神经内镜下经鼻-蝶窦垂体瘤切除入路改进及效果分析

Improvement and effect analysis of a new neuroendoscopic trans-nasal-sphenoidal pituitary tumor resection approach

目的改进特定影像学特点垂体瘤的个性化神经内镜下手术入路，分析手术效果。方法收集自2014年4月至2017年12月在上海交通大学医学院附属瑞金医院垂体瘤诊治中心手术治疗的垂体瘤患者116例，比较经典单鼻孔、双鼻孔、“一侧半”三种不同经鼻-蝶窦入路的垂体瘤手术切除效果和并发症。结果“一侧半”经鼻-蝶窦入路垂体瘤切除术对难以单鼻孔经典入路切除的垂体肿瘤达到了与双侧入路一致的手术效果，而在平均住院时间（前者6．9d，后者12．5d，P〈0．01）、嗅觉保留（平均VAS评分：前者8．6分，后者7．0分，P〈0．01）、防止术后鼻中隔穿孔（发生率前者0，后者27％）等方面具有显著优势。结论“一侧半”入路对超出进镜同侧颈内动脉内侧缘的病灶增加了掌控能力和全切除的可能性，是对双侧入路的良好补充和改进。

Objective To modify the individual neuroendoscopic surgical approach of pituitary tumors with specific imaging features, and to analyze the clinical outcomes. Methods The clinical data of 116 patients with pituitary tumors who underwent surgical treatment at the pituitary tumor diagnosis and treatment center of Ruijin Hospital from April 2014 to December 2017 were collected, then the resection effects and complication rates of pituitary tumors from three different kinds of transsphenoidal approaches （e. g. classical single nostril approach, bilateral approach, ＂one-and-a-half＂ approach ） were compared. Results Pituitary tumor resection with ＂one-and-a-half＂ trans-nasal-sphenoidal approach achieved the same surgical effects with the bilateral approach, which was difficult to resect with the single-nostril classical approach. And it had significant advantages in the average length of postoperative hospitalization （ ＂one-and- a-half＂ ：6. 9 days, bilateral： 12. 5 days, P 〈 0. 01 ）, the average postoperation VAS of olfactory retention （＂one-and-a-half＂ ：8.6, bilateral：7.0, P 〈0. 01 ） and preventing posterior nasal septum perforation （the occurrence rate of ＂one-and-a-half＂ ：0% , bilateral：27% ）. Conclusion The ＂one and a half＂ approach increases the ability to control and completely resect the lesion beyond the medial edge of the internal carotid artery on the same side of the nostril involving endoscope. It is a good supplement and improvement to the bilateral approach.