Predictive Factors, 30-Day Clinical Outcomes, and Costs Associated with Cerebrospinal Fluid Leak in Pituitary Adenoma Resection

Abstract

Cerebrospinal fluid (CSF) leak is a complication of endoscopic endonasal pituitary adenoma resection. Previous studies examining complications of pituitary adenoma resection have not examined associations of an exhaustive list of clinical and financial variables with CSF leak. We designed a retrospective analysis of 334 consecutive patients that underwent endoscopic endonasal pituitary adenoma resection at a single institution over 5 years, analyzing associations between CSF leak and demographic data, operative data, comorbidities, clinical complications and outcomes, costs, charges, and payments. Of the 20 preoperative variables studied, none were positively associated with CSF leak in between-groups comparison, although multivariate analysis revealed an association with a history of radiation to the skull base (odds ratio [OR], 8.67; 95% confidence interval [CI], 0.94–57.03; p < 0.05). CSF leak was associated with a significantly higher rate of postoperative diabetes insipidus (Δ = 33.4%, p = 0.040) and increased length of stay after operation in between-groups comparison. Multivariate analysis on postoperative variables revealed significant associations between CSF leak and intracerebral hemorrhage (OR, 17.44; 95% CI, 0.65–275.3; p < 0.05) and postoperative intracranial infection (OR, 28.73; 95% CI, 2.04–438.7; p < 0.05). Also, CSF leak was associated with significantly higher costs (Δ = $15,643, p < 0.05) and hospital charges (Δ = $46,026, p < 0.05). Operating room time, room and board, and supplies and implants were the strongest cost drivers. This study highlights the difficulty of utilizing preoperative variables to predict CSF leak, the clinical complications and outcomes of leak, and the financial subcategories that drive the costs, charges, and payments associated with this complication.

Cerebrospinal fluid leakage costs after craniotomy and health economic assessment of incidence reduction from a hospital perspective in the Netherlands

“…These results are in line with the study of Parikh et al that identified increased LOS and the association of CSF leakage with secondary complications such as meningitis as the main reasons for increased healthcare costs after transsphenoidal surgery. 10 Additionally, the costs for interventional treatment of iCSF leakage are a substantial cost driver, considering that patients who can be managed conservatively have total average costs that are comparable to patients without iCSF leakage. In the group of patients managed conservatively, though, 10/18 patients (55.6%) did not have continuous iCSF leakage, but incisional leakage that occurred once or twice, suggestive of a subcutaneous pocket that has discharged.…”

Predictors of Cerebrospinal Fluid Leaks in Endoscopic Surgery for Pituitary Tumors

“…Endoscopic skull base surgeons treating patients with pituitary adenomas can potentially change or modify their clinical management strategy to minimize the incidence of CSF leakage and its subsequent morbidities [17]. Prediction of the possibility for intraoperative or postoperative CSF leakage in endoscopic endonasal surgery for pituitary adenomas is of great interest and is discussed in some the recent publications [5,18].…”

“…Endoscopic endonasal skull base surgery has become widely implemented to be the gold standard in surgical treatment of pituitary tumors that have an estimated prevalence of 15%. Endoscopic endonasal approaches (EEA) has superior efficacy compared with microscopic approaches, as it provides enhanced visualization of the surgical field and decrease the incidence rate of postoperative cerebrospinal fluid (CSF) leaks and allow for proper management of such problem if occurred [1,2,5].…”

The effect of prior radiation on the success of ventral skull base reconstruction: A systematic review and meta‐analysis

“…Some recent studies have found that a history of pre‐ or post‐operative radiation has no significant impact on the success of skull base reconstruction 11,20,21 . Other studies have found insufficient available data to perform adequately‐powered analysis to determine if pre‐operative radiation is a significant risk factor for reconstruction failure 12,13 . The present study represents a systematic review of the current literature to estimate the effect of pre‐operative radiation therapy on the incidence of post‐operative CSF leaks in patients who undergo ventral skull base reconstruction after tumor resection.…”

“…Recently, a number of centers have reported on protocols that utilize neoadjuvant chemotherapy or definitive radiation therapy with promising results 8‐10 . For patients treated with definitive or pre‐operative radiation therapy, it is unclear whether subsequent surgery is associated with higher rates of complications 11‐13 . Given the observed challenges of reconstructing other sites in the head and neck after prior radiation treatment, many surgeons are similarly wary of operating after radiotherapy treatments 1,14‐17 .…”