翼点入路显微手术切除鞍区肿瘤

目的:通过翼点入路显微手术治疗蝶鞍区肿瘤。方法:全麻下按Yasrzl’s翼点入路咬除蝶骨嵴外侧,显微镜下显露前床突、嗅神经、视神经、视交叉、颈内动脉等,根据肿瘤情况进行切除。结果:11例病人,全切9例,近全切2例。病理示:垂体腺瘤8例,鞍结节脑膜瘤2例,颅咽管瘤1例。无1例复发。结论:翼点入路具有暴露清楚、术野清晰、鞍区4个解剖间隙可充分显露的优点,对鞍区重要结构暴露好,可直视下保护减少手术并发症,增加手术全切率。     

鞍区大型肿瘤显微手术入路的探讨

目的 探讨鞍区大型及巨大型肿瘤经显微手术治疗的临床效果。方法 主要就额下、翼点及经蝶入路，囊内先分块切除肿瘤，待肿瘤塌陷后分离包膜，电灼使之缩小，再分块切除。结果 临床病例31例，其中全切除肿瘤20例，经额下入路7例，经翼点入路9例，经蝶入路3例，经额下-翼点入路1例；次全切除肿瘤11例。结论 经翼点入路开颅时间短，手术创伤小，并发症少，是提高鞍区大型、巨大型肿瘤的全切除率，减少复发的更为理想手术入路。     

眶上经眉弓锁孔入路显微手术治疗鞍区肿瘤

目的探讨经眉弓锁孔入路显微手术切除鞍区肿瘤的技术. 方法 2001年7月～2004年6月我院采用经眉弓2.0 cm×3.0 cm游离小骨窗锁孔入路,开放鞍区脑池,显露深部结构,切除鞍区肿瘤33例. 结果 26例垂体瘤全切除19例,次全切除7例;4例颅咽管瘤全切除3例,1例次全切除;2例脑膜瘤全切除;1例视交叉胶质瘤大部分切除.术后5例出现一过性尿崩症,1例发生癫痫大发作,无出血、感染等术后并发症.33例随访4～36个月,平均27个月,全切24例肿瘤无复发,7例垂体瘤、1例颅咽管瘤、1例视交叉胶质瘤术后放疗肿瘤未见增大. 结论经眉弓锁孔入路对脑组织无效暴露少,创伤小,术后并发症少,提高了手术安全性.     

经眶上翼点入路显微手术切除巨大鞍区肿瘤

目的 总结经眶上翼点入路显微手术切巨大鞍区肿瘤的经验。方法 经上翼点入路显微手术切除巨大鞍区肿瘤18例,其中垂体腺瘤7例,颅咽管瘤8例,生殖细胞瘤、脑膜瘤、成熟性畸胎瘤各1例。结果 肿瘤全切除12例,次全切除6例。术后随访4－23个月,恢复良好12例,生活自理3例,生活需人照顾2例,死亡1例。结论 眶上翼点入路能很好地显露鞍区 肿瘤及其周围结构,显微手术是安全切除肿瘤、保护下丘脑功能的关键。     

选择性硬膜外前床突切除入路显微手术治疗鞍区肿瘤

目的 报道应用选择性硬膜外前床突（ACP）切除入路显微手术治疗鞍区肿瘤的临床疗效和体会。方法对标准翼点入路不能满意暴露的鞍区肿瘤，采用选择性硬膜外ACP切除入路进行显微手术：手术显微镜下由硬膜外选择性地切除ACP，得到楔形的床突间隙（CS），使得第Ⅲ间隙扩大；游离颈内动脉（ICA），增加视神经-颈内动脉三角（OCT）的宽度，使得第Ⅱ间隙扩大；再通过扩大了的第Ⅱ、Ⅲ间隙进行显微手术切除肿瘤。结果全部病例均成功切除前床突，无颈内动脉、视神经和动眼神经损伤。前床突切除后，病变的暴露显著改善，40例中在手术显微镜下全切28例（70．0％），其余12例（30．0％）大部分切除，术后均行立体定向放射外科治疗。手术并发症主要表现为术后一过性的下丘脑损伤症状，如尿崩、高血糖、电解质紊乱、消化道出血。1例垂体瘤患者虽镜下全切肿瘤，但因严重的下丘脑损伤症状自动出院，其余患者经积极治疗1周内均缓解，恢复良好。随访1．5个月至7年，39例肿瘤复发5例，其中镜下全切者复发1例，占全切的3．7％（1／27）；大部分切除者复发4例，占大部分切除的33．3％（4／12）。随访期间无患者死亡。结论应用显微外科技术由硬膜外选择性地切除ACP，安全有效，可改善鞍区肿瘤的暴露，扩大手术操作空间，减少手术区域内重要结构的损伤，提高鞍区肿瘤的手术全切率，是一个值得推广的显微神经外科手术入路。     

鞍结节脑膜瘤的手术入路选择及显微手术切除

目的 报道鞍结节脑膜瘤手术治疗的入路选择及显微手术的临床效果。方法回顾分析鞍结节脑膜瘤29例的临床资料，29例鞍结节脑膜瘤分别经额下、翼点或额下翼点联合入路，采用显微手术方法切除肿瘤。结果29例均采用显微手术治疗，全切除27例，大部分切除2例，无死亡。28例术后视力得到满意的恢复。结论选择正确的手术入路和采用显微手术治疗鞍结节脑膜瘤，可明显提高临床疗效。     

眉弓锁孔入路切除鞍区肿瘤25例

目的探讨鞍区及鞍周肿瘤经眉弓锁孔入路显微手术方法及临床疗效。方法回顾性分析25例经眉弓锁孔显微手术切除的鞍区及鞍周肿瘤的f临床资料和手术方法，其中颅咽管瘤7例，垂体巨大腺瘤11例，鞍结节脑膜瘤4例．微膈脑膜瘤1例，蝶骨嵴脑膜瘤1例，鞍区及Ⅲ室巨大胶质瘤1例。部分病例术中采用神经内镜辅助观察。结果术后复查MRI显示，颅咽管瘤5例全切除，2例次全切除；垂体巨大腺瘤全切除10例，次全切除1例；脑膜瘤全切除5例。次全切除1例；巨大胶质瘤1例镜下全切除。无手术死亡、颅内出血、感染等并发症，术后尿崩6例，3日至1月后恢复正常，视力下降2例，并发脑血管痉挛而行去骨瓣减压术1例。近期随访疗效良好。结论眉弓锁孔入路适用于鞍区及鞍周肿瘤的手术切除，具有手术路径短、创伤性小、切除率满意、疗效佳等特点。内镜术中辅助观察可提高肿瘤全切率，减少神经血管结构的损伤。     

神经导航在经蝶显微切除侵袭性鞍区肿瘤手术中的应用

目的 评价神经导航技术在经蝶显微切除侵袭性鞍区肿瘤手术中的应用价值。方法 在18例经蝶手术中，应用Stealstation神经导航系统指导手术，明确手术方向、肿瘤边界、肿瘤切除程度。术后均通过MRI验证肿瘤切除率。结果 18例肿瘤中，全切除或次全切除14例，大部分切除4例，均无严重术后并发症。结论 应用神经导航技术能扩大经蝶显微手术适应证，提高侵袭性鞍区肿瘤的切除率，减少手术并发症。     

翼点入路治疗鞍区脑膜瘤

目的 探讨显微手术治疗鞍区脑膜瘤的方法。方法 回顾性分析了23例鞍区脑膜瘤的临床表现、诊断和显微外科治疗结果，采用经翼点入路显微外科治疗。结果 全切17例，大部切除6例。随访1个月～6年，平均19.1个月，22例恢复良好，随访期间3例复发。结论 选择合适的手术入路，应用显微外科技术，是鞍区脑膜瘤全切并取得良好效果的关键。     

经眉弓处锁孔入路切除鞍区肿瘤24例报告

目的探讨经眉弓处锁孔入路手术切除鞍区肿瘤的可行性。方法复合静脉全麻,仰卧位。皮肤切口位于眉毛的外侧半,切口长3.5~4.0 cm,将额肌骨膜瓣牵向上,眼轮匝肌骨膜瓣牵向下,颞肌牵向外侧,颅骨钻孔定位于颞线后方(关键孔),铣刀向内侧铣开,骨瓣大小约2 cm×3 cm,磨除眶缘上方颅骨的内缘以扩大显微手术视野。弧形切开硬脑膜,使基底朝向眶缘,轻轻抬起额叶,释放脑脊液,显露肿瘤并切除。结果肿瘤全切22例,2例颅咽管瘤后部残留部分肿瘤包膜。1例ACTH腺瘤术后肾上腺皮质功能低下,应用激素替代治疗;8例术后出现暂时性尿崩,均于1周内缓解。9例术前尿崩术后尿量明显减少。1例鞍隔脑膜瘤术后术侧视力障碍加重,1周后逐渐好转。18例术后3个月MR I未见肿瘤复发。结论经眉弓处锁孔入路手术切除鞍区肿瘤可行,可明显减少手术创伤,提供鞍区足够的手术空间,有效地切除病变,手术切口美观。     

Transsphenoidal resection of sellar tumors using high-field intraoperative magnetic resonance imaging

There has been increasing experience in the utilization of intraoperative magnetic resonance imaging (iMRI) for intracranial surgery. Despite this trend, only a few U.S centers have examined the use of this technology for transsphenoidal resection of tumors of the sella. We present the largest series in North America examining the role of iMRI for pituitary adenoma resection. We retrospectively reviewed our institutional experience of 59-patients who underwent transsphenoidal procedures for sellar and suprasellar tumors with iMRI guidance. Of these, 52 patients had a histological diagnosis of pituitary adenoma. The technical results of this subgroup were examined. A 1.5-T iMRI was integrated with the BrainLAB (Feldkirchen, Germany) neuronavigation system. The majority (94%) of tumors in our series were macroadenomas. Seventeen percent of tumors were confined to the sella, 49% had suprasellar extensions without involvement of the cavernous sinus, 34% had frank cavernous sinus invasion. All patients underwent at least one iMRI, and 19% required one or more additional sets of intraoperative imaging. In 58% of patients, iMRI led to the surgeon attempting more resection. A gross total resection was obtained in 67% of the patients with planned total resections. There was one case of permanent postoperative diabetes insipidus and no other instances of new hormone replacement. In summary, iMRI was most useful for tumors of the sella with and without suprasellar extension where the information from the iMRI extended the complete resection rate from 40 to 72% and 55 to 88%, respectively. As one would expect, it did not substantially increase the rate of resection of tumors with cavernous sinus invasion. Overall, iMRI was particularly useful in guiding resection safely, aiding in clinical decision making, and allowing identification and preservation of the pituitary stalk and normal pituitary gland. Limitations of the iMRI include a need for additional personnel and training as well as additional operative time, which diminishes over time as personnel learn to optimize workflow efficiency. Additional costs are mitigated in part by using the iMRI as an immediate postoperative scan. Other data emerging from our experience suggest that preservation of normal gland and thus avoidance of hypopituitarism may be improved by iMRI use, but longer follow-up periods are required to test this conclusion. iMRI can detect unsuspected complications sooner than routine postoperative imaging, potentially leading to improved outcomes. However, larger studies are needed.     

显微外科技术在肝移植动脉重建中的应用

目的 探讨显微外科技术在肝移植动脉重建中的应用,以降低并发症的发生率,提高肝移植受者的生存率。方法 本组肝移植11例,其中亲体肝移植4例,原位肝移植7例,增采用显微外科技术行肝动脉吻合。结果 无一例患者发生肝动脉栓塞,10例患者均康复,无严重并发症。1例患者手术后8d死于多器官功能衰竭。结论 应用显微外科技术行肝动脉重建不仅对亲体肝移植,而且对全肝移植均取得良好效果。     

幕下小脑上锁孔入路显微手术切除松果体区肿瘤

目的探讨幕下小脑上锁孔入路显微手术切除松果体区肿瘤的可行性和安全性。方法依据术前神经影像学检查结果,制定个体化手术方案．采用经幕下小脑上锁孔入路,显微手术切除病变7例。骨窗大小约2．0 cm×2．5 cm,上缘达横窦和窦汇下缘。结果7例中,胚生殖细胞瘤2例；松果体细胞瘤2例；松果体母细胞瘤1例；胶质瘤1例；胆脂瘤1例。术后均行MRI检查,肿瘤全切除6例,1例次全切除。并发术后小脑肿胀、脑积水1例,再次行手术减压；1例术后出现一过性缄默及凝视；无死亡、感染及术后出血病例。近期随访效果良好。结论应用幕下小脑上锁孔入路显微手术切除松果体区肿瘤不仅可取得满意的切除率,而且手术创伤小、疗效好。     

寰枢椎肿瘤切除和重建技术的初步报告

目的 总结寰枢椎肿瘤手术显露和彻底切除的方法,评价异形钛网植骨融合内固定在寰枢椎肿瘤切除术后枕颈稳定性重建中的作用和价值.方法 2005年3月至2007年8月手术治疗6例寰枢椎肿瘤患者,男3例,女3例;年龄17～70岁,平均43.7岁;脊索瘤4例,骨巨细胞瘤1例,骨纤维异常增殖症1例.病变累及所有患者的椎体及侧块或后方结构.全部采用前方颌下颈动脉三角入路联合后方枕颈入路,按照"无瘤操作"的原则行病椎全脊椎切除,前路行异形钛网植骨融合内固定,后路行枕颈固定术,同时行Halo-vest架外固定,术后随访6～16个月.结果 C1.2切除1例,C2.3切除2例,C2切除3例.平均手术时间7.2h,平均术中出血量2400 ml.所有患者局部疼痛和神经症状减轻或消失,未出现神经、血管损伤,1例脊索瘤患者术后1年出现局部复发.至末次随访时所有患者头部位置良好,均达到枕颈区稳定,未出现内固定松动、断裂和移位.结论 按"无瘤操作"的原则行包膜外肿瘤切除可以获得较好的疗效;异形钛网植骨融合内固定术结合枕颈固定术,同时辅以Halo-vest架外固定,可以提高手术的安全性,并能在寰枢椎肿瘤切除术后有效地重建上颈椎的稳定性,实现即刻稳定,便于患者早期下床活动,提高患者生活质量,且手术操作简便易行,适合在寰枢椎肿瘤切除术中应用.     

New microsurgical technique for intraparenchymal lesions of the brain: transcylinder approach

Summary Background. Although various minimally invasive approaches, including endoscopic, stereotaxic, and ultrasound-guided surgery, have been introduced to minimize damage to healthy brain tissue, the microsurgical technique has retained a significant role in contemporary neurosurgery. A new microsurgical approach to intraparenchymal brain lesions, namely, the transcylinder approach, was developed to realize both minimal surgical access and sufficient microsurgical technique. Method. A 0.1-mm transparent polyester film was used to create a cylindrical surgical route. The film was rolled into a thin stick and used to penetrate the brain, and a computer-aided navigation system was used from inside the stick to access the lesion accurately. After the stick gained access to the lesion, it was dilated to 2 cm, and this diameter was maintained during surgery. Findings. The transcylinder approach was used in 11 cases, including intraparenchymal tumours and haematomas, and the usual microsurgical procedure was performed without difficulty. The film avoided unnecessary enlargement of the surgical field and minimized injury to the brain. Intra-operative ultrasonography also can be used to identify the lesion through the cylinder because the polyester film does not reflect the ultrasound beam. The surgical route was observed to recover to almost the same size as the initial cortical incision after removal of the cylinder. Conclusions. The transcylinder approach could be advantageous for removing tumours or haematomas in the intraventricular or intraparenchymal regions. By avoiding unnecessary retraction, it significantly reduces the risk of injury to surrounding brain tissue while facilitating precise microsurgical technique. The accuracy of this minimally invasive technique can be enhanced when used in conjunction with frameless stereotaxy and intra-operative ultrasound guidance.     

KISS1蛋白在胃肠道间质瘤中的表达及其预后预测意义

目的 检测胃肠道间质瘤(GIST)组织中KISS1蛋白的表达,分析其与GIST患者预后的关系.方法 连续收集1987年1月至2008年9月北京大学人民医院诊断治疗的GIST病例137例,以及非GIST的间叶源性肿瘤73例,采用免疫组织化学染色方法检测KISS1蛋白的表达情况,分析KISS1蛋白的表达与GIST临床病理指标及预后的关系.结果 KISS1蛋白在本组GIST组织中的表达率为40.9%,高于非GIST间叶源性肿瘤组织(P＜0.05);GIST组织中KISS1蛋白表达率与肿瘤长径、病变范围、细胞丰富程度、有无假包膜、Fletcher危险程度分级及术后转移相关(P＜0.05);KISS1蛋白阴性GIST患者的预后好于KISS1蛋白阳性患者(P＜0.05).结论 KISS1在蛋白水平的表达与GIST临床病理指标相关,与GIST患者术后转移的发生及预后相关,有可能作为新的判断GIST预后的指标.

Abstract：

Objective To evaluate KISS1 expression, and its significance in the prognosis of GIST patients. Methods In this study, 137 GIST cases and 73 non-GIST sarcoma cases were evaluated for clinicopathological characteristics and immunohistochemistry for KISS1 antibodies. Result The expression rate of KISS1 was 40.9% (56/137) in GISTs,which was significantly correlated with tumor size, disease extent, cellularity, presence of pseudocapaule, Fletcher's risk stratification and metastatic status after resection (P＜0.05). Patients with positive KISS1 expression had significantly worse disease free survival and disease specific survival (P ＜ 0.05 ). Conclusions KISS1 expression was associated with some clinicopathological characteristics as well as malignant behaviors in patients with GISTs. KISS1 might be a predictor in prognosis for GIST patients.     

经上颌骨翻转入路切除颅底侵入瘤

目的 探讨上颌骨翻转入路手术切除颅底侵入瘤的指征、手术要点及优缺点。方法 自1998年11月－2001年8月,采用上颌骨翻转入路连续切除鼻咽颅底肿瘤27例,对临床资料进行回顾性总结。结果 27例中鼻咽癌6例,鼻咽纤维血管瘤5例,鼻咽囊腺癌5例,神经鞘瘤2例,嗅神经母细胞瘤2例,脊索瘤2例,颞下翼腭窝低分化癌2例,颞下翼腭窝肉瘤2例,上颌窦癌1例。18例曾经1次或多次手术切除肿瘤后复发。侵犯颅内重要结构的17例。全部患者术中显露满意,肿瘤均得到肉眼全切除,无手术死亡,术后无偏瘫等严重并发症。本组患者术后随访2－33个月,平均随访16个月。其中2例分别术后5、8个月死于肿瘤复发;2例于术后7、12个月局部复发;1例于术后11个月出现肺转移,现带瘤生存;其余患者恢复日常生活。结论 采用上颌骨翻转入路切除原发于颅底、翼腭窝的肿瘤及广泛侵犯颅底的其他鼻咽部肿瘤,具有显露充分,手术切除彻底的优点。