近全切除策略在听神经瘤手术中的应用及疗效分析

Application and efficacy analysis of the near-total resection strategy in acoustic neuroma surgery

目的观察肿瘤切除程度与术后肿瘤复发及面神经功能的关系。方法回顾性研究天津市环湖医院2004年10月至2014年10月由同一位术者完成的听神经瘤手术患者154例。所有患者均采用枕下乙状窦后入路，术中应用近全切除策略，与面神经粘连紧密的部分肿瘤不强行切除，若该部分肿瘤残留则不磨开内听道。分析面神经功能及肿瘤复发情况与肿瘤切除程度的关系。对复发者行伽玛刀治疗。结果154例中，手术死亡1例（0．6％）。随访124例，失访30例，随访率为80．5％。随访时间8个月至10年。124例中，听神经瘤手术全切除率为19．3％（24例），近全切除率为74．2％（92例），次全切除率为6．5％（8例）；术后面神经功能良好率为91．1％（113例，House—Brackmann分级Ⅰ—Ⅲ），其中全切除组为79．1％（19／24），近全切组为94．6％（87／92），次全切除组良好比例为7／8（X2=5．72，P=0．048）。复发率为16．1％（20／124），其中全切除组复发率为0，近全切组为15．2％（14／24），次全切组的比例为6／8，差异有统计学意义（F=19．47，P=0．000）；伽玛刀治疗后，4例（3．2％）随访期肿瘤体积再次增大，行二次手术。结论听神经瘤近全切除后辅助伽玛刀治疗可有效控制肿瘤生长，能够明显提高面神经功能保留率。对于改善面神经与肿瘤粘连紧密的部分患者术后的生活质量是一种可行的治疗方案。

Objective To observe the relationship between the extent of tumor resection and postoperative tumor recurrence or facial nerve function. Methods A total of 154 patients with coustic neuroma operated by the same surgeon in Tianjin Huanhu Hospital from October 2004 to October 2014 were enrolled retrospectively. All patients were treated via suboccipital retrosigmoid transmeatal approach. The near-total resection strategy was used during operation. Part of the tumors closely adhered to the facial nerves were not removed forcibly. If there was part tumor residue, the internal auditory canal was not drilled open. The relationship between facial nerve function or tumor recurrence and tumor resection degree was analyzed. The patients with recurrent tumor were treated with Gamma knife. Results In 154 patients, 1 （0.6%） died during the operation, 124 were followed up, 30 were lost to follow up, and. the follow-up rate was 80. 5%. The follow-up time ranged from 8 months to 10 years. In 124 patients, the total resection rate of acoustic neuroma was 19.3% （n = 24）, the near-total resection rate was 74.2% （n = 92）, and subtotal resection rate was 6.5% （n = 8）. The good rate of facial nerve function in 124 patents after procedure was 91.1% （n = 113; House-Brackmann grade Ⅰ to Ⅲ）, the total resection group was 79.1% （ 19/24）, the near-total resection group was 94.6% （ 87/92）, the good proportion of the subtotal resection group was 7/8 （X2 =5.72, P = 0. 048）. The recurrence rate was 16. 1% （20/124）, including 0 in the total resection group, 15.2% in the near-total resection group, the proportion of the subtotal resection was 6/8. There were significant differences （F = 19.47, P = 0. 000）. After Gamma knife treatment, the tumor volume increased again in 4 patients （3.2%） during the follow up period. They were reoperated. Conclusions After neartotal resection of acoustic neuroma, the assisted gamma knife therapy may effectively control the growth of acoustic neuroma, and significantly improve the retention rate of facial nerve function. For the improvement of the quality of life after procedure is a feasible treatment scheme in the facial nerve and some closely tumor- adhered patients.