Impact of Multilayer Vascularized Reconstruction after Skull Base Endoscopic Endonasal Approaches

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.

Skull base repair following endonasal pituitary and skull base tumour resection: a systematic review

“…Patient-related factors considered in planning repair strategy included age (e.g. poor wound healing in the elderly), elevated body mass index, previous endonasal surgery and concomitant radiotherapy [ 10 , 28 , 35 – 41 ]. Tumour-related factors included pathology type [ 28 , 31 , 33 , 35 , 42 , 43 ], size, extension (e.g.…”

“…Repair techniques were organised into a comprehensive taxonomy according to uniting characteristics (e.g. intended function, anatomical level, material type) [ 27 , 28 ]. Each category was explored in turn in terms of sub-categories, indications, advantages, disadvantages and refinements.…”

Methods of Skull Base Repair Following Endoscopic Endonasal Tumor Resection: A Review

“…Advances in skull base reconstruction, particularly the use of vascularized local flaps, have greatly reduced the incidence of this complication and have been instrumental in the expansion of these approaches for the management of skull base malignancy (25). The importance of using vascularized flaps as part of a multi-layer, rather than a monolayer closure of skull base defects to prevent post-operative CSF leak has also been highlighted in a recent study by Simal-Julián et al (26). In this review, we will provide an overview of the latest methods used to reconstruct large skull base defects leading to high flow CSF leaks following tumor resection, as well as describing our preferred method for the repair of these defects.…”

Surgical Management of Sinonasal Cancers: A Comprehensive Review

“…If a dural resection has been performed, a duraplasty is required. In the case of an extensive defect, a multilayer technique is preferred [21]. The iliotibial tract is most often used (Figure 2D): taken from the patient's thigh, it is cut into 3 pieces which are positioned in 3 layers to close the defect: an intracranial intradural layer, an intracranial extradural layer, and an extracranial layer placed on the roof of the nasal cavity [22].…”

“…In particular, the use of synthetic absorbable sealants, synthetic dural grafts, fibrin glues, free autografts, and free tissue transfer, have significantly improved postoperative CSF leak rates [58]. The use of multi-layer techniques to close the defects was another important improvement, further decreasing the CSF leak rate [21], which became similar to that of open approaches [59]. For example, endoscopic resection of the anterior skull base results in significant dural defects, which can be efficiently closed using the fascia lata "three layers technique": the first layer is in an intracranial-intradural position, the second layer in an intracranial-intradural position, and the third layer in a purely extracranial position, upon the roof of the sinonasal cavity [22].…”