Effectiveness of Lumbar Drain Versus Hyperventilation to Facilitate Transsphenoidal Pituitary (Suprasellar) Adenoma Resection

Abstract

BackgroundDeveloping controlled hypercarbia is a known scheme of lowering the suprasellar part of the adenoma in order to assist the surgeon, which acts through raising the ICP and therefore the CSF pressure.ObjectivesThe purpose of this study is to compare the effect of introducing a lumbar drain with that of controlled hypercapnia on the quality of transsphenoidal pituitary tumor resection and CSF leak.Patients and MethodsFifty two patients with pituitary adenoma who underwent transsphenoidal hypophysectomy by the same surgeon were included. They were randomly divided into two groups. A lumbar drain catheter introduced into the L3-L4 subarachnoid space under local anesthesia in all patients. The same anesthesia was performed in both groups. In the study group, we used a saline injection into the subarachnoid space versus hypoventilation in the control group in order to increase the ICP according to the surgeon's request. The surgeon's satisfaction during the tumor resection and the resection time were assessed during the surgery. The CSF catheter was closed and sent with the patient for CSF drainage. If there was no CSF leak, the catheter removed 24 hours later. With evidence of a CSF leak, we used the catheter as a lumbar drain. The time taken for the leakage control was assessed.ResultsThe satisfaction came from 21 (87.5%) and 2 (9.1%) for surgeon in the first and the second group respectively (P = 0.0001). CSF leakage time in the first and the second group was 1.6 ± 0.24 and 5 ± 0.50 respectively. It revealed a significant difference between the two groups (P = 0.001). The mean resection time was 13.54 ± 0.66 minutes in the study group; and 30.91 ± 0.98 minutes in the control group.ConclusionsIn summary, the method described here for ICP manipulation is an effective procedure for a better visualization of the pituitary tumor during transphenoidal resection by surgeon and beneficial in managing the CSF leak following surgery.

Endoskopik Endonazal Transsfenoidal Hipofiz Cerrahisinde Farklı End Tidal CO2 Değerlerinin Hemodinami ve Cerrahiye Etkileri

“…Knowing the intracranial pressure or CSF pressure allows us to be on the safe side for these techniques to be applied easily (5). The fact that the catheter is not inserted in any way does not prevent us from applying these techniques.…”

Optimizing Perioperative Care in Transsphenoidal Pituitary Surgery: Considerations for Enhanced Recovery After Surgery

“…The use of an external lumbar drain has been investigated in the context of ESS, TSA, and other endoscopic skull base surgeries, with a preponderance of institutional experiences and RCTs. [91][92][93][94][95][96][97] Recent systematic reviews and meta-analyses suggests an overall lack of high-quality evidence regarding the efficacy of prophylactic lumbar drain placement in TSA surgery in preventing postoperative CSF leaks. Further, there remains significant variation in the documented effects of lumbar drain placement on intraoperative and postoperative CSF leaks.…”

Perioperative Management of Adult Patients With External Ventricular and Lumbar Drains: Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care

“…Acute symptomatic hydrocephalus in SAH 12 Spinal cord-protective strategy in open and endovascular thoracic aortic repair for patients at high risk of spinal cord injury 9,24,[38][39][40] Active CSF leak (due to craniofacial trauma) 41 or those at risk for CSF leak during skull base procedures [42][43][44] ; however, lumbar drains do not prevent postoperative CSF leaks 44,45 Facilitate intraoperative brain relaxation 27 and intraoperative exposure 46 CSF indicates cerebrospinal fluid; CT, computed tomography; GCS, Glasgow Coma Score; ICH, intracerebral hemorrhage; IVH, intraventricular hemorrhage; rTPA, recombinant tissue plasminogen activator; SAH, subarachnoid hemorrhage; SBP, systolic blood pressure; TBI, traumatic brain injury.…”