经蝶垂体区手术的演变:个人15年体验

Evolutions of Transsphenoidal Pituitary Surgery:Personal Experience in 15 Years

背景与目的:为追求垂体瘤的最佳治疗效果,三十年来,经蝶手术经历了一系列的演变。目前内镜下经蝶手术似为潮流。本文总结个人15年经历的五种经蝶手术,发表个人看法。方法:回顾过去15年作者实施的各类经蝶手术75例的临床及近期随访资料,比较肿瘤切除程度及手术创伤和安全性。结果:(1)不同经蝶术式垂体瘤的切除程度:垂体瘤56例,近全切18例(>95%),次全切25例(80%～95%),大部切除7例(50%～79%),部分切除6例(<50%)。其中内镜经蝶手术获得次全切除以上效果的占90.32%,部分切除占3.23%;显微镜经蝶手术获得次全切除以上效果的占50.00%～75.00%,部分切除占12.50%～30.00%。(2)不同经蝶术式并发症的发生情况:内镜经蝶手术平均每例每种并发症的发生率是4.21%,而显微镜经蝶手术为15.91%～29.55%。结论:内镜鼻内经蝶垂体区手术较显微镜下的经蝶手术有如下优点:(1)弃用了Cushing牵开器,手术入路侵袭更小:减轻了患者术后不适感;减少了鼻中隔穿孔等并发症发生的机会,因而患者更易于接受。(2)深入的内镜广角(或加成角)照明和全景视野,使得肿瘤及其临近结构显露更好,可能更多地切除肿瘤,取得更好的肿瘤治疗效果;可使重要结构辨认更确切,更易于保护,使手术更安全,从而最终达到较好的手术治疗效果。

BACKGROUND ＆ OBJECTIVE： In the past three decades, transsphenoidal surgery continued to evolve to achieve better results in pituitary adenomas. Five kinds of transsphenoidal approaches attempted by the author in the past 15 years were summarized. METHOD： Clinical and short-period follow-up data of 75 cases of pituitary adenomas treated with transsphenoidal surgery carried out by the author in the past 15 years were reviewed and analyzed retrospectively, tumor resection extent and complications were compared among the five different approaches. RESULTS： Among 56 patients, total removal was achieved in 18 cases, subtotal removal in 25 cases, major removal in 7 cases and partial removal in 6 cases, respectively. In the group treated with endoscopic transsphenoidal approach, total removal was achieved in 90.32% of the cases and partial resection in 3.23% of the cases. In the groups treated with microscopic transsphenoidal approaches, total removal was achieved in only 50.00%- 75.00% of the cases and partial removal in 12.50%-30.00% of the cases. The incidence of individual complication ingroups treated with endoscopic transsphenoidal approach was 4.21%. In microscope-assistant group, the incidence of individual complication was 15.91% -29.55% CONCLUSION： Compared with microscopic approaches, endoscopic transsphenoidal transsphenoidalapproach showed more superior. First, microinvasiveness is achieved by endoscopic transsphenoidal approach through discarding Cushing speculum commonly used in endoscopic transsphenoidal approach. Second, better visualization can be provided by endoscopic transsphenoidal approach, which facilitates the exposure of the tumor and adjacent structures. In conclusion, endoscopic transsphenoidal approach is more safe and efficient than microscopic transsphenoidal approaches in treatment of pituitary tumors.