Bilaminar Chitosan Scaffold for Sellar Floor Repair in Transsphenoidal Surgery

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.

Download Full-text

Long-term evaluation of reconstruction of the sellar floor with a silicone plate in transsphenoidal surgery

Journal of Neurosurgery ◽

10.3171/jns.1998.88.6.0949 ◽

1998 ◽

Vol 88 (6) ◽

pp. 949-953 ◽

Cited By ~ 36

Author(s):

Masanori Kabuto ◽

Toshihiko Kubota ◽

Hidenori Kobayashi ◽

Hiroaki Takeuchi ◽

Takao Nakagawa ◽

...

Keyword(s):

Mr Imaging ◽

Transsphenoidal Surgery ◽

Septal Cartilage ◽

Csf Rhinorrhea ◽

Content Type ◽

Csf Leakage ◽

Repeated Surgery ◽

Initial Procedure ◽

Sellar Floor ◽

Fine Print

Object. The authors have used a silicone plate for reconstruction of the sellar floor during rhinoseptoplastic transsphenoidal surgery because it has greater elasticity and is easier to carve than nasal septal cartilage and sphenoid sinus bone. This study was designed to evaluate the usefulness of this technique based on the authors' experience during the past 7.6 years. Methods. A silicone plate was used to reconstruct the sellar floor in 69 consecutive patients with sellar tumors that included 60 pituitary adenomas and nine Rathke's cleft cysts. The patients ranged in age from 16 to 82 years (mean 52 years). The postoperative position of the silicone plate could be clearly identified on sagittal or coronal magnetic resonance (MR) imaging as a very low intensity plate (void signal). No displacement or migration of the implanted silicone plate was observed on follow-up MR imaging in any patient. Infections of the lesion such as a pituitary abscess were not observed clinically or radiologically in any patient. Of the 16 patients with intraoperative cerebrospinal fluid (CSF) leakage, only one patient who had a ghost sella developed postoperative CSF rhinorrhea. In all seven patients who underwent repeated surgery for residual or recurrent tumor, the silicone plate that had been placed at the initial procedure was covered with a relatively thin fibrous capsule and the plate was well preserved. The silicone plate was easily removed at reoperation and was useful for detection of the sellar floor window made previously. Conclusions. These results indicate that a silicone plate can be useful for reconstruction of the sellar floor in rhinoseptoplastic transsphenoidal surgery.

Download Full-text

Osteoplastic opening of the sellar floor in transsphenoidal surgery

Neurosurgery ◽

10.1097/00006123-198703000-00015 ◽

1987 ◽

Vol 20 (3) ◽

pp. 445???6

Author(s):

E de Divitiis ◽

R Spaziante

Keyword(s):

Transsphenoidal Surgery ◽

Sellar Floor

Download Full-text

Spontaneous reossification of the sella in transsphenoidal reoperation associated with strontium ranelate

Endocrinology Diabetes and Metabolism Case Reports ◽

10.1530/edm-17-0037 ◽

2017 ◽

Vol 2017 ◽

Author(s):

Maria Mercedes Pineyro ◽

Daiana Arrestia ◽

Mariana Elhordoy ◽

Ramiro Lima ◽

Saul Wajskopf ◽

...

Keyword(s):

Bone Mass ◽

Cushing’S Disease ◽

Strontium Ranelate ◽

Transsphenoidal Surgery ◽

Cushing's Disease ◽

Delayed Puberty ◽

List Type ◽

Low Bone Mass ◽

Work Up ◽

Sellar Floor

Summary Spontaneous reossification of the sellar floor after transsphenoidal surgery has been rarely reported. Strontium ranelate, a divalent strontium salt, has been shown to increase bone formation, increasing osteoblast activity. We describe an unusual case of a young patient with Cushing’s disease who was treated with strontium ranelate for low bone mass who experienced spontaneous sellar reossification after transsphenoidal surgery. A 21-year-old male presented with Cushing’s features. His past medical history included delayed puberty diagnosed at 16 years, treated with testosterone for 3 years without further work-up. He was diagnosed with Cushing’s disease initially treated with transsphenoidal surgery, which was not curative. The patient did not come to follow-up visits for more than 1 year. He was prescribed strontium ranelate 2 g orally once daily for low bone mass by an outside endocrinologist, which he received for more than 1 year. Two years after first surgery he was reevaluated and persisted with active Cushing’s disease. Magnetic resonance image revealed a left 4 mm hypointense mass, with sphenoid sinus occupation by a hyperintense material. At repeated transsphenoidal surgery, sellar bone had a very hard consistency; surgery was complicated and the patient died. Sellar reossification negatively impacted surgery outcomes in this patient. While this entity is possible after transsphenoidal surgery, it remains unclear whether strontium ranelate could have affected sellar ossification. Learning points: Delayed puberty can be a manifestation of Cushing’s syndrome. A complete history, physical examination and appropriate work-up should be performed before initiating any treatment. Sellar reossification should always be taken into account when considering repeated transsphenoidal surgery. Detailed preoperative evaluation of bony structures by computed tomography ought to be performed in all cases of reoperation. We speculate if strontium ranelate may have affected bone mineralization at the sellar floor. We strongly recommend that indications for prescribing this drug should be carefully followed.

Download Full-text

Sellar Floor Reconstruction with Nasal Turbinate Tissue after Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Adenomas

min - Minimally Invasive Neurosurgery ◽

10.1055/s-2003-44453 ◽

2003 ◽

Vol 46 (5) ◽

pp. 289-292 ◽

Cited By ~ 19

Keyword(s):

Pituitary Adenomas ◽

Transsphenoidal Surgery ◽

Endoscopic Endonasal ◽

Nasal Turbinate ◽

Endoscopic Endonasal Transsphenoidal Surgery ◽

Sellar Floor

Download Full-text

CS-11 PITUITARY EPENDYMOMA: A CASE REPORT

Neuro-Oncology Advances ◽

10.1093/noajnl/vdz039.181 ◽

2019 ◽

Vol 1 (Supplement_2) ◽

pp. ii40-ii40

Author(s):

Tadateru Fukami ◽

Yayoi Yoshimura ◽

Ryoko Fujikawa ◽

Kazuhiko Nozaki

Keyword(s):

Pituitary Adenoma ◽

Transsphenoidal Surgery ◽

Residual Tumor ◽

Final Diagnosis ◽

Polyglycolic Acid ◽

Ophthalmological Examination ◽

Endoscopic Transsphenoidal Surgery ◽

Normal Pituitary Gland ◽

Field Of Vision ◽

Sellar Floor

Abstract INTRODUCTION Neoplasms of the sellar region generally includes pituitary adenoma, craniopharyngioma, meningioma. We report a case of pituitary ependymoma. CASE A 39 years-old man. He experienced the sense of discomfort of the inside upper part field of vision of the left eye for a few months since May, 201X. Ophthalmological examination showed right homonymous hemianopia of right upper 1/4. He was introduced to the department of neurosurgery of nearby hospital. MRI showed intrasellar tumor and the lesion was partially removed because of solidness by endoscopic transsphenoidal surgery on July, 201X. Postoperative pathological diagnosis was pituitary adenoma. The residual tumor was followed up, but the compression to the left optic nerve was not resolved. So he was introduced to our hospital in January, 201X+1 and endoscopic transsphenoidal surgery was performed on May, 201X+1. OPERATION Supposing the change to extended transsphenoidal surgery, we prepared rescue flap. Enlarging the window of sellar floor and removing the tuberculum sellae, the tumor was totally removed. The boundary between the tumor and the normal pituitary gland was obscure. We inserted fat piece to the intrasellar space, and reconstructed the sellar floor with the absorbable plate following fixation with a polyglycolic acid sheet, fibrin glue, and sinus balloon. PATHOLOGY Fusiform cells having an oval or a short spindle shape nucleus multiplied in strand and palisading pattern through capillary vessels were the main findings, and ependymal rosettes were confirmed. Immunohistchemical study showed chromograninA(focally+), synaptophysin (-), EMA (+, dot and ring pattern), CAM5.2(+), bcl-2(+), TTF-1(-), S100(focally+), GFAP(-). Final diagnosis was pituitary ependymoma. Mild diabetes insipidus was occurred postoperatively but it was controlled medically. Now he is followed up in outpatient department. DISCUSSION Pituitary ependymoma was reported only eight cases in the past literatures. Though it is extremely rare, pituitary ependymoma should be included as a differential diagnosis of the sellar tumors.

Download Full-text

Collagen Sponge Repair of Small Cerebrospinal Fluid Leaks Obviates Tissue Grafts and Cerebrospinal Fluid Diversion after Pituitary Surgery

Neurosurgery ◽

10.1097/00006123-200110000-00020 ◽

2001 ◽

Vol 49 (4) ◽

pp. 885-890 ◽

Cited By ~ 12

Author(s):

Daniel F. Kelly ◽

R. Jamshid Oskouian ◽

Igor Fineman

Keyword(s):

Cerebrospinal Fluid ◽

Transsphenoidal Surgery ◽

Collagen Sponge ◽

Fat Graft ◽

Csf Leak ◽

Tumor Removal ◽

Lumbar Drain ◽

Tissue Grafts ◽

Sellar Floor ◽

Csf Leaks

Abstract OBJECTIVE Repair of a cerebrospinal fluid (CSF) leak created at the time of transsphenoidal surgery typically involves placement of a fat, fascial, or muscle graft and sellar floor reconstruction. In this report, a simplified repair for small, “weeping” CSF leaks using collagen sponge is described. METHODS All patients underwent an endonasal transsphenoidal procedure using the operating microscope. At the completion of tumor removal, if a small CSF leak was noted but no obvious large arachnoidal defect was present, a piece of collagen sponge was fashioned to cover the exposed diaphragma sellae. Titanium mesh was then wedged into the intrasellar, extradural space and a larger piece of collagen was placed over the reconstructed sellar floor. Nasal packing was removed within 24 hours. RESULTS During an 18-month period, 62 consecutive transsphenoidal procedures were performed for tumor removal. Of 20 patients with a small CSF leak (18 pituitary adenomas, 1 Rathke's cleft cyst, and 1 chordoma), all had successful repair with collagen sponge. At follow-up examinations at 1 to 18 months, no patient had required a lumbar drain or had developed meningitis. One other patient had a large intraoperative arachnoidal defect that was unsuccessfully repaired with the collagen sponge technique; in this patient, a second operation was required with a fat graft, sellar floor reconstruction, and lumbar drainage. CONCLUSION A simplified repair of small CSF leaks after transsphenoidal surgery using a two-layered collagen sponge technique with sellar floor reinforcement is thought to be safe and effective and obviates the need for tissue grafts, fibrin glue, or lumbar drain placement.

Download Full-text