鞍底硬膜缝合及骨性重建与带蒂鼻中隔黏膜瓣技术在颅底重建中的作用及多因素分析  

Multi-factor analysis of sellar floor dural suture,bone reconstruction and pedicled nasoseptal flap in skull base reconstruction

作　　者：曹明川 李瑞春[2] 杨刚[1] 霍钢[1] 周靖 张磊[1] 王鹏 王晓澍[1] CAO Mingchuan;LI Ruichun;YANG Gang;HUO Gang;ZHOU Jing;ZHANG Lei;WANG Peng;WANG Xiaoshu(Department of Neurosurgery,The First Affiliated Hospital of Chongqing Medical University,Chongqing 400016;Department of Neurosurgery,The First Affiliated Hospital of Xi’an Jiaotong University,Xi’an 710061,China)

机构地区：[1]重庆医科大学附属第一医院神经外科,重庆400016 [2]西安交通大学第一附属医院神经外科,陕西西安710061

出　　处：《西安交通大学学报（医学版）》2023年第4期563-570,共8页Journal of Xi’an Jiaotong University（Medical Sciences）

摘　　要：目的探讨鞍底硬膜缝合(不同方式)、骨性重建与鼻中隔带蒂黏膜瓣(pedicled nasoseptal flap,PNSF)对垂体瘤经鼻内镜术中发生中、高流量脑脊液漏的重建效能及其各自作用权重。方法收集我院2015年1月至2021年4月神经内镜标准经鼻入路垂体瘤切除术中发生2~3级脑脊液漏(Kelly分级)的病例资料。将鞍底硬膜缝合方式、骨性重建、PNSF使用情况及年龄、性别、体质量指数(body mass index,BMI)、糖尿病、肿瘤大小和漏口直径等相关因素进行多因素线性回归,分析上述因素对术后脑脊液鼻漏持续时间和卧床时间的影响,重点分析硬膜缝合、骨性重建与PNSF对鞍底重建效果相关指标的影响强度(即效能强度)。结果共纳入病例281例,平均年龄(47±12.6)岁,男性占比52.6%,其中应用PNSF 93例次,骨性重建268例次,鞍底硬膜锚定式缝合109例次,补丁式缝合50例次,未缝合122例次。多因素分析结果提示:PNSF、骨性重建和鞍底硬膜缝合的应用均显著减少术后鼻漏时间[分别减少18.524、35.876和16.983/19.791(锚定缝合/补丁缝合)h,均为P<0.001]与卧床时间[分别减少16.797、58.233和18.063/21.604(锚定缝合/补丁缝合)h,均为P<0.001],其中硬膜锚定式缝合与补丁式缝合方式间差异无统计学意义。对于缩短鼻漏时间,标准化系数后修补效能强度排序为鞍底缝合>PNSF>骨性重建[标准β=0.211/0.207(锚定缝合/补丁缝合)>0.200>0.165];对减少卧床时间的效能强度排序为骨性重建>鞍底缝合>PNSF[标准β=0.239>0.206/0.210(锚定缝合/补丁缝合)>0.164]。骨性重建技术经25~30例学习曲线稳定后平均耗时(3.9±0.4)min。鞍底缝合经30~40例学习曲线平稳后平均每针缝合耗时(3.7±0.3)min,每例术中平均缝合(3.7±1.0)针,每例术中平均耗时(13.6±2.7)min。结论鞍底硬膜锚定式或补丁式缝合均可有效缩短脑脊液鼻漏持续时间和卧床时间,骨性重建提高了重建稳定性,尤其利于早Objective To evaluate the efficacy and weight of sellar floor repair techniques such as different dura suture,bone reconstruction,and pedicled nasoseptal flap(PNSF)on the skull base reconstruction of medium and high flow cerebrospinal fluid leakage during endonasal endoscopic pituitary adenoma surgery.Methods We collected the data of Grade 2-3 cerebrospinal fluid leakage(Kelly grade)during endonasal endoscopic pituitary adenoma resection in our hospital from January 2015 to April 2021.Multiple reconstruction techniques such as dura suture,bone reconstruction and PNSF,and related factors such as age,sex,body mass index(BMI),diabetes,tumor size and diameter of diaphragmatic defect were recorded and introduced to multivariate regression to analyze the effects of the above factors on the duration of postoperative cerebrospinal fluid rhinorrhea and bed rest time,with a special focus on the weight priority of dura suture,bone reconstruction,and PNSF.Results A total of 281 patients were included,with the average age of(47±12.6)years,males accounting for 52.6%.There were 93 cases of PNSF,268 cases of bone reconstruction,109 cases of dura anchor suture,50 cases of patch suture,and 122 cases without suture.The results of multivariate analysis indicated that the application of PNSF,bone reconstruction,and dura suture significantly reduced postoperative rhinorrhea time[reduced by 18.524,35.876,and 16.983/19.791(anchor suture/patch suture)hours,respectively;all P<0.001]and bed time[reduced by 16.797,58.233,and 18.063/21.604(anchor suture/patch suture)hours,respectively;all P<0.001],and there was no significant difference between anchor suture and patch suture.The weight of the standardized coefficient in reducing postoperative rhinorrhea time was dura suture>PNSF>bone reconstruction[Standardβ=0.211/0.207(anchor suture/patch suture)>0.200>0.165].The weight of reducing bed time was bone reconstruction>dura suture>PNSF[Standardβ=0.239>0.206/0.210(anchor suture/patch suture)>0.164].After stabilizing the learning curve in 25-30

关 键 词：经鼻内镜手术 颅底重建 缝合技术 骨瓣 鼻中隔带蒂黏膜瓣 垂体肿瘤 

分 类 号：R730.56[医药卫生—肿瘤] R739.41[医药卫生—临床医学]