Cerebrospinal Fluid Leak in Transnasal Transsphenoidal Surgery for Pituitary Adenoma and its Management
Article Sidebar
Main Article Content
Abstract
Introduction
Over the past few decades endoscopic transnasal transsphenoidal (ETNTS) approach has been practised for excision of pituitary tumours which has minimised the rate of complications and morbidity. However, cerebrospinal fluid (CSF) leak remains a frequent complication requiring efficient management. Various skull-base repair techniques have been described in the literature all along, but there is no universal protocol for the same. Our study aims to determine an ideal strategy for skull-base repair following ETNTS surgery and suggest a protocol at the tertiary centre for the same.
Materials and Methods
In this prospective study, patients with pituitary adenoma undergoing ETNTS excision from January 2017 to May 2019 were included. Data were collected based on the intraoperative findings of grade of CSF leak following excision, surgical method for skull-base repair, biomaterials used, and recurrence of CSF leak postoperatively and its management.
Results
A total of 141 patients between 10 to 74 years of age (mean age 42.6) underwent ETNTS excision of pituitary adenoma. Intraoperative CSF leak was observed in 30.5% patients with 14.1% of grade I, 8.5% of grade II and 7.8% of grade III and repair was done with fat closure, multilayer closure and with naso-septal flap, respectively. Postoperative recurrence of CSF leak was found in 2.83% of total cases and 9.3% of patient with intraoperative leak, which were managed appropriately. Overall closure rate was 100% with no further recurrence of CSF leak.
Conclusion
Surgical repair of skull-base in CSF leak is challenging and requires management in careful and graded fashion for favourable outcome.
Article Details
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
References
Endoscopic Cranial Base and Pituitary Surgery, An Issue of Otolaryngologic Clinics of North America Volume 49-1 - 1st Edition sindwani/978-0-323-41763
Aiyer RG, Upreti G. Endoscopic Endo-nasal Trans-Sphenoidal Approach for Pituitary Adenomas: A Prospective Study. Indian J Otolaryngol Head Neck Surg [Internet]. 2019 Aug 19 [cited 2019 Nov 27]; Available from: https://doi.org/10.1007/s12070-019-01725-8
Watkinson JC, Clarke RW, editors. Scott-Brown’s Otorhinolaryngology and Head and Neck Surgery, Eighth Edition: 3 volume set. 8 edition. Boca Raton: CRC Press; 2018. 4356 p
Park J-H, Choi JH, Kim Y-I, Kim SW, Hong Y-K. Modified Graded Repair of Cerebrospinal Fluid Leaks in Endoscopic Endonasal Transsphenoidal Surgery. J Korean Neurosurg Soc. 2015 Jul;58(1):36-42
Romero ADCB, Nora JE, Topczewski TE, Aguiar PHP de, Alobid I, Rodriguéz EF. Cerebrospinal fluid fistula after endoscopic transsphenoidal surgery: experience in a spanish center. Arquivos de Neuro-Psiquiatria. 2010 Jun;68(3):414-7
Strickland BA, Lucas J, Harris B, Kulubya E, Bakhsheshian J, Liu C, et al. Identification and repair of intraoperative cerebrospinal fluid leaks in endonasal transsphenoidal pituitary surgery: surgical experience in a series of 1002 patients. J Neurosurg. 2018;129(2):425-9
Gondim JA, Almeida JPC, Albuquerque LAF, Schops M, Gomes E, Ferraz T, et al. Endoscopic endonasal approach for pituitary adenoma: surgical complications in 301 patients. Pituitary 2011 Jun;14(2):174-83
Zhang C, Ding X, Lu Y, Hu L, Hu G. Cerebrospinal fluid rhinorrhoea following transsphenoidal surgery for pituitary adenoma: experience in a Chinese centre. Acta Otorhinolaryngol Ital. 2017 Aug;37(4):303-7
Berker M, Aghayev K, Yücel T, Hazer DB, Onerci M. Management of cerebrospinal fluid leak during endoscopic pituitary surgery. Auris Nasus Larynx. 2013 Aug;40(4):373-8
Berker M, Hazer DB, Yücel T, Gürlek A, Cila A, Aldur M, et al. Complications of endoscopic surgery of the pituitary adenomas: analysis of 570 patients and review of the literature. Pituitary. 2012 Sep;15(3):288-300
Gendeh BS. Extended applications of endoscopic sinus surgery and its reference to cranial base and pituitary fossa. Indian J Otolaryngol Head Neck Surg. 2010 Sep;62(3):264-76
Conger A, Zhao F, Wang X, Eisenberg A, Griffiths C, Esposito F, et al. Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery: trends in repair failure and meningitis rates in 509 patients. Journal of Neurosurgery 2019 Mar;130(3):861-75
Umamaheswaran P, Krishnaswamy V, Krishnamurthy G, Mohanty S. Outcomes of Surgical Repair of Skull Base Defects Following Endonasal Pituitary Surgery: A Retrospective Observational Study. Indian J Otolaryngol Head Neck Surg. 2019 Mar;71(1):66-70
Locatelli D, Vitali M, Custodi VM, Scagnelli P, Castelnuovo P, Canevari FR. Endonasal approaches to the sellar and parasellar regions: closure techniques using biomaterials. Acta Neurochir (Wien). 2009 Nov;151(11):1431-7
Sanders-Taylor C, Anaizi A, Kosty J, Zimmer LA, Theodosopoulos PV. Sellar Reconstruction and Rates of Delayed Cerebrospinal Fluid Leak after Endoscopic Pituitary Surgery. J Neurol Surg B Skull Base. 2015 Aug;76(4):281-5
Sciarretta V, Mazzatenta D, Ciarpaglini R, Pasquini E, Farneti G, Frank G. Surgical repair of persisting CSF leaks following standard or extended endoscopic transsphenoidal surgery for pituitary tumor. Minim Invasive Neurosurg. 2010 Apr;53(2):55–9.
Mehta GU, Oldfield EH. Prevention of intraoperative cerebrospinal fluid leaks by lumbar cerebrospinal fluid drainage during surgery for pituitary macroadenomas. J Neurosurg. 2012 Jun;116(6):1299-303
Jonathan GE, Sarkar S, Singh G, Mani S, Thomas R, Chacko AG. A randomized controlled trial to determine the role of intraoperative lumbar cerebrospinal fluid drainage in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas. Neurol India. 2018 Feb;66(1):133-8.