[Abstract] Objective: To summarize the experience and experience in the application of physiological reconstruction of the saddle base and nasopharyngeal airway in transsphenoidal surgery for lesions in the saddle area Methods There were 37 cases of pituitary adenoma, 5 cases of Rathke cyst, 1 case of scar formation after transsphenoidal surgery for pituitary non-functional adenoma, 1 case of pituitary abscess, 1 case of craniopharyngioma, and 1 case of germ cell tumor in the saddle area in this group. All of them were operated in a single-nostril pterygoid sinus microsurgery approach, and intraoperative reconstruction of the saddle base using autologous bone obtained in the surgical approach was strived for, and the nasal cavity was filled with a homemade simple nasopharyngeal airway with balloon.
Results: 45 patients were able to obtain more complete autologous bone pieces in the transsphenoidal surgical approach. 38 patients achieved intraoperative reconstruction of the saddle base with autologous bone, and the sources of saddle base bone reconstruction were: bony nasal septum in 4 cases, ventral wall bone of the pterygoid sinus in 26 cases, longitudinal septum of the pterygoid sinus in 6 cases, and transverse septum of the pterygoid sinus in 2 cases. All 14 cases with cerebrospinal fluid leakage during transsphenoidal surgery achieved intraoperative autologous bone reconstruction of the saddle base, and none of them had cerebrospinal fluid leakage after surgery. In 40 cases, a nasopharyngeal airway with balloon was placed in the nasal cavity on the non-operative side, and in 6 cases, a nasopharyngeal airway with balloon was placed in the nasal cavity on both sides, and all the above cases could breathe through the nasal cavity after surgery.
Conclusion: Autologous bone reconstruction of the saddle base can be achieved in the vast majority of saddle area lesions, especially pituitary adenomas, during transsphenoidal sinus surgery. Regardless of whether there had been intraoperative cerebrospinal fluid leakage, the physiological reconstruction of the saddle base cases got up and went down early after surgery. Self-made simple nasopharyngeal airway with balloon to fill the nasal cavity is a simple and easy method to fill the nasal cavity, which can meet the needs of nasal cavity filling and normal respiratory physiology in patients with saddle area lesions operated via transsphenoidal sinus.
Transsphenoidal sinus surgery is a common surgical procedure for saddle lesions. Since April 2011, we have used autologous bone saddle base physiological reconstruction and homemade simple nasopharyngeal airway with balloon to fill the nasal cavity in transsphenoidal sinus surgery for saddle lesions, and achieved satisfactory clinical results and gained some experience and experience, which are reported below.
Materials and methods
1. General data: From April 2011 to January 2012, a total of 46 cases of transsphenoidal sinus saddle area lesion resection were completed. There were 25 male cases and 21 female cases in this group, age ranged from 5 to 76 years, average 42.1±15.1 years, disease duration ranged from half month to 10 years, average 32.6±40.7 months. The lesions in the saddle area were classified as follows: pituitary adenoma in 37 cases, including 23 cases of non-functional adenoma (including 1 case of recurrence), 4 cases of prolactin adenoma, 5 cases of growth hormone adenoma, 5 cases of adrenocorticotropic adenoma (including 1 case of recurrence); pituitary Rathke cyst in 5 cases; pituitary non-functional adenoma with scar formation after transsphenoidal surgery in 1 case; pituitary abscess in 1 case; craniopharyngioma in 1 case; germ cell tumor in 1 case. The maximum diameter of lesion ranged from 3 to 46 mm, with an average of 21.5±9.8 mm. There were 7 cases with a maximum diameter of lesion ≤1 cm, 32 cases with 1 to 3 cm, and 7 cases with >3 cm.
2, retention and trimming of autologous bone: autologous bone was taken from the bony nasal septum, the ventral wall of the pterygoid sinus or the longitudinal/transverse septum of the pterygoid sinus in the transsphenoidal surgical approach, and the above bone pieces were trimmed to the appropriate size and thickness with small biting forceps according to the size of the saddle base bone window during surgery, so that the small bone pieces could be embedded in the saddle base bone window.
3.Preparation of simple nasopharyngeal airway with balloon: The nasopharyngeal airway with balloon used in this operation was taken from the common tracheal tube used for tracheal intubation in the anesthesia department of our hospital. According to the size of the patient’s nasal cavity, tracheal cannulae of 5.5~7 were selected and trimmed to a length of about 10 cm, the end of the trachea with balloon and the part of the wall containing the air injection tube were kept, and the surface of the balloon was coated with petroleum jelly after checking the integrity of the balloon.
4.Surgical method: All patients in this group were operated by microscopic approach via single nostril pterygoid sinus. 6 patients were operated under neuroguidance due to poor pterygoid sinus pneumatization, 1 patient due to bilateral internal carotid artery spacing stenosis, and 2 patients due to recurrent pituitary adenoma with unclear anatomical landmarks after previous transsphenoidal surgery. Every possible piece of intact autologous bone was preserved intraoperatively. In this group, a septal retractor was placed after separating the mucosa of the nasal septum on one side, and the septum was broken from near the base of the ventral wall of the pterygoid sinus, so that intact large bony septum could be taken intraoperatively in only a very few patients. The ventral wall of the pterygoid sinus is opened with a chisel, and the complete large bony ventral wall of the pterygoid sinus can be obtained in all first-time transsphenoidal surgery patients. In some patients, the longitudinal or transverse septum of the pterygoid sinus exists, and it is removed intact intraoperatively with septal sinus bite forceps for backup. The extent of the saddle base opening mainly depends on the size and development direction of the tumor. It should be noted that a little bone ridge should be preserved around the saddle base so that the autologous bone fragments can be embedded. For patients whose saddle base bone, especially the bone around the saddle base, has been destroyed, autologous bone saddle base reconstruction is not forced to be performed. The procedure of saddle base dural puncture, incision and excision of the lesion is the same as the previous general transsphenoidal surgical operation. For patients who can perform saddle base bone reconstruction, after resection of the lesion in the saddle area and plenty of saline flushing, the saddle is filled with a small amount of quick-impact gauze and gelatin sponge, a layer of artificial meninges is applied outside the saddle base dura, and then the pre-prepared bone piece is trimmed to the appropriate size and embedded in the saddle base bone window, and a few drops of otocerebral glue are added to fix the bone piece, which is then covered with a layer of complete artificial dura or collagen sponge to complete the saddle base bone reconstruction. Subsequently, the mucosa of the ventral wall of the pterygoid sinus and the mucosa of the nasal septum were repositioned by loosely filling the pterygoid sinus with gelatin sponge and hemostatic material. For unilateral filling of the nasopharyngeal airway with balloon on the non-operative side, a piece of oil gauze was first filled into the upper and middle nasal passages on the non-operative side, and the above nasopharyngeal airway with balloon was placed in the inferior nasal passage, then one to two oil gauze strips were filled into the nasal cavity on the operative side, and finally about 5 mL of air was injected into the balloon of the nasopharyngeal airway. If both nasal cavities are filled with balloon nasopharyngeal airway, it is also filled in the above way, except that the nasal cavity on the operated side should be filled with oil gauze strips covering the mucosal incision of the nasal septum at the same time. At the end of the procedure, the anesthesiologist can directly wake the patient and remove the tracheal tube. Most of the patients in this group were first sent to the anesthesia wake-up room, woken up to full consciousness and then removed the tracheal intubation and returned to the ward. A small number of patients were directly woken up in the operating room, removed the tracheal intubation and then sent back to the ward or returned to the ward after the turnover of the anesthesia wake-up room, which was mainly decided by the anesthesiologist according to the schedule of the operating room.
5. Criteria for judging the efficacy of treatment
Patients with pituitary adenoma are judged by the clinical manifestations, MRI examination and pituitary endocrinology examination results more than 3 months after surgery, and those who are not cured and in remission and need further radiotherapy and/or drug treatment are judged by the situation before further treatment. For patients with other saddle lesions, the efficacy of surgery was judged by the follow-up MRI findings more than 3 months after surgery combined with the extent of resection during surgery.
Results
1. Surgical situation: The time required to perform the above anatomical and physiological reconstruction during surgery was approximately 8 minutes additional surgical time compared to previous cases without saddle base bone reconstruction, mainly due to the additional time required for bone trimming for conformation and trimming of the nasopharyngeal airway with balloon. In the first 40 patients, only the non-operative side of the nasal cavity with balloon nasopharyngeal airway was placed, and in the last 6 patients, both sides of the nasal cavity with balloon nasopharyngeal airway were placed. All 45 patients in this group were able to obtain complete septum, ventral wall of the pterygoid sinus, longitudinal septum of the pterygoid sinus, or transverse septum bone pieces during the transsphenoidal approach, except for one patient who had previously undergone transsphenoidal surgery at an outside institution and had difficulty in obtaining complete bone pieces intraoperatively. 38 patients achieved intraoperative reconstruction of the saddle base with autologous bone, and the sources of bone reconstruction were: bony septum in 4 cases, ventral wall of the pterygoid sinus in 26 cases, longitudinal septum of the pterygoid sinus in 6 cases The reasons for not reconstructing the saddle base in 8 cases were: 1 case of huge tumor and complete destruction of saddle base bone in the first transsphenoidal surgery, 1 case of highly malignant germ cell tumor, 1 case of destruction of saddle base in the second transsphenoidal surgery and difficulty in obtaining a complete bone block in the surgical approach, 2 cases of huge tumor with more blood leakage from the tumor cavity and intraoperative drainage of the tumor cavity, 1 case of abscess in the saddle area, 1 case of hard and tough tumor and only partial reconstruction of the saddle base. The tumor was hard and tough, and only partial resection was achieved in 2 cases. There were 39 cases of total resection, accounting for 84.8%; 4 cases of subtotal resection, accounting for 8.7%; 2 cases of majority resection, accounting for 4.3%; and 1 case of partial resection, accounting for 2.2%. There were 14 cases of intraoperative cerebrospinal fluid leakage, all of which achieved autologous bone reconstruction of the saddle base.
2, postoperative treatment: this group of patients, regardless of whether there is intraoperative cerebrospinal fluid leakage, the day after surgery, let the pillow, 3 to 4 hours after the head of the bed can be elevated and sitting and standing, 1 day after surgery can be down to the ground. Due to the relatively loose nasal filling, some secretions from the nasal mucosa will flow out of the nasal cavity, and the nasal dressing is relatively oozing more on the postoperative day, which is a mixture of blood and nasal secretions, and the nasal dressing needs to be changed once in about 6-8 hours, but the nasal exudate is obviously reduced after 1 day postoperatively. Sometimes the nasopharyngeal airway is blocked by nasal secretions and can be aspirated using a suction tube. The nasal oil gauze and the nasopharyngeal airway with balloon are removed 3 days after surgery, and the balloon is deflated first, then the nasopharyngeal airway and oil gauze are removed in turn. During the postoperative nasal filling period, the patient could breathe normally through the nasopharyngeal airway, and his sleep quality was good, rarely waking up, avoiding oropharyngeal dryness caused by open mouth breathing, and the patient generally felt good.
3. Surgical complications: there were no fatal cases. All 14 cases of intraoperative cerebrospinal fluid leakage did not reappear after surgery. Four cases of transient delayed dilutional hyponatremia occurred 5 to 9 days after surgery and were cured by water restriction, diuresis and sodium supplementation. One case of bilateral intermuscular vein thrombosis in the calf and one case of unilateral intermuscular vein thrombosis in the calf appeared on the second postoperative day, and the intermuscular thrombosis disappeared after 1 week of anticoagulation treatment with fastidious forest, followed by long-term oral anticoagulation treatment with warfarin for 3 months, and all were cured after stopping the drug. One case required long-term hormone replacement therapy for postoperative pituitary-adrenocortical axis and pituitary-thyroid axis hypofunction, and the case had low levels of the above hormones before surgery.
4. Follow-up: 34 cases were followed up for more than 3 months after surgery. Among them, 11 cases with intraoperative cerebrospinal fluid leakage did not develop again. On follow-up MRI images, the filling and exudate in the saddle and pterygoid sinus were satisfactorily absorbed. There were 16 cases of pituitary non-functional adenoma, 15 cases were cured and 1 case progressed. Three cases of pituitary prolactin adenoma were cured. Four cases of pituitary growth hormone adenoma were cured in three cases and progressed in one case. Adrenocorticotropic hormone adenoma was cured in 3 cases. Pituitary Rathke cyst was cured in 4 cases. Pituitary abscess was cured in 1 case. Craniopharyngioma remitted in 1 case. One case of pituitary non-functional macroadenoma with local scar formation after transsphenoidal surgery was stable. One case of germ cell tumor in the saddle area received further 3-dimensional intensity-modulated conformal radiotherapy after surgery and has been in stable condition for 6 months after radiotherapy.
Discussion
Transsphenoidal approach is the most common surgical approach for saddle lesions. If cerebrospinal fluid leakage occurs during transsphenoidal surgery, saddle base reconstruction is often required, and some patients also require simultaneous lumbar subarachnoid drainage. At present, there are two main types of materials commonly used for saddle base reconstruction after transsphenoidal saddle lesion surgery: one is autologous tissue, including autologous tissue without vascular tissues, such as subcutaneous fat, muscle, broad fascia, cranial periosteum, and autologous bone, and autologous tissue with vascular tissues, such as mucosa of the pterygoid sinus with vascular tissues, mucoperiosteal flaps of the middle turbinate, inferior turbinate, nasal septum, and palate with tissues, and mucoperiosteal flaps of the posterior lateral wall of the nasal cavity The above-mentioned autologous tissues are often retained. The above-mentioned autologous tissues often require further incisions in other parts of the body or disrupt the normal anatomy of the nasal cavity, which will more or less cause some side damage to the organism. Another category is various artificial biomaterials, including various artificial meningeal patches, bioprotein gels, and saddle-bottom supports made of artificial materials such as silicone sheets, nitrile-based acrylates, hydroxyapatite cement, titanium mesh, porous high-density polyethylene, and alumina ceramics. Many literatures have reported that the use of the above artificial biomaterials can even replace autologous tissues to achieve excellent saddle-base reconstruction and prevention of postoperative cerebrospinal fluid leakage. However, there are relatively few artificial biomaterials available in China for saddle base reconstruction, except for a few brands of artificial meningeal patches and bioprotein gum, but almost no brand of artificial biomaterials for saddle base support are available, which seriously restricts the development of transsphenoidal saddle area and skull base surgery. In transsphenoidal sinus surgery, it is often necessary to perform postoperative nasal tamponade because of the need to separate the mucosa of the nasal septum and/or the ventral wall of the pterygoid sinus, and currently the main materials for nasal tamponade after transsphenoidal surgery are Vaseline gauze strips, expandable sponges (with or without ventilation channels), silicone fillers with ventilation channels, etc. Patients with solid nasal cavity filling often interfere with the normal respiratory physiology of patients, who need to open their mouths to breathe after surgery, which is not the normal physiological breathing pattern of human body. Most of the nasal fillers with airway are imported products, which are relatively expensive and have many inconveniences in clinical application due to the restriction of the current national control policy on imported medical products.
In the early days, most of the patients’ thigh fat and/or broad fascia were cut for saddle base reconstruction during transsphenoidal surgery, and those with large intraoperative cerebrospinal fluid leak were often drained from the subarachnoid space of the lumbar pool at the same time, and the patients needed to lie flat on the pillow for 7-10 days after surgery. In the past three years, some experts in our department have also adopted the artificial meninges – gelatin sponge – bioprotein glue method to reconstruct the saddle base for cases with intraoperative cerebrospinal fluid leakage, based on the artificial meninges – gelatin sponge – bioprotein glue method, and filled iodoform gauze in the pterygoid sinus as a support for the reconstructed tissue of the saddle base to facilitate the formation of fibrous scar tissue of the saddle base. However, the iodoform gauze in the pterygoid sinus had to be removed again under local anesthesia and neuroendoscopy about 10 days after surgery, and the patient continued to be hospitalized for several days for observation. In some cases, the cerebrospinal fluid leak reappeared after removal of the iodoform gauze from the pterygoid sinus, and even required a second surgery to repair the leak. In both early and recent cases, except for the case reported in this article, the nasal cavity was mostly filled with one to two Vaseline strips in each nasal cavity during transsphenoidal surgery, and the nasal strips were removed 3 days after surgery in most cases without cerebrospinal fluid leakage. In all cases without intraoperative cerebrospinal fluid leak, the patient can go down to the floor 1~3 days after surgery according to the specific situation. The technique of saddle base reconstruction and nasopharyngeal airway stuffing with homemade simple balloon is simple, practical and operable, which can solve the inconvenience of saddle base reconstruction and nasal airway stuffing in the saddle area.
The autologous bone pieces used for intraoperative saddle base reconstruction in this group of cases were all taken during the surgical approach, no additional trauma was added as a result, and there was no foreign body rejection reaction by using autologous tissue. The ability of the patient to sit and stand early after inline saddle base reconstruction is also very mechanically sound. The intracranial ergogenic pressure acts directly on the bone fragment embedded in the saddle base, which is supported by the peripheral bone window, thus the pressure transmitted to the lateral saddle base is almost zero, which is conducive to the growth of saddle base scar tissue and repair of saddle base defects, thus minimizing the occurrence of cerebrospinal fluid leakage after surgery in patients with cerebrospinal fluid leakage during transsphenoidal surgery. In our group of 14 patients who had cerebrospinal fluid leakage during transsphenoidal surgery, after inline autologous bone reconstruction of the saddle base, none of them had cerebrospinal fluid leakage postoperatively, avoiding the placement of lumbar subarachnoid drainage, and they could get up and move on the floor 1 day after surgery, achieving the effect of spending a few more minutes intraoperatively and getting off the floor and being discharged from the hospital a few days earlier after surgery. Although Sonnenburg et al. concluded that intraoperative saddle-base reconstruction could be left out for patients without cerebrospinal fluid leakage during transsphenoidal surgery, it was mainly based on the consideration of not adding additional surgical trauma and avoiding possible artifacts on postoperative imaging. The authors believe that even if there is no cerebrospinal fluid leakage in the saddle lesion during transsphenoidal surgery, autologous bone saddle base reconstruction can be performed, because autologous bone saddle base reconstruction in this group does not add additional surgical trauma and artifacts in postoperative imaging; on the contrary, because the filling in the pterygoid sinus can be reduced after bony reconstruction of the saddle base, the artifacts in the pterygoid sinus will be reduced after surgery instead, and the boundary with the saddle tissue will be clearer instead, which is more convenient for the The postoperative situation can be judged more easily. Of course, for those who have complete destruction of saddle base bone, high malignancy of tumor, destruction of saddle base after previous transsphenoidal surgery and difficulty to obtain complete bone block in surgical approach, more blood leakage from tumor cavity and need to give way to drainage of tumor cavity, hard and tough tumor which is difficult to be completely resected, if there is no cerebrospinal fluid leakage during surgery, it is not suitable to force to achieve bony reconstruction of saddle base. For inflammatory lesions such as abscesses in the saddle area, it is also inappropriate to do bony reconstruction of the saddle base if bone or foreign body residue should be avoided as much as possible.
Through the experience of more than 40 cases of transsphenoidal saddle area lesion surgery, the authors experienced that autologous bone embedded saddle base reconstruction has the following advantages: restoring the normal physiological anatomy of the saddle base; regardless of whether there is intraoperative cerebrospinal fluid leakage or not, it is early to get up and go down after surgery, and you can go down 1 day after surgery, and generally you can be discharged 3 days after surgery; early activity of patients is beneficial to reduce the chance of postoperative deep vein thrombosis and pulmonary embolism in the lower limbs; the saddle base has bony It can effectively prevent CSF leakage in patients with intraoperative CSF leakage; the filling in the pterygoid sinus can be reduced, and the filling in the pterygoid sinus can be absorbed quickly on follow-up review, reducing imaging artifacts; avoiding the backflow of blood from the pterygoid sinus into the saddle to form a tumor cavity hematoma; providing anatomical markers for recurrent patients to operate via the pterygoid again; providing convenience for re-opening cases, and the tumor can be scraped in the saddle, which is not easy to scrape the saddle base tissue It causes cerebrospinal fluid leakage; preserves the normal anatomical structures of the nasal cavity, including the mucosa of the nasal septum, the upper and middle inferior turbinates, the mucoperiosteum of the ventral wall of the pterygoid sinus, and the bony nasal septum, for cases requiring skull base reconstruction in possible future skull base surgery. Of course, there are also the following drawbacks: some of the saddle base with severe saddle base bone destruction have no support around the saddle base, so it is difficult to achieve saddle base bony reconstruction; in some recurrent cases, when the transsphenoidal surgery is performed again, it may be relatively difficult to complete the autologous bone saddle base reconstruction because there may be no autologous bone desirable and the saddle base bone has been missing, and it may be difficult to divide the edge of the bone window under the scar. To achieve the reconstruction of autologous bone saddle base in transsphenoidal saddle area lesion surgery, we need to pay attention to the following matters: to take care of each piece of intact bone during surgery: keep the bony nasal septum, ventral wall of pterygoid sinus and longitudinal/transverse septum of pterygoid sinus intact; do not oversize the saddle base window to the edge, leave some marginal bone crest to embed the bone piece, avoid damaging the intercavernous sinus when embedding, however, it is easy to stop bleeding by applying artificial hemostatic material when there is bleeding in the intercavernous sinus; embed the bone piece After embedding, a few drops of otocerebral glue can be used to reinforce the position, and the saddle base can be completely closed if there is CSF leakage during the operation.
A simple homemade nasopharyngeal airway with balloon using a common tracheal tube can be used as an alternative to nasal filling after transsphenoidal surgery, which can not only ventilate but also play the role of nasal filling; it is convenient to take materials, simple to make and has good clinical effect; patients can still use nasal breathing after surgery, which is in line with the normal respiratory physiology of human body and avoids the possible dryness of mouth and throat, peeling of the lips and mouth of some patients after bilateral nasal filling. It can avoid the dry mouth and throat, some patients’ lip peeling and oral ulceration, and keep the lips and tongue red; the patient can sleep better and avoid waking up frequently, especially for patients with large limbs and lip and tongue hypertrophy; it can also aspirate sputum through the nasopharyngeal airway; if necessary, the patient can tolerate well if the nasal stuffing time needs to be extended. However, the use of nasopharyngeal airway with balloon in transsphenoidal surgery should be noted as follows: the end of the tracheal tube is beveled toward the left bronchus, and its shape is more suitable for placement in the left nasal cavity; the right nasal cavity should be rotated 90-180 degrees or the end of the tracheal tube should be trimmed; the upper middle turbinate can be filled with a piece of Vaseline gauze to prevent the formation of adhesions in the nasal cavity due to the accumulation of blood crusts after surgery. In terms of care, since the nasal cavity is relatively loosely filled after the placement of the nasopharyngeal airway with balloon, the nasal mucosal exudate flows relatively more, so the nasal dressing needs to be changed regularly; sometimes the inner opening of the nasopharyngeal airway may be blocked by blood crusts or nasal exudate, resulting in poor ventilation, so a suction tube can be gently inserted into the nasopharyngeal airway for aspiration.