Sellar repair with autologous muscle and composite septal cartilage grafts for treatment of cerebrospinal fluid leakage following trans-sphenoidal pituitary surgery

Abstract

Context:Many reconstructive techniques have been proposed to prevent postoperative cerebrospinal fluid (CSF) leakage after trans-sphenoidal pituitary surgery. However, no total agreement has been reached to the best technique.Aim:Assessment of the efficacy of sellar repair with autologous muscle and composite septal cartilage grafts for treatment of intraoperative and delayed postoperative CSF leakage following trans-sphenoidal pituitary surgery without the use of postoperative external lumbar CSF drain.Study Design:This is a retrospective case series study, level IV evidence.Materials and Methods: Twenty three patients were involved in this study. Seventeen patients had intraoperative CSF leakage and were treated immediately by our technique. Six patients had postoperative CSF rhinorrhea and had delayed treatment with our technique after failure of conservative measures and external lumbar CSF drainage for more than three days. The technique involved intradural placement of autologous muscle graft supplemented with extradural composite septal cartilage graft, composed of a piece of the posterior cartilaginous septum with its covering mucoperichondrium on one side only to fit into the sellar defect as a double layer button.Results:CSF leak was of grade 1 in 6 patients (26.1%), grade 2 in 10 patients (43.5%) and grade 3 in 7 patients (30.4%). None of the patients in our study had postoperative CSF leak after the use of our technique during the follow up period (mean 24 ± 10.47 standard deviation months). None of the patients developed treatment-related complications. All the patients had well developed mucosal covering of the sellar defect after two months.Conclusion:Our technique of sellar repair by using autologous muscle and composite septal cartilage grafts is effective in treatment of intraoperative and delayed postoperative CSF leakage following trans-sphenoidal pituitary surgery without the use of postoperative external lumbar CSF drain even in the high-output CSF leaks.

ICAR: endoscopic skull‐base surgery

“…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.…”

“…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 .…”

Evaluating the Role of Pre-operative Cerebrospinal Fluid Diversion by Lumbar Drain in Transnasal Transsphenoidal Tumor Surgeries

“…Moreover, 9 out of the 20(45%) explored patients presented an intraoperative CSF leak, i.e., comparable to a large body of literature where the lumbar drain was not pre-operatively used; in such cases, the associated risk approximately equaled 50%. El Shazly et al [16] reported a 73.9% incidence of intra-operative leaks among 23 examined patients; however, in some studies, the incidence was observed as low as 17.9% [17].…”

Sellar Floor Reconstruction with and without Intrasellar Fat Packing after Endoscopic Resection of Large Pituitary Macroadenomas with Evident Intraoperative CSF Leak

“…6 In such patients, tight closure is needed and requires multilayer technique, using fat, fascia lata, bone, mucoperiosteum taken from the middle turbinate, and vascular pedicle nasoseptal (Hadad–Bassagasteguy) flap. 4 6 7 8 9 In addition to autografts, synthetic and bioabsorbable materials have been also used to tightly repair the sellar floor with and without external CSF lumbar drain. 10 11 12 13 14 15 16 17…”