In-Hospital Costs Associated With an Expanded Endonasal Approach to Anterior Skull Base Tumors

Objective: To determine in-hospital costs associated with performing an EEA to anterior skull base pathology and to identify drivers of cost variability for patients undergoing endoscopic anterior skull base surgery. Methods: All endoscopic anterior skull base surgeries performed over a period from January 1st, 2015 to October 24th, 2017 were evaluated. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables associated with each hospital stay and univariate analysis was performed using Stata software. Results: An EEA was associated with an average total in-hospital cost of $44 545. Compared to patients undergoing a transsphenoidal approach to pituitary tumor resection, EEA patients incurred higher in-hospital costs across all variables including a total cost increase of $15 921 (95% confidence interval $5720-26 122, P = .002). Univariate analysis of all endoscopic anterior skull base surgery patients showed a cost increase of $30 616 associated with post-operative cerebrospinal fluid (CSF) leak ($10 420-50 811, P = .004), $14 610 with post-operative diabetes insipidus (DI) ($4610-24 609, P = .004), and $11 522 with African-American patients relative to Caucasian patients ($3049-19 995, P = .008). Conclusions: Patients who undergo endoscopic EEA for resection of anterior skull base tumors typically incur greater in-hospital costs than patients undergoing a standard TSA. Post-operative complications such as CSF leak and DI, as well as ethnicity, are significant drivers of cost-variability.

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In-hospital Costs Associated with an Expanded Endonasal Approach to Anterior Skull Base Tumors

10.1055/s-0039-1679525 ◽

2019 ◽

Author(s):

Arjun Parasher ◽

David Lerner ◽

Jordan Glicksman ◽

James Palmer ◽

Nithin Adappa

Keyword(s):

Skull Base ◽

Hospital Costs ◽

Anterior Skull Base ◽

Endonasal Approach ◽

Skull Base Tumors ◽

Expanded Endonasal Approach

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Three types of dural suturing for closure of CSF leak after endoscopic transsphenoidal surgery

Journal of Neurosurgery ◽

10.3171/2018.4.jns18366 ◽

2019 ◽

Vol 131 (5) ◽

pp. 1625-1631 ◽

Cited By ~ 2

Author(s):

Takayuki Ishikawa ◽

Kazuhito Takeuchi ◽

Yuichi Nagata ◽

Jungsu Choo ◽

Teppei Kawabata ◽

...

Keyword(s):

Skull Base ◽

Transsphenoidal Surgery ◽

Skull Base Surgery ◽

Sella Turcica ◽

High Flow ◽

Anterior Skull Base ◽

Csf Leak ◽

Dural Defect ◽

Csf Leakage ◽

Dural Suturing

OBJECTIVETranssphenoidal surgery (TSS) is commonly used for anterior skull base surgery, especially in the sella turcica (sellar) region. However, because of its anatomical position, CSF leakage is a major complication of this approach. The authors introduced a new grading reconstruction strategy for anterior skull base surgery with continuous dural suturing in 2013. In this paper the authors report on their methods and results.METHODSAll patients with sellar or anterior skull base lesions that were removed with TSS or extended TSS by a single neurosurgeon between April 2013 and March 2017 at Nagoya University Hospital and several cooperating hospitals were retrospectively identified. Three methods of suturing dura were considered, depending on the dural defect.RESULTSThere were 176 TSS cases (141 conventional TSS cases and 35 extended endoscopic TSS cases) and 76 cases of Esposito’s grade 2 or 3 intradural high-flow CSF leakage. In the high-flow CSF leak group, there were 3 cases of CSF leakage after the operation. The rates of CSF leakage after surgery corresponding to grades 2 and 3 were 2.9% (1/34) and 4.7% (2/42), respectively.CONCLUSIONSDural suturing is a basic and key method for reconstruction of the skull base, and continuous suturing is the most effective approach. Using this approach, the frequency of cases requiring a nasoseptal flap and lumbar drainage can be reduced.

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Predicting post-operative cerebrospinal fluid (CSF) leak following endoscopic transnasal pituitary and anterior skull base surgery: a multivariate analysis

Acta Neurochirurgica ◽

10.1007/s00701-020-04334-5 ◽

2020 ◽

Author(s):

Cathal John Hannan ◽

Hamad Almhanedi ◽

Rafid Al-Mahfoudh ◽

Maneesh Bhojak ◽

Seamus Looby ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Multivariate Analysis ◽

Skull Base ◽

Skull Base Surgery ◽

Anterior Skull Base ◽

Csf Leak

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Is a Single-Dose, Single-Agent Perioperative Antibiotic Protocol Adequate for Endoscopic Endonasal Skull Base Surgery? A 10-Year Review of 422 Cases

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1713771 ◽

2020 ◽

Author(s):

Mark A. Hughes ◽

Nick Phillips ◽

Atul Tyagi ◽

Asim Sheikh ◽

Kavita Sethi ◽

...

Keyword(s):

Single Dose ◽

Skull Base ◽

Skull Base Surgery ◽

Single Agent ◽

Prophylactic Antibiotic ◽

Antibiotic Use ◽

Anterior Skull Base ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Postoperative Meningitis

Abstract Objectives Postoperative meningitis is a rare but potentially fatal complication of endoscopic endonasal skull base surgery. Prophylactic antibiotic use varies considerably worldwide. We sought to analyze the safety of a single-agent, single-dose protocol. Design, Setting, and Participants A retrospective review of 422 procedures performed during 404 admission episodes from 2009 to 2019, encompassing sella, parasella, and other anterior skull base pathologies. Main Outcome Measures Primary outcome measure was development of meningitis within 30 days of surgery. Additional information collected: underlying pathological diagnosis, intraoperative cerebrospinal fluid (CSF) leak, postoperative CSF leak, and primary or revision surgery. Results Of 404 admission episodes for endoscopic anterior skull base surgery, 12 cases developed meningitis. Seven had positive CSF cultures and all 12 recovered. For pathology centered on the sella (including pituitary adenoma), the rate of meningitis was 1.1% (3/283). For pathologies demanding an extended approach (including meningioma and craniopharyngioma), the rate of meningitis was 14.5% (9/62). Postoperative CSF leak requiring surgical repair increased the relative risk by 37-fold. There were no cases of meningitis following repair of long-standing CSF fistula or encephalocoele (0/26) and no cases following surgery for sinonasal tumors with skull base involvement (0/33). Conclusion For sella-centered pathologies, a single dose of intravenous co-amoxiclav (or teicoplanin) is associated with rates of meningitis comparable to those reported in the literature. Postoperative meningitis was significantly higher for extended, intradural transphenoidal approaches, especially when postoperative CSF leak occurred. Fastidious efforts to prevent postoperative CSF leak are crucial to minimizing risk of meningitis.

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Our experience with a novel CSF leak repair material in 14 patients following anterior skull base surgery

Clinical Otolaryngology ◽

10.1111/coa.13287 ◽

2019 ◽

Vol 44 (3) ◽

pp. 416-419

Author(s):

Katherine De Rome ◽

Elinor Warner ◽

Kostas Barkas ◽

Nick Thomas ◽

Sinan Barazi ◽

...

Keyword(s):

Skull Base ◽

Skull Base Surgery ◽

Anterior Skull Base ◽

Csf Leak ◽

Repair Material

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Impairment of Olfaction and Mucociliary Clearance After Expanded Endonasal Approach Using Vascularized Septal Flap Reconstruction for Skull Base Tumors

Neurosurgery ◽

10.1227/neu.0b013e318282a535 ◽

2012 ◽

Vol 72 (4) ◽

pp. 540-546 ◽

Cited By ~ 60

Author(s):

Isam Alobid ◽

Joaquim Enseñat ◽

Franklin Mariño-Sánchez ◽

Matteo de Notaris ◽

Silvia Centellas ◽

...

Keyword(s):

Visual Analogue Scale ◽

Skull Base ◽

Analogue Scale ◽

Mucociliary Clearance ◽

Skull Base Surgery ◽

Nasal Discharge ◽

Healthy Population ◽

Endonasal Approach ◽

Skull Base Tumors ◽

Expanded Endonasal Approach

Abstract BACKGROUND: Endoscopic skull base surgery is now the preferred treatment option to remove skull base tumors. OBJECTIVE: To evaluate the patient's sense of smell and mucociliary clearance time (MCT) after skull base surgery. METHODS: Patients with pituitary adenoma underwent a transnasal transsphenoidal endoscopic approach (TTEA group, n = 36), whereas patients with other benign parasellar tumors underwent an expanded endonasal approach (EEA group, n = 14) with a vascularized septal flap. Assessment of symptoms (Visual Analogue Scale), olfactometry (Barcelona Smell Test, BAST-24), and MCT (saccharin test) were performed before and 3 months after surgery. RESULTS: Before surgery, patients reported poorer BAST-24 scores on detection, identification, and forced choice than the healthy population, but both study groups had similar sinonasal symptoms, BAST-24, and MCT scores. After surgery, no changes in symptom scores (Visual Analogue Scale) were observed except for the loss of smell (26.7 ± 30.5 mm, P < .05) and posterior nasal discharge (29.7 ± 30.3 mm, P < .05) compared with baseline (5.2 ± 11.3, 19.1 ± 25.3, respectively). EEA patients reported higher loss of smell and posterior nasal discharge compared with TTEA. TTEA and EEA groups had similar scores on postoperative BAST-24. After surgery, however, patients showed prolonged saccharin test (15.6 ± 10.8 min, P < .05) compared with baseline (8.4 ± 4.4 min). In addition, EEA patients reported longer MCT than TTEA patients. CONCLUSION: EEA but not TTEA has a short-term (3 months) negative impact on patient's olfaction and mucociliary clearance. Patients should be informed about smell loss as a consequence of skull base surgery to prevent legal claims. Likewise, further research and some modifications on reconstruction flaps are encouraged to avoid damaging the olfactory neuroepithelium.

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The expanded endonasal approach for the treatment of anterior skull base tumors

Operative Techniques in Otolaryngology-Head and Neck Surgery ◽

10.1016/j.otot.2009.10.002 ◽

2010 ◽

Vol 21 (1) ◽

pp. 66-73 ◽

Cited By ~ 4

Author(s):

Amol M. Bhatki ◽

Harshita Pant ◽

Carl H. Snyderman ◽

Ricardo L. Carrau ◽

Paul Gardner ◽

...

Keyword(s):

Skull Base ◽

Anterior Skull Base ◽

Endonasal Approach ◽

Skull Base Tumors ◽

Expanded Endonasal Approach

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Pediatric Endoscopic Endonasal Approaches for Skull Base Lesions in the Very Young: Is It Safe and Effective?

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1645854 ◽

2018 ◽

Vol 79 (06) ◽

pp. 574-579 ◽

Cited By ~ 3

Author(s):

Alexander Schupper ◽

Adam Deconde ◽

Michael Levy ◽

Javan Nation

Keyword(s):

Skull Base ◽

Pediatric Patients ◽

Pediatric Population ◽

Case Series ◽

Csf Leak ◽

Skull Base Tumors ◽

Endoscopic Endonasal ◽

Expanded Endonasal Approach ◽

Recurrent Epistaxis ◽

Csf Leaks

Introduction The fully endoscopic expanded endonasal approach (EEA) has been shown to be safe and efficacious in pediatric patients. However, in the very young patient (ages six and under), the anatomical challenge of working through a small nasal corridor is problematic. The ability to repair the skull base and use a nasoseptal flap (NSF) has also been called into question. Here, we review skull base resections using EEA in patients aged 6 years and younger. Methods A retrospective chart review was conducted on pediatric patients age 6 years and younger who underwent EEA skull base resections over a 3-year period (June 2014 through June 2017). Results Eight children aged 6 and under with seven tumor pathologies underwent an EEA for the resection of their skull base tumors, with a mean follow-up of 1.45 years. Only chordoma cases required multiple-staged resections. There are no tumor recurrences to date. A high-flow intraoperative cerebrospinal fluid (CSF) leak was encountered in three cases, and there were no postoperative CSF leaks. CSF leaks were effectively repaired with NSFs. One patient suffered from postoperative hypopituitarism, one patient experienced recurrent epistaxis secondary to turbinate destruction by the tumor, and one patient expired 8 months postresection secondary to metastatic disease. Conclusion In our case series, EEA for skull base tumors in children aged 6 and under was a safe and effective surgical approach. Skull base defects are able to be effectively addressed with typical repairs including NSFs. Larger studies are warranted to further investigate this technique in this pediatric population.

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