Dural Sealants Do Not Reduce Postoperative Cerebrospinal Fluid Leaks after Endoscopic Endonasal Skull Base Surgery

Introduction: The application of cranial tissue sealants to assist with dural closure is widespread, but data are lacking regarding its utility in endoscopic endonasal surgery (EES).

Objectives: Based on a null hypothesis that the use of cranial sealants after EES does not prevent postoperative cerebrospinal fluid (CSF) leaks. A prospective study was conducted to assess the effect of sealant usage on postoperative CSF leaks following standard reconstruction.

Methods: A prospective, case-control trial of sealant usage after EES was performed from April 2017 to June 2018. The mean follow-up time was 8 months. This study accrued 200 consecutive adult and pediatric patients with skull base pathology who underwent EES. From April 2017 to November 2017, sealant was used as part of standard closure on all EES cases. From November 2017 to June 2018, no sealant was used.

Results: Two hundred consecutive adult and pediatric patients, with a mean age of 52.7 years (range, 10–87 years) were enrolled in the study. In the first 100 patients where sealant was used in the reconstruction, 48 patients had an intraoperative CSF leak. Of these 48, 26 patients had high-flow leaks. The rate of postoperative CSF leaks was 5% in the sealant group. In the subsequent 100 patients, no sealant was used with 59 intraoperative CSF leaks of which 36 were high flow leaks. The overall rate of postoperative CSF leak in this group was 3% (p = 0.64 when comparing overall leak rates). When examining the subset of high flow CSF leaks, the rate of postoperative CSF leak was 12% in the sealant group and 6% in the group without sealant (p < 0.64). One hundred seven patients within this group had a documented intraoperative CSF leak, of which 59 did not receive sealant and 48 received sealant (p = 0.16). Sixty-two of the CSF leaks were high flow. The cohort with sealant had five postoperative CSF leaks (5% rate) compared with a three leaks (3% rate) in the cohort without sealant (p = 0.72). No patient without an intraoperative leak had a postoperative CSF leak. Five of the eight patients with CSF leaks had a high-flow leak. There was no significant difference in sex, age, body mass index, smoking status, surgical pathology, or prior EES in patients with a postoperative CSF leak (Table 1). The only significant difference between the two groups was that there were more patients with sinonasal pathology in the no sealant cohort (nine patients, one leak) than the sealant cohort (one patient, 0 leaks; p = 0.04).

Conclusion: Perioperative dural sealant usage as a supplement to standard EES closure techniques does not reduce the rate of postoperative CSF leak.