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Erkan B, Demir S, Akpinar E, Hasimoglu O, Baskan F, Cirak M, Postalci LS, Tanriverdi O, Gunaldi O. Effectiveness of a Sellar Reconstruction Algorithm in Transsphenoidal Pituitary Surgery: Insights from 490 Cases. World Neurosurg 2024; 189:e1098-e1108. [PMID: 39032635 DOI: 10.1016/j.wneu.2024.07.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Accepted: 07/10/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Rhinorrhea is a common complication after endoscopic endonasal transsphenoidal pituitary surgery (EETPS). This study evaluates the effectiveness of our sellar reconstruction technique in preventing rhinorrhea. METHODS From June 2020 to March 2024, a surgical team performed 490 EETPS procedures on 458 pituitary adenoma patients. Demographic data, surgery status, and radiological and histopathological classifications were retrospectively analyzed. 4 grades for sellar reconstruction were defined based on intraoperative cerebrospinal fluid (CSF) leakage and diaphragm sella defect size. Grade 0: no CSF leakage; cavity filled with absorbable material. Grade 1: small defect; covered with fat and fascia lata grafts. Grade 2: large defect; added lumbar drainage. Grade 3: extended approach; added nasoseptal flap. RESULTS Of the 490 operations, 433 were primary and 57 recurrent. Patients were 50.2% male, mean age 49.01 years. Follow-up averaged 20.5 months. Postoperative rhinorrhea occurred in 8 cases (1.6%). In 404 surgeries (82.5%) without intraoperative CSF leakage, 3 cases (0.7%) developed postoperative rhinorrhea. CSF leakage was detected in 86 cases (17.5%), with postoperative rhinorrhea in 5 cases (5.8%). The risk of rhinorrhea was 8.3 times higher with intraoperative CSF leakage (P = 0.005). Rhinorrhea rates: 0.7% in Grade 0, 3% in Grade 1, 8.7% in Grade 2, and 0% in Grade 3 (P = 0.017). Meningitis occurred in 8 patients (1.7%) and pneumocephalus in 4 (0.9%), with one death (0.2%). The average hospital stay was 17.4 days with rhinorrhea and 5.2 without (P = 0.024). CONCLUSIONS Intraoperative CSF leakage is highly correlated with rhinorrhea. Multilayered and graded closure strategies significantly reduce postoperative rhinorrhea rates in EETPS.
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Affiliation(s)
- Buruc Erkan
- Department of Neurosurgery, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey.
| | - Suat Demir
- Department of Neurosurgery, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Ebubekir Akpinar
- Department of Neurosurgery, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Ozan Hasimoglu
- Department of Neurosurgery, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Fikret Baskan
- Department of Neurosurgery, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Musa Cirak
- Department of Neurosurgery, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Lutfi Sinasi Postalci
- Department of Neurosurgery, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Osman Tanriverdi
- Department of Neurosurgery, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Omur Gunaldi
- Department of Neurosurgery, Medicana Atakoy Hospital, Istanbul, Turkey
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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Nagm A, Ogiwara T, Hongo K. Watertight Robust Osteoconductive Barrier for Complex Skull Base Reconstruction: An Expanded-endoscopic Endonasal Experimental Study. Neurol Med Chir (Tokyo) 2019; 59:79-88. [PMID: 30787233 PMCID: PMC6434420 DOI: 10.2176/nmc.oa.2018-0262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Endoscopic skull base reconstruction (ESBR) following expanded-endoscopic endonasal approaches (EEA) in high-risk non-ideal endoscopic reconstructive candidates remains extremely challenging, and further innovations are still necessary. Here, the aim is to study the reconstructive knowledge gap following expanded-EEA and to introduce the watertight robust osteoconductive (WRO)-barrier as an alternative durable option. Distinctively, we focused on 10 clinical circumstances. A 3D-skull base-water system model was innovated to investigate the ESBR under realistic conditions. A large-irregular defect (31 × 89 mm) extending from the crista galli to the mid-clivus was achieved. Then, WRO-barrier was fashioned and its tolerance was evaluated under stressful settings, including an exceedingly high (55 cmH2O) pressure, with radiological assessment. Next, the whole WRO-barrier was drilled to examine its practical-safe removal (simulating redo-EEA) and the whole experiment was repeated. Finally, WRO-barrier was kept into place to value its 18-month long-term high-tolerance. Results in all experiments of WRO-barriers were satisfactorily fashioned to conform the geometry of the created defect under realistic circumstances via EEA, tolerated an exceedingly high pressure without evidence of leak even under stressful settings, resisted sudden-elevated pressure, and remained in its position to maintain long-term watertight seal (18 months), efficiently evaluated with neuroimaging and simply removed-and-reconstructed when redo-EEA is needed. In conclusion, WRO-barrier as an osteoconductive watertight robust design for cranial base reconstruction possesses several distinct qualities that might be beneficial for patients with complex skull base tumours.
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Affiliation(s)
- Alhusain Nagm
- Department of Neurosurgery, Shinshu University School of Medicine.,Department of Neurosurgery, Faculty of Medicine, Al-Azhar University
| | | | - Kazuhiro Hongo
- Department of Neurosurgery, Shinshu University School of Medicine
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Goto Y, Oshino S, Shimizu T, Saitoh Y. Application of atelocollagen sheet for sellar reconstruction. J Clin Neurosci 2016; 27:142-6. [PMID: 26778360 DOI: 10.1016/j.jocn.2015.08.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 06/18/2015] [Accepted: 08/18/2015] [Indexed: 11/29/2022]
Abstract
We aimed to evaluate combined use of atelocollagen sheet and fibrin glue for sellar reconstruction. Experiment 1: A plastic chamber was prepared with a hydroxyapatite lid with a hole of 10mm in diameter at its center, covered with a Gore-Tex sheet (W.L. Gore & Associates, Tokyo, Japan) 15mm in diameter and sealed with a combination of fibrin glue sealant and either atelocollagen sheet or polyglycolic acid (PGA) sheet. Air was injected into the chamber and the pressure at which air leakage occurred was measured under each situation. Mean (±standard deviation) leakage pressure was 816±162mmH2O for atelocollagen sheet (n=5), significantly higher than the 557±130mmH2O for PGA sheet (n=5, p<0.05, Wilcoxon test). Experiment 2: Bilateral 5mm bone windows were made in the temporal bone in eight rats. The surgical cavities were filled with one of four materials (fibrin glue only; fibrin glue and atelocollagen sheet; PGA sheet; or autologous fat tissue). Histological changes including the status of implanted materials and inflammatory responses were investigated 2 and 5weeks after the procedures. Both atelocollagen and PGA sheets remained at 5weeks after implantation, whereas fibrin glue and fat tissue were absorbed and undetectable at 2weeks. Inflammatory cell accumulation was less around the atelocollagen sheet compared to the PGA sheet. The combination of atelocollagen sheet and fibrin glue sealant showed sufficient adhesion force and favorable tissue affinity, suggesting this combination as a feasible material in sellar reconstruction.
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Affiliation(s)
- Yuko Goto
- Department of Neuromodulation and Neurosurgery, Graduate School of Medicine, Osaka University, 2-2, Yamadaoka, Suita, Osaka 565-0871, Japan; Department of Neurosurgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Satoru Oshino
- Department of Neurosurgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Takeshi Shimizu
- Department of Neurosurgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Youichi Saitoh
- Department of Neuromodulation and Neurosurgery, Graduate School of Medicine, Osaka University, 2-2, Yamadaoka, Suita, Osaka 565-0871, Japan; Department of Neurosurgery, Graduate School of Medicine, Osaka University, Osaka, Japan.
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Garcia-Navarro V, Anand VK, Schwartz TH. Gasket seal closure for extended endonasal endoscopic skull base surgery: efficacy in a large case series. World Neurosurg 2011; 80:563-8. [PMID: 22120292 DOI: 10.1016/j.wneu.2011.08.034] [Citation(s) in RCA: 161] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 08/05/2011] [Accepted: 08/30/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess long-term efficacy of the gasket seal, a method for watertight closure of the cranial base using autologous fascia lata held in place by a rigid buttress, in a large case series. METHODS A prospectively acquired database of all endonasal endoscopic surgeries performed over a 5-year period at Weill Cornell Medical College starting in September 2005 was reviewed. RESULTS The gasket seal was used in 46 consecutive patients. Mean age was 53 years (range 7-83 years). All patients had extensive intracranial disease with a significant intraoperative cerebrospinal fluid (CSF) leak. Pathology included craniopharyngioma (39.1%), meningioma (23.9%), and pituitary adenoma (17.4%). After a mean follow-up of 28 months (range 3-63 months), two (4.3%) patients had a postoperative CSF leak. Excluding the patients with adenomas, the CSF leak rate was 5.2% (2 of 38 patients). One leak was controlled with reoperation, and the other was stopped with a lumbar drain (LD). The significance of pathology, type of approach, exposure of the ventricular system, use of fat graft, use of nasoseptal (NS) flap, and use of lumbar drain (LD) was examined, and none of these were significant predictors of postoperative CSF leak. CONCLUSIONS Gasket seal closure is a reliable long-term effective method for achieving watertight closure of the cranial base. It can be used in association with an intracranial fat graft, NS flap, LD, and tissue sealants. In this series, none of these other factors were significant predictors of postoperative CSF leak.
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Affiliation(s)
- Victor Garcia-Navarro
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA
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