Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China.
J Neurosurg. 2013 Dec;119(6):1437-46. doi: 10.3171/2013.8.JNS13777. Epub 2013 Sep 20.
An assessment regarding both surgical approaches and the extent of resection for Rathke cleft cysts (RCCs) based on their locations has not been reported. The aim of this study was to report the results of a large series of surgically treated patients with RCCs and to evaluate the feasibility of individualized surgical strategies for different RCCs.
We retrospectively reviewed 87 cases involving patients with RCCs (16 intrasellar, 50 intra- and suprasellar, and 21 purely suprasellar lesions). Forty-nine patients were treated via a transsphenoidal (TS) approach, and 38 were treated via a transcranial (TC) approach (traditional craniotomy in 21 cases and supraorbital keyhole craniotomy in 17). The extent of resection was classified as gross-total resection (GTR) or subtotal resection (STR) of the cyst wall. Patients were thus divided into 3 groups according to the approach selected and the extent of resection: TS/STR (n = 49), TC/STR (n = 23), and TC/GTR (n = 15).
Preoperative headaches, visual dysfunction, hypopituitarism, and diabetes insipidus (DI) resolved in 85%, 95%, 55%, and 65% of patients, respectively. These rates did not differ significantly among the 3 groups. Overall, complications occurred in 8% of patients in TS/STR group, 9% in TC/STR group, and 47% in TC/GTR group, respectively (p = 0.002). Cerebrospinal fluid (CSF) leakage (3%), new hypopituitarism (9%), and DI (6%) were observed after surgery. All CSF leaks occurred in the endonasal group, while the TC/GTR group showed a higher rate of postoperative hypopituitarism (p = 0.7 and p < 0.001, respectively). It should be particularly noted that preoperative hypopituitarism and DI returned to normal, respectively, in 100% and 83% of patients who underwent supraorbital surgery, and with the exception of 1 patient who had transient postoperative DI, there were no complications in patients treated with supraorbital surgery. Kaplan-Meier 3-year recurrence-free rates were 84%, 87%, and 86% in the TS/STR, TC/STR, and TC/GTR groups, respectively (p = 0.9).
It is reasonable to adopt individualized surgical strategies for RCCs based on cyst location. Gross-total resection does not appear to reduce the recurrence rate but increase the risk of postoperative complications. The endonasal approach seems more appropriate for primarily intrasellar RCCs, while the craniotomy is recommended for purely or mainly suprasellar cysts. The supraorbital route appears to be preferred over traditional craniotomy for its minimal invasiveness and favorable outcomes. The endoscopic technique is helpful for either endonasal or supraorbital surgery.
基于位置对 Rathke 裂隙囊肿（RCC）的手术方法和切除范围进行评估尚未见报道。本研究旨在报告一系列接受手术治疗的 RCC 患者的结果，并评估针对不同 RCC 的个体化手术策略的可行性。
我们回顾性分析了 87 例 RCC 患者（16 例鞍内、50 例鞍内和鞍上、21 例单纯鞍上）。49 例患者采用经蝶窦（TS）入路治疗，38 例采用经颅（TC）入路治疗（传统开颅 21 例，眶上锁孔开颅 17 例）。根据囊肿壁的切除程度，将切除范围分为大体全切除（GTR）或次全切除（STR）。根据所选方法和切除范围，患者分为 3 组：TS/STR（n=49）、TC/STR（n=23）和 TC/GTR（n=15）。
术前头痛、视力障碍、垂体功能减退和尿崩症（DI）的缓解率分别为 85%、95%、55%和 65%。这 3 组之间的缓解率无显著差异。总的来说，TS/STR 组、TC/STR 组和 TC/GTR 组分别有 8%、9%和 47%的患者出现并发症（p=0.002）。术后发生脑脊液（CSF）漏（3%）、新发垂体功能减退（9%）和 DI（6%）。所有 CSF 漏均发生在经鼻组，而 TC/GTR 组术后垂体功能减退的发生率更高（p=0.7 和 p<0.001）。值得注意的是，眶上锁孔入路组术前垂体功能减退和 DI 患者分别有 100%和 83%恢复正常，除 1 例患者术后出现短暂性 DI 外，眶上锁孔入路组无并发症。Kaplan-Meier 3 年无复发生存率分别为 TS/STR 组 84%、TC/STR 组 87%和 TC/GTR 组 86%（p=0.9）。
根据囊肿位置，对 RCC 采用个体化手术策略是合理的。GTR 似乎不会降低复发率，但会增加术后并发症的风险。经蝶窦入路似乎更适用于主要位于鞍内的 RCC，而开颅术则适用于单纯或主要位于鞍上的囊肿。眶上锁孔入路因其微创性和良好的效果，似乎优于传统开颅术。对于经鼻或眶上锁孔手术，内镜技术均有帮助。
