Endoscopic endonasal suturing of dural reconstruction grafts: a novel application of the U-Clip technology

✓ Cerebrospinal fluid (CSF) leakage following endoscopic endonasal skull base resection can be a significant problem. A method for securing tissue grafts is needed. In this paper the authors used an endonasal suturing device to secure the graft reconstruction following endonasal tumor resection. The U-Clip anastomotic device (Medtronic), developed for cardiovascular anastomoses, was used to secure the tissue graft to native dura. A specialized needle driver and hemoclip applier were used for the application and deployment of this device. No suture tying was necessary, facilitating its endonasal application. The graft was successfully secured in its desired position to native dura by using the U-Clip anastomotic device. The patient did not suffer a postoperative CSF leak, and postoperative imaging and endoscopy revealed that the graft was in a good position. There was no complication from the use of the device. The U-Clip anastomotic device can be used as a suture device during endonasal surgery. It may prevent tissue graft migration and help prevent CSF leakage.

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Pseudocapsule-Based Resection for Pituitary Adenomas via the Endoscopic Endonasal Approach

Frontiers in Oncology ◽

10.3389/fonc.2021.812468 ◽

2022 ◽

Vol 11 ◽

Author(s):

Yuefei Zhou ◽

Jialiang Wei ◽

Feng Feng ◽

Jianguo Wang ◽

Pengfei Jia ◽

...

Keyword(s):

Pituitary Adenomas ◽

Tumor Resection ◽

Csf Leak ◽

Safe Procedure ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Csf Leakage ◽

Extracapsular Resection

IntroductionThe endoscopic endonasal approach (EEA) is a safe and effective treatment for pituitary adenomas (PAs). Since extracapsular resection (ER) of PAs improves tumor resection and endocrine remission rates, the interface between the pseudocapsule and gland draws increasing attention. However, it is difficult to precisely dissect the tumor along the exact boundary, and complete removal of the tumor increases the risks of normal tissue damage and cerebrospinal fluid (CSF) leakage. In this study, we investigated the extracapsular resection as well as the pseudocapsule histology to evaluate the effectiveness and safety of pseudocapsule-related surgical interventions.MethodsFrom December 2017 to December 2019, 189 patients of PAs via EEA in our single center were analyzed retrospectively. The images, operative details, and clinical follow-up of patients were collected. Sixty-four patients underwent pseudocapsule-based ER, and 125 patients also underwent traditional intracapsular resection (IR) with or without intensive excision for FPAs. The clinical characteristics, tumor resection, endocrinological outcomes, and postoperative morbidities of the two groups were compared. Informed consent for publication of our article was obtained from each patient. Histological examination of pseudocapsule was performed using hematoxylin and eosin and reticulin staining.ResultsThe gross total recession was 62 (96.9%) in the ER group and 107 (85.6%) cases in the IR group, whereas the endocrine remission rate was 29/31 (93.5%) and 40/53 (75.5%) cases, respectively. Anterior pituitary functions were not aggravated postoperatively in any patient, but transient diabetes insipidus (DI) occurred more in the IR group (64.0%) than in ER (48.4%). Pseudocapsule specimens were obtained in 93 patients, and clusters of small cell aggregation were detected in 11 pseudocapsule specimens (11.8%) whereas other patients showed no remarkable developed pseudocapsule. Intraoperative CSF leak occurred more in the ER group (28.1%) than in the IR group (13.6%), but no difference was seen between two groups postoperatively. No case of intracranial hematoma or pituitary crisis occurred in both groups. After a mean follow-up of 22.8 months, tumor recurrence was observed in 4 (2.1%) cases.ConclusionPseudocapsule-based extracapsular resection of PAs via EEA is an effective and safe procedure to achieve complete resection with high and sustained endocrine remission and without deteriorating pituitary function.

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Iatrogenic cerebrospinal fluid leak after repeated nasal swab tests for COVID-19: illustrative case

Journal of Neurosurgery: Case Lessons ◽

10.3171/case21421 ◽

2021 ◽

Vol 2 (17) ◽

Author(s):

Johnson Ku ◽

Chieh-Yi Chen ◽

Jason Ku ◽

Hsuan-Kan Chang ◽

Jau-Ching Wu ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Nasal Cavity ◽

Nasal Swab ◽

Cerebrospinal Fluid Leak ◽

Cribriform Plate ◽

Csf Leak ◽

Illustrative Case ◽

Endoscopic Endonasal ◽

Csf Rhinorrhea ◽

Csf Leakage

BACKGROUND Nasal swab tests are one of the most essential tools for screening coronavirus disease 2019 (COVID-19). The authors report a rare case of iatrogenic cerebrospinal fluid (CSF) leak from the anterior skull base after repeated nasal swab tests for COVID-19, which was treated with endoscopic endonasal repair. OBSERVATIONS A 41-year-old man presented with clear continuous rhinorrhea through his left nostril for 5 days after repeated nasal swabbing for COVID-19. There were no obvious risk factors for spontaneous CSF leak. Computed tomography cisternography showed contrast accumulation in the left olfactory fossa and along the left nasal cavity. Such findings aligned with a preliminary diagnosis of CSF leakage through the left cribriform plate. Magnetic resonance imaging confirmed the presence of a CSF fistula between his left cribriform plate and superior nasal concha. The patient underwent endoscopic endonasal repair. CSF rhinorrhea ceased after the surgery, and no recurrence was noted during the 12-week postoperative follow-up period. LESSONS Although rare, iatrogenic CSF leakage can be a serious complication following COVID-19 nasal swab tests, especially when infection may cause significant neurological sequelae. Healthcare providers should become familiar with nasal cavity anatomy and be well trained in performing nasal swab tests.

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Surgical Outcomes of Endoscopic Endonasal Surgery in 29 Patients with Craniopharyngioma

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1713108 ◽

2020 ◽

Author(s):

Arad Iranmehr ◽

Mostafa Esmaeilnia ◽

Khashayar Afshari ◽

Seyed Mousa Sadrehosseini ◽

Azin Tabari ◽

...

Keyword(s):

Tumor Resection ◽

Visual Outcome ◽

Extent Of Resection ◽

Csf Leak ◽

Endoscopic Endonasal Surgery ◽

Endonasal Surgery ◽

Endoscopic Endonasal ◽

Pituitary Dysfunction ◽

Before And After

Abstract Background Recently the endoscopic endonasal surgery (EES) has been introduced as a modality for the treatment of patients with craniopharyngiomas. In this study, we describe our initial experience in treatment of 29 patients with craniopharyngiomas using this approach. Methods Twenty-nine consecutive patients with craniopharyngiomas who had undergone EES in a 5-year period were studied retrospectively. Patients underwent preoperative and postoperative endocrinologic and ophthalmologic evaluations. Radiologic characteristics of tumors and extent of resection were determined. The recurrence and complications were evaluated. Results Pituitary and visual dysfunction were observed preoperatively in 89.7 and 86% of patients, respectively. After EES, visual outcome either showed an improvement or else remained unchanged in 92.3% of the cases; however, pituitary function remained unchanged and even got worsened in 34.6% of the cases. Prevalence of diabetes insipidus before and after surgery was 58.6 and 69.2%. The rate of gross total resection was 62%. Moreover, 86.2% of the tumors were almost totally resected (more than 95% of the tumor size resected). After surgery, cerebrospinal fluid (CSF) leak and meningitis occurred in four (13.8%) and two (6.9%) patients, respectively. Perioperative mortality was seen in two of the cases (6.9%). The mean follow-up was 25 months and tumor recurrence was discovered in four patients (15.3%). Conclusion The EES with the goal of maximal and safe tumor resection could be used for the treatment of most craniopharyngiomas. Although the rates of visual improvement and gross tumor resection are high, CSF leak, pituitary dysfunction, and meningitis are serious concerns.

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Snare technique for the remodeling of the redundant arachnoid pouch to prevent cerebrospinal fluid rhinorrhea and hematoma collection during transsphenoidal surgery for suprasellar-extended pituitary tumors

Journal of Neurosurgery ◽

10.3171/2015.11.jns151328 ◽

2016 ◽

Vol 125 (6) ◽

pp. 1443-1450 ◽

Cited By ~ 2

Author(s):

Ju Hyung Moon ◽

Eui Hyun Kim ◽

Sun Ho Kim

Keyword(s):

Transsphenoidal Surgery ◽

Tumor Resection ◽

Pituitary Tumors ◽

Csf Leak ◽

Arachnoid Membrane ◽

Csf Rhinorrhea ◽

Resection Cavity ◽

Postoperative Hematoma ◽

Csf Leakage ◽

Suprasellar Extension

OBJECTIVE Transsphenoidal surgery (TSS) is considered a most effective treatment for pituitary tumors with huge suprasellar extension. However, the chance of developing CSF leakage is relatively high, because tearing of the arachnoid membrane is common and there could be multiple tear points during the dissection of suprasellar tumors from the overlying arachnoid membrane. If there are multiple leaking points in the arachnoid membrane packing methods such as using fat or multilayered fascia graft may not be sufficient to seal off the leaking points. Moreover, the packing material may not provide sufficient tamponade to stop bleeding, and thus generates postoperative hematoma formation in the tumor resection cavity. To prevent these complications, the authors have developed a new technique for remodeling the redundant arachnoid pouch (the so-called snare technique) to reconstruct the diaphragm, seal off the CSF leak points completely, and reduce the dead space in the tumor resection cavity. METHODS In 9 patients with huge macroadenomas (> 2.5 cm in diameter) with suprasellar extension, the snare technique was used to remodel the arachnoid pouch after tumor removal via standard TSS between July 2009 and August 2014. Complications were investigated, including postoperative CSF rhinorrhea, postoperative hematoma collection, and visual compromise. RESULTS During the resection of the tumor, CSF leakage was encountered in 8 cases, all of which were sealed off using the snare technique. In 1 case without intraoperative CSF leakage, the snare technique was also applied after intentional puncturing of the arachnoid membrane to reduce the volume and tension of the arachnoid pouch. None of the 9 patients experienced postoperative CSF rhinorrhea. Lumbar CSF drainage was not required in any case. Magnetic resonance imaging studies performed 24 hours after surgery revealed a remarkable reduction in the height of the diaphragm in all cases. Visual deficits improved in all patients immediately after surgery. CONCLUSIONS Remodeling of the arachnoid pouch using the snare technique is simple and effective for completely sealing off the CSF leak point and preventing hematoma collection in the tumor resection cavity after TSS for huge pituitary tumors with suprasellar extension.

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Endoscopic endonasal resection of epidermoid cysts involving the ventral cranial base

Journal of Neurosurgery ◽

10.3171/2017.12.jns172575 ◽

2019 ◽

Vol 130 (5) ◽

pp. 1599-1608

Author(s):

Jonathan A. Forbes ◽

Matei Banu ◽

Kurt Lehner ◽

Malte Ottenhausen ◽

Emanuele La Corte ◽

...

Keyword(s):

Cranial Nerves ◽

Cranial Base ◽

Csf Leak ◽

Nasoseptal Flap ◽

Total Resection ◽

Endoscopic Endonasal ◽

Epidermoid Cysts ◽

Flap Coverage ◽

Csf Leakage ◽

The Impact

OBJECTIVEEpidermoid cysts (ECs) commonly extend to involve the ventral cisterns of the cranial base. When present, symptoms arise due to progressive mass effect on the brainstem and adjacent cranial nerves. Historically, a variety of open microsurgical approaches have been used for resection of ECs in this intricate region. In recent years, the endoscopic endonasal approach (EEA) has been proposed as an alternative corridor that avoids crossing the plane of the cranial nerves. To date, there is a paucity of data in the literature regarding the safety and efficacy of the EEA in the treatment of ECs of the ventral cranial base.METHODSThe authors reviewed a prospectively acquired database of EEAs for resection of ECs over 8 years at Weill Cornell, NewYork-Presbyterian Hospital. All procedures were performed by the senior authors. Standardized clinical and radiological parameters were assessed before and after surgery. Statistical tests were used to determine the impact of previous surgery and tumor volume on extent of resection and recurrence as well as the method of closure on rate of CSF leak.RESULTSBetween January 2009 and February 2017, 7 patients (4 males and 3 females; age range 16–70 years) underwent a total of 8 surgeries for EC resection utilizing the EEA. Transplanum and transclival extensions were performed in 3 and 5 patients, respectively. Methods of closure incorporated a gasket seal in 6 of 8 procedures and a nasoseptal flap in 7 of 8 procedures. Gross-total resection (GTR) was achieved in 43% of patients, and near-total resection (> 95%) was obtained in another 43%. Complications included diabetes insipidus (n = 2), postoperative CSF leak (n = 2), transient third cranial nerve palsy (n = 1), and epistaxis (n = 1). With a mean follow-up of 43.5 months, recurrence has been observed in 2 of 7 patients. In 1 case, reoperation for recurrence was required 71 months following the initial surgery. Use of the gasket-seal technique with nasoseptal flap coverage significantly correlated with the absence of postoperative CSF leakage (p = 0.018). GTR was achieved in 25% of the patients who had prior surgeries and in 50% of patients without previous resections. The mean volume of cysts in which GTR was achieved (4.3 ± 1.8 cm3) was smaller than that in which subtotal or near-total resection was achieved (12.2 ± 11 cm3, p = 0.134).CONCLUSIONSThe EEA for resection of ECs of the ventral cranial base is a safe and effective operative strategy that avoids crossing the plane of the cranial nerves. In the authors’ experience, gasket-seal closure with nasoseptal flap coverage has been associated with a decreased risk of postoperative CSF leakage.

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Anterior Skull Base Meningioma: Surgical approach and complication avoidance

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/a-1733-9320 ◽

2022 ◽

Author(s):

Bhawan Nangarwal ◽

Jaskaran Singh Gosal ◽

Kuntal Kanti Das ◽

Deepak Khatri ◽

Kamlesh Singh Bhaisora ◽

...

Keyword(s):

Skull Base ◽

Tumor Resection ◽

Vascular Complications ◽

Good Alternative ◽

Anterior Skull Base ◽

Csf Leak ◽

Medical Complication ◽

Endoscopic Endonasal ◽

Olfactory Groove ◽

Skull Base Meningioma

Background: Endoscopic endonasal approach (EEA) and keyhole transcranial approaches are being increasingly used in anterior skull base meningioma (ASBM) surgery. Objective: We compare tumor resection rates and complication profiles of EEA and supraorbital key hole approach (SOKHA) against conventional transcranial approaches (TCA). Methods: Fifty-four patients with ASBM [olfactory groove (OGM), n=19 and planum sphenoidale/tuberculum sellae (PS/TSM), n=35) operated at a single centre over 7 years were retrospectively analyzed. Results: The overall rate of GTR was higher in OGM (15/19, 78.9%) than PS-TSM group (23/35, 65.7%, p=0.37). GTR rate with OGM was 90% and 75% with TCA and EEA. Death (n=1) following medical complication (TCA) and CSF leak requiring re-exploration (n=2, one each in TCA and EEA) accounted for the major complications in OGM. For the PS/TSM group, the GTR rates were 73.3% (n=11/15), 53.8% (n=7/13) and 71.4% (n=5/7) with TCA, EEA and SOKHA respectively. Seven patients (20%) of PS-TSM developed major postoperative complications including 4 deaths (one each in TCA, SOKHA and 2 in EEA group) and 3 visual deteriorations. Direct and indirect vascular complications were common in lesser invasive approaches to PS-TSM especially if the tumor has encased intracranial arteries. Conclusions: No single approach is applicable to all ASBMs. TCA is still the best approach to obtain GTR but has tissue trauma related problems. SOKHA may be a good alternative to TCA in selected PS-TSMs while EEA may be an alternate option in some OGMs. A meticulous patient selection is needed to derive reported results of EEA for PS-TSM.

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Prevention of Cerebrospinal Fluid Rhinorrhea After Transsphenoidal Surgery by Collagen Fleece Coated With Fibrin Sealant Without Autologous Tissue Graft or Postoperative Lumbar Drainage

Operative Neurosurgery ◽

10.1227/neu.0b013e318207b4ea ◽

2011 ◽

Vol 68 (suppl_1) ◽

pp. ons130-ons137 ◽

Cited By ~ 6

Author(s):

Jin Mo Cho ◽

Jung Yong Ahn ◽

Jong Hee Chang ◽

Sun Ho Kim

Keyword(s):

Cerebrospinal Fluid ◽

Fibrin Sealant ◽

Transsphenoidal Surgery ◽

Csf Leak ◽

Autologous Tissue ◽

Csf Rhinorrhea ◽

Cerebrospinal Fluid Rhinorrhea ◽

Tissue Graft ◽

Csf Leakage ◽

Sellar Floor

Abstract BACKGROUND: Autologous tissue grafting and postoperative lumbar cerebrospinal fluid (CSF) drainage (PLD) have been used to prevent CSF rhinorrhea after transsphenoidal surgery. OBJECTIVE: To describe the technical details and efficacy of our techniques of using collagen fleece coated with fibrin sealant (TachoComb, Nycomed, Linz, Austria) instead of an autologous tissue graft and refraining from the use of PLD. METHODS: We retrospectively reviewed 307 consecutive patients who underwent a transsphenoidal surgery for pituitary adenoma from November 2005 to February 2008. Among them, 90 cases of intraoperative CSF leaks were repaired with TachoComb without an autologous tissue graft or PLD. The repair procedures were tailored according to CSF leakage type, and we used only Bioglue (Cryolife Inc, Atlanta, Georgia) for sellar floor reconstruction. RESULTS: The overall rate of CSF rhinorrhea was 2.2% (2 of 90 cases). The 2 cases of CSF rhinorrhea resulted from large arachnoid defects, and there were no adverse effects from TachoComb such as transmission of viral disease or infection. CONCLUSION: Our technique is an alternative method to the traditional autologous tissue graft technique. PLD is not an essential procedure for the prevention of CSF rhinorrhea if the intraoperative CSF leak is completely sealed off during the transsphenoidal surgery. However, in cases of large arachnoid defects, aggressive repair of the arachnoid defect and sellar floor reconstruction with bone or bony substitutes should be considered in conjunction with our methods.

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Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions

Journal of Neurosurgery ◽

10.3171/jns.2007.106.3.400 ◽

2007 ◽

Vol 106 (3) ◽

pp. 400-406 ◽

Cited By ~ 236

Author(s):

Ilya Laufer ◽

Vijay K. Anand ◽

Theodore H. Schwartz

Keyword(s):

Sella Turcica ◽

Significant Risk ◽

Csf Leak ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Rathke Cleft Cyst ◽

Extended Transsphenoidal Approach ◽

Csf Leakage ◽

Planum Sphenoidale

Object The extended transsphenoidal approach is a less invasive method for removing purely suprasellar lesions compared with traditional transcranial approaches. Most advocates have used a sublabial incision and a microscope and have reported a significant risk of cerebrospinal fluid (CSF) leakage. The authors report on a series of purely endoscopic endonasal surgeries for resection of suprasellar supradiaphragmatic lesions above a normal-sized sella turcica with a low risk of CSF leakage. Methods A purely endoscopic endonasal approach was used to remove suprasellar lesions in a series of 10 patients. Five lesions were prechiasmal (three tuberculum sellae and two planum sphenoidale meningiomas) and five were post-chiasmal (four craniopharyngiomas and one Rathke cleft cyst). The floor of the planum sphenoidale and the sella turcica was reconstructed using a multilayer closure with autologous and synthetic materials. Spinal drainage was performed in only five cases. Complete resection of the lesions was achieved in all but one patient. The pituitary stalk was preserved in all but one patient, whose stalk was invaded by a craniopharyngioma and who had preoperative diabetes insipidus (DI). Vision improved postoperatively in all patients with preoperative impairment. Six patients had temporary DI; in five, the DI became permanent. Four patients with craniopharyngiomas required cortisone and thyroid replacement. After a mean follow up of 10 months, there was only one transient CSF leak when a lumbar drain was clamped prematurely on postoperative Day 5. Conclusions A purely endoscopic endonasal approach to suprasellar supradiaphragmatic lesions is a feasible minimally invasive alternative to craniotomy. With a multilayer closure, the risk of CSF leakage is low and lumbar drainage can be avoided. A larger series will be required to validate this approach.

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Risk factors associated with postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery

Journal of Neurosurgery ◽

10.3171/2016.12.jns1694 ◽

2018 ◽

Vol 128 (4) ◽

pp. 1066-1071 ◽

Cited By ~ 24

Author(s):

Shannon Fraser ◽

Paul A. Gardner ◽

Maria Koutourousiou ◽

Mark Kubik ◽

Juan C. Fernandez-Miranda ◽

...

Keyword(s):

Risk Factors ◽

Skull Base ◽

Posterior Fossa ◽

Pedicled Flap ◽

Leakage Rate ◽

Csf Leak ◽

Free Graft ◽

Endoscopic Endonasal ◽

Lumbar Drainage ◽

Csf Leakage

OBJECTIVEThe aim in this paper was to determine risk factors for the development of a postoperative CSF leak after an endoscopic endonasal approach (EEA) for resection of skull base tumors.METHODSA retrospective review of patients who underwent EEA for the resection of intradural pathology between January 1997 and June 2012 was performed. Basic demographic data were collected, along with patient body mass index (BMI), tumor pathology, reconstruction technique, lumbar drainage, and outcomes.RESULTSOf the 615 patients studied, 103 developed a postoperative CSF leak (16.7%). Sex and perioperative lumbar drainage did not affect CSF leakage rates. Posterior fossa tumors had the highest rate of CSF leakage (32.6%), followed by anterior skull base lesions (21.0%) and sellar/suprasellar lesions (9.9%) (p < 0.0001). There was a higher leakage rate for overweight and obese patients (BMI > 25 kg/m2) than for those with a healthy-weight BMI (18.7% vs 11.5%; p = 0.04). Patients in whom a pedicled vascularized flap was used for reconstruction had a lower leakage rate than those in whom a free graft was used (13.5% vs 27.8%; p = 0.0015). In patients with a BMI > 25 kg/m2, the use of a pedicled flap reduced the rate of CSF leakage from 29.5% to 15.0% (p = 0.001); in patients of normal weight, this reduction did not reach statistical significance (21.9% [pedicled flap] vs 9.2% [free graft]; p = 0.09).CONCLUSIONSPreoperative BMI > 25 kg/m2 and tumor location in the posterior fossa were associated with higher rates of postoperative CSF leak. Use of a pedicled vascularized flap may be associated with reduced risk of a CSF leak, particularly in overweight patients.

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Endoscopic Endonasal Excision of Pituitary Tumors Using a Mono-nostril Technique

Pakistan Journal Of Neurological Surgery ◽

10.36552/pjns.v23i4.382 ◽

2019 ◽

Vol 23 (4) ◽

Author(s):

AMIR AZIZ ◽

YASER-UD- DIN ◽

ZUBAIR AHMED ◽

SHARUKH RIZVI ◽

HABIB SULTAN ◽

...

Keyword(s):

Tumor Resection ◽

Pituitary Tumors ◽

Invasive Procedure ◽

Early Discharge ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Csf Rhinorrhea ◽

Visual Status ◽

Good Cosmetic ◽

Partial Excision

Objectives: The purpose of this study is to assess the effectiveness and advantage of endoscopic mono-nostril approach to the pituitary tumors.Materials and Methods: We analyzed 70 patients undergoing transsphenoidal mono-nostril excision of pituitary tumors from September, 2016 to March, 2018.Results: We operated 70 patients, out of which 51 were males and 19 were females; the age of the patients ranged from 15 years to 65 years.In our study, out of 70 patients, 61 (87.1%) patients had excellent results with total tumor resection, marked visual improvement, early discharge on the second post-operative day, resuming their daily activities within two weeks and recurrence free interval of 1 year. Nine (12.8%) of our patients had a partial excision of the tumor, whereby there was improvement of headaches in all of them while visual status remained at the pre-operative status. Five (7.1%) of our patients had a post-operative cerebral spinal fluid (CSF) rhinorrhea, 4 (5.7%) in total excision group and 1 (1.4%) in partial excision group. These patients of CSF leak were retained in hospital and their mean stay in hospital was 12  4. Conclusion: We consider that endoscopic mono-nostril excision of the pituitary tumor is a relatively safer, effective, minimally invasive procedure; whereby there is a fast recovery, early discharge and good cosmetic results.

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