Nasoseptal Flap Takedown in Endoscopic Skull Base Surgery

Objective 1) Understand the importance of the nasoseptal flap in endoscopic skull base reconstruction. 2) Learn the techniques and limitations of nasoseptal flap takedowns and reuse during second stage and revision endoscopic skull base surgery. Methods Prospective consecutive analysis of CSF leak outcomes with nasoseptal flap takedown and reuse during endoscopic skull base surgery at a tertiary care skull base center. Results 16 consecutive cases of nasoseptal flap takedown and reuse for endoscopic endonasal intradural tumor surgery were collected prospectively and evaluated for CSF leak outcomes. 10 of these cases were planned second-stage surgeries and 6 were for revision or recurrent tumors. All 16 cases had intradural tumor extension and intra operative CSF leak. 15 of 16 had successful skull base reconstruction without postoperative CSF leak. One patient required revision endoscopic CSF leak repair and bolstering of the defect with a fat graft on post operative day 3. No flap deaths occurred. Endoscopic skull base reconstructive techniques and limitations of flap takedowns are discussed. Conclusions As the limits of endoscopic skull base surgery increases, the limits of endoscopic skull base reconstruction must also increase. The pedicled nasoseptal flap has shown great promise (4% leak rate in over 300 nasoseptal flap skull base reconstructions) at the time of the initial resection. This report illustrates the ability to takedown and reuses the nasoseptal flap in revision cases with great success (94%) and minimal additional nasal morbidity.

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

Neurosurgical FOCUS ◽

10.3171/2012.5.focus1255 ◽

2012 ◽

Vol 32 (6) ◽

pp. E7 ◽

Cited By ~ 61

Author(s):

James K. Liu ◽

Richard F. Schmidt ◽

Osamah J. Choudhry ◽

Pratik A. Shukla ◽

Jean Anderson Eloy

Keyword(s):

Skull Base ◽

Skull Base Surgery ◽

Cranial Base ◽

High Flow ◽

Csf Leak ◽

Reconstruction Technique ◽

Dural Defect ◽

Nasoseptal Flap ◽

Endoscopic Skull Base Surgery ◽

Csf Leakage

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.

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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

European Archives of Oto-Rhino-Laryngology ◽

10.1007/s00405-021-06877-4 ◽

2021 ◽

Author(s):

Woori Park ◽

Do-Hyun Nam ◽

Doo-Sik Kong ◽

Kyung Eun Lee ◽

Song I Park ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Learning Curve ◽

Skull Base ◽

Skull Base Surgery ◽

Pituitary Surgery ◽

High Flow ◽

Cerebrospinal Fluid Leakage ◽

Nasoseptal Flap ◽

Skull Base Reconstruction ◽

Endoscopic Skull Base Surgery

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Intrathecal Fluorescein in Endoscopic Skull Base Surgery

Otolaryngology ◽

10.1016/j.otohns.2006.11.012 ◽

2007 ◽

Vol 137 (2) ◽

pp. 316-320 ◽

Cited By ~ 66

Author(s):

Abtin Tabaee ◽

Dimitris G. Placantonakis ◽

Theodore H. Schwartz ◽

Vijay K. Anand

Keyword(s):

Cerebrospinal Fluid ◽

Pituitary Adenoma ◽

Skull Base ◽

Retrospective Review ◽

Skull Base Surgery ◽

Csf Leak ◽

Skull Base Reconstruction ◽

Endoscopic Skull Base Surgery ◽

High Degree ◽

The Impact

OBJECTIVES: Reconstruction following endoscopic skull base surgery requires a high degree of success to avoid the morbidity of postoperative cerebrospinal fluid (CSF) leak. The impact on outcomes of CSF visualization with intrathecal fluorescein, however, is unknown. STUDY DESIGN: A retrospective review of patients undergoing endoscopic skull base surgery with intrathecal fluorescein. A possible correlation between intraoperative fluorescein identification and postoperative CSF leak was analyzed. RESULTS: 61 patients underwent surgery for a variety of lesions including pituitary adenoma (55.7%), encephalocele (14.8%), and meningioma (9.8%). Seven (19.4%) of the 37 patients with intraoperative fluorescein leak experienced postoperative CSF leak compared to 0 of the 24 patients who did not have intraoperative fluorescein leak ( P = 0.02). All cases of CSF leak resolved with lumbar drainage alone. CONCLUSIONS: The lack of intraoperative fluorescein leak-age correlates strongly with a low risk for postoperative CSF leak. This can be used to stratify the extent of skull base reconstruction required during endoscopic skull base surgeries.

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Postoperative Continuous Positive Airway Pressure Use and Nasal Saline Rinses After Endonasal Endoscopic Skull Base Surgery in Patients With Obstructive Sleep Apnea: A Practice Pattern Survey

American Journal of Rhinology and Allergy ◽

10.1177/1945892418804987 ◽

2018 ◽

Vol 33 (1) ◽

pp. 51-55 ◽

Cited By ~ 7

Author(s):

David L. Choi ◽

Kesava Reddy ◽

Erik K. Weitzel ◽

Brian W. Rotenberg ◽

Allan Vescan ◽

...

Keyword(s):

Obstructive Sleep Apnea ◽

Standard Deviation ◽

Skull Base ◽

Airway Pressure ◽

Positive Airway Pressure ◽

Skull Base Surgery ◽

Csf Leak ◽

Cpap Therapy ◽

Endoscopic Skull Base Surgery ◽

Obstructive Sleep

Background Endoscopic skull base surgery continues to evolve in its indications, techniques, instrumentation, and postoperative care. As surgery of the skull base will often violate dura, intraoperative and postoperative cerebrospinal fluid (CSF) leak is not uncommon and represents a potential conduit for air and bacterial contamination. Patients with obstructive sleep apnea (OSA) requiring continuous positive airway pressure (CPAP) therapy undergoing skull base surgery represent a challenging group. However, there appears to be a paucity of consensus regarding the postoperative management of this patient population. The objective of this study is to examine practice patterns and expert opinion on the use of postoperative CPAP and nasal saline in patients with OSA. Methods A 14-item survey was generated by consensus among expert authors and distributed online to members of the North American Skull Base society and other international skull base community members. Data were analyzed for median, mean, and standard deviation variables. Subgroup analysis was completed between surgeons from different geographical locations and operative experience. SPSS22 was utilized for all complex statistical analysis and figures. Results Seventy-one responses were collected from skull base surgeons. In patients with OSA, respondents would resume patients’ CPAP therapy after a mean of 10.1 days (median, 7; standard deviation [SD], 10.2), without a CSF leak. In the presence of a small CSF leak, the mean duration would increase to 14.3 days (median, 14; SD, 9.8) and to 20.7 days (median, 21; SD, 11.8) in the presence of a larger leak. A surgeon’s choice to attribute the relationship between delaying the start of nasal saline and CPAP after the endoscopic skull base surgery with progressively more challenging skull base repair was found to be statistically significant ( P < .001). Conclusion Saline and CPAP therapies are initiated after the endoscopic skull base surgical repairs by surgeons at an increasing temporal delay in relation to the degree and complexity of the skull base defect repaired.

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Outcomes In Pediatric Endoscopic Skull Base Surgery: A Systematic Review

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/a-1725-9151 ◽

2021 ◽

Author(s):

Erin Mamuyac Lopez ◽

Zainab Farzal ◽

Kelly Marie Dean ◽

Craig Miller ◽

Justin Cates Morse ◽

...

Keyword(s):

Systematic Review ◽

Skull Base ◽

Pediatric Patients ◽

Skull Base Surgery ◽

Tertiary Care ◽

Case Series ◽

Csf Leak ◽

Inclusion Criteria ◽

Endoscopic Skull Base Surgery ◽

Tertiary Care Medical Center

Objectives: The frequency of endoscopic skull base surgery in pediatric patients is increasing. This study’s aim is to systematically review the literature for endoscopic skull base surgery outcomes in children/adolescents ages 0-18 years. Design: A systematic review of the literature was performed in PubMed and SCOPUS databases querying studies from 2000-2020 using PRISMA guidelines. Final inclusion criteria included: case series with 10+ patients with pediatric patients age ≤18 years, endoscopic or endoscopic-assisted skull base surgery, and outcomes reported. Setting: Tertiary care medical center Participants: Children/adolescents ages 0-18 years who underwent endoscopic skull base surgery Main Outcome Measures: Patient demographics, pathology, reconstructive technique, intra-operative findings, intra-operative and post-operative surgical complications. Results: Systematic literature search yielded 287 publications. Of these, 12 studies discussing a total of 399 patients age 0-18 years met inclusion criteria for final analysis. 7 of 12 studies discussed a single pathology. The most common pathology was a skull base defect causing CSF leak. The majority of skull base repairs were made with free tissue grafts. The most common post-operative complication was CSF leak (n=40). Twelve cases of meningitis occurred post-operatively with two of these episodes resulting in death. Conclusions: Endoscopic skull base surgery has been performed recently in the pediatric population in a variety of disease states. Inconsistent individual-level data and reporting standards are present in existing studies posing challenges for comparative analysis. Standardized reporting will aid future reviews and meta-analysis for rare skull base pathology.

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Endoscopic Endonasal Reconstruction of High-Flow Cerebrospinal Fluid Leak with Fascia Lata “Button” Graft and Nasoseptal Flap: Surgical Technique and Case Series

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1693124 ◽

2019 ◽

Vol 81 (06) ◽

pp. 645-650

Author(s):

Roshni V. Khatiwala ◽

Karthik S. Shastri ◽

Maria Peris-Celda ◽

Tyler Kenning ◽

Carlos D. Pinheiro-Neto

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Fascia Lata ◽

High Flow ◽

Csf Leak ◽

Nasoseptal Flap ◽

Endoscopic Endonasal ◽

Skull Base Reconstruction ◽

Csf Diversion ◽

Csf Leaks

Abstract Background The endoscopic endonasal approach (EEA) has become increasingly used for resection of skull base tumors in the sellar and suprasellar regions. A nasoseptal flap (NSF) is routinely used for anterior skull base reconstruction; however, there are numerous additional allografts and autografts being used in conjunction with the NSF. The role of perioperative cerebrospinal fluid (CSF) diversion is also unclear. Objective This study was aimed to analyze success of high-flow CSF leak repair during EEA procedures without use of CSF diversion through lumbar drainage. Methods A retrospective chart review of patients who had intraoperative high-flow CSF leak during EEA procedures at our institution between January 2013 and December 2017 was performed. CSF leaks were repaired with use of a fascia lata button graft and nasoseptal flap, without use of perioperative lumbar drains. Results A total of 38 patients were identified (10 male, 28 female). Patient BMIs ranged from 19.7 to 49 kg/m2 (median = 31 kg/m2), with 18 patients meeting criteria for obesity (BMI > 30 kg/m2) and 12 patients overweight (25 kg/m2 < BMI < 29.9 kg/m2). There was no incidence of postoperative CSF leak. Conclusion In our experience, the nasoseptal flap used in conjunction with the fascia lata button graft is a safe, effective and robust combination for cranial base reconstruction with high-flow intraoperative CSF leaks, without need for lumbar drains.

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Stepwise Algorithm for Skull Base Reconstruction in Endoscopic Endonasal Surgery: From the Simple to the Complex

Neurosurgery ◽

10.1093/neuros/nyz310_430 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Maria Belen Vega ◽

Philippe Lavigne ◽

Vanessa Hernandez-Hernandez ◽

Aldo Eguiluz-Menendez ◽

Eric Wang ◽

...

Keyword(s):

Skull Base ◽

Posterior Fossa ◽

Free Flaps ◽

Fat Graft ◽

Csf Leak ◽

Endoscopic Endonasal Surgery ◽

Endonasal Surgery ◽

Endoscopic Endonasal ◽

Skull Base Reconstruction ◽

Skull Base Defects

Abstract INTRODUCTION The most frequent complication of endoscopic endonasal surgery (EES) is postoperative cerebrospinal fluid (CSF) leak. This study was designed to develop a step-wise algorithm for EES reconstruction across the spectrum of skull base defects: from free mucosal graft for uncomplicated pituitary adenomas to free flaps in complex cases with recurrent leaks. METHODS All patients with skull base pathologies who underwent EES between January 2017 and December 2018 were included and retrospectively analyzed. Tumor location, reconstruction method and postoperative CSF leak were reviewed and a step-wise algorithm based on size and location of defect was developed. RESULTS Location of skull base defects was categorized as follows: anterior fossa, suprasellar, sellar and posterior fossa. For all nonsellar sites, we performed a multilayer (collagen matrix + /- fascia lata + /− fat graft + vascularized flap) reconstruction. The nasoseptal flap (NSF) was the first choice for vascularized reconstruction when available. For all sellar lesions we employed a free mucosal graft unless a high-flow CSF leak was present, in which case a single-layer reconstruction with NSF was performed. When the NSF was not available, alternative local (lateral nasal wall flap) and regional (extracranial pericranial flap) pedicled flaps were successful choices. When patients failed multiple attempts at repair, regional or microvascular free flaps were options. Lumbar spinal drainage was employed for large anterior and posterior fossa defects and during secondary repair of postoperative CSF leaks. Of 347 patients, 4.6% had a postoperative CSF leak. Of 158 patients with an intraoperative leak (45.5%), 10.1% developed a postoperative CSF leak: 7.8% for sellar/suprasellar defects and 13% for anterior/posterior fossa defects. CONCLUSION This algorithm provides a standardized, stepwise approach to the reconstruction of all skull base defects after EES based on location.

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