经蝶微创手术中的各种出血情况及处理

Various bleedings and the management in minimally invasive transsphenoidal operations

目的分析经蝶术中的各种出血情况和处理方法,以提高手术质量.方法前瞻性研究775例各种病变行经蝶手术中的出血情况及处理.结果平均出血330 ml,其中出血量＜100 ml者占17.2%,≥100～400 ml 67.4%,≥400～800 ml 13.9%,≥800 ml 1.5%.不同结构平均出血量多少依次为:颈内动脉680 ml,鞍底静脉180 ml,病变实质90 ml,鼻腔黏膜60 ml,骨质＜10 ml;造成严重出血(≥800 ml)者中,颅底静脉7例,病变实质4例,颈内动脉1例.出血相关并发症:严重蛛网膜下腔出血3例,中枢神经损伤4例,颈内动脉假性动脉瘤4例,视力恶化3例,失血性休克4例,严重鼻衄1例,鞍上动脉出血并死亡1例.结论经蝶入路手术中绝大多数病例出血较少,但少数发生严重出血,其后果严重并可能危及生命.在进入蝶鞍、鞍底和切除海绵窦内、鞍上部位肿瘤过程中,随时可能发生严重出血,术者应高度警惕.

Objective To improve the surgical quality by analyze the various bleedings in transsphenoidal operations. Methods Various bleedings in 775 cases of transsphenoidal operations were prospectively studied. Results Mean amount of hemorrhage in the operation is 330 ml, among which, <100 ml in 17.2% of the patients, ≥100 to 400 ml in 67.4%, ≥400 to 800 ml in 13.9%, and ≥800 ml in 1.5%. The order of mean hemorrhage amount in different part is as follow: sella base vein 180 ml, the lesion itself 90 ml, nasal mucosa 60 ml and bone <10 ml. Severe hemorrhage (> 800 ml) is due to sella base vein in 7 patients, lesion in 4, and internal carotid artery in 1. The complications associated with bleeding were: severe subarachnoid hemorrhage in 3 patients, central nervous system injury in 4, internal carotid artery pseudoaneurysm in 3, vision deterioration in 3, shock in 4, and severe nasal epistaxis in 1. One case (0.1%) died from supra-sella artery bleeding. Conclusion There is less blood loss in most cases of transsphenoidal operations. However, severe hemorrhage could occur in a few cases with critical consequences, and even threaten to life. Operators should be alert that severe hemorrhage could happen any time during the procedure entering into sella, sella base, as well as removing tumor in cavernous sinus or supra-sella area.