Combined approach for craniopharyngioma resection

For a large craniopharyngioma, such as the expansion of the tumor and the saddle septum around the suprachiasm and the posterior saddle, invading the third ventricle to block the interventricular pores, causing the ventricle to expand, and it is difficult to adequately remove the tumor through any of the above single approaches. The above two or more combined approaches are adopted. The most commonly used one is the combined pterional-transcallosal approach promoted by Yasargil (1990). The method removes the tumor block located on the saddle septum, the saddle and the posterior saddle through the pterional approach, and then removes the tumor located in the third ventricle and the interventricular space through the corpus callosum-lateral ventricle approach. In addition, depending on the growth of the tumor and the individual experience of the surgeon, two or more other combined approaches may be used. Treatment of diseases: pediatric craniopharyngioma craniopharyngioma Indication For a large craniopharyngioma, such as the expansion of the tumor and the saddle septum around the suprachiasm and the posterior saddle, invading the third ventricle to block the interventricular pores, causing the ventricle to expand, and it is difficult to adequately remove the tumor through any of the above single approaches. The above two or more combined approaches are adopted. The most commonly used one is the combined pterional-transcallosal approach promoted by Yasargil (1990). The method removes the tumor block located on the saddle septum, the saddle and the posterior saddle through the pterional approach, and then removes the tumor located in the third ventricle and the interventricular space through the corpus callosum-lateral ventricle approach. In addition, depending on the growth of the tumor and the individual experience of the surgeon, two or more other combined approaches may be used. Preoperative preparation 1. There must be a correct positioning diagnosis before surgery. The relationship between the location of the lesion and the surrounding structure should be analyzed before surgery in order to select the appropriate surgical approach, to obtain the best exposure, avoid the important structure of the skull as much as possible, increase the safety of the operation and strive for good Effect. 2. Skin preparation, wash the head with soap and water 1 day before the operation, shave the hair on the morning of the operation. You can also shave your head on the eve of surgery. 3. Fasting the morning of surgery. It can be enema in the evening before surgery, but when the intracranial pressure is increased, the enema should be removed to avoid sudden deterioration of the condition. 4. Give phenobarbital 0.1g orally before surgery to ensure a quiet rest. One hour before the operation, 0.1 g of phenobarbital, 0.4 mg of atropine or 0.3 mg of scopolamine were intramuscularly injected. Surgical procedure 1. The scalp incision and bone flap design depends on the selected approach. Generally, several types of scalp incisions are included in one incision. Taking the above-mentioned transsacral forehead and trans-carcass combined approach as an example, a coronal incision can be made along the coronal suture in the hairline, and the anterior approach and the trans-middle-line approach of the transsacral approach are included in the anterior approach. Inside, in order to remove the tumor through the above two approaches. 2. The precautions during surgery and the steps of tumor removal are the same as other routes. complication 1. Visual impairment is the most important neurological disorder for total or subtotal resection of craniopharyngioma. The main factor determining whether or not to recover is the degree of visual impairment before surgery and the length of duration. In general, all vision loss before surgery is more than 1 week. Even if the surgery does not pay attention to the damage of the nerve tissue, it is not easy to recover. Partial vision is reserved before surgery and it is not long. If the operation is not aggravated, the visual field damage of the postoperative vision can be gradually restored. 2. In the treatment of craniopharyngioma with diabetes insipidus, the incidence of injury or interruption of pituitary stalk and funnel is high. The occurrence, treatment and replacement therapy of diabetes insipidus have become an important subject for postoperative treatment. Postoperative clinical observation and animal experiments confirmed that there are three periods after the pituitary stalk is cut: 1 immediate polyuria: appears several minutes to several hours after surgery, can last from several hours to several days, is a neurohypophyseal traumatic shock The result of the release of vasopressin (ADH) disorders. 2 Intermittent period: urine output is normal in the first to third days after operation, which may result in the release of ADH stored in nerve tissue and the increase of blood ADH level due to hypothalamic-pituitary nerve bundle necrosis and degeneration. In this stage, the replacement treatment with pituitrin should be reduced to avoid excessive levels of ADH in the body, causing rebound in water poisoning, water retention in the body, hypotonicemia, and dilute hyponatremia, resulting in severe hypothalamus. Edema with frontal lobe. Therefore, it is necessary to combine blood, urine osmotic pressure, urine specific gravity and urine output, and timely adjust the infusion volume and the alternative treatment of ADH. 3 permanent diabetes insipidus: appeared several days after surgery, and the degeneration of the neuron reached the nucleus, resulting in decreased secretion of ADH. The treatment of diabetes insipidus mainly controls the patient's urine output to within 3000ml per day. Lighter can supplement the infusion and give thiazides (such as hydrochlorothiazide, etc.). This medicine is a diuretic to treat diabetes insipidus. The principle is still unclear. The amount of urine can be reduced by half after administration. In addition, carbamazepine, chlorpropamide (a hypoglycemic agent, antidiuretic effect) can be given. If the injury is heavier, it is necessary to give pituitrin (natural vasopressin) as a hormone replacement therapy. The effect is more precise. At the same time, attention should be paid to the balance of water and electrolytes, prevention of sodium retention, limitation of sodium salt intake, and supplementation of potassium salt. If the symptoms persist for a long time, long-acting urine collapse can be given. In recent years, there has also been a modified synthetic vasopressin analogue DDAVP (desamino-8-D-arginine vasopressin, referred to as agglutination), which has a longer and longer lasting effect than natural pituitrin and no adverse reactions such as elevated blood pressure. Intravenous infusion can be given in the early stage, and the effect after one administration can last for 18 hours. After the patient is awake, it can be changed to oral or intranasal spray, which is equivalent to 10 times the amount of intravenous infusion. In 10% to 15% of patients, the pituitary stalk can be restored within 3 years after severance, which may be related to the formation of new neurovascular units in the suprachiasmatic nucleus and the paraventricular nucleus (Antunes, 1979). 3. Patients with severe pituitary dysfunction have a hypopituitarism crisis, and emergency rescue measures should be taken according to the condition. The most important of these is adrenal insufficiency, which is closely related to surgery. General preoperative exploration of patients with adrenal insufficiency, preoperative hormone administration to prepare, intraoperative supplementation. In general, high-dose cortisone was given as a surgical stress therapy early after brain surgery, and continued for 3 to 4 days, then reduced to maintenance and changed to oral. At this time, given a large dose of hormone, it can also play a role in anti-cerebral edema, and can be given dexamethasone or methylprednisolone. The latter has a more rapid onset, reaching a peak plasma concentration at 15 minutes, and the mineralocorticoid-like effect is weak. The hypothalamic-pituitary-adrenal axis has no effect on short-term use, which is more suitable for high-dose shock treatment than the former, and is gradually reduced after the disease is stable. And continue to administer this for cerebral edema after it has subsided. However, for patients with pituitary stalk injury or severance, it is necessary to continue to give appropriate maintenance (equivalent to 10-30 mg of hydrocortisone daily) as an alternative treatment, and increase the dose appropriately when certain causes (infection, fatigue, etc.) are invaded. In order to avoid the disease getting worse. 60% to 80% of patients with pituitary stalks may have hypothyroidism and need to be treated with thyroxine instead. In addition, young women and adolescent men need to be given alternative treatments for gonadotropin to avoid symptoms caused by insufficient FSH and LH secretion (such as women's amenorrhea, men's sexual dysfunction, etc.). 4. The symptoms of hypothalamic lesions can be varied, such as lethargy and abnormal regulation of caloric metabolism. In addition, for patients undergoing end-stage approach surgery, especially in children and young adults, central appetite loss often occurs 1 to 6 months after surgery, which is characterized by bulimia, feasible hormones and symptomatic treatment.

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