Complications following 1,002 Endoscopic Endonasal Approaches at a Single Tertiary Center: Lessons Learned 2010 to 2018

Introduction: The endoscopic endonasal approach (EEA) has evolved into a mainstay of skull base surgery over the last two decades. Publications examining intraoperative and perioperative complications of this technique remain scarce, and the landmark series of 800 patients published by Kassam in 2011 examined the first era of EEA (1998–2007). We sought to examine our single-institution series of over 1,000 patients undergoing EEA neurosurgery procedures since year 2010, to elucidate safety and risk factors for complication in the perioperative and postoperative setting.

Methods: We retrospectively reviewed perioperative and postoperative complications in patients undergoing EEA between 2010 and 2018 at our institution, after IRB approval.

Results: We identified 1,002 patients meeting inclusion criteria. Pituitary adenoma was the most common pathology (38%), followed by meningioma (11%). Almost half (n = 477, 47.6%) of patients underwent an operation more complex than simple transsellar. Two patients (0.2%) suffered intraoperative carotid artery injury: one had no neurological sequelae, and one suffered permanent hemiparesis after a remote hemorrhage from antiplatelet agents. No patients died intraoperatively. Postoperatively, transient sodium/water hemostasis derangements were not uncommon (8.7%) but rarely permanent (1.5%). Sixty-one patients (6.1%) had postoperative cerebrospinal fluid leaks; 45 of which occurred within the surgical hospitalization. Six patients (0.6%) suffered meningitis, one of whom died. Three other patients died of medical complications, yielding a total mortality of 0.4%. Expanded intradural-level operations were a risk factor for complications (OR = 2.7, level IVa and OR = 6.1 for IVb, each p < 0.0001), as were anatomically expanded operations (OR = 2.3 extended sagittal plane, OR = 1.7 sagittal/coronal combined, each p < 0.002). From our data, a complicated predicted risk model is proposed.

Conclusion: Our study represents one of the largest cohorts of modern EEA, and demonstrates that even complex EEA have an acceptable safety profile at experienced centers, with low morbidity and mortality. Intraoperative and postoperative complications are nevertheless correlated with increasingly complex procedures and pathologies.