显微经蝶窦入路切除垂体腺瘤术中垂体功能保护技术探讨

目的：探讨垂体腺瘤经蝶窦手术中垂体柄和垂体组织的辨认与保护，以进一步改善垂体腺瘤的手术疗效。
方法：中南大学湘雅医院神经外科2010年10月至2012年9月单鼻孔经鼻腔蝶窦入路显微手术切除肿瘤并经病理确诊
的51例垂体腺瘤，通过术前影像学资料和术中显微解剖，仔细辨认正常腺垂体、垂体柄、神经垂体与病变组织的关
系，尽可能切除垂体腺瘤组织，达到垂体功能的保护及减少术后并发症。结果：37例(72.5%，37/51)肿瘤全切除，12
例(23.5%，12/51)肿瘤次全切除，2例(3.9%，2/51)肿瘤大部分切除。术中对正常垂体组织及垂体柄均予以完整保留。
激素测定示手术对游离三碘甲状腺原氨酸(free triiodothyronine，FT3)，促肾上腺皮质激素(adrenocorticotropic
hormone，ACTH)的影响小，而对于游离四碘甲状腺原氨酸(free tetraiodothyronine，FT4)，促甲状腺激素
(thyroid stimulating hormone，TSH)术后及随访的结果则均有明显的改善。男性睾酮测定值术前术后无明显变化(以
上结果均在无激素替代治疗作用下测定)。术后并发症主要有：尿崩患者5例(9.8%，5/51)，无永久性尿崩；电解质紊
乱(主要指低钠血症)患者17例(33.3%，17/51)；术后脑脊液鼻漏和颅内感染患者各1例(2.0%，1/51)无围手术期死亡患者。
结论：显微经蝶窦手术可以实现垂体腺瘤(包括侵犯到海绵窦内肿瘤)的有效切除；显微经蝶窦手术中术者应对正常
垂体、垂体柄及病变组织等准确辨识，这样才能达到保留和恢复垂体功能的治疗目标。

Preservation of the pituitary stalk and the gland in ranssphenoidal microsurgery for pituitary adenomas

Objective: To improve the surgical outcome of pituitary adenomas by identifying and preserving
the pituitary stalk and the gland during surgery.
Methods: From October 2010 to September 2012, the author from the Department of
Neurosurgery of Xiangya Hospital, Central South University operated on 51 patients with pituitaryadenoma. During the operations, we carefully identified the normal adenohypophysis, pituitary stalk,
neurohypophysis and the abnormal tissues either by direct observation or by medical images, aiming to
excise the tumor thoroughly, protect the pituitary function and reduce the postoperative complications.
Results: Totally 37 patients (72.5%, 37/51) had total resection of the tumor, 12 (23.5%, 12/51)
had subtotal tumor resection and the other 2 had major removal. The gland and the pituitary stalk
were well identified and reserved. Detection of hormone content proved that the operation had little
effect on the free triiodothyronine (FT3) and adrenocorticotropic hormone (ACTH), while for
free tetraiodothyronine (FT4) and thyroid stimulating hormone (TSH) and postoperative followup
significant alleviation was found. There was no significant fluctuation for the testosterone in
the men preoperatively and postoperatively (all the above results were obtained without hormone
replacement therapy). The main postoperative complications were as follows: temporary diabetes
insipidus in 5 patients (9.8%, 5/51); electrolyte disorder (the appearance of hyponatremia) in 17
(33.3%, 17/51); and cerebrospinal fluid rhinorrhea and postoperative intracranial infection in 1 (2%,
1/51). No one died during the perioperation period.
Conclusion: Microscopic transsphenoidal surgery is effective for pituitary adenomas including
tumors violating the cavernous sinus. Accurate identification of the pituitary stalk, the gland and the
abnormal tissue during the microscopic transsphenoidal operation plays a critical role in preserving
the pituitary function and promoting postoperative rehabilitation.