Closure of large skull base defects after endoscopic transnasal craniotomy

Harvey, Richard J.; Nogueira, João Flávio; Schlosser, Rodney J.; Patel, Sunil; Vellutini, Eduardo de Arnaldo Silva; Stamm, Aldo Cassol

doi:10.3171/2008.8.jns08236

Cited by 104 publications

(100 citation statements)

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“…Some authors have described their own protocols for reconstruction of the sella according to the tumor extension or intraoperative findings 2,3,4,5,8 ; however, the pedicled nasoseptal flap was not included as an option in these other protocols. Since Hadad et al 9 described vascular pedicle nasoseptal flap as a novel reconstruction technique in 2006 (Hadad-Bassagasteguy flap; HBF), it has been reported that this flap can function well to separate the intradural space from the nasosinusal cavity 6,10,11,12,15 . They reported a 4.7% rate of postoperative CSF fistula in a sample of 43 patients including 20 pituitary adenomas, all of which had presented intraoperative CSF fistula and required reoperations 9 .…”

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“…The utility of a pedicled nasoseptal flap 9 for the reconstruction of a large dural defect has recently become more widely accepted, but reports have included a variety of pathologies, approaches and reconstruction techniques 6,8,10 . To minimize the risk of postoperative CSF fistula, we have used a pedicled nasoseptal flap for pituitary adenomas, as well as for skull base tumors 11,12 . We describe our strategy for surgical management of pituitary adenomas via combined endoscopic "transseptal/transnasal" approach that provides a pedicled nasoseptal flap.…”

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Endoscopic combined “transseptal/transnasal” approach for pituitary adenoma: reconstruction of skull base using pedicled nasoseptal flap in 91 consecutive cases

Fujimoto

Balsalobre²,

Santos³

et al. 2015

Arq. Neuro-Psiquiatr.

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ARTICLEEndoscopic combined "transseptal/transnasal" approach for pituitary adenoma: reconstruction of skull base using pedicled nasoseptal flap in 91 consecutive cases O acesso endoscópico transeptal/transnasal em cirurgias de resseção de adenoma de hipófise: reconstrução da base do crânio combinado com a criação do flap naso-septal pediculado em 91 pacientes consecutivos Transsphenoidal surgery using a microscope is an established, less invasive surgery for pituitary adenomas. The advent of the endoscope for endonasal transsphenoidal surgery has provided a wider and more close-up panoramic view that has made more detailed, delicate procedures feasible and safer. Furthermore, recent advance in high definition (HD) imaging have made it possible to clearly differentiate a cleavage plane between a tumor and the cavernous sinus or the arachnoid membrane, likely contributing to improvements in patient outcomes. However, the ABSTRACT Objective: The purpose of this study was to describe the endoscopic combined "transseptal/transnasal" approach with a pedicled nasoseptal flap for pituitary adenoma and skull base reconstruction, especially with respect to cerebrospinal fluid (CSF) fistula. Method: Ninety-one consecutive patients with pituitary adenomas were retrospectively reviewed. All patients underwent the endoscopic combined "transseptal/transnasal" approach by the single team including the otorhinolaryngologists and neurosurgeons. Postoperative complications related to the flap were analyzed. Results: Intra-and postoperative CSF fistulae were observed in 36 (40%) and 4 (4.4%) patients, respectively. Among the 4 patients, lumbar drainage and bed rest healed the CSF fistula in 3 patients and reoperation for revision was necessary in one patient. Other flap-related complications included nasal bleeding in 3 patients (3.3%). Conclusion: The endoscopic combined "transseptal/transnasal" approach is most suitable for a two-surgeon technique and a pedicled nasoseptal flap is a reliable technique for preventing postoperative CSF fistula in pituitary surgery.Keywords: cerebrospinal fluid fistula, endoscopic endonasal approach, pedicled nasoseptal flap, pituitary adenoma. RESUMOObjetivo: O objetivo deste estudo foi descrever o acesso endoscópico transeptal/transnasal combinado com a criação do flap nasoseptal pediculado para reconstrução da base do crânio em cirurgias de resseção de adenoma de hipófise, especialmente nos casos que ocorrem fístula líquido cefalorraquidiano (FLC). Método: Noventa e um pacientes consecutivos portadores de adenoma de hipófise foram retrospectivamente revisados. Complicações pós-operatórias relacionadas ao flap foram analisadas. Resultados: Fístulas líquido cefalorraquidiano intra e pós-operatórias foram observadas em 36 (40%) e 4 (4,4%) dos pacientes, respectivamente. Entre os 4 pacientes, drenagem lombar e repouso absoluto foram suficientes para o fechamento da fístula e intervenção cirúrgica foi necessária em apenas um paciente. Outra complicação relacionada ao flap foi o sangramento em 3 (3,3%)...

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Endoscopic combined “transseptal/transnasal” approach for pituitary adenoma: reconstruction of skull base using pedicled nasoseptal flap in 91 consecutive cases

Fujimoto

Balsalobre²,

Santos³

et al. 2015

Arq. Neuro-Psiquiatr.

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Results with expanded endonasal resection of skull base meningiomas: technical nuances and approach selection based on an early experience

Hayhurst

Sughrue

Gore³

et al. 2016

Turkish Neurosurgery

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ABSTRACTvascularized mucosal flap reconstruction, rates of cerebrospinal fluid (CSF) leak have dropped to between 3-5% (8,11,12,17), which is comparable to the reported 3.9% leak rate following standard microscopic transsphenoidal pituitary surgery (3).These advancements in reconstruction techniques have led to renewed enthusiasm for the expanded endonasal approach (EEA) at many centers. However, while the endonasal approach yields some advantages over transcranial surgery, it is not always possible or even advisable to attempt to resect all █ INTRODUCTION E xperience with endonasal transsphenoidal pituitary procedures has taught us that whenever anatomically feasible, surgery through the nose is better tolerated than transcranial surgery. Initial clinical reports of the utility of the endonasal approach for midline skull base meningiomas were published more than a decade ago (14,15,18). However, the widespread acceptance of the expanded endonasal route has only been made possible with advances in skull base reconstruction. With the introduction of multilayered closure and a AIM: Reconstruction technique advances have created renewed enthusiasm for the expanded endonasal approach (EEA). However, as with any new technique, early experiences inevitably lead to more selective use of these techniques. We reviewed our experience of the expanded endonasal endoscopic approach for skull base meningiomas and place it in context of the literature. MATERIAL and METhODS:We performed retrospective review of all endonasal cases performed at our center for histologically proven meningioma. Tumor locations in 26 patients included the olfactory groove (n=9), tuberculum sellae (n=7), optic nerve sheath (n=1), planum sphenoidale (n=2), clival (n=1) petroclival (n=3), cavernous sinus (n=2) and extensive pan-basal meningioma (n=1). RESULTS:The median follow-up was 38.6 months. Excluding 3 patients with tumors found incidentally, pre-operative symptoms improved in 14 of 23 (61%), were the same in 8 of 23 (35%) and worsened in one of 23 patients (4%) at time of last follow-up. Of all 26 patients, 16 (62%) had complete macroscopic resection of their tumor, 5 (19%) underwent at least 90% resection, and 5 (19%) underwent subtotal resection. There were two neurological complications and one cerebrospinal fluid leak. CONCLUSION:This study presents outcomes of patients treated with endonasal endoscopic meningioma surgery. We believe that very low rates of morbidity can be achieved in carefully selected patients, thus avoiding brain manipulation.

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“…As displayed in the literature, numerous options for skull base reconstruction after endoscopic endonasal surgery, including both autologous and synthetic materials, have been described to date. [1][2][3][4][5][6][7][8][9][10][11] The primary goal of skull base reconstruction, regardless of surgical technique, includes watertight separation of the intracranial and sinonasal cavities. Failure to achieve these reconstructive goals can result in life-threatening complications such as CSF leak, meningitis, or tension pneumocephalus.…”

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confidence: 99%

“…[1][2][3][4][5][6][7][8][9][10][11] Many of these methods evolved from lessons learned from microscopic transsphenoidal approaches and incorporate a wide a range of surgical materials, including autologous fascia, muscle, fat, and bone, as well as various synthetic materials and tissue sealants for multilayered closure. The goal of reconstruction is to reduce the incidence of postoperative complications, such as infection and cerebrospinal fluid (CSF) leak.…”

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confidence: 99%