经鼻小柱-鼻中隔-蝶窦入路切除大型和巨型垂体腺瘤

Trans-sphenoidal Hypophysectomy of Large and Giant Pituitary Adenomas Through External Rhinoplasty Approach

【目的】介绍经鼻小柱 -鼻中隔 -蝶窦入路切除大型和巨型垂体腺瘤 132例的临床经验 ,探讨治疗大型和巨型垂体腺瘤的有效方法。【方法】经鼻小柱切开后 ,分离鼻中隔 ,将中隔软骨推向对侧 ,暴露后明视下截除鼻中隔骨性结构 ,达蝶窦前壁 ,参照蝶窦开口 ,在两者之间打开蝶窦 ,开窗近圆形直径 1～ 1.5cm ,进而去除窦内黏膜 ,止血后严格在中线处凿开鞍底 ,探查切除鞍内肿瘤。【结果】132例中行包膜内全切除 4 2例(31% ) ,其余行次全切除或大部分切除。术后症状立即改善者 118例 (90 % ) ;术后部分病例出现暂时性尿崩症、鼻腔渗血、脑脊液鼻漏和垂体功能低下等经对症治疗而好转。【结论】对于大型和巨型垂体腺瘤病人 ,绝大多数病人因蝶窦气化条件良好 。

To introduce the clinical experiences in trans-sphenoidal hypophysectomy for 132 patients with large and giant pituitary adenomas by external rhinoplasty approach and explore an effective measure of their treatment.Making an improved nasal column incision plus tilted short bar , the nasal septum was first separated from its mucous membrane and periost. Then the septal cartilages were pushed to the right side and Hardy's dilator was put in. Thus the front wall of the sphenoidal sinus could be visible under a ray of cold-light-source after removal of the bony nasal septum. The anterior wall of sphenoidal sinus was bored to form a hole between the two apertures of sphenoid sinus, a nearly circular window with 1～1.5 cm in diameter was opened, then the mucous membrane inside the sphenoidal sinus was taken out. The sellar bottom was chiseled through in its middle line after thorough homeostasis and the intrasellar tumors were explored and resected. The pituitary adenoma was excavated out by circumcuret with repeated curettage helped by a serial trick for increasing intracranial pressure to squeeze the tumor .After the tumor was totally or sub-totally removed, the sellar bottom was sealed by a compound of bone sheet-gelatin sponge-medical mucilage.The tumors were totally resected within their capsules in 42 out of 132 patients (31%) and sub-totally or partly removed in other patients. The symptoms and signs in 118 (90%) patients , such as headache, decreased sight etc were promptly improved after operation. Cerebrospinal rhinorrhea (13 cases ), blood oozing from nasal cavity , temporary diabetes insipidus and pituitary hypofunction occurred postoperatively in some patients but were ameliorated by anti-symptomatic treatment.[Conclusions]In view of the well gasification of sphenoid sinus and rarefied soft density of tumors convenient to aspiration, overwhelming majority of patients with large and giant pituitary adenoma can be subjected to tumor resection by trans-sphenoidal approach and good therapeutic efficacy is achieved. A series of problems concerning cure and recurrence of the tumor, influencing factors of prognosis , hardness of the tumor and operative indications are summarized and discussed in connection with literatures.