Novel Transsphenoidal Implant Plus Acellular Dermis Gasket Seal Closure in Patients Undergoing Transsphenoidal Resection of Sellar Lesions

Introduction: CSF leak following transsphenoidal resection of pituitary adenomas is an uncommon but potentially life-threatening post-operative complication. We report a novel technique for decreasing the risk of postoperative CSF leak.

Methods: We performed a retrospective review of patients undergoing transsphenoidal resection of a pituitary lesion by the senior neurosurgeon (A.H.K.) from 2011 to 2016 (N = 86, 35 males, 61 females). We excluded any patients who had a pituitary lesion that was surgically resected via craniotomy and patients who did not receive acellular dermis (AlloDerm) in their closure. In patients with noticeable intraoperative cisternal or third ventricular CSF leak or with bowing of the diaphragma inferiorly, we placed a generous acellular dermis onlay over the sellar bony defect followed by a transsphenoidal implant (Medpor TSI) anchored in the epidural or subdural space to generate a gasket seal. Additional surgical adjuncts including lumbar drain and nasoseptal flap were also noted for each case. Lumbar drains were placed prophylactically for lesions with suprasellar extension that abut the optic chiasm.

Results: Overall, there was a total intraoperative CSF leak rate of 37.2% (32 of 86) and a postoperative CSF leak rate of 5.8% (5/86). 80% of the postoperative CSF leaks (4/5) had an intraoperative leak and 40% (2/5) were craniopharyngiomas. Of the patients who were closed with both acellular dermis and a Medpor TSI gasket seal, the leak rate was 2.7% (1/36). Of the remaining CSF leak cases, three were closed with a nasoseptal flap with acellular dermis and no gasket, and one was closed with acellular dermis only; 52.3% (45/86) of patients had a lumbar drain placed preoperatively.

Conclusion: Overall, utilization of a combined acellular dermis and transsphenoidal implant gasket seal offers a safe and effective technique for preventing post-operative CSF leaks in patients undergoing transsphenoidal resection of pituitary lesions.