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

Abstract

Background The endoscopic endonasal approach (EEA) has become increasingly used for resection of skull base tumors in the sellar and suprasellar regions. A nasoseptal flap (NSF) is routinely used for anterior skull base reconstruction; however, there are numerous additional allografts and autografts being used in conjunction with the NSF. The role of perioperative cerebrospinal fluid (CSF) diversion is also unclear. Objective This study was aimed to analyze success of high-flow CSF leak repair during EEA procedures without use of CSF diversion through lumbar drainage. Methods A retrospective chart review of patients who had intraoperative high-flow CSF leak during EEA procedures at our institution between January 2013 and December 2017 was performed. CSF leaks were repaired with use of a fascia lata button graft and nasoseptal flap, without use of perioperative lumbar drains. Results A total of 38 patients were identified (10 male, 28 female). Patient BMIs ranged from 19.7 to 49 kg/m2 (median = 31 kg/m2), with 18 patients meeting criteria for obesity (BMI > 30 kg/m2) and 12 patients overweight (25 kg/m2 < BMI < 29.9 kg/m2). There was no incidence of postoperative CSF leak. Conclusion In our experience, the nasoseptal flap used in conjunction with the fascia lata button graft is a safe, effective and robust combination for cranial base reconstruction with high-flow intraoperative CSF leaks, without need for lumbar drains.

Clinical Impact of Hydroxyapatite on the Outcome of Skull Base Reconstruction for Intraoperative High-Flow CSF Leak: A Propensity Score Matching Analysis

“…Details of endoscopic endonasal surgery have been described previously ( 25 , 26 ). All surgeries were performed by an endoscopic skull base surgery team comprising a neurosurgeon (D.K.)…”

Diabetes Insipidus after Endoscopic Endonasal Pituitary Macroadenoma Resection: Correlation of Patient and Surgery-Related Risk Factors

“…Among the minor postoperative complications encountered in this study, DI occurred in 13.16% of patients. 14 In another study on 101 patients evaluating the impact of multilayer reconstruction after endoscopic skull base surgery, Simal-Julián et al reported 7 cases of postoperative DI. The surgical technique, which was applied on 32 patients with nonadenomatous sellar pathologies, involved a layer of intradural fat, an epidural layer of fascia lata, and a final layer of vascularized flap.…”

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Endoscopic Endonasal Approach to the Anterior Cranial Fossa

“…To minimize the risk of CSF leak robust multilayer reconstruction is mandatory-ideally with a combination of fascia lata, nasoseptal flap, and tissue glue in our experience. 38 Special attention must be paid to the anterior margin of the reconstruction as it often has the least amount of normal skull base to adequately appose to. Recent randomized control trials have also proved the efficacy of lumbar drain in decreasing CSF leak secondary to EEAs.…”