Cerebrospinal fluid fistula after endoscopic skull base surgery prevention

Monitoring of complications after endoscopic skull base surgery is necessary in order to standardize protocols of management and improve our surgical techniques. The presence of late-onset complications underlines the need of a special focus in postoperative care and follow-up 1)

With a suitable technical background and appropriate endoscopic skills, the surgeries of the anterior skull base cerebrospinal fluid fistulas can be performed efficiently and with a low complication rate 2).

Cerebrospinal fluid leakage after endoscopic skull base surgery remains a challenge despite multilayer reconstruction including nasoseptal flap (NSF) has become a standard technique.

Techniques to prevent postoperative cerebrospinal fluid fistula remain controversial in transsphenoidal surgery. Although direct repair of cerebrospinal fluid fistula by primary suture or patch grafting is the most desirable management, conventional stitching is extremely difficult, particularly through an endonasal route with a deep and narrow surgical corridor. To obliterate a CSF fistula, packing of autologous grafts and/or bioabsorbable materials into the sella turcica and the sphenoid sinus has generally been employed with or without postoperative CSF lumbar drainage.

Kassam et al indicated that one of the most common causes of failure in reconstruction for CSF leakage is migration of the graft by stretching under pressure of neighboring tissue or CSF, and this event might occur early in the wound-healing phase before generating a biological seal. They reported that use of the balloon to apply pressure on the graft within the sphenoid sinus was highly effective to prevent graft migration 3).

The U-clip anastomotic device (Medtronic, Minneapolis, MN) has been used for endoscopic suturing to fix a graft patch through an endonasal route 4).

The AnastoClip Vessel Closure System (VCS; LeMaitre Vascular, Boston, MA) is an automatic suture device originally invented for microsurgical vascular reconstruction 5). It was used for closure of a CSF fistula in endonasal transsphenoidal surgery. In all four patients, CSF leakage was successfully obliterated primarily with two to five clips. There was no postoperative CSF rhinorrhea or complications related to the use of the VCS. Metal artifact by the clips on postoperative images was tolerable. Primary closure of the fistula using the VCS was an effective strategy to prevent postoperative CSF leakage in transsphenoidal surgery. Future application can be expanded to reconstruction of the skull base dura via endonasal skull base approaches 6).

Jamshidi et al. demonstrated that a high-volume LP, followed by acetazolamide therapy for 10 days, can be considered in the management of post-operative CSF leaks 7).

Among patients undergoing intradural EES judged to be at high risk for CSF leak as defined by the study's inclusion criteria, perioperative lumbar drainage used in the context of vascularized nasoseptal flap closure significantly reduced the rate of postoperative CSF leaks. Clinical trial registration no.: NCT03163134 (clinicaltrials.gov) 8).

Injectable hydroxyapatite (HXA) has shown promising results in preventing CSF leakage.

Hong et al. aimed to validate the efficacy of HXA-based skull base reconstruction performed by less-experienced neurosurgeons who had short-term clinical experiences as independent surgeons. Between March 2018 and November 2022, 41 patients who experienced intraoperative high-flow CSF leakage following endoscopic endonasal surgery at two independent tertiary institutions were enrolled. Skull base reconstruction was performed using conventional multilayer techniques combined with or without HXA. The primary outcome was postoperative CSF leakage. The surgical steps and nuances were described in detail. The most common pathology was craniopharyngioma. Injectable HXA was used in 22 patients (HXA group) and conventional techniques were performed in 19 patients (control group). The HXA group achieved a significantly lower incidence of postoperative CSF leakage than the control group (0% vs. 26.3%, p = 0.016). No HXA-related complications were observed. The use of injectable HXA in skull base reconstruction was highly effective and safe. This technique and its favorable results might be readily reproduced by less-experienced neurosurgeons 9).

Constantinidis J, Konstantinidis I. Avoiding complications in endoscopic skull base surgery. Curr Opin Otolaryngol Head Neck Surg. 2017 Feb;25(1):79-85. doi: 10.1097/MOO.0000000000000327. PMID: 28027059.
Kassam A, Carrau RL, Snyderman CH, Gardner P, Mintz A. Evolution of reconstructive techniques following endoscopic expanded endonasal approaches. Neurosurg Focus. 2005 Jul 15;19(1):E8. PMID: 16078822.
Gardner P, Kassam A, Snyderman C, Mintz A, Carrau R, Moossy JJ. Endoscopic endonasal suturing of dural reconstruction grafts: a novel application of the U-Clip technology. Technical note. J Neurosurg. 2008 Feb;108(2):395-400. doi: 10.3171/JNS/2008/108/2/0395. PMID: 18240941.
Kirsch WM, Zhu YH, Hardesty RA, Chapolini R. A new method for microvascular anastomosis: report of experimental and clinical research. Am Surg. 1992 Dec;58(12):722-7. PMID: 1456593.
Kobayashi H, Asaoka K, Terasaka S, Murata JI. Primary closure of a cerebrospinal fluid fistula by nonpenetrating titanium clips in endoscopic endonasal transsphenoidal surgery: technical note. Skull Base. 2011 Jan;21(1):47-52. doi: 10.1055/s-0030-1263281. PMID: 22451799; PMCID: PMC3312411.
Jamshidi AM, Shah A, Eichberg DG, Komotar RJ, Ivan M. Conservative Management of Post-Operative Cerebrospinal Fluid Leak following Skull Base Surgery: A Pilot Study. Brain Sci. 2022 Jan 24;12(2):152. doi: 10.3390/brainsci12020152. PMID: 35203915; PMCID: PMC8870023.
Zwagerman NT, Wang EW, Shin SS, Chang YF, Fernandez-Miranda JC, Snyderman CH, Gardner PA. Does lumbar drainage reduce postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery? A prospective, randomized controlled trial. J Neurosurg. 2018 Oct 1:1-7. doi: 10.3171/2018.4.JNS172447. Epub ahead of print. PMID: 30485224.
Hong I, Kim KH, Seo Y, Choo YH, Lee HJ, Kim SH. Efficacy of hydroxyapatite-based skull base reconstruction for intraoperative high-flow cerebrospinal fluid leakage performed by less-experienced surgeons. Sci Rep. 2023 Sep 9;13(1):14886. doi: 10.1038/s41598-023-42097-y. PMID: 37689766.
  • cerebrospinal_fluid_fistula_after_endoscopic_skull_base_surgery_prevention.txt
  • Last modified: 2023/09/10 15:42
  • by administrador