Download PDF
J Neurol Surg B Skull Base 2022; 83(06): 589-593
DOI: 10.1055/s-0042-1743558
Review Article

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

Michael M. McDowell‡   *
1   Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Rachel C. Jacobs‡   *
1   Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Benita Valappil
1   Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
2   Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Hussam Abou-Al-Shaar
1   Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Georgios A. Zenonos
1   Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Eric W. Wang
2   Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Carl H. Snyderman
2   Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Paul A. Gardner
1   Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
› Author Affiliations
› Further Information
   Permissions and Reprints

Abstract

Introduction The application of cranial tissue sealants to assist with postoperative closure is widespread, but data are lacking regarding its utility in endoscopic endonasal surgery (EEA). A prospective study was conducted to assess the effect of sealant usage on postoperative cerebrospinal fluid (CSF) leak rate following standard reconstruction.

Methods A prospective trial of sealant usage after endoscopic endonasal skull base surgery was performed from May 2016 to June 2019 at a tertiary referral cranial base center. This study enrolled 300 consecutive adult and pediatric patients with skull base pathology who underwent EES in which an intraoperative CSF leak occurred. Patients were sequentially stratified into equally sized groups who did or did not receive sealant as part of their reconstruction.

Results Three hundred consecutive adult and pediatric patients were enrolled in the study and had a confirmed intraoperative CSF leak. The intervention cohort with sealant (first 150 patients) had 21 postoperative CSF leaks (14% rate) compared with 9 postoperative CSF leaks (6% rate) in the control group without sealant (p = 0.02). On multivariate analysis, sealant usage was associated with a higher rate of postoperative CSF leak (odds ratio [OR] = 2.7; p = 0.025). Male gender (OR = 2.4; p = 0.04) and high-flow intraoperative CSF leak (OR = 3.1; p = 0.038) were also found to be associated with postoperative CSF leak.

Conclusion Among all patients undergoing EES with an intraoperative CSF leak, the addition of sealant to standard closure techniques did not reduce the rate of postoperative CSF leaks.

Keywords

dural sealant - fibrin glue - cerebrospinal fluid leak - endoscopic endonasal approach - pituitary surgery - skull base

* These authors contributed equally to this paper.




Publication History

Received: 02 October 2021

Accepted: 30 January 2022

Article published online:
11 April 2022

© 2022. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Borg A, Kirkman MA, Choi D. Endoscopic endonasal anterior skull base surgery: a systematic review of complications during the past 65 years. World Neurosurg 2016; 95: 383-391
    CrossrefPubMedGoogle Scholar
  • 2 Dehdashti AR, Stofko D, Okun J, Obourn C, Kennedy T. Endoscopic endonasal reconstruction of skull base: repair protocol. J Neurol Surg B Skull Base 2016; 77 (03) 271-278
    PubMedGoogle Scholar
  • 3 Eloy JA, Choudhry OJ, Friedel ME, Kuperan AB, Liu JK. Endoscopic nasoseptal flap repair of skull base defects: is addition of a dural sealant necessary?. Otolaryngol Head Neck Surg 2012; 147 (01) 161-166
    CrossrefPubMedGoogle Scholar
  • 4 McCoul ED, Anand VK, Singh A, Nyquist GG, Schaberg MR, Schwartz TH. Long-term effectiveness of a reconstructive protocol using the nasoseptal flap after endoscopic skull base surgery. World Neurosurg 2014; 81 (01) 136-143
    CrossrefPubMedGoogle Scholar
  • 5 Thorp BD, Sreenath SB, Ebert CS, Zanation AM. Endoscopic skull base reconstruction: a review and clinical case series of 152 vascularized flaps used for surgical skull base defects in the setting of intraoperative cerebrospinal fluid leak. Neurosurg Focus 2014; 37 (04) E4
    CrossrefPubMedGoogle Scholar
  • 6 Wang EW, Zanation AM, Gardner PA. et al. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2019; 9 (Suppl. 03) S145-S365
    PubMedGoogle Scholar
  • 7 Esposito F, Dusick JR, Fatemi N, Kelly DF. Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery. Oper Neurosurg (Hagerstown) 2007; 60 (04, Suppl 2): discussion 303–304 295-303
    CrossrefPubMedGoogle Scholar
  • 8 Germani RM, Vivero R, Herzallah IR, Casiano RR. Endoscopic reconstruction of large anterior skull base defects using acellular dermal allograft. Am J Rhinol 2007; 21 (05) 615-618
    CrossrefPubMedGoogle Scholar
  • 9 Lanza DC, O'Brien DA, Kennedy DW. Endoscopic repair of cerebrospinal fluid fistulae and encephaloceles. Laryngoscope 1996; 106 (9 pt. 1): 1119-1125
    CrossrefPubMedGoogle Scholar
  • 10 Leong JL, Citardi MJ, Batra PS. Reconstruction of skull base defects after minimally invasive endoscopic resection of anterior skull base neoplasms. Am J Rhinol 2006; 20 (05) 476-482
    CrossrefPubMedGoogle Scholar
  • 11 Lorenz RR, Dean RL, Hurley DB, Chuang J, Citardi MJ. Endoscopic reconstruction of anterior and middle cranial fossa defects using acellular dermal allograft. Laryngoscope 2003; 113 (03) 496-501
    CrossrefPubMedGoogle Scholar
  • 12 Zwagerman NT, Wang EW, Shin SS. et al. Does lumbar drainage reduce postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery? A prospective, randomized controlled trial. J Neurosurg 2018; 131 (04) 1172-1178
    CrossrefPubMedGoogle Scholar
  • 13 Harvey RJ, Parmar P, Sacks R, Zanation AM. Endoscopic skull base reconstruction of large dural defects: a systematic review of published evidence. Laryngoscope 2012; 122 (02) 452-459
    CrossrefPubMedGoogle Scholar
  • 14 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 (05) 518-521
    CrossrefPubMedGoogle Scholar
  • 15 Boogaarts JD, Grotenhuis JA, Bartels RH, Beems T. Use of a novel absorbable hydrogel for augmentation of dural repair: results of a preliminary clinical study. Neurosurgery 2005; 57 (1, suppl): discussion 146–151 146-151
    PubMedGoogle Scholar
  • 16 Cosgrove GR, Delashaw JB, Grotenhuis JA. et al. Safety and efficacy of a novel polyethylene glycol hydrogel sealant for watertight dural repair. J Neurosurg 2007; 106 (01) 52-58
    CrossrefPubMedGoogle Scholar
  • 17 Kacher DF, Frerichs K, Pettit J, Campbell PK, Meunch T, Norbash AM. DuraSeal magnetic resonance and computed tomography imaging: evaluation in a canine craniotomy model. Neurosurgery 2006; 58 (1, suppl): discussion ONS140–ONS147 ONS140-ONS147
    PubMedGoogle Scholar
  • 18 Preul MC, Bichard WD, Spetzler RF. Toward optimal tissue sealants for neurosurgery: use of a novel hydrogel sealant in a canine durotomy repair model. Neurosurgery 2003; 53 (05) 1189-1198 , discussion 1198–1199
    CrossrefPubMedGoogle Scholar
  • 19 Kus LH, Rotenberg BW, Duggal N. Use of tissue glues in endoscopic pituitary surgery: a cost comparison. Can J Neurol Sci 2010; 37 (05) 650-655
    CrossrefPubMedGoogle Scholar
  • 20 Chin CJ, Kus L, Rotenberg BW. Use of duraseal in repair of cerebrospinal fluid leaks. J Otolaryngol Head Neck Surg 2010; 39 (05) 594-599
    PubMedGoogle Scholar
  • 21 Grotenhuis JA. Costs of postoperative cerebrospinal fluid leakage: 1-year, retrospective analysis of 412 consecutive nontrauma cases. Surg Neurol 2005; 64 (06) 490-493 , discussion 493–494
    CrossrefPubMedGoogle Scholar
  • 22 Than KD, Baird CJ, Olivi A. Polyethylene glycol hydrogel dural sealant may reduce incisional cerebrospinal fluid leak after posterior fossa surgery. Neurosurgery 2008; 63 (01, Suppl 1): discussion ONS186–ONS187 ONS182-ONS186
    PubMedGoogle Scholar
  • 23 Fraser S, Gardner PA, Koutourousiou M. et al. Risk factors associated with postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery. J Neurosurg 2018; 128 (04) 1066-1071
    CrossrefPubMedGoogle Scholar