Original Article
A Sandwich Technique for Prevention of Cerebrospinal Fluid Rhinorrhea and Reconstruction of the Sellar Floor after Microsurgical Transsphenoidal Pituitary Surgery Christian F. Freyschlag1 Stephanie Alice Goerke1 Claudius Thomé1 Marcel Seiz2 1 Department of Neurosurgery, Innsbruck Medical University,
Innsbruck, Austria 2 Department of Neurosurgery, University Medical Center Mannheim, Mannheim, Germany
Jochen Obernauer1
Johannes Kerschbaumer1
Address for correspondence Marcel Seiz, MD, Department of Neurosurgery, University Medical Center Mannheim, Theodor-KutzerUfer 1-3, Mannheim 68167, Germany (e-mail: [email protected]).
Abstract
Keywords
► ► ► ►
pituitary surgery transsphenoidal coated collagen fleece cerebrospinal fluid rhinorrhea
Background Cerebrospinal fluid (CSF) leaks are a well-known complication of transsphenoidal surgery. Several autologous and artificial grafts have been used to close the sellar floor in an attempt to prevent postoperative CSF rhinorrhea. Objective To evaluate and describe a sandwich technique to close the sellar floor using autologous bone, absorbable gelatin sponge, and coated collagen fleece. Methods We reviewed 50 consecutive patients between April 2010 and August 2011 who underwent transsphenoidal surgery ending with reconstruction of the sellar floor with a particular sandwich technique. Patients with an intraoperative CSF leak received an additional lumbar drain. Results There were no cases of CSF rhinorrhea at postoperative follow-up after 6 weeks and no revision surgery. Conclusion The proposed sandwich technique for closure of the sellar floor to the sphenoid sinus is a suitable alternative to autologous grafts and seems to be effective in preventing CSF rhinorrhea.
Introduction The transnasal or endonasal transsphenoidal route is the standard approach for most pituitary adenomas and other pathologies in the sellar region. Prevention and repair of cerebrospinal fluid (CSF) leak remains a challenging part of the surgical intervention. Postoperative CSF fistula, presenting preponderantly as rhinorrhea, is a major complication early after transsphenoidal surgery with an incidence ranging from 0.5 to 15%.1–3 Several different techniques have been described so far including various grafts (i.e., autologous) with or without lumbar CSF drainage. Autologous grafts like
received August 5, 2013 accepted after revision December 30, 2014
abdominal fat tissue or fascia lata are biocompatible, but most require a separate surgical incision. Thus graft harvesting increases morbidity and causes additional pain plus the risk of cosmetic disfiguration. Continuous lumbar CSF drainage is a safe and easy-to-handle procedure to prevent and treat rhinorrhea with a low risk of infection,4 but it lengthens the patient’s hospital stay and needs meticulous care when mobilizing patients. We evaluated the safety and effectiveness of a particular technique to close the sellar floor in patients with or without intraoperative CSF leak after transsphenoidal surgery and compared it with the current literature.
© Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0035-1547357. ISSN 2193-6315.
Downloaded by: Washington University. Copyrighted material.
J Neurol Surg A
Sellar Floor Reconstruction after Transsphenoidal Surgery
Freyschlag et al.
Methods
Table 1 Gender distribution, surgical and endocrinologic status, and immunohistochemical subtyping of pituitary adenomas
Patients From April 2010 to August 2011, 50 consecutive patients underwent endonasal transsphenoidal resection of intra-, supra-, and parasellar tumors at the Neurosurgical Department, Innsbruck Medical University, with a median follow-up of 15 months (range: 8–24 months). Ten patients had suspected intraoperative CSF leakage. All cases were sealed and reconstructed with the sandwich technique (►Table 1). The primary goal of the study was absence of CSF fistula. Further parameters evaluated in our population were tumor expansion (intra-, supra-, and parasellar), compression of the optic chiasm, age, and histologic diagnosis.
n ¼ 50
%
Male
34
68
Female
16
32
Primary
36
72
Recurrence
11
22
Previous subtotal resection
3
2
Characteristics Gender
Surgery
Surgical Technique
Intrasellar
12
24
Microsurgical endonasal transsphenoidal resection was performed in all 50 patients. Endoscopic-assisted surgery was applied as indicated according to the surgeon. All cases underwent the identical procedure as outlined in the following description. Endonasal tamponades are placed in all patients in both nostrils for 24 hours. If there is evidence or suspicion of intraoperative CSF leakage, it is our routine practice to insert a lumbar CSF drain within the same general anesthesia and drain 90 mL/day for at least 5 days without antibiotic prophylaxis. One of the authors (C.T.) has used a particular reconstruction technique of the sellar floor for years in transsphenoidal surgery. During the access part of the surgery, ideally one piece of bone graft is harvested from the anterior wall of the sphenoidal sinus, the vomer, and/or the sinus septum (if applicable). A fibrin sealant-coated collagen fleece (TachoSil, Nycomed, Linz, Austria) is used for watertight sealing of the sellar floor. Spongostan (Ethicon Biosurgery, Johnson & Johnson Medical, Somerville, New Jersey, United States), a gelatinous sponge of porcine origin, is used as a filling layer between the TachoSil and the bone graft (►Fig. 1). It was previously proven to be effective in preventing CSF fistulas, acting as a sealing compound in transcranial surgery.5 A small rectangle of TachoSil is placed alternating with adsorbable gelatin sponge with a bone graft finally placed to achieve a watertight seal and adequate anatomical reconstruction. It is critical for the described technique that the piece of bone is placed in the bony opening of the sellar floor and thus provides a buttress to keep both the TachoSil and Spongostan materials in place.
Intra- and parasellar
10
20
Statistical Analysis Statistical analysis was calculated with SPSS software, v.20 (IBM Corp., Armonk, New York, United States), and significance was set for p 0.05. Significance levels were calculated with the chi-square test and correlation according to the Pearson test, as appropriate.
Results Within our study population were 34 male (68%) and 16 female (32%) patients with a median age of 55 years (range: Journal of Neurological Surgery—Part A
Intra- and suprasellar
11
22
Intra-, para-, and suprasellar
17
34
No insufficiency
21
42
Complete insufficiency
3
6
Partial insufficiency
9
18
Other endocrine activity
14
28
Prolactinoma
3
6
2
4
Endocrine status
Immunohistochemical subtyping ACTH PRL
3
6
GH/PRL
2
4
GH
6
12
Inactive
33
66
Other
4
8
Abbreviations: ACTH, adrenocorticotropic hormone; GH, growth hormone; PRL, prolactin.
22–82 years). Only 24% of the adenomas were purely intrasellar; 40% were at least supra- or parasellar, and 36% were located in the intra-, supra-, and parasellar compartments. ►Table 1 shows the endocrine symptomatology and histologic types. We found 10 cases (20%) of suspected intraoperative CSF leak. All 10 patients received lumbar CSF drainage at the end of surgery. Surgery was performed for the first time in 35 patients (70%); 12 patients (24%) had a recurrence of a surgically treated adenoma, and 3 patients (6%) underwent a second surgery after a previous subtotal resection. At the time of discharge, none of our patients had evidence of CSF rhinorrhea. After 6 weeks, none of the patients presented with rhinorrhea in our outpatient clinic.Expansion to the parasellar and suprasellar compartment did not significantly influence the risk of intraoperative CSF leakage (p ¼ 0.382). Furthermore, compression of the optic chiasm (p ¼ 0.434), age (p ¼ 0.634), and histologic subtyping
Downloaded by: Washington University. Copyrighted material.
Expansion
Fig. 1 (A) Preoperative pituitary macroadenoma. (B) After endonasal transsphenoidal resection showing the sellar floor and lowered sellar diaphragm (DS). (C) The particular sandwich technique showing gelatinous sponge (GS) and TachoSil (TC) to seal the defect in the sellar dura while the sellar floor is closed and reconstructed with a piece of bone (B), serving as a buttress in the created bony defect. D, dura mater; IN, infundibulum; SS, sphenoid sinus.
(p ¼ 0.204) showed no statistical significance. Patients with a second surgical intervention after a subtotal resection showed a significantly higher incidence of CSF leakage (p ¼ 0.012).
Discussion The introduction of transsphenoidal surgery for pituitary tumors by Schloffer in 1907 constituted the beginning of natural orifice surgery in the field of neurosurgery.6 This approach necessitates dural closure of the sellar floor because postoperative CSF rhinorrhea is a common complication, with an incidence ranging between 0.5% and 15%.1–3,7 It is self-evident that with a narrow surgical corridor, closure techniques are challenging. In the history of transsphenoidal pituitary surgery, prevention of CSF rhinorrhea was usually performed with autologous grafts such as fascia
Freyschlag et al.
lata or packing of the sella with abdominal fat.1,8,9 In our study, we prospectively analyzed 50 patients after endonasal transsphenoidal surgery to evaluate a standardized sandwich technique for dural and sellar closure. There are several known risk factors for disruption of the sellar diaphragm and arachnoid and consecutive CSF leakage in transsphenoidal surgery. In the literature, tumor size,3,10,11 histopathologic tumor type,11,12 or surgeon experience9,13 are mentioned as risk factors. In our series, extensive growth, chiasmatic compression, patient age, or histopathologic tumor type did not have a significant influence on intraoperative CSF leakage. However, reoperation after previous subtotal resection showed a significant increase in intraoperative CSF leakage (p ¼ 0.012), possibly due to scarring of the arachnoidal sheets and adhesions to the sellar diaphragm. Numerous recent publications discuss dural repair after transsphenoidal surgery,7,14 such as suturing techniques for autologous fascial transplants. Ahn and Kim15 reported the use of a new set of forceps and needle holders especially designed for transsphenoidal microsurgery. In their series of 21 patients, they found no postoperative CSF rhinorrhea. Their procedure of suturing the fascial transplant seems time consuming (50–90 minutes), even for surgeons with long experience in using the developed tools. Cho et al published their retrospective series of 307 consecutive patients with pituitary adenomas, all operated microsurgically with endoscopic assistance in selected cases. They found a total of 156 intraoperative CSF leakages of which 90 were closed with the TachoComb (CSL Behring, Tokyo, Japan) in a “packing” technique. Two of these patients had to be reoperated due to CSF rhinorrhea. No standardized international regimen exists for the prevention of CSF leakage. Mehta and Oldfield16 reported the use of intraoperative lumbar drainage, resulting in a significant (p < 0.001) reduction of intraoperative CSF leakage, but they still found a 5% rate of postoperative rhinorrhea independent of the intraoperative evidence of CSF leakage. We generally place lumbar CSF drains after the surgical procedure if intraoperative CSF leakage has been detected either spontaneously or during the Valsalva maneuver. In questionable cases, the individual surgeon makes the decision to place lumbar drainage. In the series of Dlouhy et al,17 the use of lumbar drainage for resolving postoperative CSF fistula was evaluated. In their cohort of 63 sellar pathologies, they found 20 cases of intraoperative CSF leakage and one with a postoperative CSF fistula. Their standard procedure of keeping the patient bedridden with lumbar drainage for 2 to 4 days resulted in no need for reoperation. The additional use of lumbar drainage is still controversial and has to be evaluated prospectively to generate stronger evidence. Grotenhuis18 showed that using a simple liquid sealant (DuraSeal; Covidien, Waltham, Massachusetts, United States) effectively reduced hospital costs by preventing CSF leakage in 44 consecutive transsphenoidal procedures. Sealant agents increase the costs of surgical treatment dramatically. In comparison, the closure technique reported in our series is cost effective and shows favorable results in preventing CSF leakage. In our department, TachoSil costs €250 per unit Journal of Neurological Surgery—Part A
Downloaded by: Washington University. Copyrighted material.
Sellar Floor Reconstruction after Transsphenoidal Surgery
Freyschlag et al.
(95 48 mm); Spongostan (70 50 10 mm) is available for €20 per unit.
7 Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH.
Limitation 8
We are aware this study represents a small number of patients without power calculation and without a comparative study design.
Conclusion We believe that sufficient sealing and reconstruction of the sellar floor can be achieved with a simple sandwich technique using nonautologous material (TachoSil, Spongostan) in combination with autologous bone.
9
10
11
12
References 1 Black PM, Zervas NT, Candia GL. Incidence and management of
2
3
4
5
6
complications of transsphenoidal operation for pituitary adenomas. Neurosurgery 1987;20(6):920–924 Cho JM, Ahn JY, Chang JH, Kim SH. Prevention of cerebrospinal fluid rhinorrhea after transsphenoidal surgery by collagen fleece coated with fibrin sealant without autologous tissue graft or postoperative lumbar drainage. Neurosurgery 2011;68(1, Suppl Operative):130–136; discussion 136–137 Seiler RW, Mariani L. Sellar reconstruction with resorbable Vicryl patches, gelatin foam, and fibrin glue in transsphenoidal surgery: a 10-year experience with 376 patients. J Neurosurg 2000;93(5): 762–765 Açikbaş SC, Akyüz M, Kazan S, Tuncer R. Complications of closed continuous lumbar drainage of cerebrospinal fluid. Acta Neurochir (Wien) 2002;144(5):475–480 Barth M, Tuettenberg J, Thomé C, Weiss C, Vajkoczy P, Schmiedek P. Watertight dural closure: is it necessary? A prospective randomized trial in patients with supratentorial craniotomies. Neurosurgery 2008;63(4, Suppl 2):352–358; discussion 358 Schloffer H. Erfolgreiche Operation eines Hypophysentumors auf nasalem Wege. Wien Klin Wochenschr 1907;20:621–624
Journal of Neurological Surgery—Part A
13
14
15
16
17
18
Endoscopic endonasal versus open repair of anterior skull base CSF leak, meningocele, and encephalocele: a systematic review of outcomes. J Neurol Surg A Cent Eur Neurosurg 2013;74(4): 239–250 Hardy J. Transsphenoidal hypophysectomy. J Neurosurg 1971; 34(4):582–594 Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 1997;40(2): 225–236; discussion 236–237 Van Velthoven V, Clarici G, Auer LM. Fibrin tissue adhesive sealant for the prevention of CSF leakage following transsphenoidal microsurgery. Acta Neurochir (Wien) 1991;109(1–2):26–29 Sade B, Mohr G, Frenkiel S. Management of intra-operative cerebrospinal fluid leak in transnasal transsphenoidal pituitary microsurgery: use of post-operative lumbar drain and sellar reconstruction without fat packing. Acta Neurochir (Wien) 2006;148(1):13–18; discussion 18–19 Shiley SG, Limonadi F, Delashaw JB, et al. Incidence, etiology, and management of cerebrospinal fluid leaks following trans-sphenoidal surgery. Laryngoscope 2003;113(8):1283–1288 Fatemi N, Dusick JR, de Paiva Neto MA, Kelly DF. The endonasal microscopic approach for pituitary adenomas and other parasellar tumors: a 10-year experience. Neurosurgery 2008;63(4, Suppl 2):244–256; discussion 256 Malik MU, Aberle JC, Flitsch J. CSF fistulas after transsphenoidal pituitary surgery—a solved problem? J Neurol Surg A Cent Eur Neurosurg 2012;73(5):275–280 Ahn JY, Kim SH. A new technique for dural suturing with fascia graft for cerebrospinal fluid leakage in transsphenoidal surgery. Neurosurgery 2009;65(6, Suppl):65–71; discussion 71–72 Mehta GU, Oldfield EH. Prevention of intraoperative cerebrospinal fluid leaks by lumbar cerebrospinal fluid drainage during surgery for pituitary macroadenomas. J Neurosurg 2012;116(6): 1299–1303 Dlouhy BJ, Madhavan K, Clinger JD, et al. Elevated body mass index and risk of postoperative CSF leak following transsphenoidal surgery. J Neurosurg 2012;116(6):1311–1317 Grotenhuis JA. Costs of postoperative cerebrospinal fluid leakage: 1-year, retrospective analysis of 412 consecutive nontrauma cases. Surg Neurol 2005;64(6):490–493; discussion 493–494
Downloaded by: Washington University. Copyrighted material.
Sellar Floor Reconstruction after Transsphenoidal Surgery
A Sandwich Technique for Prevention of Cerebrospinal Fluid Rhinorrhea and Reconstruction of the Sellar Floor after Microsurgical Transsphenoidal Pituitary Surgery Christian F. Freyschlag1 Stephanie Alice Goerke1 Claudius Thomé1 Marcel Seiz2 1 Department of Neurosurgery, Innsbruck Medical University,
Innsbruck, Austria 2 Department of Neurosurgery, University Medical Center Mannheim, Mannheim, Germany
Jochen Obernauer1
Johannes Kerschbaumer1
Address for correspondence Marcel Seiz, MD, Department of Neurosurgery, University Medical Center Mannheim, Theodor-KutzerUfer 1-3, Mannheim 68167, Germany (e-mail: [email protected]).
Abstract
Keywords
► ► ► ►
pituitary surgery transsphenoidal coated collagen fleece cerebrospinal fluid rhinorrhea
Background Cerebrospinal fluid (CSF) leaks are a well-known complication of transsphenoidal surgery. Several autologous and artificial grafts have been used to close the sellar floor in an attempt to prevent postoperative CSF rhinorrhea. Objective To evaluate and describe a sandwich technique to close the sellar floor using autologous bone, absorbable gelatin sponge, and coated collagen fleece. Methods We reviewed 50 consecutive patients between April 2010 and August 2011 who underwent transsphenoidal surgery ending with reconstruction of the sellar floor with a particular sandwich technique. Patients with an intraoperative CSF leak received an additional lumbar drain. Results There were no cases of CSF rhinorrhea at postoperative follow-up after 6 weeks and no revision surgery. Conclusion The proposed sandwich technique for closure of the sellar floor to the sphenoid sinus is a suitable alternative to autologous grafts and seems to be effective in preventing CSF rhinorrhea.
Introduction The transnasal or endonasal transsphenoidal route is the standard approach for most pituitary adenomas and other pathologies in the sellar region. Prevention and repair of cerebrospinal fluid (CSF) leak remains a challenging part of the surgical intervention. Postoperative CSF fistula, presenting preponderantly as rhinorrhea, is a major complication early after transsphenoidal surgery with an incidence ranging from 0.5 to 15%.1–3 Several different techniques have been described so far including various grafts (i.e., autologous) with or without lumbar CSF drainage. Autologous grafts like
received August 5, 2013 accepted after revision December 30, 2014
abdominal fat tissue or fascia lata are biocompatible, but most require a separate surgical incision. Thus graft harvesting increases morbidity and causes additional pain plus the risk of cosmetic disfiguration. Continuous lumbar CSF drainage is a safe and easy-to-handle procedure to prevent and treat rhinorrhea with a low risk of infection,4 but it lengthens the patient’s hospital stay and needs meticulous care when mobilizing patients. We evaluated the safety and effectiveness of a particular technique to close the sellar floor in patients with or without intraoperative CSF leak after transsphenoidal surgery and compared it with the current literature.
© Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0035-1547357. ISSN 2193-6315.
Downloaded by: Washington University. Copyrighted material.
J Neurol Surg A
Sellar Floor Reconstruction after Transsphenoidal Surgery
Freyschlag et al.
Methods
Table 1 Gender distribution, surgical and endocrinologic status, and immunohistochemical subtyping of pituitary adenomas
Patients From April 2010 to August 2011, 50 consecutive patients underwent endonasal transsphenoidal resection of intra-, supra-, and parasellar tumors at the Neurosurgical Department, Innsbruck Medical University, with a median follow-up of 15 months (range: 8–24 months). Ten patients had suspected intraoperative CSF leakage. All cases were sealed and reconstructed with the sandwich technique (►Table 1). The primary goal of the study was absence of CSF fistula. Further parameters evaluated in our population were tumor expansion (intra-, supra-, and parasellar), compression of the optic chiasm, age, and histologic diagnosis.
n ¼ 50
%
Male
34
68
Female
16
32
Primary
36
72
Recurrence
11
22
Previous subtotal resection
3
2
Characteristics Gender
Surgery
Surgical Technique
Intrasellar
12
24
Microsurgical endonasal transsphenoidal resection was performed in all 50 patients. Endoscopic-assisted surgery was applied as indicated according to the surgeon. All cases underwent the identical procedure as outlined in the following description. Endonasal tamponades are placed in all patients in both nostrils for 24 hours. If there is evidence or suspicion of intraoperative CSF leakage, it is our routine practice to insert a lumbar CSF drain within the same general anesthesia and drain 90 mL/day for at least 5 days without antibiotic prophylaxis. One of the authors (C.T.) has used a particular reconstruction technique of the sellar floor for years in transsphenoidal surgery. During the access part of the surgery, ideally one piece of bone graft is harvested from the anterior wall of the sphenoidal sinus, the vomer, and/or the sinus septum (if applicable). A fibrin sealant-coated collagen fleece (TachoSil, Nycomed, Linz, Austria) is used for watertight sealing of the sellar floor. Spongostan (Ethicon Biosurgery, Johnson & Johnson Medical, Somerville, New Jersey, United States), a gelatinous sponge of porcine origin, is used as a filling layer between the TachoSil and the bone graft (►Fig. 1). It was previously proven to be effective in preventing CSF fistulas, acting as a sealing compound in transcranial surgery.5 A small rectangle of TachoSil is placed alternating with adsorbable gelatin sponge with a bone graft finally placed to achieve a watertight seal and adequate anatomical reconstruction. It is critical for the described technique that the piece of bone is placed in the bony opening of the sellar floor and thus provides a buttress to keep both the TachoSil and Spongostan materials in place.
Intra- and parasellar
10
20
Statistical Analysis Statistical analysis was calculated with SPSS software, v.20 (IBM Corp., Armonk, New York, United States), and significance was set for p 0.05. Significance levels were calculated with the chi-square test and correlation according to the Pearson test, as appropriate.
Results Within our study population were 34 male (68%) and 16 female (32%) patients with a median age of 55 years (range: Journal of Neurological Surgery—Part A
Intra- and suprasellar
11
22
Intra-, para-, and suprasellar
17
34
No insufficiency
21
42
Complete insufficiency
3
6
Partial insufficiency
9
18
Other endocrine activity
14
28
Prolactinoma
3
6
2
4
Endocrine status
Immunohistochemical subtyping ACTH PRL
3
6
GH/PRL
2
4
GH
6
12
Inactive
33
66
Other
4
8
Abbreviations: ACTH, adrenocorticotropic hormone; GH, growth hormone; PRL, prolactin.
22–82 years). Only 24% of the adenomas were purely intrasellar; 40% were at least supra- or parasellar, and 36% were located in the intra-, supra-, and parasellar compartments. ►Table 1 shows the endocrine symptomatology and histologic types. We found 10 cases (20%) of suspected intraoperative CSF leak. All 10 patients received lumbar CSF drainage at the end of surgery. Surgery was performed for the first time in 35 patients (70%); 12 patients (24%) had a recurrence of a surgically treated adenoma, and 3 patients (6%) underwent a second surgery after a previous subtotal resection. At the time of discharge, none of our patients had evidence of CSF rhinorrhea. After 6 weeks, none of the patients presented with rhinorrhea in our outpatient clinic.Expansion to the parasellar and suprasellar compartment did not significantly influence the risk of intraoperative CSF leakage (p ¼ 0.382). Furthermore, compression of the optic chiasm (p ¼ 0.434), age (p ¼ 0.634), and histologic subtyping
Downloaded by: Washington University. Copyrighted material.
Expansion
Fig. 1 (A) Preoperative pituitary macroadenoma. (B) After endonasal transsphenoidal resection showing the sellar floor and lowered sellar diaphragm (DS). (C) The particular sandwich technique showing gelatinous sponge (GS) and TachoSil (TC) to seal the defect in the sellar dura while the sellar floor is closed and reconstructed with a piece of bone (B), serving as a buttress in the created bony defect. D, dura mater; IN, infundibulum; SS, sphenoid sinus.
(p ¼ 0.204) showed no statistical significance. Patients with a second surgical intervention after a subtotal resection showed a significantly higher incidence of CSF leakage (p ¼ 0.012).
Discussion The introduction of transsphenoidal surgery for pituitary tumors by Schloffer in 1907 constituted the beginning of natural orifice surgery in the field of neurosurgery.6 This approach necessitates dural closure of the sellar floor because postoperative CSF rhinorrhea is a common complication, with an incidence ranging between 0.5% and 15%.1–3,7 It is self-evident that with a narrow surgical corridor, closure techniques are challenging. In the history of transsphenoidal pituitary surgery, prevention of CSF rhinorrhea was usually performed with autologous grafts such as fascia
Freyschlag et al.
lata or packing of the sella with abdominal fat.1,8,9 In our study, we prospectively analyzed 50 patients after endonasal transsphenoidal surgery to evaluate a standardized sandwich technique for dural and sellar closure. There are several known risk factors for disruption of the sellar diaphragm and arachnoid and consecutive CSF leakage in transsphenoidal surgery. In the literature, tumor size,3,10,11 histopathologic tumor type,11,12 or surgeon experience9,13 are mentioned as risk factors. In our series, extensive growth, chiasmatic compression, patient age, or histopathologic tumor type did not have a significant influence on intraoperative CSF leakage. However, reoperation after previous subtotal resection showed a significant increase in intraoperative CSF leakage (p ¼ 0.012), possibly due to scarring of the arachnoidal sheets and adhesions to the sellar diaphragm. Numerous recent publications discuss dural repair after transsphenoidal surgery,7,14 such as suturing techniques for autologous fascial transplants. Ahn and Kim15 reported the use of a new set of forceps and needle holders especially designed for transsphenoidal microsurgery. In their series of 21 patients, they found no postoperative CSF rhinorrhea. Their procedure of suturing the fascial transplant seems time consuming (50–90 minutes), even for surgeons with long experience in using the developed tools. Cho et al published their retrospective series of 307 consecutive patients with pituitary adenomas, all operated microsurgically with endoscopic assistance in selected cases. They found a total of 156 intraoperative CSF leakages of which 90 were closed with the TachoComb (CSL Behring, Tokyo, Japan) in a “packing” technique. Two of these patients had to be reoperated due to CSF rhinorrhea. No standardized international regimen exists for the prevention of CSF leakage. Mehta and Oldfield16 reported the use of intraoperative lumbar drainage, resulting in a significant (p < 0.001) reduction of intraoperative CSF leakage, but they still found a 5% rate of postoperative rhinorrhea independent of the intraoperative evidence of CSF leakage. We generally place lumbar CSF drains after the surgical procedure if intraoperative CSF leakage has been detected either spontaneously or during the Valsalva maneuver. In questionable cases, the individual surgeon makes the decision to place lumbar drainage. In the series of Dlouhy et al,17 the use of lumbar drainage for resolving postoperative CSF fistula was evaluated. In their cohort of 63 sellar pathologies, they found 20 cases of intraoperative CSF leakage and one with a postoperative CSF fistula. Their standard procedure of keeping the patient bedridden with lumbar drainage for 2 to 4 days resulted in no need for reoperation. The additional use of lumbar drainage is still controversial and has to be evaluated prospectively to generate stronger evidence. Grotenhuis18 showed that using a simple liquid sealant (DuraSeal; Covidien, Waltham, Massachusetts, United States) effectively reduced hospital costs by preventing CSF leakage in 44 consecutive transsphenoidal procedures. Sealant agents increase the costs of surgical treatment dramatically. In comparison, the closure technique reported in our series is cost effective and shows favorable results in preventing CSF leakage. In our department, TachoSil costs €250 per unit Journal of Neurological Surgery—Part A
Downloaded by: Washington University. Copyrighted material.
Sellar Floor Reconstruction after Transsphenoidal Surgery
Freyschlag et al.
(95 48 mm); Spongostan (70 50 10 mm) is available for €20 per unit.
7 Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH.
Limitation 8
We are aware this study represents a small number of patients without power calculation and without a comparative study design.
Conclusion We believe that sufficient sealing and reconstruction of the sellar floor can be achieved with a simple sandwich technique using nonautologous material (TachoSil, Spongostan) in combination with autologous bone.
9
10
11
12
References 1 Black PM, Zervas NT, Candia GL. Incidence and management of
2
3
4
5
6
complications of transsphenoidal operation for pituitary adenomas. Neurosurgery 1987;20(6):920–924 Cho JM, Ahn JY, Chang JH, Kim SH. Prevention of cerebrospinal fluid rhinorrhea after transsphenoidal surgery by collagen fleece coated with fibrin sealant without autologous tissue graft or postoperative lumbar drainage. Neurosurgery 2011;68(1, Suppl Operative):130–136; discussion 136–137 Seiler RW, Mariani L. Sellar reconstruction with resorbable Vicryl patches, gelatin foam, and fibrin glue in transsphenoidal surgery: a 10-year experience with 376 patients. J Neurosurg 2000;93(5): 762–765 Açikbaş SC, Akyüz M, Kazan S, Tuncer R. Complications of closed continuous lumbar drainage of cerebrospinal fluid. Acta Neurochir (Wien) 2002;144(5):475–480 Barth M, Tuettenberg J, Thomé C, Weiss C, Vajkoczy P, Schmiedek P. Watertight dural closure: is it necessary? A prospective randomized trial in patients with supratentorial craniotomies. Neurosurgery 2008;63(4, Suppl 2):352–358; discussion 358 Schloffer H. Erfolgreiche Operation eines Hypophysentumors auf nasalem Wege. Wien Klin Wochenschr 1907;20:621–624
Journal of Neurological Surgery—Part A
13
14
15
16
17
18
Endoscopic endonasal versus open repair of anterior skull base CSF leak, meningocele, and encephalocele: a systematic review of outcomes. J Neurol Surg A Cent Eur Neurosurg 2013;74(4): 239–250 Hardy J. Transsphenoidal hypophysectomy. J Neurosurg 1971; 34(4):582–594 Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 1997;40(2): 225–236; discussion 236–237 Van Velthoven V, Clarici G, Auer LM. Fibrin tissue adhesive sealant for the prevention of CSF leakage following transsphenoidal microsurgery. Acta Neurochir (Wien) 1991;109(1–2):26–29 Sade B, Mohr G, Frenkiel S. Management of intra-operative cerebrospinal fluid leak in transnasal transsphenoidal pituitary microsurgery: use of post-operative lumbar drain and sellar reconstruction without fat packing. Acta Neurochir (Wien) 2006;148(1):13–18; discussion 18–19 Shiley SG, Limonadi F, Delashaw JB, et al. Incidence, etiology, and management of cerebrospinal fluid leaks following trans-sphenoidal surgery. Laryngoscope 2003;113(8):1283–1288 Fatemi N, Dusick JR, de Paiva Neto MA, Kelly DF. The endonasal microscopic approach for pituitary adenomas and other parasellar tumors: a 10-year experience. Neurosurgery 2008;63(4, Suppl 2):244–256; discussion 256 Malik MU, Aberle JC, Flitsch J. CSF fistulas after transsphenoidal pituitary surgery—a solved problem? J Neurol Surg A Cent Eur Neurosurg 2012;73(5):275–280 Ahn JY, Kim SH. A new technique for dural suturing with fascia graft for cerebrospinal fluid leakage in transsphenoidal surgery. Neurosurgery 2009;65(6, Suppl):65–71; discussion 71–72 Mehta GU, Oldfield EH. Prevention of intraoperative cerebrospinal fluid leaks by lumbar cerebrospinal fluid drainage during surgery for pituitary macroadenomas. J Neurosurg 2012;116(6): 1299–1303 Dlouhy BJ, Madhavan K, Clinger JD, et al. Elevated body mass index and risk of postoperative CSF leak following transsphenoidal surgery. J Neurosurg 2012;116(6):1311–1317 Grotenhuis JA. Costs of postoperative cerebrospinal fluid leakage: 1-year, retrospective analysis of 412 consecutive nontrauma cases. Surg Neurol 2005;64(6):490–493; discussion 493–494
Downloaded by: Washington University. Copyrighted material.
Sellar Floor Reconstruction after Transsphenoidal Surgery
