Management of cerebrospinal fluid leak during endoscopic pituitary surgery

Berker, Mustafa; Aghayev, Kamran; Yücel, Taşkın; Hazer, Derya Burcu; Önerci, Metin

doi:10.1016/j.anl.2012.11.006

Cited by 28 publications

(21 citation statements)

References 26 publications

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“…Hence, although the endoscopic access to the sellar region is a relatively new technique, performing more surgeries with both hands using endoscopic guidance will certainly contribute to surgeon competence and better use of this technique. 5,6 Thus, with this report we determined a cut-off value of the number of surgeries needed to achieve better cure rates. We observed a significant increase in the cure rate after the 57th primary surgically treated case and the 108th of all surgically treated cases.…”

Section: Discussionmentioning

confidence: 99%

“…[4][5][6] Because patients with acromegaly differ from other pituitary adenoma cases with respect to increased osteoblastic activity and vascular tortuosity, 12,43 a more extended approach was performed for these particular cases. In the nasosphenoidal stage, sella was exposed from one carotid protuberance to the other, and craniocaudally from the planum sphenoidale to the clivus.…”

Section: Surgical Techniquementioning

confidence: 99%

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Treatment of acromegaly by endoscopic transsphenoidal surgery: surgical experience in 214 cases and cure rates according to current consensus criteria

Hazer

Işık

Berker

et al. 2013

JNS

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Object Acromegaly is a disease that has significant morbidity and mortality related to high levels of growth hormone (GH) and insulin-like growth factor–I (IGF-I), and is usually caused by pituitary adenomas. The goal in this study was to investigate the role of endoscopic transsphenoidal surgery and surgical experience in the treatment of GH adenoma cases in relation to surgical results and hormonal cure rates, and to perform a review of the literature. Methods The authors present a retrospective analysis of 214 GH adenoma cases. Restoration of IGF-I levels to normal for age and sex, suppression of GH levels below 0.4 μg/L on the oral glucose tolerance test, and demonstration of the total removal of the tumor on MRI studies obtained after administration of contrast material at the 3-month postoperative follow-up visit were the criteria for cure. Results In total 214 patients with a mean age of 41.9 ± 12 years (range 17–75 years) and a male/female ratio of 106/108 were enrolled in the study. Cure was achieved in 134 (62.6%) of 214 patients. One hundred sixty-nine patients were primary cases, and of these 109 (64.5%) were cured, whereas 61 patients were previously operated cases and of these 25 (41%) were cured. With a 51.1% decrease in the 1st month postoperatively, IGF-I levels were found to be predictive of cure (74.4% sensitivity and 73.7% specificity). Cut-off values for GH levels in predicting cure for the 1st day, 1st week, and 1st month postoperatively were 2.33, 2.05, and 2.25 μg/L, respectively. The cut-off value for surgical experience was 57 for primary surgeries (58.5% cure rate before this cut-off value compared with 72.6% after it; p = 0.025) and 108 for all operations (45.8% vs 79.4%, p = 0.037). Although 28 patients were found to be in remission according to the criteria in 2000, they were not in remission according to the new consensus criteria. Nine of these cases (32.1%) had random GH levels < 1 μg/L at the 1-year follow-up. The 1-year IGF-I and GH levels in these 28 patients showed no significant difference when compared with the cases defined as cured according to the current criteria. Conclusions In acromegaly treatment, transsphenoidal endoscopic surgery performed by an expert senior surgeon and increased surgical experience are important for higher cure rates. Random GH levels < 2.33 μg/L after the 1st day postoperatively and a > 50% decrease in IGF-I levels after the 1st month postoperatively are predictive of cure. Moreover, there is no urgency for additional therapy in patients with GH levels of 0.4–1 μg/L and MRI sequences showing no tumor at the 3-month follow-up, because for these cases remission can be achieved at the 1-year follow-up.

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Section: Discussionmentioning

confidence: 99%

Section: Surgical Techniquementioning

confidence: 99%

Treatment of acromegaly by endoscopic transsphenoidal surgery: surgical experience in 214 cases and cure rates according to current consensus criteria

Hazer

Işık

Berker

et al. 2013

JNS

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“…Over the last decade, the EEA has gradually become the predominant method for pituitary adenoma removal and related parasellar tumors in many centers around the world . After tumor removal, an effective skull‐base reconstruction is essential to avoid a postoperative CSF leak and related complications such as meningitis, pneumocephalus, and reoperation . Although many varied techniques for skull‐base reconstruction and CSF leak have been proposed in both the microscopic and endoscopic eras of pituitary surgery, the majority of publications follow similar principles and methodology.…”

Section: Intradural Tumorsmentioning

confidence: 99%

“…Materials frequently used in reconstruction include autologous fat, fascia lata, septal bone, and cartilage, as well as all native sphenoid sinus mucosa, free mucosal grafts, and pedicled NSFs. Allografts frequently used include Alloderm (Allergan, Branchburg, NJ), absorbable and nonabsorbable plates, and titanium mesh, as well as collagen matrix materials, all typically in multilayered fashion . Various types of tissue glues are also included in many of the reconstruction protocols.…”

Section: Intradural Tumorsmentioning

confidence: 99%

ICAR: endoscopic skull‐base surgery

Wang

Zanation

Gardner

et al. 2019

Int Forum Allergy Rhinol

152

279

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Background Endoscopic skull‐base surgery (ESBS) is employed in the management of diverse skull‐base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull‐base surgery have produced the International Consensus Statement on Endoscopic Skull‐Base Surgery (ICAR:ESBS). Methods Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence‐based review or evidence‐based review with recommendations format. Subsequently, each topic was written and then reviewed by skull‐base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. Results The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull‐base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. Conclusion A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence‐based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull‐base community to embrace these opportunities and collaboratively address these shortcomings.

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“…4,5 Several techniques have been developed because a conventional nasoseptal flap has several complications: a long operative time and olfactory disorders. 18,19 Ideally, a substitute to the vascularized flaps would be flexible, easy to handle, and have long-term survival. In addition, the substitute procedure would be safe, simple, and applicable for skull base or transsphenoidal operations.…”

Section: Discussionmentioning

confidence: 99%

A Novel Graft Material for Preventing Cerebrospinal Fluid Leakage in Skull Base Reconstruction: Technical Note of Perifascial Areolar Tissue

et al. 2014

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Objectives?Perifascial areolar tissue (PAT), a layer of loose connective tissue on the deep fascias with a rich vascular plexus, serves as a vital cover over defects with scarce vascularity. We report the usefulness of PAT as a nonvascularized alternative to flaps for reconstruction of dural defects in skull base surgery and transsphenoidal surgery while evaluating its effect on control of cerebrospinal fluid (CSF) leakage. Design?A retrospective chart analysis was performed on patients who had undergone repair of a dural defect with PAT during skull base surgery or transsphenoidal surgery between December 2004 and October 2011. Results?Twenty-one patients were included: 11 patients had received surgical treatment and/or irradiation. Fourteen of the 21 patients had pre- and/or intraoperative CSF leakage. Only one patient (4.8%) had postoperative CSF leakage requiring additional surgical repair. Ten patients underwent postoperative irradiation from 1 to 15 months after transplant of the PAT. None of the patients had postoperative CSF leakage after irradiation. Conclusion?We successfully repaired dural defects using PAT in skull base surgery and transsphenoidal surgery, even in patients with a history of multiple operations and radiotherapy. PAT may serve as a valuable tool for skull base reconstruction.

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Management of cerebrospinal fluid leak during endoscopic pituitary surgery

Cited by 28 publications

References 26 publications

Treatment of acromegaly by endoscopic transsphenoidal surgery: surgical experience in 214 cases and cure rates according to current consensus criteria

Treatment of acromegaly by endoscopic transsphenoidal surgery: surgical experience in 214 cases and cure rates according to current consensus criteria

ICAR: endoscopic skull‐base surgery

A Novel Graft Material for Preventing Cerebrospinal Fluid Leakage in Skull Base Reconstruction: Technical Note of Perifascial Areolar Tissue

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