터키안 주변부 대형 종양의 외과적 치료

하상수,김형동,김기욱,김규홍 대한신경외과학회 1996 Journal of Korean neurosurgical society Vol.25 No.4

We analyzed 56 operations in 45 patients with sellar and parasellar tumors from March. 1990 to May, 1995. to evaluat the determining factors in selecting the surgical approaches for large and giant sellar and suprasellar tumors. based on clinical. endocrinological and radiological findings. The definition of "large" is when the longest diameter of the tumor is more than 20mm on radlographic studies and the term "small" is applied to tumor of diameter below 19mm. The results were as fellows : 1) Number of the patients with small tumor was 14(31.1%) and all of them were treated with single stage transsphenoidal approach. and 42 operations were performed in31(68.9%) patients with large tumors 2) The approaches for large tumors were : transsphenoidal approach in 32 casgs ; pterional approach 5 cases ; subfrontal interhemispheric approach 4 cases ; and subfrontal paramedian approach 1 case. 3) The rate of complete removal for large and giant tumors in the first operation was 2.90% , in second operation. 72.7% ; overall the rate was 54.8% 4) Complications were : transient type diabetes insipidus in 24 cases; meningitis 2 cases ; hypothalamic injury 3 cases ; CSF rhinorrhea 1 case ; and cerebral infarction 1 case : and death 1 case 5) There was significant relationship between the size o# the tumor and tumor types(p <0.05) and the degree of suprasellar extension(p <0.05) but not with destruction of the sellar floor(p> 0.05) 6) There was significant relationship between the surgical approaches and size of the tumors(p <0.05) and degree of suprasellar extension(p <0.05). but not with degree of destruction of the sellar floor(p> 0.05) 7) In case of incomplete removal with first trassphenoidal approach. a second operation seems to be helpful 8) In second stags transcranial approach fellowing first transsphenoidal approach. it is easier to remove the tumor due to the decreased tumor size and thus, a reduced need for marked brain refraction. From our findings. we suggest guidelines in choosing the surgical approach for sellar and parasellar tumors as follows 1) Many of the tumors in the sellae and suprasellar area can be removed successfully by transsphsnoidal approach. 2) Taranssphenoidal approach can be repeated safety in stage 0. A, B and C. if the diaphragm sella remains intact 3) Tanscranial approach is recommended primarily in stage D & E. if intrasellar portion of the tumor is not significant or opening of the diaphragm sella is narrow. 4) Transsphenoidal approach followed by transcranial approach is adequate in stage D & E. if significant amount of the tumor remaining in the sella or sellar floor is severely destructed(Grade Ⅲ . Ⅳ)

경접형동 접근법

박상근 ( Sang Keun Park ) 대한뇌종양학회 2002 대한뇌종양학회지 Vol.1 No.2

First successful removal of pituitary tumor via the transsphenoidal approach was reported in 1907. Even though the admittable benefits of this approach based on direct and short extracranial route to sellar region, its clinical application came up against wall due to higher morbidity and mortality rates. But this approach had been used and developed continuously by a large numbers of named neurosurgeons. With the development of antibiotic drugs and modern microinstrumentation, transsphenoidal approach is the preferred approach for lesions confined to the sellar turcica and parasellar regions, and in some cases lesions of clibus as well. The routes of access for the transsphenoidal approach are sublabial transseptal, endonasal submucosal transseptal, direct endonasal with septal pushover, and endonasal endoscopic. Recently efforts have been made to use frameless stereotaxy, real-time intraoperative imaging, and the endoscope to improve effectiveness of the approach with minimal morbidities. Transsphenoidal surgery seems to be a reasonably safe procedure, with a mortality rate of less than 1%. However, a significant number of complications do occur, especially performed by less experienced surgeons. In hope of being better understood of this procedure the author has reviewed related literatures, and presents the history, the technique, the complications, and the modern evolution of transsphenoidal approach.

Anterior Approaches to Midline Skull Base Tumors

Kim, Jung Hoon,Kim, Chang Jin,Whang, C. Jin 대한신경외과학회 1996 Journal of Korean neurosurgical society Vol.25 No.4

지난 50년간 두개기저부 종양의 제거를 위하여 많은 수술적 접근법들이 사용되어져 왔다. 그러나 두개기저부의 접근이 대단히 어렵고 복잡하여 그 수술 결과는 만족스럽지 못하였으며. 아직도 이 부위의 접근법에 대하여 어려운 문제들이 남아있고. 또한 다양한 접근법들이 시도되고 있다. 이러한 다양한 접근법들중에서 전방접근법을 이용하여 정중두개기저부 종양에 보다 쉽게 도달할수 있으며 수술에 용이한 시야를 확보할 수 있다. 본 교실에서는 지난 1989년 6월이후 정중 두개기저부 종양으로 입원하였던 환자들중 9명의 환자들에서 12예의 전방접근법을 이용하여 종양을 제거하였다. 수술후 추적관찰기간은 5개월에서 50개월이었다. 시행되었던 전방접근법들은 transshpenoidal approach 4예. Le Fort I osteotomy 3예, lateral rhinotomy 2예, facial translocation approach 2예, 그리고 craniofacial approach 1예 이었다 시행되었던 접방접근법들에 의하여 좋은 수술시야를 확보할수 있어 수술이 용이하였다. 수술부위의 회복도 빨랐으며 환자들에게 큰 불편을 주지않았다. 수술후 성형결과도 만족할만 하였으며. Le Fort I osteotomy를 시행하였던 환자들에 있어서 부정교합과 관계된 문제는 없었다 Facia) translocation approach를 시행하였던 환자에서 nasolacrimal duct의 폐쇄 및 방부위의 감각감퇴가 발생하였다. 수술후 종양의 진행으로 그리고 뇌척수액비루에 의 한 뇌막염으로 2명의 환자가 사망하였다 저자들의 경우 전방접근법을 시행한 예가 아직 적고 그 추적관찰기간이 짧기는 하나, 정중 두개기저부 종양의 제거를 위하여 종양의 크기 위치 조직학적 분류, 그리고 환자의 연령등 여러 조건들을 고려한후 다양한 접근방법중 전방접근법도 유용하게 이용될수 있다고 생각한다. Among various approaches to midline skull base tumors. anterior approaches can provide excellent visualization of the lesion Since June 1989. If anterior procedures have been carried out on 9 consecutive patients presenting with midline skuil base tumors(four transsphenoidal approaches. three Le Fort I osteotomies, two lateral rhinotomies two facial translocation approaches. and one craniofacial approach). These anterior procedures allowed good access to the lesions Wound healing was rapid. with little discomfort to the patients Cosmetic results were also excellent, and there were no significant problems related to malocclusion in the cases of Le Fort I osteotomy. Patients who underwent facial translocation approach developed nasolacrimal duct obstruction and small area hypesthesia on the cheek. Postoperatively two patients died from tumor progression and meningitis secondary to CSF leakage. respectively Although the number of cases and follow-up period are limited in our series. we think that anterior approaches may be useful in the surgical treatment to midline skull base tumors.

임상 : 사대 척삭종의 수술 치료에 대한 비교 분석; 내시경을 이용한 경접형동 접근법의 유용성

정종철 ( Jong Chul Chung ),김승민 ( Seong Min Kim ),정성삼 ( Sung Sam Jung ),박기석 ( Ki Seok Park ),박문선 ( Moon Sun Park ),김한규 ( Han Kyu Kim ) 대한뇌종양학회 2009 대한뇌종양학회지 Vol.8 No.2

Objective:Chordomas, whether involving the clivus or simply situated anterior to the brainstem, present a technical challenge for adequate exposure and safe resection. Transsphenoidal approach is safer and easier than any other approaches, but it has some limitation of resectability in laterally extended tumor. The objective of this paper is to demonstrate the advantages of endoscope assisted transsphenoidal approach to remove paraclival lesion on the midline. Methods:Nine patients with clival chordomas underwent surgery in our institution from 2002 to 2009. There were two men and seven women who ranged in age between 4 and 59 years. Four patients underwent stage operation by both transsphenoidal surgery and transpetrosal or transcavernous surgery. Three patients underwent only transsphenoidal surgery and two underwent only transpetrosal surgery. For image guidance, both endoscope and neuronavigation system were used in all surgical procedures. Results:Gross total removal was achieved in 33.3% and subtotal removal was achieved in 55.5%. The mean follow-up period was 44.2 months. The mortality rate during the follow-up period was 11.1%. Conclusion:For accessing clival chordoma via an anterior route, visualization of the tumor with the endoscope and navigation system is readily achievable and have the advantages of confirmation the anatomy that cannot be seen in the conventional transsphenoidal approach. This study shows transsphenoidal approach become safer and easier if the tumor is located on upper two thirds of the clivus and located on the midline.

뇌하수체 종양 수술에서 변형된 Killian 절개를 사용한 비중격 연골 제거 및 재위치 방식의 경비중격 경접형동 접근법의 임상적 유용성: 42예에 대한 분석

이경철,김소연,양병욱,이용우 대한비과학회 2019 Journal of rhinology Vol.26 No.1

Background and Objectives: The conventional transseptal transsphenoidal approach can inhibit visualization of the surgicalfield and may change the shape of external nose. We used the transseptal transsphenoidal technique to remove septal cartilageexcept the L strut via a modified Killian’s incision and preserved the ‘key-stone area.’ The aim of this study was to verify theusefulness of this technique. Subjects and Method: Retrospective analysis was carried out on 42 pituitary tumor patients who received this technique bya single otolaryngologist from March 2005 to March 2012 at Kangbuk Samsung Hospital. Results: The mean patient age at time of surgery was 52 years, and 41 cases were pituitary adenoma and 1 was Rathke’s cleftcyst. Three patients had undergone prior surgery; of which 2 used a pterional approach and 1 a transsphenoidal approach. Withregard to complication, there were 2 cases of CSF leakage and 5 cases of septal laceration. There were no cases of meningitis,deformity of external nose, septal perforation, anosmia, or sinusitis. In post operation follow up, 25 cases (59.5%) had no residualtumor, while 17 cases (40.5%) had residual tumor. Conclusion: This study reveals that transseptal transsphenoidal surgery with septal cartilage removal and a replacement techniquefor a pituitary tumor are effective, allow easy exposure, and result in a low complication rate.

축주편을 이용한 경접형동 수술방법

신형진,김동규,전시영 대한신경외과학회 1989 Journal of Korean neurosurgical society Vol.18 No.7-12

Recently, transsphenoidal approach is regarded as the principal method for the resection of pituitary tumor. The sublabial transseptal transsphenoidal hypophysectomy is a classical one, but it has certain limitations and postoperative problems. So various modifications of transsphenoidal hypophysectomy have been proposed. The columellar flap is one of such modified approaches.

경접형동 안경막상부 경막내 접근법 -수술수기-

이우택,김재민,최일승,백광흠,김충현,김남규 대한신경외과학회 1999 Journal of Korean neurosurgical society Vol.28 No.10

Surgical Experience of Transsphenoidal-Supradiaphragmatic Intradural Approach to Presellar and Suprasellar Lesions

Park, Min-Woo,Kim, Jae-Min,Kim, Jae-Hoon,Bak, Koang-Hum,Kim, Choong-Hyun,Jeong, Jin-Hyeok The Korean Neurosurgical Society 2006 Journal of Korean neurosurgical society Vol.39 No.5

Objective : In selected cases, the transsphenoidal approach[TSA] can be extended anteriorly to the tuberculum sellae, chiasmatic sulcus, and planum sphenoidale to obtain direct exposure of the suprasellar cisterns and its contents. We applied this modification of the TSA to various lesions of the presellar and suprasellar areas. We evaluate our clinical experience of this technique and review the related literature. Methods : From 1999 to 2004, we used the transsphenoidal supradiaphragmatic intradural approachs[TSIAs] in 9 patients who had various lesions at the pre- and suprasellar regions. Concomitant presellar extension of the bone window was performed with the sublabial or transnasal transseptal transphenoidal techniques. After removal of the lesions, sellar or anterior cranial floor was repaired with silicone plate substitute. Results : The TSIAs have been applied in the following cases : four tuberculum sellae meningiomas, two craniopharyngiomas, two Rathke's cleft cysts, and one non-functioning macroadenoma. The complications were one case of visual acuity decrease and one cerebrospinal fluid rhinorrhea. Conclusion : The TSIA is easily applicable through a minor modification of the standard TSA. It is suitable for removing lesions located in the presellar and suprasellar area adjacent to the pituitary stalk with minimal brain manipulation and decreased morbidity.

거대뇌하수체 선종의 신경외과적 치료

정희원 대한신경외과학회 1988 Journal of Korean neurosurgical society Vol.17 No.3

In order to establish a more reasonable therapeutic guide line for giant pituitary adenomas, the authors analyzed 31 cases of giant pituitary adenoma which were operated on between January, 1985 and July, 1987. The term, 'giant' applies primarily to a pituitary adenoma with a size of 4㎝ or more in diameter. The two most common chief complaints were visual disturbance(18cases) and headache(6 cases). Endocrinologically, 17 cases(55%) were non-functioning and 14 cases(45%) produced hypersecretion syndrome : prolactionoma(8 cases), acromegaly(5 cases), and Nelson's syndrome(1 case). Twenty-eight cases showed marked suprasellar extension. Surgical treatment was given to 16 cases by transphenoidal approach and 15 cases by transcranial approach. Postoperative radiation therapy was given to 22 cases. Surgical results in the transsphenoidal group were better than in the transcranial group as there were fewer and less severe postoperative complications without a deterioration of vision. For the treatment fo the giant pituitary adenoma, decompression of the tumor through transsphenoidal approach at first followed by postoperative radiation therapy, was effective. The transcranial approach was considered to be recommendable in cases of recurrence.

Clinical Experience of Rathke's Cleft Cysts

Kim, Jung Hoom,Ha, Young Shin,Kwon, Yang,Rhim, Seung Chul,Lee, Jung Kyo,Kwun, Byung Duk,Whang, C. Jin 대한신경외과학회 1995 Journal of Korean neurosurgical society Vol.24 No.9

최근 신경방사선 기술의 발달로 인하여 이전에는 드물게 발견되던 Rathke's cleft cyst가 보다 흔히 진단된다. 저자들은 1989년 6월부터 1994년 10월까지 본원에서 치료를 받았던 9예의 Rathke's cleft cysts를 대상으로 임상적, 방사선학적, 그리고 병리학적 소견들을 분석하여 보았다. 여성에서 많이 발생하였으며, 평균연령은 25세이었다. 가장 흔한 증상 및 징후는 두통, 시야장애, 그리고 뇌하수체기능이 상등이었다. 약 77.8%에서 터어키안 및 터어키안상부에 위치하였다. CT를 시행하였던 5예에서 preenhanced CT상 low density 또는 isodensity의 소견을 보였으며, contrast-enhanced CT상 5예 중 2예에서 ring enhancement의 소견을 보였다. MRI의 소견 또한 무척 다양하여 Rathke's cleft cyst의 특징적인 소견은 발견할 수가 없었다. 6예에서 transsphenoidal approach를 그리고 3예에서 transcranial approach를 시행하였고, 주로 낭종의 부분절개 및 배액술을 시행하였다. 비록 추적기간은 짧으나 재발할 경우는 없었다. 낭종은 주로 columnar 또는 cuboidal epithelium 으로 구성되어 있었다. 수술 후 뇌하수체기능저하증을 제외하고는 대부분의 증상 및 징후는 호전되었다. 저자들은 trasnssphenoidal approach를 통한 낭종의 부분절개 및 배액술의 가장 이상적인 치료법이라고 생각한다. Rathke's cleft cysts(RCCs) are classically described as benign epithelium-lined intrasellar cysts containing mucoid material. They are thought to orignate from remnants of the Rathke's pouch. These cysts are most frequently small and asymptomatic, and generally regarded as rare lesions. With the introduction of modern neuroimaging technology, they are being diagnosed much more frequently. We reviewed clinical, radiographic, and pathological findings in nine patients with symptomatic RCCs who were treated at out hospital from June 1989 to October 1994. The lesions were more often encountered in female than male patients, and the mean age at presentation was 25 years. The most common symptom and sign were headache, visual disturbance, and pituitary dysfunction. Two cysts were entirely intrasellar and seven had intra and suprasellar components. Pre-enhanced CT scans revealed low dense or isodense lesions in five cases, and contrast-enhanced CT scans showed ring enhancement in two of five cases. MRI findings were varied with no characteristic pattern. Six patients underwent surgery by the transsphenoidal approach, and another three patients were treated by the transcranial approach. Partial excision and drainage of the cysts was most commonly performed, and there was no cyst recurrence. The cyst lining was usually composed of couboidal or columnar epithelium. Most symptoms and signs improved or resolved following surgery with the exception of hypopituitarism. Because of the relative safety and low recurrence rate, we think that partial excision and drainage of the cyst by the transsphenoidal approache is the treatment of choice.