The Value of Cerebrospinal Fluid Diversion in Extended Transnasal Endoscopic Surgery

Introduction: Cerebrospinal fluid leakage (CSF) after endoscopic surgery is a major limitation for this approach. Over the last two decades, the reported rates of CSF leakage after surgery improved significantly. Many methods, including the LD diversion in the perioperative period, are currently used to limit this complication. However, the exact value of LD diversion and its related complications are not well documented.

Methods: We reviewed cases done at King Saud University Medical City between December 2014 and July 2016. Only extended endoscopic endonasal approach (EEEA) cases were included. Clinical follow-up and perioperative complications were documented and reviewed. The LD was inserted in the operative room after intubation and removed on the third day after the procedure.

Results: A total of 20 cases of EEEA were identified during the study period (18 months). The series included three cases of anterior skull base encephaloceles, one lateral sphenoid wing encephalocele, one craniocervical junction CSF fistula, two optic pathway gliomas, five meningiomas, two clival chordomas, one olfactory groove epidermoid tumor, one giant pituitary adenoma, one frontal sinus dermoid tumor, one Meckel’s epidermoid tumor, and two craniopharyngiomas. CSF leak was the most common complication in our series. Five patients underwent reoperation because of CSF leak (25%) but only three (15%) had documented leakage. One developed postoperative meningitis. Intra-operative complications were not observed. Operative mortality was nil. No reported long-term LD related complications were observed. Complete closure was done in all cases with CSF fistula or encephalocele.

Conclusion: The perioperative insertion of LD was not associated with increased morbidity. The postoperative leakage in our series (15%) is at the lower range of the current reports. However, prospective trials are needed to evaluate the exact impact of LD usage in controlling the postoperative leakage.