鼻内镜下鼻蝶入路垂体腺瘤显微切除术(附19例报告)

目的探讨鼻内镜下鼻中隔蝶窦入路垂体腺瘤切除术的方法及并发症的防止。方法唇龈沟切口鼻内镜下经鼻中隔蝶窦径路显微切除垂体腺瘤19例,16例微腺瘤施行全切,3例大腺瘤行囊内次全切除并用无水酒精烧灼,全部病人用唇筋膜和鼻中隔骨片重建鞍底。结果肿瘤全切除16例,次全切除3例。7例术前视力损害者6例得到不同程度的恢复,所有病例症状改善,术后除1例视力一过性减退和2例嗅觉一过性减退外,其余病例均无脑脊液漏和脑膜脑膨出等并发症。术后随访3~36个月,16例肿瘤无复发,3例次全切除者肿瘤生长缓慢。结论鼻内镜唇下-鼻中隔-蝶窦入路是切除垂体腺瘤的较理想径路,术中囊内烧灼可有效地防止或减缓术后肿瘤复发,术后唇筋膜和鼻中隔骨片重建鞍底可防止相应并发症。     

鼻内镜下鼻蝶入路垂体腺瘤显微切除术19例

目的：探讨鼻内镜下鼻中隔-蝶窦入路垂体腺瘤显微切除术的方法及并发症的预防。方法：采用唇龈沟切口鼻内镜下经鼻中隔一蝶窦径路显微切除垂体腺瘤19例,肿瘤施行囊内切除并用无水乙醇烧灼．用唇筋膜和鼻中隔骨片重建鞍底,其中肿瘤全切除17例,次全切除2例。结果：7例术前视力损害者中6例得到不同程度的恢复,所有病例症状改善,术后除1例视力一过性减退和2例嗅觉一过性减退外,其余病例均无脑脊液鼻漏和脑膜脑膨出等并发症。术后随访3个月～3年,17例全切除者肿瘤无复发,2例次全切除者肿瘤生长缓慢。结论：采用鼻中隔一蝶窦入路垂体腺瘤显微切除术,术中囊内烧灼可有效地防止或减缓术后肿瘤复发。术后唇筋膜和鼻中隔骨片重建鞍底可防止相应并发症。     

经鼻蝶窦开口的术中观察及其意义

经蝶入路手术广泛应用于垂体微腺瘤、某些大型垂体腺瘤和颅咽管瘤切除。无论经口鼻蝶或经鼻蝶入路 ,鞍底的识别和定位在术中极为重要。作者对术中蝶窦开口及周围结构进行临床观察 ,总结如下 :1987年 11月～ 1997年 12月经蝶入路手术共77例 ,男 39例 ,女 38例。年龄 13～ 69岁 ,平均 34岁。垂体腺瘤 76例 (大型 30例、中型 35例、微腺瘤11例 ) ,颅咽管瘤 1例。术式 :经口唇下 -鼻 -蝶入路 66例 ,经鼻小柱切开 -鼻 -蝶入路 10例 ,经鼻翼切开 -鼻 -蝶入路 1例。蝶窦气化情况依术前常规ＣＴ增强扫描及摄蝶鞍侧位片所见 ,甲介型者例外。开口位置 …     

单鼻孔直接经蝶窦入路切除垂体腺瘤

目的报告单鼻孔直接经蝶窦入路切除垂体腺瘤32例显微手术的运用经验,并与其它经蝶入路进行比较。方法将扩张器插入手术侧鼻孔(通常采用右侧)直抵蝶窦前壁进行扩张,显露蝶窦开口,凿开前壁,进行手术。结果 31例肿瘤近全切除,1例大部切除。1例术后脑脊液鼻漏。结论此入路与其它经蝶切除鞍区病变的术式相比,对鼻部组织损伤小,不必分离鼻中隔和两侧粘膜,省时,简单,并发症少,值得临床推广。     

鼻内镜下垂体腺瘤切除术--附28例报告

目的:探讨鼻内镜下垂体腺瘤手术的治疗经验。方法:鼻内镜下经鼻中隔-蝶窦、鼻内镜辅助经鼻中隔-蝶窦和经鼻腔-蝶窦三种入路手术行垂体腺瘤切除术,共28例。结果:Hardy-Wilson分级Ⅰ级者7例全切除;Ⅱ级者7例,5例全切除,2例次全切除;Ⅲ级者11例,5例全切除,5例次全切除,1例部分切除;Ⅳ级者3例,部分切除。严重并发症蛛网膜下腔出血1例,死亡1例。术后随访2个月～56个月,手术全切除17例中1例复发。结论:鼻内镜下垂体腺瘤手术克服了显微镜下不能观察蝶窦外侧壁重要血管和神经等结构的缺点,经鼻内镜垂体腺瘤切除术具有操作简单、到达蝶鞍比较容易、损伤小的优点,符合微创外科手术原则。     

内窥镜经鼻内蝶窦垂体腺瘤切除术

目的：探讨内窥镜经鼻－蝶窦入路切除垂体腺瘤,尤其是巨大垂体腺瘤的可行性。方法：分析1995年9月－2001年2月经鼻－蝶窦内窥治疗的50例病人的诊断、手术及预后等临床资料。结果：50例患者中微腺瘤3例,局限于鞍内的大腺瘤10例,向鞍上生长未突破蝶窦者7例,向蝶窦内下陷的大腺瘤30例,其中巨大型肿瘤7例,均向上突破鞍膈向下进入蝶窦。病人术后视力视野均好转,内分泌功能异常得到改善,术后短暂性多尿者6例,术后短暂性脑脊液鼻漏者3例,均为肿瘤巨大者,均经保守治疗而治愈。术后均无鼻腔通气障碍、鼻腔粘连、鼻中隔穿孔等鼻腔并发症及血管损伤性等严重并发症。结论:内窥镜经鼻－蝶窦手术是一种微创外科手术,可完全适用于垂体腺瘤的治疗。     

鼻内镜下垂体腺瘤切除术——附28例报告

目的：探讨鼻内镜下垂体腺瘤手术的治疗经验。方法：鼻内镜下经鼻中隔-蝶窦、鼻内镜辅助经鼻中隔-蝶窦和经鼻腔-蝶窦三种入路手术行垂体腺瘤切除术，共28例。结果：Hardy-Wilson分级Ⅰ级者7例全切除；Ⅱ级者7例，5例全切除，2例次全切除；Ⅲ级者11例，5例全切除，5例次全切除，1例部分切除；Ⅳ级者3例，部分切除。严重并发症蛛网膜下腔出血1例，死亡1例。术后随访2个月～56个月，手术全切除17例中1例复发。结论：鼻内镜下垂体腺瘤手术克服了显微镜下不能观察蝶窦外侧壁重要血管和神经等结构的缺点，经鼻内镜垂体腺瘤切除术具有操作简单、到达蝶鞍比较容易、损伤小的优点，符合微创外科手术原则。     

内窥镜经鼻内蝶窦垂体腺瘤切除术

目的：探讨内窥镜经鼻－蝶窦入路切除垂体腺瘤,尤其是巨大垂体腺瘤的可行性。方法：分析１９９５年９月～２００１年２月经鼻－蝶窦内窥镜治疗的５０例病人的诊断、手术及预后等临床资料。结果：５０例患者中微腺瘤３例,局限于鞍内的大腺瘤１０例,向鞍上生长未突破蝶窦者７例,向蝶窦内下陷的大腺瘤３０例,其中巨大型肿瘤７例,均向上突破鞍膈向下进入蝶窦。病人术后视力视野均好转,内分泌功能异常得到改善,术后短暂性多尿者６例,术后短暂性脑脊液鼻漏者３例,均为肿瘤巨大者,均经保守治疗而治愈。术后均无鼻腔通气障碍、鼻腔粘连、鼻中隔穿孔等鼻腔并发症及血管损伤性等严重并发症。结论：内窥镜经鼻－蝶窦手术是一种微创外科技术,可完全适用于垂体腺瘤的治疗。     

鼻内镜下经鼻腔-蝶窦入路切除垂体大腺瘤13例

目的：了解鼻内镜技术用于经蝶窦入路切除垂体大腺瘤的可行性。方法：对13例垂体大腺瘤患者采用鼻内镜下经鼻腔-蝶窦入路切除术式。结果：肿瘤全切除9例(69．2％)，大部切除3例(23．1％)，手术失败1例(7．7％)。术后1周内视力、视野明显改善10例(76．9％)，其中7例接近或完全恢复正常。除2例短暂脑脊液漏外，无其他严重并发症及死亡病例发生。结论：鼻内镜用于经鼻腔-蝶窦入路切除垂体大腺瘤可获得满意的临床效果，但应注意避免术中出血、解剖变异、鞍旁组织向鞍内膨出、复发性垂体大腺瘤及术后不适当的瘤腔处理对鼻内镜手术操作及疗效的影响。     

内镜辅助显微镜切除垂体瘤126例报告

目的探讨内镜辅助显微镜经鼻腔蝶窦入路切除垂体瘤手术。方法126例垂体瘤病人内镜下单鼻孔入路,直达蝶窦前壁蝶嵴,打开蝶窦前壁、鞍底,显微镜下切开硬脑膜,切除肿瘤。结果肿瘤全部切除80例,次全切除26例,大部分切除20例。术后视力和内分泌症状明显改善95例,无脑脊液漏及脑膜炎发生。72例获随访,随访时间6个月至2年,鼻腔干燥3例,未发现鼻中隔穿孔、萎缩性鼻炎、嗅觉减退、鼻中隔粘连等并发症。结论内镜经鼻腔直达蝶窦入路辅助显微镜切除垂体瘤,视野清晰,损伤小,术后恢复快,鼻腔功能恢复好。     

经单鼻孔蝶窦入路显微镜下切除垂体腺瘤

目的探讨经单鼻孔蝶窦入路显微镜下切除垂体腺瘤的手术方法和疗效。方法对28例垂体腺瘤的病人采用经单鼻孔蝶窦入路行显微镜下垂体腺瘤摘除术,其中微腺瘤18例,大腺瘤10例;功能腺瘤20例,其中催乳素瘤10例、生长激素腺瘤5例、促肾上腺皮质激素腺瘤3例、促性腺激素腺瘤2例;无功能腺瘤8例。结果显微镜下全切除肿瘤20例,次全切除5例,大部分切除3例;术后无1例死亡,无脑水肿、视神经损伤、鼻中隔穿孔以及鼻腔粘连等并发症;术后所有病人血清激素水平均较术前有明显下降,随访3～6个月,未见影像学下的肿瘤复发。结论显微镜下经单鼻孔蝶窦入路切除垂体瘤具有鼻腔结构损伤小、术后并发症少、病人恢复快等优点。     

The transseptal approach to the pituitary gland.

Transseptal, transsphenoidal pituitary surgery is safe and effective in the management of various problems associated with the region of the sella turcica. This series include 285 operations on 272 patients treated from Sept. 1, 1972, to Sept. 1, 1976. The operative mortality was 1.75%. In every patient, the anatomy should be assessed preoperatively by polytomograms of the sella and the sphenoid sinus and by bilateral carotid angiography. The operating microscope and intra-operative x-ray control with the image-intensifier are essentials. Pneumoencephalography is performed whenever the possibility of an empty sella or arachnoidal cyst exists and when angiography does not satisfactorily outline the suprasellar extension of large pituitary tumors. Computerized tomographic scanning is also of value. A new group of pathologic problems, namely microadenomas (tumors less than 1 cm in diameter), has now become amenable to transseptal surgical management. This series includes a group of 50 patients with microadenomas: 45 with functioning pituitary adenomas and 5 with nonfunctioning pituitary adenomas. The transfrontal intracranial surgical approach also has specific indications. This choice is determined by the anatomy and the extent and nature of the pathologic lesion. The rhinologic concepts of exposure and reconstruction are modifications of the "maxilla-premaxilla" (Cottle) approach to the nasal septum. This allows direct midline access to the sphenoid sinus and sella turcica while preserving both the caudal end of the nasal septum and the anterior nasal spine, thereby minimizing rhinologic airway and cosmetic complications. We believe that, by combining the talents of the neurosurgeon, endocrinologist, neuroradiologist, ophthalmologist, and rhinologist, this procedure can be offered to patients with a wide range of disorders and excellent results may be anticipated.     

Approaches to sella turcica in endoscopic pituitary surgery

Recent advances in endoscopic sinus surgery suggested the potential for its surgical application to pituitary surgery. A number of institutions have reported the advantage of endoscope use in pituitary surgery, which is now widely accepted, but approaches to the sella vary in the literature. We retrospectively studied sella approaches in endoscopic pituitary surgery as rhinologists. Subjects included 6 cases of pituitary adenoma and 2 cases of Rathke's cleft cyst. A both-nostril transnasal transsphenoidal approach, our standard technique, was used in 6 cases. This approach consisted of elevation of mucoperiosteal flaps, resection of the vomer and sphenoid anterior wall, and opening of the sellar floor. Elevated mucoperiosteal flaps were used to close of the sella after tumor resection. All tumors were removed and no significant postoperative complications occurred. We found the both-nostril transnasal approach to be easy and time-saving and provided surgeon with a broad surgical field necessary to treat large tumors and accidental cases. Postoperative observation of the sella was easy for wide opening of the anterior wall of the sphenoid sinus. In our experience with reoperation, we quickly accessed the sella and easily removed tumors in the second operation. Our technique therefore has an advance in treatment of recurrence. The both-nostril transnasal approach involves the same procedures as median drainage of the sphenoid sinus, so our technique may have advantages in preventing mucocele of the sphenoid sinus as a late complication of transsphenoidal surgery. The transnasal transsphenoidal approach via both nostrils is preferable rhinologically.     

鼻内镜与手术显微镜配合经鼻-蝶窦行垂体瘤手术

目的探讨鼻内镜和显微外科技术结合应用于经鼻-蝶窦入路行垂体瘤手术的价值。方法在全麻下先经一侧鼻孔在内镜下寻找蝶窦开口,在内镜下完全打开双侧蝶窦前壁。蝶嵴上下留一部分残迹,作为中线定位的标志。然后在显微镜下切除垂体腺瘤。结果36例中30例肿瘤全部切除,6例近全切。术后视野缺损、偏盲、视力减退、泌乳、闭经及头痛等症状均有改善。术后随访1~4年,无复发。结论采用鼻内镜与显微镜结合应用于经蝶垂体瘤切除术,在内镜引导下具有定位准确,双目显微镜下允许双手操作,可克服各自的缺点,取长补短,并有良好的术野,术后并发症少,符合微创手术原则。     

鼻内镜下扩大的经鼻腔蝶窦入路治疗鞍周病变的解剖研究和临床应用

目的：通过扩大的经鼻腔蝶窦人路的内镜解剖学研究和初步临床应用,为扩大的经鼻腔蝶窦手术适应证及范围提供理论依据。方法：在4具(8侧)已经染料动脉灌注的成人尸头上模拟扩大经鼻腔蝶窦手术入路,同时测量海绵窦旁重要结构与鞍底的距离。结果：根据蝶窦后壁的骨性结构特征将蝶窦腔分为1个中间腔、2个旁中间腔及2个外侧腔。扩大经蝶手术入路可清晰显示鞍底骨膜、硬脑膜外层、海绵窦内侧壁、海绵窦内颈内动脉及其分支血管、动眼神经、滑车神经、外展神经及眼神经等结构;打开蝶骨平台可显示视神经、视交叉、垂体柄、鞍隔及视丘下部等解剖结构。临床初步用于治疗1例巨大侵入海绵窦的生长激素型垂体腺瘤患者,取得了较好的手术效果。结论：内镜扩大经鼻腔蝶窦手术入路可清晰显露蝶鞍周围的解剖结构,适用于鞍旁、鞍上病变的手术治疗,但应熟练掌握内镜鞍周解剖学及熟练的经鼻腔蝶窦手术经验。     

蝶窦的解剖及其在鞍区手术中的意义

目的　回顾近年来有关蝶窦的解剖研究，总结其在鞍区手术中的意义。方法　分析近年来有关的文献23篇。结果　蝶窦于10岁时基本气化完全，其大小、形态、气化程度和分隔均变异极大。蝶窦内中隔很少居中，视神经和颈内动脉常不同程度地凸向窦腔。后筛窦亦可伸入蝶窦，形成蝶上筛房。自蝶窦口至鞍底中心的距离大约为1.5cm。结论　经蝶入路手术中，保持与鼻底成32°夹角入路和以两侧窦口下缘连线为横轴打开窦壁，可使手术准确导向鞍内，必要时可打开蝶上筛房。蝶骨前嵴和犁骨是指引窦内中线操作的可靠标志，入窦腔后应注意识别和保护侧壁上的隆起结构。若见窦腔浅,看不到鞍底下凸，即可能存在额状位间隔、蝶窦气化不良或鞍底本身不下凸。     

内镜下经中鼻甲基板开放后筛加鼻中隔入路经蝶垂体瘤手术观察

目的观察经中鼻甲基板水平部开放后筛加鼻中隔入路经蝶窦垂体瘤手术的效果。方法50例垂体瘤患者内镜下经一侧或双侧中鼻甲基板开放后筛后加鼻中隔后段切除暴露蝶窦前壁，继之充分开放蝶窦前壁，显露鞍底切除垂体瘤。记录手术时间、出血量、住院时间、并发症（脑脊液漏、尿崩、颅内感染、神经功能损伤），术后鼻腔功能以及肿瘤全切和死亡情况。结果本组患者平均手术时间2.2 h，出血量245 ml，术后平均住院时间6.2 d，术中12例患者出现脑脊液漏，即时修补后无持续脑脊液漏发生；尿崩3例；嗅觉减退/丧失12例；术后垂体功能低下4例；无视神经损伤及颅内感染。因肿瘤压迫或卒中导致的视力下降术后均有改善。肿瘤全切率86%(43/50)，无死亡病例。结论内镜下经中鼻甲基板水平部开放后组筛窦加鼻中隔后段部分切除后充分开放蝶窦前壁显露鞍底及蝶窦内解剖结构，继而切除垂体瘤的方法，视野清晰、肿瘤全切率高、微创安全、对鼻腔鼻窦功能保护好。值得临床推广应用。     

Acellular dermal allograft for sellar reconstruction after transsphenoidal hypophysectomy

Obliteration of the sphenoid sinus using fat is often used after transsphenoidal hypophysectomy. The morbidity of this approach includes donor site complications, fat necrosis, and delayed mucocele formation. As obliteration with fat is intended to prevent cerebrospinal fluid (CSF) leakage, an alternative for this technique would be techniques used for CSF rhinorrhea repair. Instead of sinus obliteration, these defects are repaired with fascial autografts, which are unfortunately associated with donor site complications. To avoid sinus obliteration and donor site complications, we have reconstructed the sella with acellular dermal allograft in lieu of sinus obliteration. Transsphenoidal hypophysectomy was performed under combined microscopic and endoscopic visualization. For closure, the sellar anterior wall was reconstructed with acellular dermal allograft, septal cartilage/bone autograft, and fibrin glue. The sinus mucosa was then draped over the reconstruction and held in place with microfibrillar collagen hemostat slurry. The sphenoid sinus was not obliterated. Postoperatively, all patients underwent serial nasal endoscopy. Thirteen patients underwent the procedure as described for removal of pituitary adenoma. Postoperative discomfort and pain were minimal. Intraoperative CSF leaks were identified in five patients; none of these patients experienced a postoperative CSF leak. The microfibrillar collagen hemostat was cleared by sphenoid mucociliary clearance. One patient developed acute sphenoid sinusitis several weeks after surgery; this patient did not develop meningitis. One postoperative CSF leak occurred in an obese patient, in whom an intraoperative CSF leak was not identified; this leak resolved with bedrest and delayed lumbar drainage alone. Sellar reconstruction with acellular dermal allograft may eliminate the need for sphenoid sinus obliteration after transsphenoidal hypophysectomy. Acellular dermal allograft sellar reconstruction ultimately provides for an aerated, functioning sphenoid sinus without increased CSF leak risk or potential donor site morbidity.