Cerebrospinal fluid leakage during transsphenoidal surgery: postoperative external lumbar drainage reduces the risk for meningitis

Clinical and Operative Risk Factors Associated With Prolonged Length of Stay After Endoscopic Pituitary Adenoma Resection

BACKGROUND AND OBJECTIVES

Pituitary adenomas (PAs) are the most common intrasellar tumor. Clinically relevant adenomas have a prevalence of 1 per 1000 in the general population. Transsphenoidal surgery (TSS) is the most common surgical treatment and is the first-line management for most PAs. Most patients fare well postoperatively, but a subset of patients experience a prolonged length of stay (PLOS). In this article, we aim to identify demographic and clinical factors associated with PLOS after TSS for PA.

METHODS

Patients with sellar pathologies surgically treated at a single tertiary center from March 1, 2009, to May 31, 2020, were retrospectively reviewed. All patients older than 18 years receiving nonemergent endoscopic TSS for pituitary adenoma were included. Clinical and demographic characteristics were analyzed using χ2-tests and student t-tests. For those factors with a P-value less than .01, multivariate logistic regression and negative binomial regression models were constructed to estimate the adjusted odds of PLOS across predictive factors.

RESULTS

A total of 301 patients were included in the study. This cohort had an average age of 54.65 ± 15.06 years and an average body mass index of 29.47 ± 6.69. The median length of stay was 54.9 hours [25th-75th percentiles: 43.5-72.9]. Postoperative cerebrospinal fluid leak (P < .01), postoperative diabetes insipidus (DI) (P < .01), increased surgery duration (P = .01), and elevated maximal tumor dimension (P = .01) were predictive of PLOS in logistic regression. Increased surgery duration, previous pituitary radiation, intraoperative complications, and postoperative DI (all P < .01) were associated with increased rate of PLOS in negative binomial regression.

CONCLUSION

Patients undergoing endoscopic TSS for PA resection demonstrate prolonged lengths of stay if they have higher tumor burden, have lengthier surgeries with intraoperative complications, or develop postoperative complications such as cerebrospinal fluid leak or DI. Careful monitoring of these factors will allow for better resource optimization, reducing costs to both the hospital and the patient.

Prediction of intraoperative cerebrospinal fluid leaks in endoscopic endonasal transsphenoidal pituitary surgery based on a deep neural network model trained with MRI images: a pilot study

Objective

This study aimed to investigate the reliability of a deep neural network (DNN) model trained only on contrast-enhanced T1 (T1CE) images for predicting intraoperative cerebrospinal fluid (ioCSF) leaks in endoscopic transsphenoidal surgery (EETS).

Methods

396 pituitary adenoma (PA) cases were reviewed, only primary PAs with Hardy suprasellar Stages A, B, and C were included in this study. The T1CE images of these patients were collected, and sagittal and coronal T1CE slices were selected for training the DNN model. The model performance was evaluated and tested, and its interpretability was explored.

Results

A total of 102 PA cases were enrolled in this study, 51 from the ioCSF leakage group, and 51 from the non-ioCSF leakage group. 306 sagittal and 306 coronal T1CE slices were collected as the original dataset, and data augmentation was applied before model training and testing. In the test dataset, the DNN model provided a single-slice prediction accuracy of 97.29%, a sensitivity of 98.25%, and a specificity of 96.35%. In clinical test, the accuracy of the DNN model in predicting ioCSF leaks in patients reached 84.6%. The feature maps of the model were visualized and the regions of interest for prediction were the tumor roof and suprasellar region.

Conclusion

In this study, the DNN model could predict ioCSF leaks based on preoperative T1CE images, especially in PAs in Hardy Stages A, B, and C. The region of interest in the model prediction-making process is similar to that of humans. DNN models trained with preoperative MRI images may provide a novel tool for predicting ioCSF leak risk for PA patients.

Fat in the Fossa and the Sphenoid Sinus: A Simple and Effective Solution to CSF Leaks in Transsphenoidal Surgery. Cohort Study and Systematic Review

Objectives  Cerebrospinal fluid (CSF) leak following endoscopic transsphenoidal surgery (TSS) remains a challenge and is associated with high morbidity. We perform a primary repair with f at in the pituitary f ossa and further fat in the s phenoid sinus (FFS). We compare the efficacy of this FFS technique with other repair methods and perform a systematic review. Design, Patients, and Methods  This is a retrospective analysis of patients undergoing standard TSS from 2009 to 2020, comparing the incidence of significant postoperative CSF rhinorrhea (requiring intervention) using the FFS technique compared with other intraoperative repair strategies. Systematic review of current repair methods described in the literature was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Results  In all, there were 439 patients, with 276 patients undergoing multilayer repair, 68 patients FFS repair, and 95 patients no repair. No significant differences were observed in baseline demographics between the groups. Postoperative CSF leak requiring intervention was significantly lower in the FFS repair group (4.4%) compared with the multilayer (20.3%) and no repair groups (12.6%, p  < 0.01). This translated to fewer reoperations (2.9% FFS vs. 13.4% multilayer vs. 8.4% no repair, p  < 0.05), fewer lumbar drains (2.9% FFS vs. 15.6% multilayer vs. 5.3% no repair, p  < 0.01), and shorter hospital stay (median days: 4 [3-7] FFS vs. 6 (5-10) multilayer vs. 5 (3-7) no repair, p  < 0.01). Risk factors for postoperative leak included female gender, perioperative lumbar drain, and intraoperative leak. Conclusion  Autologous fat on fat graft for standard endoscopic transsphenoidal approach effectively reduces the risk of significant postoperative CSF leak with reduced reoperation and shorter hospital stay.

Ex vivo and in vivo evaluation of transsphenoidal Liqoseal application to prevent cerebrospinal fluid leakage

BACKGROUND

Despite improvements in closure techniques by using a vital nasoseptal flap, the use of sealing materials, and improved neurosurgical techniques, cerebrospinal fluid (CSF) leak after transsphenoidal surgery still is a clinically relevant problem. Liqoseal® (Polyganics bv, Groningen, The Netherlands) is a CE-approved bioresorbable sealant patch for use as an adjunct to standard methods of cranial dural closure to prevent CSF leakage. This study aims to evaluate the application of Liqoseal in transsphenoidal surgery ex vivo and in vivo.

METHODS

1. We created an ex vivo setup simulating the sphenoidal anatomy, using a fluid pump and porcine dura positioned on a conus with the anatomical dimensions of the sella to evaluate whether the burst pressure of Liqoseal applied to a bulging surface was above physiological intracranial pressure. Burst pressure was measured with a probe connected to dedicated computer software. Because of the challenging transsphenoidal environment, we tested in 4 groups with varying compression weight and time for the application of Liqoseal. 2. We subsequently describe the application of Liqoseal® in 3 patients during transsphenoidal procedures with intraoperative CSF leakage to prevent postoperative CSF leakage.

RESULTS

1. Ex vivo: The overall mean burst pressure in the transsphenoidal setup was 231 (± 103) mmHg. There was no significant difference in mean burst pressure between groups based on application weight and time (p = 0.227). 2. In Vivo: None of the patients had a postoperative CSF leak. No nose passage problems were observed. One patient had a postoperative meningitis and ventriculitis, most likely related to preoperative extensive CSF leakage. Postoperative imaging did not show any local infection, swelling, or other device-related adverse effects.

CONCLUSIONS

We assess the use of Liqoseal® to seal a dural defect during an endoscopic transsphenoidal procedure as to be likely safe and potentially effective.

Transnasal transsphenoidal pituitary surgery in a large tertiary hospital, a retrospective study

OBJECTIVES

Pituitary adenomas (PAs), although being small tumours, can have quite an impact on patients' lives causing hormonal and visual disturbances, for which surgery must be performed. As a large peripheral hospital with specialists in pituitary surgery, an assessment of the efficacy and safety of transnasal transsphenoidal pituitary surgery was made.

METHODS

A retrospective analysis of neurosurgical reports as well as pre and postoperative imaging was made to evaluate the presenting symptoms, tumoural variables, peri-operative morbidity, and long-term outcome.

RESULTS

This cohort included 105 patients who were operated for PAs over a 9-year period, with a slight male predominance. Adenomas had a mean maximum diameter of almost 25 mm, with one-third of tumours presenting with a Knosp-grade 3 or 4. As expected, most patients presented with either visual (32.4%) or hormonal (40.0%) disturbances. After surgery, 85.3% had complete resolution of visual deficits, and 97.1% had normalisation of hormonal hypersecretion. Postoperative hormonal insufficiency requiring substitution was observed in 43.1% and was significantly more frequent in males and in non-functioning pituitary adenomas (NFAs). Postoperative cerebrospinal fluid (CSF) leakage was observed in 2.9%, and merely one patient developed meningitis. Tumour recurrence was significantly more frequent in patients with partial resection as compared to complete resection (25.6 vs. 7.9%).

CONCLUSIONS

This study demonstrates that transnasal transsphenoidal pituitary surgery can be performed safely and effectively in a large non-university hospital, improving visual and/or hormonal disturbances as well as providing long-term tumour control. Patients with larger adenomas are at an increased risk to develop postoperative hypopituitarism.

Perioperative Antibiotic Use in Endoscopic Endonasal Skull Base Surgery

Background Improved evidence-based guidelines on the optimal type and duration of antibiotics for patients undergoing endoscopic endonasal transsphenoidal surgery (EETS) are needed. We analyze the infectious complications among a large cohort of EETS patients undergoing a standardized regimen of cefazolin for 24 hours, followed by cephalexin for 7 days after surgery (clindamycin if penicillin/cephalosporin allergic).

Methods A retrospective review of 132 EETS patients from 2018 to 2020 was conducted. Patient, tumor, and surgical characteristics were collected, along with infection rates. Multivariate logistic regression determined the variable(s) independently associated with infectious outcomes.

Results Nearly all patients (99%) received postoperative antibiotics with 78% receiving cefazolin, 17% receiving cephalexin, 3% receiving clindamycin, and 2% receiving other antibiotics. Fifty-three patients (40%) had an intraoperative cerebrospinal fluid (CSF) leak, and three patients (2%) developed a postoperative CSF leak requiring surgical repair. Within 30 days, no patients developed meningitis. Five patients (4%) developed sinusitis, two patients (3%) developed pneumonia, and one patient (1%) developed cellulitis at a peripheral intravenous line. Two patients (2%) developed an allergy to cephalexin, requiring conservative management. After adjustment for comorbidities and operative factors, presence of postoperative infectious complications was independently associated with increased LOS (β = 3.7 days; p = 0.001).

Conclusion Compared with reported findings in the literature, we report low rates of infectious complications and antibiotic intolerance, despite presence of a heavy burden of comorbidities and high intraoperative CSF leak rates among our cohort. These findings support our standardized 7-day perioperative antibiotic regimen.

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.

Transnasal endoscopic skull base surgery in the COVID-19 era: Recommendations for increasing the safety of the method

Transnasal endoscopic skull base surgery (eSBS) has been adopted in recent years, in great part to replace the extended procedures required by external approaches. Though sometimes perceived as “minimally invasive”, eSBS still necessitates extensive manipulations within the nose/paranasal sinuses. Furthermore, exposure of susceptible cerebral structures to light and heat emanated by the telescope should be considered to comprehensively evaluate the safety of the method. While the number of studies specifically targeting eSBS safety still remains scarce, the problem has recently expanded with the SARS-CoV-2 pandemic, which also has implications for the safety of the surgical personnel.

It must be stressed that eSBS may directly expose the surgeon to potentially high volumes of virus-contaminated aerosol. Thus, the anxiety of both the patient and the surgeon must be taken into account. Consequently, safety requirements must follow the highest standards. This paper summarizes current knowledge on SARS-CoV-2 biology and the peculiarities of human immunology in respect of the host-virus relationship, taking into account the latest information concerning the SARS-CoV-2 worrisome affinity for the nervous system. Based on this information, a workflow proposal is offered for consideration. This could be useful not only for the duration of the pandemic, but also during the unpredictable timeline involving our coexistence with the virus. Recommendations include technical modifications to the operating theatre, personal protective equipment, standards of testing for SARS-CoV-2 infection, prophylactic pretreatment with interferon, anti-IL6 treatment and, last but not least, psychological support for the patient.

Clipping Technique for the Repair of the Intraoperative Cerebrospinal Fluid Leakage during Transsphenoidal Pituitary Tumor Surgery

BACKGROUND

During transsphenoidal surgery (TSS) for a pituitary adenoma with a large suprasellar extension, cerebrospinal fluid (CSF) leakage commonly develops from a defect in the arachnoid recess or the arachnoid membrane.

OBJECTIVE

To evaluate the usefulness of a newly developed clipping technique for the repair of intraoperative CSF leakage.

METHODS

Between September 2012 and November 2016, 698 patients with pituitary adenoma were operated on with TSS. Intraoperative CSF leakage was encountered in 301 patients (43.1%). The clipping technique was used to repair CSF leakage in 144 patients: from the arachnoid recess in 100 patients and from the arachnoid membrane in 44 patients. The clipping technique used titanium clips and a newly designed clip applier. We evaluated anterior pituitary function of the patients whose CSF leakage was closed by clipping, and compared this with function in another patient group treated with different repair techniques.

RESULTS

We successfully applied clip technique in 140 out of 144 patients. This clipping technique was faster and easier for repairing CSF leakage than our previously published suture technique. In our early series, 4 patients developed unexpected CSF rhinorrhea after TSS. We found no difference in anterior pituitary function between a clipping group and others. Although titanium clip was identified on postoperative MRI, its metallic scattered artifact was very minimal and did not hinder the detection of possible remnant and recurrent tumors.

CONCLUSION

This clipping technique is a very simple and reliable method for repairing intraoperative CSF leakage when properly applied with caution.

Perioperative nasal and paranasal sinus considerations in transsphenoidal surgery for pituitary disease

Endoscopic endonasal skull base surgery has emerged as the treatment modality of choice for a range of skull base lesions, particularly pituitary adenomas. However, navigation and manipulation of the nasal corridor and paranasal sinuses requires that surgeons are aware of effective techniques to maximize patient outcomes and avoid sinonasal morbidity postoperatively. This paper is a narrative review aimed to provide an updated and consolidated report on the perioperative management of the nasal corridor and paranasal sinuses in the setting of endoscopic skull base surgery for pituitary disease. Anatomic variants and common surgical techniques are discussed. Post-operative complications are evaluated in detail. Understanding the structural implications of the endonasal approach to the sphenoid is crucial to optimization of the surgical outcomes. We propose guidelines for perioperative management of endoscopic endonasal skull base surgery for pituitary diseases. Standardized treatment algorithms can improve patient satisfaction, and increase the comparability and the quality of reported information across research studies.

Risk factors for postoperative intracranial infections in patients with pituitary adenoma after endoscopic endonasal transsphenoidal surgery: pneumocephalus deserves further study

OBJECTIVE

The authors sought to identify the relevance between pneumocephalus and postoperative intracranial infections, as well as bacteriological characteristics and risk factors for intracranial infections, in patients with pituitary adenomas after endoscopic endonasal transsphenoidal surgery.

METHODS

In total, data from 251 consecutive patients with pituitary adenomas who underwent pure endoscopic endonasal transsphenoidal surgeries from 2014 to 2018 were reviewed for preoperative comorbidities, intraoperative techniques, and postoperative care.

RESULTS

This retrospective study found 18 cases of postoperative pneumocephalus (7.17%), 9 CNS infections (3.59%), and 12 CSF leaks (4.78%). Of the patients with pneumocephalus, 5 (27.8%) had CNS infections. In patients with CNS infections, the culture results were positive in 7 cases and negative in 2 cases. The statistical analysis suggested that pneumocephalus (maximum bubble diameter of ≥ 1 cm), diaphragmatic defects (intraoperative CSF leak, Kelly grade ≥ 1), and a postoperative CSF leak are risk factors for postoperative CNS infections.

CONCLUSIONS

In pituitary adenoma patients who underwent pure endoscopic endonasal transsphenoidal surgeries, intraoperative saddle reconstruction has a crucial role for patients with postoperative intracranial infections. Additionally, postoperative pneumocephalus plays an important role in predicting intracranial infections that must not be neglected. Therefore, neurosurgeons should pay close attention to the discovery of postoperative intracranial pneumocephalus because this factor is as important as a postoperative CSF leak. Pneumocephalus (maximum bubble diameter of ≥ 1 cm), diaphragmatic defects (an intraoperative CSF leak, Kelly grade ≥ 1), and a postoperative CSF leak were risk factors predictive of postoperative intracranial infections. In addition, it is essential that operative procedures be carefully performed to avoid diaphragmatic defects, to reduce exposure to the external environment, and to decrease patients’ suffering.

Neural network-based identification of patients at high risk for intraoperative cerebrospinal fluid leaks in endoscopic pituitary surgery

OBJECTIVE

Although rates of postoperative morbidity and mortality have become relatively low in patients undergoing transnasal transsphenoidal surgery (TSS) for pituitary adenoma, cerebrospinal fluid (CSF) fistulas remain a major driver of postoperative morbidity. Persistent CSF fistulas harbor the potential for headache and meningitis. The aim of this study was to investigate whether neural network-based models can reliably identify patients at high risk for intraoperative CSF leakage.

METHODS

From a prospective registry, patients who underwent endoscopic TSS for pituitary adenoma were identified. Risk factors for intraoperative CSF leaks were identified using conventional statistical methods. Subsequently, the authors built a prediction model for intraoperative CSF leaks based on deep learning.

RESULTS

Intraoperative CSF leaks occurred in 45 (29%) of 154 patients. No risk factors for CSF leaks were identified using conventional statistical methods. The deep neural network-based prediction model classified 88% of patients in the test set correctly, with an area under the curve of 0.84. Sensitivity (83%) and specificity (89%) were high. The positive predictive value was 71%, negative predictive value was 94%, and F1 score was 0.77. High suprasellar Hardy grade, prior surgery, and older age contributed most to the predictions.

CONCLUSIONS

The authors trained and internally validated a robust deep neural network-based prediction model that identifies patients at high risk for intraoperative CSF. Machine learning algorithms may predict outcomes and adverse events that were previously nearly unpredictable, thus enabling safer and improved patient care and better patient counseling.

Bilateral caudate nucleus infarcts: A case report of a rare complication following endoscopic resection of a tuberculum sellae meningioma

Background:

We present a rare complication of bilateral caudate infarcts and necrosed nasoseptal flaps after endoscopic transsphenoidal resection of tuberculum sellae meningioma. This case highlights the importance of early and accurate diagnosis and treatment of a postoperative cerebrospinal fluid (CSF) leak and associated bacterial meningitis, and reviews any existing guidelines regarding its management.

Case Description:

A 54-year-old otherwise healthy man presented with progressive bitemporal hemianopsia. Magnetic resonance imaging of the head revealed a large, homogeneously enhancing sellar and suprasellar mass consistent with a meningioma. An endoscopic endonasal transsphenoidal approach was performed to resect the tuberculum sellae meningioma. The patient developed basal bacterial meningitis secondary to a CSF leak, requiring repair on two separate occasions. At the time of both repairs, there was evidence of necrosis of the nasoseptal flaps used for the repairs. Soon after the diagnosis of meningitis, the patient developed bilateral caudate infarcts.

Conclusion:

This report discusses the possible underlying etiologies for the bilateral caudate infarcts and necrosed flaps including bacterial meningitis with associated local vasospasm of nearby vessels resulting in infarction. This case emphasizes the importance of concise management of postendoscopic CSF leak and discusses the guidelines regarding antimicrobial therapy and the management of lumbar drains.

Cerebrospinal fluid leaks after transsphenoidal surgery - Effect of a polyethylene glycol hydrogel dural sealant

To investigate cerebrospinal fluid (CSF) leak rates after mainly endoscopic endonasal transsphenoidal surgery with and without polyethylene glycol hydrogel dural sealant (DuraSeal®), we prospectively collected data from a single-centre consecutive case series over four years from January 2007 to December 2010 inclusive. 250 patients were identified (135 male, 115 female; median age 52years, range 14-83). 180 patients received DuraSeal® (72%). 85 (34%) had intra-operative dural breach and 13 (5.2%) developed post-operative CSF leaks (3 without intra-operative dural breach) requiring lumbar drainage or formal repair. Of this group 5/251 (2.0%) patients required a formal repair. Post-operative CSF leak was seen in 5/189 (2.7%) of patients with pituitary adenoma, of which 2/5 (40%) were in cases undergoing revision surgery. 5/13 (38.4%) patients who developed a CSF leak presented with either Rathke's cleft cyst or craniopharyngioma. 3/71 patients not receiving DuraSeal® leaked (4.2%) and 10/180 patients receiving DuraSeal® leaked (5.6%). 11/234 patients without Tisseel (4.7%) and 2/16 receiving Tisseel (12.5%) leaked. 54 patients (22%) received intra-operative lumbar drains, one of whom developed subsequent CSF leak (1.9%), in contrast to 12/197 (6.1%) of patients without intra-operative lumbar drains who later developed CSF leak. The rate of post-operative CSF leak requiring re-exploration and nasoseptal flap repair was low (2.0%) in this mainly endoscopic case series without statistically significant benefit from either DuraSeal® or Tisseel. Intra-operative and post-operative lumbar drainage appears beneficial in patients at higher risk of post-operative CSF leak.

An Automated, Gravity-driven CSF Drainage System Decreases Complications and Lowers Costs

BACKGROUND

FlowSafe^TM (BeckerSmith Medical, Irvine, CA, USA) is a novel, robotic, external lumbar drainage (ELD) system, which was designed to control cerebrospinal fluid (CSF) drainage, reduce complications, and decrease treatment costs.

METHODS

 Forty-seven consecutive neurosurgical patients requiring ELD were treated using the FlowSafe system.

RESULTS

In 39 of 40 patients with traumatic and surgical dural openings, potential CSF leaks were avoided. In seven patients with suspected normal pressure hydrocephalus, post-infectious ventriculomegaly, or pseudotumor cerebrum, we were able to assess the likelihood of improvement with shunting. The system, therefore, produced what we considered to be the "desired result" in 46 of 47 patients (98%). Our one treatment failure (2%) involved a patient with unrecognized hydrocephalus who, following a Chiari repair with a dural patch graft, was drained for six days. A persistent CSF leak eventually required a reoperation. Two patients (4%) described low-pressure headaches during treatment. Both responded to temporarily suspending or reducing the drainage rate. We saw no complications. Required nursing interventions were minimal.  Conclusions: The FlowSafe system was safe and effective. In our experience, there were fewer complications compared to currently available ELD systems. The FlowSafe was well tolerated by our patients. The near elimination of nursing interventions should allow lumbar drainage to be delivered in less costly, non-intensive care unit settings. Larger trials will be needed.

A new multilayer reconstruction using nasal septal flap combined with fascia graft dural suturing for high-flow cerebrospinal fluid leak after endoscopic endonasal surgery

This study aimed to evaluate the usefulness and reliability of a new endoscopic multilayer reconstruction using nasal septal flap (NSF) to prevent high-flow cerebrospinal fluid leak after endoscopic endonasal surgery. This study was a retrospective review on 97 patients who underwent multilayer reconstructions using NSF combined with fascia graft dural suturing after endoscopic endonasal surgery between July 2012 and March 2014. Patients were divided into two groups, third ventricle opening group and nonopening group, based on the presence of a direct connection between the third ventricle and the paranasal sinus after tumor removal. Furthermore, we compared this procedure with our previous reconstruction after resection of craniopharyngioma. Finally, we checked the patients who had postoperative prolonged discomfort of the nasal cavity for over a year. Postoperative cerebrospinal fluid (CSF) leak occurred in three patients (3.1 %): one from the third ventricle opening group and the remaining two from the nonopening group. External lumbar drain was performed after surgery in only seven patients (7.2 %). The incidence of postoperative CSF leak was similar in both groups, whereas the rate of craniopharyngioma in the third ventricle opening group was significantly higher. The incidence of postoperative CSF leak after resection of craniopharyngioma was not statistically significant but obviously higher in the previous group (12.2 %) compared with that in the present group (2.3 %). Twelve patients (12.4 %) had postoperative nasal discomfort of the nasal cavity for over a year. Multilayer reconstruction using NSF combined with fascia graft dural suturing is a more reliable method for preventing postoperative high-flow CSF leakage after endoscopic endonasal surgery even if there is a direct connection between the third ventricle and the paranasal sinus. However, we should pay close attention especially to prolonged discomfort of the nasal cavity after harvesting NSF.

Direct suture technique of normal gland edge on the incised dura margin to repair the intraoperative cerebrospinal fluid leakage from the arachnoid recess during transsphenoidal pituitary tumor surgery

BACKGROUND

During transsphenoidal surgery for pituitary adenomas with large suprasellar extension, cerebrospinal fluid (CSF) leakage commonly develops from a defect at the arachnoid recess between the resected dura margin and the anterior edge of a normal pituitary gland (type 1 CSF leakage).

OBJECTIVE

To evaluate the usefulness of a direct suture technique of the normal gland edge on the incised dural margin to repair intraoperative CSF leakage from the arachnoid recess.

METHODS

Between November 2005 and December 2012, 861 patients with pituitary adenomas were operated on with transsphenoidal surgery, and intraoperative CSF leakage was encountered in 432 patients. Type 1 CSF leakage developed in a total of 122 patients, and their defects were repaired with the direct suture technique in 51 patients, whereas a fleece-coated fibrin glue patch alone was applied onto the defect in the other 71 patients. This direct suture technique required an additional 5 to 20 minutes in most cases.

RESULTS

We experienced no case of postoperative CSF rhinorrhea in the 51 patients whose defects were repaired by the direct suture technique and only 1 case of CSF rhinorrhea in 71 patients whose defects were repaired with a fleece-coated fibrin glue patch alone. There was no statistical difference in the outcome between 2 groups. Postoperative lumbar CSF drainage was not performed in any case.

CONCLUSION

Our 2 different repair techniques for arachnoid recess tears are very reliable methods for managing this type of CSF leakage. The direct suture technique may be more appropriate for type 1 CSF leakage with a wider gap and more prominent CSF leakage.

Surgical Measurement of the Sphenoid Sinus on Sagittal Reformatted CT in the Turkish Population

OBJECTIVE

The objectives of this study were to determine sinus measurements specific for the Turkish population using CT sagittal thin-slice reconstruction images and to clarify the three-dimensional anatomical features of the sphenoid sinus, along with its surrounding structures, that are relevant to performing an endoscopic sphenoidotomy.

MATERIALS AND METHODS

Images of 300 patients (165 female, 135 male) were studied. The research was conducted on the axial plane with a 1 mm slice thickness and a 0.6 mm slice interval, and sagittal reconstruction was performed with a 0.4 mm slice interval. Measurements of the sinus were obtained, and the presence of Onodi cells was researched.

RESULTS

Line 1 was found to be significantly shorter in the Turkish patients of this study compared to studies of other populations. Lines 4 and 6 were found to be longer on the left side (Line 4 right: 18.8±3.6 mm, left: 19.3±3.4 mm, p=0.027; Line 6 right: 24.1±6.8 mm, left: 24.3±6.8 mm, p=0.008). Lines 2, 3, 4 and 6 were longer in men than in women (p<0.05).

CONCLUSION

In the Turkish population, Line 1 is shorter, so the risk of skull base perforation is greater. Lines 4 and 6 are longer on the left side; thus, choosing the left ostium in sinus dilation is safer. Because of sex differences regarding Lines 2, 3, 4 and 6, sex should be considered in sphenoid sinus procedures.

Analysis of the bacterial flora in the nasal cavity and the sphenoid sinus mucosa in patients operated on with an endoscopic endonasal transsphenoidal approach

The aim of this study was to analyze the bacterial flora in the nasal cavity and sphenoid sinus and evaluate the sensitivity of these bacteria to antibiotics that can be used to prevent postoperative meningitis. Bacteria of the preoperative nasal cavity and intraoperative sphenoid sinus mucosa were cultured and analyzed in 40 patients (20 men and 20 women; mean age, 52.2 years) who underwent endoscopic transsphenoidal surgery. The sensitivity of these bacteria to cephalosporin, a representative prophylactic antibiotic, was examined. Staphylococcus epidermidis was the most frequently detected species in both spaces; 24 (38.7%) of 62 isolates in the nasal cavity and 26 (37.1%) of 70 isolates in the sphenoid sinus. In contrast, Corynebacterium species were found mainly in the nasal cavity, and anaerobic bacteria were found only in the sphenoid sinus. Bacteria that were resistant to cephalosporin were found in the nasal cavity in 3.2% of patients and in the sphenoid sinus in 20% of patients. In conclusion, the composition of bacterial flora, including bacteria that are resistant to prophylactic antibiotics, differs between the nasal cavity and the sphenoid sinus.

Effectiveness of lumbar drains on recurrence rates in endoscopic surgery of cerebrospinal fluid leaks

BACKGROUND

In cerebrospinal fluid (CSF) leakage endoscopic repair, lumbar drains (LDs) were used in an attempt to increase success rates. To critically assess the relationship between use of LDs and recurrent leaks, we embarked on this randomized prospective study.

METHODS

Patients undergoing CSF leak repair between 2000 and 2012 were randomized into two groups: 75 patients were managed without LDs and in the other group of 75 patients an LD was always placed. Different parameters were analyzed to identify their relationship with failures: occurrence of increased intracranial pressure (ICP), body mass index, smoking habits, existence of diabetes, chronic corticosteroid use, previous sinus surgery, etiology (traumatic, iatrogenic, or spontaneous leak), site, and size of the CSF leak.

RESULTS

Success rate was 93% for the whole group. Patients managed with LDs attained 95% success rate and those without LD attained 92%; the difference is not significant (p = 0.2). The only factor predictive of recurrence is increased ICP: 77% success rate versus 97% for traumatic leaks and 96% for iatrogenic leaks. Recurrence rates were identical in the two groups with increased ICP, regardless of the use of a LD (23%).

CONCLUSION

In this study, success rates of CSF repair were not associated with the use of LDs. However, the small number of cases with high success rates precludes appropriate statistical analysis.

Combined use of a gasket seal closure and a vascularized pedicle nasoseptal flap multilayered reconstruction technique for high-flow cerebrospinal fluid leaks after endonasal endoscopic skull base surgery

OBJECTIVE

To assess the efficacy of the combined use of a gasket seal closure and a vascularized pedicle nasoseptal flap (VP-NSF) multilayered reconstruction technique for high-flow cerebrospinal fluid (CSF) leaks resulting from endonasal endoscopic skull base surgery.

METHODS

From October 2009-June 2011, a VP-NSF multilayered reconstruction technique was used (single technique group) for patients with intraoperative high-flow CSF leaks; from July 2011-February 2013, a combination of a gasket seal closure and a VP-NSF multilayered reconstruction technique was used (combined technique group). A lumbar drain was placed after the operation. The rates of postoperative CSF leaks and repair-related complications in the 2 groups were analyzed.

RESULTS

The single technique group comprised 18 patients with a mean follow-up of 31.7 months; there were 5 postoperative CSF leaks (27.7%). The combined technique group comprised 15 patients with a mean follow-up of 13.6 months; no CSF leaks occurred (P < 0.05). The rate of intracranial infection in the single technique group was significantly higher than in the combined technique group.

CONCLUSIONS

The combined use of a gasket seal closure and a VP-NSF multilayered reconstruction technique for high-flow CSF leaks after endonasal endoscopic skull base surgery may significantly reduce the rates of postoperative CSF leaks and intracranial infections. Lumbar drainage after the operation is a necessary auxiliary method.

Characterization of sphenoid sinuses for Sudanese population using computed tomography

The purpose of this study is to determine the anatomical features of the sphenoid sinus using computerized tomography (CT).

100 Sudanese subjects were investigated for CT sinuses; Characterization of the sphenoid sinus and seven horizontal and vertical measurements were evaluated.

Onodi cell was found in 13 subjects, 10 of them were sellar and 3 were pre-sellar. Pneumatization was of the sellar type in 85%, presellar was 15%, and no subject was chonchal.

The mean length of vertical lines from the center of sphenoid ostium to the roof and bottom were 10.6 ± 3.1 mm, 11.1 ± 3.7 mm respectively. When the sphenoid ostium was located superior to the lowest point of the sella, the line from the center of the sphenoid sinus ostium to the posterior wall of the sinus was 15.2 ± 4.2 mm and when was located inferior, the line was 26.3 ± 5.2 mm on average. The mean length from the lowest point of the sella to the anterior wall of sphenoid sinus was 16.8 ± 3.6 mm. The line from anterior wall to posterior wall of sphenoid sinus lining skull base was 10.9 ± 3.2mm mm. The maximum depth was 25.2 ± 6.9 mm and the maximum width was 18.4 ± 5.9mm. The differences in the sphenoid sinus character take place between males and females.

The study provides essential anatomical information for Sudanese subjects and its impact in the clinical surgical practice.

Effectiveness of lumbar drain versus hyperventilation to facilitate transsphenoidal pituitary (suprasellar) adenoma resection

BACKGROUND

Developing controlled hypercarbia is a known scheme of lowering the suprasellar part of the adenoma in order to assist the surgeon, which acts through raising the ICP and therefore the CSF pressure.

OBJECTIVES

The purpose of this study is to compare the effect of introducing a lumbar drain with that of controlled hypercapnia on the quality of transsphenoidal pituitary tumor resection and CSF leak.

PATIENTS AND METHODS

Fifty two patients with pituitary adenoma who underwent transsphenoidal hypophysectomy by the same surgeon were included. They were randomly divided into two groups. A lumbar drain catheter introduced into the L3-L4 subarachnoid space under local anesthesia in all patients. The same anesthesia was performed in both groups. In the study group, we used a saline injection into the subarachnoid space versus hypoventilation in the control group in order to increase the ICP according to the surgeon's request. The surgeon's satisfaction during the tumor resection and the resection time were assessed during the surgery. The CSF catheter was closed and sent with the patient for CSF drainage. If there was no CSF leak, the catheter removed 24 hours later. With evidence of a CSF leak, we used the catheter as a lumbar drain. The time taken for the leakage control was assessed.

RESULTS

The satisfaction came from 21 (87.5%) and 2 (9.1%) for surgeon in the first and the second group respectively (P = 0.0001). CSF leakage time in the first and the second group was 1.6 ± 0.24 and 5 ± 0.50 respectively. It revealed a significant difference between the two groups (P = 0.001). The mean resection time was 13.54 ± 0.66 minutes in the study group; and 30.91 ± 0.98 minutes in the control group.

CONCLUSIONS

In summary, the method described here for ICP manipulation is an effective procedure for a better visualization of the pituitary tumor during transphenoidal resection by surgeon and beneficial in managing the CSF leak following surgery.

Gasket seal closure for extended endonasal endoscopic skull base surgery: efficacy in a large case series

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.

Polyethylene glycol (PEG) hydrogel dural sealant and collagen dural graft matrix in transsphenoidal pituitary surgery for prevention of postoperative cerebrospinal fluid leaks

Cerebrospinal fluid (CSF) rhinorrhea is the most common complication after transsphenoidal pituitary surgery. The authors compare their previous experience using an autologous fat graft and lumbar drain placement in 107 patients with their current technique of using a dural sealant and collagen matrix in 97 patients to prevent postoperative CSF leak after pituitary tumor resection. The failure rate for CSF leak repairs between the two groups was similar. The use of a dural sealant and collagen matrix, however, has the advantages of decreased length of hospital stay, decreased length of Intensive Care Unit stay, avoidance of the morbidity of an extra abdominal incision, and avoidance of the risks of lumbar CSF drainage.

Prevention of cerebrospinal fluid rhinorrhea after transsphenoidal surgery by collagen fleece coated with fibrin sealant without autologous tissue graft or postoperative lumbar drainage

BACKGROUND

Autologous tissue grafting and postoperative lumbar cerebrospinal fluid (CSF) drainage (PLD) have been used to prevent CSF rhinorrhea after transsphenoidal surgery.

OBJECTIVE

To describe the technical details and efficacy of our techniques of using collagen fleece coated with fibrin sealant (TachoComb, Nycomed, Linz, Austria) instead of an autologous tissue graft and refraining from the use of PLD.

METHODS

We retrospectively reviewed 307 consecutive patients who underwent a transsphenoidal surgery for pituitary adenoma from November 2005 to February 2008. Among them, 90 cases of intraoperative CSF leaks were repaired with TachoComb without an autologous tissue graft or PLD. The repair procedures were tailored according to CSF leakage type, and we used only Bioglue (Cryolife Inc, Atlanta, Georgia) for sellar floor reconstruction.

RESULTS

The overall rate of CSF rhinorrhea was 2.2% (2 of 90 cases). The 2 cases of CSF rhinorrhea resulted from large arachnoid defects, and there were no adverse effects from TachoComb such as transmission of viral disease or infection.

CONCLUSION

Our technique is an alternative method to the traditional autologous tissue graft technique. PLD is not an essential procedure for the prevention of CSF rhinorrhea if the intraoperative CSF leak is completely sealed off during the transsphenoidal surgery. However, in cases of large arachnoid defects, aggressive repair of the arachnoid defect and sellar floor reconstruction with bone or bony substitutes should be considered in conjunction with our methods.

Management and implications of intraoperative cerebrospinal fluid leak in transnasoseptal transsphenoidal microsurgery

BACKGROUND

Nonvascularized autologous grafts used for sellar reconstruction in transseptal transsphenoidal surgery are commonly applied in the setting of intraoperative cerebrospinal fluid (CSF) leak and have been shown to be effective in preventing postoperative complications.

OBJECTIVE

To assess the clinical implications of intraoperative CSF leak, to evaluate the efficacy of repair techniques using autologous nonvascularized materials, and to analyze the nature and timing of failures. These data may serve as a basis for assessing the utility of innovations in techniques and implant technologies.

METHODS

A review was conducted of 257 consecutive patients who underwent transsphenoidal surgery that was complicated by intraoperative CSF leak from 1995 to 2001. Sellar reconstruction was performed with autologous materials except in reoperations in which septal materials were not available; lumbar drain catheters were used selectively.

RESULTS

Six of the 257 patients (2.3%) developed postoperative CSF rhinorrhea occurring an average of 6.6 days after surgery. All 6 underwent reoperation, with 5 of 6 managed with operative lumbar drainage. Bacterial meningitis developed in 3 of 257 (1.2%). Worsening in visual function occurred in 8 of 257 (3.1%), with 1 of 257 (0.3%) suffering from permanent worsening of visual function. Additional surgery was performed in 2 of these patients, resulting in successful reversal of visual loss. Ten of 257 patients (3.9%) developed a subcutaneous hematoma at the fat graft harvest site, with 1 patient requiring surgical re-exploration.

CONCLUSIONS

Watertight closure of the sella with autologous materials is effective in preventing postoperative rhinorrhea. Complications specific to the technique include graft site hematoma (4%) and rare instances of visual loss caused by optic nerve compression.

Low-grade CSF leaks in endoscopic trans-sphenoidal pituitary surgery: efficacy of a simple and fully synthetic repair with a hydrogel sealant

BACKGROUND

Intra-operative CSF leak during endoscopic trans-sphenoidal surgery is not uncommon. Surgical repair with a variety of autologous grafts, rigid buttresses and CSF diversion techniques that add time and complexity have been reported.

OBJECTIVE

To describe a simple and purely synthetic closure for low-grade CSF leaks following endoscopic trans-sphenoidal pituitary surgery.

METHODS

A retrospective review of all endoscopic trans-sphenoidal surgery undertaken for pituitary pathology between 2005 and 2010 was carried out. The grade of CSF leak and success of graded repair was noted. Patients with no CSF leak (grade 0) had gelatin sponge placed in the tumour cavity. In those with low-grade CSF leak through small arachnoid defects (grade 1), repair was carried out using gelatin sponge and hydrogel sealant overlay. CSF diversion was not employed for low-grade CSF leaks.

RESULTS

Of the 255 endoscopic trans-sphenoidal surgeries, 158 (62%) had no leak (grade 0) and 74 (29%) had a low-grade leak (grade 1). Repairs in all cases were of grade 0, and all but two cases of grade 1 CSF leak were successful at a mean follow-up of 29 months. The 2 (2.7%) post-operative CSF leaks were seen within 6 weeks of surgery. Both cases were related to bouts of sneezing and were repaired using further trans-sphenoidal surgery and/or lumbar CSF diversion.

CONCLUSIONS

A simple purely synthetic repair of low-grade CSF leaks is described. This repair is safe and comparable in efficacy whilst avoiding the morbidity related to more complex sellar reconstructions previously described.

Otolaryngologic uses for spinal drains

Cerebrospinal fluid (CSF) fistulae have been encountered by otolaryngologists often since the advent of modern endoscopic sinus surgery, otologic surgery, and skull base surgery. Treatment of CSF leaks may include bed rest, head-of-bed elevation, stool softeners, external spinal fluid drainage, and surgery. External CSF drainage is accomplished via a lumbar spinal drain. Placement of spinal drains is often performed by neurosurgeons and anesthetists. A few otolaryngologists have been trained in the placement and management of lumbar drains, but at most otolaryngology training institutions, education in lumbar drains is not provided. However, in some circumstances, it may fall to an otolaryngologist to accomplish the task. We believe that every otolaryngologist, from the generalist in private practice to the academic neuro-otologic surgeon, should understand the proper technique for the insertion and management of a lumbar drain. Otolaryngologists should be familiar with the physiologic properties of CSF, the methods used to diagnose fistulae, and the techniques used to repair leaks. External spinal drainage is an important element in the management of CSF fistulae, and it has been used in treating perilymphatic fistulae and "gushers." Much controversy surrounds its routine use. Otolaryngologists need to understand the risks, benefits, and outcomes of spinal drain use in order to decide which patients may benefit from this procedure.

Assessing risk/benefit of lumbar drain use for endoscopic skull-base surgery

BACKGROUND

Lumbar drains (LD) are frequently employed with the goal of postoperative cerebrospinal fluid (CSF) leak prevention. LD placement is not without risk, however, and complications can significantly increase patient discomfort and resource utilization. The objective of this work was to characterize the risks, benefits, and resource utilization associated with LD use in endoscopic anterior skull-base surgery.

METHODS

A retrospective review of endoscopic anterior skull-base surgeries performed by the senior authors over the past 5 years was done. Cases with prospective LD were selected using anesthesia and billing records. Analysis was done of indications, LD duration, complications, revisions, and additional care required.

RESULTS

A total of 65 patients had LD placed prospectively at the time of surgery. LD were in place for an average of 63 ± 38 hours. Four cases (6.2%) required revision surgery for postoperative CSF leak. Leak rates did not differ between patients with neoplasm (7.7%) and without neoplasm (5.8%; p = 0.80). One readmission was attributable to a recurrent leak. Nine LD complications occurred in 8 patients (12.3%). Overall, 6 blood patches, 3 head computed tomography (CT) scans, 1 open removal of retained catheter fragments, 1 spine CT, and an infectious disease workup were required. Three readmissions and 10 additional hospital days were attributable to LD complications. No relationship was found between patient demographics or comorbidities and LD complications. Regression analysis showed no significant effect of body mass index (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.89-1.14; p = 0.87) or duration of LD (OR, 1.00; 95% CI, 0.98-1.02; p = 0.85) on complication risk. Diagnosis of neoplasm was associated with a significant increase in likelihood of complication (OR, 5.33; 95% CI, 1.11-25.64; p < 0.04).

CONCLUSION

Complications of LD may be more frequent than postoperative CSF leaks, adding significantly to health care resource utilization. It is difficult to predict which patients will suffer LD complications. Reduction of prospective LD use may avoid unnecessary morbidity and resource utilization.

One thousand endoscopic skull base surgical procedures demystifying the infection potential: incidence and description of postoperative meningitis and brain abscesses

BACKGROUND

Endonasal endoscopic skull base surgery (ESBS) is perceived as having a high risk of infection because it is performed through the sinuses, which are not sterile.

OBJECTIVE

To identify the bacteriological characteristics, incidence, mortality, and risk factors for intracranial infection after ESBS.

METHODS

A retrospective analysis of the first 1,000 ESBS procedures performed at the University of Pittsburgh Medical Center from 1998 to 2008.

RESULTS

In 18 cases (1.8%), the patient developed meningitis. In 2 cases, the patient died within 2 months after surgery, of noninfectious causes. In 11 cases, cerebrospinal fluid (CSF) cultures had positive results. There were no predominant pathogens. Male sex (odds ratio [OR], 3.97 [95% confidence interval {CI}, 1.21-13.03]; P = .02), history of a craniotomy or endonasal surgery (OR, 4.77 [95% CI, 1.68-13.56]; P = .02), surgery with higher levels of complexity (OR, 6.60 [95% CI, 1.77-24.70]; P = .003), the presence of an external ventricular drain or ventriculoperitoneal shunt at the time of surgery (OR, 6.38 [95% CI, 1.07-38.09]; P = .005), and postoperative CSF leak (OR, 12.99 [95% CI, 4.24-39.82]; P < .001) were risk factors for infection.

CONCLUSION

The incidence of infection of 1.8% in ESBS is comparable to that in open craniotomy. The most important risk factor was a postoperative CSF leak. All patients recovered from their infection.

Surgical measurement to sphenoid sinus for the Chinese in Asia based on CT using sagittal reconstruction images

The objective this study was to measure the changes of sphenoid sinusin the Chinese in AsiausingCT sagittal thin-slice reconstruction images, and to clarify the three-dimensional anatomical features of sphenoid sinus with its surrounding structures, relevant to the performing of the endoscopic sphenoidotomy. The sagittal reconstruction images were obtained from 178 CT images of 89 cases of normal adult participants (54 males and 35 females) with sphenoid sinus. We took the high-resolution axial CT images, from all the subjects, of the thickness by 0.625 mm, and reconstructed 1-mm-thick gapless sagittal CT images to measure the distance of all the sellar and pre-sellar types on the three-dimensional reconstructable sagittal plane under the bone window (4,000 at its width, and 400 at its level) in the CT images. The length of mean vertical line from the center of sphenoid ostium to the roof of sphenoid sinus of Non Onodi cell type is 10.6 ± 1.5 mm, and of Onodi cell type is 3.3 ± 1.5 mm. The length of vertical line from the center of sphenoid ostium to the lowest level of the bottom of sphenoid sinus is 12 mm ± 3.7 mm. The length of mean horizontal line from the sphenoid ostium to the posterior wall of sphenoid sinus is 18 ± 1.5 mm or 28 ± 2.5 mm. The mean horizontal line from the lowest point of the sella to the anterior wall of sphenoid sinus is 17.5 ± 1.3 mm in length. The mean horizontal distance from anterior wall to posterior wall of sphenoid sinus of Non Onodi cell type lining skull base is 10.1 ± 1.0 mm, and of Onodi cell type, is 5.2 ± 4.3 mm. The longest horizontal distance from the anterior wall to the posterior wall of sphenoid sinus is 22.0 ± 7.7 mm. The present study provides atomical information about sphenoid sinus of the Chinese in Asia with some surgical distance measured between the sphenoid ostium and the surrounding structures, which is essential to avoid the complications during surgery.

Endoscopic endonasal skull base reconstruction using a nasal septal flap: surgical results and comparison with previous reconstructions

The objective of this study is to evaluate the usefulness and reliability of endoscopic endonasal skull base reconstructions using a nasal septal flap. This study is designed as a retrospective review. Between April 2005 and November 2009, we performed 32 endoscopic endonasal skull base reconstructions for closure of large dural defects. Eleven patients underwent reconstructions using fat grafts or the fascia lata (non-flap group). Twenty one patients underwent reconstructions using a nasal septal flap with a balloon catheter (flap group). Incidence of postoperative cerebrospinal fluid (CSF) leaks and perioperative insertion rate of external lumbar drain (ELD) were compared between the two groups. Postoperative CSF leaks occurred in two patients (9.5%) in the flap group. Three patients (27.3%) presented CSF leaks in the non-flap group. The rate of insertion of ELD was 81.8% in the non-flap group. In the flap group, one patient (4.8%) should be placed with ELD postoperatively. The incidence of postoperative CSF leaks in the flap group was lower than in the non-flap group, whereas the rate of insertion of ELD in the non-flap group was higher than in the flap group. Endoscopic endonasal skull base reconstruction using a nasal septal flap without ELD seems to be useful and reliable for ventral skull base defects after endoscopic endonasal approaches as compared with our previous single-layer reconstructions using free fat grafts or fascia lata. The long-term effectiveness of nasal septal flaps to prevent intracranial complications should be confirmed.

Dural suturing for repair of cerebrospinal fluid leak in transnasal transsphenoidal surgery

OBJECTIVE

Repair of a cerebrospinal fluid (CSF) leak after transsphenoidal surgery (TSS) is usually accomplished using various graft materials. These methods are effective in most, but not all, cases.

METHODS

Since 2006, we have been directly suturing the sellar floor dura in patients with an intraoperative CSF leak. Fat and/or fascial grafts were utilized only when a major CSF leak developed. The incidence of postoperative CSF rhinorrhea was compared before and after the suture.

RESULTS

Postoperative CSF rhinorrhea developed in 3.7% (7 out of 188) of cases before 2005, but never since the dural suture was introduced (0 out of 136, 0%; P = 0.0229). Although watertight closure was not achieved in some cases, narrowing the dural defect and supporting the intrasellar graft was attained in every case. Surgical time was approximately 30 min longer in patients who underwent dural suture (148 +/- 42 min) than those who did not (119 +/- 37 min; P = 0.0001).

CONCLUSION

Direct suturing of the sellar dura is a simple, safe, and reliable surgical technique for repairing CSF leaks after TSS. Using this procedure, more than 70% of patients with an intraoperative CSF leak can avoid autologous tissue grafts.

Repeated transsphenoidal pituitary surgery (TS) via the endoscopic technique: a good therapeutic option for recurrent or persistent Cushing's disease (CD)

BACKGROUND

No data on results of repeated transsphenoidal surgery via the endoscopic technique for patients with persistent or recurrent Cushing's disease are available.

DESIGN AND PATIENTS

We retrospectively evaluated the remission rates and complications of repeated transsphenoidal surgery via the endoscopic technique in 14 patients with persistent (N = 6) or recurrent (N = 8) Cushing's disease treated in our centre between 1999 and 2007.

MAIN OUTCOMES

Remission was defined as the disappearance of symptoms of hypercortisolism with basal plasma cortisol level < or = 50 nmol/l 24-48 h after glucocorticoid withdrawal and/or suppression of plasma cortisol level < or = 50 nmol/l after 1 mg dexamethasone overnight within the first 3 months after transsphenoidal surgery.

RESULTS

With repeated endoscopic transsphenoidal surgery a remission rate of 10/14 (71%) was achieved. No patient had a relapse during a median follow-up of 24 months. Cerebrospinal fluid leakage was the most frequent complication (6 patients) and 11 patients required hormonal substitution after surgery. The success of repeated transsphenoidal surgery could not be predicted by visualization of an adenoma on MRI before first or second surgery, histopathological confirmation of an ACTH secreting adenoma after first or second surgery, treatment with cortisol lowering agents before first or second surgery, the operation technique used during the first surgery, persistent vs. recurrent disease after the first surgery, age, gender and interval between the two surgeries.

CONCLUSION

Repeated transsphenoidal surgery via the endoscopic technique is a good treatment option for selected patients with recurrent or persistent Cushing's disease following primary pituitary surgery.

Minimally invasive pituitary surgery

OBJECTIVES/HYPOTHESIS

Surgical approaches to the pituitary have undergone numerous refinements over the last 100 years. The introduction of the endoscope and the advent of minimally invasive pituitary surgery (MIPS) have revolutionized pituitary surgery. This study aims to compile and evaluate outcomes of all of the MIPS performed at our institution.

STUDY DESIGN

Retrospective, cases series of 176 consecutive patients undergoing MIPS.

METHODS

Patient demographics, tumor characteristics, and intraoperative or postoperative complications for of 176 consecutive patients undergoing MIPS were complied. Statistical analysis for categorical variables and incidence across series were conducted using Pearson's chi test and Fisher's exact tests. Odd ratios were calculated to relate the discrete variables to outcomes and designing clinical prediction of risk.

RESULTS

One hundred seventy-six patients who underwent 193 procedures. Pathologic evaluation revealed 147 of the tumors to be pituitary adenomas. Only one death occurred (mortality rate of 0.5%). The rate of diabetes insipidus occurred in 20.2% of the procedures. Vascular complications occurred in 5.2% of the procedures. Intraoperative cerebrospinal fluid (CSF) leaks were identified in 19.7% whereas postoperative CSF leak was noted in 10.3%. Resection of Rathke's cleft cyst correlated higher risk of both intraoperative and postoperative CSF leak (OR = 2.6, P <.001). Resection of tumors other than adenomata correlated with significantly higher risk of CSF leak (OR = 9.0, P = <.001). Sinusitis occurred after eleven resections (5.7%). Meningitis occurred in 2 of 193 resections (1.0%) in our series. Two neurologic complications occurred in our series, pneumocephalus and cranial neuropathy (1.0%). No other complications occurred.

CONCLUSIONS

MIPS is a safe and efficacious marriage of the endoscope to the transsphenoidal approach. Thus, a brightness and clarity of vision is combined with the unique ability to explore the tumor bed with angled views and hydroscopy. Outcomes and complication rates comparable to traditional transsphenoidal approaches have resulted but with less dissection and tissue manipulation, reduced need for packing, and greater patient comfort and acceptance.

Delayed cerebrospinal fluid leakage 10 years after transsphenoidal surgery and gamma knife surgery - case report -

A 38-year-old woman presented with repeated episodes of meningitis. She had undergone transsphenoidal tumor removal followed by gamma knife irradiation in 1994. Complete remission was achieved. Intermittent cerebrospinal fluid (CSF) leakage began in 2004, and transsphenoidal surgery was performed for direct repair of the skull base defect. Operative findings showed that the sellar floor was uncovered, and CSF continuously escaped through the cyanoacrylate polymer framework of the previous repair. Reconstruction used autologous muscle pieces and cyanoacrylate polymer adhesive. The CSF leakage was presumably due to delayed radiation damage to the mucous membrane of the skull base. Several methods for reconstruction of the sellar floor have been proposed, which all rely on tissue regeneration including the arachnoid, dura mater, and mucus membrane of the sphenoidal sinus. Preservation of the arachnoid membrane and minimizing removal of the mucous membrane are essential, especially if postoperative irradiation is anticipated.

Intracranial pressure concerns in lateral skull base surgery

This article serves as a concise review of cerebrospinal fluid metabolism and intracranial pressure regulation for otolaryngologists and lateral skull base surgeons. It examines the methodologies for maintaining cerebrospinal fluid homeostasis by preventing and treating acute elevations of intracranial pressure encountered during lateral skull base surgery.

Retrospective analysis of a new antibiotic chemoprophylaxis regimen in 170 patients undergoing endoscopic endonasal transsphenoidal surgery

BACKGROUND

The aim of this study is to evaluate the rate of infectious complications post endoscopic transspheinodal neurosurgery in patients receiving a new antibiotic chemoprophylaxis regimen.

METHODS

Clinical records of 170 patients who received prophylaxis with a third-generation cephalosporin plus aminoglycoside (160 cases) or alone (10 cases) were retrospectively analyzed. Twenty-eight patients (16.4%) had CSF leakage. The postsurgical follow-up ranged from 3 months to 4 years.

RESULTS

Of 170 patients, 2 (1.17%) developed infectious complications: 1 case of meningitis by Staphylococcus epidermidis and 1 case of sphenoid sinusitis (without microbiological diagnosis). In addition, asymptomatic sphenoid sinusitis was diagnosed in 2 other patients. The cost ranged from 22.50 to 33.34 euros/d.

CONCLUSIONS

The rate of infectious complications was very low in patients receiving prophylaxis with a third-generation cephalosporin plus aminoglycoside or alone; because of the broad-spectrum of antibiotics and their high cost, this regimen could be used in at-risk patients (eg, smokers, patients with cerebrospinal leak, or patients with Cushing diseases).

Bibliography. Current world literature. Nose and paranasal sinuses

PURPOSE OF REVIEW

Patients with advanced head and neck cancer are being treated with chemo-radiotherapy, and life is being prolonged, with or without persistent disease, for longer than was previously. Hypercalcaemia may present in patients with advanced or disseminated head and neck cancer, and, as such, these patients may present to a larger variety of clinicians for advice concerning their symptoms and illness. Modes of presentation of hypercalcaemia and treatment strategies are reviewed.

RECENT FINDINGS

There were previously few large series of head and neck cancer patients diagnosed with hypercalcaemia, which may or may not have been related to their cancer being treated. Investigations, by way of blood/serum calcium level, may identify such patients. Patients with cancer-related hypercalcaemia have a poor prognosis, but many may respond temporarily to treatment when offered, with an improvement of their quality of life and death.

SUMMARY

Hypercalcaemia should and must be considered in all patients who have or possibly have a diagnosis of a head and neck cancer and who present unwell with symptoms of fatigue, lethargy and somnolence. Investigation must include serum calcium (corrected for serum albumin binding) and parathyroid hormone level. Patients may be treated by a combination of rehydration and bisulphonate therapy until the serum calcium is reduced to a level below 3 mmol/l. The majority of patients diagnosed with hypercalcaemia due to head and neck malignancy die of their diseases in the short term, but some may enjoy a prolongation of life with reasonable quality if diagnosed and treated aggressively.