Abstract
PurposePostoperative cerebrospinal fluid rhinorrhoea (CSFR) remains a frequent complication of endonasal approaches to pituitary and skull base tumours. Watertight skull base reconstruction is important in preventing CSFR. We sought to systematically review the current literature of available skull base repair techniques.MethodsPubmed and Embase databases were searched for studies (2000–2020) that (a) reported on the endonasal resection of pituitary and skull base tumours, (b) focussed on skull base repair techniques and/or postoperative CSFR risk factors, and (c) included CSFR data. Roles, advantages and disadvantages of each repair method were detailed. Random-effects meta-analyses were performed where possible.Results193 studies were included. Repair methods were categorised based on function and anatomical level. There was absolute heterogeneity in repair methods used, with no independent studies sharing the same repair protocol. Techniques most commonly used for low CSFR risk cases were fat grafts, fascia lata grafts and synthetic grafts. For cases with higher CSFR risk, multilayer regimes were utilized with vascularized flaps, gasket sealing and lumbar drains. Lumbar drain use for high CSFR risk cases was supported by a randomised study (Oxford CEBM: Grade B recommendation), but otherwise there was limited high-level evidence. Pooled CSFR incidence by approach was 3.7% (CI 3–4.5%) for transsphenoidal, 9% (CI 7.2–11.3%) for expanded endonasal, and 5.3% (CI 3.4–7%) for studies describing both. Further meaningful meta-analyses of repair methods were not performed due to significant repair protocol heterogeneity.ConclusionsModern reconstructive protocols are heterogeneous and there is limited evidence to suggest the optimal repair technique after pituitary and skull base tumour resection. Further studies are needed to guide practice.
Highlights
Endonasal approaches to the skull base, most commonly described in the transsphenoidal approach (TSA) to pituitary lesions, have allowed minimally invasive and maximally effective surgical resection of skull base tumours
Pituitary (2021) 24:698–713 compared to transcranial approaches [1,2,3]. As these techniques have developed, access to the skull base has been bolstered, establishing the expanded endoscopic endonasal approaches (EEA)—allowing resection of larger pituitary lesions and an increasing variety of skull base tumours beyond the sella alone [4, 5]
Despite the purported advantages of endonasal approaches (TSA and EEA), postoperative cerebrospinal fluid rhinorrhoea (CSFR) remains a frequent complication, which may result in significant complications, including meningitis, pneumocephalus and the need for reoperation [6,7,8]
Summary
Endonasal approaches to the skull base, most commonly described in the transsphenoidal approach (TSA) to pituitary lesions, have allowed minimally invasive and maximally effective surgical resection of skull base tumours. They may allow early optic decompression whilst avoiding excessive vascular manipulation, resulting in superior visual outcomes. There are various available repair options with varying morbidity profiles, including reconstructive materials (e.g. fat grafts, nasoseptal flaps) and supportive measures (e.g. lumbar drains) [11, 13] These repair choices may be influenced by numerous factors, including approach (TSA or EEA), presence or grade of intraoperative CSF leak (ioCSFL) [14], patient characteristics (e.g. elevated BMI) and surgeon experience [11, 15, 16]. There is a paucity of high-quality evidence or consensus on skull base repair methodology, and surgical practice is resultantly heterogenous [11, 13, 16]
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