颅咽管瘤的手术治疗策略及术后并发症的处理

发布时间：2018-08-15 13:56

【摘要】：目的：总结颅咽管瘤的手术治疗经验，探讨颅咽管瘤手术入路的选择、术中操作要点以及后并发症的防治。在最大程度保护重要组织结构、减轻术后并发症的前提下最大限度的切除肿瘤。方法：回顾性分析从2008年5月至2014年2月在我院行手术治疗的46例颅咽管瘤患者的临床资料，术前根据患者肿瘤的影像学特点选择不同的手术入路切除肿瘤，比较不同手术入路的治疗效果。结果：46例颅咽管瘤患者当中，男性21例，女性25例。年龄9-68岁，平均年龄43.2±9岁。其中43例为首次手术，3例为复发后二次手术。首发症状主要为多饮多尿（20例）、头痛（15例）、视力下降（12例）、性功能减退（7例）、乏力嗜睡（3例）以及发育迟缓（2例）。其中2例采用神经内镜经右鼻孔-蝶窦入路，6例采用经额下入路，10例经翼点入路，12例采用经胼胝体-透明隔-穹窿间入路，16例采用经前纵裂-终板入路。29例患者获得全切，12例次全切除，5例大部切除。术后电解质紊乱41例，尿崩27例，腺垂体功能减退37例，，颅内感染12例，视力下降3例，癫痫2例，脑脊液漏2例。随访39例出院患者，平均随访28.3月，其中21例能正常生活和参加工作，9例因腺垂体功能减退需长期口服氢化可的松替代治疗，8例因顽固性尿崩需长期服用弥凝控制，3例术后视力下降，1例因下丘脑受损及腺垂体功能严重低下生活无法自理。有12例未能够全切的患者在术后3年内肿瘤复发，其中5例行伽马刀治疗，7例未再进一步治疗，无死亡病例。结论：1.显微外科手术切除是治疗颅咽管瘤的首选方式，首次手术如能全切则有望获得最佳治疗效果；2.与第三脑室关系密切的颅咽管瘤手术难度最大，采用经前纵裂-终板入路或经胼胝体-透明隔-穹窿间入路切除此类肿瘤效果较好；3.术前根据颅咽管瘤患者的影像学特征选择适当的手术入路，术中注意保护下丘脑和垂体柄是手术成功的关键；4.术后严密监测患者的意识、生命体征、电解质以及尿量的变化，及时治疗并发症能取得良好的治疗效果。
[Abstract]:Objective: to summarize the experience of surgical treatment of craniopharyngioma, to explore the choice of operative approach, operative points and prevention and treatment of postoperative complications of craniopharyngioma. Under the premise of protecting the important tissue structure and reducing the postoperative complications, the tumor was excised to the maximum extent. Methods: the clinical data of 46 patients with craniopharyngioma treated in our hospital from May 2008 to February 2014 were analyzed retrospectively. The therapeutic effects of different surgical approaches were compared. Results among 46 patients with craniopharyngioma, 21 were male and 25 were female. The average age was 43.2 卤9 years. Among them, 43 cases were the first operation and 3 cases were the second operation after recurrence. The initial symptoms were polydipsia (20 cases), headache (15 cases), visual acuity decline (12 cases), sexual dysfunction (7 cases), fatigue and lethargy (3 cases) and growth retardation (2 cases). Of them, 2 cases were treated by endoscopy through right nostril sphenoid sinus approach 6 cases by transfrontal approach 10 cases via pterygoid approach 12 cases by transcallosal pellucid septum interfornix approach 16 cases by anterior longitudinal fissure endplate approach .29 cases 12 cases of subtotal resection were obtained. 5 cases underwent subtotal resection. There were 41 cases of electrolyte disturbance, 27 cases of urinary avalanche, 37 cases of hypophysis, 12 cases of intracranial infection, 3 cases of visual acuity loss, 2 cases of epilepsy and 2 cases of cerebrospinal fluid leakage. 39 patients were followed up for an average of 28.3 months. Among them, 21 cases were able to live and work, 9 cases needed long-term oral hydrocortisone replacement therapy because of hypophysis, 8 cases needed to take Mylopsis for a long time because of intractable urinary collapse, 3 cases had visual acuity loss and 1 case had hypothalamus. Serious damage to the pituitary gland function of the life can not be taken care of. There were 12 cases of tumor recurrence within 3 years after operation. Among them, 5 cases were treated with gamma knife and 7 cases were not treated further, and there were no cases of death. Conclusion 1. Microsurgical resection is the first choice in the treatment of craniopharyngioma. The craniopharyngioma with close relationship with the third ventricle was the most difficult operation. It was better to use the anterior longitudinal fissure-endplate approach or the transcallosal septum-fornix approach to remove these tumors. According to the imaging features of patients with craniopharyngioma, the proper operative approach was chosen before operation. The key to successful operation was to protect the hypothalamus and pituitary stalk. The changes of consciousness, vital signs, electrolytes and urine volume were closely monitored after operation, and good results could be obtained by timely treatment of complications.
【学位授予单位】：重庆医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R739.41

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