内镜经鼻蝶窦手术治疗巨大垂体腺瘤（附69例报道）

Endoscopic endonasal transsphenoidal surgery for giant pituitary adenomas： a report of 69 cases

目的 探讨内镜经鼻蝶窦入路手术切除巨大垂体腺瘤的手术技巧和经验.方法 回顾性分析采用内镜经蝶窦手术治疗的巨大垂体腺瘤,并对其随访结果、并发症、手术入路的选择、肿瘤切除程度及其相关因素进行分析.结果 69例患者中,无功能性腺瘤51例,催乳素腺瘤11例,生长激素腺瘤7例.肿瘤全切除26例,次全切除23例,部分切除20例.Knosp3～4级患者的全切除率显著低于0～2级（P＜ 0.001）.术后头痛缓解83％,视力障碍改善86％,眼球运动障碍改善60％,垂体功能低下改善36％.并发症包括尿崩9例,新发垂体功能低下10例,脑脊液漏2例,颅内感染2例,无死亡病例.再次经鼻蝶窦手术9例,13例予以放疗,11例予药物治疗.结论 内镜经鼻蝶窦手术可安全有效地治疗巨大垂体腺瘤,肿瘤的生长方式和术者经验为手术入路选择的主要考虑因素.

Objective To present our experience with the surgical management of giant pituitary adenomas through endoscopic endonasal transsphenoidal approach.Methods A retrospective data analysis of all patients who underwent endoscopic endonasal transsphenoidal surgery in Nanfang Hospital between January 2007 and June 2013 was performed.Patients who presented with pituitary adenomas larger than 4 cm were included in the study.Analysis of factors related to the choice of the operative approach,extent of resection,follow-up outcome,and complications were evaluated.Results Sixty-nine patients （18%） with giant adenomas matched our inclusion criteria.This included 51 （74%） patients with nonfunctional tumors,11 （16%） prolactinomas,and 7 （10%） growth hormone-secreting adenomas.Gross total removal of the tumor was achieved in 26 cases （38%）,subtotal removal in 23 （33%）,and 20 （29%） had partial resection.Postoperative diabetes insipidus occurred in 9 cases （13%）,new anterior pituitary insufficiency in 10 （15%）,CSF leaks in 2 （3%）,and meningitis in 2（3%）.There was no dead case.The patients with Knosp score 3-4 adenomas had a higher total resection rate than those with Knosp score 0-2 （P〈0.001）.Preoperative headache,visual dysfunction,oculomotor disorders and hypopituitarism were recovered in 20 （83%）,59 （86%）,9 （60%）,and 12 （36%） cases,respectively.Nine patients with nonfunctional tumors underwent a second transsphenoidal surgery,10 underwent radiotherapy,and 14 had a follow-up care.Drug therapy was performed in 11 patients with functional tumors,and radiotherapy in 3.Conclusions Endoscopic endonasal surgery might provide safe and effective treatment for patients with giant adenomas.The selection of surgical approach should be established according to the tumor extension and personal experience.In cases in which total resection might be associated with high risk,we advocated the use of partial resection followed by adjuvant drug therapy or radiotherapy.In cases of progressive enlargement of residual lesions,a second endoscopic procedure or radiotherapy might be considered.