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

Eloy, Jean Anderson; Choudhry, Osamah J.; Shukla, Pratik A.; Kuperan, Arjuna B.; Friedel, Mark E.; Liu, James K.

doi:10.1002/lary.23285

Cited by 62 publications

(69 citation statements)

References 30 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Currently, the incidence of postoperative CSF leaks associated with the use of the nasoseptal flap is approximately 5%, which is comparable to more standard transcranial approaches. 3,7,13,17,18,[22][23][24]28,30,34,37,38 As a result, the PNSF has become the primary workhorse for closure of large skull base defects with high-flow CSF leaks that develop after endoscopic skull base surgery. 39 In our experience with 93 patients requiring PNSF reconstruction of large skull base dural defects after an EEA, we have, to date, been able to achieve an overall rate of postoperative CSF leakage of 3.2%.…”

mentioning

confidence: 99%

Surgical nuances for nasoseptal flap reconstruction of cranial base defects with high-flow cerebrospinal fluid leaks after endoscopic skull base surgery

Liu¹,

Schmidt²,

Choudhry³

et al. 2012

FOC

Self Cite

122

View full text Add to dashboard Cite

Extended endoscopic endonasal approaches have allowed for a minimally invasive solution for removal of a variety of ventral skull base lesions, including intradural tumors. Depending on the location of the pathological entity, various types of surgical corridors are used, such as transcribriform, transplanum transtuberculum, transsellar, transclival, and transodontoid approaches. Often, a large skull base dural defect with a high-flow CSF leak is created after endoscopic skull base surgery. Successful reconstruction of the cranial base defect is paramount to separate the intracranial contents from the paranasal sinus contents and to prevent postoperative CSF leakage. The vascularized pedicled nasoseptal flap (PNSF) has become the workhorse for cranial base reconstruction after endoscopic skull base surgery, dramatically reducing the rate of postoperative CSF leakage since its implementation. In this report, the authors review the surgical technique and describe the operative nuances and lessons learned for successful multilayered PNSF reconstruction of cranial base defects with high-flow CSF leaks created after endoscopic skull base surgery. The authors specifically highlight important surgical pearls that are critical for successful PNSF reconstruction, including target-specific flap design and harvesting, pedicle preservation, preparation of bony defect and graft site to optimize flap adherence, multilayered closure technique, maximization of the reach of the flap, final flap positioning, and proper bolstering and buttressing of the PNSF to prevent flap dehiscence. Using this technique in 93 patients, the authors' overall postoperative CSF leak rate was 3.2%. An illustrative intraoperative video demonstrating the reconstruction technique is also presented.

show abstract

mentioning

confidence: 99%

Surgical nuances for nasoseptal flap reconstruction of cranial base defects with high-flow cerebrospinal fluid leaks after endoscopic skull base surgery

Liu¹,

Schmidt²,

Choudhry³

et al. 2012

FOC

Self Cite

122

View full text Add to dashboard Cite

show abstract

“…We typically do not use tissue sealants or postoperative lumbar drainage for these defects, as this has not made any difference in postoperative CSF leaks. [45][46][47] With the triple-layer repair, we have found that rigid structural reconstruction of the anterior cranial base (with mesh, Medpor, or bone) is not necessary to prevent frontal lobe sagging or encephalocele formation. 48 …”

Section: Skull Base Reconstructionmentioning

confidence: 98%

Endoscopic Endonasal Approach for Olfactory Groove Meningiomas

Liu

Hattar

Eloy

2015

Neurosurgery Clinics of North America

Self Cite

View full text Add to dashboard Cite

“…In this setting, the rate of CSF leaks has fallen to 1%-8%, depending on the extent of skull base resection. 8,13,15,17,26,45 There are several reasons why the rate of CSF leak after TEA could be lower than after transsphenoidal surgery. Because the sella turcica is a bony depression within the air-filled sphenoid sinus, grafts used for dural repair are not naturally buttressed in any way.…”

Section: Anticipated Challenges To Teamentioning

confidence: 99%

Transorbital endoscopic amygdalohippocampectomy: a feasibility investigation

Chen¹,

Bohman²,

Loevner

et al. 2014

JNS

View full text Add to dashboard Cite

S urgical resection of the hippocampus is the standard of care for medically intractable temporal lobe epilepsy 46 and significantly improves seizure control and quality of life.14,42 The 2 most common surgical approaches are anterior temporal lobectomy and selective amygdalohippocampectomy, both of which are performed through a standard temporal craniotomy. Despite the marked success of these approaches, craniotomy for the treatment of temporal lobe epilepsy is not without risk. Complications range from cosmetic disfigurement to permanent neurological and cognitive disability (Table 1). Though uncommon, these complications significantly diminish quality of life for affected patients. Alternative strategies that minimize these risks while still achieving an adequate hippocampectomy, the principle goal of surgery, could further improve patient outcomes.Minimally invasive approaches have the potential to access the hippocampus with minimal disruption of the lateral temporal cortex and white matter pathways. For instance, stereotactic radiofrequency ablation permits hippocampal lesioning with 16-38 ablations through a single occipital bur hole. 29,35 Likewise, endoscopic approaches may provide access to the hippocampus and permit resection under direct visualization. The present cadaveric study examines the feasibility of a transorbital approach to the mesial temporal lobe using endoscopic visualization and image guidance. Unlike the occipital approach, the transorbital route affords the surgeon a short working distance and early access to the anterior portion of the hippocampus. We present the quantitative metrics of transorbital endoscopic amygdalohippocampectomy (TEA) predicted by predissection neuroimaging in relation to the measurements taken during the dissections. These measurements are compared with scans from 10 patients with epilepsy for clinical validation of the angles of exposure. Object. Resection of the hippocampus is the standard of care for medically intractable epilepsy in patients with mesial temporal sclerosis. Although temporal craniotomy in this setting is highly successful, the procedure carries certain immutable risks and may be associated with cognitive deficits related to cortical and white matter disruption. Alternative surgical approaches may reduce some of these risks by preserving the lateral temporal lobe. This study examined the feasibility of transorbital endoscopic amygdalohippocampectomy (TEA) as an alternative to open craniotomy in cadaveric specimens.Methods. TEA dissections were performed in 4 hemispheres from 2 injected cadaveric specimens fixed in alcohol. Quantitative predictions of the limits of exposure based on predissection imaging were compared with intradissection measurements. The extent of resection and angles of exposure during the dissection and on postdissection imaging were recorded. These measurements were validated with MRI studies from 10 epilepsy patients undergoing standard surgical evaluations.Results. The transorbital approach permitted direct access to t...

show abstract

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

Cited by 62 publications

References 30 publications

Surgical nuances for nasoseptal flap reconstruction of cranial base defects with high-flow cerebrospinal fluid leaks after endoscopic skull base surgery

Surgical nuances for nasoseptal flap reconstruction of cranial base defects with high-flow cerebrospinal fluid leaks after endoscopic skull base surgery

Endoscopic Endonasal Approach for Olfactory Groove Meningiomas

Transorbital endoscopic amygdalohippocampectomy: a feasibility investigation

Contact Info

Product

Resources

About