• CSF leak
• Pituitary adenoma
• Sellar tumors
• Skull base
• Transsphenoidal surgery

• Humans
• Neurosurgical Procedures/methods
• Sphenoid Bone/surgery

• Anterior
• Cranial fossa
• Endoscopic endonasal surgery
• Multilayer reconstruction
• Sinonasal malignancy
• Skull base
• Skull base reconstruction

• Humans
• Plastic Surgery Procedures
• Retrospective Studies
• Skull Base/diagnostic imaging
• Skull Base/surgery
• Endoscopy/methods
• Ribs/surgery

• Endonasal sphenoidal approach
• In situ bone flap
• Multilayer reconstruction
• Nasal septum mucosa flap
• Neuroendoscopy
• Skull base reconstruction

• Endoscopic
• Rathke cleft cyst
• Supraorbital
• Surgical outcome
• Surgical strategy

• Humans
• Retrospective Studies
• Hyponatremia
• Carcinoma, Renal Cell
• Diabetes Insipidus/complications
• Central Nervous System Cysts/surgery
• Central Nervous System Cysts/complications
• Kidney Neoplasms
• Treatment Outcome
• Pituitary Neoplasms/surgery
• Pituitary Neoplasms/complications

• PitNET
• complications
• endoscopic endonasal
• extended
• outcome
• pituitary adenoma
• transplanum
• transtuberculum

• endoscopic endonasal approach
• in situ bone flap
• pituitary adenoma
• post-operative CSF leakage
• post-operative hospital stays
• skull base reconstruction

Postoperative cerebrospinal fluid (CSF) leakage following endoscopic endonasal surgery (EES) is a frequent complication. This study aims to identify potential risk factors of postoperative CSF leakage.

A retrospective review of 360 patients who underwent EES was included. The associations between postoperative CSF leakage and patient demographics, medical history, tumor characteristics, and intraoperative repair techniques were analyzed; the diagnosis and repair of postoperative CSF leakage were also introduced.

Postoperative CSF leakage occurred in 14 patients (3.9%), 2 of them cured by lumbar cistern drainage, 12 underwent endoscopic repair. Among these 12 cases, 3 were repaired twice, and the rest were cured the first time. During the repair surgery, insufficient embedded fat was detected in one case detected, seven with breached inner artificial dura, three had vascularized pedicle nasoseptal flap (VP-NSF) displacement, two with VP-NSF perforation, two with VP-NSF inactivation, and one with imperfect adherence to VP-NSF to the skull base. Eight cases had intracranial infections. Excluding one case who died of severe intracranial infection, the rest were cured and discharged without obvious sequelae. Multivariate analysis revealed that the suprasellar lesion, subarachnoid invasion, and intraoperative grade 3 flow CSF leakage were the risk factors of CSF leakage after operation, while the bone flap was a protective factor.

Bone flap combined with VP-NSF and iodoform gauze for skull base reconstruction is recommended in high-risk patients, while postoperative lumbar cistern drain remains dispensable.

• National Natural Science Foundation of China
• the Key research and invention plan of Jiangxi Science and Technology Department

Cerebral spinal fluid (CSF) leak remains an important issue in endoscopic endonasal surgery (EES). A standard protocol for skull base closure has not yet been established, and the application of rigid buttress has not been given sufficient attention. To emphasize the functions of support and fixation from rigid buttress in reconstruction, we introduced the cruciate embedding fascia-bone flap (CEFB) technique using autologous bone graft to buttress the fascia lata attachment to the partially sutured skull base dural defect and evaluated its efficacy in a consecutive case series of grade II–III CSF leaks in EES.

Data from consecutive patients diagnosed with sellar region lesions with grade II–III CSF leaks during EES were collected from May 2015 to May 2020. Skull base reconstructions were performed with the CEFB or the conventional pedicle vascularized nasoseptal flap (PNSF). Related clinical data were analysed. The combined use of the CEFB and PNSF was applied to an additional supplemental case series of patients with grade III leak and multiple high-risk factors.

There were 110 and 65 patients included in the CEFB and PNSF groups, respectively. The CEFB demonstrated similar effects on the incidence of postoperative CSF leak (2.7%), intracranial infection (4.5%), and lumbar drainage (LD) placement (5.5%) as PNSF (3.1%, 3.1%, and 6.2%), but with less epistaxis (CEFB: 0%, PNSF: 6.2%) and nasal discomforts (CEFB: 0%, PNSF: 7.7%). The LD duration (CEFB: 6.67 ± 2.16 days, PNSF: 10.50 ± 2.38 days), bed-stay time (CEFB: 5.74 ± 1.58 days, PNSF: 8.83 ± 3.78 days) and hospitalization time (CEFB: 10.49 ± 5.51 days, PNSF: 13.58 ± 5.50 days) were shortened in the CEFB group. The combined use of CEFB and PNSF resulted in 0 postoperative CSF leaks in the supplemental case series of 23 highly susceptible patients.

This study suggested that the new CEFB technique has the potential to prevent postoperative CSF leak in EES. The results indicated that it can be used effectively without PNSF in suitable cases or applied in addition to a PNSF with high compatibility when necessary. Its effectiveness should be further verified with a larger cohort and better design in the next step.

Trial Registration Current Controlled Trials ChiCTR2100044764 (Chinese Clinical Trial Registry); date of registration: 27 March 2020. Retrospectively registered

• Bone flap
• CSF leak
• Endoscopic endonasal surgery
• Pedicle vascularized nasoseptal flap
• Skull base reconstruction

• CSF
• Cerebrospinal fluid
• Cerebrospinal fluid leak
• Cerebrospinal fluid rhinorrhoea
• Endoscopic endonasal
• Endoscopic transsphenoidal surgery
• Skull base surgery

• Cerebrospinal Fluid Leak/etiology
• Cerebrospinal Fluid Rhinorrhea
• Endoscopy
• Humans
• Postoperative Complications
• Retrospective Studies
• Skull Base/surgery
• Skull Base Neoplasms/surgery

• Wellcome Trust

Pilocytic astrocytomas (PAs) are World Health Organization (WHO) grade I tumors, which are relatively common, and are benign lesions in children. PAs could originate from the cerebellum, optic pathways, and third ventricular/hypothalamic region. Traditional various transcranial routes are used for hypothalamic PAs (HPAs). However, there are few studies on hypothalamic PAs treated through the endoscopic endonasal approach (EEA). This study reports the preliminary experience of the investigators and results with HPAs via expanded EEAs.

All patients with HPAs, undergone EEA in our hospital from 2017 to 2019, were retrospectively reviewed. The demographic data, clinical symptoms, complications, skull base reconstruction, prognosis, and endocrinological data were all recorded and analyzed in detail.

Finally, five female patients were enrolled. The average age of patients was 28.6 ± 14.0. All patients had complaints about their menstrual disorder. One patient had severe bilateral visual impairment. Furthermore, only one patient suffered from severe headache due to acute hydrocephalus, although there were four patients with headache or dizziness. Four cases achieved gross-total resection, and one patient achieved subtotal resection. Furthermore, there was visual improvement in one patient (case 5), and postoperative worsening of vision in one patient (case 4). However, only one patient had postoperative intracranial infection. None of the patients experienced a postoperative CSF leak, and in situ bone flap (ISBF) techniques were used for two cases for skull base repair. In particular, ISBF combined with free middle turbinate mucosal flap was used for case 5. After three years of follow-up, three patients are still alive, two patients had no neurological or visual symptoms, or tumor recurrence, and one patient had severe hypothalamic dysfunction. Unfortunately, one patient died of severe postoperative hypothalamus reaction, which presented with coma, high fever, diabetes insipidus, hypernatremia and intracranial infection. The other patient died of recurrent severe pancreatitis at one year after the operation.

Although the data is still very limited and preliminary, EEA provides a direct approach to HPAs with acceptable prognosis in terms of tumor resection, endocrinological and visual outcomes. ISBF technique is safe and reliable for skull base reconstruction.

• Endoscopic transnasal resection
• Hypothalamic
• In situ bone flap
• Pilocytic astrocytomas