A Simple Onlay Sellar Reconstruction Does not Increase the Risk of Postoperative Cerebrospinal Fluid Leak in Well-Selected Patients
03 July 2019
10 November 2019
08 January 2020 (online)
Objectives A variety of endonasal sellar repair techniques have been described; many of which are complex, expensive, and carry potential morbidity but are felt to be necessary to prevent postoperative cerebrospinal fluid (CSF) leaks. We propose an effective, technically simple repair for select sellar defects utilizing an onlay of regenerated oxidized cellulose.
Design Retrospective review of patients from a single neurosurgeon who underwent endoscopic transsphenoidal surgery for pituitary adenoma and sellar reconstruction with only an onlay of regenerated oxidized cellulose. Patients were selected for this repair technique based on the absence of: (1) intraoperative identification of a CSF leak, (2) patulous diaphragm (expanded diaphragm sella herniating to or through sellar floor defect), and (3) other prohibiting comorbidities.
Setting The present study was conducted at a tertiary care center.
Participants In this study, pituitary adenoma patients were the participants.
Outcome Measures Main outcome measure of the study is postoperative CSF leak.
Results A total of 172 patients were identified. Of these, 153 were initial resections of pituitary adenomas. Gross total resection was achieved in 142 (82.6%) cases. Average tumor size was 2.2 ± 1.1 cm. Average tumor volume was 10.4 ± 19.8 cm3. No patients had intraoperative CSF leaks. All cases were repaired with only an onlay of regenerated oxidized cellulose. There were two postoperative CSF leaks (1.16%). Pre and postoperative SNOT-22 scores were 12.9 ± 11.9 and 14.3 ± 14.9 (p = 0.796), respectively.
Conclusion The use of an onlay of regenerated oxidized cellulose alone is an effective repair technique for select sellar defects. This technique does not result in increased postoperative CSF leak rates and avoids the higher relative cost and potential morbidity associated with more complex, multilayered closures.
- 1 Jho HD, Carrau RL, Ko Y, Daly MA. Endoscopic pituitary surgery: an early experience. Surg Neurol 1997; 47 (03) 213-222 , discussion 222–223. Doi: 10.1016/S0090-3019(96)00452-1
- 2 Svider PF, Keeley BR, Husain Q. , et al. Regional disparities and practice patterns in surgical approaches to pituitary tumors in the United States. Int Forum Allergy Rhinol 2013; 3 (12) 1007-1012 . Doi: 10.1002/alr.21216
- 3 Tabaee A, Anand VK, Barrón Y. , et al. Endoscopic pituitary surgery: a systematic review and meta-analysis. J Neurosurg 2009; 111 (03) 545-554
- 4 Jalessi M, Sharifi G, Mirfallah Layalestani MR. , et al. Sellar reconstruction algorithm in endoscopic transsphenoidal pituitary surgery: experience with 240 cases. Med J Islam Repub Iran 2013; 27 (04) 186-194
- 5 Kuan EC, Yoo F, Patel PB, Su BM, Bergsneider M, Wang MB. An algorithm for sellar reconstruction following the endoscopic endonasal approach: A review of 300 consecutive cases. J Neurol Surg B Skull Base 2018; 79 (02) 177-183
- 6 Hadad G, Bassagasteguy L, Carrau RL. , et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006; 116 (10) 1882-1886
- 7 Kimple AJ, Leight WD, Wheless SA, Zanation AM. Reducing nasal morbidity after skull base reconstruction with the nasoseptal flap: free middle turbinate mucosal grafts. Laryngoscope 2012; 122 (09) 1920-1924
- 8 Soudry E, Psaltis AJ, Lee KH, Vaezafshar R, Nayak JV, Hwang PH. Complications associated with the pedicled nasoseptal flap for skull base reconstruction. Laryngoscope 2015; 125 (01) 80-85
- 9 Conger A, Zhao F, Wang X. , et al. Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery: trends in repair failure and meningitis rates in 509 patients. J Neurosurg 2018; 130 (03) 861-875 . Doi: 10.3171/2017.11.JNS172141
- 10 Gao Y, Zhong C, Wang Y. , et al. Endoscopic versus microscopic transsphenoidal pituitary adenoma surgery: a meta-analysis. World J Surg Oncol 2014; 12: 94 . Doi: 10.1186/1477-7819-12-94
- 11 Scagnelli RJ, Patel V, Peris-Celda M, Kenning TJ, Pinheiro-Neto CD. Impelemntation of free mucosal graft technique for sellar reconstruction after pituitary surgery: Outcomes of 158 consecutive patients. World Neurosurg 2019; 122: e506-e511
- 12 Soyka MB, Serra C, Regli L, Meier E, Holzmann D. Long-term olfactory outcome after nasoseptal flap reconstructions in midline skull base surgery. Am J Rhinol Allergy 2017; 31 (05) 334-337 . Doi: 10.2500/ajra.2017.31.4463
- 13 Paluzzi A, Fernandez-Miranda JC, Tonya Stefko S, Challinor S, Snyderman CH, Gardner PA. Endoscopic endonasal approach for pituitary adenomas: a series of 555 patients. Pituitary 2014; 17 (04) 307-319
- 14 Fraser S, Gardner PA, Koutourousiou M. , et al. Risk factors associated with postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery. J Neurosurg 2018; 128 (04) 1066-1071 . Doi: 10.3171/2016.12.JNS1694
- 15 Pereira EAC, Grandidge CA, Nowak VA, Cudlip SA. Cerebrospinal fluid leaks after transsphenoidal surgery - Effect of a polyethylene glycol hydrogel dural sealant. J Clin Neurosci 2017; 44: 6-10 . Doi: 10.1016/j.jocn.2017.06.016
- 16 Halvorsen H, Ramm-Pettersen J, Josefsen R. , et al. Surgical complications after transsphenoidal microscopic and endoscopic surgery for pituitary adenoma: a consecutive series of 506 procedures. Acta Neurochir (Wien) 2014; 156 (03) 441-449 . Doi: 10.1007/s00701-013-1959-7\
- 17 Cheng Y, Xue F, Wang TY. , et al. Analyses and treatments of postoperative nasal complications after endonasal transsphenoidal resection of pituitary neoplasms. Medicine (Baltimore) 2017; 96 (15) e6614 . Doi: 10.1097/MD.0000000000006614