Download PDF
J Neurol Surg B Skull Base
DOI: 10.1055/a-2065-6377
Original Article

The Predictors of Postoperative Cerebrospinal Fluid Leak in Endoscopic Endonasal Pituitary Surgery: The Role of Tumor Volume

Nuri Eralp Cetinalp 
1   Department of Neurosurgery, Cukurova University Faculty of Medicine, Adana, Turkey
,
Ozgür Tarkan
2   Department of Otolaryngology-Head and Neck Surgery, Cukurova University Faculty of Medicine, Adana, Turkey
,
Gamze Akkuş
3   Division of Endocrinology, Department of Internal Medicine, Cukurova University Faculty of Medicine, Adana, Turkey
,
Kerem Mazhar Ozsoy
1   Department of Neurosurgery, Cukurova University Faculty of Medicine, Adana, Turkey
,
Dogu Cihan Yildirim
1   Department of Neurosurgery, Cukurova University Faculty of Medicine, Adana, Turkey
,
Gulsah Seydaoglu
4   Department of Biostatistics, Cukurova University Faculty of Medicine, Adana, Turkey
,
Kadir Oktay
1   Department of Neurosurgery, Cukurova University Faculty of Medicine, Adana, Turkey
,
Tahsin Erman
1   Department of Neurosurgery, Cukurova University Faculty of Medicine, Adana, Turkey
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

Objectives Postoperative cerebrospinal fluid (Po-CSF) leak is still a challenging complication of endoscopic endonasal skull base surgery. However, data describing the predictive factors of Po-CSF leak in pure pituitary adenomas is lacking. Aim of this study is to determine the risk factors of Po-CSF leak in a pituitary adenoma group operated via pure transsellar endoscopic approach.

Design This is a retrospective cohort study.

Setting A single-center academic hospital.

Participants Patients operated for a pituitary adenoma between 2015 and 2021 and followed up until June 2022 were included.

Main Outcome Measures Demographics, comorbidities, imaging, and outcome were recorded. Univariate and multivariate logistic regression analyses were used to determine the risk factors of Po-CSF leak.

Results Of the total 170 patients with a mean age of 47.5 ± 13.8 (min: 15; max: 80), 11 (6.5%) had Po-CSF leak. Univariate analysis revealed age, diabetes mellitus (DM), and tumor volume as predictors of Po-CSF leak. According to the receiver operating characteristic analysis, 7.5 cm3 of tumor volume was found to be a good cutoff value with a sensitivity of 82% and a specificity of 75%. Hence, multivariable logistic regression model adjusted by age showed that a tumor volume of > 7.5 cm3 (odds ratio [OR]: 22.9; 95% confidence interval [CI]: 3.8–135.9, p = 0.001) and DM (OR: 8.9; 95% CI: 1.7–46.5; p = 0.010) are strong independent risk factors of Po-CSF leak in pure endoscopic endonasal pituitary surgery.

Conclusion Besides younger age and DM, a cutoff value for tumor volume > 7.5 cm3 is the most remarkable risk factor for Po-CSF leak in pure endoscopic pituitary surgery. These patients should carefully be assessed preoperatively and potential preemptive surgical strategies should be taken into consideration to avoid complications.

Keywords

pituitary - cerebrospinal fluid leak - risk factors - endoscopic endonasal

Informed Consent

This study did not require written informed consent due to its non-invasive and retrospective design.




Publication History

Received: 09 February 2023

Accepted: 27 March 2023

Accepted Manuscript online:
29 March 2023

Article published online:
13 April 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Ostrom QT, Cioffi G, Waite K, Kruchko C, Barnholtz-Sloan JS. CBTRUS statistical report: primary brain and other central nervous system tumors diagnosed in the United States in 2014-2018. Neuro-oncol 2021; 23 (12, Suppl 2): iii1-iii105
    CrossrefPubMedGoogle Scholar
  • 2 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
    CrossrefPubMedGoogle Scholar
  • 3 Kothari RU, Brott T, Broderick JP. et al. The ABCs of measuring intracerebral hemorrhage volumes. Stroke 1996; 27 (08) 1304-1305
    CrossrefPubMedGoogle Scholar
  • 4 Knosp E, Steiner E, Kitz K, Matula C. Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery 1993; 33 (04) 610-617 , discussion 617–618
    PubMedGoogle Scholar
  • 5 Zhou Q, Yang Z, Wang X. et al. Risk factors and management of intraoperative cerebrospinal fluid leaks in endoscopic treatment of pituitary adenoma: analysis of 492 patients. World Neurosurg 2017; 101: 390-395
    CrossrefPubMedGoogle Scholar
  • 6 [Anonymous] American Diabetes Association Professional Practice Committee. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2022. Diabetes Care 2022; 45 (Suppl. 01) S17-S38
    CrossrefPubMedGoogle Scholar
  • 7 Baussart B, Declerck A, Gaillard S. Mononostril endoscopic endonasal approach for pituitary surgery. Acta Neurochir (Wien) 2021; 163 (03) 655-659
    CrossrefPubMedGoogle Scholar
  • 8 Conger A, Zhao F, Wang X. 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. J Neurosurg 2018; 130 (03) 861-875
    CrossrefPubMedGoogle Scholar
  • 9 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 11 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
    CrossrefPubMedGoogle Scholar
  • 12 Qureshi T, Chaus F, Fogg L, Dasgupta M, Straus D, Byrne RW. Learning curve for the transsphenoidal endoscopic endonasal approach to pituitary tumors. Br J Neurosurg 2016; 30 (06) 637-642
    CrossrefPubMedGoogle Scholar
  • 13 Schwartz TH, Fraser JF, Brown S, Tabaee A, Kacker A, Anand VK. Endoscopic cranial base surgery: classification of operative approaches. Neurosurgery 2008; 62 (05) 991-1002 , discussion 1002–1005
    PubMedGoogle Scholar
  • 14 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
    CrossrefPubMedGoogle Scholar
  • 15 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
    CrossrefPubMedGoogle Scholar
  • 16 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
    CrossrefPubMedGoogle Scholar
  • 17 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
    CrossrefPubMedGoogle Scholar
  • 18 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 19 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
    CrossrefPubMedGoogle Scholar
  • 20 Senior BA, Ebert CS, Bednarski KK. et al. Minimally invasive pituitary surgery. Laryngoscope 2008; 118 (10) 1842-1855
    CrossrefPubMedGoogle Scholar
  • 21 Thawani JP, Ramayya AG, Pisapia JM, Abdullah KG, Lee JY, Grady MS. Operative strategies to minimize complications following resection of pituitary macroadenomas. J Neurol Surg B Skull Base 2017; 78 (02) 184-190
    PubMedGoogle Scholar
  • 22 Dallapiazza R, Bond AE, Grober Y. et al. Retrospective analysis of a concurrent series of microscopic versus endoscopic transsphenoidal surgeries for Knosp Grades 0-2 nonfunctioning pituitary macroadenomas at a single institution. J Neurosurg 2014; 121 (03) 511-517
    CrossrefPubMedGoogle Scholar
  • 23 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
    CrossrefPubMedGoogle Scholar
  • 24 Jang JH, Kim KH, Lee YM, Kim JS, Kim YZ. Surgical results of pure endoscopic endonasal transsphenoidal surgery for 331 pituitary adenomas: a 15-year experience from a single institution. World Neurosurg 2016; 96: 545-555
    CrossrefPubMedGoogle Scholar
  • 25 Jakimovski D, Bonci G, Attia M. et al. Incidence and significance of intraoperative cerebrospinal fluid leak in endoscopic pituitary surgery using intrathecal fluorescein. World Neurosurg 2014; 82 (3-4): e513-e523
    CrossrefPubMedGoogle Scholar
  • 26 Hofstetter CP, Nanaszko MJ, Mubita LL, Tsiouris J, Anand VK, Schwartz TH. Volumetric classification of pituitary macroadenomas predicts outcome and morbidity following endoscopic endonasal transsphenoidal surgery. Pituitary 2012; 15 (03) 450-463
    CrossrefPubMedGoogle Scholar
  • 27 Pérez-López C, Palpán AJ, Saez-Alegre M. et al. Volumetric study of nonfunctioning pituitary adenomas: predictors of gross total resection. World Neurosurg 2021; 147: e206-e214
    CrossrefPubMedGoogle Scholar
  • 28 DiRisio AC, Feng R, Shuman WH. et al. The Knosp Criteria Revisited: 3-dimensional volumetric analysis as a predictive tool for extent of resection in complex endoscopic pituitary surgery. Neurosurgery 2023; 92 (01) 179-185
    CrossrefPubMedGoogle Scholar
  • 29 Lee SJ, Cohen J, Chan J, Walgama E, Wu A, Mamelak AN. Infectious complications of expanded endoscopic transsphenoidal surgery: a retrospective cohort analysis of 100 cases. J Neurol Surg B Skull Base 2020; 81 (05) 497-504
    Article in Thieme ConnectPubMedGoogle Scholar
  • 30 Randhawa KS, Choi CB, Shah AD. et al. Impact of diabetes mellitus on adverse outcomes after meningioma surgery. World Neurosurg 2021; 152: e429-e435
    CrossrefPubMedGoogle Scholar
  • 31 Caputo MP, Shabani S, Mhaskar R, McMullen C, Padhya TA, Mifsud MJ. Diabetes mellitus in major head and neck cancer surgery: systematic review and meta-analysis. Head Neck 2020; 42 (10) 3031-3040
    CrossrefPubMedGoogle Scholar
  • 32 Hutter G, von Felten S, Sailer MH, Schulz M, Mariani L. Risk factors for postoperative CSF leakage after elective craniotomy and the efficacy of fleece-bound tissue sealing against dural suturing alone: a randomized controlled trial. J Neurosurg 2014; 121 (03) 735-744
    CrossrefPubMedGoogle Scholar
  • 33 Snow RB, Johnson CE, Morgello S, Lavyne MH, Patterson Jr RH. Is magnetic resonance imaging useful in guiding the operative approach to large pituitary tumors?. Neurosurgery 1990; 26 (05) 801-803
    CrossrefPubMedGoogle Scholar