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J Neurol Surg B Skull Base 2020; 81(06): 645-650
DOI: 10.1055/s-0039-1693124
Original Article

Endoscopic Endonasal Reconstruction of High-Flow Cerebrospinal Fluid Leak with Fascia Lata “Button” Graft and Nasoseptal Flap: Surgical Technique and Case Series

Roshni V. Khatiwala
1   Albany Medical College, Albany, New York, United States
,
Karthik S. Shastri 
2   Division of Otolaryngology/Head and Neck Surgery, Department of Surgery, Albany Medical Center, Albany, New York, United States
,
Maria Peris-Celda
3   Department of Neurosurgery, Albany Medical Center, Albany, New York, United States
,
Tyler Kenning
3   Department of Neurosurgery, Albany Medical Center, Albany, New York, United States
,
Carlos D. Pinheiro-Neto
2   Division of Otolaryngology/Head and Neck Surgery, Department of Surgery, Albany Medical Center, Albany, New York, United States
3   Department of Neurosurgery, Albany Medical Center, Albany, New York, United States
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Abstract

Background The endoscopic endonasal approach (EEA) has become increasingly used for resection of skull base tumors in the sellar and suprasellar regions. A nasoseptal flap (NSF) is routinely used for anterior skull base reconstruction; however, there are numerous additional allografts and autografts being used in conjunction with the NSF. The role of perioperative cerebrospinal fluid (CSF) diversion is also unclear.

Objective This study was aimed to analyze success of high-flow CSF leak repair during EEA procedures without use of CSF diversion through lumbar drainage.

Methods A retrospective chart review of patients who had intraoperative high-flow CSF leak during EEA procedures at our institution between January 2013 and December 2017 was performed. CSF leaks were repaired with use of a fascia lata button graft and nasoseptal flap, without use of perioperative lumbar drains.

Results A total of 38 patients were identified (10 male, 28 female). Patient BMIs ranged from 19.7 to 49 kg/m2 (median = 31 kg/m2), with 18 patients meeting criteria for obesity (BMI > 30 kg/m2) and 12 patients overweight (25 kg/m2 < BMI < 29.9 kg/m2). There was no incidence of postoperative CSF leak.

Conclusion In our experience, the nasoseptal flap used in conjunction with the fascia lata button graft is a safe, effective and robust combination for cranial base reconstruction with high-flow intraoperative CSF leaks, without need for lumbar drains.

Keywords

high-flow cerebrospinal fluid leak - endoscopic endonasal approach - fascia lata button graft - nasoseptal flap - pituitary adenoma - meningioma - craniopharyngioma

Financial Disclosure

None declared.




Publication History

Received: 19 April 2019

Accepted: 19 May 2019

Article published online:
31 July 2019

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Bedrosian JC, Anand VK, Schwartz TH. The endoscopic endonasal approach to repair of iatrogenic and noniatrogenic cerebrospinal fluid leaks and encephaloceles of the anterior cranial fossa. World Neurosurg 2014; 82 (6, Suppl.) S86-S94
    CrossrefPubMedGoogle Scholar
  • 2 Cavallo LM, Frank G, Cappabianca P. et al. The endoscopic endonasal approach for the management of craniopharyngiomas: a series of 103 patients. J Neurosurg 2014; 121 (01) 100-113
    CrossrefPubMedGoogle Scholar
  • 3 Doglietto F, Prevedello DM, Jane Jr. JA, Han J, Laws Jr ER. Brief history of endoscopic transsphenoidal surgery--from Philipp Bozzini to the First World Congress of Endoscopic Skull Base Surgery. Neurosurg Focus 2005; 19 (06) E3
    CrossrefPubMedGoogle Scholar
  • 4 Kassam A, Carrau RL, Snyderman CH, Gardner P, Mintz A. Evolution of reconstructive techniques following endoscopic expanded endonasal approaches. Neurosurg Focus 2005; 19 (01) E8
    CrossrefPubMedGoogle Scholar
  • 5 Esposito F, Dusick JR, Fatemi N, Kelly DF. Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery. Neurosurgery 2007; 60 (04) (Suppl. 02) 295-303 , discussion 303–304
    PubMedGoogle Scholar
  • 6 Ahn JYKS, Kim SH. A new technique for dural suturing with fascia graft for cerebrospinal fluid leakage in transsphenoidal surgery. Neurosurgery 2009; 65 (6, Suppl.) 65-71, discussion 71–72
    PubMedGoogle Scholar
  • 7 Luginbuhl AJCP, Campbell PG, Evans J, Rosen M. Endoscopic repair of high-flow cranial base defects using a bilayer button. Laryngoscope 2010; 120 (05) 876-880
    PubMedGoogle Scholar
  • 8 Pereira EAC, Grandidge CA, Nowak VA, Cudlip SA. Cerebrospinal fluid leaks after transsphenoidal surgery - Effect of a polyethylene glycol hydrogel dural sealant. J Clin Neurosci 2017; 44: 6-10
    Google Scholar
  • 9 Ransom ERPJ, Palmer JN, Kennedy DW, Chiu AG. Assessing risk/benefit of lumbar drain use for endoscopic skull-base surgery. Int Forum Allergy Rhinol 2011; 1 (03) 173-177
    CrossrefPubMedGoogle Scholar
  • 10 Sade B, Mohr G, Frenkiel S. Management of intra-operative cerebrospinal fluid leak in transnasal transsphenoidal pituitary microsurgery: use of post-operative lumbar drain and sellar reconstruction without fat packing. Acta Neurochir (Wien) 2006; 148 (01) 13-18 , discussion 18–19
    CrossrefPubMedGoogle Scholar
  • 11 Sigler AC, D'Anza B, Lobo BC, Woodard TD, Recinos PF, Sindwani R. Endoscopic skull base reconstruction: an evolution of materials and methods. Otolaryngol Clin North Am 2017; 50 (03) 643-653
    CrossrefPubMedGoogle Scholar
  • 12 Stokken J, Recinos PF, Woodard T, Sindwani R. The utility of lumbar drains in modern endoscopic skull base surgery. Curr Opin Otolaryngol Head Neck Surg 2015; 23 (01) 78-82
    PubMedGoogle Scholar
  • 13 Hadad G, Bassagasteguy L, Carrau RL. et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006; 116 (10) 1882-1886
    Google Scholar
  • 14 Fatemi N, Dusick JR, de Paiva Neto MA, Kelly DF. The endonasal microscopic approach for pituitary adenomas and other parasellar tumors: a 10-year experience. Neurosurgery 2008; 63 (04) (Suppl. 02) 244-256 , discussion 256
    CrossrefPubMedGoogle Scholar
  • 15 Ooi LYWB, Walker BR, Bodkin PA, Whittle IR. Idiopathic intracranial hypertension: can studies of obesity provide the key to understanding pathogenesis?. Br J Neurosurg 2008; 22 (02) 187-194
    CrossrefPubMedGoogle Scholar
  • 16 Pérez MABO, Bialer OY, Bruce BB, Newman NJ, Biousse V. Primary spontaneous cerebrospinal fluid leaks and idiopathic intracranial hypertension. J Neuroophthalmol 2013; 33 (04) 330-337
    CrossrefPubMedGoogle Scholar
  • 17 Dlouhy BJMK, Madhavan K, Clinger JD. et al. Elevated body mass index and risk of postoperative CSF leak following transsphenoidal surgery. J Neurosurg 2012; 116 (06) 1311-1317
    Google Scholar
  • 18 Roxbury CRST, Saavedra T, Ramanathan Jr M. et al. Layered sellar reconstruction with avascular free grafts: acceptable alternative to the nasoseptal flap for repair of low-volume intraoperative cerebrospinal fluid leak. Am J Rhinol Allergy 2016; 30 (05) 367-371
    CrossrefPubMedGoogle Scholar
  • 19 Sciarretta V, Mazzatenta D, Ciarpaglini R, Pasquini E, Farneti G, Frank G. Surgical repair of persisting CSF leaks following standard or extended endoscopic transsphenoidal surgery for pituitary tumor. Minim Invasive Neurosurg 2010; 53 (02) 55-59
    Article in Thieme ConnectPubMedGoogle Scholar
  • 20 Horiguchi K, Murai H, Hasegawa Y, Hanazawa T, Yamakami I, Saeki N. Endoscopic endonasal skull base reconstruction using a nasal septal flap: surgical results and comparison with previous reconstructions. Neurosurg Rev 2010; 33 (02) 235-241 , discussion 241
    CrossrefPubMedGoogle Scholar
  • 21 Horridge M, Jesurasa A, Olubajo F, Mirza S, Sinha S. The use of the nasoseptal flap to reduce the rate of post-operative cerebrospinal fluid leaks following endoscopic trans-sphenoidal surgery for pituitary disease. Br J Neurosurg 2013; 27 (06) 739-741
    CrossrefPubMedGoogle Scholar
  • 22 Kassam ABTA, Thomas A, Carrau RL. et al. Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 2008; 63 (01) (Suppl. 01) ONS44-ONS52 , discussion ONS52–ONS53
    PubMedGoogle Scholar
  • 23 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
  • 24 Xuejian W, Fan H, Xiaobiao Z. et al. Endonasal endoscopic skull base multilayer reconstruction surgery with nasal pedicled mucosal flap to manage high flow CSF leakage. Turk Neurosurg 2013; 23 (04) 439-445
    PubMedGoogle Scholar
  • 25 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
  • 26 Leng LZ, Brown S, Anand VK, Schwartz TH. “Gasket-seal” watertight closure in minimal-access endoscopic cranial base surgery. Neurosurgery 2008; 62 (05) (Suppl. 02) E342-E343 , discussion E343
    CrossrefPubMedGoogle Scholar
  • 27 Garcia-Navarro V, Anand VK, Schwartz TH. Gasket seal closure for extended endonasal endoscopic skull base surgery: efficacy in a large case series. World Neurosurg 2013; 80 (05) 563-568
    CrossrefPubMedGoogle Scholar
  • 28 Hu F, Gu Y, Zhang X. et al. Combined use of a gasket seal closure and a vascularized pedicle nasoseptal flap multilayered reconstruction technique for high-flow cerebrospinal fluid leaks after endonasal endoscopic skull base surgery. World Neurosurg 2015; 83 (02) 181-187
    CrossrefPubMedGoogle Scholar
  • 29 Ruiz-Juretschke F, Mateo-Sierra O, Iza-Vallejo B, Carrillo-Yagüe R. [Intraventricular tension pneumocephalus after transsphenoidal surgery: a case report and literature review]. Neurocirugia (Astur) 2007; 18 (02) 134-137
    PubMedGoogle Scholar