Neurological Surgery 脳神経外科38巻7号

2010年07月発行

総説

経蝶形骨洞手術における髄液漏修復術

著者： 天野耕作¹ 川俣貴一² 堀智勝³ 岡田芳和¹

所属機関： ¹東京女子医科大学脳神経外科 ²東京女子医科大学八千代医療センター脳神経外科 ³森山記念病院脳神経外科

ページ範囲：P.599 - P.611

Ⅰ．はじめに

　Hardyが経蝶形骨洞手術（transsphenoidal surgery ：TSS）に手術顕微鏡を導入²⁹⁾して以来40年以上が過ぎ，当手術はその利便性から広く普及し，一般的な手術となっている．近年では神経内視鏡の導入^6,7,38)により下垂体およびその近傍病変に対するTSSの適応は広がり，前頭蓋底の広汎な領域に対する拡大経蝶形骨洞手術^{11,17,19,25-27,32-34,36,37,43,45,58,63)}も行われるようになってきた．またナビゲーションシステムの導入^3,36,39,63)により当手術の安全性は向上し，さらには術中MRI ¹⁴⁾などの検査機器の進歩，手術顕微鏡の改良，摘出器具の開発^41,58)により，腫瘍の摘出率も年々向上してきている．しかしながらどんなに安全性，摘出率が向上しても，当手術最大の合併症である術後髄液漏は完全に解決されていないのが現状である．

　TSS後の髄液漏発生率は1.5～40％^{4,8,13,16,17,19,20,25,27,28,45,50,51,55,66)}と緒家の報告でばらつきがある．これは各施設で腫瘍摘出の積極性，髄液漏修復方法が異なるためと考えられるが，Ciricら¹³⁾の3.9％という報告が大規模studyで信頼に値する平均的な数字だと考えられる．また一般的なTSSの術中髄液漏発生率も，腫瘍摘出の積極性や髄液漏確認時にValsalva法を行うか否かで異なってくるが9.5～37.8％^{8,10,28,50,55,56,61,62)}とされている．TSS適応の代表例である下垂体腺腫では，腫瘍が巨大化し正常下垂体が菲薄化している場合，機能性下垂体腺腫で偽性被膜を積極的に摘出しなければならない場合⁴⁰⁾などでは術中髄液漏が起こりやすい．ラトケ囊胞でも，病理診断確定のためcyst wallを採取する²⁾際に髄液漏が発生しやすく，また自然経過の中で囊胞に穴が開き既に髄液腔と交通していることもある．頭蓋咽頭腫^26,58)，髄膜腫^14,18,27,58)も，腫瘍の全摘出を目指せば髄液漏は必発である．積極的な腫瘍摘出を行えば，必然的に術中髄液漏の発生率が上がるのは自明の理である．逆に言えば，手術中に髄液漏の発生を恐れていては，腫瘍を積極的に摘出することはできない．実際当科でも成長ホルモン産生下垂体腺腫の摘出率は年々向上してきているが，その理由の1つに髄液漏対策技術が向上してきたことが挙げられる．

　当科では，1998年にTSSを経上口唇から片側経鼻孔に変更するとともに神経内視鏡を導入して，安全性，腫瘍摘出率の向上に努めている．同時期から現在までに770例を超えるTSSを施行した．本稿ではTSSにおける術後髄液漏の予防という課題に対して，当科および各施設で行われているさまざまな工夫，手技について概説したい．

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