Pitfalls of skull base reconstruction in endoscopic endonasal approach

Abstract

Various skull base reconstruction techniques have been developed in endoscopic endonasal approach (EEA) for skull base lesions to prevent postoperative cerebrospinal fluid (CSF) leakage. This study was performed to evaluate the efficacy and pitfalls of our method of skull base reconstruction after EEA. A total of 123 patients who underwent EEA (127 surgeries) between October 2014 and May 2017 were reviewed. Our algorithm for skull base reconstruction in EEA was categorized based on intraoperative CSF leakage graded as follows: grade 0 was excluded from this study; grade 1, dural suturing with abdominal fat graft or packing of gelatin sponge into the cavity; grade 2, method for grade 1 with addition of mucosal flap or nasoseptal flap (NSF); and grade 3, duraplasty in fascia patchwork closure with NSF. Bony reconstruction was not mandatory, and there was no postoperative bed rest or initial lumbar drainage (LD) insertion in any of the cases. Postoperative CSF leakage after EEA was mostly prevented (96.3%) by our algorithm without postoperative initial LD or bed rest. On the other hand, reconstruction surgery was required for postoperative CSF leakage in two cases-one with prior multitranssphenoidal surgery and radiotherapy and another patient with poor compliance due to communication difficulties. Both of the latter patients were obese. Greater care with regard to postoperative CSF leakage is required in patients with prior EEA with radiotherapy and obesity. In such high-risk patients, initial LD or bed rest may be required to prevent postoperative CSF leakage. It is also important to restrict activities that result in increased intracranial pressure.

Skull base reconstruction: A question of flow? A critical analysis of 521 endoscopic endonasal surgeries

“…35], to the conspicuously lower rate described more recently (from 2,6% to 8,9%) [11,12,18]. In this study the overall POL rate was 5.2%, thus confirming the encouraging trend described by the evidence.…”

“…The endoscopic endonasal approach (EEA) have evolved during the years, allowing the treatment of complex skull base lesions [7]. Minimal invasiveness due to the absence of brain retraction, the development of surgical technique and technological innovation, allow these approaches to be widely spread [3,18]. Additionally, recent papers have emphasized the adherence of endoscopic procedures to oncological principles in the treatment of benign and malign skull base tumors [2].…”

“…Nevertheless, POL related complications such as meningitis and pneumocephalus still remain the main drawbacks of EEA [18][19][20]. Therefore, skull base reconstruction should be considered a crucial part of the procedures and the real challenge in the evolution of EEA [7,10,18,21].…”

“…Common principles of new strategies involve (1) filling the empty dead space, (2) obtaining a watertight closure and (3) creating meticulous multilayer dural closure to reduce the entity of intra-operative CSF flow acting on the skull base defect [3,11,18].…”

“…The literature results showed that multilayered closures could be considered essential in the reconstructive phase of EEA in both cases of ILFL and IHFL [2,3,12,21]. Furthermore, NSF combined with multilayered dural reconstruction should be performed in cases of IHFL, while no differences were reported adding vascularized flap in cases of ILFL [15,18].…”