Neurological Surgery 脳神経外科40巻12号

2012年12月発行

連載 合併症のシステマティック・レビュー─適切なInformed Consentのために

（5）経蝶形骨手術

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新百合ヶ丘総合病院脳神経外科

ページ範囲：P.1119 - P.1129

Ⅰ．はじめに

　20世紀初頭にSchloffer，Hirsch，Halstead，Cushingらが，脳深部に位置する下垂体病変に対して経蝶形骨手術（transsphenoidal surgery：TSS）という革新的な手術を創始した．しかし，手術顕微鏡も抗生剤もない当時，術中術後にさまざまな合併症が生じ致死率も高かったため，当手術が一般化することはなかった．その後，半世紀が過ぎ1965年にHardyらがTSSの革新性に再着目し，TSSに手術顕微鏡を導入した³²⁾．抗生剤の発見・普及も相まって合併症を減らすことが可能となり，以来約半世紀，TSSはその利便性から広く普及し一般的な手術となった⁶⁷⁾．

　近年，神経内視鏡の導入^8,9,43)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手術（extended TSS）^{11,21,23,25,26,28,37-41,46,47,72,79,80)}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^4,35,44,80)により当手術の安全性は向上し，さらには術中MRI ¹⁸⁾などの検査機器の導入，手術顕微鏡・内視鏡などの光学機器の進歩，摘出器具の開発^45,72)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，摘出率が向上してきたとはいっても，開頭手術では稀なTSS特有の合併症への対応には各施設で未だ苦慮しているのが現状である．画期的手術であるTSSの発展の歴史は，いかに合併症を減らすことができるかにかかってきたと思われる．したがって当手術に関する論文は，手術成績の向上に関することもさることながら，合併症を減らすためのさまざまな工夫についての著書が他分野に比べて多いのが特徴である．

　TSSは開頭クリッピング術，開頭血腫除去術などの一般的な脳神経外科手術と比較して，施設間・術者間格差の大きい手術である．それは治癒率などの治療成績以上に合併症率において顕著である．その理由はCiricらが示した（Table 1）¹⁵⁾とおりlearning curveの存在に尽きる．しかしながら術者として500例以上の経験を積むことができる脳神経外科医はCiricらの集計でも29/958（3％）と限られており，本邦ではおそらく20人に満たないであろう．その経験症例数を補うためには合併症に対する十分な知識を得ておくことが肝要である．

　本連載の主題は，患者に対する─適切なInformed Consentのために─であるが，本稿ではTSSの合併症を少しでも減らすことも目的の1つとし，その傾向とともに対策についても概説する．

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