经鼻小柱-鼻中隔-蝶窦入路切除132例大型和巨型垂体腺瘤分析

Transsphenoidal approach to hypophysectomy for large and giant pituitary adenomas:experience of 132 cases

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 鼻小柱切开是采用（左）鼻内中隔切口为基础，鼻小柱切开，增加侧斜切口或两侧鼻前庭小柱切开上翻法，后经鼻中隔-蝶窦，打开蝶窦，开窗近圆形直径1～1．5cm，中线处凿开鞍底，探查并切除鞍内肿瘤。结果 132例中行包膜内全切除42例（31．8％），其余行次全切除或大部分切除。术后症状改善者118例（89．4％）；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，绝大多数病人因蝶窦气化条件良好，同时垂体瘤大多质地为稀软性，便于吸除而可采用经蝶窦手术治疗获得良好效果。而此切口具有径路短、出血少、不需要填塞纱条等优点。

Objective To introduce the experience of large and giant pituitary adenomas in removal of 132 patients through transsphenoidal approach and explore an ideal operative method for this tumor. Methods A nasal septum incision was made followed by separation of septum from mucous membrance and periosteum on the left side. The septal cartilage was pushed towards the right side and dilated by Hardy＇s dilator. The bony septum was temoved to expose the anterior wall of sphenoid sinus and then the anterior wall was bored to reveal the whole sinus cavity. The sellar bottom was chiseled at the middle line to form a hole of 1 - 1.5 cm in diameter to uncover the dura mater, which was then incised in corss-shape after confirmation of the size and location of the tumor. Finally, the tumor was removed by repeated scraping and the sellar bottom was sealed with a compound of bone sheet-gelatin sponge-medical mucilage. Results The tumor was totally removed in 42 patients （31.8%） and sub-totally or partly removed in the others. The symptoms and signs were immediately improved in 118 （89.4 % ） patients postoperatively. Complications such as cerebrospinal fluid leakage, nasal bleeding and diabetes incipidus occurred for a short time in some patients and were cured by symptomatic treatments. Conclusion As for patients with large and giant pituitary adenomas, the vast majority of the tumor can be removed by transsphenoidal approach due to the well pneumatization of sphenoid sinus and the thin character of the tumor. This approach has the advantage of short operative pathway, less bleeding and no need of oral tamping.