摘要
目的：探讨颅咽管瘤进行显微外科手术治疗的临床效果及操作技巧,归纳、分析相关手术入路的特点,并总结术后并发症的预防和处理经验。
资料与方法：回顾性分析中南大学湘雅二医院神经外科2004年3月-2012年12月期间227例颅咽管瘤患者的临床资料。入选标准：之前均未接受类似手术或其他放、化疗,且本次术后均经病检证实为颅咽管瘤。结合相关统计学方法汇总分析后,详细对以上病例资料进行术前评估、手术治疗、术后支持处理及追踪随访等研究。
结果：1.所有病例中：男性患者125例,女性患者102例,男女比例1.23：1；成人170例(≥18岁),未成年57例(<18岁),比例2.98：1；年龄最大66岁,最小3岁,平均年龄30.6岁；病程1周到6年,平均3.5个月。主要首发症状分布情况：颅高压征：恶心、呕吐159例(70.0%),头痛187例(82.4%),视盘水肿6例(2.6%)。局灶压迫征：视力或/伴视野障碍136例(59.9%),发育迟缓21例(9.3%),月经紊乱28例(12.3%),泌乳过多9例(4.0%),多饮多尿95例(41.9%),性功能障碍11例(4.8%)；嗜睡、意识模糊或伴昏迷5例(2.2%),发热9例(4.0%)。影像学分型为：膈上型178例(78.4%),膈下型25例(11.0%),三脑室内型14例(6.2%),三脑室内室外混合型10例(4.4%)。
2.227例手术共全切除200例,全切除率88.1%,次全切除21例(9.3%),大部切除6例(2.6%),术后1年内死亡4例(1.8%)。远期随访失访21例,随访率为90.7%,随访时间为3月-8年不等,随访平均年限为5.1年,其中随访实际时间超过5年者57例(25.2%)。
3.术后3天检查,术前头痛187例获改善97例(51.9%),术前136例视力(或视野)障碍患者：明显好转者108例(79.5%),无明显变化7例(5.1%),恶化21例(15.4%)。垂体柄术中明确保留者138例,占60.8%,未确定者48例,占21.1%,未保留41例者,占18.1%。术后187例(82.4%)患者出现不同程度一过性尿崩,经治疗在2-4周内恢复正常,95例(41.9%)术后出现水电解质紊乱、血糖增高,10例(4.4%)垂体功能低下,7例(3.1%)出现一过性动眼神经麻痹,经治疗均恢复正常。
结论：1.显微外科手术是治疗颅咽管瘤有效和安全的方法。运用娴熟的显微外科操作技巧,根据病变的不同特征,结合详尽的术前评估选择合适的入路和间隙,可在治疗中取得满意效果。
2.颅咽管瘤术后并发症主要为：下丘脑损害引起的高热、意识障碍以及尿崩和水电解质的平衡紊乱。垂体柄保留的患者术后原有尿崩加重或新发尿崩、电解质紊乱的几率明显较小。
3.改良翼点及额部纵裂两种入路在肿瘤切除效果与术后复发率上的差异无明显统计学意义。
Objective:To investigate the effectiveness, and operating techniques of microsurgical treatment of craniopharyngiomas(CPs), classify and analyze the characteristics of the surgical approaches, and summarize the experience of the prevention and treatment of postoperative complications.
Materials and Methods:A retrospective analysis of clinical data and its follow-up of227cases of microsurgical treatment of CPs, which were operated from March,2004to December,2012by professors from the neurosurgical department of the Second Xiang-Ya Hospital. Admitted criteria:had no history of such kind of surgery or radiotherapy and chemotherapy before, and postoperative results were pathologically confirmed CP. Based on certain statistical methods, a thorough research was done on detailed preoperative evaluation before the surgery, as well as the approaches, preoperative, postoperative supporting processes and follow-up study of all227cases.
Results:1. In these227cases, there are125male patients,102female,170adults (age≥18years old) and57children(age<18years). And the male to female ratio is about1.23:1, and adult to child ratio is about2.98:1. The oldest one is66years old, youngest3years old, with a mean age of30.6years old; and the history of illness ranged from1week to6years, with an average time of3.5months.The first major symptom distribution was:intracranial hypertension symptoms:such as nausea, vomiting,159cases (70.0%), headache in187cases (82.4%), optic disc edema in6cases (2.6%); the focal compression symptoms: visual acuity and/or with136cases of vision impairment(59.9%), growth retardation in21cases (9.3%) to excessive lactation9cases (4.0%), polydipsia and polyuria in95cases (41.9%), menstrual disorders were seen in28patients (12.3%), and low libido in11cases (4.8%); drowsiness, confusion or coma patients with5cases (2.2%), fever9cases (4.0%). The imaging classification of CP:supradiaphragmatic178cases (78.4%), infradiaphragmatic25cases (11.0%), within the third ventricle14cases (6.2%), intra-and extraventricular mixed type10cases (4.4%).
2. Within all of the227cases, gross-total resection achieved in200cases (total resection rate88.1%), subtotal resection in21cases (9.3%), partial resection in6cases (2.6%), there were4deaths within1year after surgery(mortality1.8%). Long-term follow-up was lost in21cases because of varies reasons, total follow-up rate was90.7%. Follow-up time ranged from3months to8years, with an average follow-up period of5.1years, of which57cases (about25.2%) got a follow-up period longer than5years.
3. In an examination3days after surgery,97cases of187(51.9%) who had preoperative headache improved. In those who had preoperative visual acuity (vision) disorders:21cases of136(15.4%) deteriorated, uncertainty in7cases (5.1%), a significant improvement in visual acuity in108cases of136patients (79.5%). There138cases of227patients whose pituitary stalk were expressly reserves during operation, which accounting for60.8%,48cases(21.1%) were not determined,41cases of227(18.1%) were not retained. After resection,187cases of227patients(82.4%) suffered from a temporary period of diabetes insipidus, and all returned to normal after2-4weeks'treatment.95cases(41.9%) suffered from postoperative water-electrolyte disorder, and hyperglycemia, and10cases (4.4%) had an onset of hypopituitarism,7patients (3.1%) suffered from a temporary period of oculomotor nerve palsy, yet returned to normal after treatment.
Conclusions:1. Microsurgery treatment is an effective and safe method on treating craniopharyngiomas. With the use of microsurgical operating skills and the analysis of the characteristics of different lesions, combined with detailed preoperative evaluation to choose the right approaches and the gaps, satisfactory results can be achieved in the treatment of CPs.
2.The main postoperative complications of surgeries of CPs are: fever caused by damages to the hypothalamus, disturbance of consciousness, diabetes insipidus and water and electrolyte balance disorders. As long as the pituitary stalk is carefully reserved in surgery, the risk of the original or new-onset diabetes insipidus and water-electrolyte imbalance after operation can be significantly reduced.
3.Improved pterional approach and frontal interhemispheric approach have no significant difference on the effect of tumor resection and postoperative recurrence rate.
引文
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