| As the hotspot object for surgery research, the pituitary adnoma affects the patients'living quality because of its high incidence and recrudesce. The tumor resection is the most primary therapy means. The great changes happens in the method and effect of pituitary adnomas surgery followed with the rapid development on the related technology during nearly 20 years. The transcranial surgery with high risk and expenses has been replaced by the transsphenoidal surgery with relatively minimal-invasion and safety. The therapy standard of pituitary adnoma has been transferred from original intention of releasing oppress of tumour and saving of eyesight to striving for keeping and restoring internal secretion. It becomes the present hotspot research, that is how to lower tumour's recrudesce rate and reduce operation complications.Object: To explore the reason, frequent location and therapy measures of residual tumor after the transsphenoidal surgery of pituitary adnomas. To summarize operation complications, the preventive and therapy measures.Method: To analyze retrospectively 96 cases of pituitary adenomas treated with the transsphenoidal surgery in our hospital from January 2003 to November 2006, on the base of reviewing systemic surgery therapy articles about pituitary adnoma. All cases are composed of 36 cases of prolactin-secretion adenomas, 16 cases of somatotropin-secretion adenoma, 17 cases of mixed hormone-secretion adenomas, 26 cases of non-functioning pituitary adenomas and 1 case of adrenocorticotropic hormone-secretion adenoma. The utmost diameter of pituitary adenomas is not beyond 10mm in 16 cases, equal to 11-30mm in 38 cases, 30mm above in 42 cases among which 16 cases reaches to 40mm above and the maximum of it reaches to 58mm. The average maximum diameter is 33.2mm. Cavernous sinus were invaded by pituitary adnomas on one or both sides in 42 cases, among which the internal carotid artery were oppressed only without wraped (Knosp 1-2 grade) in 23 cases, partial wraped (Knosp 3 grade) in 14 cases, total wraped (Knosp 4 grade) in 5 cases. Transsphenoidal microsurgery were applied on 69 cases and endoscope-assisted transsphenoidal microsurgery on 27 cases.Results: Total removal of pituitary adenomas was accomplished in 73 cases (76%), subtotal removal in 13 cases (13.5%), partial removal in 10 cases (10.4%). There was not tumor residual in 16 cases with micro adenomas (≤10mm). 5 cases of residual adenomas were found among 38 cases with 10-30mm adenomas and 18 cases of it among 42 cases with﹥30mm adenomas. With the following check on pituitary hormone after operation, 48 cases(68.6%) recover normal hormone level and the others are improved with different degrees among 70 cases with the function adenomas. Improvements of visual acuity and visual fields were accomplished in 51 cases(87.9%), no changes in 5 cases(8.6%), more serious in 2 cases(3.4%). The diabetes insipidus happened in 24 cases(25%), hypopituitarism in 14 cases(14.6%). The cerebrospinal fluid rhinorrhea happened in 6 cases(6.3%),Bleeding in 6 cases(6.3%). 2 cases died, of which 1 case was hurt on hypothalamus by surgery and the other was infected. Assistant therapy were not conducted on the patients with total removal of pituitary adenomas. 9 cases were treated with r-knife stereotactic radiotherapy among 23 cases of residual adenoma,5 cases were treated with bromocriptine.72 cases have been visited following on the duration of 3-41 months and the average of 19.5 months. The menses restore normal after operation in 18 cases among 27 cases of amenorrhea. 9 cases felt the symptom obviously improved among 15 cases with acromegaly. Hormone secreting restore normal in 10 cases in 1 to 6 months after operation among 12 case of hypopituitarism. The patients checked regularly by MRI scanning in 3 months after surgery, among which 59 cases (81.9%) had no residue of tumor, 13 cases(18.1%) had obvious residue of tumor. The residual tumor include cavernous sinus in 6 cases(8.3%), suprasellar in 3 cases(4.2%), inner sellar in 1 cases(1.4%). During the follow-up periods, tumor recurrence was happened in 2 cases(2.8%),residue of tumor kept on growing in 4 cases(5.6%)。 Conclusion: The main characters which result in residue of tumor after transsphenoidal surgery includes tumor invasion heavily in cavernous sinus, the expansion on suprasellar obviously and the tumor with irregular shape, solid texture and huge cubage. In addition, the surgeon's experience and the familiarity with the sellar and parasellar anatomy have close relationship with residue of tumor. The residue of pituitary adenomas often includes cavernous sinus, suprasellar and innersellar.It is important for operator to know well with all surgery process to conduct MRI scanning before surgery, which reduce the residue of tumors. The opening scope of dura of sellar floor should be paid more attention during operation, especially the dura should be unfolded till the boundary between dura of sellar floor and the cavernous sinus in preventing from the residue of tumor in sellar. The removal of tumors should be processed sequently from backside, both sides to front side in order to avoid diaphragma descending earlier to disturb the surgery process. The integrality of diaphragma should be protected in operation. It is helpful to flush after the removal of tumor to clean out the residue pieces of tumor tissue. The degree of the removal of tumor can be judged according to the level of diaphragma descending. The endoscope could provide multi-angle, panorama visual fields and better lighting to decrease the residue of tumor effectively. The united application of endoscope and microscope during operation could exert advantages better respectively.The occurrence frequency of complications are less in transsphenoidal than in transcrinal surgery. The complications include diabetes insipidus, hypopituitarism, cerebrospinal fluid rhinorrhea, bleeding, visual deterication and hypothalamus hurting, etc. It will directly affect the patient's prognosis whether to treat with the complications correctly. It depends on improving surgery's skill, soft manipulation and the development of surgery instruments to prevent from the complications, especially the endoscope technology will play a role for the higher level of therapy in transsphenoidal surgery。Considering that the minimally invasion and economic elements of transsphenoidal surgery, the premise should be obeyed that the safety of surgery do not be lowered to pursue the rate of total removal of tumor, combining with the pituitary adenoma's pathology specialty and the improvement of integration therapy level. |
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