神经内镜扩大经鼻入路治疗鞍上型颅咽管瘤

Endoscopic endonasal surgery for suprasellar craniopharyngiomas

目的探讨多种技术辅助下神经内镜扩大经鼻入路治疗鞍上型颅咽管瘤的临床疗效。方法回顾性分析2012年9月至2016年12月复旦大学附属华山医院神经外科收治91例鞍上型颅咽管瘤患者的临床资料。所有患者均采用神经内镜扩大经鼻一鞍结节入路切除肿瘤。术后定期行门诊随访，随访内容包括鞍区增强MRI扫描和内分泌检查。结果91例患者中，全切除53例（58．2％），大部分切除13例（14．3％），次全切除25例（27．5％）。术后68例（74．7％）患者的垂体柄达到解剖保留。62例视力、视野损害的患者中，35例（56．5％）术后得到不同程度的改善。术后出现脑脊液鼻漏3例，颅内感染3例，严重电解质紊乱3例，下丘脑功能障碍2例，颅内出血2例，鼻出血2例，视力下降1例。病理学检查均为颅咽管瘤。83例患者的随访时间为3-54个月，平均（18．0±9．7）个月。内分泌检查显示新发肾上腺皮质激素轴功能减退34例，甲状腺激素轴功能减退30例，性腺激素轴功能减退15例，垂体后叶功能减退18例。鞍区MRI增强扫描发现肿瘤残留8例并进行放疗，2例复发接受再次手术。结论神经内镜扩大经鼻入路治疗鞍上型颅咽管瘤患者的疗效较好，手术优势在于可以最大限度、安全地显露肿瘤，并最大限度地保留垂体柄。

Objective To explore the endoscopic endonasal approach assisted with various new techniques in the surgical treatment of suprasellar eraniopharyngiomas. Methods Nighty-one patients （55 males, 36 females） with suprasellar craniopharyngiomas were recruited from September 2012 to December 2016, retrospectively. Endoscopic endonasal trans-tuberculum approach was applied in all patients at Neurosurgery Department of Huashan Hospital, Fudan University. After operation, all patients were asked to take regular follow-up including endocrine exams and sellar contrast MRI. Results Among the 91 cases, 53, 25 and 13 cases achieved gross-total, subtotal and ＇partial resections, respectively. Other complications included intracranial infection （3 cases） and electrolyte disturbance （3 cases）. Sixty-eight （74.7%, 68/91 ） patients obtained anatomic preservation of pituitary stalk postoperatively. Among 62 patients with original visual impairment, 35 cases （56. 5%, 35/62） were improved to different extent. Postoperative complications included cerebrospinal rhinorrhea （3 cases）, intraeranial infection （3 cases）, serious electrolyte disturbance （ 3 cases）, hypothalamic dysfunctions （2 cases）, intracranial hemorrhage （2 cases）, epistaxis （2 cases） and loss of vision （ 1 case）. All the cases were confirmed craniopharyngiomas pathologically. The follow-up period ranged from 3 months to 54 months （mean： 18.0 ＋ 9.7 months）. Endocrine exams indicated new-onset hypoadrenalism in 34 cases, hypothyroidism in 30 cases, hypogonadotropic hypogonadism in 15 cases and posterior hypopituitarism in 18 cases. Eight cases with residual tumors underwent radiotherapy and 2 recurrent cases received the second operation during contrast MRI follow-up. Conclusions Endoscopic endonasal surgery demonstrates good results in suprasellar craniopharyngiomas, which is advantageous in facilitation of maximal and safe tumor exposure and protection of the pituitary stalk.