内镜下经鼻蝶入路手术切除巨大垂体腺瘤临床分析

Endoscopic endonasal transsphenoidal surgery for giant pituitary adenomas

目的探讨内镜下经鼻蝶入路手术切除巨大垂体腺瘤的手术方法及治疗效果。方法回顾性分析2014年1月-2016年5月解放军总医院神经外科内镜下经鼻蝶入路手术治疗的76例巨大垂体腺瘤患者临床资料。男性40例,女性36例;年龄18～72岁,平均47.3岁。无功能性垂体瘤64例,功能性垂体瘤12例。术前MRI显示肿瘤最大直径为4.0～7.1 cm,平均4.8 cm。手术采用导航辅助内镜下经鼻蝶入路。术后随访头颅MRI及内分泌指标,判断肿瘤的切除程度,并对肿瘤的临床特征及是否全切进行分析。结果肿瘤全切除32例（42.1%）,次全切除26例（34.2%）,大部切除18例（23.7%）。肿瘤未达到全切和肿瘤侵犯海绵窦与肿瘤成分叶状有关（P〈0.05）,与患者性别、肿瘤大小、肿瘤是否侵袭蝶窦和筛窦、肿瘤是否侵犯三脑室、肿瘤有无出血卒中及既往有无手术史无关。术前视力减退的56例中,术后视力好转43例（76.8%）,同术前10例（17.9%）,因残留肿瘤出血出现术后视力较术前减退3例（5.3%）。术后出现脑脊液鼻漏12例,尿崩7例。术后随访62例（83.8%）,随访时间2～32个月,平均14.5个月,52例（83.9%）术后可参加日常工作和学习,4例（6.4%）肿瘤复发。结论经鼻蝶入路内镜手术能安全、有效地切除巨大垂体腺瘤。术后结合药物及放射外科治疗,可以控制残留肿瘤。

Objective To investigate the surgical procedure and effects of endoscopic endonasal transsphenoidal surgery（EETS） for giant pituitary adenomas. Methods Clinical data about 76 consecutive patients with giant pituitary adenomas who underwent EETS from January 2014 to May 2016 in our hospital were retrospectively analyzed. Of the 76 patients, 40 were male and 36 were female with age ranging from 18 to 72 years（mean age, 47.3 years）. There were 64 cases with non-functioning adenomas and 12 cases with hormone-secreting adenomas. The maximum tumor diameter varied from 4.0 to 7.1 cm, with mean diameter of 4.8 cm. Postoperative MRI and endocrine function were re-examined routinely to evaluate the therapeutic efficacy. Results Total removal of the tumor was achieved in 32 cases（42.1%）, 26 patients（34.2%） underwent subtotal resection, and 18 patients（23.7%） underwent partial removal. Factors that limited the degree of resection were a multilobular configuration of the adenoma and cavernous sinus invasion（P〈0.05, respectively）. Of the 56 cases with preoperative vision loss, vision improvement achieved in 43 cases（76.8%）, unchanged in 10 cases（17.9%）, and worsened in 3 cases（5.3%） due to apoplexy of residual tumor. The major postoperative complications included CSF leak in 12 cases, permanent diabetes insipidus in 7 cases. During a mean follow-up of 14.5 months（range 2-32 months） in 52 cases, 83.9% of the cases went back to daily life and work and 4 cases（6.4%） suffered recurrence. Conclusion Endoscopic endonasal transsphenoidal surgery provides effective management of giant pituitary adenomas with favorable results. Adjuvant therapies including medical and radiation therapies offer the chances to control the residual tumors after the maximal surgical removal of giant adenomas.