Cerebrospinal fluid leaks after transsphenoidal surgery – Effect of a polyethylene glycol hydrogel dural sealant

Abstract

To investigate cerebrospinal fluid (CSF) leak rates after mainly endoscopic endonasal transsphenoidal surgery with and without polyethylene glycol hydrogel dural sealant (DuraSeal®), we prospectively collected data from a single-centre consecutive case series over four years from January 2007 to December 2010 inclusive. 250 patients were identified (135 male, 115 female; median age 52years, range 14-83). 180 patients received DuraSeal® (72%). 85 (34%) had intra-operative dural breach and 13 (5.2%) developed post-operative CSF leaks (3 without intra-operative dural breach) requiring lumbar drainage or formal repair. Of this group 5/251 (2.0%) patients required a formal repair. Post-operative CSF leak was seen in 5/189 (2.7%) of patients with pituitary adenoma, of which 2/5 (40%) were in cases undergoing revision surgery. 5/13 (38.4%) patients who developed a CSF leak presented with either Rathke's cleft cyst or craniopharyngioma. 3/71 patients not receiving DuraSeal® leaked (4.2%) and 10/180 patients receiving DuraSeal® leaked (5.6%). 11/234 patients without Tisseel (4.7%) and 2/16 receiving Tisseel (12.5%) leaked. 54 patients (22%) received intra-operative lumbar drains, one of whom developed subsequent CSF leak (1.9%), in contrast to 12/197 (6.1%) of patients without intra-operative lumbar drains who later developed CSF leak. The rate of post-operative CSF leak requiring re-exploration and nasoseptal flap repair was low (2.0%) in this mainly endoscopic case series without statistically significant benefit from either DuraSeal® or Tisseel. Intra-operative and post-operative lumbar drainage appears beneficial in patients at higher risk of post-operative CSF leak.

ICAR: endoscopic skull‐base surgery

“…Overall postoperative CSF leak and bacterial meningitis rates in 9 recent large endoscopic pituitary adenoma series (all with over 200 patients) have ranged from 0.6% to 5%, and 0% to 3.4%, respectively. NSF usage in these series ranges from 1% to 43% and planned lumbar CSF drainage from 0.6% to 21.7% …”

“…Presumably, lumbar drains were likely used more frequently when the surgical team was more concerned about postoperative leak (ie, inadequate reconstruction or high‐risk patients). A handful of recent retrospective series were also identified since this meta‐analysis, all of which showed no influence on postoperative CSF leak rates with the use of perioperative lumbar drain …”

“…Materials frequently used in reconstruction include autologous fat, fascia lata, septal bone, and cartilage, as well as all native sphenoid sinus mucosa, free mucosal grafts, and pedicled NSFs. Allografts frequently used include Alloderm (Allergan, Branchburg, NJ), absorbable and nonabsorbable plates, and titanium mesh, as well as collagen matrix materials, all typically in multilayered fashion . Various types of tissue glues are also included in many of the reconstruction protocols.…”

“…There are several contemporary retrospective studies that add further data on reconstructive outcomes. Pereira et al . evaluated 250 primarily sellar defect reconstructions using various tissue sealants and lumbar drain use.…”

Endoscopic Endonasal Reconstruction of High-Flow Cerebrospinal Fluid Leak with Fascia Lata “Button” Graft and Nasoseptal Flap: Surgical Technique and Case Series

“…Autologous pedicled mucoperichondrial nasoseptal flaps (NSF) have become the mainstay for endonasal cranial base reconstruction, but typically multilayered repair is required, including a primary dural repair. [6][7][8][9][10][11] There are many options for the latter, including a "button" graft, which has been previously described as consisting of two pieces of autologous fascia lata sutured together in the center. 7 Lumbar drains are commonly used for diversion of CSF flow during reconstruction, but carry risks including infection, lumbar radiculitis, and increased hospital length of stay.…”