Zhang Yu Qi, Ma Zhen Yu, Wu Zhe Bao, Luo Shi Qi, Wang Zhong Cheng
Department of Neurosurgery, Beijing Tiantan Hospital, Capital University of Medical Science, Beijing, People's Republic of China.
Pediatr Neurosurg. 2008;44(6):435-43. doi: 10.1159/000172965. Epub 2008 Nov 17.
The goal of this study was to disclose the appropriate surgical approaches to radically removing pediatric craniopharyngiomas with optimal hypothalamic protection.
In 202 patients undergoing primary surgery from April 1997 to December 2002, eight approaches were used to remove craniopharyngiomas in the sellar region and the third ventricle. Among the eight approaches, the transcallosal-interseptal-interforniceal approach was used in 89 cases, the unilateral transfrontal interhemispheric approach in 68 cases, the pterional approach in 20 cases, and the other five approaches in 25 cases. Active preventive and therapeutic measurements of hypothalamic dysfunction were adopted pre- and postoperatively.
Of the 202 cases, 184 tumors were totally or nearly totally removed (91.1%); 89 cases were resected with the transcallosal-interseptal-interforniceal approach with a total and subtotal removal rate of 92.1%, and 68 cases were removed with the unilateral transfrontal interhemispheric approach with a total and subtotal removal rate of 95.6%. Two patients died (0.9%). The major postoperative complications included diabetes insipidus in 81.7% of the cases, permanent diabetes insipidus in 11.4%, electrolyte disorder in 74.8%, and seizures in 9.4%. The 5-year survival rate was 68.2%.
Appropriate approaches with direct tumor exposure should be determined in order to remove the craniopharyngioma as much as possible, while at the same time carefully protecting the anteroinferolateral wall of the third ventricle (hypothalamus). Active measurements to manage blood sodium disorder and seizures could help to ensure the safety of the operation.
本研究的目的是揭示彻底切除小儿颅咽管瘤并实现最佳下丘脑保护的合适手术入路。
1997年4月至2002年12月期间，对202例接受初次手术的患者，采用8种入路切除鞍区和第三脑室的颅咽管瘤。在这8种入路中，经胼胝体 - 透明隔 - 穹窿间入路89例，单侧经额半球间入路68例，翼点入路20例，其他5种入路25例。术前和术后均采取积极的预防和治疗下丘脑功能障碍的措施。
202例患者中，184例肿瘤实现完全或近完全切除（91.1%）；经胼胝体 - 透明隔 - 穹窿间入路切除89例，全切和次全切率为92.1%，单侧经额半球间入路切除68例，全切和次全切率为95.6%。2例患者死亡（0.9%）。主要术后并发症包括81.7%的患者出现尿崩症，11.4%为永久性尿崩症，74.8%出现电解质紊乱，9.4%出现癫痫发作。5年生存率为68.2%。
应确定合适的、能直接暴露肿瘤的入路，以便尽可能多地切除颅咽管瘤，同时仔细保护第三脑室前下外侧壁（下丘脑）。积极处理血钠紊乱和癫痫发作有助于确保手术安全。
