J Korean Neurosurg Soc.  2015 Jul;58(1):36-42. 10.3340/jkns.2015.58.1.36.

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

• Park JH
• Choi JH
• Kim YI
• Kim SW
• Hong YK

• KMID: 2067102
• DOI: http://doi.org/10.3340/jkns.2015.58.1.36

Abstract

OBJECTIVE
Complete sellar floor reconstruction is critical to avoid postoperative cerebrospinal fluid (CSF) leakage during transsphenoidal surgery. Recently, the pedicled nasoseptal flap has undergone many modifications and eventually proved to be valuable and efficient. However, using these nasoseptal flaps in all patients who undergo transsphenoidal surgery, including those who had none or only minor CSF leakage, appears to be overly invasive and time-consuming.
METHODS
Patients undergoing endoscopic endonasal transsphenoidal tumor surgery within a 5 year-period were reviewed. Since 2009, we classified the intraoperative CSF leakage into grades from 0 to 3. Sellar floor reconstruction was tailored to each leak grade. We did not use any tissue grafts such as abdominal fat and did not include any procedures of CSF diversions such as lumbar drainage.
RESULTS
Among 200 cases in 188 patients (147 pituitary adenoma and 41 other pathologies), intraoperative CSF leakage was observed in 27.4% of 197 cases : 14.7% Grade 1, 4.6% Grade 2a, 3.0% Grade 2b, and 5.1% Grade 3. Postoperative CSF leakage was observed in none of the cases. Septal bone buttress was used for Grade 1 to 3 leakages instead of any other foreign materials. Pedicled nasoseptal flap was used for Grades 2b and 3 leakages. Unused septal bones and nasoseptal flaps were repositioned.
CONCLUSION
Modified classification of intraoperative CSF leaks and tailored repair technique in a multilayered fashion using an en-bloc harvested septal bone and vascularized nasoseptal flaps is an effective and reliable method for the prevention of postoperative CSF leaks.

Keyword

Cerebrospinal fluid leak; Endoscopy; Skull base; Pituitary adenoma; Complications; Outcome

MeSH Terms

Abdominal Fat
Cerebrospinal Fluid*
Classification
Drainage
Endoscopy
Humans
Pituitary Neoplasms
Skull Base
Transplants

Figure

• 

  Fig. 1 A : The first incision was made anteriorly toward the level of one-half to one-third the height of the middle turbinate over the vomer to preserve the nasoseptal pedicle. Then, a curvilinear incision (along the white arrows) was made from the inferior border of the sphenoidal sinus ostium following the sagittal plane of the septum slightly downward. B : By using Cottle and hockey stick elevators, a mucoperiosteal flap was made from the right side of the bony nasal septum and displaced downward into the nasopharynx.

• 

  Fig. 2 Modified grading system for cerebrospinal fluid (CSF) leak after endoscopic transsphenoidal surgery.

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  Fig. 3 Schematic drawing of a lateral view of the sellar floor in grade 3 sellar floor repair. (a) Inlay and (b) outlay dural substitutes with (c) septal bone repositioned, and (d) a pedicled nasoseptal flap is applied at the sellar floor for grade 3 CSF leak repair.

• 

  Fig. 4 Endoscopic images of sellar floor repair in grade 3 CSF leak. In cases of large CSF leaks (grade 3), sellar floor reconstruction was performed in a multilayered fashion with (A) oxidative cellulose packing (Surgicel®, Ethicon; Johnson & Johnson), (B) inlay dural substitutes (Duraform®, Codman; Johnson & Johnson), (C) outlay dural substitutes, (D) septal bone, and (E) a pedicled nasoseptal flap. (F) A tissue sealant (DuraSeal®, Covidien) was applied at last.

Reference

1. Arita K, Kurisu K, Tominaga A, Ikawa F, Iida K, Hama S, et al. Size-adjustable titanium plate for reconstruction of the sella turcica. Technical note. J Neurosurg. 1999; 91:1055–1057. PMID: 10584857.

2. Berker M, Hazer DB, Yücel T, Gürlek A, Cila A, Aldur M, et al. Complications of endoscopic surgery of the pituitary adenomas : analysis of 570 patients and review of the literature. Pituitary. 2012; 15:288–300. PMID: 22161543.

3. Cappabianca P, Cavallo LM, Colao A, de Divitiis E. Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg. 2002; 97:293–298. PMID: 12186456.

4. Cappabianca P, Cavallo LM, Esposito F, Valente V, De Divitiis E. Sellar repair in endoscopic endonasal transsphenoidal surgery : results of 170 cases. Neurosurgery. 2002; 51:1365–1371. discussion 1371-1372PMID: 12445341.

5. Cho JM, Ahn JY, Chang JH, Kim SH. Prevention of cerebrospinal fluid rhinorrhea after transsphenoidal surgery by collagen fleece coated with fibrin sealant without autologous tissue graft or postoperative lumbar drainage. Neurosurgery. 2011; 68(1 Suppl Operative):130–136. discussion 136-137PMID: 21206312.

6. Couldwell WT, Weiss MH, Rabb C, Liu JK, Apfelbaum RI, Fukushima T. Variations on the standard transsphenoidal approach to the sellar region, with emphasis on the extended approaches and parasellar approaches : surgical experience in 105 cases. Neurosurgery. 2004; 55:539–547. discussion 547-550PMID: 15335421.

7. Esposito F, Dusick JR, Fatemi N, Kelly DF. Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery. Neurosurgery. 2007; 60(4 Suppl 2):295–303. discussion 303-304PMID: 17415166.

8. Freidberg SR, Hybels RL, Bohigian RK. Closure of cerebrospinal fluid leakage after transsphenoidal surgery : technical note. Neurosurgery. 1994; 35:159–160. PMID: 7741845.

9. Goel A, Muzumdar DP. Reconstruction of the sella floor using vascularized pedicled mucosal flap. Br J Neurosurg. 2003; 17:553–555. PMID: 14756486.

10. Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches : vascular pedicle nasoseptal flap. Laryngoscope. 2006; 116:1882–1886. PMID: 17003708.

11. Hardy J. Transsphenoidal hypophysectomy. J Neurosurg. 1971; 34:582–594. PMID: 5554367.

12. Horridge M, Jesurasa A, Olubajo F, Mirza S, Sinha S. The use of the nasoseptal flap to reduce the rate of post-operative cerebrospinal fluid leaks following endoscopic trans-sphenoidal surgery for pituitary disease. Br J Neurosurg. 2013; 27:739–741. PMID: 23692070.

13. Jankowski R, Auque J, Simon C, Marchal JC, Hepner H, Wayoff M. Endoscopic pituitary tumor surgery. Laryngoscope. 1992; 102:198–202. PMID: 1738293.

14. Kabuto M, Kubota T, Kobayashi H, Takeuchi H, Nakagawa T, Kitai R, et al. Long-term evaluation of reconstruction of the sellar floor with a silicone plate in transsphenoidal surgery. J Neurosurg. 1998; 88:949–953. PMID: 9609286.

15. Kaptain GJ, Kanter AS, Hamilton DK, Laws ER. Management and implications of intraoperative cerebrospinal fluid leak in transnasoseptal transsphenoidal microsurgery. Neurosurgery. 2011; 68(1 Suppl Operative):144–150. discussion 150-151PMID: 21206313.

16. Kaptain GJ, Vincent DA, Laws ER Jr. Cranial base reconstruction after transsphenoidal surgery with bioabsorbable implants. Neurosurgery. 2001; 48:232–233. discussion 233-234PMID: 11152355.

17. Kassam AB, Thomas A, Carrau RL, Snyderman CH, Vescan A, Prevedello D, et al. Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery. 2008; 63(1 Suppl 1):ONS44–ONS52. discussion ONS52-ONS53PMID: 18728603.

18. Kelly DF, Oskouian RJ, Fineman I. Collagen sponge repair of small cerebrospinal fluid leaks obviates tissue grafts and cerebrospinal fluid diversion after pituitary surgery. Neurosurgery. 2001; 49:885–889. discussion 889-890PMID: 11564250.

19. Kim BY, Shin JH, Kang SG, Kim SW, Hong YK, Jeun SS, et al. Bilateral modified nasoseptal "rescue" flaps in the endoscopic endonasal transsphenoidal approach. Laryngoscope. 2013; 123:2605–2609. PMID: 23553463.

20. Kim BY, Son HL, Kang SG, Kim SW, Hong YK, Jeun SS, et al. Postoperative nasal symptoms associated with an endoscopic endonasal transsphenoidal approach. Eur Arch Otorhinolaryngol. 2013; 270:1355–1359. PMID: 23081674.

21. Kitano M, Taneda M. Extended transsphenoidal approach with submucosal posterior ethmoidectomy for parasellar tumors. Technical note. J Neurosurg. 2001; 94:999–1004. PMID: 11409533.

22. Kobayashi S, Hara H, Okudera H, Takemae T, Sugita K. Usefulness of ceramic implants in neurosurgery. Neurosurgery. 1987; 21:751–755. PMID: 3696417.

23. Kumar A, Maartens NF, Kaye AH. Reconstruction of the sellar floor using Bioglue following transsphenoidal procedures. J Clin Neurosci. 2003; 10:92–95. PMID: 12464532.

24. Liu JK, Schmidt RF, Choudhry OJ, Shukla PA, Eloy JA. Surgical nuances for nasoseptal flap reconstruction of cranial base defects with high-flow cerebrospinal fluid leaks after endoscopic skull base surgery. Neurosurg Focus. 2012; 32:E7. PMID: 22655696.

25. Matsumoto K, Kohmura E, Tsuruzono K, Mori K, Kawano K, Tsujimura T. Silicone plate-induced granuloma presenting pituitary apoplexy-like symptoms: case report. Surg Neurol. 1995; 43:166–169. PMID: 7892663.

26. McCoul ED, Anand VK, Singh A, Nyquist GG, Schaberg MR, Schwartz TH. Long-term effectiveness of a reconstructive protocol using the nasoseptal flap after endoscopic skull base surgery. World Neurosurg. 2014; 81:136–143. PMID: 23022644.

27. Mehta GU, Oldfield EH. Prevention of intraoperative cerebrospinal fluid leaks by lumbar cerebrospinal fluid drainage during surgery for pituitary macroadenomas. J Neurosurg. 2012; 116:1299–1303. PMID: 22482793.

28. Mortini P, Losa M, Barzaghi R, Boari N, Giovanelli M. Results of transsphenoidal surgery in a large series of patients with pituitary adenoma. Neurosurgery. 2005; 56:1222–1233. discussion 1233PMID: 15918938.

29. Nyquist GG, Anand VK, Singh A, Schwartz TH. Janus flap : bilateral nasoseptal flaps for anterior skull base reconstruction. Otolaryngol Head Neck Surg. 2010; 142:327–331. PMID: 20172375.

30. Patel MR, Taylor RJ, Hackman TG, Germanwala AV, Sasaki-Adams D, Ewend MG, et al. Beyond the nasoseptal flap : outcomes and pearls with secondary flaps in endoscopic endonasal skull base reconstruction. Laryngoscope. 2014; 124:846–852. PMID: 23877996.

31. Rawal RB, Kimple AJ, Dugar DR, Zanation AM. Minimizing morbidity in endoscopic pituitary surgery : outcomes of the novel nasoseptal rescue flap technique. Otolaryngol Head Neck Surg. 2012; 147:434–437. PMID: 22492297.

32. Rivera-Serrano CM, Snyderman CH, Gardner P, Prevedello D, Wheless S, Kassam AB, et al. Nasoseptal "rescue" flap : a novel modification of the nasoseptal flap technique for pituitary surgery. Laryngoscope. 2011; 121:990–993. PMID: 21520113.

33. Seda L, Camara RB, Cukiert A, Burattini JA, Mariani PP. Sellar floor reconstruction after transsphenoidal surgery using fibrin glue without grafting or implants : technical note. Surg Neurol. 2006; 66:46–49. discussion 49PMID: 16793438.

34. Seiler RW, Mariani L. Sellar reconstruction with resorbable vicryl patches, gelatin foam, and fibrin glue in transsphenoidal surgery : a 10-year experience with 376 patients. J Neurosurg. 2000; 93:762–765. PMID: 11059655.

35. Shin JH, Kang SG, Kim SW, Hong YK, Jeun SS, Kim EH, et al. Bilateral nasoseptal flaps for endoscopic endonasal transsphenoidal approach. J Craniofac Surg. 2013; 24:1569–1572. PMID: 24036728.

36. Tomio R, Toda M, Tomita T, Yazawa M, Kono M, Ogawa K, et al. Primary dural closure and anterior cranial base reconstruction using pericranial and nasoseptal multi-layered flaps in endoscopic-assisted skull base surgery. Acta Neurochir. 2014; 156(Wien):1911–1915. PMID: 24996809.

37. Yano S, Tsuiki H, Kudo M, Kai Y, Morioka M, Takeshima H, et al. Sellar repair with resorbable polyglactin acid sheet and fibrin glue in endoscopic endonasal transsphenoidal surgery. Surg Neurol. 2007; 67:59–64. discussion 64PMID: 17210302.