Epidural Interlay Graft for Pituitary Surgery: A 4-Year Institutional Experience

Rita Snyder; Sungho Lee; Prazwal Athukuri; Emmeline Monique Tan Ngo; Meha Goyal Fox; Samer Fakhri; Masayoshi Takashima; Bahar Kapoor Force; Susan Leanne Samson; Kathleen Kelly Gallagher; Daniel Yoshor; Ali Jalali

doi:10.1055/a-2175-8181

Journal of Neurological Surgery Part B: Skull Base, Table of Contents

J Neurol Surg B Skull Base 2024; 85(S 02): e10-e15
DOI: 10.1055/a-2175-8181

Original Article

Epidural Interlay Graft for Pituitary Surgery: A 4-Year Institutional Experience

Rita Snyder

¹Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States

,

Sungho Lee

²Department of Neurosurgery, Louisiana State University, Shreveport, Luisiana, United States

,

Prazwal Athukuri

¹Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States

,

Emmeline Monique Tan Ngo

³Department of Medicine, Baylor College of Medicine, Houston, Texas, United States

,

Meha Goyal Fox

⁴Department of Otolaryngology, Baylor College of Medicine, Houston, Texas, United States

,

Samer Fakhri

⁵Section of Otolaryngology, Kelsey-Seybold Clinic, Houston, Texas, United States

,

Masayoshi Takashima

⁶Department of Otolaryngology, Houston Methodist, Houston, Texas, United States

,

Bahar Kapoor Force

³Department of Medicine, Baylor College of Medicine, Houston, Texas, United States

,

Susan Leanne Samson

⁷Departments of Medicine and Neurological Surgery, Mayo Clinic, Jacksonville, Florida, United States

,

Kathleen Kelly Gallagher

⁴Department of Otolaryngology, Baylor College of Medicine, Houston, Texas, United States

,

Daniel Yoshor

⁸Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, United States

,

Ali Jalali

¹Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States

› Author Affiliations

Abstract

Objective Sellar repair techniques with varying complexity and effectiveness have been employed to reduce the incidence of postoperative cerebrospinal fluid (CSF) leaks following endoscopic transsphenoidal pituitary surgery. This study describes our institutional experience with a minimalistic, highly effective approach to sellar repair.

Methods The authors performed a retrospective review of consecutive cases of transsphenoidal pituitary surgery performed at our institution. All included subjects underwent sellar repair with an epidural interlay graft. Relationships between patient and tumor characteristics, incidence of CSF leak, adjunct repair techniques, and endocrine outcomes were examined.

Results Three hundred and thirty-four (334) cases were included. Intraoperative CSF leak was encountered in 116 cases (34.7%), and postoperative CSF leak occurred only once (0.3%) early in the series. Seventy intraoperative CSF leaks were successfully repaired with an epidural interlay alone, including 13 high-flow leaks. Our rate of fat graft use (1.2%), nasoseptal flap (3.0%), and lumbar drain placement (6.6%) in the second half of the series showed a significant decline compared with the first half, indicating increased reliance on the interlay graft over time. Our 65% functional macroadenoma remission rate compares favorably with large historical series.

Conclusion Simple sellar repair using an epidural interlay graft is highly effective in preventing postoperative CSF leaks, including cases of high-flow intraoperative leaks. More complex repair techniques are reserved for select high-risk cases or those with inadequate sellar bony ledges. With this technique, there has been no postoperative CSF leak at our institution in over 300 consecutive transsphenoidal pituitary surgeries.

Keywords

endoscopic transsphenoidal - pituitary adenoma - pituitary surgery - sellar repair - cerebrospinal fluid leak - nasoseptal flap

Full Text

References

References
1 Shiley SG, Limonadi F, Delashaw JB. et al. Incidence, etiology, and management of cerebrospinal fluid leaks following trans-sphenoidal surgery. Laryngoscope 2003; 113 (08) 1283-1288
2 Slot EMH, Sabaoglu R, Voormolen EHJ, Hoving EW, van Doormaal TPC. Cerebrospinal fluid leak after transsphenoidal surgery: a systematic review and meta-analysis. J Neurol Surg B Skull Base 2021; 83 (02, Suppl 2): e501-e513
3 Jho HD, Carrau RL. Endoscopic endonasal transsphenoidal surgery: experience with 50 patients. J Neurosurg 1997; 87 (01) 44-51
4 Faria Jr MA, Tindall GT. Transsphenoidal microsurgery for prolactin-secreting pituitary adenomas. J Neurosurg 1982; 56 (01) 33-43
5 Hardy J, McCutcheon IE. Pituitary microadenomas. In: Apuzzo MLJ. ed. Brain Surgery: Complication Avoidance and Management. Vol 1. New York: Churchill Livingstone; 1993: 271-295
6 Tindall GT, Collins Jr WF, Kirchner JA. Unilateral septal technique for transsphenoidal microsurgical approach to the sella turcica. Technical note. J Neurosurg 1978; 49 (01) 138-142
7 Wilson CB, Dempsey LC. Transsphenoidal microsurgical removal of 250 pituitary adenomas. J Neurosurg 1978; 48 (01) 13-22
8 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
9 Wang YY, Kearney T, Gnanalingham KK. Low-grade CSF leaks in endoscopic trans-sphenoidal pituitary surgery: efficacy of a simple and fully synthetic repair with a hydrogel sealant. Acta Neurochir (Wien) 2011; 153 (04) 815-822
10 Ye Y, Wang F, Zhou T, Luo Y. Low complication rate of sellar reconstruction by artificial dura mater during endoscopic endonasal transsphenoidal surgery. Medicine (Baltimore) 2017; 96 (52) e9422
11 Zanation AM, Thorp BD, Parmar P, Harvey RJ. Reconstructive options for endoscopic skull base surgery. Otolaryngol Clin North Am 2011; 44 (05) 1201-1222
12 Chaskes MB, Khoury T, Chitguppi C. et al. A single layer synthetic dural substitute inlay is an effective sellar reconstruction technique in endoscopic transsphenoidal pituitary surgery. J Neurol Surg B Skull Base 2020; 83 (03) 291-295
13 Harvey RJ, Parmar P, Sacks R, Zanation AM. Endoscopic skull base reconstruction of large dural defects: a systematic review of published evidence. Laryngoscope 2012; 122 (02) 452-459
14 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
15 Couldwell WT, Kan P, Weiss MH. Simple closure following transsphenoidal surgery. Technical note. Neurosurg Focus 2006; 20 (03) E11
16 Strickland BA, Lucas J, Harris B. et al. Identification and repair of intraoperative cerebrospinal fluid leaks in endonasal transsphenoidal pituitary surgery: surgical experience in a series of 1002 patients. J Neurosurg 2018; 129 (02) 425-429
17 Kaptain GJ, Kanter AS, Hamilton DK, Laws ER. Management and implications of intraoperative cerebrospinal fluid leak in transnasoseptal transsphenoidal microsurgery. Neurosurgery 2011; 68 (01) , Suppl Operative ): 144-150 , discussion 150–151
18 Chabot JD, Patel CR, Hughes MA. et al. Nasoseptal flap necrosis: a rare complication of endoscopic endonasal surgery. J Neurosurg 2018; 128 (05) 1463-1472
19 Seo MY, Nam DH, Kong DS. et al. Quality of life after extended versus transsellar endoscopic skull base surgery from 767 patients. Laryngoscope 2019; 129 (06) 1318-1324
20 Tabak M, Pelsma ICM, Kruit MC, van Furth WR, Biermasz NR, Notting IC. Chiasmal herniation following treatment of pituitary macroadenoma. Pituitary 2021; 24 (01) 68-78
21 Thomas JG, Gadgil N, Samson SL, Takashima M, Yoshor D. Prospective trial of a short hospital stay protocol after endoscopic endonasal pituitary adenoma surgery. World Neurosurg 2014; 81 (3-4): 576-583
22 Caggiano C, Penn DL, Laws Jr ER. The role of the lumbar drain in endoscopic endonasal skull base surgery: a retrospective analysis of 811 cases. World Neurosurg 2018; 117: e575-e579
23 Jane Jr JA, Catalino MP, Laws Jr ER. Surgical treatment of pituitary adenomas. In: Feingold KR, Anawalt B, Blackman MR. , et al, eds. 2022. Endotext [Internet]. South Dartmouth, MA: : MDText.com, Inc PMID: 25905217
24 Buchfelder M. Treatment of pituitary tumors: surgery. Endocrine 2005; 28 (01) 67-75