神经内镜经鼻入路切除颅咽管瘤的手术经验

Surgical experiences of endoscopic endonasal approach for resection of craniopharyngiomas

目的探讨神经内镜经鼻入路切除颅咽管瘤的手术经验。方法回顾性分析2012年1月至2016年12月南昌大学第一附属医院神经外科采用内镜经鼻入路切除90例颅咽管瘤患者的临床资料，综合评价手术效果及随访结果。结果90例患者中，肿瘤全切除76例（84．5％），次全切除12例（13．3％），部分切除2例（2．2％）。术中发现垂体柄76例，保留垂体柄46例（60．5％）。术后视力改善40例，18例维持在术前水平，1例术后视力下降；术后新增垂体功能低下32例（35．6％），8例术前全垂体功能低下者，术后仍无明显改善；术后出现尿崩56例，其中30例为短暂性尿崩，26例为长期尿崩；6例（6．7％）术后出现脑脊液漏，并伴随颅内感染，均予以再次修补，成功5例；围手术期死亡4例（4．4％）。77例接受随访，时间为5—50个月，平均（23．1±13．3）个月，其中65例（84．4％）恢复正常生活，12例出现肥胖，2例复发，尚无死亡病例。结论采用神经内镜切除颅咽管瘤需双鼻道双人配合的扩大入路，内镜下能清晰辨别垂体柄、下丘脑、穿支血管等与肿瘤的关系。娴熟的内镜操作技术是完成高质量颅咽管瘤切除的重要保证，良好的颅底重建是预防术后脑脊液漏的重要环节。

Objective To present our surgical experiences with management of craniopharyngiomas （CPs） by endoscopic endonasal approach. Methods A retrospective review was conducted on clinical data of 90 patients who were treated for CPs by endoscopic endonasal approach from January 2012 to December 2016 at the Department of Neurosurgery, the first Affiliated Hospital of Nanchang University. All patients were analyzed in terms of treatment effect, complications, and follow-up results. Results Total removal of the tumors were completed in 76 cases （84.5%） , subtotal removal in 12 cases （ 13.3% ）, and partial resection in 2 cases （ 2.2% ）. The pituitary stalks were identified in 76 cases during surgery and severed in 46 cases （60.5%）. Postoperative visual acuity was improved in 40 cases, 18 cases remained at the preoperative level, and symptomatic worsening occurred in 1 case. New worsening of the anterior pituitary function was reported in 32 eases （35.6%）, all those cases with preoperative panhypopituitarism were unchanged. New diabetes insipidus occurred in 56 cases, and transient diabetes insipidus after operation occurred in 30 patients, and long-term diabetes insipidus occurred in 26 cases. Postoperative cerebrospinal fluid （CSF） leak was reported in 6 cases accompanied with intracranial infection. All those cases were repaired under endoscope again and success was achieved in 5 cases. Perioperative mortality rate was 4.4%. A total of 77 patients were followed up for 5 - 50 months with an average of 23. 1 ＋ 13.3 months, and 65 patients （84.4%） returned to normal life. Obesity developed in 12 patients. There were 2 recurrent cases and no deaths during follow-up. Conclusions Binastril, bimanual, extended endonasal approach serves as the foundation of endoscopic craniopharyngioma resection. Under endoscopy, anatomical relationship of the tumor to the stalk, hypothalamus, perforating vessels could be confirmed precisely. The same principles in tumor resection are followed as in microscopic surgery, which is the basis of high-quality excision of craniopharyngiomas purely under endoscope. Good reconstruction of skull base is an important technique to prevent postoperative CSF leakage.