Implementation of Free Mucosal Graft Technique for Sellar Reconstruction After Pituitary Surgery: Outcomes of 158 Consecutive Patients

Scagnelli, Robert; Patel, Varun; Peris-Celda, María; Kenning, Tyler J.; Pinheiro‐Neto, Carlos D.

doi:10.1016/j.wneu.2018.10.090

Cited by 35 publications

(26 citation statements)

References 16 publications

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“…For example, while some institutions employ a complex repair technique for all sellar defects, others use graded algorithms that determine reconstruction type based on the anticipated risk of postoperative CSF leak. 9,11 The majority of described sellar reconstructive techniques are multilayered. While many are effective in preventing postoperative CSF leaks, they are often overly complex, time consuming, expensive, and may result in undue morbidity.…”

Section: Discussionmentioning

confidence: 99%

A Simple Onlay Sellar Reconstruction Does Not Increase the Risk of Postoperative Cerebrospinal Fluid Leak in Well-Selected Patients

Chaskes

Fastenberg

Vimawala

et al. 2020

J Neurol Surg B Skull Base

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Objectives A variety of endonasal sellar repair techniques have been described; many of which are complex, expensive, and carry potential morbidity but are felt to be necessary to prevent postoperative cerebrospinal fluid (CSF) leaks. We propose an effective, technically simple repair for select sellar defects utilizing an onlay of regenerated oxidized cellulose. Design Retrospective review of patients from a single neurosurgeon who underwent endoscopic transsphenoidal surgery for pituitary adenoma and sellar reconstruction with only an onlay of regenerated oxidized cellulose. Patients were selected for this repair technique based on the absence of: (1) intraoperative identification of a CSF leak, (2) patulous diaphragm (expanded diaphragm sella herniating to or through sellar floor defect), and (3) other prohibiting comorbidities. Setting The present study was conducted at a tertiary care center. Participants In this study, pituitary adenoma patients were the participants. Outcome Measures Main outcome measure of the study is postoperative CSF leak. Results A total of 172 patients were identified. Of these, 153 were initial resections of pituitary adenomas. Gross total resection was achieved in 142 (82.6%) cases. Average tumor size was 2.2 ± 1.1 cm. Average tumor volume was 10.4 ± 19.8 cm3. No patients had intraoperative CSF leaks. All cases were repaired with only an onlay of regenerated oxidized cellulose. There were two postoperative CSF leaks (1.16%). Pre and postoperative SNOT-22 scores were 12.9 ± 11.9 and 14.3 ± 14.9 (p = 0.796), respectively. Conclusion The use of an onlay of regenerated oxidized cellulose alone is an effective repair technique for select sellar defects. This technique does not result in increased postoperative CSF leak rates and avoids the higher relative cost and potential morbidity associated with more complex, multilayered closures.

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Section: Discussionmentioning

confidence: 99%

A Simple Onlay Sellar Reconstruction Does Not Increase the Risk of Postoperative Cerebrospinal Fluid Leak in Well-Selected Patients

Chaskes

Fastenberg

Vimawala

et al. 2020

J Neurol Surg B Skull Base

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“…Similar to our study, Scagnelli et al showed that nasal cavity floor FMG reconstruction of sellar defects showed a low postoperative CSF leak rate and no difference in sinonasal morbidity by 3 months postoperatively. 7 A strength of our study compared with their study is that since each patient completed all three questionnaires, each patient acted as his or her own internal control, thereby controlling for subjective (personal preference) or objective factors (age, medical comorbidities, smoking history, or history of chronic rhinosinusitis) that may have influenced SNOT-22 scoring. As a posterior septectomy is routinely performed in our technique of EETS, we propose that the posterior septum harvest site results in no additional donor site morbidity, good graft survival with low rates of delayed CSF leaks, and comparable QoL outcomes.…”

Section: Discussionmentioning

confidence: 99%

“…3 While validated for patients with chronic rhinosinusitis, the SNOT-22 and its predecessor-SNOT-20-are also frequently used to assess QoL outcomes following EETS for sellar pathologies. [4][5][6][7] Prior studies have looked into the postoperative time period until QoL improvement following EETS across a variety of sellar reconstructive methods. Pledger et al showed that among 46 patients undergoing EETS for nonfunctioning pituitary tumors, patients experienced the worst nasal symptoms at 2 weeks postoperatively and improved to below baseline between 8 weeks and 1 year postoperatively.…”

Section: Introductionmentioning

confidence: 99%

“…A transient complication of a nasal cavity floor donor site includes postoperative numbness of the incisor teeth. 7 Since the posterior septum is routinely removed in EETS, the use of a posterior septum FMG would result in no additional donor site morbidity. The present study seeks to evaluate the efficacy of posterior septum FMG reconstruction among a large cohort of patients undergoing EETS for PAs.…”

Section: Introductionmentioning

confidence: 99%

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Sinonasal Quality of Life Outcomes after Endoscopic Endonasal Transsphenoidal Surgery with Posterior Septum Free Mucosal Graft Reconstruction

Chen

Wells

et al. 2020

J Neurol Surg B Skull Base

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Objective Quality of life (QoL) outcomes following endoscopic endonasal transphenoidal surgery (EETS) across a variety of reconstructive methods improve by 2 to 6 months. An option for sellar reconstruction, in the absence of a significant intraoperative cerebrospinal fluid (CSF) leak, is a free mucosal graft (FMG) from the posterior septum. We analyze sinonasal QoL outcomes in patients undergoing EETS with FMG reconstruction. Design This study was a retrospective review. Setting This study was conducted at tertiary care academic center. Participants This study group consisted of patients undergoing EETS for pituitary adenomas from 2013 to 2018. Main Outcome Measures Tumor and surgical factors were included, along with postoperative complications. Patients completed Sinonasal Outcome Test-22 (SNOT-22) questionnaires. Pre- and postoperative scores were compared among the entire cohort using linear multilevel regression. A subcohort analysis was performed among patients who completed questionnaires during the preoperative visit and two postoperative visits (within 1 month and between 2 and 3 months, respectively); pre- and postoperative total and individual domain SNOT-22 scores were compared using paired t-tests. Results A total of 243 patients underwent EETS with FMG reconstruction. Four patients (1.6%) developed a postoperative CSF leak requiring reoperation. Among the entire cohort, SNOT-22 scores increased at the first postoperative visit (p < 0.01) but returned to baseline by the second, third, and fourth postoperative visits (p = 0.27, p = 0.18, and p = 0.21). Among 48 patients who completed both preoperative and two postoperative questionnaires, scores increased within the first month (p < 0.01) but returned to baseline at 2 to 3 months (p = 0.67). Conclusion Posterior septum FMG reconstruction of sellar defects is an effective option, demonstrating early recovery of baseline sinonasal QoL by 2 to 3 months.

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“…Usefulness of the extended endonasal mucoplasty EEM in the cadaveric anatomical study and in the clinical series of patients with bilateral CRSwNP Radiological and clinical study of EEM in 4 patients with bilateral CRSwNP undergoing an extended ethmoid-sphenoidotomy The EEM has been used in endoscopic sinus surgery, for closure of low-flow CSF fistulas and for repair of large skull base defects after resection of skull base tumors 17. It has been described in skull base surgery in a large series of sellar closure after pituitary surgery18 …”

mentioning

confidence: 99%

Radioanatomical study of the extended free nasal floor mucosal graft and its clinical applications

González‐García

Moreno‐Luna

Palacios-García

et al. 2020

Laryngoscope Investig Oto

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Objectives: To perform a radio-anatomical evaluation of the nasal cavity floor free mucosal graft (endonasal extended mucoplasty, EEM) to repair mucosal defects after an extended ethmoid-sphenoidotomy. Methods: A human cadaveric study (radiological and anatomical dissection) and an in vivo study in surgical patients with CRSwNP were performed. The EEM areas were compared between 3D reconstruction from CT scans and anatomical/surgical dissections, both in cadaver specimens and in patients. Feasibility was assessed by correlation between the EEM area on CT scans and when harvested in cadavers and when grafted in patients. Usefulness was assessed by the degree of coverage of the EEM in the surface exposed after an extended ethmoid-sphenoidotomy. Both feasibility and usefulness were assessed in cadaveric specimens (n = 15) and patients (n = 4). Results: Fifteen cadaveric specimens and 4 patients with bilateral CRSwNP were included. The mean (SD) areas obtained in the cadaveric radiological and anatomical studies were 9.44 (2.07) cm 2 and 8.03 (1.36) cm 2 , respectively (intraclass correlation coefficient 0.59, moderate correlation), and in 3D reconstruction for operated patients were 10.32 (0.98) cm 2 and 11.27 (2.44) cm 2 , respectively. The coverage of the ethmoidal roof in the cadaveric dissection study was 100%, from the anterior ethmoidal artery to the posterior ethmoidal artery, covering the planun sphenoidale up to 75% in the case series. In 87.5% of the cases, up to 50% of the papiracea lamina was covered. Jaime González-García and Ramón Moreno-Luna contributed equally as first authors.

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Implementation of Free Mucosal Graft Technique for Sellar Reconstruction After Pituitary Surgery: Outcomes of 158 Consecutive Patients

Cited by 35 publications

References 16 publications

A Simple Onlay Sellar Reconstruction Does Not Increase the Risk of Postoperative Cerebrospinal Fluid Leak in Well-Selected Patients

A Simple Onlay Sellar Reconstruction Does Not Increase the Risk of Postoperative Cerebrospinal Fluid Leak in Well-Selected Patients

Sinonasal Quality of Life Outcomes after Endoscopic Endonasal Transsphenoidal Surgery with Posterior Septum Free Mucosal Graft Reconstruction

Radioanatomical study of the extended free nasal floor mucosal graft and its clinical applications

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