| Background & Objective:Pituitary adenoma is a common intracranial tumour in clinic.At present,surgical treatment is the main method.In traditional surgery,both endoscopy and microscopy have certain limitations.In the past,we tried to use PEEP(positive end expiratory pressure,PEEP)to increase intracranial pressure so that tumors breaking through the sellar septum could be reduced,and the tumors could be more fully exposed,so as to improve the Total resction rate.But in practice,it was found that premature reduction of the sellar septum made the center of the tumor collapse more obvious than around,and the sellar fossa became a "pocket" around the tumor.Some of them were squeezed between sellar floor bone and sellar septum dura mater,which affected the surgical field of vision and was not conducive to total resection of tumors.In the current work,we introduce a new method of Multimodal image fusion 3D reconstruction to assist the operation.This method can obtain precise,three-dimensional and realistic anatomical information of patients before operation,and to a certain extent avoid unstable factors such as reading and analysis of patients’ imaging data by clinicians’ personal experience.The important information such as surgical approach,maximum range and direction of sellar floor abrasion and resection range of tumors were determined by simulated operation.By this way,the total resection of tumors is improved under the condition of ensuring safety.Multimodal image fusion 3D reconstruction,represented by 3D slicer,has been widely used in basic medicine and neurosurgery,especially in the diagnosis and treatment of cerebral hemorrhage,but seldom in the diagnosis and treatment of pituitary adenomas.Tumor total cut rate were used as an evaluation index,to analyze the effect of preoperative multi-modal image fusion 3D reconstruction,intraoperative intracranial pressure increase using PEEP,age,tumor size and other factors on the total surgical resction rate,in order to improve the total resction rate of surgery,and thus to provide theoretical support for endoscopic assisted transsphenoidal pituitary adenoma resection.Participants & Methods:A total of 47 patients of neurosurgery from the Second Affiliated Hospital of Zhengzhou University between Jun 2015 and Jun 2018 were enrolled,and receive endoscopic assisted transsphenoidal pituitary adenoma resection.Postoperative pathological reports were all pituitary adenomas.Among them,there were 22 males(46.8%)and 25 females(53.2%);the age was 26~74 years old,with an average age of 46.91±11.95 years old.18 cases(38.3%)were small adenoma,24 cases(51.1%)were large adenoma,and 5 cases(10.6%)were large adenoma.25 patients(53.2%)underwent multimodal image fusion and 3D reconstruction before surgery,and 22 patients(46.8%)did not undergo multimodal image fusion and 3D reconstruction.During the operation,29 cases(61.7%)were not treated with PEEP(positive end expiratory pressure,PEEP)to increase intracranial pressure,and 18 cases(38.3%)were treated with PEEP to increase intracranial pressure.Tumor grade classification method was adopted by using the Hardy-Wilson classification.Experimental group was reconstructed by 3D slicer version 4.81.Through using a formula A × B × C / 2(A,B,and C represent the maximum diameter of the tumor measured on the sagittal,coronal,and axial slices of the MRI image,respectively),tumor volume was estimated.MRI was performed 6 months after surgery to evaluate residual tumors.The residual tumor volume was also calculated using the formula A×B×C/2 method.Total resection was determined if more than 90% of tumor was resected.The analysis of univariate and Logistic stepwise regression multivariate method was used to clarify the relationship between the above indicators and the total tumor resection rate,and to analyze the influence factors of endoscopic assisted transsphenoidal pituitary adenoma resection.Results:Univariate analysis and multivariate analysis were used to analyze the effect of preoperative multi-modal image fusion 3D reconstruction,intraoperative intracranial pressure increase using PEEP,age,tumor size and other factors on the total surgical resction rate.Univariate analysis result showed that the effect of age on the total tumor resection was not significant(P > 0.10),and the effect of tumor size,multimodal image fusion three-dimensional reconstruction assisted,use of PEEP to increase intracranial pressure on the total tumor resection was statistically significant(P < 0.10).Multivariate analysis result showed that there was no statistically significant effect of age and gender on endoscopic assisted transsphenoidal approach for total resection rate.Independent factors affecting the total tumor resection rate included tumor size,multimodal image fusion three-dimensional reconstruction assistance,and intraoperative intracranial pressure increase using PEEP.The tumor size was the protective factor for total tumor resection(partial regression coefficient of giant adenoma was-4.123,with relative risk OR of 0.016).The intraoperative intracranial pressure increase using PEEP was the protective factor for total tumor resection(partial regression coefficient was-2.455,with relative risk OR of 0.086).The multimodal image fusion 3D reconstruction was a risk factor for total tumor resection(partial regression coefficient was 2.446,with relative risk OR of 11.538).Conclusion:1.This study used endoscopic assisted transnasal approach for the treatment of pituitary adenomas with a total tumor resction rate of 76.6%.Independent factors affecting the total tumor resection rate were found to include tumor size,preoperative multimodal image fusion and three-dimensional reconstruction,and intraoperative intracranial pressure using PEEP.Among them tumor size and intraoperative intracranial pressure increase using PEEP were protective factors and multi-modal image fusion 3D reconstruction was risk factor for total tumor resection.2.The update of surgical concept,the application of new technology and equipment could improve the total resction rate of endoscopic assisted transsphenoidal pituitary adenoma resection. |
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