Deopujari Chandrashekhar E, Karmarkar Vikram S, Shah Nishit, Vashu Ravindran, Patil Rahul, Mohanty Chandan, Shaikh Salman
Department of Neurosurgery, Bombay Hospital Institute Of Medical Sciences (BHIMS), Room No. 114, 1st Floor, MRC Building, 12, New Marine Lines, Mumbai, 400020, India.
Department of ENT, Bombay Hospital Institute Of Medical Sciences (BHIMS), Mumbai, India.
Childs Nerv Syst. 2018 May;34(5):871-876. doi: 10.1007/s00381-018-3735-8. Epub 2018 Feb 12.
Craniopharyngiomas are dysontogenic tumors with benign histology but aggressive behavior. The surgical challenges posed by the tumor are well recognized. Neuroendoscopy has recently contributed to its surgical management. This study focuses on our experience in managing craniopharyngiomas in recent years, highlighting the role of combined endoscopic trans-ventricular and endonasal approach.
Ninety-two patients have been treated for craniopharyngioma from 2000 to 2016 by the senior author. A total of 125 procedures, microsurgical (58) and endoscopic (67), were undertaken. Combined endoscopic approach was carried out in 18 of these patients, 16 children and 2 young adults. All of these patients presented with a large cystic suprasellar mass associated with hydrocephalus. In the first instance, they were treated with a transventricular endoscopic procedure to decompress the cystic component. This was followed by an endonasal transsphenoidal procedure for excision within the next 2 to 6 days. All these patients improved after the initial cyst decompression with relief of hydrocephalus while awaiting remaining tumor removal in a more elective setting. Gross total resection could be done in 84% of these patients. Diabetes insipidus was the most common postsurgical complication seen in 61% patients in the immediate period but was persistent in only two patients at 1-year follow-up. None of the children in this group developed morbid obesity. There was one case of CSF leak requiring repair after initial surgery. Peri-operative mortality was seen in one patient secondary to ventriculitis.
The patients who benefit most from the combined approach are those who present with raised intracranial pressure secondary to a large tumor with cyst causing hydrocephalus. Intraventricular endoscopic cyst drainage allows resolution of hydrocephalus with restoration of normal intracranial pressure, gives time for proper preoperative work up, and has reduced incidence of CSF leak after transnasal surgery.
Combined endoscopic approach thus gives a unique opportunity to remove these lesions more radically with less morbidity.
颅咽管瘤是具有良性组织学特征但行为具有侵袭性的发育异常性肿瘤。该肿瘤带来的手术挑战已得到充分认识。神经内镜最近对其手术治疗起到了推动作用。本研究聚焦于我们近年来处理颅咽管瘤的经验，突出联合经脑室和经鼻内镜入路的作用。
2000年至2016年，资深作者共治疗了92例颅咽管瘤患者。共进行了125次手术，其中显微手术58例，内镜手术67例。18例患者采用了联合内镜入路，其中16例为儿童，2例为青年成人。所有这些患者均表现为鞍上巨大囊性肿块并伴有脑积水。首先，对他们进行经脑室内镜手术以减压囊性成分。随后在接下来的2至6天内进行经鼻蝶窦手术以切除肿瘤。所有这些患者在最初的囊肿减压后脑积水得到缓解，病情改善，同时等待在更合适的时机切除剩余肿瘤。这些患者中有84%实现了肿瘤全切除。尿崩症是最常见的术后并发症，急性期61%的患者出现，但在1年随访时仅2例持续存在。该组儿童均未发生病态肥胖。有1例患者在初次手术后出现脑脊液漏，需要进行修补。1例患者因脑室炎继发围手术期死亡。
从联合入路中获益最大的患者是那些因巨大肿瘤伴囊肿导致脑积水而出现颅内压升高的患者。脑室内镜囊肿引流可使脑积水得到缓解，颅内压恢复正常，为术前的充分准备争取时间，并降低经鼻手术后脑脊液漏的发生率。
联合内镜入路因此提供了一个独特的机会，能够以更低的发病率更彻底地切除这些病变。
