The Role of Tissue Sealants for Skull Base Reconstruction Following Endoscopic Endonasal Surgery: A Systematic Review and Meta-Analysis

Background: Postoperative cerebrospinal fluid (CSF) leakage continues to pose an important limitation of the endoscopic endonasal approach (EEA) in skull base surgery. Despite significant advances in understanding of principles of skull base reconstruction, there remains controversy regarding the role of tissue sealants for modification of postoperative CSF leak outcomes. Tissue sealants, which include fibrin glues and dural sealants, differ in their biochemical properties, methods of delivery, and resorption times. Furthermore, their absolute and relative effectiveness in preventing postoperative CSF leak has not been sufficiently explored. The present study aimed to evaluate the rates of postoperative CSF leak associated with the use and nonuse of adjunctive sealants for the repair of EEA-associated skull base defects.

Methods: The Preferred Reporting of Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for this systematic review with meta-analysis and a search encompassing the Web of Science, PubMed/MEDLINE, Scopus, and Cochrane Library databases was conducted for original studies published between January 2001 and January 2022. Studies reporting disaggregated outcomes of endoscopic skull base reconstruction patients receiving an adjunctive sealant versus those who did not and/or those who received a different sealant were included for review. Meta-analysis of risk differences (RD) was used to assess postoperative CSF leak outcome.

Results: The search yielded 2,456 unique studies, of which 15 (n = 1,217) met inclusion criteria for qualitative and quantitative analysis. Notably, only three included studies were prospective in design, and none were randomized. 50.4% of the aggregate patient cohort was female and mean age was 48.8 years, ranging from 2 to 87. Pituitary adenomas comprised the majority (55.2%) of skull base pathologies represented, followed by meningiomas (5.5%), sinonasal pathology (4.5%), craniopharyngiomas (4.3%), and Rathke's cleft cysts (3.5%). Defects were located predominantly in the sella (47.8%) and anterior cranial fossa (46.7%) and intraoperative leaks were more often low-flow (65.3%) than high-flow. On meta-analysis, reconstruction with a single fibrin or dural sealant did not reduce risk of postoperative CSF leak compared with reconstruction without either sealant (RD [95% CI] = 0.03 [−0.00, 0.06]; p = 0.08). Sub-analyses of dural sealant only cohorts (−0.04 [−0.09, 0.01]; p = 0.15) and fibrin glue only cohorts (0.04 [−0.02, 0.10]; p = 0.22) compared with no sealant cohorts were similarly unremarkable. Generally, dural sealant use was not associated with decreased postoperative CSF leak rates compared with no dural sealant use (−0.01 [−0.05, 0.02]; p = 0.52). Similarly, overall fibrin glue use regardless of combination was not associated with lower postoperative CSF leak rate compared with no fibrin glue (0.03 [−0.02, 0.08]; p = 0.20). No significant association was seen in a pairwise comparison of dural sealant and fibrin glue (−0.02 [−0.08, 0.03]; p = 0.40).

Conclusion: In this aggregate analysis, fibrin glue and dural sealant use in endoscopic skull base reconstruction do not appear to reduce postoperative CSF leak incidence alone or in combination. Further investigation of prospective randomized design may be warranted to thoroughly elucidate the clinical value of adjunct sealants in endoscopic skull base reconstruction.

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Artikel online veröffentlicht:
01. Februar 2023