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Pang JC, Bitner BF, Nottoli MM, Abiri A, Bui AT, Nguyen CH, Hsu TI, Nguyen TV, Hsu FPK, Kuan EC. Tissue Sealant Impact on Skull Base Reconstruction Outcomes: A Systematic Review and Meta-Analysis. Laryngoscope 2024; 134:3425-3436. [PMID: 38470297 DOI: 10.1002/lary.31390] [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: 10/17/2023] [Revised: 01/29/2024] [Accepted: 02/22/2024] [Indexed: 03/13/2024]
Abstract
OBJECTIVE Despite significant advances in understanding of skull base reconstruction principles, the role of tissue sealants in modifying postoperative cerebrospinal fluid (CSF) leak outcomes remains controversial. We evaluate postoperative CSF leak incidence associated with tissue sealant use in skull base defect repair during endoscopic skull base surgery (ESBS). DATA SOURCES Web of Science, PubMed/MEDLINE, Scopus, and Cochrane Library. REVIEW METHODS Systematic review and meta-analysis of risk differences (RD). A search strategy identified original studies reporting CSF leakage following ESBS with disaggregation by tissue sealant use and/or type. RESULTS 27 non-randomized studies (n = 2,403) were included for qualitative and meta-analysis. Reconstruction with a tissue sealant did not significantly reduce postoperative CSF leak risk compared with reconstruction without sealant (RD[95% CI] = 0.02[-0.01, 0.05]). Sub-analyses of dural sealant (-0.02[-0.11, 0.07]) and fibrin glue (0.00[-0.07, 0.07]) compared with no sealant were similarly unremarkable. Postoperative CSF leakage was not significantly modulated in further sub-analyses of DuraSeal (0.02[-0.02, 0.05]), Adherus (-0.03[-0.08, 0.03]), or Bioglue (-0.06[-0.23, 0.12]) versus no dural sealant use, or Tisseel/Tissucol versus fibrin glue nonuse (0.00[-0.05, 0.05]). No significant association was seen comparing dural sealant use versus fibrin glue use on pairwise (0.01[-0.03, 0.05]) or network meta-analysis (-0.01[-0.05, 0.04]). Limitations in source literature prevented sub-analyses stratified by leak characteristics, defect size and location, and accompanying reconstruction materials. CONCLUSION Tissue sealant use did not appear to impact postoperative CSF leak incidence when compared with nonuse. Higher quality studies are warranted to thoroughly elucidate the clinical value of adjunct sealant use in endoscopic skull base reconstruction. LEVEL OF EVIDENCE N/A Laryngoscope, 134:3425-3436, 2024.
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Affiliation(s)
- Jonathan C Pang
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Benjamin F Bitner
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Madeline M Nottoli
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Arash Abiri
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Anh-Tram Bui
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Cecilia H Nguyen
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Timothy I Hsu
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Theodore V Nguyen
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Frank P K Hsu
- Department of Neurological Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
- Department of Neurological Surgery, University of California, Irvine, Orange, California, U.S.A
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Darwish M, Nanous W, Hamead K, Ismail M. Sellar Floor Reconstruction with and without Intrasellar Fat Packing after Endoscopic Resection of Large Pituitary Macroadenomas with Evident Intraoperative CSF Leak. INDIAN JOURNAL OF NEUROSURGERY 2022. [DOI: 10.1055/s-0042-1742475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Abstract
Background Intraoperative cerebrospinal fluid (CSF) leak is not uncommon with endoscopic transsphenoidal surgical excision of pituitary macroadenomas. How to seal the defect and prevent postoperative leak is still a matter of debate.
Objectives In patients with CSF leak, we tried to figure out which is more important in preventing postoperative leak, is it the sellar fat packing, is it tight repair of the sellar floor, or do we need to combine them both?
Patients and Methods Over 5 years, in patients with evident intraoperative CSF leak, with growing experience supported by positive postoperative results, we shifted gradually from intrasellar packing using combined fat graft and bioabsorbable materials (SURGICEL FIBRILLAR/Gelfoam) (group A, n =15) to only bioabsorbable materials (group B, n = 18), either of which is followed by tight repair of the sellar floor.
Results Postoperative clinical assessment did not differ significantly between both groups at early, midterm, and long-term follow-up intervals. We did not have any patients with delayed postoperative CSF leak or symptomatic empty sella syndrome (ESS).
Conclusion There is no difference in the incidence of postoperative CSF leak and clinical ESS among both groups, indicating that tight sellar floor repair is more important than packing the sellar cavity with or without fat graft.
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Affiliation(s)
- Mohab Darwish
- Department of Neurosurgery, Minia University Hospital and Faculty of Medicine, Minia, Egypt
| | - Walid Nanous
- Department of Neurosurgery, Minia University Hospital and Faculty of Medicine, Minia, Egypt
| | - Khalaf Hamead
- Department of Otorhinolaryngology, Minia University Hospital and Faculty of Medicine, Minia, Egypt
| | - Mostafa Ismail
- Department of Otorhinolaryngology, Minia University Hospital and Faculty of Medicine, Minia, Egypt
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Reconstruction of Skull Base Defects in Pituitary Surgery. Otolaryngol Clin North Am 2022; 55:449-458. [DOI: 10.1016/j.otc.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Khan DZ, Ali AMS, Koh CH, Dorward NL, Grieve J, Layard Horsfall H, Muirhead W, Santarius T, Van Furth WR, Zamanipoor Najafabadi AH, Marcus HJ. Skull base repair following endonasal pituitary and skull base tumour resection: a systematic review. Pituitary 2021; 24:698-713. [PMID: 33973152 PMCID: PMC8416859 DOI: 10.1007/s11102-021-01145-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2021] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Danyal Z Khan
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Ahmad M S Ali
- Department of Neurosurgery, The Walton Centre, Liverpool, UK
| | - Chan Hee Koh
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Neil L Dorward
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Joan Grieve
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Hugo Layard Horsfall
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - William Muirhead
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Thomas Santarius
- Division of Neurosurgery, University of Cambridge and Cambridge University Hospitals, Cambridge, UK
| | - Wouter R Van Furth
- Department of Neurosurgery, University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Amir H Zamanipoor Najafabadi
- Department of Neurosurgery, University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Hani J Marcus
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK.
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK.
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Khatri D, D'Amico R, Langer DJ, Boockvar JA. Commentary: Collagen Matrix With Mucoperiosteum Graft as an Effective Fatless Flapless Reconstruction After Endoscopic Pituitary Adenoma Resection. Oper Neurosurg (Hagerstown) 2020; 19:E581-E582. [PMID: 32970117 DOI: 10.1093/ons/opaa287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 11/13/2022] Open
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Kolev D, Hadzhiyanev A, Marinov M, Bussarsky A, Popov D, Karakostov V. Endoscopic surgical resection of tuberculum sellae meningiomas based on decision-making algorithms proposed in the literature. BIOTECHNOL BIOTEC EQ 2020. [DOI: 10.1080/13102818.2020.1824619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Danny Kolev
- Clinic of Neurosurgery, St. Ivan Rilski University Hospital, Medical University of Sofia, Sofia, Bulgaria
| | - Asen Hadzhiyanev
- Clinic of Neurosurgery, St. Ivan Rilski University Hospital, Medical University of Sofia, Sofia, Bulgaria
| | - Marin Marinov
- Clinic of Neurosurgery, St. Ivan Rilski University Hospital, Medical University of Sofia, Sofia, Bulgaria
| | - Asen Bussarsky
- Clinic of Neurosurgery, St. Ivan Rilski University Hospital, Medical University of Sofia, Sofia, Bulgaria
| | - Deyan Popov
- Clinic of Neurosurgery, St. Ivan Rilski University Hospital, Medical University of Sofia, Sofia, Bulgaria
| | - Vasil Karakostov
- Clinic of Neurosurgery, St. Ivan Rilski University Hospital, Medical University of Sofia, Sofia, Bulgaria
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