Download PDF
J Neurol Surg A Cent Eur Neurosurg 2013; 74(02): 101-108
DOI: 10.1055/s-0032-1330118
Review
Georg Thieme Verlag KG Stuttgart · New York

Cranial Base Repair with Combined Vascularized Nasal Septal Flap and Autologous Tissue Graft Following Expanded Endonasal Endoscopic Neurosurgery

Stephan A. Munich
1   Department of Neurosurgery, Roswell Park Cancer Institute, Buffalo, New York, United States
,
Robert A. Fenstermaker
1   Department of Neurosurgery, Roswell Park Cancer Institute, Buffalo, New York, United States
,
Andrew J. Fabiano
1   Department of Neurosurgery, Roswell Park Cancer Institute, Buffalo, New York, United States
,
Nestor R. Rigual
2   Head and Neck Surgery and Otolaryngology, Roswell Park Cancer Institute, Buffalo, New York, United States
› Author Affiliations
Further Information

Publication History

22 September 2011

02 March 2012

Publication Date:
14 January 2013 (online)

    Permissions and Reprints

Abstract

Background The expanded endonasal endoscopic approach provides excellent visualization and access to midline skull base lesions, albeit with a relatively high risk of postoperative cerebrospinal fluid (CSF) leakage. We present our experience with the expanded endonasal endoscopic approach to the skull base in an institution where, previously, a traditional transsphenoidal approach with a surgical microscope had been used.

Patients We performed a retrospective review to identify patients who underwent expanded endonasal endoscopic surgery and analyzed demographic, pathological, and operative data with particular attention to repair of the skull base defects in 55 procedures performed on 49 patients. We compared the outcomes of 10 primary operations in which we repaired skull base defects using only autologous or allogeneic tissue grafts and 39 primary operations in which we used a vascularized mucoperichondrial nasal septal flap with or without a layered autologous tissue graft.

Results Primary expanded endonasal endoscopic procedures were performed in 49 patients with sellar pathology (33 pituitary adenomas, 4 Rathke's cleft cysts, 1 pituicytoma, 1 pituitary metastasis) and non-sellar pathology (3 meningiomas, 3 clival chordomas, 1 clival mucocele, 1 craniopharyngioma, and 2 esthesioneuroblastomas). Postoperative CSF leakage occurred following 5 of the 49 primary operations (10.2%). This occurred in 2 of 10 primary operations (20.0%) in which the skull base defect was repaired using only autologous and/or allogeneic tissue grafts, necessitating a total of 3 operative CSF leak repairs in those 2 patients. The remaining 3 postoperative CSF leaks occurred in the 39 primary operations (7.7%) in which skull base repair was performed using a mucoperichondrial nasal septal flap, necessitating operative repair in 2 of those patients.

Conclusion The repair of skull base defects created during expanded endonasal endoscopic surgery is improved by use of a mucoperichondrial nasal septal flap combined with a layered autologous tissue graft. When CSF leakage occurs despite nasal septal flap closure, the site of the leakage may be easier to localize and repair.

Keywords

cerebrospinal fluid leak - endoscopic surgery - expanded endonasal endoscopic approach - skull base - nasal septal flap - transsphenoidal surgery
 

  • References

  • 1 Black PM, Zervas NT, Candia GL. Incidence and management of complications of transsphenoidal operation for pituitary adenomas. Neurosurgery 1987; 20 (6) 920-924
    CrossrefPubMedGoogle Scholar
  • 2 Ciric I, Mikhael M, Stafford T, Lawson L, Garces R. Transsphenoidal microsurgery of pituitary macroadenomas with long-term follow-up results. J Neurosurg 1983; 59 (3) 395-401
    CrossrefPubMedGoogle Scholar
  • 3 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
    CrossrefPubMedGoogle Scholar
  • 4 Kennedy DW, Cohn ES, Papel ID, Holliday MJ. Transsphenoidal approach to the sella: the Johns Hopkins experience. Laryngoscope 1984; 94 (8) 1066-1074
    PubMedGoogle Scholar
  • 5 Laws Jr ER. Pituitary surgery. Endocrinol Metab Clin North Am 1987; 16 (3) 647-665
    PubMedGoogle Scholar
  • 6 Laws Jr ER, Kern EB. Complications of trans-sphenoidal surgery. Clin Neurosurg 1976; 23: 401-416
    PubMedGoogle Scholar
  • 7 Riche H, Jaboulay JM, Chiara Y, Peloux A. [Postoperative complications of trans-sphenoidal surgery]. Minerva Anestesiol 1992; 58 (4) (Suppl. 01) 71-72
    PubMedGoogle Scholar
  • 8 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 (2) 293-298
    CrossrefPubMedGoogle Scholar
  • 9 Cappabianca P, Cavallo LM, Esposito F, Valente V, De Divitiis E. Sellar repair in endoscopic endonasal transsphenoidal surgery: results of 170 cases. Neurosurgery 2002; 51 (6) 1365-1371 , discussion 1371–1372
    CrossrefPubMedGoogle Scholar
  • 10 Horiguchi K, Murai H, Hasegawa Y, Hanazawa T, Yamakami I, Saeki N. Endoscopic endonasal skull base reconstruction using a nasal septal flap: surgical results and comparison with previous reconstructions. Neurosurg Rev 2010; 33 (2) 235-241 , discussion 241
    CrossrefPubMedGoogle Scholar
  • 11 Jho HD. Endoscopic transsphenoidal surgery. J Neurooncol 2001; 54 (2) 187-195
    Google Scholar
  • 12 Jho HD, Carrau RL. Endoscopic endonasal transsphenoidal surgery: experience with 50 patients. J Neurosurg 1997; 87 (1) 44-51
    CrossrefPubMedGoogle Scholar
  • 13 Kabil MS, Eby JB, Shahinian HK. Fully endoscopic endonasal vs. transseptal transsphenoidal pituitary surgery. Minim Invasive Neurosurg 2005; 48 (6) 348-354
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Romero AC, Nora JE, Topczewski TE, Aguiar PH, Alobid I, Rodriguéz EF. Cerebrospinal fluid fistula after endoscopic transsphenoidal surgery: experience in a Spanish center. Arq Neuropsiquiatr 2010; 68 (3) 414-417
    CrossrefPubMedGoogle Scholar
  • 15 Carrabba G, Dehdashti AR, Gentili F. Surgery for clival lesions: open resection versus the expanded endoscopic endonasal approach. Neurosurg Focus 2008; 25 (6) E7
    PubMedGoogle Scholar
  • 16 Cavallo LM, Messina A, Esposito F , et al. Skull base reconstruction in the extended endoscopic transsphenoidal approach for suprasellar lesions. J Neurosurg 2007; 107 (4) 713-720
    CrossrefPubMedGoogle Scholar
  • 17 Couldwell WT, Weiss MH, Rabb C, Liu JK, Apfelbaum RI, Fukushima T. Variations on the standard transsphenoidal approach to the sellar region, with emphasis on the extended approaches and parasellar approaches: surgical experience in 105 cases. Neurosurgery 2004; 55 (3) 539-547 , discussion 547–550
    CrossrefPubMedGoogle Scholar
  • 18 Dehdashti AR, Ganna A, Witterick I, Gentili F. Expanded endoscopic endonasal approach for anterior cranial base and suprasellar lesions: indications and limitations. Neurosurgery 2009; 64 (4) 677-687 , discussion 687–689
    CrossrefPubMedGoogle Scholar
  • 19 Dehdashti AR, Karabatsou K, Ganna A, Witterick I, Gentili F. Expanded endoscopic endonasal approach for treatment of clival chordomas: early results in 12 patients. Neurosurgery 2008; 63 (2) 299-307 , discussion 307–309
    CrossrefPubMedGoogle Scholar
  • 20 Dusick JR, Esposito F, Kelly DF , et al. The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J Neurosurg 2005; 102 (5) 832-841
    CrossrefPubMedGoogle Scholar
  • 21 Frank G, Pasquini E, Doglietto F , et al. The endoscopic extended transsphenoidal approach for craniopharyngiomas. Neurosurgery 2006; 59 (1) (Suppl. 01) ONS75-ONS83 , discussion ONS75–ONS83
    Google Scholar
  • 22 Frank G, Sciarretta V, Calbucci F, Farneti G, Mazzatenta D, Pasquini E. The endoscopic transnasal transsphenoidal approach for the treatment of cranial base chordomas and chondrosarcomas. Neurosurgery 2006; 59 (1) (Suppl. 01) ONS50-ONS57 , discussion ONS50–ONS57
    PubMedGoogle Scholar
  • 23 Kassam A, Thomas AJ, Snyderman C , et al. Fully endoscopic expanded endonasal approach treating skull base lesions in pediatric patients. J Neurosurg 2007; 106 (2, Suppl) 75-86
    PubMedGoogle Scholar
  • 24 Kitano M, Taneda M. Subdural patch graft technique for watertight closure of large dural defects in extended transsphenoidal surgery. Neurosurgery 2004; 54 (3) 653-660 , discussion 660–661
    CrossrefPubMedGoogle Scholar
  • 25 Laws ER, Kanter AS, Jane Jr JA, Dumont AS. Extended transsphenoidal approach. J Neurosurg 2005; 102 (5) 825-827 , discussion 827–828
    CrossrefPubMedGoogle Scholar
  • 26 Zanation AM, Carrau RL, Snyderman CH , et al. Nasoseptal flap reconstruction of high flow intraoperative cerebral spinal fluid leaks during endoscopic skull base surgery. Am J Rhinol Allergy 2009; 23 (5) 518-521
    CrossrefPubMedGoogle Scholar
  • 27 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
    CrossrefPubMedGoogle Scholar
  • 28 Cook SW, Smith Z, Kelly DF. Endonasal transsphenoidal removal of tuberculum sellae meningiomas: technical note. Neurosurgery 2004; 55 (1) 239-244 , discussion 244–246
    CrossrefPubMedGoogle Scholar
  • 29 Kaptain GJ, Vincent DA, Sheehan JP, Laws Jr ER. Transsphenoidal approaches for the extracapsular resection of midline suprasellar and anterior cranial base lesions. Neurosurgery 2001; 49 (1) 94-100 , discussion 100–101
    CrossrefPubMedGoogle Scholar
  • 30 Luginbuhl AJ, Campbell PG, Evans J, Rosen M. Endoscopic repair of high-flow cranial base defects using a bilayer button. Laryngoscope 2010; 120 (5) 876-880
    PubMedGoogle Scholar
  • 31 Cappabianca P, Cavallo LM, Mariniello G, de Divitiis O, Romero AD, de Divitiis E. Easy sellar reconstruction in endoscopic endonasal transsphenoidal surgery with polyester-silicone dural substitute and fibrin glue: technical note. Neurosurgery 2001; 49 (2) 473-475 , discussion 475–476
    CrossrefPubMedGoogle Scholar
  • 32 Draf W, Schick B. How I do it: endoscopic-microscopic anterior skull base reconstruction. Skull Base 2007; 17 (1) 53-58
    Article in Thieme ConnectPubMedGoogle Scholar
  • 33 Seda L, Camara RB, Cukiert A, Burattini JA, Mariani PP. Sellar floor reconstruction after transsphenoidal surgery using fibrin glue without grafting or implants: technical note. Surg Neurol 2006; 66 (1) 46-49 , discussion 49
    CrossrefPubMedGoogle Scholar
  • 34 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
    CrossrefPubMedGoogle Scholar
  • 35 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 36 Fabiano AJ, Rigual NR, Belber CS, Fenstermaker RA. Endoscopic sellar floor reconstruction with concha bullosa bone autograft and nasal septal flap: technical case report. Minim Invasive Neurosurg 2009; 52 (2) 86-88
    Article in Thieme ConnectPubMedGoogle Scholar
  • 37 Laufer I, Anand VK, Schwartz TH. Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. J Neurosurg 2007; 106 (3) 400-406
    CrossrefPubMedGoogle Scholar
  • 38 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
    CrossrefPubMedGoogle Scholar
  • 39 Matsumoto K, Kohmura E, Tsuruzono K, Mori K, Kawano K, Tsujimura T. Silicone plate-induced granuloma presenting pituitary apoplexy-like symptoms: case report. Surg Neurol 1995; 43 (2) 166-169
    Google Scholar
  • 40 Kassam AB, Thomas A, Carrau RL , et al. Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 2008; 63 (1) (Suppl. 01) ONS44-ONS52 , discussion ONS52–ONS53
    CrossrefPubMedGoogle Scholar
  • 41 Kassam AB, Prevedello DM, Carrau RL , et al. Endoscopic endonasal skull base surgery: analysis of complications in the authors' initial 800 patients. J Neurosurg 2011; 114 (6) 1544-1568
    CrossrefPubMedGoogle Scholar
  • 42 Conger BT, Riley K, Woodworth BA. The draf iii mucosal grafting technique: a prospective study. Otolaryngol Head Neck Surg 2012; 146 (4) 664-668
    CrossrefPubMedGoogle Scholar
  • 43 Hirsch O. Successful closure of cere brospinal fluid rhinorrhea by endonasal surgery. AMA Arch Otolaryngol 1952; 56 (1) 1-12
    CrossrefPubMedGoogle Scholar
  • 44 Smith SJ, Eralil G, Woon K, Sama A, Dow G, Robertson I. Light at the end of the tunnel: the learning curve associated with endoscopic transsphenoidal skull base surgery. Skull Base 2010; 20 (2) 69-74
    Article in Thieme ConnectPubMedGoogle Scholar
  • 45 Koc K, Anik I, Ozdamar D, Cabuk B, Keskin G, Ceylan S. The learning curve in endoscopic pituitary surgery and our experience. Neurosurg Rev 2006; 29 (4) 298-305 , discussion 305
    CrossrefPubMedGoogle Scholar
  • 46 O'Malley Jr BW, Grady MS, Gabel BC , et al. Comparison of endoscopic and microscopic removal of pituitary adenomas: single-surgeon experience and the learning curve. Neurosurg Focus 2008; 25 (6) E10
    PubMedGoogle Scholar
  • 47 de Divitiis E, Cavallo LM, Cappabianca P, Esposito F. Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors: Part 2. Neurosurgery 2007; 60 (1) 46-58 , discussion 58–59
    PubMedGoogle Scholar
  • 48 Gardner PA, Kassam AB, Snyderman CH , et al. Outcomes following endoscopic, expanded endonasal resection of suprasellar craniopharyngiomas: a case series. J Neurosurg 2008; 109 (1) 6-16
    Google Scholar
  • 49 Carrau RL, Snyderman CH, Kassam AB. The management of cerebrospinal fluid leaks in patients at risk for high-pressure hydrocephalus. Laryngoscope 2005; 115 (2) 205-212
    CrossrefPubMedGoogle Scholar
  • 50 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 (2) 89-93
    CrossrefPubMedGoogle Scholar
  • 51 Grady RE, Horlocker TT, Brown RD, Maxson PM, Schroeder DR. Mayo Perioperative Outcomes Group. Neurologic complications after placement of cerebrospinal fluid drainage catheters and needles in anesthetized patients: implications for regional anesthesia. Anesth Analg 1999; 88 (2) 388-392
    PubMedGoogle Scholar