Management of cerebrospinal fluid leak after surgical removal of pituitary adenomas

Arimantas Tamašauskas,Vytenis Deltuva,Saulius Vaitkus,Daiva Rastenytė,Wolfgang Draf,Kęstutis Šinkūnas,Algimantas Matukevičius

doi:10.3390/medicina44040039

Abstract

Objectives. The aim of the study was to evaluate the frequency and the causes of the intra- and postoperative cerebrospinal fluid (CSF) leaks and to discuss the sella closure methods. Methods. During the period from 1995 to 2005, 313 patients underwent 356 transsphenoidal operations for pituitary adenoma. Microadenoma was found in 80 (22.5%) cases, and in 276 (77.5%) cases, macroadenoma was removed. Two different methods to close the sella were used. The first one consisted packing the sella turcica and sphenoidal sinus with autologous fat and restoring the defect of sella turcica with autologous bone. In more resent practice, the regenerated oxidized cellulose (Surgicel®) and collagen sponge with human fibrin (TachoSil®) were used to cover the sella membrane defect, followed by packing the sella with autologous fat and covering the dural defect with Surgicel® and TachoSil®. Results. Adenoma was totally removed in 198 (55.6%) cases out of 356. Microadenoma was totally removed in 91.3% and macroadenoma in 45.3% of cases, respectively. Postoperative complications were noted in 40 (11.2%) patients. Two (0.6%) patients died after surgery. Intraoperative CSF leakage was observed in 58 (16.3%) cases. Postoperative CSF leakages were observed in 3 cases, when the method of packing the sella with just autologous fat was used, whereas in 29 cases when the sella fat packing was used together with Surgicel® and TachoSil® to cover the sella membrane and dural defects, no postoperative CSF leakages were observed. Conclusions. The technique of covering the sella membrane and dural defects with Surgicel® and TachoSil® in the presence of intraoperative CSF leakage appeared to be the most reliable one, as no postoperative CSF leakage applying this technique has been observed.

Highlights

Transsphenoidal approach has been a major technique for surgical treatment of sellar pathology since the 1960s
Microadenoma was totally removed in 91.3% and macroadenoma in 45.3% of cases, respectively
Postoperative cerebrospinal fluid (CSF) leakages were observed in 3 cases, when the method of packing the sella with just autologous fat was used, whereas in 29 cases when the sella fat packing was used together with Surgicel® and TachoSil® to cover the sella membrane and dural defects, no postoperative CSF leakages were observed

Summary

Introduction

Transsphenoidal approach has been a major technique for surgical treatment of sellar pathology since the 1960s. Frequent occurrence of intraoperative CSF leakage poses an important problem, being reported in 15 to 30% of cases [4, 8]. Various techniques for packing the sella turcica and closing the CSF leakage have been advocated by different authors. In the past decades transsphenoidal approach has remained the major method in pituitary surgery, neither the risks of intraoperative and postoperative CSF leakage nor its closure techniques have been discussed appropriately. No unanimous agreement has been reached so far as to the techniques of closing the CSF fistula and the sella turcica. The aim of the present study was to present the frequency and the causes of intra- and postoperative CSF leaks as well as to discuss various sella closure methods and to introduce a new multilayer technique for the sella closure

Objectives

Methods

Results

Discussion

Conclusion