鞍上及鞍内颅咽管瘤经翼点入路和额底入路手术疗效的研究  

Study on efficacy of microsurgery removal of craniopharyngiomas via pterional and subfrontal approach

作　　者：毕建华[1] 王小峰 齐春晓[3] 杨康[4] 车宁伟 魏明海[4] 尹剑[4] 

机构地区：[1]哈尔滨市第一医院脑外一科,150010 [2]渭南市中心医院神经外科 [3]大连医科大学附属第二医院神经外二科 [4]大连医科大学附属第二医院神经外一科

出　　处：《临床神经外科杂志》2017年第2期120-125,共6页Journal of Clinical Neurosurgery

基　　金：国家自然科学基金面上项目(81671298)

摘　　要：目的探讨经翼点及额底入路显微外科手术切除鞍上及鞍内颅咽管瘤的效果、垂体柄保留、下丘脑保护,以及手术操作技巧和术后处理。方法回顾性分析行显微外科手术治疗的25例首次就诊的颅咽管瘤患者的临床资料。主要总结分析术前、术后症状及辅助检查的改善。特别对采用翼点入路(15例)与额底入路(10例)两种术式在肿瘤切除程度及垂体柄保留方面的差异进行比较。另结合手术经验分析手术入路的选择及术中注意事项。结果本组患者颅咽管瘤的全切率为84%。经额底入路患者的全切率为86.7%,经翼点入路患者的全切率为80%;二者之间的差异无统计学意义(P=0.523)。22例患者的垂体柄保留,垂体柄的保留率为88%;其中经翼点入路的患者13例,经额底入路的患者9例;垂体柄保留率的差异也无统计学意义(P=0.654)。手术效果:头痛的缓解率为90.9%,视力障碍的缓解率为61.5%,视野改善率为40%;下丘脑-垂体-甲状腺轴改善率为16.7%,下丘脑-垂体-肾上腺轴改善率15.4%,泌乳素改善率85.7%,下丘脑-垂体-性腺轴改善率44.4%。3例部分切除患者术后行放疗,2年后复查未见肿瘤复发。所有随访患者的Karnofsky评分平均值为90分。结论显微神经外科手术是颅咽管瘤的最主要治疗方法,手术可明显改善患者的症状,挽救视力及视野;可终止内分泌功能损害进一步发展,但对已有的内分泌紊乱改善不明显。经翼点入路和额底入路在肿瘤切除程度及垂体柄保护方面无显著差异,而手术成功的关键是对术后并发症做出及时正确的处理。Objective To summarize the microsurgery removal results of CP,postoperative complications,the protection of pituitary stalk and hypothalamus,to discuss the approaches and the operative experiences,so that we can make a better guide for medical work. Methods It was retrospectively analyzed that 25 cases of CP with microsurgery in Dalian Medical University from January 2010 to December 2013. It is summarized that the comparation between preoperative symptoms and postoperative symptoms. The results were analyzed by Fisher＇s exact probability of SPSS 19. 0. Meanwhile we discuss the strategies of pituitary stalk protection in microsurgery. Results The total resection rate was 84% with 86. 7% in subfrontal approach and 80% in pterional approach. The protection rate of pituitary stalk was 88%. After Fisher test,the difference between the he resection degree of two groups was not statistically significant（ P = 0. 523）,the pituitary stalk protection of two groups also was not statistically significant（ P = 0. 654）. The direct effect of operation：headache relief rate was 90. 9%. The vision of the remission rate was 61. 5%,the vision improvement rate was 40%. The hypothalamic pituitary thyroid axis improvement rate was 16. 7%,the hypothalamic pituitary adrenal axis prolactin improvement rate was 15. 4%,improvement rate of85. 7%,the hypothalamic pituitary gonadal axis to improve the rate of 44. 4%. 3 cases of subtotal resection in patients with postoperative radiotherapy after 2 years survived without recurrence,the average Karnofsky score of 90. Conclusion Microsurgery could improve significantly headache relief rate,but improve partly visual disorder and endocrine disorder. There were no statistically significance in terms of suprasellar and intrasellar CP＇s resection degree and pituitary stalk protection between pterional approach and subfrontal approach. Better prognosis would be guaranteed by close monitoring and positive management of complications.

关 键 词：颅咽管瘤 手术效果 翼点入路 额底入路 

分 类 号：R734.2[医药卫生—肿瘤]