Predicting post-operative cerebrospinal fluid (CSF) leak following endoscopic transnasal pituitary and anterior skull base surgery: a multivariate analysis

Hannan, Cathal John; Almhanedi, Hamad; Al-Mahfoudh, Rafid; Bhojak, Maneesh; Looby, Seamus; Javadpour, Mohsen

doi:10.1007/s00701-020-04334-5

Cited by 40 publications

(45 citation statements)

References 28 publications

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“…There is also evidence to suggest that posterior fossa defects have a higher proclivity for post-operative CSF leak, which may not be surprising given their dependent location and the requirement for any vascularized nasoseptal flap to be transposed to a greater extent than if they were being used for an anterior fossa or sellar defect (69,70). The rate of post-operative CSF leak has been shown to decrease as the experience of the operating surgeon increases, with data from our series of 270 endoscopic cases identifying a CSF leak rate of 21% in the first 90 cases, as compared to 1% in the last 90 cases (66).…”

Section: Post-operative Csf Leak: Risk Factorsmentioning

confidence: 84%

“…In the latter third of a series of 270 patients (operated between July 2006 and June 2016) undergoing endoscopic surgery for resection of pituitary and skull base tumors, 1/90 (1%) patients experienced a post-operative CSF leak. When only EEA with high flow intra-operative CSF leaks were repaired using the following technique, 1/28 (4%) of patients experienced a post-operative CSF leak (66).…”

Section: Skull Base Repair: the Dublin Techniquementioning

confidence: 99%

“…Prior to the adoption of this technique in 2013, we utilized a fat graft, covered with an onlay graft of dural substitute/fascia lata secured with dural sealant. In the setting of a high flow intra-operative CSF leak, a post-operative CSF leak was noted in 7 of 20 cases (35%) (66).…”

Section: Skull Base Repair: the Dublin Techniquementioning

confidence: 99%

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

2020

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Following the introduction of fully endoscopic techniques for the resection of pituitary tumors, there was a rapid expansion of the indications for endonasal endoscopic surgery to include extrasellar tumors of the skull base. These techniques offer significant advantages over traditional open surgical approaches to the skull base, including improved tumor resection, and better post-operative neurological outcomes. Following their introduction, however, the initial rate of post-operative CSF leak was unacceptably high. Post-operative CSF leak following skull base surgery is a major source of morbidity, and can lead to the development of life-threatening intracranial infection. The use of vascularized naso-septal flaps transformed the management of these patients, significantly reducing the rate of post-operative CSF leak and increasing the number of patients that could benefit from this less invasive treatment modality. Adequate repair of iatrogenic defects in the skull base is of crucial importance for patients with skull base tumors, as the development of a post-operative CSF leak, and the associated complications can significantly delay the administration of the adjunctive oncological therapies these patients require. In this review, we provide an overview of the latest evidence regarding skull base reconstruction following endoscopic skull base surgery, and describe the skull base repair technique in use at our institution.

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Section: Post-operative Csf Leak: Risk Factorsmentioning

confidence: 84%

Section: Skull Base Repair: the Dublin Techniquementioning

confidence: 99%

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

2020

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“…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.…”

Section: Resultsmentioning

confidence: 99%

“…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. suprasellar extension) [ 31 ] and consistency [ 43 ].…”

Section: Resultsmentioning

confidence: 99%

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

et al. 2021

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Purpose Postoperative cerebrospinal fluid rhinorrhoea (CSFR) remains a frequent complication of endonasal approaches to pituitary and skull base tumours. Watertight skull base reconstruction is important in preventing CSFR. We sought to systematically review the current literature of available skull base repair techniques. Methods Pubmed and Embase databases were searched for studies (2000–2020) that (a) reported on the endonasal resection of pituitary and skull base tumours, (b) focussed on skull base repair techniques and/or postoperative CSFR risk factors, and (c) included CSFR data. Roles, advantages and disadvantages of each repair method were detailed. Random-effects meta-analyses were performed where possible. Results 193 studies were included. Repair methods were categorised based on function and anatomical level. There was absolute heterogeneity in repair methods used, with no independent studies sharing the same repair protocol. Techniques most commonly used for low CSFR risk cases were fat grafts, fascia lata grafts and synthetic grafts. For cases with higher CSFR risk, multilayer regimes were utilized with vascularized flaps, gasket sealing and lumbar drains. Lumbar drain use for high CSFR risk cases was supported by a randomised study (Oxford CEBM: Grade B recommendation), but otherwise there was limited high-level evidence. Pooled CSFR incidence by approach was 3.7% (CI 3–4.5%) for transsphenoidal, 9% (CI 7.2–11.3%) for expanded endonasal, and 5.3% (CI 3.4–7%) for studies describing both. Further meaningful meta-analyses of repair methods were not performed due to significant repair protocol heterogeneity. Conclusions Modern reconstructive protocols are heterogeneous and there is limited evidence to suggest the optimal repair technique after pituitary and skull base tumour resection. Further studies are needed to guide practice.

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Clinical characteristics and temporal trends of lumbar drain use in minimally invasive resection of pituitary neoplasms

Bitner,

Torabi,

Hong

et al. 2024

World j. otorhinolaryngol.-head neck surg.

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ObjectivesAppropriate scenarios of lumbar drain (LD) use in endonasal skull base surgery is an active area of investigation. However, existing data is limited. The purpose of this study is to evaluate the robustness of the NSQIP database to characterize morbidity and complications associated with LD usage concurrent to minimally invasive resection of pituitary tumors.MethodsA cross‐sectional analysis of the American College of Surgeons National Surgical Quality Improvement Program database was used to query patients undergoing transnasal resection of pituitary tumor. Patients were stratified by concurrent perioperative use of LD and outcomes were compared.ResultsA total of 1714 patients underwent minimally invasive endonasal (microscopic or endoscopic) pituitary tumor resection, of which LD was concurrently placed in 98 (5.7%) cases. Operative time was significantly longer for patients who had LD placed compared to those without (176.5 min (IQR 114.8–229.5) vs. 137 min [IQR 100–185]), (p < 0.001) with a significantly longer length of stay (5 days [IQR 4–6] vs. 3 days [IQR 2–5]), (p < 0.001). Multivariate regression demonstrated LD placement was an independent predictor of postoperative medical complication (OR 2.41, 95% CI 1.15–5.03, p = 0.020) and unplanned readmission (OR 2.06, 95% CI 1.02–4.16, p = 0.044), but not CSF leak (OR 2.30, 95% CI 0.51–10.26; p = 0.276). Temporal analysis during the study period demonstrated a decrease in LD use from 8% to 5% (R2 = 0.60; p = 0.025).ConclusionsThe NSQIP database provides a large patient population for examining LD use in endoscopic pituitary adenoma resection. LD use for minimally invasive pituitary surgery is associated with postoperative medical complications and unplanned readmissions, with no apparent impact on reconstructive outcomes, and there is overall decreasing usage. Clinical judgment should be exercised in selecting appropriate scenarios for use.

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Predicting post-operative cerebrospinal fluid (CSF) leak following endoscopic transnasal pituitary and anterior skull base surgery: a multivariate analysis

Cited by 40 publications

References 28 publications

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

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

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

Clinical characteristics and temporal trends of lumbar drain use in minimally invasive resection of pituitary neoplasms

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