原位骨瓣在经鼻内镜颅咽管瘤手术颅底重建中的应用

Clinical application of in situ bone flap in skull base reconstruction in endoscopic endonasal surgery for craniopharyngioma

目的通过比较内镜扩大经鼻入路颅咽管瘤手术的不同颅底重建方法,探讨原位骨瓣颅底重建的可行性和优势。方法回顾性纳入2016年7月至2017年12月于空军军医大学西京医院神经外科行内镜扩大经鼻入路颅咽管瘤手术的26例患者,均采用颅底原位骨瓣修补(完全骨性重建),设为试验组;纳入2015年3月至2016年6月采用裁剪后的鼻中隔骨片或人工骨基质修补(部分骨性重建)的31例患者作为对照组。比较两组颅内感染的发生率,腰大池置管的比率、手术至下床活动的时间以及住院时长。结果试验组无一例发生颅内感染,对照组发生颅内感染2例,两组颅内感染发生比例的差异无统计学意义(P=0.291)。试验组(3.8%,1/26)与对照组(29.0%,9/31)行腰大池置管引流比率的差异有统计学意义(P=0.013)。与对照组比较,试验组手术至下床活动的时间缩短[(7.5±1.1)d对比(12.1±2.4)d,P<0.001];试验组的住院时长少于对照组[(8.2±0.9)d对比(13.5±1.8)d,P<0.001]。所有病例随访3~32个月,未见迟发性脑脊液漏和脑组织疝出的发生。结论对于内镜扩大经鼻入路颅咽管瘤手术,采用人工生物膜、原位骨瓣以及带蒂鼻中隔黏膜瓣多层修补可有效减少脑脊液漏的发生,缩短患者的住院时间;颅底原位骨瓣是一种有效的重建方式,其临床应用前景好,可尝试临床推广。

Objectives To compare different methods of the skull base reconstruction in craniopharyngioma surgery via extended endoscopic endonasal approach (EEEA) and to investigate the advantage and feasibility of in situ bone flap in skull base reconstruction. Methods Twenty-six cases with craniopharyngiomas who underwent complete osseous skull base reconstruction using in situ bone flap in skull base reconstruction and repair in EEEA were enrolled retrospectively into the experimental group at Department of Neurosurgery, Xijing Hospital, Air Force Medical University from July 2016 to December 2017. Thirty-one cases with craniopharyngiomas who underwent partial osseous skull base reconstruction using fashioned piece of nasoseptal bone or artificial bone matrix from March 2015 to June 2016 were enrolled into the control group. The rates of intracranial infection and lumbar cisterna drainage, time from surgery to out-of-bed activity and hospitalization length were compared between the 2 groups. Results Intracranial infection occurred in 2 cases in the control group, whereas no intracranial infection was reported in experimental group. There was no statistically significant difference between the 2 groups (P=0.291). Lumbar cisterna drainage rate in the control group (29.0%, 9/31)was significantly higher than that in the experimental group (3.8%, 1/26, P=0.013). Compared with those in control group, patients in the experimental group were able to get off bed earlier (7.5±1.1 d vs. 12.1±2.4 d, P<0.001). The hospitalization length in the control group was also longer than that in the experimental group (13.5±1.8 d vs. 8.2±0.9 d, P<0.001). There was no delayed cerebrospinal fluid leak or brain hernia during the follow-up period lasting for 3-32 months. Conclusions The multilayer repair using duramax, in situ bone flap and vascularized pedicled nasoseptal flap could significantly reduce the incidence of cerebrospinal fluid rhinorrhea and shorten hospitalization length. Skull base reconstruction using in situ bone flap seems to be an effective procedure for EEEA. The clinical efficacy of using the method in EEEA for craniopharyngioma is valid with bright prospects and deserves clinical promotion.