经鼻蝶入路手术鞍底开窗方案的制订与评估

Establishment and evaluation of fenestration of sellar floor with transnasal transsphenoidal approach

目的探讨显微镜下经鼻蝶入路垂体腺瘤手术中影响个体化鞍底开窗方案制订的因素,并对其效果进行评估。方法连续性收集2014年3月至2015年3月联勤保障部队第900医院神经外科收治的51例垂体腺瘤患者的临床资料,患者术前行鼻窦CT和垂体MRI扫描,观测肿瘤和蝶鞍的形态特征、左右侧颈内动脉海绵窦段(CSICA)的最小间距;术中观察肿瘤质地并记录颈内动脉损伤情况;术后MRI观察肿瘤有无残留及残瘤的位置,对开窗效果进行评估。结果肿瘤居中24例,偏左11例,偏右16例;鞍上扩展42例,鞍下扩展5例,鞍旁扩展15例,前后颅窝扩展各2例;分叶型12例,哑铃型2例,椭圆型37例,有囊变者15例;鞍底形态呈隆起型29例,平坦型5例,弧型12例,鞍底破坏无法判断5例。本研究51例患者中,46例鞍底形态完整,其鞍长为8.4~27.2 mm,平均(18.0±4.4)mm,鞍面为9.8~30.4 mm,平均(19.6±4.7)mm,鞍窗为6.3~29.4 mm,平均(16.4±4.9)mm,鞍角为31.6°~166.8°,平均(83.3±32.0)°;5例鞍底形态不完整,其鞍长为9.4~29.3 mm,平均(19.3±5.4)mm,而其鞍面、鞍窗及鞍角无法测量。骨性蝶鞍上口呈炒锅型18例,筛型5例,囊袋型15例,直桶型13例;双侧CSICA最小间距为11.9~28.4 mm,平均(20.5±4.2)mm,左侧CSICA距中线的最短距离为5.9~15.6 mm,平均(10.6±2.3)mm,右侧CSICA距中线的最短距离为5.3~15.1 mm,平均(10.0±2.4)mm;肿瘤质地软者43例,肿瘤质地硬者18例,无颈内动脉损伤;肿瘤全切35例,残留16例。鞍底开窗的大小和边界适宜49例,仅有2例鞍底开窗过小,降低了肿瘤的切除程度。结论术前全面评估肿瘤和蝶鞍的形态特征及重要毗邻结构的情况,对经鼻蝶手术鞍底开窗方案的制订有重要指导意义,尤其要关注CSICA的解剖因素。

Objective To investigate the factors influencing the formulation of individualized fenestration of sellar floor with transsphenoidal pituitary adenoma surgery under the microscope and the effect is evaluated.Methods The clinical data of 51 patients with pituitary adenoma in Neurosurgery Department of 900 Hospital of the Joint Logistics Team from March 2014 to March 2015 were continuously collected,and preoperative sinus CT and pituitary MRI scans were performed to observe the morphological characteristics of the tumor and sella turcica and the minimum distance between the left and right cavernous segment internal carotid artery(CSICA).The texture of the tumor was observed and the injury of internal carotid artery was recorded.Postoperative MRI was used to observe the residual tumor and residual tumor location,and the effect of fenestration was evaluated.Results There were 24 cases in the middle,11 cases to the left,16 cases to the right;42 cases of suprasellar extension,5 cases of infrasellar extension,15 cases of parasellar extension,1 case of anterior fossa extension and 1 case of posterior fossa extension;12 cases of lobulated type,2 cases of dumbbell type,37 cases of ellipsoid type,15 cases of cystic change;29 cases with protuberant type of sellar floor,5 cases with flat type,12 cases with arc type,and 5 cases with destruction of sellar floor.Among 51 patients,there were 46 cases with intact sellar floor,of whom the sellar length was 8.4 to 27.2 mm,with an average of(18.0±4.4)mm,the saddle surface was 9.8 to 30.4 mm,with an average of(19.6±4.7)mm,the sellar window was 6.3 to 29.4 mm,with an average of(16.4±4.9)mm,and the sellar angle was 31.6°to 166.8°,with an average of(83.3±32.0)°.The shape of sellar floor was incomplete in 5 cases,of whom the sellar length was 9.4 to 29.3 mm,with an average of(19.3±5.4)mm,but the saddle surface,sellar window and sellar angle could not be measured.The bony sellar upper orifice of 18 cases were frying pan type,5 cases were sieve type,15 cases were bag type and 13 cases were straight barrel type.The minimum distance between bilateral CSICA was 11.9 to 28.4 mm,with an average of(20.5±4.2)mm,and the shortest distance between left CSICA and midline was 5.9 to 15.6 mm,with an average of(10.6±2.3)mm,the shortest distance between the right CSICA and the midline was 5.3 to 15.1 mm,with an average of(10.0±2.4)mm.The tumors were soft in 43 cases,hard in 18 cases,and no internal carotid artery injury was found.Total tumor resection was performed in 35 cases and residual in 16 cases.The size and boundary of sellar floor fenestration were appropriate in 49 cases,only 2 cases with the small size,which reduced the degree of tumor resection.Conclusion The preoperative comprehensive evaluation of the morphology and important adjacent structures of the sellar bottom is of important guiding significance for the decision of transnasal transsphenoidal surgery,particular attention should be paid to the anatomical factors of CSICA.