Single Institutional Experience with Bioabsorbable Steroid Eluting Stent Treatment of Recurrent Rathke’s Cleft Cyst

Introduction: Rathke’s cleft cysts (RCC) can recur after surgical drainage or resection, at a rate of approximately 8% after an endoscopic transnasal transsphenoidal (TNTS) approach. One common method to prevent cyst recurrence involves making a permanent marsupialization of the RCC to minimize cyst wall closure and subsequent cyst reaccumulation. Despite this method, RCC can still recur with scar formation leading to cyst wall closure. Therefore, we aimed to optimize the creation of a permanent stoma between recurrent RCCs and the sphenoid sinus by placing bioabsorbable steroid eluting stents during revision TNTS surgery. We present here the largest single institutional series of bioabsorbable steroid eluting stenting for the treatment of recurrent RCC that were previously marsupialized.

Methods: We performed a retrospective chart review of all patients who underwent endoscopic TNTS for remarsupialization with subsequent stent placement for a recurrent RCC, diagnosed based on histopathologic analysis from prior surgeries or from the most recent procedure. The stents (Propel Mini, Intersect ENT, Palo Alto, California) consisted of a bioabsorbable, sustained drug release platform of poly-(DL-lactide-co-glycolide) and polyethylene glycol embedded with 370 micrograms of mometasone furoate which was gradually released over time. The revision TNTS surgeries consisted of remarsupialization, followed by stent placement. In some instances, an additional nasoseptal flap was created.

Results: Six patients underwent drainage of recurrent RCC via marsupialization followed by stent placement (Table 1). All patients underwent surgeries via an endoscopic TNTS approach both during the revision and the previous surgeries. The median age was 40.5, and the number of prior drainage procedures ranged from 1 to 3. The stents were placed directly into the cyst cavity through the wall opening ([Fig. 1]). The stents were bioabsorbable and were not removed after surgery, but were evaluated endoscopically at 2 and 6 weeks after surgery. The patients were followed for a mean of 19 months after revision surgery with no evidence of recurrence on endoscopic exam or imaging. While only one patient had transient diabetes insipidus that self-resolved, no patient had cerebrospinal fluid leak during or after the operation or permanent endocrinopathy.

Conclusion: In all six patients, the use of a bioabsorbable steroid eluting stent had no unanticipated consequences. All drainage pathways of all the recurrent RCCs remained patent and there has been no evidence of recurrence in all patients. The use of this technology may decrease recurrence rates in revision or complex cases where patients have extensive scarring operative field from prior drainage procedures. Longer follow-up of the current cases and further study in an even larger cohort are warranted.

Table 1 Patients’ demographics of recurrent RCC via marsupialization

Fig. 1 The cyst cavity through the wall opening.