scholarly journals Novel concepts and strategies in skull base reconstruction after endoscopic endonasal surgery

ACTA IMEKO ◽  
2020 ◽  
Vol 9 (4) ◽  
pp. 67
Author(s):  
Domenico Solari ◽  
Ida Papallo ◽  
Lorenzo Ugga ◽  
Luigi M. Cavallo ◽  
Ilaria Onofrio ◽  
...  
Keyword(s):  
Additive Manufacturing ◽  
Skull Base ◽  
Endoscopic Technique ◽  
Leak Rate ◽  
Csf Leak ◽  
Endoscopic Endonasal Surgery ◽  
Endonasal Surgery ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Functional Features

<p align="left">Recently, a variety of craniofacial approaches has been adopted to enter the skull base, among those, the endonasal endoscopic technique. An effective watertight thereafter:  the reconstruction can be performed using different materials, both autologous and non-autologous, individually or combined in a multilayer fashion. The current study was focused on the development of new advanced devices and techniques, aiding in reducing postoperative CSF leak rate. Additive manufacturing allows the design of devices with tailored structural and functional features and, as well, injectable semi-IPNs and composites; therefore specific mechanical/rheological and injectability studies are valuable. Accordingly, we propose  new additive-manufactured and injectable devices.</p>

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

Neurosurgery ◽  
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.

scholarly journals Nasoseptal flap necrosis: a rare complication of endoscopic endonasal surgery

2018 ◽  
Vol 128 (5) ◽  
pp. 1463-1472 ◽  
Author(s):  
Joseph D. Chabot ◽  
Chirag R. Patel ◽  
Marion A. Hughes ◽  
Eric W. Wang ◽  
Carl H. Snyderman ◽  
...  
Keyword(s):  
Skull Base ◽  
Final Analysis ◽  
Csf Leak ◽  
Nasoseptal Flap ◽  
Endoscopic Endonasal Surgery ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
University Of Pittsburgh ◽  
The University ◽  
Pittsburgh Medical

OBJECTIVEThe vascularized nasoseptal flap (NSF) has become the workhorse for skull base reconstruction during endoscopic endonasal surgery (EES) of the ventral skull base. Although infrequently reported, as with any vascularized flap the NSF may undergo ischemic necrosis and become a nidus for infection. The University of Pittsburgh Medical Center’s experience with NSF was reviewed to determine the incidence of necrotic NSF in patients following EES and describe the clinical presentation, imaging characteristics, and risk factors associated with this complication.METHODSThe electronic medical records of 1285 consecutive patients who underwent EES at the University of Pittsburgh Medical Center between January 2010 and December 2014 were retrospectively reviewed. From this first group, a list of all patients in whom NSF was used for reconstruction was generated and further refined to determine if the patient returned to the operating room and the cause of this reexploration. Patients were included in the final analysis if they underwent endoscopic reexploration for suspected CSF leak or meningitis. Those patients who returned to the operating room for staged surgery or hematoma were excluded. Two neurosurgeons and a neuroradiologist, who were blinded to each other’s results, assessed the MRI characteristics of the included patients.RESULTSIn total, 601 patients underwent NSF reconstruction during the study period, and 49 patients met the criteria for inclusion in the final analysis. On endoscopic exploration, 8 patients had a necrotic, nonviable NSF, while 41 patients had a viable NSF with a CSF leak. The group of patients with a necrotic, nonviable NSF was then compared with the group with viable NSF. All 8 patients with a necrotic NSF had clinical and laboratory evidence indicative of meningitis compared with 9 of 41 patients with a viable NSF (p < 0.001). Four patients with necrotic flaps developed epidural empyema compared with 2 of 41 patients in the viable NSF group (p = 0.02). The lack of NSF enhancement on MR (p < 0.001), prior surgery (p = 0.043), and the use of a fat graft (p = 0.004) were associated with necrotic NSF.CONCLUSIONSThe signs of meningitis after EES in the absence of a clear CSF leak with the lack of NSF enhancement on MRI should raise the suspicion of necrotic NSF. These patients should undergo prompt exploration and debridement of nonviable tissue with revision of skull base reconstruction.

scholarly journals Skull base reconstruction: A question of flow? A critical analysis of 521 endoscopic endonasal surgeries

PLoS ONE ◽  
2021 ◽  
Vol 16 (3) ◽  
pp. e0245119
Author(s):  
Giuseppe Di Perna ◽  
Federica Penner ◽  
Fabio Cofano ◽  
Raffaele De Marco ◽  
Bianca Maria Baldassarre ◽  
...  
Keyword(s):  
Skull Base ◽  
Surgical Approach ◽  
Leak Rate ◽  
Low Flow ◽  
Csf Leak ◽  
Anatomical Site ◽  
Skull Base Tumor ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Rate Analysis

Introduction Post-operative CSF leak still represents the main drawback of Endoscopic Endonasal Approach (EEA), and different reconstructive strategies have been proposed in order to decrease its rate. Objective To critically analyze the effectiveness of different adopted reconstruction strategies in patients that underwent EEA. Materials and methods Adult patients with skull base tumor surgically treated with EEA were retrospectively analyzed. Data recorded for each case concerned patient demographics, type of surgical approach, histotype, anatomical site of surgical approach, intra-operative CSF leak grade (no leak (INL), low flow (ILFL), high flow (IHFL)), reconstructive adopted strategy, Lumbar Drain positioning, post-operative CSF leak rate and intra/post-operative complications. Results A total number of 521 patients (January 2012-December 2019) was included. Intra-operative CSF leak grade showed to be associated with post-operative CSF leak rate. In particular, the risk to observe a post-operative CSF leak was higher when IHFL was encountered (25,5%; Exp(B) 16.25). In particular, vascularized multilayered reconstruction and fat use showed to be effective in lowering post-operative CSF leaks in IHFL (p 0.02). No differences were found considering INL and ILFL groups. Yearly post-operative CSF leak rate analysis showed a significative decreasing trend. Conclusion Intra-operative CSF leak grade strongly affected post-operative CSF leak rate. Multilayer reconstruction with fat and naso-septal flap could reduce the rate of CSF leak in high risk patients. Reconstructive strategies should be tailored according also to the type and the anatomical site of the approach.

Collagen Matrix With Mucoperiosteum Graft as an Effective Fatless Flapless Reconstruction After Endoscopic Pituitary Adenoma Resection

2020 ◽  
Author(s):  
Mostafa Shahein ◽  
Alaa S Montaser ◽  
Juan M Revuelta Barbero ◽  
Guillermo Maza ◽  
Alexandre B Todeschini ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Skull Base ◽  
Collagen Matrix ◽  
Leak Rate ◽  
Fat Graft ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Group A ◽  
Group B

Abstract BACKGROUND Proper skull base reconstruction after endoscopic endonasal pituitary surgery is of great importance to decrease the rate of complications. OBJECTIVE To assess the safety and efficacy of reconstruction with materials other than fat graft and naso-septal flaps (NSF) to avoid their associated morbidities. METHODS The authors’ institutional database for patients who underwent endoscopic endonasal approach for pituitary adenoma was reviewed. Exclusion criteria included recurrence, postradiation therapy, and reconstruction by fat graft or NSF. They were divided into group A, where collagen matrix (CM) (DuraGen® Plus Matrix, Integra LifeSciences Corporation, Plainsboro, New Jersey) alone was used; group B, where CM and simple mucoperiosteum graft were used and group C, which included cases without CM utilization. RESULTS The study included 252 patients. No age, gender, or body mass index statistically significant difference between groups. Group B included the largest tumor size (23.0 mm) in comparison to groups A (18.0 mm) and C (13.0 mm). Suprasellar extension was more frequently present (49.4%) in comparison to groups A (29.8%, P = .001) and C (21.2%, P &lt; .001). Postoperative cerebrospinal fluid (CSF) leak rate was 0%, 2.9%, and 6% in groups A, B, and C, respectively. In group B, the CSF leak rate decreased from 45.9% intraoperatively to 2.9% postoperatively (P &lt; .001). In group A, the CSF leak reduction rate was almost statistically significant (P = .06). CONCLUSION Utilization of CM and simple mucosperiosteal graft in skull base reconstruction following pituitary adenoma surgery is an effective method to avoid the morbidities associated with NSF or fat graft.

scholarly journals Effects of Cruciate Embedding Fascia-Bone Flap Technique on Grade II - III Cerebral Spinal Fluid Leak in Endoscopic Endonasal Surgery

2021 ◽  
Author(s):  
WenJi Zhao ◽  
Gang Yang ◽  
RuiChun Li ◽  
Gang Huo ◽  
Dong Gao ◽  
...  
Keyword(s):  
Skull Base ◽  
Cerebral Spinal Fluid ◽  
Spinal Fluid ◽  
Bone Flap ◽  
Csf Leak ◽  
Dural Defect ◽  
Endoscopic Endonasal Surgery ◽  
Endonasal Surgery ◽  
Endoscopic Endonasal ◽  
Grade Ii

Abstract Background: Cerebral spinal fluid (CSF) leak remains an important issue in endoscopic endonasal surgery. A standard protocol of skull base closure has not been established yet, and application of rigid buttress has not been given sufficient attention. To emphasize the functions of support and fixation from rigid buttress in reconstruction, we introduce a technique of cruciate embedding fascia-bone flap (CEFB) using autologous bone graft to buttress fascia lata attaching to partially sutured skull base dural defect, and evaluate its efficacy in a consecutive case series of grade II-III CSF leak in EES.METHODS: Data of consecutive patients with grade II-III CSF leak during EES were collected between May 2015 and May 2020. Skull base reconstructions were performed either with the CEFB, conventional PNSF, or combination of 2 methods. Related clinical data were compared and analyzed respectively.RESULTS: There are 110, 65, and 23 patients included in CEFB, PNSF, and combination group respectively. CEFB demonstrated statistically similar effects on postoperative CSF leak (2.7%) and intracranial infection (4.5%) compared to PNSF (3.1%, 3.1%), but with less morbidity of epistaxis (CEFB: 0%, PNSF: 6.2%) and nasal discomforts (CEFB: 0%, PNSF: 7.7%). The bed stay time (CEFB: 5.74d, PNSF: 8.83d) and hospitalization time (CEFB: 10.49d, PNSF: 13.58d) were shortened in CEFB group. Combination of CEFB and PNSF achieved 0 postoperative CSF leak in 23 highly susceptible patients with grade III leak and multiple high risk factors.CONCLUSION: The CEFB technique is reliable and feasible to prevent postoperative CSF leak in EES. It can be used safely without PNSF in suitable cases, or applied in association with PNSF with high compatibility and security when necessary.Trial Registration：Current Controlled Trials ChiCTR2100044764 (Chinese Clinical Trial Registry), as well as the date of registration 27th March, 2020. Retrospectively registered.

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