J Neurol Surg B Skull Base 2020; 81(02): 128-135
DOI: 10.1055/s-0039-1677705
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Impact of Multilayer Vascularized Reconstruction after Skull Base Endoscopic Endonasal Approaches

Juan Antonio Simal-Julián
1   Neurosurgical Department HUiP La Fe Valencia, Valencia, Spain
,
Pablo Miranda-Lloret
1   Neurosurgical Department HUiP La Fe Valencia, Valencia, Spain
,
Laila Pérez de San Román Mena
1   Neurosurgical Department HUiP La Fe Valencia, Valencia, Spain
,
Pablo Sanromán-Álvarez
1   Neurosurgical Department HUiP La Fe Valencia, Valencia, Spain
2   Neurosurgical Department H Álvaro Cunqueiro Vigo, Spain
,
Alfonso García-Piñero
3   ENT Department HUiP La Fe, Valencia, Pontevedra, Spain
,
Rosa Sanchis-Martín
4   Anaesthesiology Department H General Universitario de Valencia, Valencia, Spain
,
Carlos Botella-Asunción
1   Neurosurgical Department HUiP La Fe Valencia, Valencia, Spain
,
Amin Kassam
5   Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
› Author Affiliations
Funding No funding was received for this research.
Further Information

Publication History

02 October 2018

15 December 2018

Publication Date:
28 February 2019 (online)

Abstract

Background The use of vascularized flap to reconstruct the skull base defects has dramatically changed the postoperative cerebrospinal fluid (CSF) leak rates allowing the expansion of endoscopic skull base procedures. At present, there is insufficient scientific evidence to permit identification of the optimal reconstruction technique after the endoscopic endonasal approach (EEA).

Objective The main purpose of this article is to establish the risk factors for failure in the reconstruction after EEA and whether the use of a surgical reconstruction protocol can improve the surgical results.

Material and Methods A retrospective cohort study was conducted in our institution, selecting patients that underwent EEA with intraoperative CSF leak. Two reconstructive protocols were defined based on different reconstructive techniques; both were vascularized but one monolayer and the other multilayer. A multivariate analysis was performed with outcome variable presentation of postoperative leak.

Results One hundred one patients were included in the study. Patients reconstructed with protocol 1, with the diagnosis different to the pituitary adenoma and older than 45 years old had higher risk of presenting postoperative leak, and with statistically significant differences when we adjusted for the remaining variables.

Conclusion The vascularized reconstructions after endoscopic endonasal skull base approaches have demonstrated to be able to obtain a low rate of postoperative CSF leak. The multilayer vascularized technique may provide a more evolved technique, even reducing the postoperative leak rates comparing with the monolayer vascularized one. The reconstructive protocol employed in each case, as well as age and histological diagnosis, is independent risk factor for presenting postoperative leak.

Ethical approval

For this type of study formal consent is not required.


Informed consent: Informed consent was obtained from all individual participants included in the study.


 
  • References

  • 1 Hegazy HM, Carrau RL, Snyderman CH, Kassam A, Zweig J. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis. Laryngoscope 2000; 110 (07) 1166-1172
  • 2 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
  • 3 McCoul ED, Anand VK, Singh A, Nyquist GG, Schaberg MR, Schwartz TH. Long-term effectiveness of a reconstructive protocol using the nasoseptal flap after endoscopic skull base surgery. World Neurosurg 2014; 81 (01) 136-143
  • 4 Soudry E, Turner JH, Nayak JV, Hwang PH. Endoscopic reconstruction of surgically created skull base defects: a systematic review. Otolaryngol Head Neck Surg 2014; 150 (05) 730-738
  • 5 Patel MR, Stadler ME, Snyderman CH. , et al. How to choose? Endoscopic skull base reconstructive options and limitations. Skull Base 2010; 20 (06) 397-404
  • 6 Thorp BD, Sreenath SB, Ebert CS, Zanation AM. Endoscopic skull base reconstruction: a review and clinical case series of 152 vascularized flaps used for surgical skull base defects in the setting of intraoperative cerebrospinal fluid leak. Neurosurg Focus 2014; 37 (04) E4
  • 7 Van Effenterre R, Boch AL. Craniopharyngioma in adults and children: a study of 122 surgical cases. J Neurosurg 2002; 97 (01) 3-11
  • 8 de Divitiis E, Cappabianca P, Cavallo LM, Esposito F, de Divitiis O, Messina A. Extended endoscopic transsphenoidal approach for extrasellar craniopharyngiomas. Neurosurgery 2007; 61 (05) (Suppl. 02) 219-227 , discussion 228
  • 9 Frank G, Pasquini E, Doglietto F. , et al. The endoscopic extended transsphenoidal approach for craniopharyngiomas. Neurosurgery 2006; 59 (01) (Suppl. 01) ONS75-ONS83 , discussion ONS75–ONS83
  • 10 Benatar MJ, Dassonville O, Chamorey E. , et al. Impact of preoperative radiotherapy on head and neck free flap reconstruction: a report on 429 cases. J Plast Reconstr Aesthet Surg 2013; 66 (04) 478-482
  • 11 Zanation AM, Carrau RL, Snyderman CH. , et al. Nasoseptal flap reconstruction of high flow intraoperative cerebral spinal fluid leaks during endoscopic skull base surgery. Am J Rhinol Allergy 2009; 23 (05) 518-521
  • 12 Chivukula S, Koutourousiou M, Snyderman CH, Fernandez-Miranda JC, Gardner PA, Tyler-Kabara EC. Endoscopic endonasal skull base surgery in the pediatric population. J Neurosurg Pediatr 2013; 11 (03) 227-241
  • 13 Kassam A, Thomas AJ, Snyderman C. , et al. Fully endoscopic expanded endonasal approach treating skull base lesions in pediatric patients. J Neurosurg 2007; 106 (2, Suppl): 75-86
  • 14 Kassam AB, Prevedello DM, Carrau RL. , et al. Endoscopic endonasal skull base surgery: analysis of complications in the authors' initial 800 patients. J Neurosurg 2011; 114 (06) 1544-1568
  • 15 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
  • 16 Kassam AB, Thomas A, Carrau RL. , et al. Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 2008; 63 (01) (Suppl. 01) ONS44-ONS52 , discussion ONS52–ONS53
  • 17 Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 1997; 40 (02) 225-236 , discussion 236–237
  • 18 Mortini P, Losa M, Barzaghi R, Boari N, Giovanelli M. Results of transsphenoidal surgery in a large series of patients with pituitary adenoma. Neurosurgery 2005; 56 (06) 1222-1233 , discussion 1233
  • 19 Dehdashti AR, Ganna A, Karabatsou K, Gentili F. Pure endoscopic endonasal approach for pituitary adenomas: early surgical results in 200 patients and comparison with previous microsurgical series. Neurosurgery 2008; 62 (05) 1006-1015 , discussion 1015–1017
  • 20 Ahmed OH, Marcus S, Tauber JR, Wang B, Fang Y, Lebowitz RA. Efficacy of perioperative lumbar drainage following endonasal endoscopic cerebrospinal fluid leak repair. Otolaryngol Head Neck Surg 2017; 156 (01) 52-60
  • 21 D'Anza B, Tien D, Stokken JK, Recinos PF, Woodard TR, Sindwani R. Role of lumbar drains in contemporary endonasal skull base surgery: meta-analysis and systematic review. Am J Rhinol Allergy 2016; 30 (06) 430-435
  • 22 Ransom ER, Palmer JN, Kennedy DW, Chiu AG. Assessing risk/benefit of lumbar drain use for endoscopic skull-base surgery. Int Forum Allergy Rhinol 2011; 1 (03) 173-177
  • 23 Eloy JA, Kuperan AB, Choudhry OJ, Harirchian S, Liu JK. Efficacy of the pedicled nasoseptal flap without cerebrospinal fluid (CSF) diversion for repair of skull base defects: incidence of postoperative CSF leaks. Int Forum Allergy Rhinol 2012; 2 (05) 397-401