Subscribe to RSS
Sellar Floor Reconstruction with and without Intrasellar Fat Packing after Endoscopic Resection of Large Pituitary Macroadenomas with Evident Intraoperative CSF Leak
Background Intraoperative cerebrospinal fluid (CSF) leak is not uncommon with endoscopic transsphenoidal surgical excision of pituitary macroadenomas. How to seal the defect and prevent postoperative leak is still a matter of debate.
Objectives In patients with CSF leak, we tried to figure out which is more important in preventing postoperative leak, is it the sellar fat packing, is it tight repair of the sellar floor, or do we need to combine them both?
Patients and Methods Over 5 years, in patients with evident intraoperative CSF leak, with growing experience supported by positive postoperative results, we shifted gradually from intrasellar packing using combined fat graft and bioabsorbable materials (SURGICEL FIBRILLAR/Gelfoam) (group A, n =15) to only bioabsorbable materials (group B, n = 18), either of which is followed by tight repair of the sellar floor.
Results Postoperative clinical assessment did not differ significantly between both groups at early, midterm, and long-term follow-up intervals. We did not have any patients with delayed postoperative CSF leak or symptomatic empty sella syndrome (ESS).
Conclusion There is no difference in the incidence of postoperative CSF leak and clinical ESS among both groups, indicating that tight sellar floor repair is more important than packing the sellar cavity with or without fat graft.
Article published online:
26 April 2022
© 2021. Neurological Surgeons' Society of India. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India
- 1 Couldwell WT, Kan P, Weiss MH. Simple closure following transsphenoidal surgery. Technical note. Neurosurg Focus 2006; 20 (03) E11
- 2 Tabaee A, Anand VK, Brown SM, Lin JW, Schwartz TH. Algorithm for reconstruction after endoscopic pituitary and skull base surgery. Laryngoscope 2007; 117 (07) 1133-1137
- 3 Chen HC, Lee ST. Need for intrasellar packing in sellar reconstruction of transsphenoidal surgery: less is more?. J Clin Neurosci 2006; 13 (04) 423-427
- 4 Sciarretta V, Mazzatenta D, Ciarpaglini R, Pasquini E, Farneti G, Frank G. Surgical repair of persisting CSF leaks following standard or extended endoscopic transsphenoidal surgery for pituitary tumor. Minim Invasive Neurosurg 2010; 53 (02) 55-59
- 5 Ismail M, Fares AA, Abdelhak B, D'Haens J, Michel O. Sellar reconstruction without intrasellar packing after endoscopic surgery of pituitary macroadenomas is better than its reputation. Ger Med Sci 2016; 14: Doc07
- 6 Kong DS, Kim HY, Kim SH. et al. Challenging reconstructive techniques for skull base defect following endoscopic endonasal approaches. Acta Neurochir (Wien) 2011; 153 (04) 807-813
- 7 Leng LZ, Brown S, Anand VK, Schwartz TH. “Gasket-seal” watertight closure in minimal-access endoscopic cranial base surgery. Neurosurgery 2008;62(05, Suppl 2):E342–E343, discussion E343
- 8 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
- 9 El Shazly AA, El Wardany MA, Abo El Ezz TA. Sellar repair with autologous muscle and composite septal cartilage grafts for treatment of cerebrospinal fluid leakage following trans-sphenoidal pituitary surgery. Asian J Neurosurg 2016; 11 (04) 433-439
- 10 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
- 11 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 (05) 762-765
- 12 Arita K, Kurisu K, Tominaga A. et al. Size-adjustable titanium plate for reconstruction of the sella turcica. Technical note. J Neurosurg 1999; 91 (06) 1055-1057
- 13 Kelly DF, Oskouian RJ, Fineman I. Collagen sponge repair of small cerebrospinal fluid leaks obviates tissue grafts and cerebrospinal fluid diversion after pituitary surgery. Neurosurgery 2001; 49 (04) 885-889 , discussion 889–890
- 14 Cappabianca P, Cavallo LM, Valente V. et al. Sellar repair with fibrin sealant and collagen fleece after endoscopic endonasal transsphenoidal surgery. Surg Neurol 2004; 62 (03) 227-233 , discussion 233
- 15 Kaptain GJ, Vincent DA, Laws Jr ER. Cranial base reconstruction after transsphenoidal surgery with bioabsorbable implants. Neurosurgery 2001; 48 (01) 232-233 , discussion 233–234
- 16 Yano S, Tsuiki H, Kudo M. et al. Sellar repair with resorbable polyglactin acid sheet and fibrin glue in endoscopic endonasal transsphenoidal surgery. Surg Neurol 2007; 67 (01) 59-64 , discussion 64
- 17 Zeden JP, Baldauf J, Schroeder HWS. Repair of the sellar floor using bioresorbable polydioxanone foils after endoscopic endonasal pituitary surgery. Neurosurg Focus 2020; 48 (06) E16
- 18 Jho HD. Endoscopic transsphenoidal surgery. J Neurooncol 2001; 54 (02) 187-195
- 19 Castelnuovo P, Pistochini A, Locatelli D. Different surgical approaches to the sellar region: focusing on the “two nostrils four hands technique”. Rhinology 2006; 44 (01) 2-7
- 20 Ismail M, Abdelaziz AA, Darwish M. A comparison between collaborative and single surgeon approach in endoscopic endonasal surgery to sphenoid sinus. Eur Arch Otorhinolaryngol 2019; 276 (04) 1095-1100
- 21 Kassam A, Carrau RL, Snyderman CH, Gardner P, Mintz A. Evolution of reconstructive techniques following endoscopic expanded endonasal approaches. Neurosurg Focus 2005; 19 (01) E8