Implementation of Free Mucosal Graft Technique for Sellar Reconstruction after Pituitary Surgery: Outcomes of 158 Consecutive Patients

Introduction: Cerebrospinal fluid (CSF) leak is a common complication after surgeries involving sellar reconstruction. Various techniques, such as the nasoseptal flap, have been developed to limit the rate of postoperative CSF leak. However, the nasoseptal flap causes several complications due to donor site morbidity. A free mucosal graft may be just as effective in reducing CSF leaks as well as reducing postoperative nasal discomfort. This study aims to assess the operative outcomes of the free mucosal graft after pituitary resection.

Methods: A retrospective chart review was performed for patients who underwent endoscopic endonasal resection of pituitary adenomas at a single-center institution. The following data were collected: demographic data, occurrence of intraoperative CSF leak, postoperative CSF leak, other complications, and mucosal graft healing at one month. Sinonasal Outcome Test-22 (SNOT-22) was also recorded preoperatively, 1 and 3 months postoperatively.

Results: A total of 158 charts were reviewed, including patients who underwent no graft reconstruction, free mucosal graft reconstruction ([Fig. 1]), and nasoseptal flap reconstruction. In patients who underwent no reconstruction (n = 27), there was a 7.4% postoperative CSF leak rate, while in patients undergoing free mucosal graft reconstruction (n = 122), there was a 0.82% postoperative CSF leak rate (p <  0.05; [Table 1]). SNOT-22 scores for patients with free mucosal graft reconstruction showed no significant worsening postoperatively. Additionally, in all free mucosal graft patients, the donor site showed total or near-total mucosalization at 1 month postoperatively.

Conclusion: The free mucosal graft is a simple and effective means of sellar reconstruction in patients undergoing endonasal endoscopic pituitary resection and has a similar efficacy to nasoseptal flaps. The free mucosal graft technique also does not worsen sinonasal morbidity postoperatively.

Table 1 CSF Leak rates in patients undergoing pituitary resection with either free mucosal graft reconstruction, nasoseptal flap reconstruction, or no reconstruction

	Intraoperative CSF leaks	Postoperative CSF leaks
Free mucosal graft (n = 122)	48 (39%)	1 (0.82%)
Nasoseptal flap (n = 9)	6 (67%)	0 (0%)
No reconstruction (n = 27)	7 (26%)	2 (7.4%)

Fig. 1 Intraoperative images obtained with a 0-degree endoscope. (A) Inlay collagen dural graft (Durepair) placed in contact with dural layer. (B) Overlay free mucosal graft placed over entire sellar defect. Entire border of the graft is in contact with bone.