How to Avoid Complication in Endoscopic Transnasal Skull Base Surgery: Lesson Learned from the Last 129 Consecutive Cases

Objective: To present a case series of endoscopic skull base transnasal surgeries (TNS) to highlight complications and tricks for avoid them.

Methods: A series of 129 consecutive (2012–2015) patients treated through an endoscopic transnasal approach is presented, focusing on postoperative complications. In the present series, there were 84 (65.1%) pituitary adenomas, 11 chordomas (8.5%), 9 craniopharyngiomas (6.9%), 5 meningiomas (3.8%), 4 metastases (3.1%), 3 chondroma/chondrosarcoma (2.3%), and 11 different types of lesions (8.5%).

Results: The case series comprised 66 males and 63 females with a mean age of 52 years. Complications were recorded in 39 (30%) patients: of these, 37 (95%) directly related to surgical procedure and 2 (5%) not related. The most frequent complications were as follows: CSF fistula (19 patients; 2 of these patients developed meningitis too), 7 diabetes insipidus, 3 infections (without CSF fistula), 4 transient neurological deficits (e.g., CN palsy). Nasal crusting and poor nasal function were observed in 16% of cases, mainly when an extended approach was performed. Mortality was 0.8%: one patient died due to CNS infection following CSF fistula.

Conclusion: Despite advances in reconstruction techniques CSF fistula still represent a major issue. One out of 19 patients with CSF leakage died, accounting for a mortality rate of ~5%. The concept of mini-invasiveness should be rethought at the light of the consideration that mini-invasiveness should be related to outcome and not to the lack of skin incision. The nasal issue also cannot be minimized if a correct evaluation of the invasiveness must be done.