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

Abstract

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 fat in the pituitary fossa and further fat in the sphenoid 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.

Keywords

transsphenoidal - endoscopic - CSF leak - repair - sellar - fat graft

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (name of institute/committee) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

For this type of study formal, consent is not required.

Publication History

Received: 29 September 2021

Accepted: 30 January 2022

Accepted Manuscript online:
01 February 2022

Article published online:
08 June 2022

• References

• 1 Solari D, Villa A, De Angelis M, Esposito F, Cavallo LM, Cappabianca P. Anatomy and surgery of the endoscopic endonasal approach to the skull base. Transl Med UniSa 2012; 2: 36-46
• 2 Black PM, Zervas NT, Candia GL. Incidence and management of complications of transsphenoidal operation for pituitary adenomas. Neurosurgery 1987; 20 (06) 920-924
• 3 Daudia A, Biswas D, Jones NS. Risk of meningitis with cerebrospinal fluid rhinorrhea. Ann Otol Rhinol Laryngol 2007; 116 (12) 902-905
• 4 Akbari H, Malek M, Ghorbani M. et al. Clinical outcomes of endoscopic versus microscopic trans-sphenoidal surgery for large pituitary adenoma. Br J Neurosurg 2018; 32 (02) 206-209
• 5 Strickland BA, Lucas J, Harris B. 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 (02) 425-429
• 6 Messerer M, De Battista JC, Raverot G. et al. Evidence of improved surgical outcome following endoscopy for nonfunctioning pituitary adenoma removal. Neurosurg Focus 2011; 30 (04) E11
• 7 National Heart L, and Blood Institute (NHLBI).. Study Quality Assessment Tool. Accessed December 5, 2021 at: https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools
• 8 Agam MS, Wedemeyer MA, Wrobel B, Weiss MH, Carmichael JD, Zada G. Complications associated with microscopic and endoscopic transsphenoidal pituitary surgery: experience of 1153 consecutive cases treated at a single tertiary care pituitary center. J Neurosurg 2018; 30 (05) 1576-1583
• 9 Ahn S, Park J-S, Kim D. et al. Surgical experience in prevention of postoperative CSF leaks using abdominal fat grafts in endoscopic endonasal transsphenoidal surgery for pituitary adenomas. J Neurol Surg B Skull Base 2021; 82 (05) 522-527
• 10 Berker M, Hazer DB, Yücel T. et al. Complications of endoscopic surgery of the pituitary adenomas: analysis of 570 patients and review of the literature. Pituitary 2012; 15 (03) 288-300
• 11 Bokhari AR, Davies MA, Diamond T. Endoscopic transsphenoidal pituitary surgery: a single surgeon experience and the learning curve. Br J Neurosurg 2013; 27 (01) 44-49
• 12 Burkett CJ, Patel S, Tabor MH, Padhya T, Vale FL. Polyethylene glycol (PEG) hydrogel dural sealant and collagen dural graft matrix in transsphenoidal pituitary surgery for prevention of postoperative cerebrospinal fluid leaks. J Clin Neurosci 2011; 18 (11) 1513-1517
• 13 Caggiano C, Penn DL, Laws Jr ER. The role of the lumbar drain in endoscopic endonasal skull base surgery: a retrospective analysis of 811 cases. World Neurosurg 2018; 117: e575 –e579
• 14 Cavallo LM, Frank G, Cappabianca P. et al. The endoscopic endonasal approach for the management of craniopharyngiomas: a series of 103 patients. J Neurosurg 2014; 121 (01) 100-113
• 15 Charalampaki P, Ayyad A, Kockro RA, Perneczky A. Surgical complications after endoscopic transsphenoidal pituitary surgery. J Clin Neurosci 2009; 16 (06) 786-789
• 16 Dallapiazza RF, Grober Y, Starke RM, Laws Jr ER, Jane Jr JA. Long-term results of endonasal endoscopic transsphenoidal resection of nonfunctioning pituitary macroadenomas. Neurosurgery 2015; 76 (01) 42-52 , discussion 52–53
• 17 Dehdashti AR, Ganna A, Karabatsou K, Gentili F. Pure endoscopic endonasal approach for pituitary adenomas: early surgical results in 200 patients and comparison with previous microsurgical series. Neurosurgery 2008; 62 (05) 1006-1015 , discussion 1015–1017
• 18 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 (04) 371-376 , discussion 376
• 19 Faraj MK, Sagban WJ. Endoscopic transsphenoidal approach to skull base lesions. A clinical prospective study. Neurosciences (Riyadh) 2018; 23 (01) 35-38
• 20 Gondim JA, Almeida JP, Albuquerque LA. et al. Endoscopic endonasal approach for pituitary adenoma: surgical complications in 301 patients. Pituitary 2011; 14 (02) 174-183
• 21 Gondim JA, Almeida JP, de Albuquerque LA, Gomes E, Schops M, Mota JI. Endoscopic endonasal transsphenoidal surgery in elderly patients with pituitary adenomas. J Neurosurg 2015; 123 (01) 31-38
• 22 Hannan CJ, Almhanedi H, Al-Mahfoudh R, Bhojak M, Looby S, Javadpour M. Predicting post-operative cerebrospinal fluid (CSF) leak following endoscopic transnasal pituitary and anterior skull base surgery: a multivariate analysis. Acta Neurochir (Wien) 2020; 162 (06) 1309-1315
• 23 Hobbs CG, Darr A, Carlin WV. Management of intra-operative cerebrospinal fluid leak following endoscopic trans-sphenoidal pituitary surgery. J Laryngol Otol 2011; 125 (03) 311-313
• 24 Kim JH, Lee JH, Lee JH, Hong AR, Kim YJ, Kim YH. Endoscopic transsphenoidal surgery outcomes in 331 nonfunctioning pituitary adenoma cases after a single surgeon learning curve. World Neurosurg 2018; 109: e409-e416
• 25 López-García R, Abarca-Olivas J, Monjas-Cánovas I, Picó Alfonso A, Moreno-López P, Gras-Albert JR. Endonasal endoscopic surgery in pituitary adenomas: Surgical results in a series of 86 consecutive patients. Neurocirugia (Astur : Engl Ed) 2018; 29 (04) 161-169
• 26 Magro E, Graillon T, Lassave J. et al. Complications related to the endoscopic endonasal transsphenoidal approach for nonfunctioning pituitary macroadenomas in 300 consecutive patients. World Neurosurg 2016; 89: 442-453
• 27 Pablo A, Sofia B, Maximiliano T. et al. Endoscopic versus microscopic pituitary adenoma surgery: a single-center study. Neurol India 2019; 67 (04) 1015-1021
• 28 Patel KS, Komotar RJ, Szentirmai O. et al. Case-specific protocol to reduce cerebrospinal fluid leakage after endonasal endoscopic surgery. J Neurosurg 2013; 119 (03) 661-668
• 29 Patel PN, Stafford AM, Patrinely JR. et al. Risk factors for intraoperative and postoperative cerebrospinal fluid leaks in endoscopic transsphenoidal sellar surgery. Otolaryngol Head Neck Surg 2018; 158 (05) 952-960
• 30 Shiley SG, Limonadi F, Delashaw JB. et al. Incidence, etiology, and management of cerebrospinal fluid leaks following trans-sphenoidal surgery. Laryngoscope 2003; 113 (08) 1283-1288
• 31 Tamasauskas A, Sinkūnas K, Draf W. et al. Management of cerebrospinal fluid leak after surgical removal of pituitary adenomas. Medicina (Kaunas) 2008; 44 (04) 302-307
• 32 Thakur JD, Corlin A, Mallari RJ. et al. Pituitary adenomas in older adults (≥ 65 years): 90-day outcomes and readmissions: a 10-year endoscopic endonasal surgical experience. Pituitary 2021; 24 (01) 14-26
• 33 Vimawala S, Chitguppi C, Reilly E. et al. Predicting prolonged length of stay after endoscopic transsphenoidal surgery for pituitary adenoma. Int Forum Allergy Rhinol 2020; 10 (06) 785-790
• 34 Wang F, Zhou T, Wei S. et al. Endoscopic endonasal transsphenoidal surgery of 1,166 pituitary adenomas. Surg Endosc 2015; 29 (06) 1270-1280
• 35 Wang YY, Kearney T, Gnanalingham KK. Low-grade CSF leaks in endoscopic trans-sphenoidal pituitary surgery: efficacy of a simple and fully synthetic repair with a hydrogel sealant. Acta Neurochir (Wien) 2011; 153 (04) 815-822
• 36 Wengier A, Ram Z, Warshavsky A, Margalit N, Fliss DM, Abergel A. Endoscopic skull base reconstruction with the nasoseptal flap: complications and risk factors. Eur Arch Otorhinolaryngol 2019; 276 (09) 2491-2498
• 37 Xue H, Wang X, Yang Z, Bi Z, Liu P. Risk factors and outcomes of cerebrospinal fluid leak related to endoscopic pituitary adenoma surgery. Br J Neurosurg 2020; 34 (04) 447-452
• 38 Zhan R, Chen S, Xu S, Liu JK, Li X. Postoperative low-flow cerebrospinal fluid leak of endoscopic endonasal transsphenoidal surgery for pituitary adenoma: wait and see, or lumbar drain?. J Craniofac Surg 2015; 26 (04) 1261-1264
• 39 Fouad W. Review of empty sella syndrome and its surgical management. Alexandria J Med 2011; 47 (02) 139-147
• 40 Nizamani WM, Siddiqui M, Ali Momin SN, Waqas M, Jooma R. Resolution of symptomatic secondary empty sella syndrome following lumbar-peritoneal shunt. Surg Neurol Int 2018; 9: 72
• 41 Slavin ML, Lam BL, Decker RE, Schatz NJ, Glaser JS, Reynolds MG. Chiasmal compression from fat packing after transsphenoidal resection of intrasellar tumor in two patients. Am J Ophthalmol 1993; 115 (03) 368-371
• 42 Okasha MM, Ibrahim AA, Schroeder H. et al. Evaluation of endoscopic repair of cerebrospinal fluid rhinorrhea. Interdiscip Neurosurg 2021; 23: 101032
• 43 Laws Jr ER, Thapar K. Surgical management of pituitary adenomas. Baillieres Clin Endocrinol Metab 1995; 9 (02) 391-405
• 44 Kubota T, Hayashi M, Kabuto M. et al. Reconstruction of the skull base using a silicone plate during transsphenoidal surgery. Surg Neurol 1991; 36 (05) 360-364
• 45 Hadad G, Bassagasteguy L, Carrau RL. et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006; 116 (10) 1882-1886
• 46 Boling CC, Karnezis TT, Baker AB. et al. Multi-institutional study of risk factors for perioperative morbidity following transnasal endoscopic pituitary adenoma surgery. Int Forum Allergy Rhinol 2016; 6 (01) 101-107
• 47 Lobatto DJ, de Vries F, Zamanipoor Najafabadi AH. et al. Preoperative risk factors for postoperative complications in endoscopic pituitary surgery: a systematic review. Pituitary 2018; 21 (01) 84-97
• 48 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 (06) 1311-1317
• 49 Karnezis TT, Baker AB, Soler ZM. et al. Factors impacting cerebrospinal fluid leak rates in endoscopic sellar surgery. Int Forum Allergy Rhinol 2016; 6 (11) 1117-1125
• 50 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 (06) 570-579
• 51 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
• 52 Laws Jr ER, Fode NC, Redmond MJ. Transsphenoidal surgery following unsuccessful prior therapy. An assessment of benefits and risks in 158 patients. J Neurosurg 1985; 63 (06) 823-829
• 53 Nishioka H, Haraoka J, Ikeda Y. Risk factors of cerebrospinal fluid rhinorrhea following transsphenoidal surgery. Acta Neurochir (Wien) 2005; 147 (11) 1163-1166 , discussion 1166
• 54 Kong DS, Kim HY, Kim SH. et al. Challenging reconstructive techniques for skull base defect following endoscopic endonasal approaches. Acta Neurochir (Wien) 2011; 153 (04) 807-813
• 55 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 (01) 127-131
• 56 van Aken MO, Feelders RA, de Marie S. et al. Cerebrospinal fluid leakage during transsphenoidal surgery: postoperative external lumbar drainage reduces the risk for meningitis. Pituitary 2004; 7 (02) 89-93
• 57 Zhan R, Li X, Li X. Endoscopic endonasal transsphenoidal approach for apoplectic pituitary tumor: surgical outcomes and complications in 45 patients. J Neurol Surg B Skull Base 2016; 77 (01) 54-60
• 58 Cappabianca P, Cavallo LM, Colao A, de Divitiis E. Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg 2002; 97 (02) 293-298
• 59 Ajlan A, Achrol AS, Albakr A. et al. Cavernous sinus involvement by pituitary adenomas: clinical implications and outcomes of endoscopic endonasal resection. J Neurol Surg B Skull Base 2017; 78 (03) 273-282