垂体腺瘤卒中经鼻蝶入路术后复发的再手术探讨

Reoperation for recurrent pituitary apoplexy after the successful initial transnasal-sphenoidal approach surgery

目的探讨垂体腺瘤卒中经鼻蝶入路切除术后复发的再次手术方法。方法21例垂体腺瘤卒中患者首次手术经鼻蝶入路全切除肿瘤，术后9个月-5年内肿瘤复发；再次手术时仍经鼻蝶入路，术中准确定位、充分扩大磨除蝶窦前壁和鞍底骨质，先将鞍内卒中的陈旧性血性液体缓慢排空，再由浅入深将肿瘤反复刮除干净，使得鞍膈充分下陷以争取全切除。结果大部分复发肿瘤质地较软、血供丰富，其中17例仍伴有卒中；再次手术18例全切除，3例呈侵袭性生长只作大部分切除，术后行立体定向放射治疗；术后15例临床症状改善，复查激素水平好转；5例有暂时性尿崩，3例有垂体功能低下表现．经服药对症处理后好转；2例术中出现脑脊液漏。使用肌肉和脂肪填塞后消失。再次手术后随访3个月-5年，仅1例大部分切除的患者在二次手术后1年又出现残余肿瘤明显增大，行第三次经鼻蝶入路手术切除．其余未见肿瘤复发或残余肿瘤增大。结论垂体腺瘤卒中经鼻蝶入路术后复发，再次经鼻蝶入路仍然能够达到较高的全切率，术中准确定位、充分扩大鞍底骨窗、将卒中周边的肿瘤反复刮除以获得鞍隔充分下陷，是获得肿瘤全切以及改善症状的关键。

Objective To discuss the reoperation method for recurrent pituitary apoplexy after the suc- cessful initial transnasal-sphenoidal surgery. Methods Twenty-one patients with pituitary apoplexy were found recurrence after previous tumor resection via transsphenoidal surgery in 9 months to 5 years. In the reoper- ation, transsphenoidal approach would be still used. The anterior wall of sphenoid sinus and the sellar floor were located accurately, and then the remnants of them were removed as large as possible to expand the range of bone window. Next, the intraseflar hematoma was cleared away gently, and the residual tumor was removed pro- gressively and thoroughly to make sure the sellar diaphragm subsiding fully and finally removed the whole tumor. Results Most of recurrent tumors were found to be of soft texture with rich blood supply, and 17 cases were still apoplexy. In 18 cases of the 21 patients, total resection was achieved. However, for the other 3 cases with tumor aggressive growth, only massive resection was achieved, and underwent stereotactic radiosurgery postoperatively. Postoperative clinical symptoms were alleviated in 15 cases, whose hormones were also de- creased. Temporary diabetes insipidus and hypopituitarism appeared in 5 and 3 cases respectively, but all of these postoperative complications were relieved after symptomatic treatment. Two cases of intraoperative cere- brospinal fluid leakage were resolved by packing the cavity with muscle and fat flaps. All cases were followed up for 3 months- 5 years, residual tumor enlarged in only 1 case of massive resection, which umderwent transsphe- noidal surgery for the third time, no other cases recurred. Conclusion Operation via the transsphenoidal ap- proach of recurrent pituitary apoplexy after successful initial transsphenoidal surgery could achieve high total re- section rate. While the accurate locating, full expansion of the saddle bone window, and repeatedly scraping the apoplexy tumor to get a full subsidence for the sellar diaphragm, are the key points to remove tumors totally as well as to improve the symptoms.