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

Khan, Danyal Z.; Ali, Ahmad M.; Koh, Chan Hee; Dorward, Neil; Grieve, Joan; Horsfall, Hugo Layard; Muirhead, William; Santarius, Thomas; Furth, Wouter R. van; Najafabadi, Amir H Zamanipoor; Marcus, Hani J.

doi:10.1007/s11102-021-01145-4

Cited by 35 publications

(30 citation statements)

References 154 publications

(242 reference statements)

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“…CSF rhinorrhoea for both TSA (28/726, 3.9%) and EEA (10/140, 7.1%) are lower than generally reported in the literature ( 6 , 7 , 9 , 10 , 12 , 23 ). This may reflect the ongoing improvement in endonasal skull-base repair and CSF rhinorrhoea rates, demonstrated by recent meta-analyses over time ( 24 ).…”

Section: Discussioncontrasting

confidence: 52%

“…Tissue grafts, tissue glues, and construct support strategies (e.g., rigid buttresses and CSF diversion) were less frequent in the absence of neurosurgical involvement. CSF rhinorrhoea for both TSA (28/726, 3.9%) and EEA (10/140, 7.1%) are lower than generally reported in the literature (6,7,9,10,12,23). This may reflect the ongoing improvement in endonasal skullbase repair and CSF rhinorrhoea rates, demonstrated by recent metaanalyses over time (24).…”

Section: Discussion Principal Findingsmentioning

confidence: 54%

“…An international expert consensus on TSA workflow highlighted the potential for practice variations, particularly in closure, due to a variety of skull-base repair options (5). Previous systematic reviews examining skull-base repair techniques across endonasal skull-base neurosurgery found absolute heterogeneity across studies and centres, likely due to a paucity of high-level comparative evidence (6). Similarly, there is variance in postoperative cerebrospinal fluid (CSF) rhinorrhoea rates, one of the commonest postoperative complicationsgenerally up to 5% in TSA and 20% in EEA (4, [7][8][9][10][11][12].…”

Section: Introductionmentioning

confidence: 99%

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CSF rhinorrhoea after endonasal intervention to the skull base (CRANIAL): A multicentre prospective observational study

2023

Front. Oncol.

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ObjectiveDespite progress in endonasal skull-base neurosurgery, cerebrospinal fluid (CSF) rhinorrhoea remains common and significant. The CRANIAL study sought to determine 1) the scope of skull-base repair methods used, and 2) corresponding rates of postoperative CSF rhinorrhoea in the endonasal transsphenoidal approach (TSA) and the expanded endonasal approach (EEA) for skull-base tumors.MethodsA prospective observational cohort study of 30 centres performing endonasal skull-base neurosurgery in the UK and Ireland (representing 91% of adult units). Patients were identified for 6 months and followed up for 6 months. Data collection and analysis was guided by our published protocol and pilot studies. Descriptive statistics, univariate and multivariable logistic regression models were used for analysis.ResultsA total of 866 patients were included - 726 TSA (84%) and 140 EEA (16%). There was significant heterogeneity in repair protocols across centres. In TSA cases, nasal packing (519/726, 72%), tissue glues (474/726, 65%) and hemostatic agents (439/726, 61%) were the most common skull base repair techniques. Comparatively, pedicled flaps (90/140, 64%), CSF diversion (38/140, 27%), buttresses (17/140, 12%) and gasket sealing (11/140, 9%) were more commonly used in EEA cases. CSF rhinorrhoea (biochemically confirmed or requiring re-operation) occurred in 3.9% of TSA (28/726) and 7.1% of EEA (10/140) cases. A significant number of patients with CSF rhinorrhoea (15/38, 39%) occurred when no intraoperative CSF leak was reported. On multivariate analysis, there may be marginal benefits with using tissue glues in TSA (OR: 0.2, CI: 0.1-0.7, p<0.01), but no other technique reached significance. There was evidence that certain characteristics make CSF rhinorrhoea more likely – such as previous endonasal surgery and the presence of intraoperative CSF leak.ConclusionsThere is a wide range of skull base repair techniques used across centres. Overall, CSF rhinorrhoea rates across the UK and Ireland are lower than generally reported in the literature. A large proportion of postoperative leaks occurred in the context of occult intraoperative CSF leaks, and decisions for universal sellar repairs should consider the risks and cost-effectiveness of repair strategies. Future work could include longer-term, higher-volume studies, such as a registry; and high-quality interventional studies.

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Section: Discussioncontrasting

confidence: 52%

Section: Discussion Principal Findingsmentioning

confidence: 54%

Section: Introductionmentioning

confidence: 99%

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CSF rhinorrhoea after endonasal intervention to the skull base (CRANIAL): A multicentre prospective observational study

2023

Front. Oncol.

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“…Free tissue grafts, vascularized flaps, gasket sealing and lumbar drains are most commonly used to prevent postoperative CSF leaks ( 25 ). Based on our data and the surgical experience of our team, for patients with high risk of postoperative CSF leakage, rigorous skull base reconstruction and perioperative lumbar drainage are beneficial to reduce the occurrence of postoperative CSF leakage.…”

Section: Discussionmentioning

confidence: 99%

Risk factors and management associated with postoperative cerebrospinal fluid leak after endoscopic endonasal surgery for pituitary adenoma

Zhao

Fang

et al. 2022

Front. Surg.

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ObjectiveTo determine risk factors and management for the development of a postoperative cerebrospinal fluid (CSF) leak after an endoscopic endonasal surgery (EES) for pituitary adenomas.MethodsThe clinical data of 400 patients who underwent EES for resection of pituitary adenomas from December 2018 to November 2019 in the Department of Neurosurgery of Beijing Tiantan Hospital were retrospectively reviewed. Age, gender, body mass index (BMI), tumor size, Knosp grade, suprasellar extension grade, sellar floor erosion grade, repeated transsphenoidal surgery, intraoperative CSF leak, use of pedicled nasoseptal flap and lumbar drain were collected and analyzed.ResultsPostoperative CSF leak occurred in 14 of 400 patients (3.5%). Age, gender, BMI, tumor size, Knosp grade and repeated transsphenoidal surgery were not risk factors for CSF leak. Suprasellar extension grade (≥B 6.0% vs. <B 1.4%; p = 0.024), sellar floor erosion grade (≥III 5.7% vs. <III 0.6%; p = 0.020) and intraoperative CSF leak (Yes 7.5% vs. No 2.0%; p = 0.009) were factors associated with an increased postoperative CSF leak rate.ConclusionsHigher suprasellar extension grade, higher sellar floor erosion grade and intraoperative CSF leak were risk factors for postoperative CSF leak after endoscopic treatment of pituitary adenoma. Strict skull base reconstruction including use of a pedicled nasoseptal flap and perioperative lumbar drainage may avoid postoperative CSF leak.

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“…Known risk groups for postoperative CSF leak are patients with higher BMI, third ventricle invasion, craniopharyngioma, previous skull base irradiation, prior surgery and intra-operative CSF leak (74,78,(80)(81)(82). For these patients particularly, tailored skull base reconstruction methods are critical to prevent and/or manage CSF leak optimally (83). Also, preventive ELD placement may result in more efficient use of resources and indirectly lower costs, however it will also increase LOS in short-stay protocols.…”

Section: Postoperative Csf Leakmentioning

confidence: 99%

Costs and Its Determinants in Pituitary Tumour Surgery

Dekkers

Vries²,

Najafabadi³

et al. 2022

Front. Endocrinol.

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PurposeValue-based healthcare (VBHC) provides a framework to improve care by improving patient outcomes and reducing healthcare costs. To support value-based decision making in clinical practice we evaluated healthcare costs and cost drivers in perioperative care for pituitary tumour patients.MethodsWe retrospectively assessed financial and clinical data for surgical treatment up to the first year after surgery of pituitary tumour patients treated between 2015 and 2018 in a Dutch tertiary referral centre. Multivariable regression analyses were performed to identify determinants of higher costs.Results271 patients who underwent surgery were included. Mean total costs (SD) were €16339 (13573) per patient, with the following cost determinants: surgery time (€62 per minute; 95% CI: 50, 74), length of stay (€1331 per day; 95% CI 1139, 1523), admission to higher care unit (€12154 in total; 95% CI 6413, 17895), emergency surgery (€10363 higher than elective surgery; 95% CI: 1422, 19305) and postoperative cerebrospinal fluid leak (€14232; 95% CI 9667, 18797). Intradural (€7128; 95% CI 10421, 23836) and combined transsphenoidal/transcranial surgery (B: 38494; 95% CI 29191, 47797) were associated with higher costs than standard. Further, higher costs were found in these baseline conditions: Rathke’s cleft cyst (€9201 higher than non-functioning adenoma; 95% CI 1173, 17230), giant adenoma (€19106 higher than microadenoma; 95% CI 12336, 25877), third ventricle invasion (€14613; 95% CI 7613, 21613) and dependent functional status (€12231; 95% CI 3985, 20477). In patients with uncomplicated course, costs were €8879 (3210) and with complications €17551 (14250).ConclusionsLength of hospital stay, and complications are the main drivers of costs in perioperative pituitary tumour healthcare as were some baseline features, e.g. larger tumors, cysts and dependent functional status. Costs analysis may correspond with healthcare resource utilization and guide further individualized care path development and capacity planning.

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

Cited by 35 publications

References 154 publications

CSF rhinorrhoea after endonasal intervention to the skull base (CRANIAL): A multicentre prospective observational study

CSF rhinorrhoea after endonasal intervention to the skull base (CRANIAL): A multicentre prospective observational study

Risk factors and management associated with postoperative cerebrospinal fluid leak after endoscopic endonasal surgery for pituitary adenoma

Costs and Its Determinants in Pituitary Tumour Surgery

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