Mattozo Carlos A, Dusick Joshua R, Esposito Felice, Mora Hugo, Cohan Pejman, Malkasian Dennis, Kelly Daniel F
Division of Neurosurgery, University of California at Los Angeles, David Geffen School of Medicine, USA.
Neurosurgery. 2006 May;58(5):857-65; discussion 857-65. doi: 10.1227/01.NEU.0000209930.88242.1C.
In a series of patients with residual endocrine-inactive macroadenomas who underwent repeat surgery, we assess possible reasons for prior subtotal removal, reoperative success, complication rates, and patient impressions.
All patients were identified who had a prior subtotal removal of an endocrine-inactive macroadenoma and were reoperated on for residual sellar tumor via an endonasal approach.
Over 6 years, of 188 consecutive patients with endocrine-inactive adenomas, 30 (16%) had repeat surgery (age, 15-77 yr; median interval between surgeries, 25 mo; median follow-up, 20 mo). Maximal tumor diameter averaged 2.4 +/- 0.9 cm. At reoperation, a suboptimal bony exposure was seen in all 30 patients: at the sphenoid keel, the sella, or both in 97, 93, and 90% of patients, respectively. Cavernous sinus invasion was seen in 16 (53%) patients and a fibrous/rubbery consistency in 12 (40%). Gross total tumor removal was achieved in 17 (57%) patients, including 12 of 14 (86%) with noninvasive tumors and 5 of 16 (31%) with invasive tumors, (P < 0.01). All six fibrous/rubbery but noninvasive tumors were totally removed. Of 16 patients with preoperative visual loss, 15 (94%) improved. Complications included one each of cerebrospinal fluid leak, delayed sinusitis, and new hypothyroidism. In 17 patients with prior sublabial surgery who completed questionnaires, the second (endonasal) surgery was associated with an easier recovery, less pain, and better nasal airflow in 82, 88, and 93%, respectively (P < 0.0001).
In patients with residual sellar endocrine-inactive adenomas, a suboptimal opening at the sphenoid keel or sella at the first surgery and a high proportion of fibrous/rubbery tumors likely contributed to prior subtotal removal of otherwise accessible tumor. With a wider exposure, most noninvasive tumors can be totally removed, whereas invasive tumors can be effectively debulked. An endonasal reoperation is well tolerated with a low complication rate.
在一系列接受再次手术的残留内分泌无活性大腺瘤患者中，我们评估先前次全切除的可能原因、再次手术成功率、并发症发生率及患者感受。
纳入所有先前接受过内分泌无活性大腺瘤次全切除且经鼻入路再次手术切除残留鞍区肿瘤的患者。
6年间，188例连续的内分泌无活性腺瘤患者中，30例（16%）接受了再次手术（年龄15 - 77岁；两次手术间隔时间中位数为25个月；随访时间中位数为20个月）。肿瘤最大直径平均为2.4±0.9厘米。再次手术时，所有30例患者均存在骨质暴露欠佳的情况：分别有97%、93%和90%的患者在蝶骨嵴、鞍区或两者均存在骨质暴露欠佳。16例（53%）患者存在海绵窦侵袭，12例（40%）肿瘤质地为纤维样/橡皮样。17例（57%）患者实现了肿瘤全切，包括14例非侵袭性肿瘤中的12例（86%）以及16例侵袭性肿瘤中的5例（31%），（P<0.01）。所有6例纤维样/橡皮样但非侵袭性的肿瘤均实现全切。16例术前有视力丧失的患者中，15例（94%）视力改善。并发症包括1例脑脊液漏、1例迟发性鼻窦炎和1例新发甲状腺功能减退。17例先前接受过唇下手术且完成问卷的患者中，第二次（经鼻）手术分别在82%、88%和93%的患者中与恢复更容易、疼痛减轻及鼻腔通气改善相关（P<0.0001）。
在残留鞍区内分泌无活性腺瘤患者中，首次手术时蝶骨嵴或鞍区开口欠佳以及纤维样/橡皮样肿瘤比例较高可能是导致原本可切除肿瘤先前次全切除的原因。通过更广泛的暴露，大多数非侵袭性肿瘤可实现全切而侵袭性肿瘤可有效减瘤。经鼻再次手术耐受性良好，并发症发生率低。
