Fascia patchwork closure for endoscopic endonasal skull base surgery

Extended Endoscopic Endonasal Transplanum and Transdorsum Sellar Approach for the Resection of Retroinfundibular Craniopharyngioma With Two-Piece Dural Opening: A Technical Case Report

The surgical treatment of retroinfundibular craniopharyngiomas is challenging due to their location and the surrounding neurovascular structures. In this report, the transdorsum sellar approach with posterior clinoidectomy, the efficacy of direct cyst puncture, and the suitability of a two-piece dural opening are presented. A 56-year-old male with visual and cognitive disturbances was referred to our hospital. Preoperative CT and MRI demonstrated a mostly cystic lesion with calcifications in the suprasellar and retroinfundibular areas. The imaging findings were suspected craniopharyngioma, and an extended endoscopic endonasal transdorsum sellar approach with posterior clinoidectomy was performed for direct access to the lesion. Two pieces of the dura were opened to prevent postoperative CSF leakage. The patient's postoperative course was uneventful. The endoscopic transdorsum sellar approach gives direct access to the posterior cranial fossa. A direct puncture of the cyst without CSF drainage is helpful for large cystic lesions. A two-piece dural opening is easy to suture and can reduce the chance of postoperative CSF leakage.

Creation of low cost, simple, and easy-to-use training kit for the dura mater suturing in endoscopic transnasal pituitary/skull base surgery

Training kits for laparoscopes for deep suturing under endoscopes are commercially available; however, previously reported training kits for endoscopic transnasal transsphenoidal pituitary/skull base surgery (eTSS) were not available in the market. Moreover, the previously reported low cost, self-made kit has the drawback of being unrealistic. This study aimed to create a low cost training kit for eTSS dura mater suturing that was as close to real as possible. Most necessary items were obtained from the 100-yen store ($1 store) or from everyday supplies. As an alternative to the endoscope, a stick-type camera was used. Through the assembly of the materials, a simple and easy-to-use training kit was created, which is almost identical to the actual dural suturing situation. In eTSS, a simple and easy-to-use training kit for dural suturing was successfully created at a low cost. This kit is expected to be used for deep suture operations and the development of surgical instruments for training.

Continuous Dural Suturing for the Closure of Grade 1 to 2 Cerebrospinal Fluid Leakage After Pituitary Adenoma Removal Using an Endoscopic Endonasal Approach

In this study, we aim at evaluating continuous dural suturing in patients with grade 1 to 2 cerebrospinal fluid (CSF) leakage after pituitary adenoma removal using an endoscopic endonasal approach. The study population comprised 381 pituitary adenoma patients who underwent endoscopic endonasal removal of the tumor. The degree of intraoperative CSF leakage was graded based on Esposito method. Cranial base repair using continuous dural suturing was performed according to the grade of CSF leakage. Intraoperative grade 1 to 2 CSF leakage was identified in 143 patients (37.5%). Continuous dural suturing to repair the cranial base was accepted by 61 patients and refused by 82 patients. Among patients who accepted dural suturing, the incidence of postoperative CSF leakage was reduced and the length of hospital stay was shortened. Patients with low-flow leakage were treated using a reduced vascularized pedicled nasoseptal flap. In conclusion, our graded cranial base repair method using the dural suturing technique is simple and effective.

Optimal Multiple-Layered Anterior Skull Base Reconstruction Using a 360° Suturing Technique

BACKGROUND

Advances in technique and instrumentation have improved outcomes after resection of anterior skull base tumors. However, cerebrospinal fluid (CSF) leak occurs in 4%-20% of patients. To reduce the risk of CSF leak, we have developed a novel reconstruction technique that consists of a 4-layered graft with patchwork suturing and hard material.

OBJECTIVE

To evaluate the effectiveness of this reconstruction technique when used for resection of anterior skull base tumors.

METHODS

This case series included 59 patients with anterior skull base tumors in whom the 4-layered closure technique was used. The main outcome measures were complications, including CSF leak, meningitis, postoperative bleeding, and infection.

RESULTS

There were no CSF leak cases or serious complications after closure of the anterior skull base using the 4-layered technique.

CONCLUSION

Closure of the anterior skull base in 4 layers prevented CSF leak and was not associated with any serious complications. However, further studies in larger numbers of patients are needed to confirm our outcomes using this closure method.

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

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.

Heterogeneity in Outcome Reporting in Endoscopic Endonasal Skull Base Reconstruction: A Systematic Review

Objective  Presently, there are no standards for reporting outcomes of endoscopic endonasal skull base reconstruction (ESBR). This is problematic as a lack of consistent reporting makes synthesizing findings in systematic reviews and meta-analysis challenging. Thus, the aim of this study was to systematically review and describe the patterns of reporting outcomes in ESBR as a foundation for developing reporting guidelines. Study Design  Present study is a systematic review. Methods  Embase, PubMed, CINAHL, Cochrane Library, and Web of Science were searched for all publications with ≥25 patients and a focus on ESBR. The reporting patterns of each study's variables and outcomes were assessed. Results  A total of 112 studies were included in the review. The most commonly reported demographic variables were the number of included patients ( n  = 112, 100%) and types of pathologies treated ( n  = 104, 92.9%). Meanwhile, the most routinely described preoperative variable was history of prior treatment ( n  = 48, 42.9%). Type of reconstruction was a commonly reported intraoperative variable ( n  = 110, 98.2%), though the rate of intraoperative cerebrospinal fluid (CSF) leak was noted in only 76 studies (67.9%). With regard to postoperative outcomes, postoperative CSF leak rate was routinely provided ( n  = 101, 90.2%), but reporting of other surgical complications was more inconsistent. Ultimately, of the 43 variables and outcomes reviewed, a median of 12 (range: 4-22) was reported in each study. Conclusion  There is significant heterogeneity in the outcomes reported in studies relating to ESBR. This highlights the need for the development of standard reporting guidelines to minimize bias and improve interstudy comparability.

Single-Layer Fascia Patchwork Closure for the Extended Endoscopic Transsphenoidal Transtuberculum Transplanum Approach: Deep Suturing Technique and Preliminary Results

OBJECTIVE

To describe a single-layer fascia patchwork closure (FPWC) without nasoseptal flap (NSF) and compare postoperative cerebrospinal fluid (CSF) leakage between FPWC using NSF and single-layer FPWC without NSF for the extended endoscopic transsphenoidal transtuberculum transplanum approach.

METHODS

Forty-five cases of suprasellar tumor in 42 patients were treated with extended endoscopic transsphenoidal removal, resulting in extensive, high-flow CSF leakage. Following the intradural procedure for treatment of various suprasellar tumors, fascia lata was inlaid subdurally on the cranial base defect and patch-sutured around its entire circumference under endoscope visualization, using an average of 17 stitches. Septal bone or hydroxyapatite plate was used for the hard support material against pulsatile intracranial pressure. NSF was added in the earlier 17 cases. Closure was completed without NSF in the more recent 28 cases when the Valsalva maneuver confirmed watertight closure. Two recent cases required NSF after Valsalva maneuver and were included in the FPWC + NSF group.

RESULTS

Postoperative CSF leakage did not occur in the FPWC + NSF group but occurred in 2 patients in the single-layer FPWC group (7.1%) (P = 0.52). There was no significant difference in CSF leakage between single-layer FPWC and FPWC + NSF. The mean suturing time for FPWC was 85.8 minutes, and the shortest was 39 minutes in a recent case (mean, 17 stitches; n = 35, video analysis).

CONCLUSIONS

Single-layer FPWC may be a viable technical option for effective skull base reconstruction after the extended endoscopic transsphenoidal transtuberculum transplanum approach.

Cerebrospinal Fluid Leak after Transsphenoidal Surgery: A Systematic Review and Meta-analysis

Background Cerebrospinal fluid (CSF) leak is widely recognized as a challenging and commonly occurring postoperative complication of transsphenoidal surgery (TSS).

The primary objective of this study is to benchmark the current prevalence of CSF leak after TSS in the adult population.

Methods The authors followed the PRISMA guidelines. The PubMed, Embase, and Cochrane Library databases were searched for articles reporting CSF leak after TSS in the adult population. Meta-analysis was performed using the Untransformed Proportion metric in OpenMetaAnalyst. For two between-group comparisons a generalized linear mixed model was applied.

Results We identified 2,408 articles through the database search, of which 70, published since 2015, were included in this systematic review. These studies yielded 24,979 patients who underwent a total of 25,034 transsphenoidal surgeries. The overall prevalence of postoperative CSF leak was 3.4% (95% confidence interval or CI 2.8–4.0%). The prevalence of CSF leak found in patients undergoing pituitary adenoma resection was 3.2% (95% CI 2.5–4.2%), whereas patients who underwent TSS for another indication had a CSF leak prevalence rate of 7.1% (95% CI 3.0–15.7%) (odds ratio [OR] 2.3, 95% CI 0.9–5.7). Patients with cavernous sinus invasion (OR 3.0, 95% CI 1.1–8.7) and intraoperative CSF leak (OR 5.9, 95% CI 3.8–9.0) have increased risk of postoperative CSF leak. Previous TSS and microscopic surgery are not significantly associated with postoperative CSF leak.

Conclusion The overall recent prevalence of CSF leak after TSS in adults is 3.4%. Intraoperative CSF leak and cavernous sinus invasion appear to be significant risk factors for postoperative CSF leak.

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.

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

BACKGROUND

With technical improvement, accumulating lesions could be resected using endoscopic endonasal surgery. However, cerebrospinal fluid leakage is still a concern. Intraoperative dural defect reconstruction is critical.

METHOD

We developed a new knotting technique for dural closure during endoscopic skull base surgery. We presented a step-by-step description of the fascia lata inlay and autologous dural patch intermittent suturing method following cross-reinforcing principles and emphasized the key points of the novel intranasal knotting technique.

CONCLUSION

The new intranasal knotting and suturing technique is a feasible method to close the dura and to prevent cerebrospinal fluid leakage.

Pituitary surgery's epidemiology using a national inpatient database in Japan

BACKGROUND

Between 2010 and 2014, microscopic transsphenoidal surgery (mTSS) was performed more frequently than endoscopic TSS (eTSS) in the USA. However, few epidemiological studies on pituitary surgery are currently available.

METHODS

We performed a retrospective study on patients who had undergone pituitary surgery between July 2010 and March 2016. To this end, a nationwide inpatient database in Japan was used. Patients' characteristics, diagnoses, types of surgery, complications, and discharge status were examined.

RESULTS

A total of 16,253 inpatients who received pituitary surgery were identified. Patients were diagnosed with diseases for insurance claims described below: pituitary adenoma, hyperprolactinemia, other pituitary disorders (e.g., Rathke's cleft cyst), hyperpituitarism, craniopharyngioma, acromegaly, Cushing's disease, and pituitary cancer. Among them, pituitary adenomas, primarily the non-functioning ones, were the most frequent (66.9%). A total of 14,285 (88%) patients underwent TSS, while 1968 (12%) patients were treated using transcranial surgery. The number of patients undergoing TSS increased each year. The number of eTSS operations was 8140 (77%) and that of mTSS operations was 2419 (23%). Of note, eTSS increased each year. We found that high-volume hospitals more frequently selected eTSS. Compared with mTSS, eTSS was associated with a reduction of hyponatremia incidence (odds ratio, 0.69; p = 0.019). Additionally, it was not associated with other major complications.

CONCLUSION

The present study showed that both TSS and eTSS increased on a yearly basis. We believe that the present study will be the basis of future epidemiological investigations of pituitary surgery.

Pitfalls of skull base reconstruction in endoscopic endonasal approach

Various skull base reconstruction techniques have been developed in endoscopic endonasal approach (EEA) for skull base lesions to prevent postoperative cerebrospinal fluid (CSF) leakage. This study was performed to evaluate the efficacy and pitfalls of our method of skull base reconstruction after EEA. A total of 123 patients who underwent EEA (127 surgeries) between October 2014 and May 2017 were reviewed. Our algorithm for skull base reconstruction in EEA was categorized based on intraoperative CSF leakage graded as follows: grade 0 was excluded from this study; grade 1, dural suturing with abdominal fat graft or packing of gelatin sponge into the cavity; grade 2, method for grade 1 with addition of mucosal flap or nasoseptal flap (NSF); and grade 3, duraplasty in fascia patchwork closure with NSF. Bony reconstruction was not mandatory, and there was no postoperative bed rest or initial lumbar drainage (LD) insertion in any of the cases. Postoperative CSF leakage after EEA was mostly prevented (96.3%) by our algorithm without postoperative initial LD or bed rest. On the other hand, reconstruction surgery was required for postoperative CSF leakage in two cases-one with prior multitranssphenoidal surgery and radiotherapy and another patient with poor compliance due to communication difficulties. Both of the latter patients were obese. Greater care with regard to postoperative CSF leakage is required in patients with prior EEA with radiotherapy and obesity. In such high-risk patients, initial LD or bed rest may be required to prevent postoperative CSF leakage. It is also important to restrict activities that result in increased intracranial pressure.

Reconstruction of Dural Defects in Endoscopic Transnasal Approaches for Intradural Lesions Using Multilayered Fascia with a Pressure-Control Spinal Drainage System

OBJECTIVE

Nasoseptal flap reconstruction is a widely accepted method for reducing cerebrospinal fluid (CSF) leakage after endoscopic transnasal surgeries (ETSs). However, this method is associated with nasal complications and is difficult to apply repeatedly in recurrent cases. Therefore, alternative methods are needed.

METHODS

Layers of autologous fascia lata were placed on the inside and outside of the dural defect to sufficiently cover it, and the grafts were compressed with an inflated balloon. A lumbar drainage system with a pressure-control valve was used for 72 hours postoperatively. We retrospectively analyzed data on patients with skull base lesions showing intracranial extensions that required wide opening of the ventral dura in ETS. Fifty cases (47 skull base tumors and 3 others) were included, 28 of which were recurrent cases.

RESULTS

In 21 cases (42%), the nasal septum was not intact because of the previous ETS. Seventeen patients (34%) had a history of radiotherapy and 9 (18%) had undergone multisession radiotherapies. None of the 50 patients required additional surgery for postoperative CSF rhinorrhea, and 2 had intermittent CSF leakage that resolved with prolonged lumbar drainage placement for a week. Previous multisession radiotherapy was the only significant risk factor for the need of prolonged drainage (P = 0.029).

CONCLUSIONS

The multilayer closure method with a pressure-control spinal drainage system is a simple, safe, and effective method for preventing postoperative CSF leakage, which can be readily applied to dural defects in any parts of the skull base regions and in patients with various conditions.