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Snyder R, Rubino F, Seaman S, Banu M, Su SY, Hanna EY, DeMonte F, Raza SM. Impact of Previous Surgery and/or Radiation Therapy on Endoscopic Reconstruction Outcomes. Oper Neurosurg (Hagerstown) 2025; 28:496-505. [PMID: 39185868 DOI: 10.1227/ons.0000000000001318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 07/04/2024] [Indexed: 08/27/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The impact of prior local therapies, including radiation and surgery, on reconstruction outcomes after endonasal surgery is currently not well known. Reconstruction nuances in the preoperative setting merit further evaluation to avoid potential postoperative complications that can hinder overall tumor management and negatively impact patient outcome. We sought to determine whether prior treatments increase risk of reconstruction-related postoperative morbidity and to evaluate the effectiveness of our current treatment paradigm for skull base reconstruction. METHODS A retrospective review of all endonasal surgeries for tumor resection between March 2000 and March 2022 was performed. Patients were grouped based on treatment history. Patient demographics, operative, and postoperative reconstruction-related morbidity data were collected, including cerebrospinal fluid leak, sinonasal morbidity, and infectious complications. Variables significantly associated with postoperative complications in the univariate analysis were included in the multivariate Cox proportional hazards regression model. Complication-free survival curves were generated, and the log-rank test evaluated the relationship between complication-free survival and the different clinical, surgical, and treatment parameters. All statistical analyses were performed with SPSS 26 (IBM Corp) and Graph Pad 9.0 (GraphPad Software). RESULTS A total of 418 patients were included. 291 patients had no prior treatments, 49 patients had previously received radiation, and 78 patients had prior surgeries. Of the 49 patients who had prior radiation, 27% underwent reconstruction with tunneled pericranial flaps vs 16% of treatment-naïve patients. On multivariate analysis, prior treatment was not significantly associated with reconstruction-related complications. Negative smoking history, no leak or small intraoperative leak, and use of vascularized flap in reconstruction were protective factors. CONCLUSION In patients undergoing endonasal surgery, prior radiation and/or surgery does not appear to significantly increase the risk of immediate or delayed reconstruction complications using our current reconstructive management plan, which incorporates an upfront regional flap for high-risk cases.
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Affiliation(s)
- Rita Snyder
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston , Texas , USA
| | - Franco Rubino
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston , Texas , USA
| | - Scott Seaman
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston , Texas , USA
| | - Matei Banu
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston , Texas , USA
| | - Shirley Y Su
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston , Texas , USA
| | - Ehab Y Hanna
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston , Texas , USA
| | - Franco DeMonte
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston , Texas , USA
| | - Shaan M Raza
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston , Texas , USA
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Suárez M, Gomar-Alba M, Villalonga JF, Alonso P, Baldoncini M, Campero A. Anatomy of the sellar barrier: From magnetic resonance imaging to the operating room. J Clin Neurosci 2025; 135:111170. [PMID: 40080963 DOI: 10.1016/j.jocn.2025.111170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2025] [Revised: 02/28/2025] [Accepted: 03/05/2025] [Indexed: 03/15/2025]
Abstract
BACKGROUND The sellar barrier concept concerns the correlation between the components of the pituitary fossa roof and the risk of intraoperative cerebrospinal fluid (CSF) leak during pituitary tumor surgery. Our team previously classified the sellar barrier according to its thickness on contrast-enhanced T1-weighted magnetic resonance imaging (MRI) sections into three subtypes: strong, mixed or weak. The purpose of this study is to complement the preoperative analysis of the sellar barrier with T2-weighted MRI sections to enhance our knowledge of the anatomical configuration of the sellar barrier and its correlation with the intraoperative findings. METHOD A retrospective descriptive study was performed in which medical records, neuroimaging and surgical videos of patients undergoing endoscopic endonasal surgery for pituitary tumors from January 2021 to January 2024 were reviewed. In all cases, the anatomy of the sellar barrier was evaluated by an expert neuroradiologist using pre-surgical T1-weighted MRI with gadolinium and T2-weighted images with sagittal and coronal cuts. Subsequently, the anatomical structures of the sellar barrier were compared with the direct endoscopic view observed in the operating room. RESULTS A total of 108 patients were included in this study. According to the preoperative neuroimaging findings, an experienced neuroradiologist classified the type of sellar barrier as strong, mixed or weak. Additionally, the T2-weighted imaging study was systematically implemented to identify the anatomical components of the sellar barrier. We found a high correlation between the preoperative neuroimaging description and the intraoperative endoscopic view of the sellar barrier. We present eight illustrative cases herein. CONCLUSIONS The use of T2-weighted sequences in conjunction with gadolinium-enhanced T1-weighted images enhances the preoperative knowledge of the sellar barrier by discriminating its anatomical components with high precision. As in any neurosurgical procedure, a detailed preoperative neuroimaging study and evaluation is highly recommended in order to offer the best possible treatment to our patients affected by pituitary tumors.
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Affiliation(s)
- Mauro Suárez
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina
| | - Mario Gomar-Alba
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina; Department of Neurosurgery, Hospital Universitario Torrecárdenas, Almería. Spain.
| | - Juan F Villalonga
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina
| | - Paula Alonso
- Coordinación Neuroimágenes Resonancia Magnética, Diagnósticos Gamma, San Miguel de Tucumán, Argentina
| | - Matías Baldoncini
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina
| | - Alvaro Campero
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina; Servicio de Neurocirugía Hospital Padilla, Tucumán, Argentina
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Snyder R, Lee S, Athukuri P, Ngo EMT, Fox MG, Fakhri S, Takashima M, Force BK, Samson SL, Gallagher KK, Yoshor D, Jalali A. Epidural Interlay Graft for Pituitary Surgery: A 4-Year Institutional Experience. J Neurol Surg B Skull Base 2024; 85:e10-e15. [PMID: 39444773 PMCID: PMC11495900 DOI: 10.1055/a-2175-8181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/12/2023] [Indexed: 10/25/2024] Open
Abstract
Objective Sellar repair techniques with varying complexity and effectiveness have been employed to reduce the incidence of postoperative cerebrospinal fluid (CSF) leaks following endoscopic transsphenoidal pituitary surgery. This study describes our institutional experience with a minimalistic, highly effective approach to sellar repair. Methods The authors performed a retrospective review of consecutive cases of transsphenoidal pituitary surgery performed at our institution. All included subjects underwent sellar repair with an epidural interlay graft. Relationships between patient and tumor characteristics, incidence of CSF leak, adjunct repair techniques, and endocrine outcomes were examined. Results Three hundred and thirty-four (334) cases were included. Intraoperative CSF leak was encountered in 116 cases (34.7%), and postoperative CSF leak occurred only once (0.3%) early in the series. Seventy intraoperative CSF leaks were successfully repaired with an epidural interlay alone, including 13 high-flow leaks. Our rate of fat graft use (1.2%), nasoseptal flap (3.0%), and lumbar drain placement (6.6%) in the second half of the series showed a significant decline compared with the first half, indicating increased reliance on the interlay graft over time. Our 65% functional macroadenoma remission rate compares favorably with large historical series. Conclusion Simple sellar repair using an epidural interlay graft is highly effective in preventing postoperative CSF leaks, including cases of high-flow intraoperative leaks. More complex repair techniques are reserved for select high-risk cases or those with inadequate sellar bony ledges. With this technique, there has been no postoperative CSF leak at our institution in over 300 consecutive transsphenoidal pituitary surgeries.
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Affiliation(s)
- Rita Snyder
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
| | - Sungho Lee
- Department of Neurosurgery, Louisiana State University, Shreveport, Luisiana, United States
| | - Prazwal Athukuri
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
| | | | - Meha Goyal Fox
- Department of Otolaryngology, Baylor College of Medicine, Houston, Texas, United States
| | - Samer Fakhri
- Section of Otolaryngology, Kelsey-Seybold Clinic, Houston, Texas, United States
| | - Masayoshi Takashima
- Department of Otolaryngology, Houston Methodist, Houston, Texas, United States
| | - Bahar Kapoor Force
- Department of Medicine, Baylor College of Medicine, Houston, Texas, United States
| | - Susan Leanne Samson
- Departments of Medicine and Neurological Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | | | - Daniel Yoshor
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Ali Jalali
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
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Sarkar S, Corrales CE, Laws ER, Smith TR. Intrasellar Arachnoid Diverticulae as a Risk Factor for Intraoperative Cerebrospinal Fluid Leakage in Patients Undergoing Endoscopic Transsphenoidal Surgery. Oper Neurosurg (Hagerstown) 2024; 27:180-186. [PMID: 38329346 DOI: 10.1227/ons.0000000000001079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/19/2023] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Intrasellar arachnoid diverticulae can often be identified on preoperative imaging in patients undergoing endoscopic transsphenoidal surgery. The objective of this study was to characterize arachnoid diverticulae both qualitatively and quantitatively in a large institutional cohort of patients with pituitary tumors and to evaluate its association with intraoperative cerebrospinal fluid (CSF) leak. METHODS Preoperative imaging studies of 530 patients who underwent primary endoscopic transsphenoidal resection of pituitary tumors were examined both quantitatively and qualitatively for the presence of an intrasellar arachnoid diverticulum. A matched cohort analysis was performed to compare patients with a "significant" (>50% sellar depth) diverticulum with those with nonsignificant/no diverticulum. Morphologically, diverticulae were separately classified as Type 1 (ventral CSF cleft with no tumor/gland tissue between sellar face and infundibulum) or Type 2 (central CSF cleft with tumor/gland tissue between sellar face and infundibulum). RESULTS Arachnoid diverticulae were noted in 40.2% of cases, and diverticulum depth was linearly correlated with tumor size and body mass index. A significant diverticulum was identified in 66 cases (12.5%) and was significantly associated with the functional tumor subtype ( P = .005) and intraoperative CSF leak ( P < .001). Type 1 clefts were associated with nonfunctional pathology ( P = .034) and the presence of suprasellar extension ( P = .035) and tended to be deeper than Type 2 clefts ( P < .001), with a higher incidence of intraoperative CSF leak ( P = .093). On logistic regression analysis, only the presence of a significant diverticulum was independently associated with intraoperative CSF leak (odds ratio 4.545; 95% CI 2.418-8.544; P < .001). CONCLUSION The presence of an intrasellar arachnoid diverticulum should alert the surgeon to an elevated risk of intraoperative CSF leak during transsphenoidal surgery for pituitary tumors. A relatively limited surgical exposure tailored to the craniocaudal extent of the sellar pathology should be considered in these patients.
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Affiliation(s)
- Sauradeep Sarkar
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston , Massachusetts , USA
- Computatonal Neuroscience Outcomes Center, Harvard Medical School, Boston , Massachusetts , USA
| | - C Eduardo Corrales
- Department of Otolaryngology, Head and Neck Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston , Massachusetts , USA
| | - Edward R Laws
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston , Massachusetts , USA
| | - Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston , Massachusetts , USA
- Computatonal Neuroscience Outcomes Center, Harvard Medical School, Boston , Massachusetts , USA
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Devarajan A, Vasan V, Dullea JT, Zhang JY, Vasa D, Schupper AJ, Nichols N, Ranti D, McCarthy L, Rao M, Sudhir S, Cho L, Rutland JW, Post KD, Bederson J, Shrivastava RK. Clinical and Operative Risk Factors Associated With Prolonged Length of Stay After Endoscopic Pituitary Adenoma Resection. Neurosurgery 2024; 95:392-399. [PMID: 38421190 DOI: 10.1227/neu.0000000000002890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 01/04/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Pituitary adenomas (PAs) are the most common intrasellar tumor. Clinically relevant adenomas have a prevalence of 1 per 1000 in the general population. Transsphenoidal surgery (TSS) is the most common surgical treatment and is the first-line management for most PAs. Most patients fare well postoperatively, but a subset of patients experience a prolonged length of stay (PLOS). In this article, we aim to identify demographic and clinical factors associated with PLOS after TSS for PA. METHODS Patients with sellar pathologies surgically treated at a single tertiary center from March 1, 2009, to May 31, 2020, were retrospectively reviewed. All patients older than 18 years receiving nonemergent endoscopic TSS for pituitary adenoma were included. Clinical and demographic characteristics were analyzed using χ 2 -tests and student t -tests. For those factors with a P -value less than .01, multivariate logistic regression and negative binomial regression models were constructed to estimate the adjusted odds of PLOS across predictive factors. RESULTS A total of 301 patients were included in the study. This cohort had an average age of 54.65 ± 15.06 years and an average body mass index of 29.47 ± 6.69. The median length of stay was 54.9 hours [25th-75th percentiles: 43.5-72.9]. Postoperative cerebrospinal fluid leak ( P < .01), postoperative diabetes insipidus (DI) ( P < .01), increased surgery duration ( P = .01), and elevated maximal tumor dimension ( P = .01) were predictive of PLOS in logistic regression. Increased surgery duration, previous pituitary radiation, intraoperative complications, and postoperative DI (all P < .01) were associated with increased rate of PLOS in negative binomial regression. CONCLUSION Patients undergoing endoscopic TSS for PA resection demonstrate prolonged lengths of stay if they have higher tumor burden, have lengthier surgeries with intraoperative complications, or develop postoperative complications such as cerebrospinal fluid leak or DI. Careful monitoring of these factors will allow for better resource optimization, reducing costs to both the hospital and the patient.
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Affiliation(s)
- Alex Devarajan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York , New York , USA
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Wu Q, Song NY. A Novel Nasal Endoscopy-Assisted Method for Sealing Cerebrospinal Fluid Rhinorrhea. J Craniofac Surg 2024; 35:1507-1508. [PMID: 39042072 PMCID: PMC11198945 DOI: 10.1097/scs.0000000000010278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 04/03/2024] [Indexed: 07/24/2024] Open
Abstract
Cerebrospinal fluid (CSF) rhinorrhea is one of the most common complications after trans-sphenoidal surgery. At present, transcranial or endoscopic surgery for CSF leakage requires general anesthesia to remove autologous fat or fascia to repair the leak, which is traumatic and costly. The authors present a case of a 25-year-old male patient with pituitary adenoma who experienced CSF rhinorrhea 10 days after undergoing endoscopic resection of the tumor. The authors innovatively sequential filled the leak with a gelatin sponge soaked in povidone-iodine solution and iodinated gauze under outpatient nasal endoscopy. The follow-up of 6 months showed no recurrence of CSF leakage. CSF leakage is the most common complication of trans-sphenoidal surgery. The authors suggest that for small cerebrospinal fluid leaks in the early stage after trans-sphenoidal surgery, the leakage should be first filled with gelatin sponge and iodoform gauze sequentially under outpatient nasal endoscopy, which may achieve a complete cure.
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Baussart B, Hudelist B, Reina V, Villa C, Bertherat J, Assié G, Gaillard S. Diaphragm reconstruction using a TachoSil patch as alternative to intrasellar packing for small focal diaphragm defects in pituitary surgery: a cohort study. Acta Neurochir (Wien) 2024; 166:258. [PMID: 38853198 DOI: 10.1007/s00701-024-06152-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/31/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND During pituitary surgery, CSF leaks are often treated by intrasellar packing, using muscle or fat grafts. However, this strategy may interfere with the interpretation of postoperative MRI and may impact the quality of resection in cases of second surgery, due to the existence of additional fibrous tissue. We present an alternative technique, using a diaphragm reconstruction with a heterologous sponge combining fibrinogen and thrombin (TachoSil), applied in selected patients with low-flow CSF leaks. This study investigates the surgical outcome of patients treated with this strategy. METHODS From a cohort of 2231 patients treated from June 2011 to June 2023 by endoscopic endonasal approach for pituitary surgery, the surgical technique of diaphragm repair with TachoSil patch performed in 55 patients (2.6%) was detailed, and the rate of closure failure was analyzed at 6 months postoperatively. No intrasellar packing was used and sellar floor reconstruction was performed whenever possible. The rate of postoperative CSF leak was compared with that reported in three previous publications that also used the TachoSil patch technique. RESULTS Patients were mostly women (F/M ratio: 1.2) with a median age of 53.6 years. Surgery was indicated for non-functioning adenomas, Cushing's disease, acromegaly, and Rathke's cleft cysts in 38/55 (69.1%), 6/55 (10.9%), 5/55 (9.1%) and 6/55 (10.9%) patients respectively. The rate of postoperative CSF leak was 1.8% (n = 1/55), which was not significantly different from that reported in the three cohorts from the literature (2.8%, p > 0.05). No postoperative meningitis was recorded. CONCLUSIONS In highly selected patients with low-flow CSF leaks related to small focal diaphragm defects, diaphragm reconstruction using a TachoSil patch can be a safe and valuable alternative to intrasellar packing.
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Affiliation(s)
- Bertrand Baussart
- Department of Neurosurgery, Assistance Publique-Hôpitaux de Paris, La Pitié-Salpêtrière University Hospital, Assistance Publique Hôpitaux de Paris, 47-83 Boulevard de L'Hôpital, 75013, Paris, France.
- Université Paris Cité, CNRS, INSERM, Institut Cochin, 75014, Paris, France.
| | - Benoit Hudelist
- Department of Neurosurgery, Assistance Publique-Hôpitaux de Paris, La Pitié-Salpêtrière University Hospital, Assistance Publique Hôpitaux de Paris, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Vincent Reina
- Department of Neurosurgery, Assistance Publique-Hôpitaux de Paris, La Pitié-Salpêtrière University Hospital, Assistance Publique Hôpitaux de Paris, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Chiara Villa
- Department of Neuropathology, Assistance Publique-Hôpitaux de Paris, La Pitié-Salpêtrière University Hospital, Paris, France
| | - Jérôme Bertherat
- Université Paris Cité, CNRS, INSERM, Institut Cochin, 75014, Paris, France
- Department of Endocrinology, Center for Rare Adrenal Diseases, Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Guillaume Assié
- Université Paris Cité, CNRS, INSERM, Institut Cochin, 75014, Paris, France
- Department of Endocrinology, Center for Rare Adrenal Diseases, Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Stephan Gaillard
- Department of Neurosurgery, Assistance Publique-Hôpitaux de Paris, La Pitié-Salpêtrière University Hospital, Assistance Publique Hôpitaux de Paris, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
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Jolly K, Gupta KK, Egbuji O, Naik PP, Ahmed SK. Endoscopic transsphenoidal surgery reconstruction using the fibrin sealant patch Tachosil ®. Br J Neurosurg 2024; 38:498-502. [PMID: 33769186 DOI: 10.1080/02688697.2021.1905771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 03/25/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The incidence of CSF leak following endoscopic transsphenoidal surgery remains the most important measure in the success of any repair. The nasoseptal flap (NSF) has played a pivotal role in reconstructing defects. However, morbidity associated with the NSF includes bleeding, septal injury, altered smell and crusting. Tachosil® is an absorbable fibrin sealant patch that promotes haemostasis and wound healing. The purpose of this study was to evaluate the effectiveness of Tachosil® to repair intraoperative defects during an endoscopic transsphenoidal approach. MATERIALS AND METHODS All patients who underwent an endoscopic transsphenoidal approach with the use of Tachosil® at the Queen Elizabeth Hospital Birmingham, between January 2013 and June 2020 were retrospectively analysed. Tachosil® was used as an overlay patch over of the bony defect, in a multi-layered repair depending on the defect and grade of CSF leak. The primary outcome measure was post-operative CSF leak. RESULTS A total of 52 primary procedures where Tachosil® was used as the overlay were analysed. There were 23 (44.2%) intraoperative CSF leaks. The overall post-operative CSF leak rate was 7.8% (n = 4), with all cases having had a Tachosil® overlay reconstruction with no NSF. A formal NSF was harvested in only five cases alongside the Tachosil® patch, where a grade 2 or more leak was identified at the time of the primary procedure, none of which developed a post-operative leak. No patient had any post-operative adverse outcomes that were attributed to Tachosil®. CONCLUSIONS We believe this to be the largest case series evaluating the endoscopic use of Tachosil® in skull base reconstruction. Our data show that in endoscopic transsphenoidal approach, Tachosil® may be used safely in a multi-layered approach as an effective alternative to the NSF in low flow CSF leak cases, or alongside a NSF in higher flow leaks.
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Affiliation(s)
- Karan Jolly
- Department of Otolaryngology, New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Keshav Kumar Gupta
- Department of Otolaryngology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ofuchi Egbuji
- Department of Otolaryngology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paresh Pramod Naik
- Department of Otolaryngology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Shahzada Khuram Ahmed
- Department of Otolaryngology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Lin M, Wang W, Tang L, Zhou Y, Li W, Xiao J, Peng Z, Xia X. Predictive value of suprasellar extension for intracranial infection after endoscopic transsphenoidal pituitary adenoma resection. World J Surg Oncol 2023; 21:363. [PMID: 37993849 PMCID: PMC10664274 DOI: 10.1186/s12957-023-03243-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/13/2023] [Indexed: 11/24/2023] Open
Abstract
OBJECTIVE To investigate the relationship between suprasellar extension (SSE) and intracranial infection after endoscopic endonasal transsphenoidal approach (EETA) for pituitary adenoma resection. METHODS We retrospectively analyzed 94 patients with suprasellar extended pituitary adenoma admitted to the Department of Neurosurgery of the Affiliated Hospital of Guilin Medical College from January 2018 to December 2021. We measured the preoperative magnetic resonance sagittal SSE and collected clinical data and divided the patients into groups according to the presence of postoperative intracranial infection. The critical value for the SSE was calculated by using a working characteristic curve for the subjects. The risk factors for intracranial infection after EETA resection of pituitary adenomas were analyzed by multivariate regression analysis. RESULTS Among the 94 patients, 12 cases (12.8%) were placed in the infection group and 82 cases (87.2%) in the non-infection group. The cut-off value for the SSE in the sagittal position was 15.6 mm, the sensitivity was 75%, the specificity was 87.8%, and the area under the curve (AUC) was 0.801. The coronary cut-off value for the SSE was 15.8 mm, the sensitivity was 66.7%, the specificity was 79.3%, and the AUC was 0.787. The SSE values in the sagittal and coronal positions were correlated with postoperative intracranial infection (P < 0.05). After univariate analysis, those with significant differences were included in the multivariate regression analysis. It was concluded that the extension distance of the tumor above the sella in the sagittal position was ≥ 15.6 mm, the tumor texture was hard, and the postoperative cerebrospinal fluid leakage were the independent risk factors for intracranial infection after EETA resection of suprasellar extended pituitary tumors (P < 0.05). CONCLUSIONS The value of SSE on sagittal MRI can predict intracranial infection in patients with suprasellar extended pituitary adenoma after endoscopic endonasal transsphenoidal resection. This finding recommends neurosurgeons pay more attention to the imaging characteristics of pituitary adenomas and select appropriate treatment plans in combination with the intraoperative conditions to reduce the incidence of intracranial infection.
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Affiliation(s)
- Mingjian Lin
- Department of Neurosurgery, GaoZhou People's Hospital, Gaozhou, 525200, Guangdong, China
| | - Wenbo Wang
- Department of Neurosurgery, Nanxishan Hospital of Guangxi Zhuang Autonomous Region, Guilin, 541001, Guangxi, China.
| | - Lejian Tang
- Department of Neurosurgery, Nanxishan Hospital of Guangxi Zhuang Autonomous Region, Guilin, 541001, Guangxi, China
| | - Yunxiang Zhou
- Department of Neurosurgery, Affiliated Hospital of Guilin Medical College, Guilin, 541001, Guangxi, China
| | - Wencai Li
- Department of Neurosurgery, Huizhou Central People's Hospital, Huizhou, 516000, China
| | - Jing Xiao
- Department of Neurosurgery, Affiliated Hospital of Guilin Medical College, Guilin, 541001, Guangxi, China
| | - Zhizhu Peng
- Department of Neurosurgery, Nanxishan Hospital of Guangxi Zhuang Autonomous Region, Guilin, 541001, Guangxi, China
| | - Xuewei Xia
- Department of Neurosurgery, Affiliated Hospital of Guilin Medical College, Guilin, 541001, Guangxi, China
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Qian M, Chen X, Zhang LY, Wang ZF, Zhang Y, Wang XJ. " In situ bone flap" combined with vascular pedicled mucous flap to reconstruction of skull base defect. World J Clin Cases 2023; 11:7053-7060. [PMID: 37946785 PMCID: PMC10631404 DOI: 10.12998/wjcc.v11.i29.7053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/10/2023] [Accepted: 09/25/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND At present, neuroendoscopy technology has made rapid development, and great progress has been made in the operation of lesions in the saddle area of the skull base. However, the complications of cerebrospinal fluid and intracranial infection after the operation are still important and life-threatening complications, which may lead to poor prognosis. AIM To investigate the method of in situ bone flap combined with nasal septum mucosal flap for reconstruction of enlarged skull base defect by endonasal sphenoidal approach and to discuss its application effect. METHODS Clinical data of 24 patients undergoing transnasal sphenoidal endoscopic approach in the Department of Neurosurgery, Affiliated 2 Hospital of Nantong University from January 2019 to December 2022 were retrospectively analyzed. All patients underwent multi-layer reconstruction of skull base using in situ bone flap combined with nasal septum mucosa flap. The incidence of intraoperative and postoperative cerebrospinal fluid leakage and intracranial infection were analyzed, and the application effect and technical key points of in situ bone flap combined with nasal septum mucosa flap for skull base bone reconstruction were analyzed. RESULTS There were 5 cases of high flow cerebrospinal fluid (CSF) leakage and 7 cases of low flow CSF leakage. Postoperative cerebrospinal fluid leakage occurred in 2 patients (8.3%) and intracranial infection in 2 patients (8.3%), which were cured after strict bed rest, continuous drainage of lumbar cistern combined with antibiotic treatment, and no secondary surgical repair was required. The patients were followed up for 8 to 36 months after the operation, and no delayed cerebrospinal fluid leakage or intracranial infection occurred during the follow-up. Computed tomography reconstruction of skull base showed satisfactory reconstruction after surgery. CONCLUSION The use of in situ bone flap combined with vascular pedicled mucous flap to reconstruction of skull base defect after endonasal sphenoidal approach under neuroendoscopy has a lower incidence of cerebrospinal fluid leakage and lower complications, which has certain advantages and is worthy of clinical promotion.
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Affiliation(s)
- Ming Qian
- Department of Neurosurgery, Affiliated Hospital 2 of Nantong University, Nantong 226000, Jiangsu Province, China
| | - Xi Chen
- Department of Nursing, Affiliated Hospital 2 of Nantong University, Nantong 226001, Jiangsu Province, China
| | - Long-Yao Zhang
- Department of Neurosurgery, Affiliated Hospital 2 of Nantong University, Nantong 226000, Jiangsu Province, China
| | - Zhi-Feng Wang
- Department of Neurosurgery, Affiliated Hospital 2 of Nantong University, Nantong 226000, Jiangsu Province, China
| | - Yi Zhang
- Department of Neurosurgery, Affiliated Hospital 2 of Nantong University, Nantong 226000, Jiangsu Province, China
| | - Xue-Jian Wang
- Department of Neurosurgery, Affiliated Hospital 2 of Nantong University, Nantong 226000, Jiangsu Province, China
- Department of Neurosurgery, Nantong Clinical Medical College, Kangda College, Nanjing Medical University, Nantong 226000, Jiangsu Province, China
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11
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Mekonnen M, Hovis G, Mahgerefteh N, Chandla A, Malkhasyan Y, Zhang AB, Yang I. A Case Series of DuraMatrix-Onlay ® Plus in Cranial Surgery Is Associated With a Low Complication Profile. Brain Tumor Res Treat 2023; 11:232-238. [PMID: 37953446 PMCID: PMC10641318 DOI: 10.14791/btrt.2023.0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND DuraMatrix-Onlay® Plus is a collagen dura membrane derived from purified bovine Achilles tendon. The matrix provides a scaffold for collagen synthesis and is intended to be used as an onlay without the need for dural sutures. The study aims to describe our experience with 33 consecutive patients who underwent a duraplasty procedure using the novel DuraMatrix-Onlay® Plus collagen dura membrane. METHODS This is a retrospective case series of 33 patients who underwent a duraplasty procedure at a single academic hospital in Los Angeles, CA, USA between May 2016 and March 2017. The primary outcome was the incidence rate of cerebrospinal fluid (CSF) leak. Secondary outcomes included rates of patient infection, dural substitute complication, and removal. RESULTS Thirty-three patients underwent a duraplasty procedure using the DuraMatrix-Onlay® Plus material. The average age of the patients was 41.12±7.34 years (range 2-75 years). There were 18 (54.5%) females and 15 (45.5%) males. The majority of procedures were elective operations for the resection of a lesion (n=19, 58%), and the average graft size was 17.69±4.73 cm². At an average follow-up of 3 months, there were no postoperative CSF leaks. The rates of patient infection, dural substitute complication, and removal were 6%, 6%, and 3%, respectively. CONCLUSION DuraMatrix-Onlay® Plus is associated with a low rate of postoperative CSF leakage and an acceptable complication profile. This result supports the use of collagen matrices for dural closure in general neurosurgical procedures.
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Affiliation(s)
- Mahlet Mekonnen
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Gabrielle Hovis
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Natalie Mahgerefteh
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Anubhav Chandla
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Yelena Malkhasyan
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ashley B Zhang
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Isaac Yang
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Head and Neck Surgery, University of California, Los Angeles, Los Angeles, CA, USA
- Jonsson Comprehensive Cancer Center, Ronald Reagan UCLA Medical Center of the David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
- Department of Neurosurgery, Harbor-UCLA Medical Center, Torrance, CA, USA
- Los Angeles Biomedical Research Institute (LA BioMed), Harbor-UCLA Medical Center, Torrance, CA, USA.
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12
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Chang H, Zhao K, Qiu J, Ji XJ, Chen WG, Li BY, Lv C, Xiong ZC, Chen SB, Shu XJ. Prediction of intraoperative cerebrospinal fluid leaks in endoscopic endonasal transsphenoidal pituitary surgery based on a deep neural network model trained with MRI images: a pilot study. Front Neurosci 2023; 17:1203698. [PMID: 37575298 PMCID: PMC10413098 DOI: 10.3389/fnins.2023.1203698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/13/2023] [Indexed: 08/15/2023] Open
Abstract
Objective This study aimed to investigate the reliability of a deep neural network (DNN) model trained only on contrast-enhanced T1 (T1CE) images for predicting intraoperative cerebrospinal fluid (ioCSF) leaks in endoscopic transsphenoidal surgery (EETS). Methods 396 pituitary adenoma (PA) cases were reviewed, only primary PAs with Hardy suprasellar Stages A, B, and C were included in this study. The T1CE images of these patients were collected, and sagittal and coronal T1CE slices were selected for training the DNN model. The model performance was evaluated and tested, and its interpretability was explored. Results A total of 102 PA cases were enrolled in this study, 51 from the ioCSF leakage group, and 51 from the non-ioCSF leakage group. 306 sagittal and 306 coronal T1CE slices were collected as the original dataset, and data augmentation was applied before model training and testing. In the test dataset, the DNN model provided a single-slice prediction accuracy of 97.29%, a sensitivity of 98.25%, and a specificity of 96.35%. In clinical test, the accuracy of the DNN model in predicting ioCSF leaks in patients reached 84.6%. The feature maps of the model were visualized and the regions of interest for prediction were the tumor roof and suprasellar region. Conclusion In this study, the DNN model could predict ioCSF leaks based on preoperative T1CE images, especially in PAs in Hardy Stages A, B, and C. The region of interest in the model prediction-making process is similar to that of humans. DNN models trained with preoperative MRI images may provide a novel tool for predicting ioCSF leak risk for PA patients.
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Affiliation(s)
- Hui Chang
- School of Computer and Information Engineering and Henan Engineering Research Center of Intelligent Technology and Application, Henan University, Kaifeng, Henan Province, China
| | - Kai Zhao
- The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jun Qiu
- Department of Critical Care Medicine, The Second People’s Hospital of Yibin, Yibin, Sichuan Province, China
| | - Xiang-Jun Ji
- Department of Neurosurgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Wu-Gang Chen
- School of Computer and Information Engineering and Henan Engineering Research Center of Intelligent Technology and Application, Henan University, Kaifeng, Henan Province, China
| | - Bo-Yuan Li
- School of Computer and Information Engineering and Henan Engineering Research Center of Intelligent Technology and Application, Henan University, Kaifeng, Henan Province, China
| | - Cheng Lv
- School of Mathematics and Computer Sciences, Nanchang University, Nanchang, Jiangxi Province, China
| | - Zi-Cheng Xiong
- School of Computer and Information Engineering and Henan Engineering Research Center of Intelligent Technology and Application, Henan University, Kaifeng, Henan Province, China
| | - Sheng-Bo Chen
- School of Computer and Information Engineering and Henan Engineering Research Center of Intelligent Technology and Application, Henan University, Kaifeng, Henan Province, China
| | - Xu-Jun Shu
- Department of Neurosurgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
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13
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Hashiba T, Nonaka M, Iwamura H, Kamei T, Takeda J, Asai A. Refractory Delayed Pneumocephalus after Transsphenoidal Cyst Drainage for Rathke's Cleft Cyst in a Patient with a Cerebrospinal Fluid Shunt. Asian J Neurosurg 2023; 18:342-346. [PMID: 37397060 PMCID: PMC10310442 DOI: 10.1055/s-0043-1768573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023] Open
Abstract
A 75-year-old man presented with bilateral lower limb weakness to our hospital from another clinic. Radiological examinations implied the possibilities of idiopathic normal pressure hydrocephalus (iNPH) and a suprasellar cyst, but both were observed conservatively at that time. Due to the progressive gait disturbance, a lumboperitoneal shunt was implanted 1 year later. The clinical symptoms improved, but the cyst had grown after another year, causing visual impairment. Transsphenoidal drainage of the cyst was performed, but delayed pneumocephalus occurred. Repair surgery was performed with temporary suspension of shunt function, but pneumocephalus relapsed two and a half months after the resumption of shunt flow. In the second repair surgery, the shunt was removed because it was assumed that it would prevent closure of the fistula by lowering intracranial pressure. Two and a half months later, after confirming involution of the cyst and no pneumocephalus, a ventriculoperitoneal shunt was implanted, and cerebrospinal fluid (CSF) leakage has not relapsed since then. The coexistence of idiopathic normal pressure hydrocephalus (iNPH) and Rathke's cleft cyst (RCC) is rare, but it can occur. RCC can be cured by simple drainage, but delayed pneumocephalus can occur in cases whose intracranial pressure decreases due to CSF shunting. When simple drainage without sellar reconstruction for RCC is attempted after CSF shunting for coexistent iNPH, attention should be paid to changes in intracranial pressure, and it is desirable to stop the flow of the shunt for a certain period.
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Affiliation(s)
- Tetsuo Hashiba
- Department of Neurosurgery, Kansai Medical University, Osaka, Japan
| | - Masahiro Nonaka
- Department of Neurosurgery, Kansai Medical University, Osaka, Japan
| | - Haruka Iwamura
- Department of Neurosurgery, Kansai Medical University, Osaka, Japan
| | - Takamasa Kamei
- Department of Neurosurgery, Kansai Medical University, Osaka, Japan
| | - Junichi Takeda
- Department of Neurosurgery, Kansai Medical University, Osaka, Japan
| | - Akio Asai
- Department of Neurosurgery, Kansai Medical University, Osaka, Japan
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14
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Baig Mirza A, Boardman T, Okasha M, El-Hariri HM, Al Banna Q, Syrris C, Baig Mirza K, Vastani A, Visagan R, Shapey J, Maratos E, Barazi S, Thomas N. Fat in the Fossa and the Sphenoid Sinus: A Simple and Effective Solution to CSF Leaks in Transsphenoidal Surgery. Cohort Study and Systematic Review. J Neurol Surg B Skull Base 2023; 84:143-156. [PMID: 36895808 PMCID: PMC9991530 DOI: 10.1055/a-1757-3069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 01/30/2022] [Indexed: 10/19/2022] Open
Abstract
Objectives Cerebrospinal fluid (CSF) leak following endoscopic transsphenoidal surgery (TSS) remains a challenge and is associated with high morbidity. We perform a primary repair with f at in the pituitary f ossa and further fat in the s phenoid sinus (FFS). We compare the efficacy of this FFS technique with other repair methods and perform a systematic review. Design, Patients, and Methods This is a retrospective analysis of patients undergoing standard TSS from 2009 to 2020, comparing the incidence of significant postoperative CSF rhinorrhea (requiring intervention) using the FFS technique compared with other intraoperative repair strategies. Systematic review of current repair methods described in the literature was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Results In all, there were 439 patients, with 276 patients undergoing multilayer repair, 68 patients FFS repair, and 95 patients no repair. No significant differences were observed in baseline demographics between the groups. Postoperative CSF leak requiring intervention was significantly lower in the FFS repair group (4.4%) compared with the multilayer (20.3%) and no repair groups (12.6%, p < 0.01). This translated to fewer reoperations (2.9% FFS vs. 13.4% multilayer vs. 8.4% no repair, p < 0.05), fewer lumbar drains (2.9% FFS vs. 15.6% multilayer vs. 5.3% no repair, p < 0.01), and shorter hospital stay (median days: 4 [3-7] FFS vs. 6 (5-10) multilayer vs. 5 (3-7) no repair, p < 0.01). Risk factors for postoperative leak included female gender, perioperative lumbar drain, and intraoperative leak. Conclusion Autologous fat on fat graft for standard endoscopic transsphenoidal approach effectively reduces the risk of significant postoperative CSF leak with reduced reoperation and shorter hospital stay.
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Affiliation(s)
- Asfand Baig Mirza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Timothy Boardman
- GKT School of Medical Education, King's College London, London, United Kingdom
| | - Mohamed Okasha
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Qusai Al Banna
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Christoforos Syrris
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Amisha Vastani
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Ravindran Visagan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Jonathan Shapey
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom.,Department of Surgical and Interventional Engineering, School of Biomedical Engineering and Imaging Science, King's College London, United Kingdom
| | - Eleni Maratos
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Sinan Barazi
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Nick Thomas
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
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15
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Hasegawa H, Shinya Y, Ono M, Kikuta S, Kondo K, Saito N. Kashimé: A Novel Knotless Surgical Suture to Simplify Dural Stitches in Endoscopic Transnasal Surgery. Oper Neurosurg (Hagerstown) 2023; 24:417-424. [PMID: 36701657 DOI: 10.1227/ons.0000000000000545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/26/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Dural suturing is an effective adjunct to skull base dural repair in endoscopic transnasal surgery, although it is technically cumbersome. Here, we presented a novel surgical suture "Kashimé" (Kono Seisakusho) that can be tightened without tying. OBJECTIVE To examine the efficacy of Kashimé for skull base dural repair in endoscopic transnasal surgery. METHODS Kashimé was used in 8 patients with skull base dural defects during nonpedicled flap-based multilayered skull base reconstruction to close or approximate the gaps between the dural edges or secure a free fascial graft. The time required for each dural stitch (passing a needle through the dura, pulling out the thread, and tightening it) and the incidence of postoperative cerebrospinal fluid leakage were the study end points. RESULTS Based on our preliminary experiences with 12 stitches used, no postoperative cerebrospinal fluid leakage was observed. The learning curve was steep, and the mean (±SD) time was 127 (±44) seconds for a single stitching procedure, except for the first case. Regarding the metal artifact, although a beam hardening artifact was not observed on computed tomography, a 4- to 9-mm diameter image defect was observed on magnetic resonance imaging. CONCLUSION Kashimé can help surgeons to complete a single dural stitch in endoscopic transnasal surgery for approximately 2 minutes. It may be an optimal tool for skull base reconstruction, but the efficacy and safety need to be investigated.
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Affiliation(s)
- Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo, Bunkyo, Tokyo, Japan
| | - Yuki Shinya
- Department of Neurosurgery, The University of Tokyo, Bunkyo, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Bunkyo, Tokyo, Japan
| | - Shu Kikuta
- Department of Otorhinolaryngology, The University of Tokyo, Bunkyo, Tokyo, Japan
| | - Kenji Kondo
- Department of Otorhinolaryngology, The University of Tokyo, Bunkyo, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo, Bunkyo, Tokyo, Japan
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16
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Machine learning driven prediction of cerebrospinal fluid rhinorrhoea following endonasal skull base surgery: A multicentre prospective observational study. Front Oncol 2023; 13:1046519. [PMID: 37035179 PMCID: PMC10076706 DOI: 10.3389/fonc.2023.1046519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/27/2023] [Indexed: 04/11/2023] Open
Abstract
Background Cerebrospinal fluid rhinorrhoea (CSFR) is a common complication following endonasal skull base surgery, a technique that is fundamental to the treatment of pituitary adenomas and many other skull base tumours. The CRANIAL study explored CSFR incidence and related risk factors, particularly skull base repair techniques, via a multicentre prospective observational study. We sought to use machine learning to leverage this complex multicentre dataset for CSFR prediction and risk factor analysis. Methods A dataset of 865 cases - 725 transsphenoidal approach (TSA) and 140 expanded endonasal approach (EEA) - with cerebrospinal fluid rhinorrhoea as the primary outcome, was used. Relevant variables were extracted from the data, and prediction variables were divided into two categories, preoperative risk factors; and repair techniques, with 6 and 11 variables respectively. Three types of machine learning models were developed in order to predict CSFR: logistic regression (LR); decision tree (DT); and neural network (NN). Models were validated using 5-fold cross-validation, compared via their area under the curve (AUC) evaluation metric, and key prediction variables were identified using their Shapley additive explanations (SHAP) score. Results CSFR rates were 3.9% (28/725) for the transsphenoidal approach and 7.1% (10/140) for the expanded endonasal approach. NNs outperformed LR and DT for CSFR prediction, with a mean AUC of 0.80 (0.70-0.90) for TSA and 0.78 (0.60-0.96) for EEA, when all risk factor and intraoperative repair data were integrated into the model. The presence of intraoperative CSF leak was the most prominent risk factor for CSFR. Elevated BMI and revision surgery were also associated with CSFR for the transsphenoidal approach. CSF diversion and gasket sealing appear to be strong predictors of the absence of CSFR for both approaches. Conclusion Neural networks are effective at predicting CSFR and uncovering key CSFR predictors in patients following endonasal skull base surgery, outperforming traditional statistical methods. These models will be improved further with larger and more granular datasets, improved NN architecture, and external validation. In the future, such predictive models could be used to assist surgical decision-making and support more individualised patient counselling.
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17
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Zhou L, Wang B, Ye L, Gao P, Cheng H. Continuous Dural Suturing for the Closure of Grade 1 to 2 Cerebrospinal Fluid Leakage After Pituitary Adenoma Removal Using an Endoscopic Endonasal Approach. J Craniofac Surg 2023; 34:629-632. [PMID: 36104835 DOI: 10.1097/scs.0000000000008962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/11/2022] [Indexed: 11/26/2022] Open
Abstract
In this study, we aim at evaluating continuous dural suturing in patients with grade 1 to 2 cerebrospinal fluid (CSF) leakage after pituitary adenoma removal using an endoscopic endonasal approach. The study population comprised 381 pituitary adenoma patients who underwent endoscopic endonasal removal of the tumor. The degree of intraoperative CSF leakage was graded based on Esposito method. Cranial base repair using continuous dural suturing was performed according to the grade of CSF leakage. Intraoperative grade 1 to 2 CSF leakage was identified in 143 patients (37.5%). Continuous dural suturing to repair the cranial base was accepted by 61 patients and refused by 82 patients. Among patients who accepted dural suturing, the incidence of postoperative CSF leakage was reduced and the length of hospital stay was shortened. Patients with low-flow leakage were treated using a reduced vascularized pedicled nasoseptal flap. In conclusion, our graded cranial base repair method using the dural suturing technique is simple and effective.
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Affiliation(s)
- Lv Zhou
- Department of Neurosurgery, the First Affiliated Hospital of Anhui Medical University, HeFei, AnHui Province, China
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18
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Pailler JI, Villalonga JF, Ries-Centeno T, Saenz A, Baldoncini M, Pipolo DO, Cárdenas Ruiz-Valdepeñas E, Kaen A, Hirtler L, Roytowski D, Solari D, Cervio A, Campero A. Clinical Applicability of the Sellar Barrier Concept in Patients with Pituitary Apoplexy: Is It Possible? LIFE (BASEL, SWITZERLAND) 2023; 13:life13010158. [PMID: 36676107 PMCID: PMC9861876 DOI: 10.3390/life13010158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 01/06/2023]
Abstract
There is evidence of association between sellar barrier thickness and intraoperative cerebrospinal fluid (CSF) leakage, impacting the postoperative prognosis of the patients. The aim of this study is to analyze the clinical applicability of the sellar barrier concept in a series of operated patients with pituitary apoplexy (PA). A retrospective study was conducted including 47 patients diagnosed with PA who underwent surgical treatment through a transsphenoidal approach. Brain magnetic resonance imaging (MRI) of the patients were evaluated and classified utilizing the following criteria: strong barrier (greater than 1 mm), weak barrier (less than 1 mm), and mixed barrier (less than 1 mm in one area and greater than 1 mm in another). The association between sellar barrier types and CSF leakage was analyzed, both pre- and intraoperatively. The preoperative MRI classification identified 10 (21.28%) patients presenting a weak sellar barrier, 20 patients (42.55%) with a mixed sellar barrier, and 17 patients (36.17%) exhibiting a strong sellar barrier. Preoperative weak and strong sellar barrier subtypes were associated with weak (p ≤ 0.001) and strong (p = 0.009) intraoperative sellar barriers, respectively. Strong intraoperative sellar barrier subtypes reduced the odds of CSF leakage by 86% (p = 0.01). A correlation between preoperative imaging and intraoperative findings in the setting of pituitary apoplexy has been observed.
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Affiliation(s)
- José Ignacio Pailler
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, San Miguel de Tucumán 4000, Argentina
| | - Juan Francisco Villalonga
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, San Miguel de Tucumán 4000, Argentina
- Correspondence:
| | | | - Amparo Saenz
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, San Miguel de Tucumán 4000, Argentina
| | - Matías Baldoncini
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, San Miguel de Tucumán 4000, Argentina
| | - Derek Orlando Pipolo
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, San Miguel de Tucumán 4000, Argentina
| | | | - Ariel Kaen
- Hospital Virgen del Rocío, 41013 Sevilla, Spain
| | - Lena Hirtler
- Endoscopic Laboratory of Anatomy Center, Medical University of Vienna, 1090 Vienna, Austria
| | - David Roytowski
- Department of Neurosurgery, University of Cape Town, Cape Town 7701, South Africa
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita’ degli Studi di Napoli Federico II, 80131 Naples, Italy
| | - Andrés Cervio
- Departamento de Neurocirugía, FLENI, Buenos Aires 1625, Argentina
| | - Alvaro Campero
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, San Miguel de Tucumán 4000, Argentina
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19
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CSF rhinorrhoea after endonasal intervention to the skull base (CRANIAL): A multicentre prospective observational study. Front Oncol 2023; 12:1049627. [PMID: 36688936 PMCID: PMC9846732 DOI: 10.3389/fonc.2022.1049627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 10/24/2022] [Indexed: 01/09/2023] Open
Abstract
Objective Despite progress in endonasal skull-base neurosurgery, cerebrospinal fluid (CSF) rhinorrhoea remains common and significant. The CRANIAL study sought to determine 1) the scope of skull-base repair methods used, and 2) corresponding rates of postoperative CSF rhinorrhoea in the endonasal transsphenoidal approach (TSA) and the expanded endonasal approach (EEA) for skull-base tumors. Methods A prospective observational cohort study of 30 centres performing endonasal skull-base neurosurgery in the UK and Ireland (representing 91% of adult units). Patients were identified for 6 months and followed up for 6 months. Data collection and analysis was guided by our published protocol and pilot studies. Descriptive statistics, univariate and multivariable logistic regression models were used for analysis. Results A total of 866 patients were included - 726 TSA (84%) and 140 EEA (16%). There was significant heterogeneity in repair protocols across centres. In TSA cases, nasal packing (519/726, 72%), tissue glues (474/726, 65%) and hemostatic agents (439/726, 61%) were the most common skull base repair techniques. Comparatively, pedicled flaps (90/140, 64%), CSF diversion (38/140, 27%), buttresses (17/140, 12%) and gasket sealing (11/140, 9%) were more commonly used in EEA cases. CSF rhinorrhoea (biochemically confirmed or requiring re-operation) occurred in 3.9% of TSA (28/726) and 7.1% of EEA (10/140) cases. A significant number of patients with CSF rhinorrhoea (15/38, 39%) occurred when no intraoperative CSF leak was reported. On multivariate analysis, there may be marginal benefits with using tissue glues in TSA (OR: 0.2, CI: 0.1-0.7, p<0.01), but no other technique reached significance. There was evidence that certain characteristics make CSF rhinorrhoea more likely - such as previous endonasal surgery and the presence of intraoperative CSF leak. Conclusions There is a wide range of skull base repair techniques used across centres. Overall, CSF rhinorrhoea rates across the UK and Ireland are lower than generally reported in the literature. A large proportion of postoperative leaks occurred in the context of occult intraoperative CSF leaks, and decisions for universal sellar repairs should consider the risks and cost-effectiveness of repair strategies. Future work could include longer-term, higher-volume studies, such as a registry; and high-quality interventional studies.
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20
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Baussart B, Venier A, Jouinot A, Reuter G, Gaillard S. Closure strategy for endoscopic pituitary surgery: Experience from 3015 patients. Front Oncol 2023; 12:1067312. [PMID: 36686774 PMCID: PMC9846073 DOI: 10.3389/fonc.2022.1067312] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/05/2022] [Indexed: 01/05/2023] Open
Abstract
Introduction Effective strategies are required to ensure optimal management of the crucial closure step in endoscopic pituitary surgery. Many surgical techniques have been reported but no significant consensus has been defined. Methods Between January 2006 and March 2022, 3015 adult patients with pituitary adenomas were operated on by a single expert neurosurgical team, using a mononostril endoscopic endonasal approach. Based of preoperative risk factors of and operative findings, a detailed closure strategy was used. Body mass index >40, sellar floor lysis, number of surgeries>2, large skull base destruction, prior radiotherapy were considered as preoperative risk factors for closure failure. All patients treated with an expanded endonasal approach were excluded. Results Patients were mostly women (F/M ratio: 1.4) with a median age of 50 (range: 18 -89). Intraoperative CSF leak requiring specific surgical management was observed in 319/3015 (10.6%) of patients. If intraoperative leak occurred, patients with predictive risk factors were managed using a Foley balloon catheter in case of sellar floor lysis or BMI>40 and a multilayer repair strategy with a vascularized nasoseptal flap in other cases. Postoperative CSF leak occurred in 29/3015 (1%) of patients, while meningitis occurred in 24/3015 (0.8%) of patients. In patients with intraoperative leak, closure management failed in 11/319 (3.4%) of cases. Conclusion Based on our significant 16-year experience, our surgical management is reliable and easy to follow. With a planned and stepwise strategy, the closure step can be optimized and tailored to each patient with a very low failure rate.
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Affiliation(s)
- Bertrand Baussart
- Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France,Université Paris Cité, Institut Cochin, CNRS, INSERM, Paris, France,*Correspondence: Bertrand Baussart, ;
| | - Alice Venier
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Anne Jouinot
- Université Paris Cité, Institut Cochin, CNRS, INSERM, Paris, France
| | - Gilles Reuter
- Department of Neurosurgery, Centre Hospitalier Universitaire (CHU) de Liège, Bat B35, Domaine Universitaire du Sart-Tilman, Liège, Belgium
| | - Stephan Gaillard
- Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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21
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Ibrahim B, Mandel M, Ali A, Najera E, Obrzut M, Adada B, Borghei-Razavi H. Pituitary Adenomas: Classification, Clinical Evaluation and Management. Skull Base Surg 2022. [DOI: 10.5772/intechopen.103778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Pituitary adenomas are one of the most common brain tumors. They represent approximately 18% of all intracranial, and around 95% of sellar neoplasms. In recent years, our understanding of the pathophysiology and the behavior of these lesions has led to better control and higher curative rates. The treatment decision is largely dependent on type of the adenoma, clinical presentation, and the size of the lesion. In addition, incidental pituitary lesions add uncertainty in the decision-making process, especially for pituitary adenomas that can be medically managed. When surgery is indicated, the endoscopic endonasal transsphenoidal approach is the technique of choice, but open standard craniotomy approaches can also be the option in selected cases. The following chapter will review the classification, clinical presentation, pathophysiology, diagnostic work-up, selection of surgical approach, and treatment complications in pituitary adenomas.
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22
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Mattogno PP, Caccavella VM, Giordano M, D'Alessandris QG, Chiloiro S, Tariciotti L, Olivi A, Lauretti L. Interpretable Machine Learning-Based Prediction of Intraoperative Cerebrospinal Fluid Leakage in Endoscopic Transsphenoidal Pituitary Surgery: A Pilot Study. J Neurol Surg B Skull Base 2022; 83:485-495. [PMID: 36091632 PMCID: PMC9462964 DOI: 10.1055/s-0041-1740621] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 11/12/2021] [Indexed: 01/18/2023] Open
Abstract
Purpose Transsphenoidal surgery (TSS) for pituitary adenomas can be complicated by the occurrence of intraoperative cerebrospinal fluid (CSF) leakage (IOL). IOL significantly affects the course of surgery predisposing to the development of postoperative CSF leakage, a major source of morbidity and mortality in the postoperative period. The authors trained and internally validated the Random Forest (RF) prediction model to preoperatively identify patients at high risk for IOL. A locally interpretable model-agnostic explanations (LIME) algorithm is employed to elucidate the main drivers behind each machine learning (ML) model prediction. Methods The data of 210 patients who underwent TSS were collected; first, risk factors for IOL were identified via conventional statistical methods (multivariable logistic regression). Then, the authors trained, optimized, and audited a RF prediction model. Results IOL reported in 45 patients (21.5%). The recursive feature selection algorithm identified the following variables as the most significant determinants of IOL: Knosp's grade, sellar Hardy's grade, suprasellar Hardy's grade, tumor diameter (on X, Y, and Z axes), intercarotid distance, and secreting status (nonfunctioning and growth hormone [GH] secreting). Leveraging the predictive values of these variables, the RF prediction model achieved an area under the curve (AUC) of 0.83 (95% confidence interval [CI]: 0.78; 0.86), significantly outperforming the multivariable logistic regression model (AUC = 0.63). Conclusion A RF model that reliably identifies patients at risk for IOL was successfully trained and internally validated. ML-based prediction models can predict events that were previously judged nearly unpredictable; their deployment in clinical practice may result in improved patient care and reduced postoperative morbidity and healthcare costs.
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Affiliation(s)
- Pier Paolo Mattogno
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemell iIstituto di Ricovero e Cura a Carattere Scientifico Università Cattolica del Sacro Cuore, Rome, Italy
| | - Valerio M. Caccavella
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemell iIstituto di Ricovero e Cura a Carattere Scientifico Università Cattolica del Sacro Cuore, Rome, Italy
| | - Martina Giordano
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemell iIstituto di Ricovero e Cura a Carattere Scientifico Università Cattolica del Sacro Cuore, Rome, Italy
| | - Quintino G. D'Alessandris
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemell iIstituto di Ricovero e Cura a Carattere Scientifico Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sabrina Chiloiro
- Department of Endocrinology, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico Università Cattolica del Sacro Cuore, Rome, Italy
| | - Leonardo Tariciotti
- Unit of Neurosurgery, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- University of Milan, Milan, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemell iIstituto di Ricovero e Cura a Carattere Scientifico Università Cattolica del Sacro Cuore, Rome, Italy
| | - Liverana Lauretti
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemell iIstituto di Ricovero e Cura a Carattere Scientifico Università Cattolica del Sacro Cuore, Rome, Italy
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23
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Wang P, Cheng S, Li Y, Liu L, Liu J, Zhao Q, Luo S. Prediction of Lumbar Drainage-Related Meningitis Based on Supervised Machine Learning Algorithms. Front Public Health 2022; 10:910479. [PMID: 35836985 PMCID: PMC9273930 DOI: 10.3389/fpubh.2022.910479] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background Lumbar drainage is widely used in the clinic; however, forecasting lumbar drainage-related meningitis (LDRM) is limited. We aimed to establish prediction models using supervised machine learning (ML) algorithms. Methods We utilized a cohort of 273 eligible lumbar drainage cases. Data were preprocessed and split into training and testing sets. Optimal hyper-parameters were archived by 10-fold cross-validation and grid search. The support vector machine (SVM), random forest (RF), and artificial neural network (ANN) were adopted for model training. The area under the operating characteristic curve (AUROC) and precision-recall curve (AUPRC), true positive ratio (TPR), true negative ratio (TNR), specificity, sensitivity, accuracy, and kappa coefficient were used for model evaluation. All trained models were internally validated. The importance of features was also analyzed. Results In the training set, all the models had AUROC exceeding 0.8. SVM and the RF models had an AUPRC of more than 0.6, but the ANN model had an unexpectedly low AUPRC (0.380). The RF and ANN models revealed similar TPR, whereas the ANN model had a higher TNR and demonstrated better specificity, sensitivity, accuracy, and kappa efficiency. In the testing set, most performance indicators of established models decreased. However, the RF and AVM models maintained adequate AUROC (0.828 vs. 0.719) and AUPRC (0.413 vs. 0.520), and the RF model also had better TPR, specificity, sensitivity, accuracy, and kappa efficiency. Site leakage showed the most considerable mean decrease in accuracy. Conclusions The RF and SVM models could predict LDRM, in which the RF model owned the best performance, and site leakage was the most meaningful predictor.
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Affiliation(s)
- Peng Wang
- Department of Neurosurgery, Cancer Prevention and Treatment Institute of Chengdu, Chengdu Fifth People's Hospital (The Second Clinical Medical College, Affiliated Fifth People's Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, China
| | - Shuwen Cheng
- Department of Neurosurgery, Cancer Prevention and Treatment Institute of Chengdu, Chengdu Fifth People's Hospital (The Second Clinical Medical College, Affiliated Fifth People's Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, China
| | - Yaxin Li
- West China Fourth Hospital/West China School of Public Health, Sichuan University, Chengdu, China
| | - Li Liu
- Department of Neurosurgery, Cancer Prevention and Treatment Institute of Chengdu, Chengdu Fifth People's Hospital (The Second Clinical Medical College, Affiliated Fifth People's Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, China
| | - Jia Liu
- Department of Neurosurgery, Cancer Prevention and Treatment Institute of Chengdu, Chengdu Fifth People's Hospital (The Second Clinical Medical College, Affiliated Fifth People's Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, China
| | - Qiang Zhao
- Department of Neurosurgery, Cancer Prevention and Treatment Institute of Chengdu, Chengdu Fifth People's Hospital (The Second Clinical Medical College, Affiliated Fifth People's Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, China
| | - Shuang Luo
- Department of Neurosurgery, Cancer Prevention and Treatment Institute of Chengdu, Chengdu Fifth People's Hospital (The Second Clinical Medical College, Affiliated Fifth People's Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, China
- *Correspondence: Shuang Luo
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24
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Rutland JW, Dullea JT, Oermann EK, Feng R, Villavisanis DF, Gilja S, Shuman W, Lander T, Govindaraj S, Iloreta AMC, Chelnis J, Post K, Bederson JB, Shrivastava RK. Post-operative vision loss: analysis of 587 patients undergoing endoscopic surgery for pituitary macroadenoma. Br J Neurosurg 2022; 36:494-500. [PMID: 35264032 DOI: 10.1080/02688697.2022.2047888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
PURPOSE Vision loss following surgery for pituitary adenoma is poorly described in the literature and cannot be reliably predicted with current prognostic models. Detailed characterization of this population is warranted to further understand the factors that predispose a minority of patients to post-operative vision loss. MATERIALS AND METHODS The medical records of 587 patients who underwent endoscopic transsphenoidal surgery at the Mount Sinai Medical Centre between January 2013 and August 2018 were reviewed. Patients who experienced post-operative vision deterioration, defined by reduced visual acuity, worsened VFDs, or new onset of blurry vision, were identified and analysed. RESULTS Eleven out of 587 patients who received endoscopic surgery for pituitary adenoma exhibited post-operative vision deterioration. All eleven patients presented with preoperative visual impairment (average duration of 13.1 months) and pre-operative optic chiasm compression. Seven patients experienced visual deterioration within 24 h of surgery. The remaining four patients experienced delayed vision loss within one month of surgery. Six patients had complete blindness in at least one eye, one patient had complete bilateral blindness. Four patients had reduced visual acuity compared with preoperative testing, and four patients reported new-onset blurriness that was not present before surgery. High rates of graft placement (10/11 patients) and opening of the diaphragma sellae (9/11 patients) were found in this series. Four patients had hematomas and four patients had another significant post-operative complication. CONCLUSIONS While most patients with pituitary adenoma experience favourable ophthalmological outcomes following endoscopic transsphenoidal surgery, a subset of patients exhibit post-operative vision deterioration. The present study reports surgical and disease features of this population to further our understanding of factors that may underlie vision loss following pituitary adenoma surgery. Graft placement and opening of the diaphragma sellae may be important risk factors in vision loss following ETS and should be an area of future investigation.
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Affiliation(s)
- John W Rutland
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jonathan T Dullea
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eric K Oermann
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rui Feng
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dillan F Villavisanis
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shivee Gilja
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - William Shuman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Travis Lander
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Satish Govindaraj
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alfred M C Iloreta
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James Chelnis
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kalmon Post
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua B Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Raj K Shrivastava
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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25
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Hannan CJ, Nolan D, Corr P, Amoo M, Murray D, Looby S, Javadpour M. Sinonasal outcomes associated with the use of BioGlue® in endoscopic transsphenoidal pituitary surgery. Neurosurg Rev 2022; 45:2249-2256. [PMID: 35083593 DOI: 10.1007/s10143-021-01723-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 12/03/2021] [Accepted: 12/19/2021] [Indexed: 11/30/2022]
Abstract
Concerns have been raised in the neurosurgical literature regarding the use of BioGlue®, a tissue sealant initially developed for cardiothoracic surgery, due to reports of an increased incidence of infection, wound breakdown, and CSF fistulae. The aim of this study was to determine if the use of BioGlue® in skull base repair impacts on the sinonasal outcomes and the incidence of post-operative infection following endoscopic pituitary surgery. SNOT-22 questionnaires were completed pre-operatively, and at 6, 12, and 24 weeks post-operatively by 50 patients. Pre- and post-operative MRI scans were reviewed and assessed for evidence of post-operative sinusitis. Patient records were consulted to ascertain the incidence of post-operative infection. Repeated measures ANOVA and Wilcoxon signed rank test were used for data analysis. Statistical analysis revealed a significant difference in the mean SNOT-22 scores across the four time intervals (F(1.605, 78.642) = 9.180, p = 0.001). This difference was powered by a deterioration at 6 weeks that recovered completely by 12 weeks. The mean SNOT-22 score in the study cohort at 24 weeks was 16.84/110 (range 0-57, ± 2.04) which was lower than the mean pre-operative score and is consistent with mild rhinosinusitis. There were no cases of post-operative meningitis and 1/50 (2%) case of post-operative sinusitis in this cohort. The use of BioGlue® in endoscopic endonasal pituitary surgery does not appear to lead to significant sinonasal morbidity. Previous concerns about the use of BioGlue® in transcranial procedures may not apply to extradural application of this tissue sealant in endoscopic transnasal surgery.
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Affiliation(s)
- Cathal John Hannan
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester, England
| | - Deirdre Nolan
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Paula Corr
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Michael Amoo
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Daniel Murray
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Seamus Looby
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland. .,Royal College of Surgeons in Ireland, Dublin, Ireland. .,Department of Academic Neurology, Trinity College Dublin, Dublin, Ireland.
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26
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Gao W, Wang X, Fang Y, Hong Y, Yan W, Zhang S, Li C. Diagnostic Value of Non-Contrast CT in Cerebrospinal Fluid Leakage After Endoscopic Transnasal Surgery for Sellar and Suprasellar Tumors. Front Oncol 2022; 11:735778. [PMID: 35127466 PMCID: PMC8810488 DOI: 10.3389/fonc.2021.735778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 12/13/2021] [Indexed: 11/29/2022] Open
Abstract
We aimed to study the relationship between pneumocephalus on non-contrast CT (NCCT) and post-operative cerebrospinal fluid leakage (p-CFL) after endoscopic transsphenoidal sellar and suprasellar tumor surgeries. Data from patients who underwent endoscopic treatment for sellar or suprasellar tumors from January 2018 to March 2020 were consecutively collected and reviewed. The NCCT pneumocephalus (NP) was measured the first day after operation and the first day after the expansive sponge was extracted. p-CFL was determined according to post-operative clinical symptoms, high resolution CT and glucose test, and expert consensus. Of the 253 patients enrolled in this study, 32 (12.6%) had p-CFL. Compared with patients without p-CFL, patients with p-CFL had a higher occurrence of intra-operative CFL, a longer operation time, a higher rate of pneumocephalus on first-day NCCT after operation (i.e., first-day NP), and a higher rate of NP volume change between two NCCT measurements (referred to as the NP change) (all p < 0.05). In multivariate regression analysis, first-day NP was independently associated with p-CFL occurrence [odds ratio (OR)=6.395, 95% confidence interval (CI)=2.236-18.290, p=0.001). After adding the NP change into the regression model, first-day NP was no longer independently associated with p-CFL, and NP change (OR = 19.457, 95% CI = 6.095–62.107, p<0.001) was independently associated with p-CFL. The receiver operating characteristic curve comparison analysis showed that NP change had a significantly better predicting value than first-day NP (area under the curve: 0.988 vs. 0.642, Z=6.451, p=0.001). NP is an effective imaging marker for predicting p-CFL after endoscopic sellar and suprasellar tumors operation, and the NP change has a better predicting value.
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Affiliation(s)
- Wei Gao
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
- Department of Neurosurgery, Changxing People’s Hospital, Changxing, China
| | - Xiaoyu Wang
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Yuanjian Fang
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Yuan Hong
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Wei Yan
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Sheng Zhang
- Department of Neurology, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, China
- *Correspondence: Sheng Zhang, ; Chenguang Li,
| | - Chenguang Li
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
- *Correspondence: Sheng Zhang, ; Chenguang Li,
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27
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Zhou Y, Wei J, Feng F, Wang J, Jia P, Yang S, Gao D. Pseudocapsule-Based Resection for Pituitary Adenomas via the Endoscopic Endonasal Approach. Front Oncol 2022; 11:812468. [PMID: 35111684 PMCID: PMC8801736 DOI: 10.3389/fonc.2021.812468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/22/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction The 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. Methods From 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. Results The 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. Conclusion Pseudocapsule-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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Affiliation(s)
- Yuefei Zhou
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Jialiang Wei
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Feng Feng
- Department of Rehabilitation Medicine, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Jianguo Wang
- Department of Neurosurgery, Shenmu County Hospital, Yulin, China
| | - Pengfei Jia
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Shuangwu Yang
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Dakuan Gao
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
- *Correspondence: Dakuan Gao,
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28
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Stumpo V, Staartjes VE, Regli L, Serra C. Machine Learning in Pituitary Surgery. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 134:291-301. [PMID: 34862553 DOI: 10.1007/978-3-030-85292-4_33] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Machine learning applications in neurosurgery are increasingly reported for diverse tasks such as faster and more accurate preoperative diagnosis, enhanced lesion characterization, as well as surgical outcome, complications and healthcare cost prediction. Even though the pertinent literature in pituitary surgery is less extensive with respect to other neurosurgical diseases, past research attempted to answer clinically relevant questions to better assist surgeons and clinicians. In the present chapter we review reported ML applications in pituitary surgery including differential diagnosis, preoperative lesion characterization (immunohistochemistry, cavernous sinus invasion, tumor consistency), surgical outcome and complication predictions (gross total resection, tumor recurrence, and endocrinological remission, cerebrospinal fluid leak, postoperative hyponatremia). Moreover, we briefly discuss from a practical standpoint the current barriers to clinical translation of machine learning research. On the topic of pituitary surgery, published reports can be considered mostly preliminary, requiring larger training populations and strong external validation. Thoughtful selection of clinically relevant outcomes of interest and transversal application of model development pipeline-together with accurate methodological planning and multicenter collaborations-have the potential to overcome current limitations and ultimately provide additional tools for more informed patient management.
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Affiliation(s)
- Vittorio Stumpo
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Victor E Staartjes
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
| | - Luca Regli
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Carlo Serra
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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29
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Zhou Z, Zuo F, Chen X, Zhao Q, Luo M, Jiang X, Duan Y. Risk factors for postoperative cerebrospinal fluid leakage after transsphenoidal surgery for pituitary adenoma: a meta-analysis and systematic review. BMC Neurol 2021; 21:417. [PMID: 34706659 PMCID: PMC8555154 DOI: 10.1186/s12883-021-02440-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 10/12/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Postoperative cerebrospinal fluid (CSF) leakage represents a challenge even for experienced pituitary surgeons. We aimed to quantitatively synthesize data from studies regarding the risk factors for postoperative CSF leakage after transsphenoidal surgery (TSS) for pituitary adenoma (PA). METHODS PubMed, Web of Science, The Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), Wanfang database, and VIP database were searched for case-control and cohort studies, focusing on the risk factors associated with postoperative CSF leakage after TSS for PA. Pooled odds ratios (ORs) and 95% confidence intervals were calculated to determine the risk factors. RESULTS A total of 34 case-control and cohort studies involving a total of 9,144 patients with PA were included in this systematic review. The overall rate of postoperative CSF leakage after TSS for PA was 5.6%. Tumor size, adenoma consistency, revision surgery, and intraoperative CSF leakage were independent risk factors for postoperative CSF leakage (ORs, 3.18-6.33). By contrast, the endoscopic approach showed a slight protective benefit compared with the microscopic approach in TSS (OR, 0.69). CONCLUSIONS This review provides a comprehensive overview of the quality of the evidence base, informing clinical staff of the importance of screening risk factors for postoperative CSF leakage after TSS for PA. More attention should be paid to PA patients at high risk for CSF leakage after TSS to reduce complications and improve prognosis.
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Affiliation(s)
- Zhihuan Zhou
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
- Department of Neurosurgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
| | - Feifei Zuo
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
- Department of Neurosurgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
| | - Xiaoqun Chen
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
- Department of Neurosurgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
| | - Qinqin Zhao
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
- Department of Neurosurgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
| | - Mengna Luo
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, PR China
| | - Xiaobing Jiang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
- Department of Neurosurgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China
| | - Yuyu Duan
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China.
- Department of Neurosurgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, PR China.
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Ahn S, Park JS, Kim DH, Kim SW, Jeun SS. Surgical Experience in Prevention of Postoperative CSF Leaks Using Abdominal Fat Grafts in Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Adenomas. J Neurol Surg B Skull Base 2021; 82:522-527. [PMID: 34513557 DOI: 10.1055/s-0040-1712179] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 03/19/2020] [Indexed: 10/23/2022] Open
Abstract
Objective Cerebrospinal fluid (CSF) leaks are the most common complication during endonasal endoscopic transsphenoidal approach (EETSA) and prevention of postoperative CSF leaks is critical. In this study, we report a single surgeon's experience of sellar floor reconstruction using abdominal fat grafts for prevention of postoperative CSF leaks in EETSA for pituitary adenomas. Study Design This study is presented as case series with retrospective chart review. Setting Present study was conducted at tertiary referral center. Participants A total of 216 patients who underwent surgery via EETSA for pituitary adenomas between 2008 and 2018 at our institution were evaluated. When an intraoperative CSF leak occurred, sellar floor reconstruction was performed using a fat graft harvested from the abdomen via a 2-cm skin incision. Main Outcome Measures Primary outcome and measures of this study was postoperative CSF leaks. Results A total of 53 patients showed intraoperative CSF leaks (24.5%) and 2 patients showed postoperative CSF leaks (0.93%). There were no postoperative CSF leaks in any patients who showed intraoperative CSF leaks and received sellar floor reconstruction using fat grafts. There were also no postoperative CSF leaks in 12 patients who received preventative sellar floor reconstruction using fat grafts due to extensive arachnoid herniation without intraoperative CSF leaks. However, there were two postoperative CSF leaks in patients who did not show intraoperative CSF leaks and did not receive sellar floor reconstruction. Conclusion The effectiveness of sellar floor reconstruction using abdominal fat grafts in patients receiving EETSA for pituitary adenoma was reported. We suggest that identification of intraoperative CSF leaks is important and preventive sellar floor reconstruction without evidence of intraoperative CSF leaks can also be beneficial.
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Affiliation(s)
- Stephen Ahn
- Department of Neurosurgery, The Catholic University of Korea, Seoul St. Mary's Hospital, College of Medicine, Seoul, Republic of Korea
| | - Jae-Sung Park
- Department of Neurosurgery, The Catholic University of Korea, Seoul St. Mary's Hospital, College of Medicine, Seoul, Republic of Korea
| | - Do H Kim
- Department of Otolaryngology-Head and Neck Surgery, The Catholic University of Korea, Seoul St. Mary's Hospital, College of Medicine, Seoul, Republic of Korea
| | - Sung W Kim
- Department of Otolaryngology-Head and Neck Surgery, The Catholic University of Korea, Seoul St. Mary's Hospital, College of Medicine, Seoul, Republic of Korea
| | - Sin-Soo Jeun
- Department of Neurosurgery, The Catholic University of Korea, Seoul St. Mary's Hospital, College of Medicine, Seoul, Republic of Korea
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The incidence of postoperative cerebrospinal fluid leakage after elective cranial surgery: a systematic review. Neurosurg Rev 2021; 45:1827-1845. [PMID: 34499261 DOI: 10.1007/s10143-021-01641-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/12/2021] [Accepted: 09/02/2021] [Indexed: 10/20/2022]
Abstract
Cerebrospinal fluid (CSF) leakage is a major complication after elective neurosurgical procedures. The aim of this systematic literature review is to summarize the incidence rates of postoperative cerebrospinal fluid leakage for neurosurgical procedures, classified by surgical approach. The Pubmed, Cochrane, Embase, and Web of Science databases were searched for studies reporting the outcome of patients undergoing elective neurosurgical procedures. The number of patients, surgical approach, and indication for surgery were recorded for each study. Outcomes related to CSF leakage such as clinical manifestation and treatment were reported as well. One hundred and thirteen studies were included, reporting 94,695 cases. Overall, CSF leaks were present in 3.8% of cases. Skull base surgery had the highest rate of CSF leakage with 6.2%. CSF leakage occurred in 5.9% of anterior skull base procedures, 6.4% of middle fossa, and 5.2% of transpetrosal surgeries. 5.8% of reported infratentorial procedures were complicated by CSF leakage versus 2.9% of supratentorial surgeries. CSF leakage remains a common serious adverse event after cranial surgery. There exists a need for standardized procedures to reduce the incidence of postoperative CSF leakage, as this serious adverse event may lead to increased health care costs.
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Van Gerven L, Qian Z, Starovoyt A, Jorissen M, Meulemans J, van Loon J, De Vleeschouwer S, Lambert J, Bex M, Vander Poorten V. Endoscopic, Endonasal Transsphenoidal Surgery for Tumors of the Sellar and Suprasellar Region: A Monocentric Historical Cohort Study of 369 Patients. Front Oncol 2021; 11:643550. [PMID: 34026618 PMCID: PMC8138557 DOI: 10.3389/fonc.2021.643550] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/06/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The endoscopic endonasal transsphenoidal approach (EETA) is an established technique for the resection of a large variety of benign sellar and suprasellar lesions, mostly pituitary adenomas. It has clear advantages over the microscopic approach, like a superior close-up view of the relevant anatomy and the tumor-gland interface, an enlarged working angle, as well as an increased panoramic vision inside the surgical area. We have been performing the EETA for over a decade, and this study will focus on perioperative and postoperative outcomes and complications and their association with the learning curve. MATERIAL AND METHODS All patients in our tertiary referral center (n = 369) undergoing an EETA for a lesion of the sellar and suprasellar region between January 1st 2008 and December 31st 2018 were included, and data were retrospectively retrieved from the electronic patient records. RESULTS Median follow-up after surgery was 55 months. Pituitary adenomas (n = 322) were the most frequent pathology. Headache (43.4%) and loss of vision (29.3%) were the most common presenting symptoms. Median procedure duration was significantly longer during the initial 5 years (106 versus 79 minutes; p <0.0001), but incidence of peri- and postoperative CSF leaks in the early years was not significantly higher. Knosp grade >2 was associated with perioperative CSF leak (p =0.002), and perioperative CSF leak was associated with postoperative CSF leak (p <0.001). Almost all cases of meningitis were preceded by a postoperative CSF leak. In 22.4% of patients, tumor recurrence required additional therapy. Perioperative (iatrogenic) mortality was 0.8%. The overall hospital stay decreased over time from an average of 7 to 5 days, and the case load increased yearly (p =0.015). CONCLUSION The EETA is an excellent technique with complication rates comparable to or even lower than those in large microsurgical series in the literature. EETA has a significant learning curve affecting the procedure duration. Throughout the first 10 years following the transition from the microscopic approach to the EETA in our cohort, the caseload increased and hospital stay was reduced, while no increase in peri- and postoperative complications was observed.
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Affiliation(s)
- Laura Van Gerven
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Otorhinolaryngology, KU Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and transplantation, Allergy and Clinical Immunology Research Unit, KU Leuven, Leuven, Belgium
| | - Zhen Qian
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Anastasiya Starovoyt
- Department of Neurosciences, Experimental Otorhinolaryngology, KU Leuven, Leuven, Belgium
| | - Mark Jorissen
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Jeroen Meulemans
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, Section Head and Neck Oncology, KU Leuven, Leuven, Belgium
| | - Johannes van Loon
- Neurosciences, Research Group Experimental Neurosurgery and Neuroanatomy and Leuven Brain Institute, Leuven, Belgium
| | - Steven De Vleeschouwer
- Neurosciences, Research Group Experimental Neurosurgery and Neuroanatomy and Leuven Brain Institute, Leuven, Belgium
| | - Julie Lambert
- Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Marie Bex
- Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Vincent Vander Poorten
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, Section Head and Neck Oncology, KU Leuven, Leuven, Belgium
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Hunsaker J, Khan M, Makarenko S, Evans J, Couldwell W, Karsy M. Prediction of Readmission and Complications After Pituitary Adenoma Resection via the National Surgical Quality Improvement Program (NSQIP) Database. Cureus 2021; 13:e14809. [PMID: 34123604 PMCID: PMC8191857 DOI: 10.7759/cureus.14809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2021] [Indexed: 02/07/2023] Open
Abstract
Introduction Pituitary adenomas are common intracranial tumors (incidence 4:100,000 people) with good surgical outcomes; however, a subset of patients show higher rates of perioperative morbidity. Our goal was to identify risk factors for postoperative complications or readmission after pituitary adenoma resection. Methods We undertook a retrospective cohort study of patients who underwent surgery for pituitary adenoma in 2006-2018 by using the National Surgical Quality Improvement Program database. The main outcome measures were patient complications and the 30-day readmission rate. Results Among the 2,292 patients (mean age 53.3±15.9 years), there were 491 complications in 188 patients (8.2%). Complications and 30-day readmission have remained stable over time rather than declined. Unplanned readmission was seen in 141 patients (6.2%). Multivariable analysis demonstrated that hypertension (OR=1.6; 95% CI= 1.1, 2.1; p=0.005) and high white blood cell count (OR=1.08; 95% CI=1.03, 1.1; p=0.0001) were independent predictors of complications. Return to the operating room (OR=5.9, 95% CI=1.7, 20.2, p=0.0005); complications (OR=4.1, 95% CI=1.6, 10.6, p=0.004); and blood urea nitrogen (OR=1.08, 95% CI=1.02, 1.2, p=0.02) were independent predictors of 30-day readmission. Conclusion Using one of the largest datasets of pituitary adenoma patients, we identified perioperative factors most critical for patient outcome. One strength of this study is adjusting for cofactors that predict outcomes, which has not been done previously. Several patient biomarkers, namely white blood cell count and blood urea nitrogen, may serve as preoperative markers that might identify patients at higher risk. Control of blood pressure and renal disease may be perioperative management strategies that can impact the outcome.
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Affiliation(s)
- Joshua Hunsaker
- Neurological Surgery, University of Utah, Salt Lake City, USA
| | - Majid Khan
- Medicine, Reno School of Medicine, University of Nevada, Reno, USA
| | - Serge Makarenko
- Neurological Surgery, University of Utah, Salt Lake City, USA
| | - James Evans
- Neurosurgery, Thomas Jefferson Medical College, Philadelphia, USA
| | | | - Michael Karsy
- Neurological Surgery, University of Utah, Salt Lake City, USA
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Golden N, Niryana W, Awyono S, Mardhika PE, Putra MB, Biondi MS. Transcranial approach as surgical treatment for giant pituitary adenoma during COVID 19 pandemic - What can we learn?: A case report. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2021; 25:101153. [PMID: 33654658 PMCID: PMC7906516 DOI: 10.1016/j.inat.2021.101153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 02/13/2021] [Accepted: 02/15/2021] [Indexed: 11/18/2022]
Abstract
Introduction In the COVID 19 pandemic, pituitary surgery is one of challenging surgical treatment, especially the involving transsphenoid approach. It was reported that the aerosolisation and mucosal involvement increase the risk of viral transmission during operation. Therefore, transcranial is a safer surgical approach during COVID-19 pandemic. This study aimed to reported transcranial approach to treat giant pituitary adenoma with aggressive visual disturbance which require urgent surgical management. Case presentation We reported a 21-year old male, who required urgent surgery because of progressive visual disturbance due to giant pituitary adenoma. On brain MRI with contrast, it was revealed an extraaxial tumor extending anteriorly over plannum sphenoidal with the greatest diameter was 5.34 cm. Transcranial approach was chosen to resect the tumor. Near total removal of the tumor was achieved without damaging vital neurovascular structure. The visual acuity was improved and no significant postoperative complication. Pathology examination revealed pituitary adenoma. Conclusion Transcranial surgery for pituitary adenoma is still an armamentarium in neurosurgical practice, especially in the COVID 19 pandemic to provide safer surgical approach.
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Affiliation(s)
- Nyoman Golden
- Department of Neurosurgery, Faculty of Medicine, Sanglah Hospital, Universitas Udayana, Bali, Indonesia
| | - Wayan Niryana
- Department of Neurosurgery, Faculty of Medicine, Sanglah Hospital, Universitas Udayana, Bali, Indonesia
| | - Steven Awyono
- Department of Neurosurgery, Faculty of Medicine, Sanglah Hospital, Universitas Udayana, Bali, Indonesia
| | - Putu Eka Mardhika
- Department of Neurosurgery, Faculty of Medicine, Sanglah Hospital, Universitas Udayana, Bali, Indonesia
| | - Made Bhuwana Putra
- Department of Neurosurgery, Faculty of Medicine, Sanglah Hospital, Universitas Udayana, Bali, Indonesia
| | - Made Stefanus Biondi
- Department of Neurosurgery, Faculty of Medicine, Sanglah Hospital, Universitas Udayana, Bali, Indonesia
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Villalonga JF, Solari D, Cavallo LM, Cappabianca P, Prevedello DM, Carrau R, Martinez-Perez R, Hardesty D, Fuchssteiner C, Saenz A, Abbritti RV, Valencia-Ramos C, Kaen A, Bernat AL, Cardenas E, Hirtler L, Gomez-Amador JL, Liu J, Froelich S, Cervio A, Campero A. The sellar barrier on preoperative imaging predicts intraoperative cerebrospinal fluid leak: a prospective multicenter cohort study. Pituitary 2021; 24:27-37. [PMID: 32918661 DOI: 10.1007/s11102-020-01082-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The type of sellar barrier observed between a pituitary tumor and cerebrospinal fluid (CSF) on preoperative magnetic resonance imaging (MRI) may predict intraoperative CSF leak during endonasal pituitary surgery. This is the first multicentric prospective cohort trial to study the sellar barrier concept and CSF leak rate during endoscopic pituitary surgery. METHODS This multi-center, international study enrolled patients operated for pituitary adenomas via fully endoscopic endonasal surgery over a period of 4 months. The independent variable was the subtype of sellar barrier observed on preoperative MRI (strong, mixed or weak); the dependent variable was the presence of an intraoperative CSF leak. The primary goal was to determine the association between a particular type of sellar barrier and the risk of intraoperative CSF leak. Appropriate statistical methods were then applied for data analysis. RESULTS Over the study period, 310 patients underwent endoscopic endonasal surgery for pituitary tumor. Preoperative imaging revealed a weak sellar barrier in 73 (23.55%), a mixed sellar barrier in 75 (24.19%), and a strong sellar barrier in 162 (52.26%) patients. The overall rate of intraoperative CSF leak among all patients was 69 (22.26%). A strong sellar-type barrier was associated with significantly reduced rate of intraoperative CSF leak (RR = 0.08; 95% CI 0.03-0.19; p < 0.0001), while a weak sellar barrier associated with higher rates of CSF leak (RR = 8.54; 95% CI 5.4-13.5; p < 0.0001). CONCLUSIONS The preoperative MRI of pituitary patients can suggest intraoperative CSF leak rates, utilizing the concept of the sellar barrier. Patients with a weak sellar barrier carry a higher risk for an intraoperative CSF leak, whereas a strong sellar barrier on MRI seems to mitigate intraoperative CSF leak. We propose that preoperatively assessment of the sellar barrier can prepare surgeons for intraoperative CSF leak repair.
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Affiliation(s)
- Juan F Villalonga
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Lamadrid 875, San Miguel de Tucumán, Tucumán, Argentina.
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Luigi M Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Paolo Cappabianca
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Daniel M Prevedello
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Ricardo Carrau
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Rafael Martinez-Perez
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Douglas Hardesty
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Christoph Fuchssteiner
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Amparo Saenz
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Lamadrid 875, San Miguel de Tucumán, Tucumán, Argentina
| | | | | | - Ariel Kaen
- Hospital Virgen del Rocío, Sevilla, Spain
| | - Anne-Laure Bernat
- Lariboisière University Hospital - Assistance Publique, Paris, France
| | | | - Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | | | - James Liu
- Rutgers New Jersey Medical School, Newark, NY, USA
| | | | | | - Alvaro Campero
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Lamadrid 875, San Miguel de Tucumán, Tucumán, Argentina
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CSF Rhinorrhoea After Endonasal Intervention to the Skull Base (CRANIAL) - Part 1: Multicenter Pilot Study. World Neurosurg 2021; 149:e1077-e1089. [PMID: 33444844 PMCID: PMC8105646 DOI: 10.1016/j.wneu.2020.12.171] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 01/29/2023]
Abstract
Background CRANIAL (CSF Rhinorrhoea After Endonasal Intervention to the Skull Base) is a prospective multicenter observational study seeking to determine 1) the scope of skull base repair methods used and 2) corresponding rates of postoperative cerebrospinal fluid (CSF) rhinorrhea in the endonasal transsphenoidal approach (TSA) and the expanded endonasal approach (EEA) for skull base tumors. We sought to pilot the project, assessing the feasibility and acceptability by gathering preliminary data. Methods A prospective observational cohort study was piloted at 12 tertiary neurosurgical units in the United Kingdom. Feedback regarding project positives and challenges were qualitatively analyzed. Results A total of 187 cases were included: 159 TSA (85%) and 28 EEA (15%). The most common diseases included pituitary adenomas (n = 142/187), craniopharyngiomas (n = 13/187). and skull base meningiomas (n = 4/187). The most common skull base repair techniques used were tissue glues (n = 132/187, most commonly Tisseel), grafts (n = 94/187, most commonly fat autograft or Spongostan) and vascularized flaps (n = 51/187, most commonly nasoseptal). These repairs were most frequently supported by nasal packs (n = 125/187) and lumbar drains (n = 20/187). Biochemically confirmed CSF rhinorrhea occurred in 6/159 patients undergoing TSA (3.8%) and 2/28 patients undergoing EEA (7.1%). Four patients undergoing TSA (2.5%) and 2 patients undergoing EEA (7.1%) required operative management for CSF rhinorrhea (CSF diversion or direct repair). Qualitative feedback was largely positive (themes included user-friendly and efficient data collection and strong support from senior team members), demonstrating acceptability. Conclusions Our pilot experience highlights the acceptability and feasibility of CRANIAL. There is a precedent for multicenter dissemination of this project, to establish a benchmark of contemporary practice in skull base neurosurgery, particularly with respect to patients undergoing EEA.
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Shahein M, Montaser AS, Barbero JMR, Maza G, Todeschini AB, Otto BA, Carrau RL, Prevedello DM. Collagen Matrix With Mucoperiosteum Graft as an Effective Fatless Flapless Reconstruction After Endoscopic Pituitary Adenoma Resection. Oper Neurosurg (Hagerstown) 2020; 19:E573-E580. [PMID: 32710760 DOI: 10.1093/ons/opaa212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 04/30/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Proper skull base reconstruction after endoscopic endonasal pituitary surgery is of great importance to decrease the rate of complications. OBJECTIVE To assess the safety and efficacy of reconstruction with materials other than fat graft and naso-septal flaps (NSF) to avoid their associated morbidities. METHODS The authors' institutional database for patients who underwent endoscopic endonasal approach for pituitary adenoma was reviewed. Exclusion criteria included recurrence, postradiation therapy, and reconstruction by fat graft or NSF. They were divided into group A, where collagen matrix (CM) (DuraGen® Plus Matrix, Integra LifeSciences Corporation, Plainsboro, New Jersey) alone was used; group B, where CM and simple mucoperiosteum graft were used and group C, which included cases without CM utilization. RESULTS The study included 252 patients. No age, gender, or body mass index statistically significant difference between groups. Group B included the largest tumor size (23.0 mm) in comparison to groups A (18.0 mm) and C (13.0 mm). Suprasellar extension was more frequently present (49.4%) in comparison to groups A (29.8%, P = .001) and C (21.2%, P < .001). Postoperative cerebrospinal fluid (CSF) leak rate was 0%, 2.9%, and 6% in groups A, B, and C, respectively. In group B, the CSF leak rate decreased from 45.9% intraoperatively to 2.9% postoperatively (P < .001). In group A, the CSF leak reduction rate was almost statistically significant (P = .06). CONCLUSION Utilization of CM and simple mucosperiosteal graft in skull base reconstruction following pituitary adenoma surgery is an effective method to avoid the morbidities associated with NSF or fat graft.
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Affiliation(s)
- Mostafa Shahein
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio.,Department of Neurological Surgery, Aswan University, Aswan, Egypt
| | - Alaa S Montaser
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio.,Department of Neurological Surgery, Ain Shams University, Cairo, Egypt
| | - Juan M Revuelta Barbero
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio
| | - Guillermo Maza
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Alexandre B Todeschini
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio
| | - Bradley A Otto
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio.,Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Ricardo L Carrau
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio.,Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Daniel M Prevedello
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio.,Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
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Khatri D, D'Amico R, Langer DJ, Boockvar JA. Commentary: Collagen Matrix With Mucoperiosteum Graft as an Effective Fatless Flapless Reconstruction After Endoscopic Pituitary Adenoma Resection. Oper Neurosurg (Hagerstown) 2020; 19:E581-E582. [PMID: 32970117 DOI: 10.1093/ons/opaa287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 11/13/2022] Open
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Tan DCH, Robinson S, Wickremesekera A. An unusual case of post-nasal "clicking" after pituitary surgery. J Clin Neurosci 2020; 81:70-71. [PMID: 33222972 DOI: 10.1016/j.jocn.2020.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/31/2020] [Accepted: 09/06/2020] [Indexed: 10/23/2022]
Abstract
We report a case of a 64-year-old female who represented two months after pituitary surgery with the novel complication of intermittent disabling post-nasal pulsatile "clicking". Imaging and endoscopic examination showed a residual sella cleft with the tumour capsule and diaphragma cupping against the anterior sella bony defect with each pulsation, causing the clicking. The clicking resolved following second redo surgical endoscopic repair to jail a fat graft within the residual cleft with a central barricade of conchal cartilage graft and onlay standard repair.
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Affiliation(s)
- David Chi Hau Tan
- Department of Neurosurgery, Wellington Regional Hospital, Capital & Coast District Health Board, New Zealand
| | - Simon Robinson
- Wakefield Sinus and Endoscopic Skull Base Surgery, Wakefield Hospital, Wellington, New Zealand
| | - Agadha Wickremesekera
- Department of Neurosurgery, Wellington Regional Hospital, Capital & Coast District Health Board, New Zealand
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Abhinav K, Tyler M, Dale OT, Mohyeldin A, Fernandez-Miranda JC, Katznelson L. Managing complications of endoscopic transsphenoidal surgery in pituitary adenomas. Expert Rev Endocrinol Metab 2020; 15:311-319. [PMID: 32744080 DOI: 10.1080/17446651.2020.1800452] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 07/21/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Over the last two decades there has been a gradual shift from the traditional microscopic approach toward the use of endoscopic endonasal approach for resection of pituitary adenomas. Multiple medical and surgical complications can occur following endoscopic transsphenoidal resection of adenomas. AREAS COVERED We discuss the evolution of the surgical practice from the use of the 'microscope' to the 'endoscope' in the resection of pituitary adenomas. We present a comprehensive review of the medical and surgical complications following surgery with particular emphasis on both the prevention and management of electrolyte disturbance, cerebrospinal fluid leak and the rare but dreaded complication of internal carotid injury (ICA). We also searched the PubMed database to identify relevant literature between 1984 and 2019. EXPERT OPINION Use of endoscope compared with microscope may be associated with better preservation of pituitary gland function with similar extent of resection. Overall medical and surgical complications can be safely managed in high volume centers in association with endocrinologists and skull base trained otolaryngologists. Understanding of anatomico-technical nuances and meticulous surgical technique are important toward preventing ICA injury. Ongoing surgical and technical developments coupled with imaging advances will likely lead to better future outcomes for patients with functioning and nonfunctioning adenomas.
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Affiliation(s)
- Kumar Abhinav
- Department of Neurosurgery, Institute of Clinical Neuroscience, Center for Endoscopic and Pituitary Skull Base Surgery, Southmead Hospital , Bristol, UK
| | - Matthew Tyler
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota , Minneapolis, MN, USA
| | - Oliver T Dale
- Department of ENT-Head and Neck Surgery, University Hospitals Bristol , Bristol, UK
| | - Ahmed Mohyeldin
- Department of Neurosurgery, Stanford University School of Medicine , Stanford, CA, USA
| | | | - Laurence Katznelson
- Department of Neurosurgery, Stanford University School of Medicine , Stanford, CA, USA
- Department of Medicine, Stanford University School of Medicine , Stanford, CA, USA
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Staartjes VE, Zattra CM, Akeret K, Maldaner N, Muscas G, Bas van Niftrik CH, Fierstra J, Regli L, Serra C. Neural network-based identification of patients at high risk for intraoperative cerebrospinal fluid leaks in endoscopic pituitary surgery. J Neurosurg 2020; 133:329-335. [PMID: 31226693 DOI: 10.3171/2019.4.jns19477] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 04/08/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Although rates of postoperative morbidity and mortality have become relatively low in patients undergoing transnasal transsphenoidal surgery (TSS) for pituitary adenoma, cerebrospinal fluid (CSF) fistulas remain a major driver of postoperative morbidity. Persistent CSF fistulas harbor the potential for headache and meningitis. The aim of this study was to investigate whether neural network-based models can reliably identify patients at high risk for intraoperative CSF leakage. METHODS From a prospective registry, patients who underwent endoscopic TSS for pituitary adenoma were identified. Risk factors for intraoperative CSF leaks were identified using conventional statistical methods. Subsequently, the authors built a prediction model for intraoperative CSF leaks based on deep learning. RESULTS Intraoperative CSF leaks occurred in 45 (29%) of 154 patients. No risk factors for CSF leaks were identified using conventional statistical methods. The deep neural network-based prediction model classified 88% of patients in the test set correctly, with an area under the curve of 0.84. Sensitivity (83%) and specificity (89%) were high. The positive predictive value was 71%, negative predictive value was 94%, and F1 score was 0.77. High suprasellar Hardy grade, prior surgery, and older age contributed most to the predictions. CONCLUSIONS The authors trained and internally validated a robust deep neural network-based prediction model that identifies patients at high risk for intraoperative CSF. Machine learning algorithms may predict outcomes and adverse events that were previously nearly unpredictable, thus enabling safer and improved patient care and better patient counseling.
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Affiliation(s)
- Victor E Staartjes
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- 2Amsterdam UMC, Vrije Universiteit Amsterdam, Neurosurgery, Amsterdam Movement Sciences, Amsterdam, The Netherlands; and
| | - Costanza M Zattra
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Kevin Akeret
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nicolai Maldaner
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Giovanni Muscas
- 3Department of Neurosurgery, Tuscany School of Neurosurgery, University of Firenze, Firenze, Italy
| | | | - Jorn Fierstra
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Carlo Serra
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Enhanced recovery and accelerated discharge after endoscopic transsphenoidal pituitary surgery: safety, patient feedback, and cost implications. Acta Neurochir (Wien) 2020; 162:1281-1286. [PMID: 32144485 DOI: 10.1007/s00701-020-04282-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 02/27/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) is a constant motivation. There is growing evidence that an endoscopic (rather than microscopic) transsphenoidal approach to pituitary tumours can play a role, facilitating faster recovery and a commensurate reduction in length of stay (LOS). Reducing LOS is beneficial to both patients and healthcare systems. We sought to assess the safety, patient feedback, and resource implications of adopting an enhanced recovery and accelerated discharge policy for elective pituitary surgery. METHODS We retrospectively assessed two consecutive cohorts of patients undergoing elective surgery for pituitary adenoma in a single UK centre between July 2016 and November 2019. The pre-ERAS cohort included 52 sequential patients operated prior to protocol change. The ERAS cohort included 55 sequential patients operated after a protocol change. Patient demographic data, tumour characteristics, intra- and post-operative CSF leak, the rate and cause of readmission (within 30 days), and the mean and median LOS were recorded. Patient feedback was collected from a subset of patients (n = 23) in the ERAS group. RESULTS The two cohorts were well-matched with respect to their demographic, pathological, and operative characteristics. The rates of readmission within 30 days of discharge were similar between the two groups (8% pre-ERAS cohort, 9% ERAS cohort, p = 0.75). In the pre-ERAS cohort, the mean LOS was 4.5 days and median LOS was 3 days. This compares with significant reduction in LOS for the ERAS group: mean of 1.7 days and median of 1 day (p < 0.05). Thirty-nine of 55 patients in the ERAS group were discharged on post-operative day 1. Patient feedback was very positive in the ERAS group (mean patient satisfaction score of 9.7/10 using a Likert scale). CONCLUSIONS An enhanced recovery protocol after elective endoscopic pituitary surgery is safe, reduces length of stay, and is associated with high patient satisfaction.
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Xue H, Wang X, Yang Z, Bi Z, Liu P. Risk factors and outcomes of cerebrospinal fluid leak related to endoscopic pituitary adenoma surgery. Br J Neurosurg 2020; 34:447-452. [PMID: 32319826 DOI: 10.1080/02688697.2020.1754336] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Hai Xue
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingchao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhijun Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhiyong Bi
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Pinan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neural Reconstruction, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
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44
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The sellar barrier and intraoperative CSF leak in elderly patients. J Clin Neurosci 2020; 73:48-50. [PMID: 32070673 DOI: 10.1016/j.jocn.2020.01.078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 12/19/2019] [Accepted: 01/26/2020] [Indexed: 12/30/2022]
Abstract
Cerebral spinal fluid (CSF) leak is a significant complication in pituitary surgery, increasing both patient morbidity and mortality. In a recent publication, Campero et al. observed worse postoperative prognosis and increased risk of intraoperative CSF leak in patients with reduced sellar barrier thickness. The objective of this study was to analyze the association between sellar barrier thickness and intraoperative CSF leak in older individuals. A retrospective review was conducted of 44 transsphenoidal surgery resections for pituitary adenomas, 24 microscopic and 20 purely endoscopic procedures. Presence of intraoperative CSF fistula was significantly greater in patients with weak sellar barrier (thickness under 1 mm), compared to strong sellar barrier (52.94% vs 3.70% p < 0.0001, respectively). Application of this novel concept may help improve surgical technique selection as well as predict risk of intraoperative CSF leak and need for eventual use of flaps for reconstruction.
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45
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Villalonga JF, Fuchssteiner C, Solari D, Campero A, Cavallo LM, Cappabianca P, Hirtler L. Endoscopic anatomy of the sellar barrier: From the anatomical model to the operating room. Clin Anat 2020; 33:468-474. [PMID: 31943393 DOI: 10.1002/ca.23566] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/18/2019] [Accepted: 01/11/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND The sellar barrier concept reflects the association between the components of the roof of the pituitary fossa and the risk of intraoperative cerebrospinal fluid (CSF) leak in the surgery of pituitary adenomas. We based our concept in previous reports on the microsurgical anatomy of the pituitary fossa's superior wall. However, proof of the usefulness of this concept in endoscopic approaches is yet missing. The aim of this study was to describe the endoscopic anatomy of the sellar barrier and its subtypes in a laboratory setting and to provide evidence of its clinical usefulness. METHODS We provided anatomical models in six fresh-frozen head and neck specimens. We performed an endoscopic endonasal approach and recreated a pathological model of each possible subtype of sellar barrier. To demonstrate the usefulness of this model in clinical practice, we conducted a prospective study including all patients with pituitary adenoma operated by an endoscopic approach between June and July 2019. RESULTS We successfully recreated the models for each subtype of sellar barrier. When analyzing the clinical cases, we found that intraoperatively, 73.69% (14) had a strong sellar barrier; 21.05% (4) had mixed sellar barrier, and 5.26% (1) had weak sellar barrier. We recorded one case of intraoperative CSF leak in a patient with a weak sellar barrier by magnetic resonance imaging. CONCLUSION We described the endoscopic anatomy of the sellar barrier and we recreated the three subtypes in anatomical models. We also identified these subtypes in a series of clinical cases, proving its clinical usefulness.
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Affiliation(s)
- Juan F Villalonga
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, San Miguel de Tucumán, Tucumán, Argentina.,Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria.,Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Christoph Fuchssteiner
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Domenico Solari
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Alvaro Campero
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, San Miguel de Tucumán, Tucumán, Argentina
| | - Luigi M Cavallo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Paolo Cappabianca
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
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Jiménez Zapata HD, Rodríguez Berrocal V, Vior Fernández C, Sánchez FM, García Fernández A. Sellar Diaphragm Reconstruction with Tachosil During Endoscopic Endonasal Surgery: Technical Note. J Neurol Surg B Skull Base 2019; 81:275-279. [PMID: 32500002 DOI: 10.1055/s-0039-1688781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 03/23/2019] [Indexed: 12/17/2022] Open
Abstract
This report introduces a new closure technique for the management of intraoperative cerebrospinal fluid (CSF) leakage during endoscopic endonasal surgery. The procedure is based on the combination of a traditional autologous tissue flap with a heterologous fibrin graft (TachoSil). We performed a retrospective analysis on 121 patients with pituitary adenomas treated in our center by the senior neurosurgeon (author V.R.B) in the previous 4 years. Only one patient (0.8%) developed a CSF leakage and no adverse events were found related to the use of TachoSil. Compared with other techniques used previously, sellar diaphragm reconstruction with TachoSil seems to be an effective and inexpensive alternative.
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Fujita Y, Taniguchi M, Tsuzuki T, Nakai T, Uozumi Y, Kimura H, Kohmura E. Application of a Minimally Invasive Liposuction Technique for Harvesting Fat during Transsphenoidal Surgery: A Technical Note. Neurol Med Chir (Tokyo) 2019; 59:184-190. [PMID: 30814422 PMCID: PMC6527964 DOI: 10.2176/nmc.tn.2018-0270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Secure reconstruction in transsphenoidal surgery (TSS) is important for the prevention of the major and serious complication of postoperative cerebrospinal fluid (CSF) leak. Although abdominal fat can be safely and effectively used as a reconstruction tissue, harvesting it from the abdominal wall is traumatic and invasive, resulting in cosmetic problems. In this report, we present a method of harvesting abdominal fat using a minimally invasive liposuction technique to avoid cosmetic issues. Since 2016, we have been using fat harvested from the abdominal wall by suctioning with a dedicated syringe for reconstruction after TSS in selected cases. The liquefied fat obtained by the liposuction technique was wrapped with an oxycellulose sheet and changed its form to what we termed “fatty candy”. In this form, the fat maintained its configuration and could be handled almost as easily as a conventional fat graft. In our experienced series, there was no case with wound complication nor postoperative or late-onset CSF leak during a postoperative follow-up of at least 3 months. The fat harvested by this simple and minimally invasive liposuction technique can be expected to provide an autologous graft that is adequate not only for prevention of cosmetic problems but also for prevention of postoperative CSF leak.
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Affiliation(s)
- Yuichi Fujita
- Department of Neurosurgery, Kobe University Graduate School of Medicine
| | - Masaaki Taniguchi
- Department of Neurosurgery, Kobe University Graduate School of Medicine
| | | | - Tomoaki Nakai
- Department of Neurosurgery, Kobe University Graduate School of Medicine
| | - Yoichi Uozumi
- Department of Neurosurgery, Kobe University Graduate School of Medicine
| | - Hidehito Kimura
- Department of Neurosurgery, Kobe University Graduate School of Medicine
| | - Eiji Kohmura
- Department of Neurosurgery, Kobe University Graduate School of Medicine
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Macdonald RL. Letter to the Editor. Limited data? J Neurosurg 2019; 130:670-671. [PMID: 30554185 DOI: 10.3171/2018.9.jns182618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- R Loch Macdonald
- 1Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; and
- 2University of Toronto, ON, Canada
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49
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Kessler RA, Garzon-Muvdi T, Kim E, Ramanathan M, Lim M. Utilization of the Nasoseptal Flap for Repair of Cerebrospinal Fluid Leak after Endoscopic Endonasal Approach for Resection of Pituitary Tumors. Brain Tumor Res Treat 2019; 7:10-15. [PMID: 31062526 PMCID: PMC6504757 DOI: 10.14791/btrt.2019.7.e19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 10/17/2018] [Accepted: 11/13/2018] [Indexed: 12/02/2022] Open
Abstract
Background One of the most frequent complications after endoscopic endonasal approach (EEA) for resection of pituitary tumors is cerebrospinal fluid (CSF) leaks. With the introduction of the pedicled nasoseptal flap, the reconstruction of the skull base has improved significantly resulting in a decrease in the occurrence of persistent CSF leaks. We present our experience utilizing the pedicled nasoseptal flap technique after EEA for reconstruction of the skull base in cases where CSF leak was detected. Methods Data for patients undergoing EEA for pituitary tumors was retrospectively reviewed. These included demographic, clinical, operative, radiographic, and pathological information. Incidence of post-operative complications and CSF leaks were recorded. Descriptive statistical analysis was performed. Results Between 2008 and 2015, 67 patients and 69 hospital admissions with pituitary tumors underwent a nasoseptal flap to reconstruct a skull base defect at Johns Hopkins Hospital. The mean age at surgery was 54.5±14.2 years. Fifty-two percent of patients were male. Forty-six percent of patients were white, 33% African-American, and 12% belonged to other racial groups. There was an intraoperative CSF leak in 39% of patients. Seventy percent of patients with an intraoperative CSF leak had a nasoseptal flap reconstruction of the skull base. There were zero postoperative CSF leaks. Conclusion With the introduction of the pedicled nasoseptal flap for reconstruction of the skull base after EEA for resection of pituitary adenomas, the incidence of postoperative CSF leaks has decreased significantly. In this retrospective analysis, we demonstrate the effectiveness of the use of nasoseptal flap in repairing CSF leak after EEA.
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Affiliation(s)
- Remi A Kessler
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Tomas Garzon-Muvdi
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Eileen Kim
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Murugappan Ramanathan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Michael Lim
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Endoscopic Endonasal Surgery for Removal of Pituitary Adenomas: A Surgical Case Series of Treatment Results Using Different 2- and 3-Dimensional Visualization Systems. World Neurosurg 2018; 119:e80-e86. [PMID: 30010078 DOI: 10.1016/j.wneu.2018.07.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 07/02/2018] [Accepted: 07/03/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic endonasal transsphenoidal surgery (EETS) is a common treatment for patients with pituitary adenomas (PAs). A disadvantage of endoscopic surgery has been the lack of stereoscopic vision and depth perception. Recent developments offer high-definition 3-dimensional (3D-HD) visualization with a higher resolution and better image quality compared with 3D standard endoscopy (3D-SD). In this study, we compared treatment results of surgically treated patients with PAs using 3 different visualization systems: 2-dimensional (2D)-HD, 3D-SD, and 3D-HD. METHODS Data from patients with primary PAs that were surgically treated between December 2008 and December 2017 were analyzed. Preoperative and postoperative tumor size and location, perioperative complications, and ophthalmologic, endocrine, and clinical outcomes were compared. RESULTS A total of 170 patients underwent endoscopic resection of a primary PA (54 patients with 2D-HD, 75 with 3D-SD, and 41 with 3D-HD). Preoperatively, no statistical differences were found for tumor size, extension, and endocrine and ophthalmologic status. Tumor resection was not statistically different among the 3 groups. Complete resection was performed in 33 patients (80%) in the 3D-HD group, 54 patients (72%) in the 3D-SD group, and 39 patients (72%) in the 2D-HD group. The number of complications was not different across the groups (P = 0.436). Ophthalmologic outcomes did not differ based on EETS technique. The rate of new pituitary insufficiency was slightly lower in the 3D-HD group compared with 2D-HD and 3D-SD groups (4.8%, 16.6%, and 12%, respectively; P = 0.290). CONCLUSIONS Although the resection rate was higher in the 3D-HD group, and subjective advantages of the 3D-HD endoscopes were noted, there were no significant differences in terms of gross total resection or new hormonal deficits among the 3 groups.
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