摘要
第一部分扩大经蝶窦手术入路的显微、内镜解剖学研究
目的
本研究将通过解剖学研究,来探讨扩大经蝶窦手术入路的特点,主要包括扩大经蝶窦手术入路相关的解剖参数及显微镜和内镜下的解剖特点,通过解剖学研究,进一步弄清鞍区和鞍旁的显微解剖结构及相互关系,通过扩大经蝶窦手术入路的解剖学研究,为扩大经蝶窦手术适应证及范围提供理论依据。
材料和方法
国人成年带颈头颅冷冻标本12具(24侧),颈总动脉、椎动脉灌注红色乳胶,颈内静脉灌注蓝色乳胶。冠状位和矢状位各切开1具标本,采用显微镜下逐层解剖并拍照;10具标本先行模拟经典的内镜下经鼻蝶窦入路,然后分别向前颅底区、向下斜坡区、向两侧海绵窦区扩展,进行内镜下的解剖观察并测量,主要观察鞍区和鞍旁解剖结构的内镜下特点及相互位置关系。
结果
1.内镜下,在鼻腔内,蝶筛隐窝和后鼻孔是确定蝶窦开口的重要解剖标志。在显微镜下,依靠蝶窦前壁尖尖的形状来定位蝶窦开口。
2.筛前动脉为额隐窝与筛顶的分界,筛后动脉是确定视神经管隆突的解剖标志。
3.蝶腭孔上缘距蝶窦开口下极的距离是11.81mm±2.61mm(8.23～16.86mm)。蝶腭孔后缘有一锐利突起的小骨片约3.0mm×4.0mm,可以作为确定蝶腭孔的解剖标志。
4.蝶窦是经鼻蝶窦入路中重要的解剖结构,蝶窦后壁的斜坡凹陷是全鞍型蝶窦最可靠的确定鞍底的解剖标志。
5.颈内动脉海绵窦段分为5段,有3个动脉分支,其在蝶窦外侧壁上形成颈内动脉隆突,与视神经管隆突形成视神经—颈内动脉隐窝,是内镜手术中确定中线的重要标志。
6.内镜下经鼻蝶窦入路可清晰的显露海绵窦内结构。垂体侧方与海绵窦内侧壁之间仅有一层硬膜结构。颈内动脉海绵窦段是此入路所见的海绵窦内的主要结构,颈内动脉海绵窦段前曲段的内侧缘距垂体中线的距离为11.94mm±1.90mm(9.02mm～14.86mm),后曲段的内侧缘距垂体中线的距离为7.96mm±2.07mm(5.64mm～11.58mm)。
结论
1.鞍区和鞍旁解剖结构复杂,全面掌握、熟悉鞍区和相邻周边的解剖学,是开展扩大经蝶窦手术的基础。
2.与经蝶窦手术鼻腔出血关系最密切的血管是鼻中隔后动脉,在扩大蝶窦开口时容易损伤,引起出血。
3.手术中,首先要根据解剖标志来判断双侧蝶窦开口的位置,严格按照中线入路。双侧的颈内动脉隆突,双侧的视神经—颈内动脉隐窝是内镜下术中确定中线的标志。
4.内镜下利用解剖结构在颅底区形成的隆起和凹陷可确定经鼻蝶窦入路的重要解剖标志,并可根据这些标志确立正确的手术方向。如在鞍型蝶窦中,斜坡凹陷是重要的判断鞍底的解剖标志。
5.在切开鞍底硬膜时采用在鞍底稍偏下方切开,可最大程度的减少前海绵间窦的出血。在术中应选择合理的切开硬膜和止血方式。
6.少数病例颈内动脉表面无骨质保护,处理不当可损伤颈内动脉,导致大出血这一严重并发症。
第二部分扩大经蝶窦手术入路治疗侵袭性垂体腺瘤的临床研究
目的
总结北京协和医院采用扩大经蝶窦手术入路治疗117例侵袭性垂体腺瘤患者的临床经验,探讨在临床上应用扩大经蝶窦手术入路在治疗侵袭性垂体腺瘤的可行性和疗效,使其成为一种可以推广的临床技术。
资料和方法
回顾性分析了北京协和医院自1999年9月至2007年3月采用扩大经蝶窦手术入路治疗117例侵袭性垂体腺瘤病例,探讨了术中切除肿瘤的技术,对其疗效进行分析。
结果
本组病例中男性49例,女性68例。年龄12岁～75岁,平均43.9岁。病程3天～25年,平均42.3月。临床表现中视力下降60例,视野障碍96例,月经紊乱或闭经39例,泌乳13例。术前垂体功能低下10例。术前应用生长抑素治疗3例患者,溴隐亭治疗11例,卡麦角林治疗1例。影像学检查,大腺瘤77例(肿瘤直径1～4cm),巨大腺瘤40例(肿瘤直径≥4cm);肿瘤向前方及额叶底部生长14例,向侧方生长包绕海绵窦103例,其中有3例侵入颞叶下方,向后方生长破坏斜坡27例,突破鞍底向蝶窦生长45例,向两个方向以上呈侵袭性生长者57例。手术显微镜下肿瘤全切除73例,次全切除40例,大部切除4例;手术并发症包括短暂性脑脊液鼻漏7例;颅神经不全麻痹5例;垂体功能低下5例,其中1例需终生激素替代;颈内动脉损伤2例;单眼失明2例;永久性尿崩症1例;无死亡病例。19例患者手术后行放射治疗,15例行γ刀治疗,25例予药物治疗。随访3个月～8年,2例患者出现肿瘤复发而予γ刀治疗,无再手术病例。
结论
1.扩大经鼻蝶窦手术入路是治疗侵袭性垂体腺瘤的首选手术方式,其创伤小,患者恢复时间短。
2.术中神经内镜的应用,可以减少显微镜下看不到的“死角”,尤其是用成角度内镜,可以减少肿瘤的残留,减少复发率。
3.术中神经导航的应用,对于蝶窦发育不佳,二次手术的患者来说,可以减少手术的并发症。
4.分泌性垂体腺瘤的内分泌学治愈,仍然是一个难题。
5.应加强侵袭性垂体腺瘤患者围手术期水、电解质、激素失衡或紊乱的处理。
6.侵袭性垂体腺瘤的治疗,是一个多科协作的课题,需密切随访,必要时可采用药物治疗及放射治疗等综合治疗方法来提高治愈率,防止肿瘤复发。
Objectives
The goles in this study were to investigate the characteristics of extended transsphenoidal approach through the anatomic study. The characteristics include the anatomic parameter and characteristics under microscopic and ensoscopic.To make clear of microscopic structure and the relationship between sella region and parasella region. To establish an anatomic basis for clinical application of this anatomy study.
Materials and Methods
Twelve(twenty-four sides) human cadaver heads, in which the common carotid artery and the vertebral artery were injected with red latex ,the internal jugular vein was injected with blue latex.Two injected adult cadaveric heads were sectioned longitudinally and coronally respectively, taken photograph and studied by microscope, ten specimens were resected with endoscopy thropugh simulated classic transsphenoidal approach. The extention of the surgical exposure in version of endoscopy to the anterior skull base, the cavernous sinus(CS) and clivus.The anatomic observation and measurements were abtained. To observe the endoscopic characteristics of the sella region and parasellar region and their relationships.
Results
1. Sphenoethmoid recess and posterior nasal aperture were the landmarks to determine sphenoidal ostium. The sphenoidal ostium was determined by the spinous shape of anterior sphenoidal wall under microscopy.
2. Anterior ethmoidal artery was a landmark to identify ethmoid roof and frontal recess. Posterior ethmoidal artery was a landmark to determine optic prominence.
3. The distance between superior margin of sphenopalatine foramen and lower border of sphenoidal ostium is 11.81mm±2.61mm(8.23-16.86mm).There is a sharp protuberant microsclere whose size is about 3.0mm×4.0mm.It is an anatomic landmarks to determine sphenopalatine foramen.
4. Sphenoidal sinus was the most important structure in this transnasal-sphenoidal approach. The most common and certain anatomic landmarks in the posterior bony wall of sellar-type sphenoidal sinus was clival indentation, which is the certain landmark to identify the sellar floor.
5. The cavernous internal carotid artery can be divided into five segments and three vessal branchs. The optico-carotid recess is the landmark for the midline definition during operation through endoscopy. The optico-carotid recess is located between carotid prominence which is formed on the lateral wall of sphenoidal sinus and optic prominence.
6. The cavernous sinus could be exposed clearly through transnasal-sphenoidal approach. The medial wall of the cavernous sinus lateral to the pituitary gland is only a thin dura. The cavernous internal carotid artery is the most important structure in the cavernous sinus of extended transsphenoidal approach. The distance between the media edge of the anterior bend of cavernous internal carotid artery and the midline of pituitary gland is 11.94mm±1.90mm(9.02mm-14.86mm), the distance between the media edge of the posterior bend and the midline of pituitary gland is 7.96mm±2.07mm(5.64mm-11.58mm).
Conclusion
1. Sellar and parasellar region are a complicated anatomic structure. Overall prehension and be familiar with the anatomic study of the sellar and parasellar region can provide the operation basis of the extended transsphenoidal approach.
2. The posterior nasal septal artery and the nasal cavity haemorrhage have the most intimate relationships. The posterior nasal septal artery was injured easily during the sphenoidal ostium enlargement.
3. To determine the location of the sphenoidal ostium by anatomic landmark during operation is the first mission and abide by median line approach strictly.The bilateral carotid prominences and optic-carotid recesses are the landmark to determine median line under endoscopy during operation.
4. The important anatomic landmark of transnasal-sphenoidal approach can be determined through endoscopic prominence and recess which were formed in the basilar region,which can also guide the correct direction of operation.Such as the common and certain anatomic landmarks in the posterior bony wall of sellar-type sphenoidal sinus is clival indentation, which is the certain landmark to identify the sellar floor.
5. The hemorrhage of anterior intercarvenous sinus can be decreased greatly if the discission place of the sellar floor dura below the sellar floor slightly. The style of dura discussion and haemostasis should be choiced rationally.
6. There have no bone protection on the surface of internal carotid artery in less cases, so internal carotid artery can be damaged and caused hemorrhage when treatment inappropriately.
Objectives
The purpose of this article is to summarize the clinical experience of 117 patients with invasive pituitary adenoma underwent surgery via extended transsphenoidal approach at the Neurosurgical Department of Peking Union Medical College Hospital in Beijing. To study the feasibility and value of the extended transsphenoidal approach to invasive pituitary adenoma and make the technique into a clinical method of pituitary adenoma.
Methods
Between September 1999 and March 2007, 117 patients with invasive pituitary adenoma underwent surgery via extended transsphenoidal approach at the Neurosurgical Department of Peking Union Medical College Hospital in Beijing. The clinical data and follow-up of this series were retrospectively analyzed.The skills of tumors resection during operation were investigated and the therapeutic effects were analyzed.
Results
There were 49 male and 68 female.The patients ranged in age from 12 to 75 years (mean age is 43.9 years).The disease course ranged from three days to twenty-five years.The average is 42.3 monthes.The clinical manifestations includes 60 cases of visual descend, 96 cases of field of vision disorder,39 cases of menstruation confusion or amenorrhea,13 cases of lactation. 10 cases has hypopituitarism before operation. Somatostatin was applicated in 3 cases before operation. Bromocriptine was applicated in 11 cases,while cabergoline was applicated in 1 case.This series included 77 macroadenomas (diameter of neoplasm is 1 - 4cm) and 40 giant adenomas (diameter of neoplasm is greater than 4cm).Among them, 14 adenomas extended anteriorly to the anterior cranial base, 103 laterally to the cavernous sinus,27 posteriorly to the clivus, and 45 inferiorly to the sphenoidal sinus.57 adenomas involved multiple direction structures. Total tumor removal was achieved in 73 cases, subtotal removal in 40, and partial removal in 4 cases. There was no perioperative mortality. Transient postoperative complications included 7 cases of CSF fistulae, 5 cases of partial cranial nerve palsy. 5 cases developed acute panhypopituitarism,in which lcase needed hormone replaced all his life. Permanent neurological complications included 2 cases of carotid artery injury, 2 cases of monocular blindness, one case of permanent diabetes insipidus.None of patient dead. 19 patients were treated with postoperative common radiotherapy. 15 patients underwent gamma knife treatment. 25 patients received medicine treatment. The follow-up period ranged from 3 months to 8 years. The tumor recurred in two patients and then was treated with gamma knife. No patient needed re-operation.
Conclusion
1. The extended transsphenoidal approach has been proved to be the first choice to remove the invasive pituitary adenomas, which has less trauma and the coincidence time of patients is shorter than transcranial approach.
2. The application of neuroendoscopy during operation can decrease the "dead area" which cannot be seen under microscopy. Expecially, the using of angled endoscopy can decrease the residual of neoplasm and decrease recurrence rate.
3. The application of neuro-navigation during operation can decrease the operation complications,especially for those that the development of sphenoid sinus was unsuitable or patients who experienced twice operations.
4. The endocrinology healing of functioning pituitary adenoma remained a tough problem.
5. Take important in dealing with water ,electrolyte and hormone balance or disturbance during operation.
6. The treatment of invasive pituitary adenoma is a multiple-department cooperation task and required close follow-up. Medicine treatment and radiotherapy are comprehensive treatments for invasive pituitary adenomas to decrease neoplasm recurrence.
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