下垂体腫瘍に対する顕微鏡手術から内視鏡手術へ--同一術者による治療成績の比較

Transsphenoidal Surgery for Pituitary Tumors from Microsurgery to the Endoscopic Surgery: Single Surgeon's Experience

Ⅰ．はじめに

　下垂体腫瘍に対する手術は，Hardyらによる口唇下切開による経蝶形骨洞到達法による顕微鏡下の手術¹⁸⁾から始まり，顕微鏡下の経鼻的手術^10,16,39)，さらに近年では顕微鏡手術に比してより広い視野が得られる³²⁾内視鏡手術が導入されてきている．内視鏡手術にも，内視鏡を顕微鏡手術の補助として使用する方法^15,23)，さらに内視鏡単独手術として，鼻鏡を使用した内視鏡手術^2,36)，鼻鏡を使用しない内視鏡単独手術^4,11,24)がある．さらに内視鏡単独手術にも，一側の鼻腔経由²⁴⁾と両側鼻腔経由にて行う方法^{4,6,11,28,37)}がある．われわれは，2003年に内視鏡手術を導入し，徐々に従来の口唇下切開による顕微鏡手術から，両側鼻腔経由の内視鏡手術へと移行してきた²²⁾．内視鏡単独手術は，顕微鏡手術に比して摘出度が高く，合併症率が低いとの報告もあるが^11,13)，顕微鏡手術と内視鏡手術の治療成績を比較した報告は少ない^11,13,33)．今回，同一術者による顕微鏡手術から内視鏡手術への移行に伴う，治療成績，合併症などを比較し，内視鏡手術の有用性を検討した．

　We reviewed results of the surgical outcome of pituitary tumors treated via the transsphenoidal approach between January,1994 and January,2010 at our institution. This data included 100 patients (124 procedures) treated through the sublabial transsphenoidal approach and 45 patients (54 procedures) treated through the endoscopic endonasal (bilateral nostrils) transsphenoidal approach performed by a single surgeon. The extent of tumor removal was significantly improved with endoscopic surgery; adjuvant gamma knife radiosurgery was needed for 65% of patients undergoing microsurgery vs. 30% for patients who had endoscopic surgery (p＜0.0001). Patients who underwent endoscopic surgery had less intraoperative blood loss (mean volume: 100 mL for microsurgery patients vs. 30 mL for endoscopic surgery patients,p＜0.0001),less pain,and less need for postoperative hormone replacement therapy (19% for microsurgery patients vs. 6% for endoscopic surgery patients; p＜0.05). CSF leakage and meningitis were experienced in one microsurgery patient (1%) and one endoscopic surgery patient (2.2%). Endoscopic surgery is a reasonable alternative to microsurgery and our experience supports the concept that an otolaryngologist/neurosurgeon team skilled in endoscopic techniques and pituitary surgery can safely make the transition from microsurgery to endoscopic surgery.