Prevention Better than Cure: Reducing CSF Leaks in Transsphenoidal Surgery

Objective: To evaluate the routine use of a pedicled nasoseptal flap (NSF) as a primary repair for intraoperative CSF leaks compared with fat/fascia lata graft and lumbar drain.

Design: A retrospective review of all patients undergoing transsphenoidal surgery from January 2008 to present.

Patients/Materials and Methods: Before September 2009, 43 cases were performed microscopically (MTSS), and since then 103 cases were performed endoscopically (ETSS).

Results: In the MTSS group, intraoperative CSF leaks were repaired with fat graft, Tisseel, and lumbar drain insertion. Intraoperative leaks in the ETSS group were routinely repaired with a pedicled nasoseptal flap. A nasoseptal flap could not be harvested in patients who had previous transsphenoidal surgery (PTSS); in these cases, intraoperative repair was fashioned using free graft and DuraSeal.

Lumbar drainage was used in the management of patients in the MTSS and PTSS groups. One patient in the ETSS group developed constipation and had a CSF leak on straining. The patient returned to theater, where the flap was repositioned and DuraSeal used. The second patient was a child with a craniopharyngioma and hydrocephalus that required flap repositioning and treatment for hydrocephalus.

Conclusions: The advent of the pedicled nasoseptal flap conveys a significant advantage in preventing CSF leak, decreasing postoperative morbidity and shortening hospital stay.