Endoscopic transsphenoidal pituitary tumor resection

Endoscopic transsphenoidal sinus pituitary tumor resection is based on microsurgery. Advances in neuroimaging (CT/MR) have enabled early detection of small and medium pituitary tumors. Although neuroendoscopy systems are mostly used for the treatment of intraventricular lesions, endoscopic (NE) surgery or endoscopic assisted microsurgery (NAM) transnasal-sphenoid sinus can be used after instrumental improvement and clinical experience. Pituitary tumor resection. The main advantage of this surgical procedure is that the trauma is small and the endoscope enters through the nasal cavity without the need to separate the nasal septum. Jho et al (1997) reported 48 cases of microsurgery with endoscopic assistance. At present, endoscopic removal of pituitary tumors does not require removal of the turbinate. Compared with simple microsurgery, endoscopic or endoscopic-assisted microsurgery has the following advantages: (1) the use of nasal cavity to expose the saddle bottom, no need to strip the nasal septum mucosa; 2 postoperative discomfort decreased, hospitalization days shortened; When the brightness of the mirror is good and the angle of view is wide, it is easy to distinguish the boundary between the tumor and the normal tissue during the operation; 4 is a surgical method with small trauma, safety and effectiveness. Treatment of diseases: sphenoid sinus malignancy Indication 1. Small in-sag tumors in the volume. 2. Recurrence after transsphenoidal microsurgery. Contraindications 1. A-type sphenoid sinus, bone drill to remove the sphenoid sinus bottom. 2. A huge pituitary tumor with difficulty in endoscopic resection. Preoperative preparation Endocrine examination Includes a comprehensive determination of multiple endocrine hormones in the pituitary gland. Such as growth hormone, prolactin, adrenocorticotropic hormone, thyroid stimulating hormone, follicle stimulating hormone, luteinizing hormone and some hypothalamic endocrine hormones. 2. Imaging examination In addition to the normal and multi-trajectory tomograms of the sella, thin-slice CT and MRI scans of the sella should be performed where possible. 3. Drug preparation Patients with obvious hypopituitarism should receive appropriate replacement therapy before surgery, usually given dexamethasone or prednisone for 2 to 3 days. A large pituitary adenoma initially diagnosed as prolactin can be given bromocriptine for 2 to 4 weeks, 7.5 mg per day, which can reduce the tumor or improve vision. However, the preparation and treatment of bromocriptine should not be too long before the operation (not more than 2 to 3 months), otherwise the fibrous tissue in the tumor can be proliferated and the operation is difficult. 4. Repeat the intranasal rinsing of the patient several days before the operation, or periodically add antibiotic solution. The nose hair was cut off 1 day before the operation, and washed, and the antibiotic solution was added dropwise. Surgical procedure 1. Disinfect the nostrils, nasal cavity and upper lip, and stuff the sterile gauze in the oropharynx. 2. Place the cotton pad soaked with phenylephrine into the nasal cavity for a while to reduce congestion of the nasal mucosa. 3. Place a 4 to 6 mm diameter hard endoscope in the right or left nasal cavity (larger). Usually the sphenoid sinus opening is found with a 0° or 30° sight glass. 4. On the side of the endoscope, use the Kerrison rongeur to expand the sphenoid sinus opening to the posterior and the contralateral sphenoid sinus opening to a diameter of 1.5 to 2 cm. After fully revealing the sphenoid sinus, the rongeur is used to remove the sphenoid sinus septum. To the bottom of the saddle, the anterior wall of the sphenoid sinus is opened by high-speed drilling, and the endoscope with a diameter of 6 to 8 mm is fed. 5. Electrocoagulation of the dura mater and then incision, the biopsy forceps, curettes and other special microscopic instruments can be applied through the endoscopic working channel, all or most of the pituitary tumors are removed, such as no cerebrospinal fluid leakage during operation, no fat filling, other treatment Same as "transsphenoidal pituitary adenoma resection". complication Cerebrospinal fluid leakage Due to the tearing of the arachnoid sac on the saddle in the operation. As the cerebrospinal fluid flows into the saddle tumor bed, and the saddle bottom is not well repaired, the stuffed muscle block is not tight enough or falls off, and a cerebrospinal fluid rhinorrhea is formed. The key to its prevention is that the muscle block filled in the saddle should be sufficient. The bone piece for repairing the saddle bottom should be firm or adhered with bio-adhesive tightly; in addition, the arachnoid surrounding the pituitary should not be torn too much during the operation. If it does, apply the fascia carefully. Sometimes mild cerebrospinal fluid leakage after surgery, a small amount of exudation of the nasal dressing, self-healing after more than a few days. If the cerebrospinal fluid leaks more, the silicone tube can be implanted through the lumbar spinal canal for continuous drainage, and the leak can be self-healing after a few days. In more serious cases, the saddle bottom needs to be repaired again. When dealing with concurrent cerebrospinal fluid leakage, special attention should be paid to grasping the timing, avoiding excessive observation waiting, missing the timing of repair, and causing serious intracranial infection, resulting in death of the patient. 2. Meningitis Generally, it is caused by intracranial infection of the arachnoid membrane in the saddle pool or intracranial infection after cerebrospinal fluid leakage. In addition to the application of antibiotics to control infection, cerebrospinal fluid leakage should be repaired in time. 3. Diabetes insipidus Due to injury to the posterior pituitary or pituitary stalk during surgery. Among them, the symptoms caused by the posterior pituitary injury are mild and easy to recover, and the treatment with pituitrin can be gradually improved after about 1 week. The closer the injury is to the pituitary stalk and the funnel, the heavier the diabetes insipidus is, and it is difficult to recover. 4. Cavernous sinus, internal carotid artery and cranial nerve injury Because the approach is more complicated, and the neurosurgeon is not familiar with the nasal and sphenoid sinus anatomy or the intraoperative operation deviates from the midline, the important structure on both sides of the saddle is damaged. The general statistical incidence rate is about 0.5%. In the Department of Neurosurgery, General Hospital of PLA, 550 cases of cerebral sinus pituitary adenoma were injured in the internal carotid artery. Four cases of intracranial hemorrhage occurred during operation. The operation occurred after the compression of the muscle piece. One patient underwent carotid angiography and the other patient underwent carotid angiography for 3 weeks after surgery. These 2 cases all saw pseudoaneurysm of the cavernous sinus segment of the internal carotid artery and were cured after balloon embolization. In the other case, nasal hemorrhage suddenly occurred 20 days after the operation, and the bleeding stopped after the right carotid artery was compressed. The side of the common carotid artery was cured by emergency surgery. There was also one case of postoperative consciousness, sudden and severe headache the next day, and massive bleeding of the nose and mouth did not be treated in time and died, which may be related to carotid injury. A similar situation rarely occurred after 1991. 5. Optic nerve or optic chiasm damage According to reports in the literature, the highly vaporized sphenoid sinus, the optic canal can be partially exposed to the sphenoid sinus, can cause optic nerve damage when tearing the sphenoid sinus mucosa, in addition to seeing the saddle septum to damage the optic nerve or vision during tumor resection cross. For the removal of large or extended tumors on the saddle, the operation is particularly careful. 6. Nasal septum perforation The nasal septum mucosa was removed from both sides by the oral and sphenoid sinus approach and the nasal septal cartilage was partially removed. The mucosal exfoliation was incomplete and prone to perforation of the nasal septum. This complication can be greatly prevented by peeling the nasal septum mucosa from one side and retaining the septal cartilage. Others include sinusitis and ophthalmoplegia. 7. Protracted blood sodium reduction Kelly (1995), Olson (1997) and others have found that about 25% of patients with pituitary tumors within 2 to 7 days after surgery, blood sodium reduction (<130mmol is blood sodium reduction), can be combined with hematuria osmotic pressure, water metabolism Change. The pathophysiological mechanism is complicated. In addition to the factors of surgery and the lack of food intake, it may also be related to the increase of vasopressin and vasopressin secretion in the posterior pituitary and pituitary stalk injury during surgery. Care should be taken to monitor changes in water and salt metabolism and to correct diuretics at any time.