内镜颅底手术并发严重鼻出血诊断与治疗
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摘要
目的总结经鼻内镜颅底手术后严重鼻出血的原因与治疗方法。方法与结果选择2007年2月至2018年1月经鼻内镜颅底手术后发生迟发性鼻出血的患者共12例,经内镜下电凝止血术(7例)、DSA辅助内镜下电凝止血术(1例)、DSA辅助超选择性动脉栓塞术(3例)和DSA辅助超选择性动脉栓塞术联合内镜下电凝止血术(1例)等外科手术治疗,11例成功止血、1例死亡;平均随访(17.21±3.42)个月,无复发。结论经鼻内镜颅底手术后鼻出血主要发生于术后>7～14d,手术方式与出血部位和责任动脉有关。内镜下电凝止血术效果良好,且无严重并发症;颈内动脉假性动脉瘤形成患者可通过内镜下电凝止血术联合动脉栓塞术治愈。
Objective To summarize the causes, treatment, and prognosis of severe epislaxis after transnasal endoscopic skull base surgery. Methods and Results There were 12 patients with delayed severe epistaxis after transnasal endoscopic skull base surgery from February 2007 to January 2018.Surgical methods included endoscopic electrocoagulation hemostasis in 7 cases(7/12), DSA-assisted endoscopic electrocoagulation hemostasis in one case(1/12), DSA-assisted superselective arterial embolization in 3 cases(3/12), and DSA-assisted superselective arterial embolization combined with endoscopic electrocoagulation hemostasis in one case(1/12). Successful hemostasis occurred in 11 cases,and one case died. Patients were followed up for(17.21 ± 3.42) months without epistaxis recurrence.Conclusions Epistaxis mainly occurs over 7 to 14 d after transnasal endoscopic skull base surgery. The choice of operation methods is related to the location of bleeding and responsible artery. Endoscopic electrocoagulation hemostasis is an effective method without serious complications. Patients with internal carotid artery(ICA) pseudoaneurysms can be cured by endoscopic electrocoagulation hemostasis plus arterial embolization.
Objective To summarize the causes, treatment, and prognosis of severe epislaxis after transnasal endoscopic skull base surgery. Methods and Results There were 12 patients with delayed severe epistaxis after transnasal endoscopic skull base surgery from February 2007 to January 2018.Surgical methods included endoscopic electrocoagulation hemostasis in 7 cases(7/12), DSA-assisted endoscopic electrocoagulation hemostasis in one case(1/12), DSA-assisted superselective arterial embolization in 3 cases(3/12), and DSA-assisted superselective arterial embolization combined with endoscopic electrocoagulation hemostasis in one case(1/12). Successful hemostasis occurred in 11 cases,and one case died. Patients were followed up for(17.21 ± 3.42) months without epistaxis recurrence.Conclusions Epistaxis mainly occurs over 7 to 14 d after transnasal endoscopic skull base surgery. The choice of operation methods is related to the location of bleeding and responsible artery. Endoscopic electrocoagulation hemostasis is an effective method without serious complications. Patients with internal carotid artery(ICA) pseudoaneurysms can be cured by endoscopic electrocoagulation hemostasis plus arterial embolization.
引文
[1] Han HL, Wang CY, Liu JF, Li Y, Wang NY, Yang DZ. Etiology and treatment of delayed epistaxis after endoscopic surgery[J].Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi, 2011, 25:925-928.[韩红蕾,王成元,刘剑锋,李原,王娜亚,杨大章.鼻内镜术后迟发性鼻出血的原因和治疗[J].临床耳鼻咽喉头颈外科杂志,2011,25:925-928.]
[2] Shikary T, Andaluz N, Meinzen-Derr J, Edwards C,Theodosopoulos P, Zimmer LA. Operative learning curve after transition to endoscopic transsphenoidal pituitary surgery[J].World Neurosurg, 2017, 102:608-612.
[3] Karppinen A, Kivipelto L, Vehkavaara S, Ritvonen E, Tikkanen E, Kivisaari R, Hernesniemi J, Setala K, Schalin-Jantti C,Niemela M. Transition from microscopic to endoscopic transsphenoidal surgery for nonfunctional pituitary adenomas[J]. World Neurosurg, 2015, 84:48-57.
[4] Nishioka H, Ohno S, Ikeda Y, Ohashi T, Haraoka J. Delayed massive epistaxis following endonasal transsphenoidal surgery[J]. Acta Neurochir(Wien), 2007, 149:523-527.
[5] Ammirati M, Wei L, Ciric I. Short-term outcome of endoscopic versus microscopic pituitary adenoma surgery:a systematic review and meta-analysis[J]. J Neurol Neurosurg Psychiatry,2013, 84:843-849.
[6] Abdelkader M, Leong SC, White PS. Endoscopic control of the sphenopalatine artery for epistaxis:long-term results[J]. J Larygol Otol, 2007, 121:759-762.
[7] Hol MK, Hiuzing EH. Treatment of inferior turbinate pathology:a review and critical evaluation of different techniques[J].Rhinology, 2000, 38:157-166.
[8] Oka T, Sugiu K, Ishida J, Hishikawa T, Ono S, Tokunaga K,Date I. Usefulness of endovascular treatment for delayed massive epistaxis following endoscopic endonasal transsphenoidal surgery:a case report[J]. No Shinkei Geka,2012, 40:55-60.
[9] De Los Reyes KM, Gross BA, Frefichs KU, Dunn IF, Lin N,Rincon-Torroella J, Annino DJ, Laws ER. Incidence, riskfactors and management of severe post-transsphenoidal epistaxis[J]. J Clin Neurosci, 2015, 22:116-122.
[10] Zhai X, Zhang JL, Hu YL, Liu G. Characteristics and treatment of epistaxis patients with long-term oral aspirin[J]. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi, 2015, 50:860-862.[翟翔,张金玲,胡云磊,刘钢.长期口服阿司匹林鼻出血患者的特点及治疗[J].中华耳鼻咽喉头颈外科杂志,2015, 50:860-862]
[11] Wang Z, Su N, Wu RL, Zhang XJ, Zhang Z. Endoscopic endonasal transsphenoidal surgery for invasive pituitary adenoma[J]. Zhonghua Shen Jing Wai Ke Ji Bing Yan Jiu Za Zhi,2014,13:276-278.[王忠,苏宁,吴日乐,张晓军,张仲.神经内镜下经鼻蝶入路切除垂体腺瘤[J].中华神经外科疾病研究杂志,2014, 13:276-278.]
[12] Tuchman A, Khalessi AA, Attenello FJ, Amar AP, Zada G.Delayed cavernous carotid artery pseudoaneurysm caused by absorbable plate following transsphenoidal surgery:case report and review of the literature[J]. J Neurol Surg Rep, 2013, 74:10-16.
[13] Jho HD, Ha HG. Endoscopic endonasal skull base surgery. Part1:the midline anterior fossa skull base[J]. Minim Invasive Neurosurg, 2004, 47:1-8.
[14] Raymond J, Hardy J, Czepko R, Roy D. Arterial injuries in transsphenoidal surgery for pituitary adenoma:the role of angiography and endovascular treatment[J]. AJNR Am J Neuroradiol, 1997, 18:655-665.
[15] de Divitiis E, Cavallo LM, Cappabianca P, Esposito F.Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors:part 2[J]. Neurosurgery,2007, 60:46-59.
[16] Wang N, Chen G, Zhi XL, Chen WJ, Xu YQ, Ling F. Diagnosis and treatment of internal carotid artery injury in endonasal transsphenoidal approach for pituitary adenoma resection[J].Zhongguo Xian Dai Shen Jing Ji Bing Za Zhi, 2008, 8:329-330.[王宁,陈革,支兴龙,陈文劲,徐跃峤,凌锋.经鼻蝶入路垂体腺瘤切除术并发颈内动脉损伤的诊断与治疗[J].中国现代神经疾病杂志,2008, 8:329-330.]
[17] Chen HR, Bai RL, Huang CG, Hu GH, Luo C, Yuan GL, Lu YC. Diagnosis and treatment of traumatic carotid cavernous fistula combined with sphenoid sinus pseudoaneurysm[J]. Jie Ru Fang She Xue Za Zhi,2008, 17:543-546.[陈怀瑞,白如林,黄承光,胡国汉,骆纯,袁国良,卢亦成.创伤性颈动脉海绵窦瘘合并蝶窦假性动脉瘤的诊断和治疗[J].介入放射学杂志,2008, 17:543-546.]
[18] Gu DY, LüD, Yu R, Chen F. The diagnosis and treatment of pseudoaneurysm of internal carotid artery in sphenoid sinus(a report of 7 cases)[J]. Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi,2016, 30:1717-1720.[辜德英,吕丹,余蓉,陈飞.蝶窦颈内动脉假性动脉瘤的诊治分析(附7例报告)[J].临床耳鼻咽喉头颈外科杂志,2016, 30:1717-1720.]
[2] Shikary T, Andaluz N, Meinzen-Derr J, Edwards C,Theodosopoulos P, Zimmer LA. Operative learning curve after transition to endoscopic transsphenoidal pituitary surgery[J].World Neurosurg, 2017, 102:608-612.
[3] Karppinen A, Kivipelto L, Vehkavaara S, Ritvonen E, Tikkanen E, Kivisaari R, Hernesniemi J, Setala K, Schalin-Jantti C,Niemela M. Transition from microscopic to endoscopic transsphenoidal surgery for nonfunctional pituitary adenomas[J]. World Neurosurg, 2015, 84:48-57.
[4] Nishioka H, Ohno S, Ikeda Y, Ohashi T, Haraoka J. Delayed massive epistaxis following endonasal transsphenoidal surgery[J]. Acta Neurochir(Wien), 2007, 149:523-527.
[5] Ammirati M, Wei L, Ciric I. Short-term outcome of endoscopic versus microscopic pituitary adenoma surgery:a systematic review and meta-analysis[J]. J Neurol Neurosurg Psychiatry,2013, 84:843-849.
[6] Abdelkader M, Leong SC, White PS. Endoscopic control of the sphenopalatine artery for epistaxis:long-term results[J]. J Larygol Otol, 2007, 121:759-762.
[7] Hol MK, Hiuzing EH. Treatment of inferior turbinate pathology:a review and critical evaluation of different techniques[J].Rhinology, 2000, 38:157-166.
[8] Oka T, Sugiu K, Ishida J, Hishikawa T, Ono S, Tokunaga K,Date I. Usefulness of endovascular treatment for delayed massive epistaxis following endoscopic endonasal transsphenoidal surgery:a case report[J]. No Shinkei Geka,2012, 40:55-60.
[9] De Los Reyes KM, Gross BA, Frefichs KU, Dunn IF, Lin N,Rincon-Torroella J, Annino DJ, Laws ER. Incidence, riskfactors and management of severe post-transsphenoidal epistaxis[J]. J Clin Neurosci, 2015, 22:116-122.
[10] Zhai X, Zhang JL, Hu YL, Liu G. Characteristics and treatment of epistaxis patients with long-term oral aspirin[J]. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi, 2015, 50:860-862.[翟翔,张金玲,胡云磊,刘钢.长期口服阿司匹林鼻出血患者的特点及治疗[J].中华耳鼻咽喉头颈外科杂志,2015, 50:860-862]
[11] Wang Z, Su N, Wu RL, Zhang XJ, Zhang Z. Endoscopic endonasal transsphenoidal surgery for invasive pituitary adenoma[J]. Zhonghua Shen Jing Wai Ke Ji Bing Yan Jiu Za Zhi,2014,13:276-278.[王忠,苏宁,吴日乐,张晓军,张仲.神经内镜下经鼻蝶入路切除垂体腺瘤[J].中华神经外科疾病研究杂志,2014, 13:276-278.]
[12] Tuchman A, Khalessi AA, Attenello FJ, Amar AP, Zada G.Delayed cavernous carotid artery pseudoaneurysm caused by absorbable plate following transsphenoidal surgery:case report and review of the literature[J]. J Neurol Surg Rep, 2013, 74:10-16.
[13] Jho HD, Ha HG. Endoscopic endonasal skull base surgery. Part1:the midline anterior fossa skull base[J]. Minim Invasive Neurosurg, 2004, 47:1-8.
[14] Raymond J, Hardy J, Czepko R, Roy D. Arterial injuries in transsphenoidal surgery for pituitary adenoma:the role of angiography and endovascular treatment[J]. AJNR Am J Neuroradiol, 1997, 18:655-665.
[15] de Divitiis E, Cavallo LM, Cappabianca P, Esposito F.Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors:part 2[J]. Neurosurgery,2007, 60:46-59.
[16] Wang N, Chen G, Zhi XL, Chen WJ, Xu YQ, Ling F. Diagnosis and treatment of internal carotid artery injury in endonasal transsphenoidal approach for pituitary adenoma resection[J].Zhongguo Xian Dai Shen Jing Ji Bing Za Zhi, 2008, 8:329-330.[王宁,陈革,支兴龙,陈文劲,徐跃峤,凌锋.经鼻蝶入路垂体腺瘤切除术并发颈内动脉损伤的诊断与治疗[J].中国现代神经疾病杂志,2008, 8:329-330.]
[17] Chen HR, Bai RL, Huang CG, Hu GH, Luo C, Yuan GL, Lu YC. Diagnosis and treatment of traumatic carotid cavernous fistula combined with sphenoid sinus pseudoaneurysm[J]. Jie Ru Fang She Xue Za Zhi,2008, 17:543-546.[陈怀瑞,白如林,黄承光,胡国汉,骆纯,袁国良,卢亦成.创伤性颈动脉海绵窦瘘合并蝶窦假性动脉瘤的诊断和治疗[J].介入放射学杂志,2008, 17:543-546.]
[18] Gu DY, LüD, Yu R, Chen F. The diagnosis and treatment of pseudoaneurysm of internal carotid artery in sphenoid sinus(a report of 7 cases)[J]. Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi,2016, 30:1717-1720.[辜德英,吕丹,余蓉,陈飞.蝶窦颈内动脉假性动脉瘤的诊治分析(附7例报告)[J].临床耳鼻咽喉头颈外科杂志,2016, 30:1717-1720.]