The Use of Fibrin Sealants in Reducing Postoperative Complications in Skull Base Surgery: A Systematic Review and Meta-Analysis

Hänel W. Eberly; Mattie Rosi-Schumacher; Bao Y. Sciscent; Nguyen Truong; Tonya S. King; David Goldenberg; Neerav Goyal

doi:10.1055/a-2493-1134

Journal of Neurological Surgery Part B: Skull Base, Table of Contents

J Neurol Surg B Skull Base
DOI: 10.1055/a-2493-1134

Original Article

The Use of Fibrin Sealants in Reducing Postoperative Complications in Skull Base Surgery: A Systematic Review and Meta-Analysis

Authors

Hänel W. Eberly

¹Department of Otolaryngology-Head and Neck Surgery, Penn State Milton S. Hershey Medical Center and Penn State College of Medicine, Hershey, Pennsylvania, United States
Mattie Rosi-Schumacher

²Department of Otolaryngology-Head and Neck Surgery, Jacobs School of Medicine and Biomedical Sciences, The State University of New York at Buffalo, Buffalo, New York, United States
Bao Y. Sciscent

¹Department of Otolaryngology-Head and Neck Surgery, Penn State Milton S. Hershey Medical Center and Penn State College of Medicine, Hershey, Pennsylvania, United States
Nguyen Truong

¹Department of Otolaryngology-Head and Neck Surgery, Penn State Milton S. Hershey Medical Center and Penn State College of Medicine, Hershey, Pennsylvania, United States
Tonya S. King

³Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, United States
David Goldenberg

¹Department of Otolaryngology-Head and Neck Surgery, Penn State Milton S. Hershey Medical Center and Penn State College of Medicine, Hershey, Pennsylvania, United States
Neerav Goyal

¹Department of Otolaryngology-Head and Neck Surgery, Penn State Milton S. Hershey Medical Center and Penn State College of Medicine, Hershey, Pennsylvania, United States

Abstract

Objective To determine if using fibrin sealants (FS) during skull base (SB) surgery reduces complications.

Methods PubMed, Cochrane, Web of Science, and Embase databases were searched for studies of patients who underwent SB surgery with use of an FS. A systematic review was conducted according to PRISMA guidelines. Primary outcomes included incidence of cerebrospinal fluid (CSF) leak, revision surgery, infection, and drain placement. Methods for meta-analysis were performed including tests of homogeneity and both fixed-effects and random-effects models.

Results A total of 30 articles met the inclusion criteria. There were 3,681 patients, including 2,220 patients who received FS and 1,461 patients who did not. The most common surgical approaches were posterior fossa (27.4%) and transsphenoidal (18.2%). The FS group was less likely to have a lumbar drain placed (1.7% versus 8.1% of the control group). The difference in drain placement incidence between groups for the studies which included both groups was −0.135 (95% CI [−0.285, 0.016], p = 0.079) for the random-effects model and −0.038 (95% CI [−0.068, −0.008], p = 0.014) for the fixed-effects model. The incidence of CSF leak was 11.3% in the control group and 6.8% in the FS group. The rate of infection was higher in the control group (6.1%) compared with the FS group (3.3%), although not statistically significant. The rate of revision surgery was similar between the two groups (3.0% in the control group versus 2.4% in the FS group).

Conclusion Patients who underwent SB surgery with FS may have lower incidences of drain placement than patients whose surgery did not involve FS.

Keywords

skull base - fibrin sealants - cerebrospinal fluid leak - lumbar drainage

Full Text

References

References
1 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
2 Hutter G, von Felten S, Sailer MH, Schulz M, Mariani L. Risk factors for postoperative CSF leakage after elective craniotomy and the efficacy of fleece-bound tissue sealing against dural suturing alone: a randomized controlled trial. J Neurosurg 2014; 121 (03) 735-744
3 Banu MA, Szentirmai O, Mascarenhas L, Salek AA, Anand VK, Schwartz TH. Pneumocephalus patterns following endonasal endoscopic skull base surgery as predictors of postoperative CSF leaks. J Neurosurg 2014; 121 (04) 961-975
4 Horowitz G, Fliss DM, Margalit N, Wasserzug O, Gil Z. Association between cerebrospinal fluid leak and meningitis after skull base surgery. Otolaryngol Head Neck Surg 2011; 145 (04) 689-693
5 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
6 McDowell MM, Jacobs RC, Valappil B. et al. Dural sealants do not reduce postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery. J Neurol Surg B Skull Base 2022; 83 (06) 589-593
7 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
8 George B, Matula C, Kihlström L, Ferrer E, Tetens V. Safety and efficacy of TachoSil (absorbable fibrin sealant patch) compared with current practice for the prevention of cerebrospinal fluid leaks in patients undergoing skull base surgery: a randomized controlled trial. Neurosurgery 2017; 80 (06) 847-853
9 Grey EG. Fibrin as a hemostatic in cerebral surgery. Surg Gynecol Obstet 1915; 21 (03) 452-454
10 Spotnitz WD. Fibrin sealant: the only approved hemostat, sealant, and adhesive—a laboratory and clinical perspective. ISRN Surg 2014; 2014: 203943
11 Bayer IS. Advances in fibrin-based materials in wound repair: a review. Molecules 2022; 27 (14) 4504
12 Nishihira S, McCaffrey TV. The use of fibrin glue for the repair of experimental CSF rhinorrhea. Laryngoscope 1988; 98 (6 Pt 1): 625-627
13 de Almeida JR, Ghotme K, Leong I, Drake J, James AL, Witterick IJ. A new porcine skull base model: fibrin glue improves strength of cerebrospinal fluid leak repairs. Otolaryngol Head Neck Surg 2009; 141 (02) 184-189
14 Bouhout S, Kam J, Robert MC, Harissi-Dagher M. Cost-effectiveness analysis : fibrin glue versus sutures for conjonctival fixation during pterygion surgery. Can J Ophthalmol 2022; 57 (01) 41-46
15 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372: n71
16 OCEBM Levels of Evidence Working Group. The Oxford Levels of Evidence 2. Accessed at: https://www.cebm.ox.ac.uk/resources/levels-of-evidence/ocebm-levels-of-evidence
17 Higgins J, Thomas J, Chandler J. et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.4. Updated August 2023. Accessed at: www.training.cochrane.org/handbook
18 Sterne JA, Hernán MA, Reeves BC. et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016; 355: i4919
19 Sterne JAC, Savović J, Page MJ. et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019; 366: l4898
20 Severson M, Schaurich CG, Strecker-McGraw MK. Cerebrospinal Fluid Leak. In: StatPearls. StatPearls Publishing; 2024
21 Le C, Strong EB, Luu Q. Management of anterior skull base cerebrospinal fluid leaks. J Neurol Surg B Skull Base 2016; 77 (05) 404-411
22 Stopa BM, Leyva OA, Harper CN. et al. Decreased incidence of CSF leaks after skull base fractures in the 21st century: an institutional report. J Neurol Surg B Skull Base 2020; 83 (01) 59-65
23 Naunheim MR, Sedaghat AR, Lin DT. et al. Immediate and delayed complications following endoscopic skull base surgery. J Neurol Surg B Skull Base 2015; 76 (05) 390-396
24 Scheithauer S, Bürgel U, Bickenbach J. et al. External ventricular and lumbar drainage-associated meningoventriculitis: prospective analysis of time-dependent infection rates and risk factor analysis. Infection 2010; 38 (03) 205-209
25 Ackerman PD, Spencer DA, Prabhu VC. The efficacy and safety of preoperative lumbar drain placement in anterior skull base surgery. J Neurol Surg Rep 2013; 74 (01) 1-9
26 Daudia A, Biswas D, Jones NS. Risk of meningitis with cerebrospinal fluid rhinorrhea. Ann Otol Rhinol Laryngol 2007; 116 (12) 902-905
27 Green AL, Arnaud A, Batiller J. et al. A multicentre, prospective, randomized, controlled study to evaluate the use of a fibrin sealant as an adjunct to sutured dural repair. Br J Neurosurg 2015; 29 (01) 11-17
28 Yildirim AE, Dursun E, Ozdol C. et al. Using an autologous fibrin sealant in the preventing of cerebrospinal fluid leak with large skull base defect following endoscopic endonasal transsphenoidal surgery. Turk Neurosurg 2013; 23 (06) 736-741
29 Hong CK, Kim YB, Hong JB, Lee KS. Sealing of cerebrospinal fluid leakage during conventional transsphenoidal surgery using a fibrin-coated collagen fleece. J Clin Neurosci 2015; 22 (04) 696-699
30 Spitaels J, Moore J, Zaidman N. et al. Fibrin-coated collagen fleece versus absorbable dural sealant for sellar closure after transsphenoidal pituitary surgery: a comparative study. Sci Rep 2022; 12 (01) 7998
31 Whitlock EL, Kasukurthi R, Yan Y, Tung TH, Hunter DA, Mackinnon SE. Fibrin glue mitigates the learning curve of microneurosurgical repair. Microsurgery 2010; 30 (03) 218-222
32 Kassam A, Horowitz M, Carrau R. et al. Use of Tisseel fibrin sealant in neurosurgical procedures: incidence of cerebrospinal fluid leaks and cost-benefit analysis in a retrospective study. Neurosurgery 2003; 52 (05) 1102-1105 , discussion 1105

Supplementary Material

Supplementary Material (PDF)