Modified Graded Repair of Cerebrospinal Fluid Leaks in Endoscopic Endonasal Transsphenoidal Surgery

Park, Jae-Hyun; Choi, Jai Ho; Kim, Young Il; Kim, Sung Won; Hong, Yong-Kil

doi:10.3340/jkns.2015.58.1.36

Cited by 48 publications

(42 citation statements)

References 38 publications

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“…The overall ioCSF leak rate in our study was 27% (178 of 658): 25% in the shorter postoperative LoS group and 44% in the longer postoperative LoS group. The ioCSF leak rate was similar to the range of 17.5% to 27.4% reported in earlier studies involving the ETS approach for pituitary adenoma 12‐14 . Our institution has implemented a simplified protocol for management of ioCSF leaks, which includes reconstruction with a dural synthetic and duraseal for low‐flow CSF leaks.…”

Section: Discussionsupporting

confidence: 77%

Predicting prolonged length of stay after endoscopic transsphenoidal surgery for pituitary adenoma

Vimawala

Chitguppi

Reilly

et al. 2020

Int Forum Allergy Rhinol

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Background: Endoscopic transsphenoidal surgery (ETS) for the resection of pituitary adenoma has become more common throughout the past decade. Although most patients have a short postoperative hospitalization, others require a more prolonged stay. We aimed to identify predictors for prolonged hospitalization in the se ing of ETS for pituitary adenomas. Methods: A retrospective chart review as performed on 658 patients undergoing ETS for pituitary adenoma at a single tertiary care academic center from 2005 to 2019. Length of stay (LoS) was defined as date of surgery to date of discharge. Patients with LoS in the top 10th percentile (prolonged LoS [PLS] >4 days, N = 72) were compared with the remainder (standard LoS [SLS], N = 586). Results:The average age was 54 years and 52.5% were male. The mean LoS was 2.1 days vs 7.5 days (SLS vs PLS). On univariate analysis, atrial fibrillation (p = 0.002), hypertension (p = 0.033), partial tumor resection (p < 0.001), apoplexy (p = 0.020), intraoperative cerebrospinal fluid (ioCSF) leak (p = 0.001), nasoseptal flap (p = 0.049), postoperative diabetes insipidus (DI) (p = 0.010), and readmis-sion within 30 days (p = 0.025) were significantly associated with PLS. Preoperative continuous positive airway pressure (CPAP) (odds ratio, 15.144; 95% confidence interval, 2.596-88.346; p = 0.003) and presence of an ioCSF leak (OR, 10.362; 95% CI,; p = 0.004) remained significant on multivariable analysis. Conclusion:For patients undergoing ETS for pituitary adenomas, an ioCSF leak or preoperative use of CPAP predicted PLS. Additional common reasons for PLS included postoperative CSF leak (10 of 72), management of DI or hypopituitarism (15 of 72), or reoperation due to surgical or medical complications (14 of 72). C 2020 ARS-AAOA, LLC.

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Section: Discussionsupporting

confidence: 77%

Predicting prolonged length of stay after endoscopic transsphenoidal surgery for pituitary adenoma

Vimawala

Chitguppi

Reilly

et al. 2020

Int Forum Allergy Rhinol

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“…After tumor removal is complete, inspection of the sella and parasellar space is required to determine the presence and magnitude of a CSF leak. Several grading scales ranging from 3‐point to 4‐point scales have been proposed in multiple publications, all of which include no leaks, small leaks, and large leaks . Provocative testing with a Valsalva maneuver by the anesthesiologist, or use of intrathecal fluorescein, are advocated by some authors to help identify small leaks, as well as to assess the integrity of the repair.…”

Section: Intradural Tumorsmentioning

confidence: 99%

“…Materials frequently used in reconstruction include autologous fat, fascia lata, septal bone, and cartilage, as well as all native sphenoid sinus mucosa, free mucosal grafts, and pedicled NSFs. Allografts frequently used include Alloderm (Allergan, Branchburg, NJ), absorbable and nonabsorbable plates, and titanium mesh, as well as collagen matrix materials, all typically in multilayered fashion . Various types of tissue glues are also included in many of the reconstruction protocols.…”

Section: Intradural Tumorsmentioning

confidence: 99%

“…The literature remains unclear on the benefit of intraoperative and perioperative CSF diversion with a lumbar drain. At some centers, it is used routinely with good success, predominantly for larger high‐grade leaks, whereas in others it may be associated with a higher failure and meningitis rate . Two recent meta‐analyses and a review article failed to find benefit of perioperative lumbar drain placement in patients with pituitary adenomas and other skull‐base tumors, and 1 emphasized potential risk of major complications including meningitis and ventriculitis .…”

Section: Intradural Tumorsmentioning

confidence: 99%

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ICAR: endoscopic skull‐base surgery

Wang

Zanation

Gardner

et al. 2019

Int Forum Allergy Rhinol

160

279

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Background Endoscopic skull‐base surgery (ESBS) is employed in the management of diverse skull‐base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull‐base surgery have produced the International Consensus Statement on Endoscopic Skull‐Base Surgery (ICAR:ESBS). Methods Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence‐based review or evidence‐based review with recommendations format. Subsequently, each topic was written and then reviewed by skull‐base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. Results The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull‐base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. Conclusion A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence‐based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull‐base community to embrace these opportunities and collaboratively address these shortcomings.

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“…The surgical technique was identical to the method described in a recent publication of the author group24). All operations were performed via the binostrils-four hands technique.…”

Section: Methodsmentioning

confidence: 99%

Parasellar Extension Grades and Surgical Extent in Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Adenomas : A Single Surgeon's Consecutive Series with the Aspects of Reliability and Clinical Validity

Lee

Park

Lee

et al. 2016

J Korean Neurosurg Soc

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ObjectiveThe inter-rater reliability of the modified Knosp's classification was measured before the analysis. The clinical validity of the parasellar extension grading system was evaluated by investigating the extents of resection and complication rates among the grades in the endoscopic endonasal transsphenoidal surgery (EETS) for pituitary adenomas.MethodsFrom November 2008 to August 2015, of the 286 patients who underwent EETS by the senior author, 208 were pituitary adenoma cases (146 non-functioning pituitary adenomas, 10 adrenocorticotropic hormone-secreting adenomas, 31 growth hormone-secreting adenomas, 17 prolactin-secreting adenomas, and 4 thyroid-stimulating hormone-secreting adenomas; 23 microadenomas, 174 macroadenomas, and 11 giant adenomas). Two neurosurgeons and a neuroradiologist independently measured the degree of parasellar extension on the preoperative sellar MRI according to the modified Knosp's classification. Inter-rater reliability was statistically assessed by measuring the intraclass correlation coefficient. The extents of resection were evaluated by comparison of the pre- and post-operative MR images; the neurovascular complications were assessed by reviewing the patients' medical records. The extent of resection was measured in each parasellar extension grade; thereafter, their statistical differences were calculated.ResultsThe intraclass correlation coefficient value of reliability across the three raters amounted to 0.862. The gross total removal (GTR) rates achieved in each grade were 70.0, 69.8, 62.9, 21.4, 37.5, and 4.3% in Grades 0, 1, 2, 3A, 3B, and 4, respectively. A significant difference in the extent of resection was observed only between Grades 2 and 3A. In addition, significantly higher complication rates were observed in the groups above Grade 3A.ConclusionAlthough the modified Knosp's classification system appears to be complex, its inter-rater reliability proves to be excellent. Regarding the clinical validity of the parasellar extension grading system, Grades 3A, 3B, and 4 have a negative predictive value for the GTR rate, with higher complication rates.

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Modified Graded Repair of Cerebrospinal Fluid Leaks in Endoscopic Endonasal Transsphenoidal Surgery

Cited by 48 publications

References 38 publications

Predicting prolonged length of stay after endoscopic transsphenoidal surgery for pituitary adenoma

Predicting prolonged length of stay after endoscopic transsphenoidal surgery for pituitary adenoma

ICAR: endoscopic skull‐base surgery

Parasellar Extension Grades and Surgical Extent in Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Adenomas : A Single Surgeon's Consecutive Series with the Aspects of Reliability and Clinical Validity

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