顱咽管瘤的經(jīng)鼻切除術(shù)（Endonasal resection of craniopharyngiomas）-INC國(guó)際神經(jīng)外科醫(yī)生集團(tuán)

　　英文原文：

　　Gardner and colleagues have described their series of 16 patients who underwent an endoscopic, expanded endonasal approach (EEA) for craniopharyngioma between 1999 and 2006. The primary outcomes of their study included the following: endocrine and ophthalmological results, ex- tent of resection, and complications. The majority of their patients underwent planned complete resection. In these patients, 73% (8 of 11) had a gross-total resection without recurrence during a mean follow-up of 34 months. No patient in the series experienced visual worsening. The postoperative rate of permanent diabetes insipidus (DI) was 8%. Cerebrospinal fluid (CSF) leaks were documented in 58% of patients. In 1 patient, a stroke occurred from a perforating vessel from a posterior cerebral artery injury.

　　Of interest here is the classification of craniopharyngio- mas into a system that is best appreciated by the endoscopic, endonasal neurosurgeon: Type I, preinfundibular; Type II, transinfundibular; and Type III, retroinfundibular. In the- ory, this is an attractive classification system. In practice, however, there will be instances in which the craniopharyngiomas are either too large and the stalk obscured, or the MR images will be inadequate to fully ascertain the location of the tumor with respect to the infundibulum. I would like to commend the authors on their willingness to tackle some of the more difficult types of craniopharyngiomas (for example, the Type IIIa and IIIb lesions) through an EEA. Years ago, I would have thought such an approach to the “retrochiasmatic” craniopharyngioma would have been impossible. Now, with the advent of the techniques that have been uniquely shared by the minimally invasive neurosurgeon and otolaryngologist and which are expounded on in this study, craniopharyngiomas of all types can be the target of EEA.

　　As with all new techniques that come forward for analysis when compared with established, conventional ones, a critical review of the complications must be undertaken. Here, it is clear that EEA for craniopharyngioma is well tol- erated, and the vast majority of patients do well after tumor resection. Endocrine and ophthalmological functions were reasonably well preserved and/or maintained. The one area, of course, where greater strides will need to be taken and where improvements in technique will be mandatory is with the rate of CSF leakage. However, it sounds as though the authors are well on their way to improving their out- comes with CSF leaks by using vascularized mucosal flaps together with local reinforcement of the sellar floor.

　　This report by Gardner and associates is more than a technical note, but is not yet quite at the level of the larger published series on craniopharyngioma1-4 in which more patients with craniopharyngioma have been studied and followed, in some instances, for longer periods of time. In all series, however, including the present one, recurrences of craniopharyngioma are a fact of life. The rate of recurrence may be as high as 40% in some series. The treatment of the recurrent craniopharyngioma is a vexing problem, and one wonders whether patients who were first treated using the EEA would again be candidates for a repeated procedure using this approach.

　　The EEA described here was performed in adults. As craniopharyngiomas commonly occur in children, it would be interesting to use this approach in the child with a craniopharyngioma. In this regard, the limitations would likely be similar to those observed with the transsphenoidal approach in this age group: small nares, nonpneumatized sella, and smaller midline corridor between the carotid arteries.

　　Finally, as the authors expand their series and gather more patients for analysis, I exhort them to analyze the effects of EEA on the neuropsychology of their patients. It is here that I suspect that EEA may be a beneficial approach over craniotomy and subfrontal or pterional approaches to craniopharyngioma.

　　中文翻譯：

　　Gardner和他的同事描述了他們?cè)?999年至2006年間對(duì)16例顱咽管瘤患者進(jìn)行的內(nèi)鏡下擴(kuò)大鼻道入路(EEA)治療。他們的研究的主要結(jié)果包括:內(nèi)分泌和眼科結(jié)果，切除前，和并發(fā)癥。他們的大多數(shù)病人都接受了計(jì)劃中的全切除手術(shù)。在這些患者中，73%(11例中的8例)在平均34個(gè)月的隨訪中進(jìn)行了總切除，沒(méi)有復(fù)發(fā)。在這個(gè)系列中沒(méi)有病人出現(xiàn)視覺(jué)惡化。術(shù)后長(zhǎng)期性尿崩癥(DI)發(fā)生率為8%。58%的患者有腦脊液(CSF)滲漏的記錄。1例發(fā)生腦后動(dòng)脈損傷穿孔血管卒中。

　　我們感興趣的是顱咽- mas系統(tǒng)的分類它是由內(nèi)窺鏡，鼻內(nèi)神經(jīng)外科醫(yī)生較能理解的:I型，漏斗前;II型,transinfundibular;III型，漏斗后。在理論上，這是一個(gè)有吸引力的分類系統(tǒng)。然而，在實(shí)踐中，有時(shí)顱咽管瘤太大，莖部模糊不清，或者M(jìn)R圖像不足以完全確定腫瘤相對(duì)于漏斗部的位置。我想贊揚(yáng)作者們?cè)敢馔ㄟ^(guò)EEA來(lái)處理一些較困難類型的顱咽管瘤(例如，IIIa型和IIIb型病變)。幾年前，我認(rèn)為這種治療“交叉后”顱咽管瘤的方法是不可能的?，F(xiàn)在，隨著微創(chuàng)神經(jīng)外科醫(yī)生和耳鼻喉科醫(yī)生所技術(shù)的出現(xiàn)，以及本研究中所闡述的技術(shù)，各種類型的顱咽管瘤都可以成為EEA的目標(biāo)。

　　與全部新出現(xiàn)的分析技術(shù)相比，現(xiàn)有的，傳統(tǒng)的，一個(gè)關(guān)鍵的審查并發(fā)癥需進(jìn)行?？梢?jiàn)，顱咽管瘤的EEA治療進(jìn)展良好，多數(shù)患者腫瘤切除后恢復(fù)良好。內(nèi)分泌和眼科功能得到合理的保存和/或維持。當(dāng)然，有一個(gè)領(lǐng)域需要更大的進(jìn)步，技術(shù)上的改進(jìn)是需的，那就是CSF的泄漏率。然而，這聽(tīng)起來(lái)好像作者們?cè)诤棉D(zhuǎn)他們的方法上做得很好--通過(guò)使用帶血管蒂的粘膜瓣和顱底的局部加固來(lái)好轉(zhuǎn)CSF泄漏。

　　Gardner和同事的這篇報(bào)告不僅僅是一個(gè)技術(shù)說(shuō)明，但還沒(méi)有達(dá)到顱咽管瘤1 - 4系列報(bào)道的水平，在該系列報(bào)道中，對(duì)更多的顱咽管瘤患者進(jìn)行了研究，并在某些情況下進(jìn)行了更長(zhǎng)時(shí)間的隨訪。然而，在全部的病例中，包括目前的病例，顱咽管瘤的復(fù)發(fā)是不可避免的。某些系列的復(fù)發(fā)率可能高達(dá)40%。復(fù)發(fā)性顱咽管瘤的治療是一個(gè)令人煩惱的問(wèn)題，人們想知道一次使用EEA治療的患者是否會(huì)再次成為使用這種方法重復(fù)手術(shù)的候選人。

　　這里描述的EEA是在成人中進(jìn)行的。由于顱咽管瘤通常發(fā)生在兒童中，因此對(duì)顱咽管瘤兒童采用這種方法將是很有趣的。在這方面，局限性可能與經(jīng)蝶竇入路在這個(gè)年齡組中觀察到的局限性類似:鼻孔小、非氣化蝶鞍、頸動(dòng)脈間更小的中線走廊。

　　較后，隨著作者擴(kuò)大他們的系列并收集更多的患者進(jìn)行分析，我建議他們分析EEA對(duì)患者神經(jīng)心理的影響。在這里，我懷疑相對(duì)于開(kāi)顱術(shù)和額下入路或翼點(diǎn)入路，EEA可能是一種治療顱咽管瘤的有益方法。

　　該論文作者為INC國(guó)際神經(jīng)外科醫(yī)生集團(tuán)旗下國(guó)際神經(jīng)外科顧問(wèn)團(tuán)(WANG)成員、國(guó)際神經(jīng)外科學(xué)院院長(zhǎng)(2011-2014)James T. Rutka教授。

　　資料來(lái)源：https://sci-hub.se/https://www.ncbi.nlm.nih.gov/pubmed/18590425