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Godse NR, Sreenath SB, Sbeih F, Woodard TD, Kshettry VR, Recinos PF, Sindwani R. Fascia Lata: Another Workhorse for Complex Skull Base Reconstruction. Am J Rhinol Allergy 2023:19458924231170955. [PMID: 37081750 DOI: 10.1177/19458924231170955] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
BACKGROUND Multiple methods exist for skull base reconstruction of defects created by expanded endonasal approaches. While the nasoseptal flap (NSF) has been well established as the workhorse of mucosal reconstruction in complex skull base defects in multi-layered closures, a variety of options exist for the inner layer of multilayer reconstruction, including fascia lata (FL). OBJECTIVE To present our experience and outcomes in utilizing FL in multiple ways to reconstruct a wide variety of complex skull base defects. METHODS Retrospective review was performed from May 2017 to February 2022 to identify 50 consecutive patients who underwent endoscopic skull base reconstruction using FL. RESULTS FL was employed for reconstruction in 50 patients included in the study: 37 undergoing primary expanded endonasal skull base surgery and 13 revision cases. A wide range of complex pathology was treated, with meningioma and craniopharyngioma being the two most common. FL was utilized as a "button" graft (34/50, 68.0%), free graft inlay/onlay (13/50, 26.0%), and as a button graft combined with onlay (3/50, 6.0%). Expanded surgery defects addressed included tuberculum sella/sphenoid planum (36/50, 72.0%), clivus (6/50, 12.0%), and cribriform/planum (8/50, 16.0%). Successful reconstruction with fascia lata was accomplished in 46/50 cases (92%), with only 4 cases (8%) requiring revision for post-op CSF leak. Donor-site complications were rare with only 1 case (2.0%) of post-op seroma. CONCLUSION FL, usually with NSF, offers a versatile option for the reconstruction of challenging defects with excellent outcomes and minimal morbidity. FL is emerging as a workhorse for reconstruction of the inner layer of complex skull base defects.
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Affiliation(s)
- Neal R Godse
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Satyan B Sreenath
- Department of Otolaryngology-Head and Neck Surgery, Indiana University, Indianapolis, IN, USA
| | - Firas Sbeih
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Troy D Woodard
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Minimally Invasive Cranial Base and Pituitary Surgery Section, Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| | - Varun R Kshettry
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Minimally Invasive Cranial Base and Pituitary Surgery Section, Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| | - Pablo F Recinos
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Minimally Invasive Cranial Base and Pituitary Surgery Section, Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| | - Raj Sindwani
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Minimally Invasive Cranial Base and Pituitary Surgery Section, Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
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Pool C, Abiri A, Kuan EC. Skull Base Reconstruction following Surgical Treatment of Sinonasal Malignancies. J Neurol Surg Rep 2023; 84:e17-e20. [PMID: 36741228 PMCID: PMC9894721 DOI: 10.1055/a-2009-8865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 01/03/2023] [Indexed: 01/12/2023] Open
Abstract
Skull base defects following resection of anterior cranial fossa and sinonasal tumors are not uncommon. Advances in endoscopic techniques have allowed for entirely endonasal resection and reconstruction of these tumors. This article discusses techniques in the evaluation and management of anterior skull base defects.
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Affiliation(s)
- Christopher Pool
- Departments of Otolaryngology – Head and Neck Surgery, Kaiser Permanente Orange County, Anaheim, California, United States
| | - Arash Abiri
- Departments of Otolaryngology – Head and Neck Surgery and Neurological Surgery, University of California, Irvine, Orange, California, United States
| | - Edward C. Kuan
- Departments of Otolaryngology – Head and Neck Surgery and Neurological Surgery, University of California, Irvine, Orange, California, United States,Address for correspondence Edward C. Kuan, MD, MBA Department of Otolaryngology – Head and Neck Surgery, University of California – Irvine101 The City Drive South, Orange, CA 92868United States
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Golbin DA, Vecherin AV, Cherekaev VA, Lasunin NV, Tsukanova TV, Mindlin SN, Shifrin MA. Predictive model for preoperative risk calculation of cerebrospinal fluid leak after resection of midline craniofacial mass lesions. World Neurosurg X 2023; 18:100163. [PMID: 36818738 PMCID: PMC9932183 DOI: 10.1016/j.wnsx.2023.100163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 01/26/2023] Open
Abstract
Background Complex anterior skull base defects produced by resection of mass lesions vary in size and configuration and may be extensive. We analyzed the largest single-center series of midline craniofacial lesions extending intra- and extracranially. The study aims at the development of a predictive model for preoperative measurement of the risk of the postoperative cerebrospinal fluid (CSF) leak based on patients' characteristics and surgical plans. Methods 166 male and 149 female patients with mean age 40,5 years (1 year and - 81 years) operated for benign and tumor-like midline craniofacial mass lesions were retrospectively analyzed using logistic regression method (Ridge regression algorithm was selected). The overall CSF leak rate was 9.6%. The ROSE algorithm and 'glmnet' software suite in R were used to overcome the cohort's disbalance and avoid overtraining the model. Results The most influential modifiable negative predictor of the postoperative CSF leak was the use of extracranial and combined approaches. Use of transbasal approaches, gross total resection, utilization of one or two vascularized flaps for skull base reconstruction were the foremost modifiable predictors of a good outcome. Criterium of elevated risk was established at 50% with a specificity of the model as high as 0.83. Conclusions The performed study has allowed for identifying the most significant predictors of postoperative CSF leak and developing an effective formula to estimate the risk of this complication using data known for each patient. We believe that the suggested web-based online calculator can be helpful for decision making support in off-pattern clinical situations.
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Affiliation(s)
- Denis A. Golbin
- Department of Craniofacial and Skull Base Surgery, N.N. Burdenko National Medical Research Center for Neurosurgery, Moscow, Russia
- Corresponding author. Department of Craniofacial and Skull Base Surgery, N.N. Burdenko National Medical Research Center for Neurosurgery, 4th Tverskaya-Yamskaya, 16 125047 Moscow, Russia.
| | - Alexander V. Vecherin
- Department of Psychology, Faculty of Social Sciences, National Research University Higher School of Economics, Moscow, Russia
| | - Vasily A. Cherekaev
- Department of Craniofacial and Skull Base Surgery, N.N. Burdenko National Medical Research Center for Neurosurgery, Moscow, Russia
| | - Nikolay V. Lasunin
- Department of Craniofacial and Skull Base Surgery, N.N. Burdenko National Medical Research Center for Neurosurgery, Moscow, Russia
| | - Tatyana V. Tsukanova
- Laboratory of Information Technologies and Artificial Intelligence, N.N. Burdenko National Medical Research Center for Neurosurgery, Moscow, Russia
| | - Sergey N. Mindlin
- Laboratory of Neuroanatomy and Cryopreservation, N.N. Burdenko National Medical Research Center for Neurosurgery, Moscow, Russia
| | - Michael A. Shifrin
- Laboratory of Information Technologies and Artificial Intelligence, N.N. Burdenko National Medical Research Center for Neurosurgery, Moscow, Russia
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Kim BK, Kong DS, Nam DH, Hong SD. Comparison of Graft Materials in Multilayer Reconstruction with Nasoseptal Flap for High-Flow CSF Leak during Endoscopic Skull Base Surgery. J Clin Med 2022; 11:jcm11226711. [PMID: 36431187 PMCID: PMC9697000 DOI: 10.3390/jcm11226711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/10/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Cerebrospinal fluid (CSF) leak is a crucial complication after endoscopic skull base surgery. Therefore, multilayer reconstruction with grafts is as essential as a reconstruction with pedicled flaps. Although widely used, the multilayer technique with autologous fascia lata has drawbacks, such as additional wound and donor site complications. We compared acellular dermal graft and banked homologous fascia lata graft (alternative grafts) with autologous fascia lata graft for high-flow CSF leak repair. We retrospectively enrolled 193 subjects who underwent endoscopic skull base reconstruction with multilayer fascial grafts and nasoseptal flap for high-flow CSF leaks from November 2014 to February 2020 at a single institution. Acellular dermal matrix (ADM), banked homologous fascia lata, and autologous fascia lata were used in 48 (24.9%), 102 (52.8%), and 43 (22.3%) patients, respectively. Postoperative CSF leaks occurred in 23 (11.9%) patients and meningitis in 8 (4.1%). There was no significant difference in postoperative CSF leak (p = 0.36) and meningitis (p = 0.17) across the graft groups. Additionally, we could not find out contributing risk factors for postoperative CSF leak and meningitis. ADM and banked homologous fascia lata are non-inferior to autologous fascia lata for endoscopic skull base reconstruction in water-tight reconstruction or safety without additional donor site morbidities.
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Affiliation(s)
- Byung Kil Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu 41404, Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Do-Hyun Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Sang Duk Hong
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
- Correspondence:
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Omura K, Nomura K, Mori R, Ishii Y, Aoki S, Takeda T, Tochigi K, Tanaka Y, Otori N, Kojima H. Optimal Multiple-Layered Anterior Skull Base Reconstruction Using a 360° Suturing Technique. Oper Neurosurg (Hagerstown) 2022; 22:e1-e6. [PMID: 34982903 DOI: 10.1227/ons.0000000000000013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 08/24/2021] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Kazuhiro Omura
- Department of Otolaryngology, The Jikei University School of Medicine, Tokyo, Japan.,Department of Otolaryngology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Kazuhiro Nomura
- Department of Otolaryngology, Tohoku Kosai Hospital, Sendai, Japan
| | - Ryosuke Mori
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yudo Ishii
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Satoshi Aoki
- Department of Otolaryngology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Teppei Takeda
- Department of Otolaryngology, The Jikei University School of Medicine, Tokyo, Japan
| | - Kosuke Tochigi
- Department of Otolaryngology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Yasuhiro Tanaka
- Department of Otolaryngology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Nobuyoshi Otori
- Department of Otolaryngology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiromi Kojima
- Department of Otolaryngology, The Jikei University School of Medicine, Tokyo, Japan
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Shaikh N, O'Brien D, Makary C, Turner M. Intraoperative Indocyanine Green Angiography for Assessing Flap Perfusion in Skull Base Reconstruction: A Systematic Review. J Neurol Surg B Skull Base 2021; 83:e492-e500. [PMID: 35832991 DOI: 10.1055/s-0041-1732309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/06/2021] [Indexed: 10/20/2022] Open
Abstract
Abstract
Objective This study was aimed to study the current use of intraoperative indocyanine green (ICG) angiography during skull base reconstruction and understand its efficacy in predicting postoperative magnetic resonance imaging (MRI) enhancement and flap.
Study Design The Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and Google Scholar databases were searched from the date of inception until August 2020 for studies of ICG flap perfusion assessment during skull base reconstruction. The primary outcome of interest was the development of cerebrospinal fluid (CSF) leak after skull base reconstruction. Secondary outcomes of interest included postoperative meningitis, flap MRI enhancement, flap necrosis, flap perfusion measurements, and total complications.
Results Search results yielded 189 studies, from which seven studies with a total of 104 patients were included in the final analysis. There were 44 nasoseptal flaps (NSF), two lateral nasal wall flaps (LNWF), 14 pericranial flaps (PCF), and 44 microvascular free flaps. The rates of CSF leak and postoperative MRI enhancement were 11 and 94%, respectively. There was one case of postoperative meningitis. Pooled analysis of the available data showed that intraoperative ICG flap perfusion was associated with flap enhancement on postoperative MRI (p = 0.008) and CSF leak (p = 0.315) by Fisher's exact test.
Conclusion The available literature suggests intraoperative ICG enhancement is associated with postoperative MRI enhancement. Given the small sample sizes in the literature and the rarity of complications associated with skull base reconstruction, intraoperative ICG enhancement has not been predictive of flap necrosis or postoperative complications such as CSF leak or meningitis.
Level of Evidence This study presents level 3 evidence as a systematic review of case studies, case reports, and retrospective and prospective trials with no blinding, controls, and inconsistently applied reference standards.
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Affiliation(s)
- Noah Shaikh
- Department of Otolaryngology, West Virginia University, Morgantown, West Virginia, United States
| | - Daniel O'Brien
- Division of Otolaryngology, University of Alberta, Edmonton, Alberta, Canada
| | - Chadi Makary
- Department of Otolaryngology, West Virginia University, Morgantown, West Virginia, United States
| | - Meghan Turner
- Department of Otolaryngology, West Virginia University, Morgantown, West Virginia, United States
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Xu JC, Lehrich BM, Yasaka TM, Fong BM, Hsu FPK, Kuan EC. Characteristics and overall survival in pediatric versus adult skull base chordoma: a population-based study. Childs Nerv Syst 2021; 37:1901-1908. [PMID: 33459820 DOI: 10.1007/s00381-021-05046-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 01/14/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Less than 5% of chordomas occur in pediatric patients. While many studies have explored the treatment and outcomes of skull base chordomas, few have focused on the differences between pediatric and adult populations. The aim of this study is to analyze the epidemiological variables and clinical outcomes between pediatric and adult skull base chordomas using a large-sample, population-based cancer database. METHODS The National Cancer Database was queried between 2004 and 2015 for skull base chordomas. We stratified patients as pediatric (<18 years) and adults (≥18 years). We compared several clinical covariates between the two groups. RESULTS Our cohort consisted of 658 patients, 61 pediatric (9.3%), and 597 adults (90.7%). Pediatric patients were more likely to have larger tumor size (41.4 ± 15.7 mm versus 34.1 ± 15.8 mm, p < 0.01) and universally treated at academic facilities. There was no significant difference in overall survival. CONCLUSIONS Pediatric skull base chordomas are rare tumors that are managed with aggressive surgical resection, followed by radiation. While there may be difference between tumor presentation, outcomes between pediatric and adult patients are similar.
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Affiliation(s)
- Jordan C Xu
- Department of Neurosurgery, University of California, Irvine, CA, USA
| | - Brandon M Lehrich
- Medical Scientist Training Program, University of Pittsburgh and Carnegie Mellon University, Pittsburgh, PA, USA
| | - Tyler M Yasaka
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Brendan M Fong
- Department of Neurosurgery, University of California, Irvine, CA, USA
| | - Frank P K Hsu
- Department of Neurosurgery, University of California, Irvine, CA, USA
| | - Edward C Kuan
- Department of Neurosurgery, University of California, Irvine, CA, USA. .,Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA.
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