(3/33，占9.1%)与传统组的(2/40，5.0%以及5/40，12.5%)相比，差异不具备统计学意义(P > 0.05)。值得注意的是，鞍隔缝合技术组在减少术后平均卧床时间(2.79 ± 0.60天相较于5.73 ± 1.84天，P < 0.01)和缩短平均住院时长(5.73 ± 1.84天对比8.43 ± 4.26天，P < 0.01)方面表现良好，具有统计学意义。此外，该组术后嗅觉功能障碍的发生率(0/33)及鼻部不适报告(4/33，12.1%)均明显低于传统组(2/40, 5.0%, 14/40, 35%, P< 0.05)，具有统计学意义。随访影像学检测证实，鞍隔缝合组的重建结构保持在位，无迟发性脑脊液漏发生。结论：研究结论显示，采用鞍隔缝合技术于经蝶垂体腺瘤切除手术中，对中量脑脊液漏的修复效果确切，能够有效地重建手术区域的解剖结构。此技术的一大优势在于避免了带蒂鼻中隔黏膜瓣所带来的额外的鼻腔损伤，从而有助于缩减患者的卧床恢复期及总体住院时长，同时对提升患者的主观感受具有积极影响，在临床上有重要应用潜力。

Abstract: Objective: In the context of moderate flow cerebrospinal fluid leakage during endonasal endoscopy for pituitary tumors, how to properly complete skull base reconstruction to reduce postoperative cerebrospinal fluid leaks and infection rates has always been a hot topic in skull base surgery research. This study introduces a method that directly reconstructs the diaphragm sellae itself, rather than simply reconstructing at the sellar floor levels, and can be used in conjunction with our mature reconstructive strategies for the sellar floor (such as dura suturing technique, bone-mucosa embedding technique, etc.), thereby achieving a more secure and reliable skull base reconstruction, while comparing its effectiveness with traditional multi-layer reconstruction techniques. Methods: A retrospective analysis of the cases of medium-flow cerebrospinal fluid leakage during endoscopic transsphenoidal approach pituitary tumor resection in our hospital from September 2016 to June 2022, which was divided into the diaphragm sellae suturing group (where the damaged diaphragm sellae was directly sutured to the adjacent dura, and the sellar floor was reconstructed by CBEF technique) and the traditional multilayer reconstruction group (fat + fascia lata + PNSF, referred as the traditional group). Clinical data from the two groups (cerebrospinal fluid leakage, intracranial infections, lumbar drainage, epistaxis, average bed rest time, and average hospital stay etc.) were compared and analyzed. Results: The diaphragm sellae suturing group and the traditional group included 33 and 40 cases, respectively. The baseline data of the two groups were comparable. The diaphragm sellae suturing group avoided additional trauma to the nasal cavity, and its reconstruction effect was comparable to that of the traditional group: Incidence of postoperative cerebrospinal fluid leakage (0/33) and intracranial infection rate (3/33, 9.1%) were no statistical difference compared to traditional group (2/40, 5.0% and 5/40, 12.5%) (P > 0.05). And compared with the traditional group, the average postoperative bed stay time (2.79 ± 0.60 vs 5.73 ± 1.84 days, P < 0.01) and the average postoperative hospital stay (5.73 ± 1.84 vs 8.43 ± 4.26 days, P < 0.01) of the diaphragm sellae suturing group were significantly shorter. The incidences of postoperative olfactory disturbance (0/33) and nasal discomfort (4/33, 12.1%) in the diaphragm sellae suturing group were significantly lower than those in the traditional group (2/40, 5.0% and 14/40, 35.0%) (P < 0.05). Follow-up imaging showed that the reconstructed structure of the diaphragm sellae suturing group was stable, and there was no delayed cerebrospinal fluid leakage. Conclusion: The diaphragm sellae suturing technique has a reliable effect on repairing medium-flow leaks during transsphenoidal pituitary tumor resection, which can restore the anatomical layers of the surgical area, avoid additional trauma from the Pedicled Nasoseptal Flap, which helps shorten bed rest and hospitalization time and improves the subjective experience of patients, and has high clinical application value.