Endonasal endoscopic skull base multilayer reconstruction surgery with nasal pedicled mucosal flap to manage high flow csf leakage

Abstract

AIm: Multilayer reconstruction of skull base using nasal pedicled mucosal flap has been widely accepted as a standard method for repairing high flow cerebrospinal fluid [CSF] leakage. In this study, we analyzed our outcome and summarized several valuable operation experiences from this technique. mAterIAl and methOds: This study included 20 consecutive patients who underwent endoscopic endonasal multilayer reconstruction using a nasal pedicled mucosal flap to repair high flow CSF leakage and were available for follow-up. results:In this series, all cases encountered intraoperative high-flow CSF leakage, including 11 (55%) patients with opening of third ventricles (TV) and 9 (45%) patients with wide opening of cistern (CS). After endoscopic endonasal multilayer reconstruction with nasal pedicled mucosal flap, 3 patients (15.0%) encountered CSF leakage in the early postoperative period but were successfully repaired; 2 patients (10.0%) encountered late postoperative CSF leakage. In the TV group, the ratio of CSF leakage was 18.2% (2/11); while the incidence of CSF leakage was 11.1% (1/9) in the CS group. One patient developed meningitis due to CSF leakage four month after surgery, then gave up treatment and died.COnClusIOn: Multilayer reconstruction with nasal pedicled flap seems to be useful and reliable for the treatment of ventral skull base defects using endoscopic endonasal approach.KeywOrds: Endoscopic, Pedicled mucosal flap, Multilayer reconstruction, High-flow CSF leakage ÖZ AmAÇ: Nazal pediküllü mukozal flep kullanarak kafatası tabanının çok tabakalı rekonstrüksiyonu, yüksek akışlı beyin omurilik sıvısı sızıntısını tamir etmek için standart bir yöntem olarak yaygın olarak kabul edilmiştir. Bu çalışmada bu teknikle sonuçlarımızı analiz ettik ve ameliyatlarımızdan elde ettiğimiz çeşitli değerli deneyimlerimizi özetledik. yÖntem ve GereÇler: Bu çalışmaya yüksek akışlı BOS sızıntısını tamir etmek için nazal pediküllü mukozal flep kullanılarak endoskopik endonazal çok tabakalı rekonstrüksiyon yapılan ve daha sonra takibi yapılabilen arka arkaya 20 hasta dahil edildi.BulGulAr: Bu seride tüm vakalarda yüksek akışlı BOS sızıntısı vardı ve bunlar arasında üçüncü ventrikül açıklığı olan 11 (%55) hasta ve geniş sistern açıklığı olan 9 (%45) hasta vardı. Nazal pediküllü mukozal fleple endoskopik endonazal çok tabakalı rekonstrüksiyon sonrasında, 3 hastada (%15,0) erken postoperatif dönemde BOS sızıntısı oldu ama başarıyla tamir edildi; 2 hastada (%10,0) geç postoperatif BOS sızıntısı oldu. Üçüncü ventrikül açıklığı grubunda BOS sızıntısı insidansı %18,2 (2/11) iken geniş sistern açıklığı grubunda BOS sızıntısı insidansı %11,1 (1/9) bulundu. Bir hastada ameliyattan 4 ay sonra BOS sızıntısı nedeniyle menenjit gelişti ve hasta tedaviyi uygulamayıp öldü. sOnuÇ: Nazal pediküllü fleple çok tabakalı rekonstrüksiyon, endoskopik endonazal yaklaşım kullanılarak ventral kafatası tabanı defektlerinin tedavisinde faydalı ve güvenilir görünmektedir.

Management of cerebrospinal fluid rhinorrhea: an evidence‐based review with recommendations

“…The general finding of these studies was that there is no significant difference in repair success rate between free tissue grafts and vascularized flaps, or for any other repair technique or material used. Results all fell within the standard overall success rate of 70% to 100% on first attempt,,,, and 86% to 100% on second attempt ,,…”

“…There are a variety of different graft materials available for endoscopic repair of CSF leaks, including fat, bone, allografts, free mucosal grafts, and vascularized grafts, as well as glues or sealants to secure these materials in place. Following an extensive literature search on the topic of endoscopic repair for CSF rhinorrhea, the overall success rate ranges from 70% to 100% on first attempt,,,, and 86% to 100% on second attempt,, for all reported repair materials. We conducted a review of the available literature to determine if any of these methods are superior with supporting literature.…”

Posterior nasoseptal flap in the reconstruction of skull base defects following endonasal surgery

“…4 Xuejian reported a single death due to post-operative meningitis out of 20 patients investigated. 13 The latter study, however, did not specify the kind of mucosal vascular flap used in that particular patient. None of our patients had significant post-operative nasal synechiae, nasal obstruction or significant nasal crusting.…”

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

“…18 The autologous vascularized mucoperichondrial NSF is regarded as one of the most effective techniques for reconstruction of dural defects after endoscopic cranial base surgery. 1,13,[20][21][22][23][24] NSF usage has led to a decreased incidence of CSF leaks when compared with autologous avascular grafts and lumbar drain insertions, especially in high-flow CSF leak. 21,23 Zanation et al observed a postoperative CSF leak rate of 5.7% in a cohort of 70 patients who received an NSF for reconstruction after intradural lesion resection, but noted that other risk factors, such as age of patients, size of dural defect, and whether or not the patients received radiation therapy afterwards were correlated in the incidence of postoperative CSF leak.…”