Cross-reinforcing suturing and intranasal knotting for dural defect reconstruction during endoscopic endonasal skull base surgery

Endoscopic endonasal resection of symptomatic Rathke's cleft cysts: outcomes of the strategy to maintain the fenestration open

PURPOSE

The study intends to clarify the optimal endoscopic endonasal surgical strategy for symptomatic Rathke's cleft cysts (RCCs).

METHODS

We retrospectively analyzed patients with RCCs that underwent EEA surgery. The strategy for surgical and reconstruction method selection was presented. Patients were split into groups of fenestration open or closed. Pre- and postoperative symptoms, imaging, ophthalmologic, and endocrinologic exams were reviewed. The incidence of complications and the recurrence rates were determined.

RESULTS

The 75 individuals were all received primary operations. The fenestration closed group contained 32 cases, while the fenestration open group contained 43 cases. The median follow-up period was 39 months. The three primary complaints were headache (n = 51, 68.00%), vision impairment (n = 45, 60.00%), and pituitary dysfunction (n = 16, 21.33%). Of the 51 patients with preoperative headaches, 48 (94.12%) reported improvement in their symptoms following surgery. Twenty-three out of 45 patients (51.11%) experienced an improvement in visual impairment. Pituitary dysfunction was found improved in 14 out of 16 individuals (87.50%). There was no discernible difference in the rate of symptom alleviation between both groups. There were three patients (3/75, 4.00%) had cyst reaccumulation. One of them (1/75, 1.33%), which needed reoperation, was healed using pterional approach. In term of complications, cerebral infections occurred in two patients (2/75, 2.67%). Both of them recovered after antibiotic treatment. No postoperative cerebrospinal fluid rhinorrhea occurred. One patient (1/75, 1.33%) in the open group experienced epistaxis. There was no persistent hypopituitarism or diabetes insipidus (DI). Analysis of headache related factors showed that the presence of wax like nodules was related to it.

CONCLUSION

RCC was successfully treated with endoscopic endonasal surgery with few problems when the fenestration was kept as open as feasible. Preoperative identification of T2WI hypointense nodules may be a potential reference factor for surgical indication.

Application of dural suturing in the endoscopic endonasal approach to the sellar region

Objectives

The endoscopic endonasal approach (EEA) is widely used in the treatment of cranial base tumors. Skull base reconstruction is a crucial part of EEA, which has a great impact on patients’ prognosis. In this study, we report our experience with sellar dural suturing in cranial base reconstruction and retrospectively analyze its effect.

Methods

The clinical data of 134 patients who suffered intraoperative CSF leakage and underwent EEA surgery in the Department of Neurosurgery of the First Affiliated Hospital of Nanjing Medical University from October 2018 to November 2020 were retrospectively collected and analyzed. According to whether sellar dural suturing was performed during the operation, they were divided into a suture group (55 cases) and a control group (79 cases).

Results

The results showed that dural suturing of the sellar floor effectively reduced the postoperative hospitalization duration (p = 0.026) and the use rates of lumbar drainage (p = 0.047), autologous fat transplantation (p = 0.038), and pedicled nasoseptal flaps (p = 0.026).

Conclusion

Sellar dural suturing under endoscopy is a promising and effective method for cranial base reconstruction in EEA surgery and is worthy of clinical application.

Effects of cruciate embedding fascia-bone flap technique on grade II-III cerebral spinal fluid leak in endoscopic endonasal surgery

Background

Cerebral spinal fluid (CSF) leak remains an important issue in endoscopic endonasal surgery (EES). A standard protocol for skull base closure has not yet been established, and the application of rigid buttress has not been given sufficient attention. To emphasize the functions of support and fixation from rigid buttress in reconstruction, we introduced the cruciate embedding fascia-bone flap (CEFB) technique using autologous bone graft to buttress the fascia lata attachment to the partially sutured skull base dural defect and evaluated its efficacy in a consecutive case series of grade II–III CSF leaks in EES.

Methods

Data from consecutive patients diagnosed with sellar region lesions with grade II–III CSF leaks during EES were collected from May 2015 to May 2020. Skull base reconstructions were performed with the CEFB or the conventional pedicle vascularized nasoseptal flap (PNSF). Related clinical data were analysed. The combined use of the CEFB and PNSF was applied to an additional supplemental case series of patients with grade III leak and multiple high-risk factors.

Results

There were 110 and 65 patients included in the CEFB and PNSF groups, respectively. The CEFB demonstrated similar effects on the incidence of postoperative CSF leak (2.7%), intracranial infection (4.5%), and lumbar drainage (LD) placement (5.5%) as PNSF (3.1%, 3.1%, and 6.2%), but with less epistaxis (CEFB: 0%, PNSF: 6.2%) and nasal discomforts (CEFB: 0%, PNSF: 7.7%). The LD duration (CEFB: 6.67 ± 2.16 days, PNSF: 10.50 ± 2.38 days), bed-stay time (CEFB: 5.74 ± 1.58 days, PNSF: 8.83 ± 3.78 days) and hospitalization time (CEFB: 10.49 ± 5.51 days, PNSF: 13.58 ± 5.50 days) were shortened in the CEFB group. The combined use of CEFB and PNSF resulted in 0 postoperative CSF leaks in the supplemental case series of 23 highly susceptible patients.

Conclusion

This study suggested that the new CEFB technique has the potential to prevent postoperative CSF leak in EES. The results indicated that it can be used effectively without PNSF in suitable cases or applied in addition to a PNSF with high compatibility when necessary. Its effectiveness should be further verified with a larger cohort and better design in the next step.

Trial Registration Current Controlled Trials ChiCTR2100044764 (Chinese Clinical Trial Registry); date of registration: 27 March 2020. Retrospectively registered

Pretreating cavernous sinus with hemostatic agent injection molding during endoscopic endonasal pituitary surgery: technical note

OBJECTIVE

To clarify the technical pearls of cavernous sinus molding technique with hemostatic agent injection during endoscopic endonasal pituitary surgery.

METHODS

All patients pretreated with cavernous sinus hemostatic agent injection molding technique for hemostasis in endoscopic endonasal surgery for pituitary adenoma resection between November 2017 and June 2021 were included. A small incision was made in the cavernous sinus wall before intracavernous manipulation. The hemostatic agent was injected with gentle pressure. It spread along the venous channels and established partial molding of the cavernous sinus. Intraoperative bleeding, surgical field score, and complications were evaluated.

RESULTS

Thirty-eight patients with pituitary adenoma requiring cavernous sinus manipulation were pretreated with this technique. Technically, the tailored thin blunt metal tube with its 1 cm head end bended up 45° were the best instrument to accomplish injection. Multi-spot injections were preferred to control different compartments of the cavernous sinus, which both had a better effect in bleeding control and helped to reduce the influence of trigemino-cardiac reflex. Postoperative complications, including temporal lobe edema, hemorrhage, and exophthalmos were not observed.

CONCLUSION

Pretreating cavernous sinus with hemostatic agent injection molding technique during endoscopic endonasal pituitary surgery is a practical, effective and safe method for intracavernous bleeding control.

Surgical Correction of a Clivus Cerebrospinal Fluid Fistula: A Technical Report

BACKGROUND

Cerebrospinal fistulas of the clivus region often result from previous surgical intervention at the skull base. The localization and size of the fistula determine the appropriate treatment strategy. When flap closure is not possible, the microsuture technique with autograft placement provides a favorable outcome.

METHODS

We present a technical report on the application of the microsuture technique for clivus region cerebrospinal fluid fistula closure in a patient with previous chordoma treatment and nonspecific coronavirus disease 2019 complications.

RESULTS

The application of the microsuture technique resulted in stable remission of the fistula and complete regression of the clinical manifestations.

CONCLUSIONS

The microsuture technique for clivus region fistula closure is a potentially valuable alternative to vascularized flap closure.