Intraoperative Repair of Cerebrospinal Fluid Rhinorrhea in Skull Base Tumor Resection: A Retrospective Study of Acellular Dermal Matrix Versus Turbinate Flap.

The acellular dermal matrix (ADM) and turbinate flap (TF) have been widely used in the reconstruction of skull base defects. However, owing to the lack of reported data, the therapeutic effects have been controversial. The purpose of the present study was to compare the effect of the ADM and TF on cerebrospinal fluid (CSF) rhinorrhea after nasal endoscopic resection of a skull base tumor. The data from 46 patients who had undergone nasal endoscopic resection of a skull base tumor and repair of CSF rhinorrhea were retrospectively analyzed. The patients were divided into ADM and TF groups according to the difference in repair materials used. We compared and analyzed the intraoperative information and postoperative outcomes. The operation time, blood loss, defect area, and need for blood transfusion were not significantly different between the ALT and TF groups. The postoperative length of hospital stay (14.33 ± 3.66 vs. 16.76 ± 5.51 days; P = 0.669) and the incidence of complications, including wound infection (1 vs. 0; P = 0.270), intracranial infection (1 vs. 1; P = 0.900), hemorrhage (2 vs. 3; P = 0.788), 15-day CSF leak (1 vs. 2; P = 0.658), and respiratory infection (2 vs. 1; P = 0.450) were comparable between the 2 groups. The 6-month (0 vs. 0; P = 1.000) and 12-month (0 vs. 0; P = 1.000) incidence of recurrence also showed no significant differences. The use of the ADM for patients with CSF rhinorrhea showed comparable results in terms of postoperative outcomes compared with the use of TF. ADM could serve as a safe and feasible alternative for endoscopic repair of CSF rhinorrhea after nasal endoscopic resection of skull base tumors.

Zhong B ，Song NY ，Deng D ，Li LK ，Du JT ，Liu F ，Liu YF ，Liu SX ... -  《-》

Comparative analysis of transnasal endoscopic reconstruction techniques for managing cerebrospinal fluid rhinorrhea in skull base defects.

The nasal skull base is located into the deep position of nasal cavity and closely related to important nerves and vessels. The complete removal of tumors in this area poses a complex surgical challenge.In order to investigate the clinical efficacy of utilizing free middle turbinate mucosa (FMT), fascia lata, and pedicled nasal septum flap (known as the Hadad-Bassagasteguy flap, HBF) for the treatment of cerebrospinal fluid (CSF) rhinorrhea, a retrospective analysis was conducted on clinical data from 65 patients who underwent skull base reconstruction following endoscopic resection of nasal-skull base tumors. The selection of the repair material was based on the size and location of the defect. For defects less than 1.5 cm (n = 24), FMT was chosen, while for defects greater than or equal to 1.5 cm (n = 16), HBF was preferred. In cases where HBF was not available or not suitable (specifically, when the defect was located on the posterior wall of the frontal sinus), fascia lata was selected (n = 25). The repair outcomes of all 65 patients were summarized, and subsequently, a comparison was made between the use of fascia lata and HBF. The overall success rate for one-time repairs was 93.8 %. Specifically, the success rates for repairs using FMT, fascia lata, and HBF were 91.7 %, 96.0 %, and 93.8 %, respectively. Throughout the follow-up period, there were 2 cases of postoperative CSF leakage out of 24 patients who underwent FMT reconstruction, 1 case out of 25 patients who underwent fascia lata reconstruction, and 1 case out of 16 patients who underwent HBF reconstruction. The occurrence of postoperative complications, such as intracranial infection, lung infection, and epistaxis, was observed in both the fascia lata group and the HBF group. However, there were no statistically significant differences between the two groups. The transnasal endoscopic reconstruction of skull base defect using HBF, fascia lata, and FMT demonstrated satisfactory repair effects in managing CSF rhinorrhea. Generally, FMT has been found to be a dependable repair material for small defects measuring less than 1.5 cm, while in the case of larger defects equal to or exceeding 1.5 cm, both HBF and fascia lata can be utilized with comparable repair outcomes. The selection of fascia lata becomes a viable option when HBF is unavailable or not suitable.

Tan Y ，Li J ，Liu Y ，Du J ... -  《-》

Nasoseptal flap repair after endoscopic transsellar versus expanded endonasal approaches: is there an increased risk of postoperative cerebrospinal fluid leak?

The development of expanded endoscopic endonasal approaches (EEAs) has allowed resection of cranial-base lesions beyond the sella. One major criticism is an increased risk of postoperative cerebrospinal fluid (CSF) leakage because of the larger skull base defect. We evaluated our experience with vascularized pedicled nasoseptal flap (PNSF) reconstruction and compared the postoperative CSF leak rates between patients undergoing endoscopic transsphenoidal (transsellar) approaches versus expanded EEA (transplanum-transtuberculum, transcribriform, transclival). Retrospective analysis at a tertiary care medical center. A retrospective review of a prospective database was performed on patients who underwent PNSF reconstruction for intraoperative high-flow CSF leaks after EEA between December 2008 and August 2011. Demographic data, repair materials, surgical approach, and incidence of postoperative CSF leaks were collected. Thirty-seven transsellar defects (group I) were repaired with a PNSF, and 32 expanded EEA defects (19 transplanum-transtuberculum, 10 transcribriform, three transclival) (group II) were repaired with a PNSF. No postoperative CSF leaks occurred in group I. One delayed postoperative CSF leak was encountered in group II leading to a 3.1% leak rate in that group. The incidence of postoperative CSF leakage was not significantly different between the two groups (P > .05). Our overall success rate in this series using a PNSF was 98.6%. Based on our data, there is no significant increased risk of postoperative CSF leak between transsellar and expanded EEA defects when a PNSF is used. The potential risk of postoperative CSF leaks associated with larger defects created through expanded EEA can be minimized by multilayered closure with a PNSF and meticulous surgical technique.

Eloy JA ，Choudhry OJ ，Shukla PA ，Kuperan AB ，Friedel ME ，Liu JK ... -  《-》

Challenges and surgical nuances in reconstruction of large planum sphenoidale tuberculum sellae defects after endoscopic endonasal resection of parasellar skull base tumors.

Endoscopic endonasal transplanum transtuberculum (EETT) resection of parasellar skull base (SB) tumors often results in large SB defects with intraoperative high-flow cerebrospinal fluid (CSF) leaks. Reconstruction of these defects can be challenging because of the large defects size, communication with the suprasellar cistern, and close proximity to the optic nerves and chiasm. Recent studies have postulated that transplanum defects may be associated with increased postoperative CSF leakage. We review our experience with reconstruction of transplanum defects after EETT resection of parasellar SB tumors. Challenges encountered during these repairs and our operative nuances for successful reconstruction are discussed. A retrospective analysis was performed between March 2010 and February 2012 on patients undergoing reconstruction of transplanum defects after EETT resection of parasellar SB tumors. Repair materials, defect sizes, postoperative CSF leakage, postoperative CSF diversion, and demographic data were collected. Nineteen patients who underwent 22 repairs with a pedicled nasoseptal flap (PNSF) were identified. The mean age was 47.6 years (range, 12-68 years). Average defect size was 5.6 cm(2) (range, 2.2-10.4 cm(2)). Three failed repairs necessitated a revision procedure. All three revisions were successfully reconstructed with the previously used PNSF. The mean follow-up period was 13.5 months (range, 1-26 months). The overall success rate was 86.4% for transplanum defects alone, as compared to 97.0% for our comprehensive PNSF experience in 99 repairs. Repair of large transplanum defects after EETT resection of parasellar SB tumors presents a unique challenge. Using a PNSF along with meticulous multilayer closure may help decrease postoperative CSF leaks.

Eloy JA ，Shukla PA ，Choudhry OJ ，Singh R ，Liu JK ... -  《-》

Radiographic enhancement of the nasoseptal flap does not predict postoperative cerebrospinal fluid leaks in endoscopic skull base reconstruction.

Cerebrospinal fluid (CSF) leaks continue to be the most common postoperative complication in expanded endonasal skull base procedures. Currently, a multilayer closure using a vascularized nasoseptal flap is most commonly performed for large ventral skull base defects in an effort to avoid postoperative CSF leaks. We correlated nasoseptal flap enhancement with postoperative CSF leak rates in a group of skull base reconstruction patients. The nasoseptal flap enhancement was determined by immediate postoperative gadolinium-enhanced magnetic resonance imaging (MRI), which allowed for imaging of the flap's vascular pedicle. Our aim was to identify whether nasoseptal flap enhancement contributed to reduction of postoperative CSF leak rates. Retrospective cohort study. We reviewed 19 patients who underwent expanded endoscopic resections of skull base lesions of advanced complexity. We calculated the incidence of CSF leaks and measured the presence of nasoseptal flap enhancement. Of the 19 patients with immediate postoperative MRIs, three developed postoperative CSF leaks. All three CSF leaks were in cases with enhancing vascular pedicles. In contrast, we had three patients without evidence of flap enhancement, none of whom developed a postoperative CSF leak (Fisher exact test, P = 1.0). CSF leak was associated with posterior fossa lesions (P = .25). Nasoseptal flap enhancement was associated with younger age (P = .15). This retrospective cohort study demonstrates that although the vascularized pedicled nasoseptal flap is effective for closure of expanded endonasal skull base procedures, our experience found the actual enhancement of the flap itself does not appear to effect postoperative CSF leak rates.

Adappa ND ，Learned KO ，Palmer JN ，Newman JG ，Lee JY ... -  《-》