Anatomic Study And Clinical Application Of Extended Endoscopic Endonasal Approach To The Suprasellar Cistern

Part One The anatomic study of endoscopic endonasal approach to sellar regionObject: To learn about the anatomic landmarks of endoscopic endonasal approach to the sellar region via dissection of the cadaver specimen,to simulate surgical process and to lay the foundation for the safe and effective operation in sellar region.Methods: Six fresh frozen cadaver heads and 6 formalin-fixed cadaver heads were dissected.The anatomic structures of the nasal cavity and sellar region were observed by endoscopy,and their mutual anatomic relationships were further investigated.The measurement of sphenoid ostium,sellar floor,optic canal,internal carotid artery protuberance and other typical anatomical distance were observed.The sphenopalatine foramen region structures were dissected,and separated the sphenopalatine artery branch and path,then explored the safety range of the nasal mucosal flap.Results: The distance between the choana arch and sphenoid ostium was 14.9±3.2mm.The distance between columella nasito and sphenoid ostium was 68.7±3.5mm.The length diameter of the bony sphenoid ostium was 5.5±0.5mm,and the width was 3.5±0.2mm.Distance between the bilateral sphenoid ostium center was 12.1±1.2mm.Ipsilaterally speaking,the distance between sphenoid ostium and the intracranial opening of the optic canal,the internal carotid artery,and the tuberculum sellae were respectively 15.2±3.6mm,13.7±2.3mm and 15.5±2.9mm.The distance between the bilateral sphenopalatine foramen inner sides was 18.3±2.4mm.It was 6.8±1.3mm far from the homolateral sphenoid ostium.The distance between the medical OCR(opticocarotid recess)was 11.3±1.2mm.Conclusion: The endonasal endoscopic approach is widely used in clinical practice.It is very helpful to understand the anatomical landmarks and important structures of the region in selecting approaches.The sphenoid ostium,optic canal and OCR are important bony landmarks.It is necessary to protect internal structure of the sphenopalatine foramen.Part Two The study of anatomy and clinical application of extended endoscopic endonasal approach from planum sphenoidale and tuberculum sellae to suprasellar cistern1.The anatomic study of extended endoscopic endonasal approach to suprasellar cisternObjective: To have a detailed understanding of the suprasellar cistern by extended endonasal along planum sphenoidaleand tuberculum sellae,and its related anatomic structure and location,to explore the surgical approaches and surgical difficulties of extended endoscopic endonasal approaches(EEEA)for craniopharyngiomas,and to provide guidance for clinical operation.Methods: The extended endonasal approach along planum sphenoidale and tuberculum sellae to the suprasellar cistern is of far path,and narrow space.All of anatomy used fresh frozen cadaver heads.Resecting the middle turbinate and the posterior ethmoid sinus to simulate EEEA for cranipharyngioma surgery.The head position remained at the same angle as a normal real operation.The length and width of middle turbinate was measured,and the available range of mucosal flap for repairing the skull base was explored.Drilled the skull base window and measured the size,distance between the tuberculum sellae and the optic chiasm.Measured the size of the pituitary stalk and pituitary,as well as the gray matter in the third ventricle.Results: The resection of middle turbinate size was measured,its averaged length was 36.4±5.7mm,and the width was 18.1±3.4mm.The range of bone window was 31.4±5.9mm and 25.6±3.8mm(length and width).The distance from the posterior border of the tuberculum sellae to the anterior border of optic chiasma was 5.7±1.1mm.The distance from the bottom of the saddle to the third ventricle was 73.1±9.6mm.The length of pituitary stalk was 9.5±2.3mm.There were more variations in the size of the gray matter of thalamus,and the upper-lower distance was about 4.7±1.3mm,and the anterior-posterior was 6.2±3.0mm.Conclusion: The fresh frozen heads anatomy can be a good way to know important structures of the suprasellar cistern and the third ventricle in endoscopy.Observing the spatial relationships among them and fully understanding of anatomical data is the key to the craniopharyngioma surgery.As for craniopharyngioma in the midline,EEEA can reach completely.The training of the surgery can significantly shorten the learning curve,and is more important in terms of expanding the clinical application of endoscopic surgery.2.The clinical application and analysis of extended endoscopic endonasal approach in craniopharyngioma surgeryObjective: To summarize and analyze the therapeutic effects and complications of EEEA for the midline craniopharyngioma in our department.Methods: Retrospective analysis of the clinical data in a group of 48 cases in our department treated with endoscopic surgery.All the patients were treated with EEEA,and the skull base window was removed big enough,and the tumors were removed by the up-down space of optic chiasm.Statistically analyzed the cases of tumor resection degree,electrolyte disorders,diabetes insipidus,hypopituitarism,living quality and vision changes.Results: All tumors were confirmed to be craniopharyngioma by pathology.Total resection was achieved in 35 cases,subtotal resection in 13 cases.Pituitary stalk completely preserved in 13 casesin operation,partly was 24 cases,and undetermined was 11 cases.29 cases had postoperative diabetes insipidus and 32 cases had electrolyte disorders,34 cases had hypopituitarism,27 cases had hypothyroidism,and 1 case had intracranial infection.2 cases had exacerbation of visual disturbance,and 19 cases had visual improvement.7 cases had tumor recurrence and underwent endoscopic reoperation.Conclusion: It can be more effective for the removal of suprasellar craniopharyngioma by resecting middle turbinate,the anterior wall of sphenoid sinus,posterior ethmoid sinus and enough skull base bone window.According to the up-down spaces of optic chiasm,it can effective to resect craniopharyngioma.The endplate approach can successfully resect the third ventricle tumor.EEEA in craniopharyngioma shows good advantages in resection rate and postoperative complications.Part Three The method and clinical application study of extended endoscopic endonasal approach for skull base reconstruction1.Study of the correlation between nasal epithelial cell culture and different materialsObjective: To investigate the differences of growth and adherence of human nasal epithelial cells in three kinds of materials: autologous bone,artificial bone matrix and duramax.Methods: HE staining and CD 31,Ki-67 immunofluorescence staining were used to observe the inflammatory infiltration,angiogenesis and cell proliferation respectively.The autologous bone,artificial and dura materials were cultured of human nasal epithelial cells in 24 well plates.Light microscope were used to determine the cell morphology,and Hoechst(nuclear)/ PKH 26 staining(membrane)staining was employed to observe the cell number.CCK-8 method was conducted to compare cell proliferation among the three groups.Adhesion and extension were observed by scanning electron microscope after immersion in ethanol.Results: After the repair,inflammatory cell infiltrated the mucosa,which still has the blood vessels and cell proliferation to some degree.The immunofluorescence showed that cell number of per visual field in autologous and artificial bone groups tend to be more than duramax group(P<0.05),and autologous bone worked better than artificial bone,which was also statistically different(P<0.05).The cells in autologous bone group presented good stretching and adhesion ability than other two groups under electron microscopy.Conclusion: Human nasal epithelial cells could survive,proliferate and maintain adhesion ability in autologous bone,artificial bone matrix and duramax.The autogenous bone material has better cell adhesion and growth compared to others.2.The clinical analysis of different kinds of reconstruction in extended endonasal approachObjective: Reconstruction of the skull base plays an important role in the prevention of cerebrospinal fluid rhinorrhea and intracranial infection after operation.To comparative analysis of different methods,to analyze advantages of original skull flap in skull base reconstruction,and to explore its application.Methods: The clinical data of 61 cases of skull base reconstruction and repair after EEEA were analyzed retrospectively.The original bone flap of skull base was served as the experimental group(30 cases),trimmed nasal septum bone or artificial bone as the control group 1(18 cases),fascia and fat filling repair as the control group 2(13 cases),which was a total of 31 cases of the control group.Then,we analyzed postoperative time for hospitalization,cerebrospinal fluid rhinorrhea,intracranial infection and lumbar cisterna drainage rate,and explored the advantage and feasibility of original bone flap repair.Results: There was no death in the perioperative period,and no statistical difference between the two groups in tumor resection.Patients in the experimental group were able to get off of bed on average 7.5 days after the operation,the control group need more than 12 days.The cases of lumbar cisterna drainage in the control group were 6 and 13 respectively,which were statistically significant compared with the experimental group.The control group 2 were treated with reoperation in 4 cases.Conclusion: With the duramax,original bone flap and vascularized pedicled nasoseptal flap,the multilayer repair can significantly reduce the incidence of infection,cerebrospinal fluid rhinorrhea and accelerate rehabilitation.Original bone flap is an effective treatment for EEEA.It shows some advantage,and we can try to recommend this way to others.This approach might be a good way to repair skull base.The long-term effects need to be futher observed.