BioGlue for prevention of postoperative cerebrospinal fluid leaks in transsphenoidal surgery: A case series

BACKGROUND: The efficacy of BioGlue (CryoLife, Inc, Atlanta, Ga) surgical adhesive in transsphenoidal surgery was assessed as an adjunct in the prevention of postoperative CSF leaks. METHODS: All patients in whom BioGlue was used for an intraoperative skull base reconstruction were retrospectively identified. Intraoperative CSF leaks were graded according to size (grade 1, small weeping leak without obvious diaphragmatic defect; grade 2, moderate leak with a definite diaphragmatic defect; grade 3, large diaphragmatic and/or dural defect). CSF leak repair was tailored to CSF leak grade. BioGlue was applied as a reinforcement over collagen sponge as the last layer of the repair. RESULTS: Over 28 months, a total of 282 patients underwent endonasal surgery. Of these patients, 124 (79 women; age range, 8-84 years), in 128 procedures, had an intraoperative CSF leak repair reinforced with BioGlue. Pathology included 80 pituitary adenomas, 11 craniopharyngiomas, 7 Rathke's cleft cysts, 6 chordomas, 5 meningiomas, 4 spontaneous CSF leaks, 3 arachnoid cysts, and 8 other parasellar pathologies. There were 62 (48.4%) grade 1, 41 (32.0%) grade 2, and 25 (19.5%) grade 3 leak repairs. The overall repair failure rate was 1.6% (2 cases), with the failures occurring in patients with grade 3 leaks, including 1 who developed meningitis; there was no failure of grades 1 and 2 leaks. The 2 failures were attributed largely to technical aspects of the repair rather than to failure of BioGlue per se. CONCLUSIONS: BioGlue appears to be an effective adjunct in preventing postoperative CSF leaks after transsphenoidal surgery. However, careful attention to technical details of the repair is still required to prevent failures, especially when closing large dural and diaphragmatic defects.     

Collagen sponge repair of small cerebrospinal fluid leaks obviates tissue grafts and cerebrospinal fluid diversion after pituitary surgery

OBJECTIVE: Repair of a cerebrospinal fluid (CSF) leak created at the time of transsphenoidal surgery typically involves placement of a fat, fascial, or muscle graft and sellar floor reconstruction. In this report, a simplified repair for small, "weeping" CSF leaks using collagen sponge is described. METHODS: All patients underwent an endonasal transsphenoidal procedure using the operating microscope. At the completion of tumor removal, if a small CSF leak was noted but no obvious large arachnoidal defect was present, a piece of collagen sponge was fashioned to cover the exposed diaphragma sellae. Titanium mesh was then wedged into the intrasellar, extradural space and a larger piece of collagen was placed over the reconstructed sellar floor. Nasal packing was removed within 24 hours. RESULTS: During an 18-month period, 62 consecutive transsphenoidal procedures were performed for tumor removal. Of 20 patients with a small CSF leak (18 pituitary adenomas, 1 Rathke's cleft cyst, and 1 chordoma), all had successful repair with collagen sponge. At follow-up examinations at 1 to 18 months, no patient had required a lumbar drain or had developed meningitis. One other patient had a large intraoperative arachnoidal defect that was unsuccessfully repaired with the collagen sponge technique; in this patient, a second operation was required with a fat graft, sellar floor reconstruction, and lumbar drainage. CONCLUSION: A simplified repair of small CSF leaks after transsphenoidal surgery using a two-layered collagen sponge technique with sellar floor reinforcement is thought to be safe and effective and obviates the need for tissue grafts, fibrin glue, or lumbar drain placement.     

Spontaneous postoperative cerebrospinal fluid leaks following application of anti-adhesion barrier gel: case report and review of the literature

STUDY DESIGN: This report documents cerebrospinal fluid leakage after application of anti-adhesion barrier gel in a single-surgeon clinical series of 27 patients treated with ADCON-L (Gliatech, Cleveland, OH) during surgery. OBJECTIVE: To discuss a heretofore unreported postoperative complication when using an anti-adhesion barrier gel for lumbar spinal surgery. SUMMARY OF BACKGROUND DATA: Anti-adhesion barrier gel has been touted as a beneficial adjunct to lumbar surgery. No previous report has been identified that documents the complication encountered in this series. METHODS: During the time that ADCON-L was used, in a 9-month period, all spinal surgeries were reviewed, and those cases where ADCON-L was used were documented. The reports of all surgeries then were reviewed for complications during surgery, and clinical follow-up information was obtained. RESULTS: Five of 27 cases receiving ADCON-L during surgery developed cerebrospinal fluid leakage. Three of these patients required reoperation. CONCLUSION: The excessive rate of cerebrospinal fluid leakage after the use of ADCON-L is significant, and the morbidity associated with its use outweighs the potential benefit of the product.     

The incidence of postoperative cerebrospinal fluid leakage after elective cranial surgery: a systematic review

Cerebrospinal fluid (CSF) leakage is a major complication after elective neurosurgical procedures. The aim of this systematic literature review is to summarize the incidence rates of postoperative cerebrospinal fluid leakage for neurosurgical procedures, classified by surgical approach. The Pubmed, Cochrane, Embase, and Web of Science databases were searched for studies reporting the outcome of patients undergoing elective neurosurgical procedures. The number of patients, surgical approach, and indication for surgery were recorded for each study. Outcomes related to CSF leakage such as clinical manifestation and treatment were reported as well. One hundred and thirteen studies were included, reporting 94,695 cases. Overall, CSF leaks were present in 3.8% of cases. Skull base surgery had the highest rate of CSF leakage with 6.2%. CSF leakage occurred in 5.9% of anterior skull base procedures, 6.4% of middle fossa, and 5.2% of transpetrosal surgeries. 5.8% of reported infratentorial procedures were complicated by CSF leakage versus 2.9% of supratentorial surgeries. CSF leakage remains a common serious adverse event after cranial surgery. There exists a need for standardized procedures to reduce the incidence of postoperative CSF leakage, as this serious adverse event may lead to increased health care costs.

     

游离背阔肌肌瓣联合自体脂肪填充序列治疗修复半侧颜面萎缩

目的:探讨游离背阔肌肌瓣联合自体脂肪填充序列治疗修复半侧颜面萎缩的效果。方法:对9例半侧颜面萎缩患者,采用I期行游离背阔肌肌瓣移植,于术后0.5～1年行Ⅱ期自体脂肪填充术。根据面部对称情况行1～3次自体脂肪填充,观察其临床效果。结果:9例肌瓣全部成活,术后0.5～1年观察肌瓣轻度下垂,可见局限性凹陷。经1-3次自体脂肪填充后面部外观明显改善,对称性良好,供区无明显功能障碍。结论:游离背阔肌肌瓣联合自体脂肪填充序列治疗是矫治中、重度半侧颜面萎缩的较好选择,结合不同手术特点的综合治疗,能够显著提高中、重度半侧颜面萎缩的治疗效果。     

Costs of postoperative cerebrospinal fluid leakage: 1-year, retrospective analysis of 412 consecutive nontrauma cases

BACKGROUND: Cerebrospinal fluid (CSF) leaks are widely recognized as commonly occurring postoperative complications of neurosurgical procedures. We will focus on the direct costs associated with CSF leaks in a single center across multiple neurosurgical procedures, based on a retrospective analysis. We will also compare the costs of using a synthetic agent to prevent such leaks with these costs from a more recent study. METHODS: The single-center retrospective study was carried out at the Neurosurgical Center Nijmegen (University Medical Center St Radboud and Canisius Wilhelmina Hospital, Nijmegen, Netherlands) from January 01, 1999, until December 31, 1999. Four hundred twelve consecutive, nontrauma, elective procedures were examined. RESULTS: By applying strict criteria for CSF leakage (including those self-limiting subcutaneous minor CSF collection), we found an overall leak rate of 10.7% with a lower number for supratentorial and transsphenoidal procedures and much higher numbers for infratentorial procedures and extensive skull base procedures (6 [12.8%] of 47 and 18 [34.6%] of 52, respectively). The CSF leak in these 44 patients was associated with high additional costs which accounted for 21.7% of the total costs of all 412 procedures or on average 1508 per patient and procedure. If DuraSeal (Confluent Surgical, Inc, Waltham, MA) were to be used prophylactically for every procedure, and assuming a 4% leak rate postprocedure (which was achieved in a more recent study of 46 patients using DuraSeal), there would be a saving of 550 for every procedure (reduction in additional costs of CSF leak minus the cost of the sealant), or a total saving of 226600 in the series of 412 patients. CONCLUSION: Our analysis establishes that CSF leaks occur with high frequency and incur significant costs across all types of surgical procedures. A direct correlation of this complication (and ensuring costs) is observed with more extensive procedures, and reduction of these significant costs can be achieved by using augmentation of the dural closure with DuraSeal.     

Spontaneous spinal cerebrospinal fluid leaks and minor skeletal features of Marfan syndrome: a microfibrillopathy.

OBJECT: Spontaneous spinal cerebrospinal fluid (CSF) leaks are increasingly recognized as a cause of postural headaches. The authors examined a group of patients suffering from spontaneous spinal CSF leaks who also had minor skeletal features of Marfan syndrome for abnormalities of fibrillin-containing microfibrils. METHODS: Patients with spontaneous CSF leaks were evaluated for the clinical characteristics of connective tissue disorders. Skin biopsies were obtained in three patients with skeletal manifestations that constitute part of the Marfan syndrome phenotype. Cultured fibroblasts were studied for fibrillin-1 synthesis and incorporation into the extracellular matrix (ECM) by performing quantitative metabolic labeling and immunohistochemical analysis. Among 20 consecutive patients found to have spinal CSF leaks, four (20%) exhibited minor skeletal features of Marfan syndrome, but lacked any ocular or cardiovascular abnormalities. The mean age of these patients (30 years) was lower than that of the 16 patients without skeletal abnormalities (44 years; p = 0.01). Abnormalities in fibrillin-1 metabolism and immunostaining were detected in all three patients with the skeletal abnormalities who underwent examination, but not in a control patient without these skeletal manifestations. CONCLUSIONS: Twenty percent of patients who experience spontaneous spinal CSF leaks have minor skeletal features of Marfan syndrome. The authors demonstrated abnormalities in fibrillin-1 protein deposition in all patients examined, but only one person was found to have a fibrillin-1 abnormality typically found in classic Marfan syndrome. The results indicate that there is a heterogeneous involvement of other components of ECM microfibrils at the basis of this cerebrospinal manifestation. In addition, the authors identified a connective-tissue etiological factor in a group of disorders not previously classified as such.     

Results after endoscopic treatment of postoperative upper gastrointestinal fistulas and leaks using combined Vicryl plug and fibrin glue

Background The incidence of clinically relevant anastomotic leaks after upper gastrointestinal surgery is approximately 4% to 20%, and the associated mortality is up to 80%. Depending on the clinical presentation, the treatment options include surgery, conservative treatment with or without external drainage or endoscopic treatment.Methods This report presents nine cases of anastomotic leaks or fistulae after surgery for upper gastrointestinal cancers that were treated by insertion of a Vicryl plug and sealing with fibrin glue. Under sedation, all nine patients underwent endoscopic lavage of the cavity at the site of anastomotic leakage. The entrance to the cavity then was filled with Vicryl mesh and sealed off with fibrin glue. After the procedure, the patients underwent endoscopy and a water-soluble contrast study for assessment of the result.Results Seven of the nine patients had complete healing of the anastomotic leak or fistula after one to two endoscopic treatments. In one case, the treatment failed immediately because of a large and direct tracheoesophageal fistula. Another patient experienced recurrent intrathoracic abscesses after initial technical success.Conclusions Postoperative upper gastrointestinal fistulas or anastomotic leaks can be managed successfully with little morbidity by means of endoscopic insertion of Vicryl mesh with fibrin glue, thereby avoiding repetitive major surgery and its associated risks.     

Use of Tisseel fibrin sealant in neurosurgical procedures: incidence of cerebrospinal fluid leaks and cost-benefit analysis in a retrospective study

OBJECTIVE: To determine the clinical efficacy and cost effectiveness of using the fibrin sealant (FS) Tisseel (Baxter Healthcare Corp., Deerfield, IL) for patients undergoing anterior cranial base, infratemporal, and retromastoid surgical procedures. METHODS: A retrospective review was performed, comparing two matched populations of patients who underwent surgical procedures using anterior cranial, infratemporal, or retromastoid approaches to intracranial pathological lesions. The incidences of cerebrospinal fluid (CSF) leaks in matched groups treated with the FS Tisseel or treated without FS were compared. The costs of Tisseel use were examined in comparison with the costs of postoperative management of CSF leaks and/or tension pneumocranium with spinal drainage and occasionally surgical reexploration, when lumbar drainage failed. RESULTS: Patients who received the FS Tisseel exhibited no detectable postoperative CSF leaks or tension pneumocranium. Patients who did not receive Tisseel demonstrated 4 to 16% incidences of postoperative leaks, depending on the surgical approach used. The costs of treating those leaks far exceeded the costs of using Tisseel, even if it were used indiscriminately for all patients. CONCLUSION: This retrospective review indicates that the FS Tisseel reduces the incidence of postoperative CSF leaks and tension pneumocranium while reducing overall management costs. Further prospective study is needed to determine which patients can benefit most from FS use.     

Pathophysiology of cerebrospinal fluid in head injury: Part 1. Pathological changes in cerebrospinal fluid solute composition after traumatic injury

After head injury, many complex neurochemical events occur locally, at the site of initial injury, and globally, as a result of secondary phenomena. Neurochemical alterations in the cerebrospinal fluid after injury can be utilized to reflect these events. The authors review the role of the cerebrospinal fluid in the treatment of head injury as it relates to the diagnosis, prognosis, and further elucidation of the pathophysiological manifestations of head injury at the cellular and biochemical level.     

防治乳腺癌术后皮下积液的方法改进：附204例报告

目的:探讨乳腺癌患者术后皮下积液的防治措施.方法:回顾性分析2007年1月-2012年1月204例手术治疗的乳腺癌患者临床资料,其中106例(改良组)行常规腋窝淋巴结清扫,并于术中行淋巴管结扎、皮瓣与胸壁固定,术后双根引流管负压引流,98例(对照组)行传统手术方法,即在常规腋窝淋巴结清扫后置引流管1根负压引流.观察比较两组患者术后皮下积液发生情况.结果:改良组与对照组发生皮下积液分别为9例(8.5％)和21例(21.4％),改良组术后积液发生率明显低于对照组(X 2=6.796,P＜0.05).对发生皮下积液者,经穿刺抽液,调整引流管位置或重新置管等相应措施,均获得治愈.结论:改良手术方法可以降低乳腺癌患者术后皮下积液的发生,且未增加手术难度,值得临床应用.     

Reconstruction of diaphragm using autologous fascia lata: an experimental study in dogs

BACKGROUND: We investigated whether fascia lata is an appropriate material for reconstruction of the diaphragm. METHODS: A diaphragmatic defect (2 cm by 5 cm) was reconstructed with a patch of autologous fascia lata in the experimental group (n = 12) and with expanded polytetrafluoroethylene in the control group (n = 12). Maximal tensile strength at the sutured region was measured serially. RESULTS: The maximal tensile strength at the sutured region reconstructed with the fascia lata was 1.14 +/- 0.50 kgf 15 days and 2.04 +/- 0.94 kgf 30 days after operation. The values were higher than those of expanded polytetrafluoroethylene (p < 0.0001). These values of fascia lata were close to the original maximal tensile strength of the muscular region of the diaphragm (1.52 to 1.66 kgf). CONCLUSIONS: Reconstruction of diaphragm using autologous fascia lata is safe, easy, and inexpensive, and provides smooth wound healing. The only disadvantage is the necessity of a femoral incision for harvest; nevertheless, it may be worthwhile to use fascia lata in clinical trials to further assess its suitability as a reconstruction material.     

Spinal cord injury after ascending aorta and aortic arch replacement combined with antegrade stent grafting: role of postoperative cerebrospinal fluid drainage

Ascending aorta and aortic arch replacement combined with antegrade stent grafting of the descending thoracic aorta represents an emerging hybrid surgical approach for complex and extensive thoracic aortic disease. We present a case of a patient at low risk for spinal cord ischemia who underwent hybrid thoracic aortic surgery (aortic arch replacement and E-vita prosthesis implantation) and developed a spinal cord injury (SCI) after the intervention. Treatment aimed at increasing spinal cord perfusion pressure with the aid of cerebrospinal fluid (CSF) drainage was effective in recovering neuromuscular function.     

Upregulation of cerebrospinal fluid and peripheral prostaglandin E2 in a rat postoperative pain model

Analgesic management of postoperative pain associated with thoracic surgery remains a difficult clinical challenge. In the present study we used a thoracic muscle incision model to characterize pain-related behavior and changes in prostaglandin E2 (PGE2) in both thoracic cerebrospinal fluid (CSF) and incision site tissues. A deep muscle incision was made in the left thoracic region of rats anesthetized with isoflurane, propofol, or spinal bupivacaine. Thoracic CSF and incision site tissue concentrations of PGE2 were monitored for 6 h using microdialysis loop catheters. Postoperative pain-related behavior was assessed by recording exploratory locomotive activity. Thoracic muscle surgery decreased rearing and ambulation. Oral ketorolac or rofecoxib 3 mg/kg restored normal rearing and ambulation. Postoperative CSF PGE2 concentration increased most (threefold) with spinal anesthesia, and not at all with propofol. With surgery under isoflurane or spinal bupivacaine, presurgical oral administration of ketorolac or rofecoxib 3 mg/kg reduced postsurgical CSF PGE2 levels and tissue PGE2 levels. Intrathecal ketorolac (4 microg) reduced CSF PGE2 after surgery without affecting tissue PGE2 levels, whereas intrathecal L-745,337 (80 microg) did not reduce CSF PGE2. Thoracic surgical wounds increase pain-related behavior and CSF and tissue PGE2 levels, all of which can be attenuated by oral cyclooxygenase inhibitors.     

Cranioplasty using autologous calvarial bone graft in combination with titanium mesh plates for patients with a history of bone infections after initial cranioplasty

We present a modified method for reconstruction of calvarial bone defects for patients with a history of infectious complications. Three patients who had experienced implanted bone infections underwent reconstruction of calvarial bone defect. For reconstruction of the calvarial bone defects, autologous split calvarial bone grafts were used to cover the calvarial bone defect. The full or half layered fronto-parietal bone used as implants were fixed with titanium mini-plates for primary bone defect site, while the new bone defect site caused by getting autologous bone graft were covered with titanium mesh plates assisted by residual half layered calvarias. The average follow-up span of patients was 64 months. Evaluated clinical and radiologic results are stable, showing no measurable side effects. Split calvarial bone graft in combination with titanium mesh plates is recommended in patients with a history of infection or high risk of infection.     

Functional outcome and postoperative complications after the microsurgical removal of large vestibular schwannomas via the retrosigmoid approach: a meta-analysis

For large (≥30 mm) or giant (≥40 mm) vestibular schwannomas (VSs) for which microsurgical removal is the main treatment option, complete tumour resection and the preservation of acceptable facial nerve function can be safely and successfully achieved via the retrosigmoid approach. We performed a meta-analysis to provide a reliable estimate of functional outcome and postoperative complications for patients treated surgically for large VSs. We conducted a comprehensive search in Pubmed, Embase and the Chinese National Knowledge Infrastructure (CNKI) databases to identify publications that included only patients in whom the VSs were >3.0 cm in maximal diameter and microsurgically removed by a retrosigmoid approach. Pooled estimates of proportions with corresponding 95 % confidence intervals were calculated using the Freeman–Tukey double arcsine transformation. This meta-analysis revealed that the pooled proportion of gross total resections was 79.1 % (95 % CI, 64.2–90.8 %; I ²?=?95.4 %). By combining microsurgical techniques with continuous electrophysiological monitoring, the anatomical preservation of the facial nerve at the end of surgery was achieved in 88.8 % (95 % CI, 83.6–93.2 %; I ²?=?76.1 %) of the patients. The pooled proportion of good postoperative facial nerve function (House–Brackmann (HB) grades I–II) was 62.9 % (95 % CI, 50.0–74.9 %; I ²?=?91.1 %). Cerebrospinal fluid leakage was reported in 7.8 % (95 % CI, 4.8–11.4 %; I ²?=?49.8 %) of the patients. The mortality rate was 0.87 % (95 % CI, 0.22–1.78 %; I ²?=?4.9 %). Our meta-analysis revealed that for large VSs, very favourable results can be obtained using the retrosigmoid approach with minimal mortality, especially with respect to anatomical and functional facial nerve preservation.