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DOI: 10.1055/s-0042-1743978
An Algorithm for Sellar Reconstruction Following Endoscopic Transsphenoidal Surgery for Pituitary Adenoma: A Review of 582 Cases
Objectives: Endoscopic transsphenoidal surgery is an increasingly popular approach to sellar and parasellar pathology. Sellar reconstruction algorithms have been described that stratify patients based on the risk of postoperative cerebrospinal fluid (CSF) leak to minimize the complexity of the repair necessary for each patient. Many of these algorithms remain overly complex, and employ repair techniques that confer morbidity to patients. We review our experience with sellar reconstruction following transsphenoidal pituitary surgery and propose a highly effective, yet simple and low morbidity, algorithm.
Methods: A retrospective review of patients who underwent transsphenoidal surgery for pituitary adenoma by a single neurosurgeon between 2005 and 2020 at a tertiary care center was performed. Patients without an intraoperative CSF leak or a patulous diaphragm (diaphragm herniating to the sellar floor) were repaired with an oxidized cellulose onlay. Patients with a low flow intraoperative CSF leak or a patulous diaphragm were repaired with a synthetic dural substitute inlay with dural sealant glue. Patients with a persistent leak around the synthetic dural substitute inlay or a high flow leak were reconstructed with a synthetic dural substitute inlay with a nasoseptal flap (NSF) onlay. A persistent leak around the inlay graft was always due to a leak at the anterior aspect of the diaphragma sellae at the junction with the tuberculum sellae. Risk factors such as medical comorbidities (including conditions portending poor wound healing, OSA requiring an early return to CPAP, and the need for adjuvant radiotherapy) and surgical considerations (including revision surgery for recurrent tumor and intraoperative dural resection due to tumor invasion) lead to a repair upgrade at the discretion of the surgeon on a case-by-case basis.
Results: Five hundred eighty-two patients were reviewed. There was an overall leak rate of 1.5% (9/582). Leak rates of 1.0% (2/197), 1.7% (6/347), and 2.6% (1/38) were seen for patients reconstructed with an oxidized cellulose onlay only, a synthetic dural substitute inlay only, and a dural substitute inlay/NSF onlay, respectively. Six patients in the inlay/NSF group had an inlay-onlay button graft. The NSF reconstruction group had the highest rate of post-operative morbidity, including sinusitis in 23.7% of patients (vs. 8.6% in the onlay only group and 15.0% in the inlay only group, p = 0.019) and crusting in 42.1% of patients (vs 4.6% in the onlay only group and 6.3% in the inlay only group, p < 0.001). However, there was no significant difference between pre- and post-operative Sinonasal Outcome Test (SNOT-22) scores among the 3 groups. All reconstruction techniques healed equally well radiographically as assessed by mucosal thickness, soft-tissue enhancement, and air-fluid levels.
Conclusion: The proposed algorithm for sellar reconstruction is highly effective and minimizes complexity and morbidity. 94% of patients were repaired with a single layer reconstruction, without a flap or graft. The overall CSF leak rate was 1.5% without the addition of packing material or lumbar drainage.
Publikationsverlauf
Artikel online veröffentlicht:
15. Februar 2022
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