Risk factors for postoperative cerebrospinal fluid leakage after transsphenoidal surgery for pituitary adenoma: a meta-analysis and systematic review

Cerebrospinal Fluid Leakage Due to Dural Thinning after Endoscopic Pituitary Tumor Resection

Sellar reconstruction is important for preventing cerebrospinal fluid (CSF) leakage after transsphenoidal pituitary surgery. This report describes how, despite standard sellar reconstruction, CSF exudation resulted from dural thinning at the anterior skull base, outside the intrasellar area manipulated during pituitary tumor resection. A 76-year-old man underwent endoscopic transsphenoidal surgery for a pituitary tumor extending toward the anterior skull base. After opening the sellar floor, intractable bleeding from the anterior intercavernous sinus occurred during bone removal at the anterior skull base. Pseudocapsule-based extracapsular resection was completed after stopping the bleeding. On the 10th postoperative day, the patient developed CSF rhinorrhea complicated by marked pneumocephalus, and emergency endoscopic repair of the CSF leak was performed. CSF leakage originated from the thinned dura at the anterior skull base located outside the intrasellar area manipulated during tumor resection. The thinned dural area at the anterior skull base coincided with the site of intractable bleeding of the anterior intercavernous sinus during bone removal in tumor resection. The thinned anterior skull base dura was covered with fascia, overlaid with fat, and closed with the nasoseptal flap. Endoscopic CSF leak repair was successful. Severe damage to the anterior intercavernous sinus can cause extensive exposure of the single-layered inner meningeal dura, where thinning might result in CSF exudation. Therefore, use of autologous tissues to cover and reinforce the severely damaged area of the anterior intercavernous sinus might help prevent postoperative CSF exudation.

Clinical Application of Artificial Intelligence in Prediction of Intraoperative Cerebrospinal Fluid Leakage in Pituitary Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Postoperative cerebrospinal fluid (CSF) leakage is the leading adverse event in transsphenoidal surgery. Intraoperative CSF (ioCSF) leakage is one of the most important predictive factors for postoperative CSF leakage. This systematic review and meta-analysis aimed to evaluate the effectiveness of artificial intelligence (AI) models in predicting ioCSF.

METHODS

Literature records were retrieved on June 13, 2024, using the relevant key terms without filters in PubMed, Embase, Scopus, and Web of Science. Records were screened according to the eligibility criteria, and the data from the included studies were extracted. The quality assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. The meta-analysis, sensitivity analysis, and meta-regression were conducted using R software.

RESULTS

Our results demonstrate that the AI models achieved a pooled sensitivity of 93.4% (95% confidence interval [CI]: 74.8%-98.6%) and specificity of 91.7% (95% CI: 75%-97.6%). The subgroup analysis revealed that the pooled sensitivities in machine learning and deep learning were 86.2% (95% CI: 83%-88.8%) and 99% (95% CI: 93%-99%), respectively (P < 0.01). The subgroup analysis demonstrated a pooled specificity of 92.1% (95% CI: 63.1%-98.7%) for machine learning and 90.6% (95% CI: 78.2%-96.3%) for deep learning models (P = 0.87). The diagnostic odds ratio meta-analysis revealed an odds ratio 114.6 (95% CI: 17.6-750.9). The summary receiver operating characteristic curve demonstrated that the overall area under the curve of the studies was 0.955, which is a considerable performance.

CONCLUSIONS

AI models have demonstrated promising performance for predicting the ioCSF leakage in pituitary surgery and can optimize the treatment strategy.

Wrapping method for better fat handling in endoscopic trans-sphenoidal surgery

Background

Fat is commonly used for preventing cerebrospinal fluid (CSF) leakage during endoscopic transsphenoidal surgery (ETSS). However, fat is soft, slippery, and sometimes not easy to handle. The present study aimed to examine the efficacy of our Surgicel® wrapping method, which allows for better fat handling, in preventing the occurrence of CSF leakage among patients undergoing ETSS.

Methods

We used fat tissues removed from the abdomen. The fat was cut with scissors into pieces that were approximately 5 mm in size. Surgicel® was also cut into 2.5 cm2. The fat tissues were encased with these Surgicel® squares and slightly moistened with a saline solution.

Results

Between January 2023 and August 2024, 34 patients aged 18-86 years (average 54.9 years) underwent ETSS. Among these patients, 20 had pituitary tumors, 6 had Rathke's cysts, and 8 had other conditions. None of the patients had CSF leakage postoperatively. The use of Surgicel®-wrapped fat during ETSS is better than the use of fat alone.

Conclusion

The Surgicel® wrapping method allows for better fat handling during ETSS.

Analysis of factors influencing the occurrence of diabetes insipidus following neuroendoscopic transsphenoidal resection of pituitary adenomas and risk assessment

Objective

Studies have revealed a higher prevalence of diabetes insipidus in patients following resection of pituitary adenoma surgery. By comprehensively analysing the clinical history of patients undergoing endoscopic transnasal sphenoidal resection for pituitary adenomas, the factors influencing development of postoperative diabetes insipidus were investigated and a predictive model was developed to assess its risk.

Methods

A retrospective analysis was conducted on the medical records of 281 patients with pituitary adenomas who underwent neuroendoscopic transsphenoidal resection at our institution between October 2020 and October 2022. The Mann-Whitney U test, chi-square test, and logistic regression analysis were used to identify the independent factors that potentially contribute to the development of postoperative diabetes insipidus. Additionally, a nomogram was constructed to evaluate the predicted risk of postoperative diabetes insipidus in patients with pituitary adenomas.

Results

Diabetes insipidus occurred in 100 (35.59 %) of the 281 enrolled patients. The results of the multifactorial logistic regression analysis revealed that diabetes, hypertension, cardiopathy, preoperative serum cortisol level, cerebrospinal fluid leakage, and tumour texture independently influenced the occurrence of postoperative diabetes insipidus (P < 0.05). A nomogram was developed to evaluate the risk of postoperative diabetes insipidus in patients with pituitary adenoma.

Conclusions

Multiple independent risk factors associated with the patient and tumour were identified in predicting diabetes insipidus. Early recognition of these risk factors may contribute to the prevention or reduction of diabetes insipidus incidence following pituitary adenoma surgery.

Patients at Greatest Risk of Missing Initial 1-Year Follow-Up After Pituitary Adenoma Resection

OBJECTIVE

Routine evaluation and surveillance imaging after pituitary adenoma (PA) endoscopic endonasal transsphenoidal resection (EETS) is a neurosurgical practice to identify tumor recurrence. This study aims to identify social and clinical factors that may contribute to patients missing their initial 1-year follow-up appointment and provide guidance for targeted education to improve patient adherence with postoperative treatment plans, ultimately reducing unknown adenoma recurrence.

METHODS

The authors performed a single-center retrospective review of patients who underwent EETS for PAs from 2007 to 2023. Patients were analyzed for sociodemographic factors, presenting symptoms, time to surgery, surgical outcomes, and adherence to postoperative follow-up visits at 1 year after surgery.

RESULTS

A total of 256 patients with PAs treated by EETS met inclusion criteria; 218 (85%) of these patients attended 1-year follow-up, and 38 (15%) missed this visit. Twenty-nine (76%) individuals who missed their 1-year follow up were men (P = 0.006). Divorced/widowed/separated patients were 2 times more likely to miss their follow-up compared with their married counterparts (P = 0.008). Additional significant risk factors included older age, as the mean age for patients who missed their 1-year appointment was 60.1 years compared with 54.7 years (P = 0.028). Patients with visual field deficits at initial presentation were also less likely to follow-up at 1 year (P = 0.03).

CONCLUSIONS

Risk factors of missed 1-year follow-up appointments after PA resection include male sex, divorced/widowed/separated marital status, older age, and the presence of visual deficits at initial presentation. Increased education efforts can be selectively aimed at these at-risk patient cohorts to improve patient compliance and reduce consequences of undetected tumor recurrence.

Conventional clinical signs and symptoms are poor predictors of postoperative cerebrospinal fluid leak: A single-centre cohort perspective

BACKGROUND

Postoperative cerebrospinal fluid (CSF) leak remains a concerning complication of the endoscopic endonasal approach (EEA) for skull base pathology. Signs and symptoms suggesting CSF leak often trigger additional workup during the postoperative course. We systematically evaluate associations between subjectively reported clinical signs/symptoms noted during the immediate postoperative period and incidence of postoperative CSF leaks.

METHODS

Retrospective chart review was conducted at a tertiary academic medical centre including 137 consecutive patients with intraoperative CSF leak during EEA with primary repair between July 2018 and August 2022. Postoperative CSF leak associations with clinical signs and symptoms were evaluated using positive (PPV) and negative predictive values (NPV), sensitivity, specificity and odds ratio (OR) via univariate logistic regression.

RESULTS

Seventy-nine patients (57.7%) had high-flow leaks repaired and 5 (3.6%) developed CSF leaks postoperatively. Of reported symptoms, rhinorrhea was most common (n = 52, 38.0%; PPV [95% CI] = 7.6% [4.8%, 11.9%]), followed by severe headache (n = 47, 34.3%; 6.3% [3.1%, 12.5%]), dizziness (n = 43, 31.4%; 2.3% [0.4%, 12.1%]), salty or metallic taste (n = 20, 14.6%; 9.9% [3.3%, 25.8%]), and throat drainage (n = 10, 7.3%; 9.9% [1.7%, 41.4%]). Nausea or vomiting constituted the most reported sign concerning for CSF leak (n = 73, 53.3%; PPV [95% CI] = 4.1% [2.0%, 8.1%]). On univariate regression, no sign or symptom, including rhinorrhea (OR [95% CI] = 7.00 [0.76-64.44]), throat drainage (3.42 [0.35-33.86]), salty/metallic taste (4.22 [0.66-27.04]), severe headache (3.00 [0.48-18.62]), dizziness (0.54 [0.06-4.94]), fever (3.16 [0.50-19.99]), and nausea/vomiting (1.33 [0.22-8.21]), associated with postoperative CSF leak.

CONCLUSIONS

A range of subjectively reported symptoms and signs failed to predict postoperative CSF leak. Further investigation is warranted to inform appropriate attention and response.

Risk factors associated with postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery: Two-center retrospective cohort study

Background

Over the past two decades, endoscopic endonasal skull base surgery (EESBS) has revolutionized the treatment of skull base tumors by enabling minimal access to resect significant pathologies such as meningiomas, pituitary adenomas, and chordomas. Despite its efficacy, complications such as cerebrospinal fluid (CSF) leak pose significant challenges, with an average incidence of 8.9% following EESBS. Therefore, our study aims to investigate the risk factors associated with postoperative CSF leak after employing an endoscopic endonasal approach for skull base surgery, focusing on patients treated at King Abdul-Aziz Medical City in Jeddah and King Abdullah Medical City in Makkah, Saudi Arabia.

Methods

A retrospective review of patients who underwent an endoscopic endonasal approach for the resection of intradural skull base pathology between January 2016 and December 2022 was performed with a total of 51 patients. Basic demographic data were collected, along with patient comorbidities, presenting symptoms, tumor pathology, tumor site, the extent of resection, and outcomes.

Results

51 participants were analyzed, with a mean age of 43.41. Male participants comprised (58.8%), while headaches were the most common symptom (74.5%), followed by visual disturbances (51.0%). Nonsecretory tumors predominated, primarily located in the sellar and suprasellar regions (58.8%). Gross total resection was performed in the majority (56.9%), with a 9.8% incidence of postoperative CSF leak. Notably, all four patients with CSF leak experienced preoperative headaches. Hypertension was prevalent in Cases 1 and 4, with Case 4 having a history of neurological disease and radiation therapy. Anterior skull base tumors were most frequent in Cases 3 and 4.

Conclusion

The incidence of CSF leakage after surgery in this study was similar to that previously reported. It is worth noting that repeated surgeries may increase the risk of postoperative CSF leakage. Therefore, it is important to carefully evaluate the surgical approach for tumor removal and skull base reconstruction, considering the tumor characteristics and the patient's overall condition.

Surgical outcomes in patients with acromegaly: Microscopic vs. endoscopic transsphenoidal surgery

Transsphenoidal resection of growth hormone-secreting pituitary neuroendocrine tumors remains the first-line treatment for acromegaly. This can be performed through microsurgery or endoscopic surgery. For the past decades, endoscopic surgery has become the preferred technique in an increasing number of centers worldwide. However, whether it offers superior clinical outcomes has yet to be determined. In this paper, we performed a narrative review of the literature comparing both techniques in the treatment of acromegaly. We critically assessed available comparative studies from an objective perspective to determine their suitability for defining superiority of either technique. Available evidence displays substantial methodological variations and reports conflicting findings. Although endoscopic surgery provides a wider exposure and enhanced visibility of the surgical field, this does not consistently translate into better clinical outcomes, as most tumors are equally accessible through both techniques. Postoperative outcomes such as remission and complication rates are similar between both techniques. The management of acromegaly should be performed by experienced pituitary neurosurgeons, regardless of the approach. The involvement of a multidisciplinary team in a dedicated pituitary center is critical to ensure optimal outcomes.

Risk factors of cerebrospinal fluid leakage after neuroendoscopic transsphenoidal pituitary adenoma resection: a systematic review and meta-analysis

Introduction

Cerebro spinal fluid (CSF) leakage is common and might lead to severe postoperative complications after endoscopic transsphenoidal pituitary adenoma resection. However, the risk factors of postoperative CSF leakage are still controversial. This article presents a systematic review to explore the explicit risk factors of CSF leakage after endoscopic transsphenoidal pituitary adenomere section.

Methods

PRISMA and AMSTAR guidelines were followed to assess the methodological quality of the systematic review. PubMed, Medline, Embase, Web of Science, Cochrane, Clinical Trails, CNKI, CBM, Wan Fang, and VIP databases were searched for all studies on postoperative CSF leak risk factors. The quality of the included studies was assessed by the Newcastle-Ottawa scale. Review Manager 5.4 software was used to calculate the pooled effect size of potential factors with statistical significance.

Results

A total of 6775 patients with pituitary adenoma across 18 articles were included, containing 482 cases of postoperative CSF leakage (accounting for 7.11%). All of the articles had a quality score > 5, indicating good quality. Meta-analysis showed that an increased risk of CSF leak was found for higher levels of BMI (MD=1.91, 95% CI (0.86,2.96), bigger tumor size [OR=4.93, 95% CI (1.41,17.26)], greater tumor invasion (OR=3.01, 95% CI (1.71, 5.31), the harder texture of tumor [OR=2.65, 95% CI (1.95,3.62)], intraoperative cerebrospinal fluid leakage [OR=5.61, 95% CI (3.53,8.90)], multiple operations [OR=2.27, 95% CI (1.60,3.23)].

Conclusion

BMI, multiple operations, tumor size, tumor invasion, hard texture, and intraoperative cerebrospinal fluid leakage are the risk factors of postoperative CSF leakage. Clinical doctors should pay attention to these risk factors, and conduct strict skull base reconstruction and careful postoperative management.

Intraoperative cerebrospinal fluid leakage and residual tumors in endoscopic transsphenoidal surgery for pituitary adenoma: risk analysis and nomogram development

BACKGROUND

Endoscopic transsphenoidal surgery is the primary method used to treat pituitary adenomas (PAs) at present; however, this technique is associated with certain risks, including cerebrospinal fluid leakage (CFL) and residual tumors (RTs). In this study, we aimed to identify specific risk factors for intraoperative CFL (ioCFL) and postoperative RT in patients with pituitary adenoma and construct a corresponding nomogram for risk assessment.

METHODS

We collected a range of information from 782 patients who underwent endoscopic transsphenoidal PA resection in the Department of Neurosurgery at Beijing Tiantan Hospital between 2019 and 2021. Patients were then randomly assigned to training and validation groups (in a 8:2 ratio) with R software. Univariate and multivariable logistic regression models were then used to screen variables related to ioCFL and RT. These variables were then used to construct a predictive nomogram. Finally, the accuracy of the nomogram was validated by receiver operating characteristic curve (ROC) analysis, calibration plots, and decision curve analysis (DCA).

RESULTS

Univariate and multivariable logistic regression models identified four risk factors for ioCFL (Hardy grade, tumor size, position, and consistency) and five risk factors for RT (operation time, tumor size, consistency, Knosp grade, and primary/recurrence type). The area under the ROC curve (AUC) for the ioCFL risk model was 0.666 and 0.697 for the training and validation groups, respectively. For RT, the AUCs for the two groups were 0.788 and 0.754, respectively. The calibration plots for the ioCFL and RT models showed high calibration quality and DCA analysis yielded excellent efficiency with regards to clinical decision making.

CONCLUSION

Tumor size, growth characteristics, and invasion location were identified as the main factors affecting intraoperative CFL and RT. With our novel nomogram, surgeons can identify high-risk patients according to preoperative and intraoperative tumor performance and reduce the probability of complications.

Current and Future Perspectives of Microscopic and Endoscopic Transsphenoidal Surgery for Pituitary Adenomas: A Narrative Review

Transsphenoidal resection remains the standard treatment for most pituitary adenomas. However, the ideal surgical approach to safely access these lesions, either microsurgical or endoscopic, continues to be debated. Since the introduction of endoscopic transsphenoidal surgery, centers around the world have increasingly adopted this technique, experiencing a shift away from the conventional microsurgical approach. Large series reporting the efficacy and safety of endoscopic surgery have fueled a growing interest in comparing clinical outcomes between both approaches. Still, proving superiority of either surgical approach remains an elusive task due to the inherent drawbacks of surgical observational studies, as we are still faced with a growing body of evidence reporting conflicting results. Thus, a comprehensive discussion regarding the reach and limitations of both techniques becomes necessary. In this narrative review, we perform a critical appraisal of the literature and provide an expert opinion on the state-of-the-art in transsphenoidal surgery for pituitary adenomas. The advantages and limitations of each approach are assessed and compared from a technical standpoint, and their reported outcomes evaluated in the framework of this transition phase. Available evidence should be interpreted in light of individual patient characteristics and within the context of each medical center, taking into consideration the known impact that surgical expertise and multidisciplinary management hold on clinical outcomes.

Comparison of microscopic transsphenoidal surgery and neuroendoscopic transsphenoidal surgery in pituitary adenoma resection and the risk factors of postoperative cerebrospinal fluid leakage

OBJECTIVE

To compare microscopic transsphenoidal surgery (MTS) and neuroendoscopic transsphenoidal surgery (NTS) in pituitary adenoma (PA) resection and analyze the risk factors of postoperative cerebrospinal fluid leakage (CFL).

METHODS

The clinical data of 127 patients with PA treated in Xi'an International Medical Center Hospital from January 2019 to January 2021 were analyzed retrospectively. Among them, 54 patients treated by MTS for PA resection were assigned to the control group, while the rest of the 73 patients treated by NTS for PA resection were assigned to the study group. The total tumor resection rate, decrease of hormone levels after operation, alleviation of primary symptoms and complications were compared between the two groups. Logistics regression analysis was conducted to analyze the risk factors of CFL.

RESULTS

The control group experienced a shorter operation time than the study group (P<0.001). The resection rates of the control and study groups were comparable, but the study group showed a lower incidence of postoperative complications than the control group (P = 0.004). In addition, the study group showed better alleviation of primary symptoms than the control group (P = 0.013). After surgery, the two groups presented decreased levels of prolactin and growth hormone (P<0.001), and also showed decreased average adrenocorticotropic hormone (P<0.001). Moreover, the two groups were not significantly different in the levels of prolactin, growth hormone and adrenocorticotropic hormone after surgery (P>0.05). According to multivariate logistics regression analysis, body mass index (BMI) (P = 0.003, OR = 8.791, 95% CI: 2.050-37.693), intraoperative CFL (P = 0.002, OR = 21.614, 95% CI: 0.305-153.162) and therapeutic regimen (P = 0.011, OR = 7.060, 95% CI: 1.554-32.076) were independent risk factors for postoperative CFL.

CONCLUSION

Compared with MTS, endoscopic transsphenoidal surgery requires a notably longer time, but it can strongly improve the total resection rate of patients and reduce the incidence of postoperative complications. Endoscopic surgery is a protective factor of postoperative CFL.

Skull base reconstruction using in situ bone flap in patients with pituitary adenomas treated by endoscopic endonasal approach

Objective

The objective of this study is to study the effect of in situ bone flap (ISBF) repositioning, a recently proposed rigid skull base reconstruction technique, on patients diagnosed with pituitary adenoma undergoing endoscopic endonasal approach (EEA).

Method

A retrospective analysis was conducted on 188 patients with pituitary adenomas who underwent EEA from February 2018 to September 2022. Patients were divided into the ISBF group and non-ISBF group, according to whether ISBF was used during skull base reconstruction.

Results

Of the 75 patients in the non-ISBF group, 6 had postoperative cerebrospinal fluid (CSF) leakage (8%), while only 1 of 113 patients in the ISBF group (0.8%) had postoperative CSF leakage, indicating that the incidence of postoperative CSF leakage in the ISBF group was significantly lower than that in the non-ISBF group (P = 0.033). In addition, we also found that the postoperative hospitalization days of patients in the ISBF group (5.34 ± 1.24) were significantly less than those in the non-ISBF group (6.83 ± 1.91, P = 0.015).

Conclusion

ISBF repositioning is a safe, effective, and convenient rigid skull base reconstruction method for patients with pituitary adenoma treated by EEA, which can significantly reduce the rate of postoperative CSF leakage and shorten postoperative hospital stays.

[Application of ethmoid artery pedicled septal floor mucosa flap in repair of postoperative cerebrospinal fluid leak after transsphenoidal pituitary surgery]

Objective:To investigate the safety and effectiveness of the ethmoid artery pedicled septal floor mucosal flap in repair of postoperative cerebrospinal fluid leakage after transsphenoidal pituitary tumor surgery.Methods: The clinical data of 6 patients with cerebrospinal fluid leak in Department of Otolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from June 2011 to June 2022. In 6 patients with postoperative cerebrospinal fluid leakage after transsphenoidal pituitary surgery, the bilateral posterior septal arteries were sacrificed due to the endoscopic transsphenoidal expanded approach, so the ethmoid artery pedicled septal floor mucosal flaps were adopted.Results:All patients had good growth of the mucosal flaps during postoperative follow-up without recurrent cerebrospinal fluid leakage. Conclusion:Cerebrospinal fluid leakage is still one of the postoperative complications of pituitary surgery. For patients with bilateral posterior septal arteries sacrificed through the transsphenoidal approach, when the classic posterior septal artery pedicled mucosal flap is not available, the ethmoid artery pedicled septal floor mucosal flap is one of the alternative methods.

A simple surgical technique for sellar closure after transsphenoidal resection of pituitary adenomas in the context of risk factors for cerebrospinal fluid leaks and meningitis

OBJECTIVE

The transsphenoidal approach is the standard for most pituitary tumors. Despite low morbidity, postoperative CSF fistulas and meningitis are specific complications. Various surgical closure techniques for intraoperative CSF (iCSF) leak and sellar reconstruction have been described. For many years the authors have applied synthetic materials for iCSF leak repair and sellar closure in a standardized fashion in their department. Here they analyze the surgical outcome as well as risk factors for iCSF leak and meningitis.

METHODS

All patients with transsphenoidal resection of a pituitary adenoma performed by the same surgeon between January 2013 and December 2019 were screened retrospectively. A small amount of iCSF flow without a diaphragmatic defect was classified as a minor leak, and obvious CSF flow with or without a diaphragmatic defect was classified as a major leak. In case of iCSF leak, a fibrin- and thrombin-coated sponge was used to cover the diaphragmatic defect and another one was used for the sellar opening. A gelatin sponge was placed in the sphenoid sinus as an abutment. The primary and secondary outcomes were the number of postoperative CSF (pCSF) leaks and meningitis, respectively. Clinical, histological, and perioperative data from medical records were collected to identify risk factors for CSF leak and meningitis.

RESULTS

Of 417 transsphenoidal surgeries, 359 procedures in 348 patients with a median age of 54 years were included. There were 96 iCSF leaks (26.7%; 37.5% major, 62.5% minor). In 3 of 359 cases (0.8%) a pCSF fistula occurred, requiring revision surgery in 2 patients and a lumbar drain in 1 patient. Meningitis occurred in 3 of 359 cases (0.8%). All 3 patients recovered without sequelae after antibiotic therapy. According to univariate analysis, risk factors for iCSF leak were macroadenoma (p = 0.006) and recurrent adenoma (p = 0.032). An iCSF leak was found less often in functioning adenomas (p = 0.025). In multivariate analysis recurrent tumors remained as a risk factor (p = 0.021) for iCSF leak. Patients with iCSF leak were at increased risk for a pCSF leak (p = 0.005). A pCSF leak in turn represented the key risk factor for meningitis (p = 0.033).

CONCLUSIONS

Patients with macroadenomas and recurrent adenomas are especially at risk for iCSF leak. An iCSF leak in turn increases the risk for a pCSF leak, which carries the risk for meningitis. The authors' surgical technique leads to a very low rate of pCSF leaks and meningitis without using autologous graft materials. Hence, this technique is safe and improves patient comfort by avoiding the disadvantages of autologous graft harvesting.

The outcomes of surgical treatment via transsphenoidal approach for patients with nonfunctioning pituitary adenoma: a single institution's experience

BACKGROUND

Nonfunctioning pituitary adenoma is a primary benign brain neoplasm and the transsphenoidal approach is known for a safe and effective first-line surgical treatment for pituitary tumours. The aim of this study was to retrospectively analyse the outcomes of the transsphenoidal approach for nonfunctioning pituitary adenomas treated at a single institute.

METHODS

A total of 181 patients who underwent transsphenoidal approach with nonfunctioning pituitary adenoma at a single institute from March 1998 to November 2018 were included in this study. Ninety-six (53.0%) men and 85 (47.0%) women aged 21-79 years were included. The median outpatient follow-up duration was 58 months, and the median magnetic resonance imaging follow-up duration was 54 months. We assessed the surgical and clinical outcomes, complications, hormonal outcomes and recurrence tendency.

RESULTS

The overall total resection rate of a transsphenoidal approach for nonfunctioning pituitary adenoma was 84.0%. Visual impairment was improved after surgery in 115 (93.5%) of 123 patients. Of the 80 patients who complained of preoperative endocrine dysfunction, 62 (77.5%) patients recovered normal postoperative endocrine function. Diabetes insipidus, which occurred in 22 (12.2%) patients, was the most common complication. A total of 21 (11.6%) patients showed recurrence on average 57.6 months after surgery. The average recurrence period after surgery was 96.3 months in the total resection group of 6 patients and 42.1 months in the subtotal resection group of 15 patients. In multivariate analysis, the extent of resection was identified as a significant predictor of tumour recurrence with a hazard ratio of 6.093 and a p-value of 0.002.

CONCLUSIONS

It is meaningful to report long-term surgical results within a single institution, and through this, it was reconfirmed that transsphenoidal approach is an effective and safe treatment for nonfunctioning pituitary adenoma. Long-term follow-up is required due to the possibility of recurrence. In addition, performing total resection during surgery helps to lower the risk of recurrence.KEY MESSAGESTranssphenoidal approach is an effective and safe treatment modality for pituitary adenoma.Complete resection is a significant predictor for the recurrence of pituitary adenomaLong-term follow-up is necessary for the treatment of nonfunctioning pituitary adenomas.

Cirugía endoscópica transnasal de base de cráneo: Análisis de las complicaciones en los primeros 120 procedimientos

Antecedentes:

El abordaje endoscópico endonasal (AEE) presenta ventajas potenciales a los abordajes abiertos tradicionales. Sin embargo, se han descrito complicaciones como la fístula de líquido cefalorraquídeo (LCR), trastornos visuales y meningitis postquirúrgica. El objetivo de este trabajo es presentar la experiencia acumulada en 120 casos de cirugía endoscópica de base de cráneo realizadas por un mismo equipo quirúrgico, y describir y analizar las principales complicaciones postoperatorias según la complejidad de los casos.

Métodos:

Estudio retrospectivo sobre nuestra base de datos de pacientes operados de AEE de base de cráneo por diversas patologías entre julio de 2011 y marzo de 2022.

Resultados:

Se analizaron 120 cirugías con AEE de base de cráneo. El 57.14% fueron realizadas en mujeres. La mediana de edad fue de 44 años. El 26.66% fueron reintervenciones. La patología más frecuente fue el adenoma hipofisario (49.17%) seguida de la fístula de LCR (8.33%). El AEE más utilizado fue el transelar 65.83%. Se registraron 26 complicaciones, sin diferencias según la complejidad. Se constataron 13 casos de diabetes insípida (DI) y 8 de fístula de LCR. Esta fue más frecuente en pacientes con fístula intraoperatoria de LCR. La mediana de internación fue de 5.5 días.

Conclusiones:

El AEE de base de cráneo se ha vuelto una opción cada vez más utilizada para el manejo quirúrgico de la patología de la base de cráneo, con una baja frecuencia de complicaciones postoperatorias inmediatas y baja mortalidad. El perfeccionamiento de la técnica como la mejoría en los cuidados postoperatorios se asocian a una menor estancia hospitalaria.

Factors Influencing Cerebrospinal Fluid Leaking following Pituitary Adenoma Transsphenoidal Surgery: A Meta-Analysis and Comprehensive Review

Background

Surgical resection is the main method to treat pituitary adenoma. Cerebrospinal fluid leakage (CSF Leak) is the main complication after transsphenoidal surgery. The impact of postoperative CSF Leak can be predicted in advance, and preventive measures can be taken in time. Clinically, a variety of factors may affect the occurrence of postoperative CSF Leak. In this study, meta-analysis was used to investigate the risk factors of postoperative CSF Leak as a clinical reference.

Methods

The databases PubMed, Medline, Embrase, Cochrane library, CNKI, and CBM were searched for all studies on the risk factors of postoperative CSF Leak. Studies were screened and finally included. The quality of the included studies was assessed by the Newcastle-Ottawa scale. We used Revman 5.4 software to conduct the pooled effect size of every potential statistically significant factor.

Results

13 articles with a total of 5967 patients with pituitary adenoma and 405 cases of postoperative CSF Leak were finally included, accounting for 6.79%. All of the 13 articles had a quality score > 5, indicating good quality. Meta-analysis showed that patient age (OR = 0.71, 95% CI (0.41, 1.20), P = 0.20) was not a factor influencing postoperative CSF Leak, while BMI (MD = 2.26, 95% CI (1.31, 3.20), P < 0.00001), tumor size (MD = 1.35, 95% CI (0.22, 2.49), P = 0.02), whether a second operation was performed (OR = 2.20, 95% CI (1.45, 3.33), P = 0.0002), and intraoperative CSF Leak (OR = 8.88, 95% CI (3.64, 21.69), P < 0.00001) were risk factors for postoperative CSF Leak in patients. Discussion. BMI, tumor size, reoperation, and intraoperative CSF Leak are the risk factors of postoperative CSF Leak. However, not all the factors were covered in this study, it is still worth continuing to deeply investigate in this topic.