Acellular Dermal Allograft for Sellar Repair after Transsphenoidal Approach to Pituitary Adenomas

Objectives Our practice has transitioned from using fat autograft to acellular dermal matrix (AlloDerm, LifeCell Corp, Woodlands, Texas, USA). We present the largest series to our knowledge of AlloDerm for sellar floor repair after transsphenoidal approach to pituitary adenoma and compare rates of postoperative cerebrospinal fluid (CSF) leak with an earlier cohort of patients whose CSF leaks were repaired with fat autograft.Design This is a retrospective cohort study comparing sellar repair with fat autograft versus inlay Alloderm between the years 2003 and 2012. The primary end point was postoperative CSF leak.Results A total of 429 patients (368 primary; 83 revision operations) without intraoperative lumbar drainage were included. A total of 18 postoperative CSF leaks were observed (3.9%). Intraoperative CSF leak occurred in 160 cases (35.5%). Among this subset of patients with intraoperative CSF leak, 95 underwent repair with AlloDerm and 46 underwent repair with fat autograft, with postoperative CSF leak rates of 8.4% and 15.2%, respectively (p = 0.34, chi-square test); 19 patients underwent repair with other techniques or no repair at all, with postoperative leak rate of 0%.Conclusions AlloDerm is an effective alternative to fat autograft in cases of low-flow CSF leak following transsphenoidal resection of pituitary adenoma.     

Scarless Abdominal Fat Graft Harvest for Neurosurgical Procedures: Technical Note

Background Abdominal fat grafts are often harvested for use in skull base reconstruction and cerebrospinal fluid (CSF) leak repairs, and for operations traversing the nasal sinuses or mastoid bone. Although the endoscopic transnasal surgery has gained significant popularity, in part because it is considered “scarless,” a common adjunct, the abdominal fat graft, can result in a disfiguring scar across the abdomen. Objective This is the first report of a scarless abdominal fat graft technique for skull base reconstruction. Methods Ten patients with a median age of 56.5 years (range: 45–73 years) underwent endoscopic transsphenoidal tumor resection with intraumbilical fat graft harvest. Careful circumferential fat dissection at the umbilicus, with progressive retraction of the graft, was crucial to ensure maximal visualization and to prevent injury to the subcutaneous vessels and rectus fascia. Results Following reconstruction of the sellar skull base, all patients did well postoperatively with no evidence of CSF leak. At 12-week follow-up for all patients, there was no evidence of scar, intracavity hematoma, or wound infection. Conclusions Fat graft harvest through an intraumbilical incision results in a scar-free abdominal harvest, and is a useful procedural adjunct to complement “scarless” brain surgery.     

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.     

Banked Fascia Lata in Sellar Dura Reconstruction after Endoscopic Transsphenoidal Skull Base Surgery

Objectives Cerebrospinal fluid (CSF) leakage is an undesirable complication of transsphenoidal skull base surgery. The issue of the most appropriate sellar dura repair remains unresolved, although a multilayer technique using autologous fascia lata is widely used. We describe the novel application of a homologous banked fascia lata graft as an alternative to an autologous one in the reconstruction of sellar dura defects in endoscopic transsphenoidal surgery. Design The clinical records of patients who underwent endoscopic transsphenoidal surgery at our department from June 2012, when we started using homologous fascia lata, up to July 2014 were reviewed retrospectively. The data concerning diagnosis, reconstruction technique, and surgical outcome were analyzed. Results We treated 16 patients successfully with banked fascia lata. Twelve patients presented intraoperative CSF leakage, and four patients were treated for postoperative rhinoliquorrhea. Banked fascia lata was used in a single-to-multilayer technique, depending on the anatomical features of the defect and of the sellar floor. No complications or failures in sella reconstruction occurred. Conclusion A banked fascia lata graft proved reliable and safe in providing an effective sellar dura reconstruction. Used in a multilayer strategy, it should be considered a viable alternative to an autologous fascia lata graft.     

Risk factors of cerebrospinal fluid rhinorrhea following transsphenoidal surgery

Summary Objective. Cerebrospinal fluid (CSF) rhinorrhea is a potentially life-threatening complication following transsphenoidal surgery (TSS). Methods. To elucidate the risk factors that may affect the incidence of postoperative CSF rhinorrhea, we retrospectively reviewed 200 consecutive cases of TSS performed by a single surgeon for 168 adenomas and 32 other sellar and parasellar lesions. Results. Intra-operative CSF leakage was encountered in 38 cases (19.0%). Its incidence did not correlate to tumor size. Among 4 microadenoma cases with CSF leak, 3 were ACTH adenomas. In contrast, postoperative CSF rhinorrhea was observed in 5 cases (2.5%), all following TSS for adenomas. It was frequently noted in cases with prior TSS (3/40, 7.5%, p = 0.0235) and prior radiotherapy (2/7, 28.6%, p<0.0001). Two cases who required surgical intervention had received TSS and radiotherapy previously. Conclusion. The risk of postoperative CSF rhinorrhea is significantly increased in cases with prior TSS or radiotherapy or both. In addition, these cases tended to show delayed CSF leaks and require sellar reconstruction for its treatment. When a CSF leak was encountered during TSS in these high-risk cases, thorough sellar reconstruction and long-term follow-up is necessary.     

Immediate and Delayed Complications Following Endoscopic Skull Base Surgery

Objectives To characterize the temporal distribution and resolution rate of postoperative complications from endoscopic skull base surgery. Design Retrospective review of patients undergoing endoscopic resection of paranasal sinus or skull base neoplasm from 2007 to 2013. Setting Massachusetts General Hospital/Massachusetts Eye and Ear Infirmary Cranial Base Center. Participants Fifty-eight consecutive patients. Main Outcome Measures Postoperative complications were categorized as cerebrospinal fluid (CSF) leak, pituitary, orbital, intracranial, or sinonasal. Complications were temporally categorized as “perioperative” (within 1 week), “early” (after 1 week and within 6 months), or “delayed” (after 6 months). Results The most common perioperative complications were diabetes insipidus (19.0%), CSF leak (5.2%), and meningitis (5.2%), with resolution rates of 75%, 100%, and 100%, respectively. Overall, CSF leak occurred in 13.8% of patients and resolved in all cases. A total of 53.8% of all complications were evident within 1 week of surgery. Chronic rhinosinusitis was the most common delayed complication (3.4%). Hypopituitarism and delayed complications were less likely to resolve (p = 0.014 and p = 0.080, respectively). Conclusions Monitoring of complications after endoscopic skull base surgery should focus on neurologic complications and CSF leak in the early postoperative period and development of chronic rhinosinusitis in the long term. Late-onset complications and hypopituitarism are less likely to resolve.     

Decreased Rate of CSF Leakage Associated with Complete Reconstruction of Suboccipital Cranial Defects

Background Cerebrospinal fluid (CSF) leakage represents a major source of morbidity following microvascular decompression (MVD) surgery. The objective of this study was to retrospectively assess whether complete versus incomplete reconstruction of the suboccipital cranial defect influences the incidence of CSF leakage following MVD.Methods We reviewed the charts of 100 patients who consecutively underwent MVD for trigeminal neuralgia by two attending neurosurgeons between July 2004 and April 2010. Operative variables including incomplete or complete calvarial reconstruction, primary dural closure or dural closure with adjunct, and use of lumbar drainage were recorded. The effect of complete calvarial reconstruction on the incidence of postoperative CSF leakage was examined using a multivariate logistic regression model.Results Of the 36 patients whose wound closure was reconstructed with a complete cranioplasty, 2 (5.6%) patients experienced a postoperative CSF leak. Of the 64 patients whose wound closure was augmented with an incomplete cranioplasty, 15 (23.4%) experienced a postoperative CSF leak. There was suggestive but inconclusive evidence that the risk of CSF leakage following MVD was smaller with complete reconstruction of calvarial defect than with incomplete reconstruction (two-sided p value = 0.059), after accounting for age, dural closure method, use of lumbar drainage, and previous MVD.Conclusion Complete reconstruction of the suboccipital cranial defect decreases the risk of CSF leakage.     

Endoscopic Management of Cerebrospinal Fluid Rhinorrhea: The Charing Cross Experience

Objective To describe our experience of cerebrospinal fluid (CSF) rhinorrhea management.Design Retrospective.Setting Charing Cross Hospital, London, a tertiary referral center.Participants Fifty-four patients with CSF rhinorrhea managed from 2003 to 2011.Main outcome measures Surgical technique; Recurrence.Results Etiologically, 36 were spontaneous and 18 traumatic. Eight patients with spontaneous and two with traumatic leaks had previous failed repairs in other units. Success rates after first and second surgery were 93% and 100%, respectively. Mean follow-up was 21 months. Four patients, all of spontaneous etiology, had recurrences; three of these underwent successful second repair with three layered technique, and the fourth had complete cessation of the leak after gastric bypass surgery and subsequent weight reduction. Adaptation of anatomic three-layered repair since then averted any further failure in the following 7 years. Mean body mass index was 34.0 kg/m² in spontaneous and 27.8 kg/m² in traumatic cases (p < 0.05). Fifty percent of spontaneous leaks were from the cribriform plate, 22% sphenoid, 14% ethmoid, and 14% frontal sinus. In the traumatic CSF leak group: 33.3% were from the cribriform plate, 33.3% sphenoid, 22.2% ethmoid, and 11.1% frontal.Conclusion Endoscopic CSF fistula closure is a safe and effective operation. All sites of leak can be accessed endoscopically. We recommend the use of an anatomic three-layered closure in difficult cases.     

Cerebrospinal fluid rhinorrhea following endocopic trans-sphenoidal pituitary surgery: Experience from 337 patients

IntroductionCerebrospinal fluid (CSF) leak is a frequent complication after trans-sphenoidal pituitary surgery. We try to determine the incidence, risk factors, diagnostic procedures, and management of CSF leaks following trans-sphenoidal pituitary macroadenoma surgery.MethodsA retrospective analysis of 337 patients data.ResultsPostoperative CSF leaks occurred in 11 patients (3,1%). Ten patients had to be reoperated. Three patients had meningitis. Intraoperative CSF leak is the only significant predictive factor of postoperative CSF leak. Revision surgery, wide opening of the sella turcica and insufficient reconstruction of the sellar floor also seem to play a role (for six cases of postoperative CSF leak, the closure material had been excluded).ConclusionPrevention of the postoperative CSF leak needs screening of intra-operative CSF leak. The strength of the sellar floor is essential in order to avoid the ejection of the closure material, related to the intracranial pression.     

Reconstruction of the sellar dura in transsphenoidal surgery using an expanded polytetrafluoroethylene dural substitute

BACKGROUND: The transsphenoidal approach for resecting pituitary tumors has classically included reconstruction of the anterior wall of the sella turcica. A variety of materials have been used in this process for the purpose of both recreating the original anatomy and preventing postoperative cerebrospinal fluid (CSF) leaks. We studied the use of an ePTFE dural substitute (GORE Preclude MVP, W.L. Gore & Associates, Flagstaff, Arizona, USA), as a method for obtaining reliable reconstruction of the sellar dura. METHODS: A prospective alternate case trial was designed to assess this new dural substitute wherein 60 patients who underwent transsphenoidal surgical resection of intrasellar lesions larger than 1 cm were included. Thirty patients had the sellar dura closed with ePTFE dural substitute, whereas 30 patients underwent anterior wall reconstruction as ordinarily performed in our institution. RESULTS: Each patient was reassessed at closure, and the operative site and sphenoid sinus were evaluated with 3-months-postoperative magnetic resonance imaging. Three patients experienced postoperative CSF leaks: 1 with ePTFE dural substitute and 2 without. All 3 patients underwent a second operation to repair the CSF leak, without further complications. No other postoperative complications were noted in the series. CONCLUSION: Expanded polytetrafluoroethylene dural substitute provides a safe and effective adjunctive method for reconstruction of the sellar dura.     

The Endoscopic Hemi-Transseptal Approach to the Sella Turcica: Operative Technique and Case-Control Study

Background The hemi-transeptal (Hemi-T) approach was developed to facilitate a binasal two-surgeon endoscopic approach for sellar tumors, with preservation of the nasoseptal flap and selective mobilization for reconstruction. Methods A retrospective case-control study was performed comparing the Hemi-T approach with previously used methods of sellar exposure and reconstruction. Outcome measures included operative time and postoperative nasal morbidity. Results A total of 23 patients underwent the Hemi-T approach versus 42 in whom traditional exposure was performed. Operative time was significantly shorter using the Hemi-T technique (152.6 ± 56.8 versus 205.2 ± 61.3 minutes; p = 0.001), as was the length of hospital stay (3.3 ± 1.9 versus 5.4 ± 3.6 days; p = 0.004). There was no difference in the rates of intraoperative or postoperative cerebrospinal fluid leak, cartilage necrosis, septal perforation, or mucosal adhesions. Conclusion The Hemi-T approach facilitates binasal two-surgeon access to the sella without compromise of the pedicle during the extended sphenoidotomies and tumor removal. Operative time and nasal morbidity is not increased, and iatrogenic injury to the nasal cavity is minimized when a flap is not required.     

Minimally Invasive Technique for Repairing CSF Leaks Due to Defects of Posterior Table of Frontal Sinus

Objective Cerebrospinal fluid (CSF) leaks from the frontoethmoid and sphenoid region can be easily dealt with endoscopic approaches, but CSF rhinorrhea due to frontal sinus fractures are difficult to treat solely by the nasal endoscopic approach and may require external repair. The technique described targets defects of the posterior table of the frontal sinus where conventional osteoplastic approach of obliteration is usually done. This technique is minimally invasive and involves repair using an endoscope via a frontal trephine. Methods We have treated five cases of traumatic CSF rhinorrhea with this technique, and the mean follow-up is 1 year (range: 10–14 months). The frontal sinus is opened by making a small stab incision (frontal trephine), and the defect site is localized by visualization via endoscope through the trephine. The repair is then performed with fat, bone graft, and fibrin glue. Results Closure of the defect was achieved in a single stage in all the patients, and none of them had a recurrence of leak in the 1-year follow-up period. Conclusion This is a good technique for superiorly and laterally placed posterior table defects of the frontal sinus with minimal morbidity and excellent closure rates.     

Impact of Chemoradiotherapy on CSF Leak Repair after Skull Base Surgery

Background Transnasal endoscopic resection (TER) has become the treatment of choice for many skull base tumors. A major limitation of TER is the management of large dural defects and the need for repair of cerebrospinal fluid (CSF) leaks, particularly among patients who are treated with chemotherapy (CTX) or radiotherapy (RT). The objective of this study is to determine the impact of CTX and RT on the success of CSF leak repair after TER. Methods We performed a retrospective chart review of a single-institution experience of TER from 1992 to 2011. Results We identified 28 patients who had endoscopic CSF leak repair after resection of malignant skull base tumors. Preoperative RT was utilized in 18 patients, and 9 had undergone CTX. All patients required CSF leak repair with rotational flaps after cribriform and/or dural resection. CSF leak repair failed in three patients (11%). A history of RT or CTX was not associated with failed CSF leak repair. Conclusion Adjuvant or neoadjuvant CTX or RT is not associated with failed CSF leak repair. Successful CSF leak repair can be performed in patients with malignant skull base tumors with an acceptable risk profile.     

The Management of Spontaneous Otogenic CSF Leaks: A Presentation of Cases and Review of Literature

Objective The types of otogenic cerebrospinal fluid (CSF) fistulae were previously classified into defects through, adjacent to, or distal to the otic capsule. This article presents cases of the three different types of spontaneous CSF fistulae and reviews pertinent literature. We examine the management of the different types of otogenic CSF leaks with modern audiovestibular testing, imaging, and surgical techniques. Design Case series and review of the literature. Setting Academic tertiary neurotologic referral practice. Participants Four patients identified through a retrospective search. Main outcome measures Resolution of CSF leak and absence of meningitis. Results Surgical intervention was performed on the four cases described in this series; none had a return of CSF otorrhea in the postoperative period or meningitis. Conclusions Otogenic CSF fistulae may lead to life-threatening infection and in congenital forms are typically not diagnosed unless meningitis has occurred. Rapid and proper recognition, work-up, and treatment of such leaks decrease the risk of permanent neurologic sequelae as well as recurrent meningitis.     

Sellar floor reconstruction after transsphenoidal surgery using fibrin glue without grafting or implants: technical note

BACKGROUND: Different techniques have already been described for reconstructing the sellar floor after transsphenoidal (TS) procedures. This paper reports on the use of fibrin glue alone without grafting or the use of implants in the reconstruction of the sellar floor after TS. METHODS: Five hundred sixty-seven patients who submitted to TS for pituitary and sellar region tumors were studied. No intraoperative cerebrospinal fluid (CSF) leak occurred in 503 patients (group 1); in the remaining 64 patients (group 2), intraoperative CSF leak was noted. In group 1 patients, closure of the sellar floor consisted of packing the surgical bed with hemostatic material only. When CSF leak was noted, the surgical bed was covered with a layer of hemostatic material and the intrasellar space was filled up with fibrin glue. An additional layer of hemostatic material was added at the topography of the preexisting sellar floor, and a second amount of fibrin glue was applied over it. At the end of surgery, a continuous lumbar CSF drainage system was installed in group 2 patients and kept for 5 days. Prophylactic antibiotics were administered during this period. RESULTS: We did not observe delayed CSF leak, meningitis, or visual loss in group 1 patients. In group 2, 2 patients presented with complications: 1 patient got meningitis but no overt CSF leak, and the other disclosed a delayed postoperative leak treated by reoperation. DISCUSSION: Our results showed that closure of the sellar floor with hemostatic material and fibrin glue without grafting or the use of implants is a safe and efficient method to prevent postoperative complications after TS. Generally speaking, there is no need for grafting or the use of implants at the end of TS.     

A Novel Graft Material for Preventing Cerebrospinal Fluid Leakage in Skull Base Reconstruction: Technical Note of Perifascial Areolar Tissue

Objectives Perifascial areolar tissue (PAT), a layer of loose connective tissue on the deep fascias with a rich vascular plexus, serves as a vital cover over defects with scarce vascularity. We report the usefulness of PAT as a nonvascularized alternative to flaps for reconstruction of dural defects in skull base surgery and transsphenoidal surgery while evaluating its effect on control of cerebrospinal fluid (CSF) leakage. Design A retrospective chart analysis was performed on patients who had undergone repair of a dural defect with PAT during skull base surgery or transsphenoidal surgery between December 2004 and October 2011. Results Twenty-one patients were included: 11 patients had received surgical treatment and/or irradiation. Fourteen of the 21 patients had pre- and/or intraoperative CSF leakage. Only one patient (4.8%) had postoperative CSF leakage requiring additional surgical repair. Ten patients underwent postoperative irradiation from 1 to 15 months after transplant of the PAT. None of the patients had postoperative CSF leakage after irradiation. Conclusion We successfully repaired dural defects using PAT in skull base surgery and transsphenoidal surgery, even in patients with a history of multiple operations and radiotherapy. PAT may serve as a valuable tool for skull base reconstruction.     

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.     

Endoscopic Endonasal Transclival Approaches: Case Series and Outcomes for Different Clival Regions

Objective Transclival endoscopic endonasal approaches to the skull base are novel with few published cases. We report our institution''s experience with this technique and discuss outcomes according to the clival region involved. Design Retrospective case series. Setting Tertiary care academic medical center Participants All patients who underwent endoscopic endonasal transclival approaches for skull base lesions from 2008 to 2012. Main Outcome Measures Pathologies encountered, mean intraoperative time, intraoperative complications, gross total resection, intraoperative cerebrospinal fluid (CSF) leak, postoperative CSF leak, postoperative complications, and postoperative clinical course. Results A total of 49 patients underwent 55 endoscopic endonasal transclival approaches. Pathology included 43 benign and 12 malignant lesions. Mean follow-up was 15.4 months. Mean operative time was 167.9 minutes, with one patient experiencing an intraoperative internal carotid artery injury. Of the 15 cases with intraoperative cerebrospinal fluid (CSF) leaks, 1 developed postoperative CSF leak (6.7%). There were six other postoperative complications: four systemic complications, one case of meningitis, and one retropharyngeal abscess. Gross total resection was achieved for all malignancies approached with curative intent. Conclusions This study provides evidence that endoscopic endonasal transclival approaches are a safe and effective strategy for the surgical management of a variety of benign and malignant lesions. Level of Evidence 4.     

Use of Titanium Mesh for Middle Cranial Fossa Skull Base Reconstruction

Objectives Temporal bone encephaloceles are usually encountered in the setting of a congenital defect of the tegmen or as an acquired defect after mastoid surgery. A variety of methods have been described in the literature for rigid reconstruction of tegmen defects. We introduce a new method of repair using orbital floor titanium mesh reconstruction plates to reconstruct the floor of the middle cranial fossa, and evaluate the outcomes, complications, and recurrence rates of temporal bone encephaloceles with this technique. Design Retrospective chart review of consecutively treated patients. Setting Tertiary care academic center. Participants Eight patients with middle cranial fossa skull base defects from January 2007 to February 2011. Main Outcome Measures Outcome measures included resolution of cerebrospinal fluid leak (CSF) and development of postoperative infection. Results One of nine patients had a postoperative CSF (cerebrospinal fluid) leak. There were no long-term complications of CSF leak or infection. Conclusions Titanium mesh is a safe and effective substitute for bone grafts in reconstruction of the middle cranial fossa skull base when rigid reconstruction is required.