Kaptain G J, Vincent D A, Sheehan J P, Laws E R
Department of Neurosurgery, Oregon Health Sciences University, Portland, USA.
Neurosurgery. 2001 Jul;49(1):94-100; discussion 100-1.
The transsphenoidal approach is an effective method for treating tumors contained within the sella or extending into the suprasellar cistern. The technique of tumor dissection is predicated on preservation of the integrity of the diaphragma, i.e., intracapsular removal. Gross total extracapsular dissection may, however, be accomplished either by using a standard approach to the pituitary fossa or by extending the exposure to include removal of a portion of the planum sphenoidale and division of the superior intercavernous sinus.
Included in this series were 14 patients with parasellar or sellar tumors with extension into the anterior fossa and/or suprasellar cistern. For 4 of 14 patients (29%), extracapsular access was gained by broaching the tumor capsule from within the pituitary fossa. For the remaining 10 of 14 patients (71%), the dura of the floor of the sella and the planum sphenoidale was exposed, using neuronavigation to verify the limits of bony dissection; extracapsular tumor resection was performed using the operating microscope and endoscopy as indicated. The dural defect was repaired with abdominal fat, the sellar floor and planum sphenoidale were reconstructed, and in selected cases a lumbar drain was placed.
Seven of 14 tumors (50%) were craniopharyngiomas, 3 of 14 (21%) were pituitary adenomas, and 2 of 14 (14%) were meningiomas. There was one case of lymphocytic hypophysitis and one yolk sac tumor. Gross total resection was possible in 11 of 14 cases (79%). Immediate postoperative visual function worsened in 2 of 14 cases (14%), improved in 3 of 14 cases (21%), and was stable in the remainder of cases. Postoperatively, 2 of 14 patients (14%) developed bacterial meningitis. Overt postoperative cerebrospinal fluid rhinorrhea was not observed.
Gross total extracapsular resection of midline suprasellar tumors via a transsphenoidal approach is possible but is associated with a higher risk of complications than is standard transsphenoidal surgery.
经蝶窦入路是治疗局限于蝶鞍内或延伸至鞍上池的肿瘤的有效方法。肿瘤切除技术的关键在于保持鞍膈的完整性，即囊内切除。然而，通过采用标准的垂体窝入路或扩大暴露范围以包括切除部分蝶骨平台和切开海绵间上窦，也可以完成肿瘤的大体全囊外切除。
本系列研究纳入了14例鞍旁或鞍区肿瘤延伸至前颅窝和/或鞍上池患者。14例患者中有4例（29%）通过从垂体窝内打开肿瘤包膜获得囊外入路。其余10例（71%）患者，暴露蝶鞍底部和蝶骨平台的硬脑膜，使用神经导航确定骨切除范围；根据需要使用手术显微镜和内镜进行囊外肿瘤切除。用腹部脂肪修复硬脑膜缺损，重建蝶鞍底部和蝶骨平台，部分病例放置腰大池引流管。
14例肿瘤中有7例（50%）为颅咽管瘤，3例（21%）为垂体腺瘤，2例（14%）为脑膜瘤。有1例淋巴细胞性垂体炎和1例卵黄囊瘤。14例中有11例（79%）实现了大体全切除。术后14例中有2例（14%）视力立即恶化，3例（21%）视力改善，其余病例视力稳定。术后，14例患者中有2例（14%）发生细菌性脑膜炎。未观察到明显的术后脑脊液鼻漏。
经蝶窦入路对中线鞍上肿瘤进行大体全囊外切除是可行的，但与标准经蝶窦手术相比，并发症风险更高。
