内镜经蝶入路治疗老年巨大垂体腺瘤的临床应用

目的 探讨应用扩大经蝶手术入路在内镜下治疗老年巨大垂体腺瘤的可行性.方法 采用扩大经蝶入路治疗10例老年巨大垂体腺瘤病人.结果 扩大经蝶入路术中所有肿瘤镜下全切,术后所有病人视力障碍均有好转,术前头痛者术后症状均减轻或消失：术后发生短暂性尿崩症5例,短暂性脑脊液鼻漏2例,均经保守治疗而痊愈.结论 内镜扩大经蝶手术入路可以充分显露以垂体窝为中心的解剖结构,可用于老年巨大垂腺瘤的手术治疗.     

显微手术治疗大及巨大垂体腺瘤的入路选择

56例大及巨大垂体腺瘤，分别采用经蝶入路或经颅入路在显微镜下切除肿瘤。手术均顺利，其中肿瘤全切除44例，次全切除9例，部分切除2例。认为采用显微外科技术，针对肿瘤的特点选择不同的手术入路是提高垂体腺瘤全切率的关键。     

老年垂体腺瘤的经蝶显微手术治疗

目的：对22例老年人垂体腺瘤的经蝶显微手术治疗,探讨老年性垂体腺瘤的临床特点及治疗原则,方法：本组老年人垂体腺瘤均经血清激素检查,CT或MRI扫描确诊,采用经蝶显微手术治疗,术后治疗特别注意水和电解质的平衡,结果：无分泌功能腺瘤17例,肿瘤全切12例,次全切7例,大部分切除3例,无手术死亡,无并发症死亡。在平均3．1年随访中,20例恢复良好,2例症状复发,结论：老年性垂体腺瘤绝大部分为无功能性,经蝶入路显微手术切除是一种安全,有效的方法,但要注意手术适应症的选择和术后体液,电解质平衡。     

经鼻蝶窦入路显微手术治疗垂体腺瘤

目的 探讨经鼻蝶窦入路切除垂体腺瘤的显微手术治疗及术后处理.方法 回顾性分析经单鼻孔蝶窦入路显微手术切除的38例垂体微腺瘤患者的临床资料.38例垂体腺瘤中泌乳素( PRL)腺瘤18例,生长激素(GH)腺瘤12 例,促肾上腺皮质激素(ACTH)腺瘤5例, 无分泌功能腺瘤3例.结果 肿瘤全切33例, 次全切5例;术后复查激素水平,降至正常26例, 下降大于50%的4例, 8例变化不明显.结论 单鼻孔经蝶入路显微手术切除垂体腺瘤是一种安全、有效的方法.     

垂体腺瘤:经蝶入路显微手术基础与改良

自从Schloffer于1907年首先采用经蝶手术治疗垂体腺瘤以后[1],该手术入路不断改良发展,尤其近十余年以来随着显微器械的改进以及高清神经内镜和手术显微镜的不断推陈出新,传统的"经唇下-鼻中隔-蝶窦入路"切除垂体腺瘤的手术方法逐步被"经单鼻孔-蝶窦入路"所取代.同时随着显微技术的进步,经鼻蝶入路在鞍区病变手术中应用越来越广泛,具有疗效满意、损伤小、手术时间短、肿瘤全切率高、并发症少、术后康复时间短、手术死亡率极低、垂体功能保存率高等优点[2],"经鼻蝶显微手术为功能保护性手术"已成为广大神经外科医师的共识.     

经鼻蝶窦入路垂体腺瘤切除术46例疗效观察

目的观察经鼻蝶窦入路手术治疗垂体腺瘤的效果。方法 46例垂体腺瘤患者均采用单鼻孔经鼻蝶窦入路显微镜下肿瘤切除术。结果肿瘤全切39例,次全切或大部分切除6例,未能切除1例。术后发生脑脊液漏3例,尿崩症19例,视力下降2例。结论经鼻蝶入路垂体腺瘤切除术是治疗垂体腺瘤安全有效的术式。术前准确评估病情、熟悉解剖和精湛的手术操作是手术成功的保证。     

脑肿瘤

经蝶入路切除垂体腺瘤的显微手术,因入路简便,能选择性切除肿瘤,保留甚至恢复正常垂体功能,死亡率和病残率低。作者报道,经口、鼻中隔、蝶窦入路切除垂体腺瘤25例,男7例,女18例。年龄21～55岁,平均33.9岁。肿瘤临床分型;闭经溢乳综合征14例;肢端肥大症5例;柯兴氏及Nelson′s综合征各1例;非分泌性腺瘤4例。肿瘤直径<1cm者10例;1～2cm者8例;>2cm7例。术前作血清催乳素检查,蝶鞍点片,颈动脉造影,气脑造影,薄层断层蝶鞍摄片和海绵间窦造影等。肿瘤全切除17例,次全切除6例,大部切除2     

老年人垂体腺瘤的手术治疗

目的：探讨显微外科治疗老年人垂体腺瘤的临床综合疗效，以选择对该类型肿瘤的最佳手术方法。方法：回顾性分析显微手术治疗的老年人垂体腺瘤190例，将其分为经蝶手术组和经颅手术组，对肿瘤的手术切除率、术后并发症、术后随访进行对比分析。结果：经蝶组158例，肿瘤全切除112例(71．0％)，次全切除30例，部分切除16例；经颅组32例，全切除8例(25．0％)，次全切除16例，部分切除8例。经蝶组住院时间短，治疗费用较少，手术后生活质量较高。结论：经蝶显微手术可作为大多数老年垂体腺瘤患者的首选手术方法。     

小骨瓣纵裂入路显微外科手术切除巨大侵袭性垂体瘤14例报道

目的探索巨大侵袭性垂体腺瘤根治性切除的手术入路、方法及效果.方法选择14例巨大侵袭性垂体腺瘤采用小骨瓣经纵裂显微外科手术,肿瘤最大径4.2 cm～5.7 cm.结果肿瘤全切11例,大部切除3例.全部病例术后无脑脊液漏,无严重并发症,无死亡.结论小骨瓣纵裂入路显微外科手术切除巨大侵袭性垂体腺瘤是对脑组织损伤小、并发症少、全切率高的手术方法.     

神经内镜与显微镜下老年患者经蝶垂体腺瘤切除术的比较

目的分析比较神经内镜与显微镜对老年患者经蝶垂体腺瘤手术效果和并发症。方法回顾性分析神经内镜下125例和显微镜下151例经蝶垂体腺瘤切除老年病例的手术效果及手术并发症。结果神经内镜组肿瘤全切除率79.2%,手术并发症发生率12%;显微镜组肿瘤全切除率70.2%,并发症发生率41.1%。结论神经内镜下经蝶垂体腺瘤切除术的肿瘤全切除率较高,手术并发症发生率较低,对老年患者是一种安全、有效、微创的手术方式。     

Transcranial surgery for pituitary adenomas

Following a century of evolution and refinements in standard surgical techniques, the vast majority of operations for pituitary adenoma to date are performed utilizing transsphenoidal approaches. From current large series one obtains the impression that certainly less than 10% of these tumors require craniotomies. However, still several tumors, which’s volume is mainly localized outside of the sella require transcranial approaches, of which the pterional and subfrontal routes are the most widely used. The goal of surgical treatment is rapid eradication of the tumor mass, decompression of visual pathways and elimination of hormonal oversecretion whilst preserving the normal gland and avoiding potential surgical complications. Even with microsurgical techniques and standardized approaches, there is still some mortality associated with transcranial approaches and morbidity is undoubtly higher than with transsphenoidal operations. However, a selection bias must be considered, which shifts tumors with a larger size, less favourable prognosis and higher complication rate into the transcranial series. Moreover, with extended transsphenoidal approaches, lesions have become accessible for transsphenoidal surgery, which previously have been considered as contraindications. In this article current indications and limitations for transcranial surgery of pituitary adenomas, the preoperative workup, surgical techniques, results, and complications are briefly reviewed.     

Endoscopic endonasal transsphenoidal surgery: surgical results of 228 pituitary adenomas treated in a pituitary center

Pituitary tumors are challenging tumors in the sellar region. Surgical approaches to the pituitary have undergone numerous refinements over the last 100 years. The introduction of the endoscope have revolutionized pituitary surgery. The aim of this study is to report the results of a consecutive series of patients undergoing pituitary surgery using a pure endoscopic endonasal approach and to evaluate the efficacy and safety of this procedure. We reviewed the data of 228 consecutive patients who underwent endonasal transsphenoidal adenoma removal over an 10-year period. Pre- and post-operative hormonal status (at least 3 months after surgery) were analyzed and compared with clinical parameters presented by the patients. Tumor removal rate, endocrinological outcomes, and complications were retrospectively assessed in 228 patients with pituitary adenomas who underwent 251 procedures between December 1998 and December 2007. There were 93 nonfunctioning adenomas, 58 growth hormone-secreting, 41 prolactin-secreting, 28 adrenocorticotropin hormone secreting, 7 FSH-LH secreting and 1 thyroid-stimulating hormone-secreting adenomas. Gross total removal was achieved in 79.3% of the cases after a median follow-up of 61.5 months. The remission results for patients with nonfunctioning adenomas was 83% and for functioning adenomas were 76.3% (70.6% for GH hormone-secreting, 85.3% for prolactin hormone-secreting, 71.4% for ACTH hormone-secreting, 85.7% for FSH-LH hormone-secreting and 100% for TSH hormone-secreting), with no recurrence at the time of the last follow-up. Post-operative complications were present in 35 (13.9%) cases. The most frequent complications were temporary and permanent diabetes insipidus (six and two cases, respectively), syndrome of inappropriate antidiuretic hormone secretion (two cases) and CSF leaks (eight cases). There was no death related to the procedure in this series. The endoscopic endonasal approach for resection of pituitary adenomas, provides acceptable results representing a safe alternative procedure to the microscopic approach. This less invasive method, associated with a small number of complications, provides excellent tumor removal rates and represents an important tool for the achievement of good results in the pituitary surgery, mainly for the complete removal of large adenomas.     

Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of giant pituitary adenomas

Giant (>4 cm) pituitary macroadenomas often require surgery to decompress the optic nerves. Compared with traditional open or transsphenoidal microscopic methods, the extended endoscopic endonasal transsphenoidal approach offers the potential for aggressive resection via a minimal access corridor. We conducted a systematic review of the literature to further our understanding of the role of endoscopy in the management of these challenging lesions. MEDLINE search of the modern literature (1995-2010) to identify surgical series for pediatric and adult pituitary adenomas >4 cm in maximal diameter. Patient and tumor characteristics, resection, morbidity and visual outcome were compared by approach. Chi-square and Fisher's exact tests with post-hoc Bonferroni analysis were used for statistical analyses. Sixteen studies (478 patients) were included. Compared with the open cohort, the endoscopic cohort had higher rates of gross total resection (47.2% vs. 9.6%; P < 0.003) and improved visual outcome (91.1% vs. 45.7%; P < 0.003). The microscopic transsphenoidal cohort had lower rate of total resection and worse visual outcomes than the endoscopic group. There were no instances of postoperative CSF leak reported in the endoscopic group. The transcranial group had a higher rate perioperative mortality compared to the transsphenoidal group (P = 0.004). In select cases, the endoscopic endonasal approach is safe and effective for the treatment of giant pituitary adenomas, with the potential for gross total resection and improved visual outcome. CSF leak, which is a major limitation of the endonasal approach, may be avoided using meticulous multi-layer closure and vascularised nasoseptal flaps.     

经蝶入路显微外科治疗老年人垂体腺瘤

目的探讨老年人垂体腺瘤（ＳＰＡ）的手术疗效。方法总结经ＣＴ扫描或ＭＲＩ确诊的５６例ＳＰＡ经蝶显微外科治疗的临床资料，３５例经唇下－鼻中隔－蝶窦入路、２１例经鼻前庭－鼻中隔－蝶窦入路行肿瘤切除术。结果本组微腺瘤７例，大腺瘤３０例，巨大腺瘤１９例，术后无死亡。４８例获长期随访（平均３．５年），４１例恢复良好；７例术后平均３．４年肿瘤复发，其中２例再次手术，５例采用药物、放疗或放射外科治疗，于３个月时复查见患者恢复较为满意。结论采取经蝶显微外科治疗ＳＰＡ，是一种安全、有较的方法     

老年人垂体腺瘤49例术后临床分析

目的 探讨老年人垂体腺瘤的临床特点和治疗效果。方法 回顾分析49例手术及病理证实的老年人垂体腺瘤资料。结果 49例患者平均病程4．4年。视力视野障碍46例（93．8％）,头痛20例（40．8％）,内分泌障碍16例（32．7％）。肿瘤大于3cm25例（51．0％）,大部及部分切除11例（22．4％）,以经碾人路效果为好。术后常规放疗28例,肿瘤控制率93．0％,其中50％发生垂体功能低下。随访7－127个月（平均50．5个月）,视力改善27例（58．7％）,生活理43例（87＝8％）;40例术后3个月－5年复查CT或MRI提示肿瘤消失30例（61．2％）,残瘤静止5例（10．2％）,复发5例（10．2％）。结论 老年人垂体腺瘤以大腺瘤和无功能腺瘤为多;临床以视力视野改变为主;经碟人路显微手术是首选治疗方法;术后辅以放疗可控制或延缓肿瘤复发,但需注意视力损害及垂体功能低下的严重并发症。     

Surgical treatment of aggressive pituitary adenomas and pituitary carcinomas

Surgery of aggressive pituitary adenomas and pituitary carcinomas is part of the interdisciplinary management of these difficult to treat tumors. Invasion, giant size and unusual, asymmetric extent of these tumors frequently require modifications or extensions of the standard approaches for transsphenoidal and transcranial surgery. Frequently, only debulking procedures can be performed. In aggressive and hormone secreting adenomas, the remission rates achieved by surgery alone are relatively poor and adjuvant medical treatments or irradiation are needed. Safe resection of as much tumor as possible and symptomatic control is aimed at, rather than remission. Many procedures are required for rapid progression of lesions or recurrences, in order to extend the survival of the patients. Metastases of pituitary carcinomas within the cranial cavity or spine can be attacked. Since they can occur anywhere in the brain or spinal canal they require the entire battery of neurosurgical approaches. Unfortunately, in this group of pituitary tumors, the complication rates are higher than in primary operations of enclosed adenomas. The respective techniques with their facilities and limitations are reviewed in this article.

     

Treatment of pituitary adenomas]

There has been a dramatic development in the treatment of pituitary adenomas during the last two decades. The main factors which led to this development were the introduction of transsphenoidal surgery, the development of new imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) and the introduction of newer dopaminergic agents. Present status of the treatment of pituitary adenoma is reported here. This report is based on the experiences of 381 cases of pituitary adenomas treated at the Department of Neurosurgery, Hiroshima University School of Medicine within the last 16 years. There are some problems which have to be solved in order to achieve further development in the treatment of pituitary adenomas. Our experience in this field and a need for future development are listed below. 1) The transsphenoidal adenomectomy gives high cure rates in cases of micro and expansive prolactinomas and growth hormone secreting adenomas. 2) Results of the transsphenoidal surgery in cases of ACTH secreting adenomas is not satisfactory. In order to get higher cure rate, a more elaborate operative techniques and an introduction of more effective drug therapy are needed. 3) Further safety and curability in pituitary surgery will be achieved by the exploitation of new imaging modalities such as MRI.     

Pituitary tumors secreting growth hormone and prolactin

The pathophysiology of functional adenomas of the anterior pituitary gland can be understood in the context of the central neural control of anterior pituitary secretion and by the fact that the cell types of the anterior pituitary gland generally express a single polypeptide hormone. Functional pituitary adenomas arise de novo from one or more of these cell types, but a defect in hypothalamic regulation can contribute to tumorigenesis and sometimes result in persistent tumor recurrence despite local surgical cure. The recent advances in molecular biology, radioimmunoassay, neuroradiology, and transsphenoidal microneurosurgery techniques have greatly improved our understanding of the pathophysiology of these tumors, enhanced diagnostic accuracy, and led to newer medical and surgical therapeutic approaches. This conference reviews the molecular and cellular pathophysiology, causes, diagnosis, clinical features, and medical and surgical management of the two common functional pituitary adenomas, prolactinoma and somatotropinoma.