CSF Fistulas after Transsphenoidal Pituitary Surgery—A Solved Problem?

Muhammad Usman Malik; Jens C. Aberle; Joerg Flitsch

doi:10.1055/s-0032-1304808

Journal of Neurological Surgery Part A: Central European Neurosurgery, Table of Contents

J Neurol Surg A Cent Eur Neurosurg 2012; 73(05): 275-280
DOI: 10.1055/s-0032-1304808

Original Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

CSF Fistulas after Transsphenoidal Pituitary Surgery—A Solved Problem?

Muhammad Usman Malik

¹Department of Neurosurgery, Rawalpindi Medical College, HFH, Rawalpindi, Pakistan

²Department of Neurosurgery, University Klinic Eppendorf, Martinistrasse, Hamburg, Germany

,

Jens C. Aberle

³Department of Endocrinology, Clinic of Internal Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany

,

Joerg Flitsch

⁴Pituitary Unit, Clinic of Neurosurgery, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany

› Author Affiliations

Abstract

Objective Transsphenoidal surgery has been the gold standard for intra- and suprasellar lesions as well as some extrasellar pathologies for more than 40 years. This approach, with proper surgical expertise, is very safe with a low morbidity and mortality rate. However, as with every surgical treatment, complications can occur and may result in serious consequences for the patient. The goal of this article is to focus on cerebrospinal fluid (CSF) fistulas after transsphenoidal surgery and discuss possible risk factors and treatment options, including less common procedures in persistent CSF fistulas.

Methods Over a period of 24 months, 339 consecutive patients underwent a total of 363 transsphenoidal surgeries for different pathologies in our institution. There were 282 patients with pituitary adenomas and 57 patients with nonadenomateous lesions.

Results CSF fistulas occurred in total of six patients (1.77%), most frequently after surgery for nonadenomateous lesions (7%). The rate was only 0.7% after surgery for pituitary adenomas. In three patients, a simple resurgery with repacking of the sella using muscle, fat, and fibrin glue was performed. All three patients received a lumbar drainage for 5 days as well. All three patients had recurrent CSF fistulas despite surgical repair, requiring multiple resurgeries. In two patients, the implantation of a ventriculoperitoneal (vp) shunt with programmable valve for continuous lowering of the CSF pressure was required. In both patients, the vp shunt was explanted 2 to 3 months after the last proven rhinorrhea. Out of the 339, 2 patients developed meningitis due to CSF fistulas (0.59%).

Conclusions CSF fistulas continue to present a problem after transsphenoidal surgery and require sophisticated technical measures to treat this complication. Failure after repair can occur and necessitates more intense treatment modalities. The usage of the transsphenoidal approach in other skull base lesions leads to higher rates of CSF fistulas and subsequently higher frequency of meningitis.

Keywords

transsphenoidal - cerebrospinal fluid fistulas - pituitary surgery - cerebrospinal fluid leak

Full Text

References

References
1 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
2 Briggs RJ, Wormald PJ. Endoscopic transnasal intradural repair of anterior skull base cerebrospinal fluid fistulae. J Clin Neurosci 2004; 11 (6) 597-599
3 Cappabianca P, Esposito F, Cavallo LM , et al. Use of equine collagen foil as dura mater substitute in endoscopic endonasal transsphenoidal surgery. Surg Neurol 2006; 65 (2) 144-148 , discussion 149
4 Cappabianca P, Esposito F, Magro F , et al. Natura abhorret a vacuo—use of fibrin glue as a filler and sealant in neurosurgical “dead spaces”. Technical note. Acta Neurochir (Wien) 2010; 152 (5) 897-904
5 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
6 Dusick JR, Mattozo CA, Esposito F, Kelly DF. BioGlue for prevention of postoperative cerebrospinal fluid leaks in transsphenoidal surgery: A case series. Surg Neurol 2006; 66 (4) 371-376 , discussion 376
7 El-Banhawy OA, Halaka AN, Altuwaijri MA, Ayad H, El-Sharnoby MM. Long-term outcome of endonasal endoscopic skull base reconstruction with nasal turbinate graft. Skull Base 2008; 18 (5) 297-308
8 Esposito F, Dusick JR, Fatemi N, Kelly DF. Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery. Neurosurgery 2007; 60 (4, Suppl 2) 295-303 , discussion 303–304
9 Gendeh BS, Mazita A, Selladurai BM, Jegan T, Jeevanan J, Misiran K. Endonasal endoscopic repair of anterior skull-base fistulas: the Kuala Lumpur experience. J Laryngol Otol 2005; 119 (11) 866-874
10 Han ZL, He DS, Mao ZG, Wang HJ. Cerebrospinal fluid rhinorrhea following trans-sphenoidal pituitary macroadenoma surgery: experience from 592 patients. Clin Neurol Neurosurg 2008; 110 (6) 570-579
11 Jagannathan J, Okonkwo DO, Prevedello DM, Kanter AS, Laws Jr ER. Arachnoid diverticula associated with anterior cranial base tumors: technical case report. Neurosurgery 2007; 61 (1) E172-E173
12 Kaptain GJ, Vincent DA, Sheehan JP, Laws Jr ER. Transsphenoidal approaches for the extracapsular resection of midline suprasellar and anterior cranial base lesions. Neurosurgery 2008; 62 (6, Suppl 3) 1264-1271
13 Kennedy DW, Cohn ES, Papel ID, Holliday MJ. Transsphenoidal approach to the sella: the Johns Hopkins experience. Laryngoscope 1984; 94 (8) 1066-1074
14 Ludecke DK, Abe T. Transsphenoidal microsurgery for newly diagnosed acromegaly: a personal view after more than 1,000 operations. Neuroendocrinology 2006; 83 (3–4) 230-239
15 Mortini P, Losa M, Barzaghi R, Boari N, Giovanella M. Results of transsphenoidal surgery is a large series of patients with pituitary adenoma. Neurosurgery 2005; 56 (6) 1222-1233
16 Nishioka H, Haraoka J, Ikeda Y, Boari N, Giovanelli M. Risk factors of cerebrospinal fluid rhinorrhea following transsphenoidal surgery. Acta Neurochir (Wien) 2005; 147 (11) 1163-1166, discussion 1166
17 Nishioka H, Izawa H, Ikeda Y, Namatame H, Fukami S, Haraoka J. Dural suturing for repair of cerebrospinal fluid leak in transnasal transsphenoidal surgery. Acta Neurochir (Wien) 2009; 151 (11) 1427-1430
18 Rabadán AT, Hernández D, Ruggeri CS. Pituitary tumors: our experience in the prevention of postoperative cerebrospinal fluid leaks after transsphenoidal surgery. J Neurooncol 2009; 93 (1) 127-131
19 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
20 Sherman JH, Pouratian N, Okonkwo DO, Jane Jr JA, Laws ER. Reconstruction of the sellar dura in transsphenoidal surgery using an expanded polytetrafluoroethylene dural substitute. Surg Neurol 2008; 69 (1) 73-76 , discussion 76
21 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
22 Sonnenburg RE, White D, Ewend MG, Senior B. Sellar reconstruction: is it necessary?. Am J Rhinol 2003; 17 (6) 343-346
23 Tabaee A, Anand VK, Barrón Y , et al. Endoscopic pituitary surgery: a systematic review and meta-analysis. J Neurosurg 2009; 111 (3) 545-554
24 Tabaee A, Anand VK, Brown SM, Lin JW, Schwartz TH. Algorithm for reconstruction after endoscopic pituitary and skull base surgery. Laryngoscope 2007; 117 (7) 1133-1137
25 Tabaee A, Placantonakis DG, Schwartz TH, Anand VK. Intrathecal fluorescein in endoscopic skull base surgery. Otolaryngol Head Neck Surg 2007; 137 (2) 316-320
26 Wormald PJ, McDonogh M. ‘Bath-plug’ technique for the endoscopic management of cerebrospinal fluid leaks. J Laryngol Otol 1997; 111 (11) 1042-1046