Endoscopic Reconstruction of the Anterior Skull Base Following Tumor Resection: Application of a Novel Bioabsorbable Plate

Abstract

Objective: Endoscopic repair of skull base defects is required following resection of intracranial pathology via the endoscopic endonasal approach (EEA). Many closure techniques have been described, but choosing between techniques remains controversial. We report outcomes of 560 EEA procedures of skull base reconstruction performed on 508 patients over a 15-year-period. Halfway through this period, we adopted the use of a rigid, bioabsorbable extrasellar plate for reconstruction, enabling a comparison between this technique and those used previously.Methods: All patients undergoing EEA from 2005 to 2019 at our institution were retrospectively reviewed. Demographic information, surgical pathology, tumor dimensions and radiographic features, reconstructive technique, and patient-related outcomes were collected and analyzed with univariate and multivariate statistical modeling.Results: Five-hundred sixty procedures were performed on 508 patients. The series complication rate was 8.2%. Overall, cerebrospinal fluid (CSF) leak rate was 5.0% but varied significantly across closure techniques (p < 0.001). Critically, the CSF leak rate in the 272 cases prior to our 2013 adoption of the Resorb-X Plate (RXP) was 8.5%, whereas leak rate in the subsequent 288 cases was 1.7%. RXP was protective against CSF leak (p = 0.001), whereas gross total resection (GTR) correlated with increased leak rate (p = 0.001). Patient BMI was significantly associated with risk of leak (p = 0.047). Other variables did not impact leak risk. Conclusion:Reconstructive technique, extent of resection, and patient BMI significantly contributed to CSF leak rate. GTR was associated with increased leak risk while the RXP was protective. The bioabsorbable RXP is an effective option for rigid skull base repair with comparatively few complications.

Sellar Reconstruction With a Bioabsorbable Plate After Endoscopic Transsphenoidal Pituitary Adenoma Resection: Safe and Efficacious

“…One of the 28 patients (3.7%) developed a postoperative CSF leak; this patient had also undergone a subsequent pterional craniotomy. In 2022, Piscopo et al 11 reviewed outcomes of 560 EETS cases reconstructed with either the RTX, autologous fat graft, DuraGen/GelFoam alone, or nasoseptal flap. Multivariate analysis revealed that RXP was protective against CSF leak compared to other techniques, including autologous grafts or nasoseptal flap.…”

“…Rigid synthetic implants such as the Medpor implant (Stryker; Kalamazoo, MI) [7][8][9] have also been described with favorable results, but carry the risk of implant extrusion and infection over the long term. 10 A technique utilizing a rigid, bioabsorbable plate, the Resorb-X plate (RXP; KLS-Martin, Jacksonville, FL, USA), has previously been reported for reconstruction of the anterior skull base following EETS 11 as well as for reconstruction of skull base defects for CSF rhinorrhea. 12 The primary objective of this study was to examine the incidence and risk factors of developing postoperative CSF leak in patients who underwent EETS for resection of a pituitary adenoma with subsequent use of the RXP as part of a multilayered closure.…”

Preoperative, technical, and postoperative considerations for skull base reconstruction: a practical review of critical concepts

“…No reconstruction or secondary intention Absorbable hemostatic agents (32) Dural sealant (119) Direct suturing "Shoelace" technique (120)(121)(122) Implants or allografts Commercial collagen matrix (123,124) Porcine small intestine submucosa (50,125) Acellular dermal matrix (49,(126)(127)(128) Bovine dura (125) Rigid reconstruction options -"Gasket seal" technique (54)(55)(56) -Bone grafts (27) -Bioabsorbable plates (53) Free autologous grafts Nasal mucosal graft (septum, floor, turbinate) (31,32,(129)(130)(131)(132) Orbital or abdominal fat graft (133,134) Fascia lata graft (135,136) Local rotational flaps Nasoseptal flap (8) Extended nasoseptal flap (137)(138)(139) -Pedicle release (140) Middle turbinate flap (141)(142)(143) Lateral nasal wall flap (35)(36)(37) Anterior ethmoid artery system -Septal flip flap (144) Rhinopharyngeal flap (38,145) Sphenoid mucosal flaps (nonpedicled) (146)<...…”

“…Use of rigid skull base reconstruction with bioabsorbable plates or bone grafts to buttress fat graft repairs ("gasket seal") has been studied in several single-institutional retrospective cohorts, with generally excellent outcomes (53)(54)(55)(56)(57) . Piscopo et al…”