The History of Autologous Fat Graft Use for Prevention of Cerebrospinal Fluid Rhinorrhea After Transsphenoidal Approaches

Intradural fat graft packing is not indispensable in preventing postoperative cerebrospinal fluid leakage in endoscopic endonasal pituitary adenoma surgeries

Objectives

Is intradural fat graft packing indispensable in preventing postoperative cerebrospinal fluid leakage in endoscopic endonasal pituitary adenoma surgeries? This study aimed to review the methods and outcomes of our graded sellar floor reconstruction strategy without fat graft packing in endoscopic endonasal pituitary adenoma surgeries.

Methods

From March 2018 to December 2022, 200 patients underwent endoscopic endonasal pituitary adenoma resection by a single author in our institute. We applied different graded skull base reconstruction strategies in different periods. Intradural fat graft packing was used to reconstruct the skull base in the early period, from March 2018 to June 2019, but fat graft was not used in the late period, from January 2020 to December 2022. The effect of these different graded skull base reconstruction strategies and whether intradural fat graft packing is necessary were evaluated by observing the incidence of postoperative cerebrospinal fluid leak.

Results

In the early period, fat graft was used to reconstruct skull base when the intraoperative cerebrospinal fluid (CSF) leakage existed. There were two patients who suffered from postoperative cerebrospinal fluid leak in this group. In the late period, fat graft was not used to reconstruct the skull base, and no patient suffered from postoperative cerebrospinal fluid leakage in this group.

Conclusions

Intradural fat graft packing is unnecessary in the endoscopic endonasal pituitary adenoma resection. The outcome of our graded sellar floor reconstruction strategy is satisfactory.

Closure strategy for endoscopic pituitary surgery: Experience from 3015 patients

Introduction

Effective strategies are required to ensure optimal management of the crucial closure step in endoscopic pituitary surgery. Many surgical techniques have been reported but no significant consensus has been defined.

Methods

Between January 2006 and March 2022, 3015 adult patients with pituitary adenomas were operated on by a single expert neurosurgical team, using a mononostril endoscopic endonasal approach. Based of preoperative risk factors of and operative findings, a detailed closure strategy was used. Body mass index >40, sellar floor lysis, number of surgeries>2, large skull base destruction, prior radiotherapy were considered as preoperative risk factors for closure failure. All patients treated with an expanded endonasal approach were excluded.

Results

Patients were mostly women (F/M ratio: 1.4) with a median age of 50 (range: 18 -89). Intraoperative CSF leak requiring specific surgical management was observed in 319/3015 (10.6%) of patients. If intraoperative leak occurred, patients with predictive risk factors were managed using a Foley balloon catheter in case of sellar floor lysis or BMI>40 and a multilayer repair strategy with a vascularized nasoseptal flap in other cases. Postoperative CSF leak occurred in 29/3015 (1%) of patients, while meningitis occurred in 24/3015 (0.8%) of patients. In patients with intraoperative leak, closure management failed in 11/319 (3.4%) of cases.

Conclusion

Based on our significant 16-year experience, our surgical management is reliable and easy to follow. With a planned and stepwise strategy, the closure step can be optimized and tailored to each patient with a very low failure rate.

The Fate of Fat Graft in Extended Endoscopic Transtuberculum-Transplanum Approaches

OBJECTIVE

To analyze the long-term fate of autologous fat graft in skull base reconstruction after an extended endoscopic transtuberculum-transplanum approach.

METHODS

Data from 98 consecutive patients undergoing a transtuberculum-transplanum approach and skull base reconstruction using the 3F technique between June 2017 and January 2022 were retrospectively analyzed. Fat graft volume was measured on postoperative day 1 computed tomography scan and early (≤15 days), 3-month, and 1-year magnetic resonance imaging scans. Fat graft volumes and resorption rate were calculated in patients with a complete radiological follow-up and correlated to demographic, pathological, and surgical features.

RESULTS

Fat volumes and resorption rate were calculated in 55 patients. Mean volume of fat on postoperative day 1 computed tomography scan was 3.58 ± 1.89 cm3 and on early, 3-month, and 1-year postoperative magnetic resonance imaging scans was 2.45 ± 1.57 cm3, 1.40 ± 0.76 cm3, and 0.92 ± 0.56 cm3, respectively. Resorption rate was 44% after 3 months and 67% after 1 year. Resorption rate did not significantly correlate with demographic, pathological, and surgical features. Cerebrospinal fluid leak requiring redo surgery occurred in 1 patient (1/98, 1.2%). There were 6 cases of visual worsening (6/98, 6.1%); no cases correlated to fat overpacking. No delayed complications at the donor site or at the grafting site were noted.

CONCLUSIONS

Autologous fat graft in skull base reconstruction is observed to shrink significantly over time, reaching 67% in 1 year. Its use is associated with excellent outcomes, making it a favored material for skull base reconstruction.

Radiological evolution of autograft fat used for skull base reconstruction after transsphenoidal surgery for pituitary adenomas

PURPOSE

Cerebro-spinal fluid leak after transsphenoidal surgery for pituitary adenomas may be prevented by skull base reconstruction with fat autograft. However, graft changes may interfere with the interpretation of postoperative images. Our aim is to describe the radiological evolution of the fat autograft.

METHODS

A retrospective analysis was performed, including patients undergoing a transsphenoidal surgery for pituitary adenomas with a fat autograft for skull base reconstruction. Clinical and radiological data were collected, with assessment of fat autograft and extent of resection. Statistical analysis was performed using Kruskal-Wallis and Wilcoxon signed-rank test while Spearman's Rho was used to analyze the relationship between variables.

RESULTS

Seventy-two patients were included. Macroadenomas were diagnosed in 62 cases (86.1%) and in 21 cases an invasion of the cavernous sinus was described (29%). Gross total resection was achieved in 84.7% of cases. The volume of the fat graft significantly decreased between 3 months and 1 year after surgery (p = 0.01) and between 1 year and the last follow-up (mean 4.63 years, p < 0.01). Fat signal ratio significantly diminished between 3 months and 1 year in unenhanced and enhanced T1-weighted sequences (p = 0.04 and p = 0.02 respectively). Volume reduction was related to the decrease in signal ratio in unenhanced T1 sequences (p = 0.008).

CONCLUSION

Fat resorbs with time: almost 50% of the fat volume is lost during the first year after surgery and 60% is resorbed at 4.6 years. T1-signal, before and after gadolinium injection, also decreases during the first year, probably because of the progressive fibrosis of the graft. This information will contribute to the interpretation of postoperative images.

Surgical Experience in Prevention of Postoperative CSF Leaks Using Abdominal Fat Grafts in Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Adenomas

Objective  Cerebrospinal fluid (CSF) leaks are the most common complication during endonasal endoscopic transsphenoidal approach (EETSA) and prevention of postoperative CSF leaks is critical. In this study, we report a single surgeon's experience of sellar floor reconstruction using abdominal fat grafts for prevention of postoperative CSF leaks in EETSA for pituitary adenomas. Study Design  This study is presented as case series with retrospective chart review. Setting  Present study was conducted at tertiary referral center. Participants  A total of 216 patients who underwent surgery via EETSA for pituitary adenomas between 2008 and 2018 at our institution were evaluated. When an intraoperative CSF leak occurred, sellar floor reconstruction was performed using a fat graft harvested from the abdomen via a 2-cm skin incision. Main Outcome Measures  Primary outcome and measures of this study was postoperative CSF leaks. Results  A total of 53 patients showed intraoperative CSF leaks (24.5%) and 2 patients showed postoperative CSF leaks (0.93%). There were no postoperative CSF leaks in any patients who showed intraoperative CSF leaks and received sellar floor reconstruction using fat grafts. There were also no postoperative CSF leaks in 12 patients who received preventative sellar floor reconstruction using fat grafts due to extensive arachnoid herniation without intraoperative CSF leaks. However, there were two postoperative CSF leaks in patients who did not show intraoperative CSF leaks and did not receive sellar floor reconstruction. Conclusion  The effectiveness of sellar floor reconstruction using abdominal fat grafts in patients receiving EETSA for pituitary adenoma was reported. We suggest that identification of intraoperative CSF leaks is important and preventive sellar floor reconstruction without evidence of intraoperative CSF leaks can also be beneficial.

Autologous Temporalis Subfascial Fat Graft for Skull Base Repair: A Novel Technique

BACKGROUND

Autologous abdominal fat grafts are occasionally used in the repair of skull base exposures. This surgical procedure typically requires an additional surgical site and may have unexpected postoperative complications.

OBJECTIVE

To describe an operative technique for harvesting subfascial fat from the temporal extension of the buccal fat pad for the repair of skull base defects.

METHODS

We review the pertinent anatomy of the temporalis subfascial fat pad and discuss the technique used to harvest the subfascial fat component in a clinical presentation.

RESULTS

A pretemporal approach was performed for clip ligation of an anterior circulation aneurysm. A standard frontotemporal incision was made with an interfascial flap to preserve the frontalis branches of the facial nerve. The subfascial fat was inspected and determined to be adequate for harvesting. Monopolar cauterization was carefully utilized to remove the fat. During closure, the graft was used to repair a pneumatized clinoid sinus and for the dural repair of the pretemporal exposure. The patient did not have any postoperative complications.

CONCLUSION

Autologous temporalis subfascial fat graft is a viable and safe technique for skull base dural and sinus repair during frontotemporal approaches in select patients. This technique avoids an additional surgical procedure and potential complications that may be associated with it.

Abdominal Fat Graft for Sellar Reconstruction: Retrospective Outcomes Review and Technical Note

BACKGROUND

The transsphenoidal approach is the standard of care for the treatment of pituitary adenomas and is increasingly employed for many anterior skull base tumors. Persistent postoperative cerebrospinal fluid (CSF) leaks can result in significant complications.

OBJECTIVE

To analyze our series of patients undergoing abdominal fat graft repair of the sellar floor defect following transsphenoidal surgery, describe and investigate our current, routine technique, and review contemporary and past methods of skull base repair.

METHODS

A recent consecutive series (2008-2017) of 865 patients who underwent 948 endonasal procedures for lesions of the sella and anterior skull base was retrospectively reviewed. Three hundred eighty patients underwent reconstruction of the sellar defect with an abdominal fat graft.

RESULTS

The diagnoses of the 380 patients receiving fat grafts were the following: 275 pituitary adenomas (72.4%), 50 Rathke cleft cysts (13.2%), 12 craniopharyngiomas (3.2%), and a variety of other sellar lesions. Fourteen patients had persistent postoperative CSF leak requiring reoperation and included: 5 pituitary adenomas (1.3%), 4 craniopharyngiomas (1.1%), 2 arachnoid cysts (0.53%), 2 prior CSF leaks (0.53%), and 1 Rathke cleft cyst (0.26%). Four patients (1.1%) developed minor abdominal donor site complications requiring reoperation: 1 hematoma, 2 wound complications, and 1 keloid formation resulting in secondary periumbilical infection.

CONCLUSION

Minimizing postoperative CSF leaks following endonasal anterior skull base surgery is important to decrease morbidity and to avoid a prolonged hospital stay. We present an evolved technique of abdominal fat grafting that is effective and safe and includes minimal morbidity and expense.

Postoperative CSF leakages after transsphenoidal surgery for pituitary adenomas: Analysis of a series of 302 surgical procedures

INTRODUCTION

Transsphenoidal surgical removal is the preferred treatment of most pituitary adenomas. Postoperative cerebrospinal fluid (CSF) leakage is the leading cause of morbidity after this procedure, with an incidence rate that varies from 0,5-15% in the main published series.

OBJECTIVES

The primary objective of this study was to establish the incidence of postoperative CSF leakage in a sample of surgeries performed at the University Hospital of La Ribera by the same surgical team. The secondary objectives were to: ascertain the distinctive features between patients with and without postoperative CSF leakage, identify risk factors for their development, evaluate the relationship between the surgical technique for closing the sella turcica and the onset of postoperative CSF leakage and evaluate different treatment regimens for this complication.

METHODS

The data of 302 consecutive transsphenoidal surgical procedures for pituitary adenoma removal which were performed between 1999 and 2017 were retrospectively reviewed.

RESULTS AND CONCLUSIONS

The incidence of postoperative CSF leakage in our series was 2,3% (in accordance with similar published studies). It was possible to correlate intraoperative CSF leakage with two variables: pituitary macroadenoma and tumors with suprasellar extension (P<.005). This correlation did not exist for postoperative CSF leakage. We found a statistically significant correlation between intraoperative and postoperative CSF leakage (P<.005). Due to the low incidence of postoperative CSF leakage in our series, it was not possible to identify risk factors for its development.

The 3F (Fat, Flap, and Flash) Technique For Skull Base Reconstruction After Endoscopic Endonasal Suprasellar Approach

BACKGROUND

Endoscopic endonasal surgery is a rapidly evolving field that offers the possibility of treating a wide variety of skull base lesions. Reconstruction of the osteodural defect is of utmost importance, as an effective and watertight closure is mandatory. Over the years, various techniques and materials have been adopted in an effort of providing a resilient and reliable method of closure.

MATERIALS AND METHODS

We retrospectively analyzed data from a series of 25 patients who underwent skull base reconstruction according to a novel paradigm following endoscopic endonasal transtuberculum-transplanum approaches for tumor removal between June 2017 and June 2018. The 3F strategy involves autologous fat grafting, nasoseptal flap coverage, and flash mobilization out of the bed following the operation.

RESULTS

The 3F technique achieved successful watertight closure in 24 of 25 cases (96%). One case of postoperative cerebrospinal fluid rhinorrhea developed on postoperative day 10, which did not require reoperation. No perioperative complications related to the 3F strategy (e.g., overpacking, infections, or hematomas) occurred. No donor graft site infections or hematomas developed.

CONCLUSIONS

The 3F skull base reconstruction is a safe and effective method in achieving watertight closure after extended endoscopic endonasal approaches. Despite this study reporting a preliminary experience in a small series of patients, it seems that the 3F technique can be considered as a viable solution among the wide kaleidoscope of available skull base reconstruction methods.

Anterior Skull Base Reconstruction: Does Fat Preparation Matter?

Objectives  This article aims (1) to determine whether there is any difference in cerebrospinal fluid (CSF) leak rate after anterior skull base autologous fat reconstruction based on how the fat is prepared, and (2) to measure impact on surgical times by reconstruction type.

Design  Translational animal model surgical technique 3-arm trial, comparing two different methods of autologous fat skull base reconstruction versus a nonreconstructed control group.

Setting  Animal study.

Subjects  Adult Sprague-Dawley rats.

Main Outcome Measures  Resolution of CSF rhinorrhea after repair of a surgically created anterior skull base defect.

Results  Both wet (uncompressed) and dry (compressed) fat reconstruction of an anterior skull base defect demonstrated lower CSF leak rates than nonreconstructed defects. Dry fat reconstruction achieved significance in superiority of controlling CSF leak over no reconstruction (64% success vs. 31%); while wet fat reconstruction trended toward significance (50% vs. 31%). Reconstruction procedure time was longer than nonreconstructed controls, but there was no significant difference between type of fat preparation in surgical time.

Conclusions  This study demonstrates that drying and compressing the fat graft improves autologous fat reconstruction success for anterior skull base defects, and does not add significantly to surgical time over nonprepared fat.

Use of Autologous Fat Grafts for the Endoscopic Reconstruction of Skull Base Defects: Indications, Outcomes, and Complications

Background The use of abdominal free fat is a traditional surgical method for the repair and reconstruction of the anterior skull base. Our objective is to assess the outcomes associated with the autologous fat graft to endoscopically repair anterior skull base defects at a single tertiary care center. Methods All patients, who underwent endoscopic skull base repair utilizing abdominal free fat from September 2009 to June 2016, were included for retrospective chart review. Evaluated outcome measurements included (1) the successful closure of preoperative and intraoperative cerebrospinal fluid (CSF) leaks and (2) complications at both donor and recipient graft sites during the postoperative periods. Four representative clinical cases have additionally been selected to highlight the common indications for which the fat graft may be effective in skull base reconstruction. Results Of the 27 patients who were identified for inclusion in this review, 25 (92.6%) demonstrated successful repair of preoperative or intraoperative CSF leaks following primary skull base repair. Two patients developed recurrent CSF leaks occurring about 1 week after their primary closures, and a secondary closure rate of 96.3% was achieved with use of fat grafts. Other complications included seroma and hematoma formation at the abdominal donor sites, each occurring in 1 patient. Conclusions The use of autologous fat remains a viable option for grafting material during endoscopic skull base reconstruction. Despite the wide variety of closure techniques in skull base surgery, autologous fat provides safe and easily accessible material to repair CSF leaks.

Ethmoidal encephalocele associated with cerebrospinal fluid fistula: indications and results of mini-invasive transnasal approach

Anterior skull base defects with encephalocele in adults are quite rare and can be a cause of spontaneous rhinoliquorrhea; however, cerebrospinal fluid (CSF) fistula can be not rarely misdiagnosed for several months or years. Five adult patients affected by ethmoidal encephalocele with CSF fistula were treated in our institute from 2006 through to 2011. Onset of clinical history was represented by rhinoliquorrhea, which was precociously recognized in only 1 patient; in the other 4, it was misdiagnosed for a period ranging from 11 months to 5 years. After clinical diagnosis of CSF fistula and after brain magnetic resonance imaging, ethmoidal encephalocele was evident in all patients; preoperative study was completed by spiral computed tomography scan, to clearly identify the skull base bone defect. All patients were operated on by transsphenoidal endonasal endoscope-assisted microsurgical approach through 1 nostril. The herniated brain was coagulated and removed, and reconstruction of cranial base was performed. Postoperative rhinoliquorrhea or other complications did not occur in any patient at short and late follow-up. All patients were discharged after a few days. Endonasal endoscope-assisted microsurgical approach was effective in exposing and repairing the ethmoidal bone defect; tridimensional vision and wide lateral and superior exposition of the operative field were possible in each patient, thanks to the use of microscope and angulated endoscope.

Banked Fascia Lata in Sellar Dura Reconstruction after Endoscopic Transsphenoidal Skull Base Surgery

Objectives Cerebrospinal fluid (CSF) leakage is an undesirable complication of transsphenoidal skull base surgery. The issue of the most appropriate sellar dura repair remains unresolved, although a multilayer technique using autologous fascia lata is widely used. We describe the novel application of a homologous banked fascia lata graft as an alternative to an autologous one in the reconstruction of sellar dura defects in endoscopic transsphenoidal surgery. Design The clinical records of patients who underwent endoscopic transsphenoidal surgery at our department from June 2012, when we started using homologous fascia lata, up to July 2014 were reviewed retrospectively. The data concerning diagnosis, reconstruction technique, and surgical outcome were analyzed. Results We treated 16 patients successfully with banked fascia lata. Twelve patients presented intraoperative CSF leakage, and four patients were treated for postoperative rhinoliquorrhea. Banked fascia lata was used in a single-to-multilayer technique, depending on the anatomical features of the defect and of the sellar floor. No complications or failures in sella reconstruction occurred. Conclusion A banked fascia lata graft proved reliable and safe in providing an effective sellar dura reconstruction. Used in a multilayer strategy, it should be considered a viable alternative to an autologous fascia lata graft.

Neuroendoscopic endonasal management of cerebrospinal fluid rhinorrhea

Neuroendoscopic endonasal approach has gained popularity in managing traumatic, spontaneous, and especially iatrogenic cerebrospinal fluid (CSF) rhinorrhea. The authors examined 8 patients presenting with CSF rhinorrhea between December 2012 and June 2014: 5 patients had iatrogenic leak, 2 patients had traumatic leak, and 1 patient had a spontaneous onset of CSF rhinorrhea. Sites of the CSF leaks were detected through computed tomographic cisternography and magnetic resonance imaging in the patients with traumatic and spontaneous leaks. All patients received neuroendoscopic endonasal surgery for the CSF leak. The largest defect was 22 mm in maximum diameter. Endoscopic supraciliary "keyhole" approach was performed in 1 patient after confirmation of a frontal sinus leak using the endoscopic endonasal approach. The success rate was 100% in the first attempt. Follow-up period ranged from 3 to 24 months, and no recurrence was reported. Identifying the leak site and choosing the appropriate surgical technique remain the most important factor in surgical success.