The Efficacy of Bariatric Surgery Referral in Preventing CSF Leak Recurrence following Repair

Introduction: Lateral skull base CSF leaks can be surgically repaired with good efficacy; however, several risk factors have been identified that may increase the risk of recurrence of CSF leak following repair—idiopathic intracranial hypertension (IIH), obesity, and obstructive sleep apnea (OSA). Many patients with these risk factors are referred to bariatric surgery for evaluation of medical and/or surgical weight loss treatment to prevent CSF leak recurrence as well as to treat other comorbidities; however, no previous studies have analyzed the efficacy of this.

Methods: A retrospective review was conducted from a single tertiary neurotologic referral center from 2009 to 2020 on 42 patients (>18 years old) who underwent lateral skull base repair (transmastoid, middle cranial fossa or combined) for CSF leak +/− encephalocele, followed postoperatively for a mean of 3.4 years. CSF leak etiologies included spontaneous, traumatic, iatrogenic, and cholesteatoma. A subset of patients was followed up by a bariatric surgery team for medical versus surgical weight management. Demographic data was collected, including pre- and postoperative BMI, history of OSA, IIH, diabetes and smoking.

Results: Preoperative BMI did not reach significance (p = 0.053) as a risk factor for postoperative CSF leak; however, active smokers were over 4 times more likely to leak again than nonsmokers. Additionally, patients followed up by the bariatric team had a significant association with increased postoperative CSF leak. Patients seen by the bariatric team had significantly higher BMI (48.5 vs. 31.9), higher incidence of OSA (67 vs. 27%) and IIH (67 vs. 27%), higher CSF leak rates (56 vs. 9%), and need for revision CSF leak repair (22 vs. 3%) compared to those that were not. Patients undergoing preoperative bariatric surgery (n = 3) demonstrated a higher percent decrease in BMI (−9.8%) compared to conservative lifestyle modifications (−2.2%, p = 0.23). However, there was no significant decrease in risk of postoperative CSF leak despite bariatric surgery.

No patient demographics were associated with the approach utilized for CSF leak repair (transmastoid, MCF, or combined). Further, the choice of approach did not significantly impact postoperative CSF leak risk or need for revision CSF leak repair ([Figs. 1] and [2]).

Conclusions: Patients at higher risk for recurrent CSF leak (BMI >40, history of OSA and IIH) were more likely to be referred to bariatric surgery prior to CSF leak repair. Bariatric surgery is effective in decreasing the BMI in patients at high-risk for spontaneous CSF leak when compared to conservative lifestyle modifications and may be used to treat the comorbidities that occur in these patients, such as diabetes, hypertension, and cardiovascular disease. However, further data is required to evaluate its efficacy in preventing recurrence of CSF leak following initial repair. Given that elevated BMI is a known risk factor for recurrent CSF leak, neurotologists/neurosurgeons should consider bariatric surgery referral prior to repair.

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Publication History

Article published online:
05 February 2024