Learning curve and technical nuances of endoscopic skull base reconstruction with nasoseptal flap to control high-flow cerebrospinal fluid leakage: reconstruction after endoscopic skull base surgery other than pituitary surgery

Park, Woori; Nam, Do‐Hyun; Kong, Doo‐Sik; Lee, Jun Young; Park, Song I; Kim, Hyo Yeol; Chung, Seung‐Kyu; Jung, Yong Gi; Hong, Sang Duk

doi:10.1007/s00405-021-06877-4

Cited by 9 publications

(21 citation statements)

References 10 publications

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“…Despite increased intraoperative CSF leakage, postoperative CSF leakage has steadily decreased. Previous studies have also found similar downward trends in postoperative CSF leakage ( 16 , 28 , 34 , 35 ). It undoubtedly reflects the increasing proficiency with sellar reconstruction techniques.…”

Section: Discussionsupporting

confidence: 76%

The learning curve of endoscopic endonasal transsphenoidal surgery for pituitary adenomas with different surgical complexity

et al. 2023

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ObjectiveTo investigate the learning curve under different surgical complexity in endoscopic transsphenoidal approach for pituitary adenoma.Methods273 patients undergoing endoscopic transsphenoidal surgery for pituitary adenoma were collected retrospectively and divided into three groups chronologically (early, middle, and late periods). Surgical complexity was differentiated based on Knosp classification (Knsop grade 0–2 vs. Knosp grade 3–4), tumor maximum diameter (MD) (macroadenomas vs. giant adenomas), and history of previous surgery for pituitary adenoma (first operation vs. reoperation). Then the temporal trends in operative time, surgical outcomes, and postoperative complications were evaluated from early to late.ResultsThe median operative time decrease from 169 to 147 min across the three periods (P = 0.001). A significant decrease in operative time was seen in the simple groups [Knosp grade 0–2 adenoma (169 to 137 min, P < 0.001), macroadenoma (166 to 140 min, P < 0.001), and first operation (170.5 to 134 min, P < 0.001)] but not in their complex counterparts (P > 0.05). The GTR rate increased from 51.6% to 69.2% (P = 0.04). The surgical period was an independent factor for GTR in the simple groups [Knosp grade 0–2 adenoma: OR 2.076 (95%CI 1.118–3.858, P = 0.021); macroadenoma: OR = 2.090 (95%CI 1.287–3.393, P = 0.003); first operation: OR = 1.809 (95%CI 1.104–2.966, P = 0.019)] but not in the complex groups. The biochemical cure rate increased over periods without statistical significance (from 37.5% to 56.3%, P = 0.181). Although intraoperative CSF leakage rose (from 20.9% to 35.2%) and postoperative CSF leakage reduced (from 12.1% to 5.5%), there was no statistically significant trend across the three time periods (P > 0.05).ConclusionThis study showed that complex operations might have a prolonged learning curve. Differentiating surgical difficulty and using multivariate combined analysis may be more helpful in clinical practice.

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Section: Discussionsupporting

confidence: 76%

The learning curve of endoscopic endonasal transsphenoidal surgery for pituitary adenomas with different surgical complexity

et al. 2023

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“…5-7, 21,27-29 Moreover, initial results from institutions currently at the expert level showed CSF leakage rates in the range of 23-60%. 7,21,27,30 Of course, it takes time to master the skills, but the complications of CSF leakage pose serious risks to the patient. 31 In this study, patients who underwent surgery in the early phase, the control group, showed a 26.3% CSF leakage rate and 15.8% CSF leakage-related meningitis.…”

Section: Discussionmentioning

confidence: 99%

“…Su ciently long and wide harvesting, rigorous preparation of the recipient surgical bed, and avoidance of vascular pedicle injury are essential. 7 In HXA-based reconstruction, it is advantageous to widen the NSF, because the HXA layer covers the bony defect and creates additional volume within the sinus.…”

Section: Discussionmentioning

confidence: 99%

“…13 Several authors have emphasized the learning curve of the surgeon and the importance of adherence to the basic techniques in skull base reconstruction. 6,7,21,26,27 The steep early learning curve in skull base reconstruction has been reported widely in the literature. In most centers, there is a decrease in postoperative CSF leakage as well as an increase in the rate of the extent of resection after the rst 50 to 200 cases, after which the results tend to plateau.…”

Section: Discussionmentioning

confidence: 99%

“…The overall CSF leakage rate in the literature varied widely according to tumor characteristics, location, surgical techniques, and surgeons' expertise. [5][6][7] Multilayered skull base reconstruction is now a standard technique for repairing skull base defects. The goal of skull base reconstruction for CSF leakage is to achieve watertight closure until the scar formation seals the defect.…”

Section: Introductionmentioning

confidence: 99%

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Efficacy of hydroxyapatite-based skull base reconstruction for intraoperative high-flow cerebrospinal fluid leakage performed by less-experienced surgeons: a two-institution study

Hong

Kim

Seo

et al. 2023

Preprint

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Cerebrospinal fluid (CSF) leakage after endoscopic skull base surgery remains a challenge despite multilayer reconstruction including nasoseptal flap (NSF) has become a standard technique. Injectable hydroxyapatite (HXA) has shown promising results to prevent CSF leakage. This study aimed to validate the efficacy of HXA-based skull base reconstruction performed by less-experienced neurosurgeons who had short-term clinical experiences as independent surgeons. Between March 2018 and November 2022, 41 patients who experienced intraoperative high-flow CSF leakage following endoscopic endonasal surgery at two independent tertiary institutions were enrolled. Skull base reconstruction was performed using conventional multilayer techniques combined with or without HXA. The primary outcome was postoperative CSF leakage. The surgical steps and nuances were described in detail. The most common pathology was craniopharyngioma. Injectable HXA was used in 22 patients (HXA group) and conventional techniques were performed in 19 patients (control group). The HXA group achieved a significantly lower incidence of postoperative CSF leakage than the control group (0% vs. 26.3%, p = 0.016). No HXA-related complications were observed. The use of injectable HXA in skull base reconstruction was highly effective and safe. This technique and its favorable results might be readily reproduced by less-experienced neurosurgeons.

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Safety and efficacy of hydroset cranioplasty as an adjunct to gasket-seal and nasoseptal flap closure of the skull base. A case-controlled study

Desai,

Kapur,

Hammond

et al. 2024

Acta Neurochir

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Learning curve and technical nuances of endoscopic skull base reconstruction with nasoseptal flap to control high-flow cerebrospinal fluid leakage: reconstruction after endoscopic skull base surgery other than pituitary surgery

Cited by 9 publications

References 10 publications

The learning curve of endoscopic endonasal transsphenoidal surgery for pituitary adenomas with different surgical complexity

The learning curve of endoscopic endonasal transsphenoidal surgery for pituitary adenomas with different surgical complexity

Efficacy of hydroxyapatite-based skull base reconstruction for intraoperative high-flow cerebrospinal fluid leakage performed by less-experienced surgeons: a two-institution study

Safety and efficacy of hydroset cranioplasty as an adjunct to gasket-seal and nasoseptal flap closure of the skull base. A case-controlled study

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