A Sandwich Technique for Prevention of Cerebrospinal Fluid Rhinorrhea and Reconstruction of the Sellar Floor after Microsurgical Transsphenoidal Pituitary Surgery

Abstract

Background Cerebrospinal fluid (CSF) leaks are a well-known complication of transsphenoidal surgery. Several autologous and artificial grafts have been used to close the sellar floor in an attempt to prevent postoperative CSF rhinorrhea.

Objective To evaluate and describe a sandwich technique to close the sellar floor using autologous bone, absorbable gelatin sponge, and coated collagen fleece.

Methods We reviewed 50 consecutive patients between April 2010 and August 2011 who underwent transsphenoidal surgery ending with reconstruction of the sellar floor with a particular sandwich technique. Patients with an intraoperative CSF leak received an additional lumbar drain.

Results There were no cases of CSF rhinorrhea at postoperative follow-up after 6 weeks and no revision surgery.

Conclusion The proposed sandwich technique for closure of the sellar floor to the sphenoid sinus is a suitable alternative to autologous grafts and seems to be effective in preventing CSF rhinorrhea.

Keywords

pituitary surgery - transsphenoidal - coated collagen fleece - cerebrospinal fluid rhinorrhea

• References

• 1 Black PM, Zervas NT, Candia GL. Incidence and management of complications of transsphenoidal operation for pituitary adenomas. Neurosurgery 1987; 20 (6) 920-924
• 2 Cho JM, Ahn JY, Chang JH, Kim SH. Prevention of cerebrospinal fluid rhinorrhea after transsphenoidal surgery by collagen fleece coated with fibrin sealant without autologous tissue graft or postoperative lumbar drainage. Neurosurgery 2011; 68 (1, Suppl Operative): 130-136 ; discussion 136–137
• 3 Seiler RW, Mariani L. Sellar reconstruction with resorbable Vicryl patches, gelatin foam, and fibrin glue in transsphenoidal surgery: a 10-year experience with 376 patients. J Neurosurg 2000; 93 (5) 762-765
• 4 Açikbaş SC, Akyüz M, Kazan S, Tuncer R. Complications of closed continuous lumbar drainage of cerebrospinal fluid. Acta Neurochir (Wien) 2002; 144 (5) 475-480
• 5 Barth M, Tuettenberg J, Thomé C, Weiss C, Vajkoczy P, Schmiedek P. Watertight dural closure: is it necessary? A prospective randomized trial in patients with supratentorial craniotomies. Neurosurgery 2008; 63 (4) (Suppl. 02) 352-358 ; discussion 358
• 6 Schloffer H. Erfolgreiche Operation eines Hypophysentumors auf nasalem Wege. Wien Klin Wochenschr 1907; 20: 621-624
• 7 Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH. Endoscopic endonasal versus open repair of anterior skull base CSF leak, meningocele, and encephalocele: a systematic review of outcomes. J Neurol Surg A Cent Eur Neurosurg 2013; 74 (4) 239-250
• 8 Hardy J. Transsphenoidal hypophysectomy. J Neurosurg 1971; 34 (4) 582-594
• 9 Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 1997; 40 (2) 225-236 ; discussion 236–237
• 10 Van Velthoven V, Clarici G, Auer LM. Fibrin tissue adhesive sealant for the prevention of CSF leakage following transsphenoidal microsurgery. Acta Neurochir (Wien) 1991; 109 (1–2) 26-29
• 11 Sade B, Mohr G, Frenkiel S. Management of intra-operative cerebrospinal fluid leak in transnasal transsphenoidal pituitary microsurgery: use of post-operative lumbar drain and sellar reconstruction without fat packing. Acta Neurochir (Wien) 2006; 148 (1) 13-18 ; discussion 18–19
• 12 Shiley SG, Limonadi F, Delashaw JB , et al. Incidence, etiology, and management of cerebrospinal fluid leaks following trans-sphenoidal surgery. Laryngoscope 2003; 113 (8) 1283-1288
• 13 Fatemi N, Dusick JR, de Paiva Neto MA, Kelly DF. The endonasal microscopic approach for pituitary adenomas and other parasellar tumors: a 10-year experience. Neurosurgery 2008; 63 (4) (Suppl. 02) 244-256 ; discussion 256
• 14 Malik MU, Aberle JC, Flitsch J. CSF fistulas after transsphenoidal pituitary surgery—a solved problem?. J Neurol Surg A Cent Eur Neurosurg 2012; 73 (5) 275-280
• 15 Ahn JY, Kim SH. A new technique for dural suturing with fascia graft for cerebrospinal fluid leakage in transsphenoidal surgery. Neurosurgery 2009; 65 (6, Suppl): 65-71 ; discussion 71–72
• 16 Mehta GU, Oldfield EH. Prevention of intraoperative cerebrospinal fluid leaks by lumbar cerebrospinal fluid drainage during surgery for pituitary macroadenomas. J Neurosurg 2012; 116 (6) 1299-1303
• 17 Dlouhy BJ, Madhavan K, Clinger JD , et al. Elevated body mass index and risk of postoperative CSF leak following transsphenoidal surgery. J Neurosurg 2012; 116 (6) 1311-1317
• 18 Grotenhuis JA. Costs of postoperative cerebrospinal fluid leakage: 1-year, retrospective analysis of 412 consecutive nontrauma cases. Surg Neurol 2005; 64 (6) 490-493 ; discussion 493–494