内镜经鼻蝶入路手术治疗鞍区囊性病变46例临床分析

Treatment of cystic lesions in sella through transsphenoidal endoscopic endonasal approach： retrospective analysis of 46 cases

目的 分析鞍区囊性病变患者的临床和影像学特征并总结内镜经鼻蝶入路手术治疗的手术经验。方法 回顾性分析2003年6月至2013年9月在天津市环湖医院经手术和病理确诊的鞍区囊性病变46例患者的临床资料,其中颅咽管瘤11例,囊性垂体瘤14例,Rathke囊肿12例,垂体脓肿9例。比较46例患者的临床特点、影像学特征、手术治疗方法及术后复发情况。结果 全部患者均采用内镜下经鼻蝶入路手术治疗。术后头痛缓解26例,未缓解8例;垂体功能者恢复正常18例,未恢复15例;尿崩症恢复正常8例,未恢复正常4例;视力、视野改善12例,未改善2例。全部病例随访6 ～72个月,术后复发7例,其中颅咽管瘤4例,垂体脓肿2例,囊性垂体腺瘤1例。无严重并发症及死亡病例发生。46例患者中颅咽管瘤患者发病年龄较小、视力和视野症状明显、肿瘤多位于鞍上、第三脑室压迫、手术易复发。囊性垂体腺瘤常呈囊实性,侵犯海绵窦、实性部分均匀强化。Rathke囊肿表现为单纯囊性,临床症状出现较晚。垂体脓肿病程短,容易出现尿崩症,多个激素水平低下,影像学检查可见病变环形强化。结论 鞍区囊性病变的临床特点和影像学特征互相重叠,但又有一定的特异性。内镜经鼻蝶入路微创手术治疗鞍区囊性病变是安全、有效的手术治疗方法。

Objective To analyze the clinical and imaging characteristics of patients with cystic lesions in sella region and to describe the experience of endoscopic transsphenoidal surgery.Methods Fourty-six cases of cystic lesions in sella region confirmed by surgery and pathology between June 2003 and September 2013 were retrospectively analysed.The clinical features,imaging,surgical technique and postoperative recurrence in 46 cases were presented.Results All lesions were resected through transsphenoidal endoscopic endonasal approach.Followed up lasted from 6 months to 6 years.Postoperatively,headache was recovered in 26 cases and wasn＇t recovered in 8 cases,visual was improved in 12 cases and wasn＇t improved in 2 cases,hypopituitarism was relieved in 18 cases and wasn＇t relieved in 15 cases,polyuria was disappeared in 8 cases and wasn＇t disappeared in 4 cases.Seven cases recurred,including 4 cases of craniopharyngioma,2 cases of pituitary abscess,1 case of cystic adenoma.There were no death and serious complication.The small age of onset,visual acuity and visual field symptoms,tumor in suprasellar,third ventricle compression was easy to occur in craniopharyngioma;cystic tumor,cavernous sinus invasion,the solid part homogeneous enhancement could be seen in cystic adenoma;Rathke cyst showed simple cystic,lighter clinical symptoms and a short course.Prone to diabetes insipidus,low multiple hormone level and the lesions of annular enhancement was more common in pituitary abscess.Conclusions The clinical features and imaging of cystic lesions in sella region feature overlap each other,but there are certain specificity.Transsphenoidal endoscopic endonasal approach for the surgery of cystic lesions in sella is effective and safe.