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Vol. 10. Issue 2.
Pages 108-118 (January 1999)
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Vol. 10. Issue 2.
Pages 108-118 (January 1999)
Métodos reconstructivos en cirugía tumoral de base de cráneo
Reconstructive techniques in cranial base tumor surgery
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G. Sánchez Aniceto, A. Romance García, R. Gutiérrez Díaz, J. Montalvo Moreno
Servicio de Cirugía Maxilofacial. Hospital Universitario 12 de Octubre. Madrid
R. Díez Lobato*, A. Cabrera Yesares*
* Servicio de Neurocirugía. Hospital Universitario 12 de Octubre. Madrid
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Resumen
Objetivos

Describir la experiencia de los autores durante los últimos cinco años en el tratamiento quirúrgico de 37 pacientes con patología tumoral de base de cráneo, dedicando una atención especial a los métodos reconstructivos empleados, y resultados obtenidos en cuanto a supervivencia e incidencia de complicaciones graves.

Material y métodos

Un total de 37 pacientes con patología neoplásica de la base craneal fueron intervenidos quirúrgicamente entre octubre de 1992 y septiembre de 1997. Veinte pacientes presentaban tumores benignos o pseudotumores, y diecisiete tumores malignos. Catorce de ellos habían sido sometidos a procedimientos quirúrgicos previos sobre el tumor y cuatro habían recibido radioterapia. La mayor parte de las neoplasias afectaban el segmento anterior de la fosa craneal media (n=18), o la fosa craneal anterior, en su sector lateral (n=15) o en su sector central (n=13). Veintitrés pacientes precisaron abordajes quirúrgicos combinados intra-extracraneales. Los abordajes más comúnmente utilizados han sido los transfrontoorbitarios (n=18), el lateral preauricular infratemporal (n=13), diversos tipos de maxilotomías (n=11), rinotomía pediculada (n=5), y translocación facial (n=3).

Describimos los defectos postquirúrgicos de los 37 pacientes en lo que respecta a la integridad o no de la duramadre, vía aerodigestiva superior, piel, esqueleto craneofacial, cavidades (maxilar, órbita, infratemporal), pares craneales y arteria carótida interna. Los métodos reconstructivos empleados incluyeron: colgajos locales (galea-pericráneo, 21 casos; fascia parietotemporal, 4), colgajos miofasciales (músculo temporal, 9 casos; galea-frontal 2 casos), miocutáneos (pectoral mayor, 2 casos) y colgajos libres microvasculares (dorsal ancho, 3 casos; recto abdominal, 1 caso). En 24 casos se reconstruyeron con injertos óseos autólogos (calota craneal) rebordes, paredes orbitarias y/o bóveda craneal. La fijación habitualmente empleada para los segmentos óseos movilizados e injertos fue mediante microosteosíntesis con placas y tornillos de titanio. En 13 pacientes se empleó el metilmetacrilato para defectos extensos craneales o relleno de fosa temporal.

Resultados

En 31 pacientes (84% de los casos) se consiguió resección completa del tumor. Un paciente falleció en el postoperatorio tardío (4 semanas) por hemorragia incoercible procedente de la arteria carótida interna. Catorce pacientes recibieron radioterapia postoperatoria. El seguimiento medio de los pacientes ha sido de 31 meses (rango 2–60 meses) con una supervivencia global del 80% (69% para los tumores malignos) y una supervivencia libre de enfermedad del 58% (44% para tumores malignos). Veinte pacientes (56%) presentaron complicaciones postquirúrgicas: neurológicas (11 pacientes), relacionadas con el abordaje (9 pacientes), de la herida quirúrgica (7 pacientes), fístula de líquido cefalorraquídeo (4 pacientes), y sistémicas (3 pacientes).

Conclusiones

Una metodología reconstructiva adecuada es imprescindible para conseguir resultados aceptables en términos de supervivencia y calidad de vida en pacientes con patología tumoral de base de cráneo.

Palabras clave:
Métodos reconstructivos
Base craneal
Tumor
Abordaje transfacial
Summary

In this article the authors describe their experience during the last five years with the surgical treatment of 37 patients presenting skull base neoplasms. Special attention is given to reconstructive techniques and the final results in terms of survival and major complications.

Methods and materials

Thirty-seven patiens with skull base neoplasms underwent surgical treatment between october, 1992 and september, 1997. Twenty patients presented with benign tumors or pseudotumor, and seventeen had malignant neoplasms. Fourteen patients underwent previous surgical procedures and four also received radiation therapy. Most tumors affected the middle cranial fossa at its anterior segment (n=18) or the anterior cranial fossa at its lateral (n=15) or central portion (n=13). Twenty-three patients underwent combined intra-extracranial approaches. The most commonly used approaches were transfrontoorbital (n=18), lateral preauricular-infratemporal (n=13), different types of maxillotomies (n=11), pedided rhinotomy (n=5) and facial translocation (n=3). Postsurgical deffects in the 37 patients are described in detail, namely integrity of duramater, superior aerodigestive tract, skin, craniofacial skeleton, cavities (maxilla, orbit, infratemporal), cranial nerves, and internal carotid artery. Reconstructive techniques induded: local flaps (galeal-pericranial, 21 cases; temporoparietalis fascia, 4), myofascial flaps (temporalis musde, 9 cases; galeal-frontalis, 2 cases), myocutaneous (pectoralis major, 2 cases), and microvascular free flaps (lattissimus dorsi, 3 cases, rectus abdominis, 1 case). In 24 cases, autologous bone grafts (calvarial) were used to reconstruct orbital rims, walls or cranial vault defects. Osteotomized bone segments and grafts were usually fixed with titanium microplates and screws. Thirteen patiens underwent cranial vault or temporal fossa methyl-methacrylate reconstruction.

Results

In thirty-one cases (84%) complete resection of tumor was achieved. One patient died in the late postoperative period (4 weeks) due to internal carotid artery bleeding. Fourteen patients received postoperative radiation therapy. Medium follow-up has been 31 months (range 2–60 months); the overall survival rate was 80% (69% for malignant tumors) and the disease-free survival rate 58% (44% for malignant tumors). Twenty patients (56%) suffered postsurgical complications: neurologic (11 patients), approach-related (9 patients), surgical wound related (7 patients), cerebrospinal fluid fistula (4 patients) and systemic (3 patients).

Conclusions

Suitable reconstructive principIes are essential to achieve fair results in terms of survival and life-quality in patients with skull base neoplasms.

Key words:
Reconstructive techniques
Cranial base
Tumor
Transfacial approach

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