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颅咽管瘤的经鼻切除术(Endonasal resection of craniopharyngiomas)

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  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.



  我们感兴趣的是颅咽- mas系统的分类它是由内窥镜,鼻内神经外科医生最能理解的:I型,漏斗前;II型,transinfundibular;III型,漏斗后。在理论上,这是一个有吸引力的分类系统。然而,在实践中,有时颅咽管瘤太大,茎部模糊不清,或者MR图像不足以完全确定肿瘤相对于漏斗部的位置。我想赞扬作者们愿意通过EEA来处理一些较困难类型的颅咽管瘤(例如,IIIa型和IIIb型病变)。几年前,我认为这种治疗“交叉后”颅咽管瘤的方法是不可能的。现在,随着微创神经外科医生和耳鼻喉科医生所独有的技术的出现,以及本研究中所阐述的技术,各种类型的颅咽管瘤都可以成为EEA的目标。


  Gardner和同事的这篇报告不仅仅是一个技术说明,但还没有达到颅咽管瘤1 - 4系列报道的水平,在该系列报道中,对更多的颅咽管瘤患者进行了研究,并在某些情况下进行了更长时间的随访。然而,在所有的病例中,包括目前的病例,颅咽管瘤的复发是不可避免的。某些系列的复发率可能高达40%。复发性颅咽管瘤的治疗是一个令人烦恼的问题,人们想知道首次使用EEA治疗的患者是否会再次成为使用这种方法重复手术的候选人。



  该论文作者为INC国际神经外科医生集团旗下世界神经外科顾问团(WANG)成员、世界神经外科学院院长(2011-2014)James T. Rutka教授。