Liu J K, Das K, Weiss M H, Laws E R, Couldwell W T
Department of Neurosurgery, New York Medical College, Valhalla, New York 10595, USA.
J Neurosurg. 2001 Dec;95(6):1083-96. doi: 10.3171/jns.2001.95.6.1083.
Initial attempts at transcranial approaches to the pituitary gland in the late 1800s and early 1900s resulted in a mortality rate that was generally considered prohibitive. Schloffer suggested the use of a transsphenoidal route as a safer, alternative approach to the sella turcica. He reported the first successful removal of a pituitary tumor via the transsphenoidal approach in 1906. His procedure underwent a number of modifications by interested surgeons, the culmination of which was A. E. Halstead's description in 1910 of a sublabial gingival incision for the initial stage of exposure. From 1910 to 1925, Cushing, combining a number of suggestions made by previous authors, refined the transsphenoidal approach and used it to operate on 231 pituitary tumors, with a mortality rate of 5.6%. As he developed increasing expertise with transcranial surgery, however, Cushing reduced his mortality rate to 4.5%. With the transcranial approach, he was able to verify suprasellar tumors and achieve better decompression of the optic apparatus, resulting in better recovery of vision and a lower recurrence rate. As a result he and most other neurosurgeons at the time abandoned the transnasal in favor of the transcranial approaches. Norman Dott, a visiting scholar who studied with Cushing in 1923, returned to Edinburgh, Scotland, and continued to use the transsphenoidal procedure while others pursued transcranial approaches. Dott introduced the procedure to Gerard Guiot, who published excellent results with the transsphenoidal approach and revived the interest of many physicians throughout Europe in the early 1960s. Jules Hardy, who used intraoperative fluoroscopy while learning the transsphenoidal approach from Guiot, then introduced the operating microscope to further refine the procedure; he thereby significantly improved its efficacy and decreased surgical morbidity. With the development of antibiotic drugs and modern microinstrumentation, the transsphenoidal approach became the preferred route for the removal of lesions that were confined to the sella turcica. The evolution of the transsphenoidal approaches and their current applications and modifications are discussed.
19世纪末20世纪初，最初尝试经颅入路垂体手术时，死亡率普遍被认为过高。施洛费尔建议采用经蝶窦途径作为一种更安全的替代方法进入蝶鞍。1906年，他报告了首例经蝶窦入路成功切除垂体肿瘤的病例。他的手术方法经众多感兴趣的外科医生进行了多次改进，最终在1910年由A.E.霍尔斯特德描述了用于初期暴露的唇下牙龈切口。1910年至1925年期间，库欣综合了先前作者提出的诸多建议，完善了经蝶窦入路，并使用该方法对231例垂体肿瘤进行手术，死亡率为5.6%。然而，随着他在经颅手术方面的专业技能不断提高，库欣将死亡率降至4.5%。采用经颅入路，他能够确认鞍上肿瘤并更好地对视器进行减压，从而使视力恢复更好且复发率更低。因此，他和当时的大多数其他神经外科医生放弃了经鼻入路而倾向于经颅入路。1923年与库欣一同学习的访问学者诺曼·多特回到苏格兰爱丁堡，继续使用经蝶窦手术方法，而其他人则采用经颅入路。多特将该手术方法介绍给了热拉尔·吉奥，吉奥发表了经蝶窦入路的出色成果，并在20世纪60年代初重新唤起了欧洲许多医生的兴趣。朱尔斯·哈代在向吉奥学习经蝶窦入路时使用术中荧光透视，随后引入手术显微镜以进一步完善该手术；他由此显著提高了手术效果并降低了手术并发症发生率。随着抗生素药物和现代微型器械的发展，经蝶窦入路成为切除局限于蝶鞍病变的首选途径。本文将讨论经蝶窦入路的发展历程及其当前的应用和改进。
