Sellar repair with fibrin sealant and collagen fleece after endoscopic endonasal transsphenoidal surgery

OBJECTIVE: To determine, in patients undergoing sellar repair after endoscopic endonasal transsphenoidal surgery, the clinical efficacy of a combination of fibrin sealant/collagen fleece compared to the use of fibrin sealant or collagen fleece alone, in preventing CSF-related (cerebrospinal fluid) postoperative complications. METHODS: From a retrospective analysis of our series of 242 consecutive endoscopic transsphenoidal procedures, in 56 out of the 90 cases in which the sella had been repaired, fibrin sealant and/or collagen fleece was employed, both in combination with one or multiple layers of other materials. The incidence of postoperative CSF leaks and the need for a postoperative lumbar drainage in the groups of fibrin sealant or collagen fleece treated patients were compared to the group of patients treated with the fibrin sealant/collagen fleece combination. RESULTS: In 2 out of 16 fibrin sealant treated patients a postoperative CSF leak presented, and in 6 out of these 16 subjects a postoperative lumbar drainage was necessary; patients who received a fibrin sealant/collagen fleece combination exhibited no detectable postoperative CSF leak, and no postoperative lumbar drainage was used. CONCLUSIONS: Closure of the sella turcica with fibrin sealant in combination with a collagen fleece is a safe and effective method to prevent CSF fistulas. When used in combination, the collagen fleece enhances the sealing and tissue regeneration properties of the fibrin sealant, thus reducing the incidence of postoperative CSF leaks, obviating the need for a lumbar drain placement.     

BioGlue for prevention of postoperative cerebrospinal fluid leaks in transsphenoidal surgery: A case series

BACKGROUND: The efficacy of BioGlue (CryoLife, Inc, Atlanta, Ga) surgical adhesive in transsphenoidal surgery was assessed as an adjunct in the prevention of postoperative CSF leaks. METHODS: All patients in whom BioGlue was used for an intraoperative skull base reconstruction were retrospectively identified. Intraoperative CSF leaks were graded according to size (grade 1, small weeping leak without obvious diaphragmatic defect; grade 2, moderate leak with a definite diaphragmatic defect; grade 3, large diaphragmatic and/or dural defect). CSF leak repair was tailored to CSF leak grade. BioGlue was applied as a reinforcement over collagen sponge as the last layer of the repair. RESULTS: Over 28 months, a total of 282 patients underwent endonasal surgery. Of these patients, 124 (79 women; age range, 8-84 years), in 128 procedures, had an intraoperative CSF leak repair reinforced with BioGlue. Pathology included 80 pituitary adenomas, 11 craniopharyngiomas, 7 Rathke's cleft cysts, 6 chordomas, 5 meningiomas, 4 spontaneous CSF leaks, 3 arachnoid cysts, and 8 other parasellar pathologies. There were 62 (48.4%) grade 1, 41 (32.0%) grade 2, and 25 (19.5%) grade 3 leak repairs. The overall repair failure rate was 1.6% (2 cases), with the failures occurring in patients with grade 3 leaks, including 1 who developed meningitis; there was no failure of grades 1 and 2 leaks. The 2 failures were attributed largely to technical aspects of the repair rather than to failure of BioGlue per se. CONCLUSIONS: BioGlue appears to be an effective adjunct in preventing postoperative CSF leaks after transsphenoidal surgery. However, careful attention to technical details of the repair is still required to prevent failures, especially when closing large dural and diaphragmatic defects.     

Use of equine collagen foil as dura mater substitute in endoscopic endonasal transsphenoidal surgery

OBJECTIVE: This study describes the use of a novel collagen-based dural substitute in endoscopic endonasal transsphenoidal surgery. METHODS: Operative records were reviewed for a 12-month period for all patients who underwent surgery by means of an endoscopic endonasal transsphenoidal approach since we began using TissuDura (Baxter, Vienna, Austria) collagen-only dural substitute in January 2004. RESULTS: During the 12-month period evaluated, we performed an endoscopic endonasal transsphenoidal operation for a variety of pituitary lesions on 72 consecutive patients. Among these, 15 patients (20.8%) required the implant of the collagen foil. Nine patients (60%) presented an intraoperative CSF leak (3 small weeping of CSF and 6 larger leaks); in these cases, the TissuDura was used against the arachnoid membrane, followed by the other materials used for the repair. In 7 other subjects without any evidence of CSF escape, the collagen foil was used to protect and enforce the arachnoidal membrane descent into the sellar cavity to prevent its possible postoperative rupture and consequent CSF leak. Fibrin glue was used in all cases. A postoperative CSF leak with meningitis occurred in only 1 (6.7%) of the 15 subjects. The patient required a reoperation for CSF fistula repair and intravenous antibiotics. CONCLUSIONS: Even if based on a relatively small patient series, our experience demonstrated that the use of TissuDura in transsphenoidal surgery is safe and biocompatible, as compared with other dural substitutes.     

Acellular Dermal Allograft for Sellar Repair after Transsphenoidal Approach to Pituitary Adenomas

Objectives Our practice has transitioned from using fat autograft to acellular dermal matrix (AlloDerm, LifeCell Corp, Woodlands, Texas, USA). We present the largest series to our knowledge of AlloDerm for sellar floor repair after transsphenoidal approach to pituitary adenoma and compare rates of postoperative cerebrospinal fluid (CSF) leak with an earlier cohort of patients whose CSF leaks were repaired with fat autograft.Design This is a retrospective cohort study comparing sellar repair with fat autograft versus inlay Alloderm between the years 2003 and 2012. The primary end point was postoperative CSF leak.Results A total of 429 patients (368 primary; 83 revision operations) without intraoperative lumbar drainage were included. A total of 18 postoperative CSF leaks were observed (3.9%). Intraoperative CSF leak occurred in 160 cases (35.5%). Among this subset of patients with intraoperative CSF leak, 95 underwent repair with AlloDerm and 46 underwent repair with fat autograft, with postoperative CSF leak rates of 8.4% and 15.2%, respectively (p = 0.34, chi-square test); 19 patients underwent repair with other techniques or no repair at all, with postoperative leak rate of 0%.Conclusions AlloDerm is an effective alternative to fat autograft in cases of low-flow CSF leak following transsphenoidal resection of pituitary adenoma.     

Symptomatic Pneumocephalus after Transsphenoidal Surgery

Background

Symptomatic pneumocephalus after transsphenoidal surgery, though reported, is a rare phenomenon. We report three cases of pneumocephalus in a series of 300 transsphenoidal operations for sellar/suprasellar mass lesions done over the past 12 years.

Methods and Results

Three cases of symptomatic pneumocephalus occurring after transsphenoidal surgery are presented to illustrate the causative factors, methods of prevention, and management. In case 1, an intraoperative cerebrospinal fluid (CSF) leak occurred and drainage of CSF through a lumbar subarachnoid drain resulted in pneumocephalus, in spite of repair of the sellar floor. In case 2, partial excision of tumor and subsequent reduction of intracranial pressure due to a ventriculoperitoneal (VP) shunt led to pneumocephalus. In case 3, radiotherapy-induced shrinkage of a partially excised tumor resulted in pneumocephalus. The sellar floor had not been repaired in cases 2 and 3 as there was no intraoperative CSF leak and only a partial excision had been done. Conservative management failed in the two patients in whom it was tried. Repair of the sella and sphenoid sinus had to be done in all three cases.

Conclusions

Repair of the sellar floor should be done after a transsphenoidal approach in all cases, even when no intraoperative leak has been identified and only a partial excision of tumor has been done. Once pneumocephalus has occurred, the sellar floor and sphenoid sinus should be repaired early before reducing the intracranial pressure (ICP) by tapping ventricular air and draining or diverting CSF.     

Prolonged Jackson-Pratt drainage in the management of lumbar cerebrospinal fluid leaks

BACKGROUND: Cerebrospinal fluid (CSF) leak is a complication of spinal surgery. Intraoperative or postoperative identification of a CSF leak often results in wound healing complications, lumbar drain placement, and/or reoperation. These complications usually extend a patient's hospital stay, can be painful, and have their own associated risks. The authors describe a technique that may improve on traditional interventions by managing postoperative CSF leaks after lumbar instrumentation without an additional procedure or extended hospitalization. METHODS: A retrospective review of lumbar instrumentation cases performed by 5 attending surgeons from the Division of Neurosurgery, University of California at San Diego, was performed. In all, 184 charts were reviewed, spanning a 3-year period. There were 16 cases in which a dural tear and repair were carried out and subsequently treated with subfascial Jackson-Pratt (JP) drainage. Of those 16 cases, 8 patients were managed with prolonged JP drainage using the intraoperatively placed subfascial drain. Patients were discharged home on oral antibiotics according to the customary criteria with the JP drain in place and were instructed regarding proper drain maintenance. Jackson-Pratt drains were removed in clinic in a delayed fashion, approximately 10 to 17 days postoperatively. Patients were subsequently reevaluated at regular intervals for any persistent CSF leak. RESULTS: In the 8 cases reviewed, all patients were discharged in a time frame comparable to that of patients undergoing similar instrumentation in which no CSF leak was identified, or in whom a CSF leak was identified and repaired intraoperatively. No patients suffered complications arising from prolonged drain presence. No patients suffered from persistent CSF leak after drains were removed. CONCLUSION: Our study suggests that routine intraoperative subfascial JP drain placement aids in the early diagnosis of postoperative lumbar CSF leak. Primary closure of dural tear remains the standard of care. Furthermore, in select cases, prolonged JP drainage in the setting of postoperative CSF leak may be a useful technique for the treatment of these leaks.     

Sellar Reconstruction and Rates of Delayed Cerebrospinal Fluid Leak after Endoscopic Pituitary Surgery

Objectives Delayed cerebrospinal fluid (CSF) leaks are a complication in transsphenoidal surgery, potentially causing morbidity and longer hospital stays. Sella reconstruction can limit this complication, but is it necessary in all patients? Design Retrospective review. Setting Single-surgeon team (2005–2012) addresses this trend toward graded reconstruction. Participants A total of 264 consecutive patients with pituitary adenomas underwent endoscopic transsphenoidal resections. Sellar defects sizable to accommodate a fat graft were reconstructed. Main outcomes Delayed CSF leak and autograft harvesting. Results Overall, 235 (89%) had reconstruction with autograft (abdominal fat, septal bone/cartilage) and biological glue. Delayed CSF leak was 1.9%: 1.7%, and 3.4% for reconstructed and nonreconstructed sellar defects, respectively (p = 0.44). Complications included one reoperation for leak, two developed meningitis, and autograft harvesting resulted in abdominal hematoma in 0.9% and wound infection in 0.4%. Conclusion In our patients, delayed CSF leaks likely resulted from missed intraoperative CSF leaks or postoperative changes. Universal sellar reconstruction can preemptively treat missed leaks and provide a barrier for postoperative changes. When delayed CSF leaks occurred, sellar reconstruction often allowed for conservative treatment (i.e., lumbar drain) without repeat surgery. We found universal reconstruction provides a low risk of delayed CSF leak with minimal complications.     

Lumbar epidural blood patch to treat a large, symptomatic postsurgical cerebrospinal fluid leak of 5 weeks duration in a 3-year-old

A 3-yr-old with B-cell lymphoma presented with a 5-wk history of 400 mL/day cerebrospinal fluid (CSF) leak, which precluded chemotherapy, after placement of an Omaya reservoir and drain. Surgical repair was unsuccessful. Symptoms included irritability, failure to eat and noncommunication. After lumbar epidural blood patch with 7 mL the symptoms resolved immediately, allowing recommencement of chemotherapy. Epidural blood patch should be considered as possible early treatment for CSF leaks. IMPLICATIONS: An epidural blood patch successfully treated a large cerebrospinal fluid leak of long duration in a 3-yr-old. Considering the distress of such a leak to the patient, staff, and parents, epidural blood patch may be considered as an early treatment option.     

Management of intra-operative cerebrospinal fluid leak in transnasal transsphenoidal pituitary microsurgery: use of post-operative lumbar drain and sellar reconstruction without fat packing

Summary Background. This study aims at describing primary reconstruction of sella turcica using lyophilized dura graft and fibrin glue without fat packing of the sphenoid sinus, together with postoperative lumbar drain in the management of intraoperative cerebrospinal fluid (CSF) leak. Method. Records of 127 consecutive patients undergoing 129 transnasal transsphenoidal procedures were reviewed retrospectively with respect to intra- and post-operative CSF leak and lumbar drain use. One hundred and ten patients had adenomas (60 secreting adenomas, 48 non-functioning), 10 Rathke’s cleft cysts and 9 miscellaneous lesions. Findings. Intra-operative leak was detected in 43 (33.3%) of 129 procedures: 38 (34.5%) of 110 adenoma related procedures and 5 (26.3%) of 19 non-adenomas. Among adenomas, leak occurred in 35 (41.2%) of 85 patients with suprasellar extension (SSE) and in 3 (12%) of 25 without SSE (p = 0.007). Lumbar drain was used in 61 cases (47.3%): in 34 it was inserted immediately before and in 27 at the end of procedure. In 24 of 34 patients (70.6%) with pre-operative drain (all adenomas), saline infusion was used to mobilize SSE. Only 2 patients (1.6%) developed post-operative leak, requiring an endoscopic procedure with fascia and muscle obliteration of the sphenoid sinus. Conclusions. Meticulous duroplasty and routine postoperative lumbar drain has shown satisfactory results in dealing with intra-operative CSF leaks. It compares favorably with other techniques and obviates the need for fat harvesting. In patients with SSE, where leak occurs more frequently, we recommend inserting the lumbar drain before the procedure. As an adjunctive benefit, this allows for the saline-infusion method to mobilize the SSE without producing the venous engorgement of the Valsalva maneuver.     

Low-grade CSF leaks in endoscopic trans-sphenoidal pituitary surgery: efficacy of a simple and fully synthetic repair with a hydrogel sealant

Background

Intra-operative CSF leak during endoscopic trans-sphenoidal surgery is not uncommon. Surgical repair with a variety of autologous grafts, rigid buttresses and CSF diversion techniques that add time and complexity have been reported.

Objective

To describe a simple and purely synthetic closure for low-grade CSF leaks following endoscopic trans-sphenoidal pituitary surgery.

Methods

A retrospective review of all endoscopic trans-sphenoidal surgery undertaken for pituitary pathology between 2005 and 2010 was carried out. The grade of CSF leak and success of graded repair was noted. Patients with no CSF leak (grade 0) had gelatin sponge placed in the tumour cavity. In those with low-grade CSF leak through small arachnoid defects (grade 1), repair was carried out using gelatin sponge and hydrogel sealant overlay. CSF diversion was not employed for low-grade CSF leaks.

Results

Of the 255 endoscopic trans-sphenoidal surgeries, 158 (62%) had no leak (grade 0) and 74 (29%) had a low-grade leak (grade 1). Repairs in all cases were of grade 0, and all but two cases of grade 1 CSF leak were successful at a mean follow-up of 29?months. The 2 (2.7%) post-operative CSF leaks were seen within 6?weeks of surgery. Both cases were related to bouts of sneezing and were repaired using further trans-sphenoidal surgery and/or lumbar CSF diversion.

Conclusions

A simple purely synthetic repair of low-grade CSF leaks is described. This repair is safe and comparable in efficacy whilst avoiding the morbidity related to more complex sellar reconstructions previously described.     

颈椎手术并发脑脊液漏的处理

目的 探讨颈椎手术并发脑脊液漏（CSFL）的处理方法及其疗效。方法 对11例颈椎手术并发CSFL的患者，后路手术采用自体筋膜修补2例，前路手术采用自体筋膜明胶海绵堵塞9例，手术后仍存在CSFL患者采取去枕头高足低位、延长脱水剂应用时间、行腰穿蛛网膜下腔引流。结果 2例后路手术CSFL患者修补成功。9例前路行硬膜堵塞患者4例仍有CSFL，行腰穿蛛网膜下腔引流，切口引流或漏出0—3d停止．切口在引流后7d拆线均愈合。结论 CSFL术中采用修补或堵塞硬膜破口术后采用头高足低位、延长脱水剂应用时间可减少手术后CSFL的发生；术后持续腰穿蛛网膜下腔引流，能有效终止切口内CSFL，有利于切口愈合，避免感染发生。     

Risk factors of cerebrospinal fluid rhinorrhea following transsphenoidal surgery

Summary Objective. Cerebrospinal fluid (CSF) rhinorrhea is a potentially life-threatening complication following transsphenoidal surgery (TSS). Methods. To elucidate the risk factors that may affect the incidence of postoperative CSF rhinorrhea, we retrospectively reviewed 200 consecutive cases of TSS performed by a single surgeon for 168 adenomas and 32 other sellar and parasellar lesions. Results. Intra-operative CSF leakage was encountered in 38 cases (19.0%). Its incidence did not correlate to tumor size. Among 4 microadenoma cases with CSF leak, 3 were ACTH adenomas. In contrast, postoperative CSF rhinorrhea was observed in 5 cases (2.5%), all following TSS for adenomas. It was frequently noted in cases with prior TSS (3/40, 7.5%, p = 0.0235) and prior radiotherapy (2/7, 28.6%, p<0.0001). Two cases who required surgical intervention had received TSS and radiotherapy previously. Conclusion. The risk of postoperative CSF rhinorrhea is significantly increased in cases with prior TSS or radiotherapy or both. In addition, these cases tended to show delayed CSF leaks and require sellar reconstruction for its treatment. When a CSF leak was encountered during TSS in these high-risk cases, thorough sellar reconstruction and long-term follow-up is necessary.     

Delayed cerebrospinal fluid leakage 10 years after transsphenoidal surgery and gamma knife surgery - case report -

A 38-year-old woman presented with repeated episodes of meningitis. She had undergone transsphenoidal tumor removal followed by gamma knife irradiation in 1994. Complete remission was achieved. Intermittent cerebrospinal fluid (CSF) leakage began in 2004, and transsphenoidal surgery was performed for direct repair of the skull base defect. Operative findings showed that the sellar floor was uncovered, and CSF continuously escaped through the cyanoacrylate polymer framework of the previous repair. Reconstruction used autologous muscle pieces and cyanoacrylate polymer adhesive. The CSF leakage was presumably due to delayed radiation damage to the mucous membrane of the skull base. Several methods for reconstruction of the sellar floor have been proposed, which all rely on tissue regeneration including the arachnoid, dura mater, and mucus membrane of the sphenoidal sinus. Preservation of the arachnoid membrane and minimizing removal of the mucous membrane are essential, especially if postoperative irradiation is anticipated.     

Cerebrospinal fluid pressure monitoring after repair of cerebrospinal fluid leaks.

OBJECTIVE: To measure intracranial pressures (ICPs) via lumbar drains after surgical repair of cerebrospinal fluid (CSF) leaks. METHODS: We conducted a retrospective review of ICP measurements through lumbar drains during the immediate postoperative period after CSF leak repair. RESULTS: Eight patients with spontaneous CSF leaks underwent surgery and postoperative CSF pressures were measured via lumbar drains. ICP was elevated in 7/8 patients (mean, 32.5 cm H(2)O). Diuretics reduced ICP (mean, 10 cm H(2)O). Three traumatic CSF leaks patients served as controls (mean, ICP 14 cm H(2)O). CONCLUSION: Measurement of ICP through lumbar drains provides important information regarding the pathophysiology of CSF leaks that has an impact on subsequent medical and surgical treatment. Although the precise cause and mechanism of spontaneous CSF leaks are not fully understood, this study indicates that elevated ICP plays a role and that further medical or surgical treatment to correct the intracranial hypertension may be warranted.     

Cerebrospinal fluid rhinorrhea following endocopic trans-sphenoidal pituitary surgery: Experience from 337 patients

IntroductionCerebrospinal fluid (CSF) leak is a frequent complication after trans-sphenoidal pituitary surgery. We try to determine the incidence, risk factors, diagnostic procedures, and management of CSF leaks following trans-sphenoidal pituitary macroadenoma surgery.MethodsA retrospective analysis of 337 patients data.ResultsPostoperative CSF leaks occurred in 11 patients (3,1%). Ten patients had to be reoperated. Three patients had meningitis. Intraoperative CSF leak is the only significant predictive factor of postoperative CSF leak. Revision surgery, wide opening of the sella turcica and insufficient reconstruction of the sellar floor also seem to play a role (for six cases of postoperative CSF leak, the closure material had been excluded).ConclusionPrevention of the postoperative CSF leak needs screening of intra-operative CSF leak. The strength of the sellar floor is essential in order to avoid the ejection of the closure material, related to the intracranial pression.     

Endoscopic repair of cerebrospinal fluid rhinorrhea.

Endoscopic repair of cerebrospinal fluid rhinorrhea is a promising alternative to traditional repair techniques. This article reports our experience with 21 cases (10 spontaneous, 8 iatrogenic, and 3 traumatic). Various diagnostic radiographic modalities were used, including computer-aided techniques. Most repairs were accomplished with a free fascial graft positioned in the epidural space. Postoperative lumbar drainage was used in 15 cases. Initial repair was successful in 18 cases (85.7%). In all 3 failures, the surgeon had difficulty with proper graft placement. Additionally, 2 of these cases were confounded by early inadvertent removal of the lumbar drain. All patients in whom the procedure failed underwent a second successful endoscopic repair. There were no major complications. In our experience endoscopic repair of cerebrospinal fluid rhinorrhea is a safe and effective approach that can be improved with computer-aided localization devices. Proper graft placement is critical, and lumbar drainage is an important adjunct in selected cases.     

Endoscopic cerebrospinal fluid rhinorrhea repair: Is a lumbar drain necessary?

OBJECTIVES: To determine the necessity for lumbar drains during endoscopic cerebrospinal fluid (CSF) rhinorrhea repair. METHODS: Thirty-three patients underwent endoscopic repair of CSF rhinorrhea without a lumbar drain during a 7-year period. The size of the dural defect ranged from a microleak (less than 1 mm dural defect) to a 3-cm dural defect of the anterior skull base. RESULTS: All of the procedures in patients with smaller defects (<5 mm) were performed on an outpatient basis. Thirty-two patients (97%) had complete resolution of their CSF leak after 1 procedure without any recurrence (average follow-up 29 months). CONCLUSION: A lumbar drain is not routinely necessary for successful closure of CSF rhinorrhea of any size. Smaller dural defects may be safely performed on an outpatient basis without complications.     

Sellar floor reconstruction after transsphenoidal surgery using fibrin glue without grafting or implants: technical note

BACKGROUND: Different techniques have already been described for reconstructing the sellar floor after transsphenoidal (TS) procedures. This paper reports on the use of fibrin glue alone without grafting or the use of implants in the reconstruction of the sellar floor after TS. METHODS: Five hundred sixty-seven patients who submitted to TS for pituitary and sellar region tumors were studied. No intraoperative cerebrospinal fluid (CSF) leak occurred in 503 patients (group 1); in the remaining 64 patients (group 2), intraoperative CSF leak was noted. In group 1 patients, closure of the sellar floor consisted of packing the surgical bed with hemostatic material only. When CSF leak was noted, the surgical bed was covered with a layer of hemostatic material and the intrasellar space was filled up with fibrin glue. An additional layer of hemostatic material was added at the topography of the preexisting sellar floor, and a second amount of fibrin glue was applied over it. At the end of surgery, a continuous lumbar CSF drainage system was installed in group 2 patients and kept for 5 days. Prophylactic antibiotics were administered during this period. RESULTS: We did not observe delayed CSF leak, meningitis, or visual loss in group 1 patients. In group 2, 2 patients presented with complications: 1 patient got meningitis but no overt CSF leak, and the other disclosed a delayed postoperative leak treated by reoperation. DISCUSSION: Our results showed that closure of the sellar floor with hemostatic material and fibrin glue without grafting or the use of implants is a safe and efficient method to prevent postoperative complications after TS. Generally speaking, there is no need for grafting or the use of implants at the end of TS.     

Sellar repair with resorbable polyglactin acid sheet and fibrin glue in endoscopic endonasal transsphenoidal surgery

BACKGROUND: Cerebrospinal fluid leakage after transsphenoidal surgery represents a serious problem. Various methods to prevent postoperative CSF leakage are available, but immediate and tight dural closure is still difficult. The efficacy of a novel sellar repair was described. METHODS: The sellar repair using absorbable PGA sheet and fibrin glue was applied to 18 consecutive patients with sellar tumors that include 13 pituitary adenomas, 2 craniopharyngiomas, 2 Rathke's cleft cysts, and 1 meningioma within 135 patients who were treated with endoscopic endonasal transsphenoidal approach. The reaction speed and strength between PGA sheets and fibrin glue were examined in vitro. RESULTS: Polyglactin acid sheets were adhered to the rabbit skin with fibrin glue within 3 minutes and withstood a pressure of more than 220 mm Hg. Postoperative CSF leakage of the patients was not observed in any patients, and excellent adhesion of the PGA sheets to surrounding mucosa was estimated by endoscopic observation after the surgery. CONCLUSIONS: Repair of the sellar floor with PGA sheet and fibrin glue is a safe and effective method to prevent postoperative CSF leakage, which decreases the necessity for lumbar drainage after the operation.     

Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract: predictors of success.

INTRODUCTION: Cerebrospinal fluid (CSF) leaks may arise as a complication of endoscopic sinus surgery, trauma, or hydrocephalus, or they may occur spontaneously without any identifiable cause. Despite general agreement that CSF leaks should not be left untreated, their initial management, the surgical indications, and the technique of repair are controversial. OBJECTIVE: We undertook this study to ascertain whether a particular surgical technique or material was more successful for repair. Additionally, we tried to identify which specific characteristics of the patient, the CSF fistula, or the adjunctive treatment influenced the result of the repair. Study Design: We completed a retrospective review of all patients undergoing endoscopic repair of a CSF leak at our academic hospitals. RESULTS: Forty-eight patients with 53 CSF fistulas were included in the study. Fifty sites were successfully repaired endoscopically on the first attempt. Three persistent leaks were repaired successfully on the second attempt. Location and size of the leak, cause, technique, and choice of material used for the repair did not significantly affect surgical outcome. However, the presence of hydrocephalus had a statistically significant negative influence on surgical outcome. All patients with increased intraventricular pressure required a ventricular shunt in addition to a second endoscopic repair. CONCLUSION: If the surgical technique is sound, endoscopic repair of CSF leaks is highly successful, independent of the choice of the material and technique used in the repair.