Surgical Repair of Persisting CSF Leaks Following Standard or Extended Endoscopic Transsphenoidal Surgery for Pituitary Tumor

Abstract

In this article, the aim of the authors is to discuss their experience with skull base reconstruction in endoscopic transsphenoidal and extended transsphenoidal surgery for pituitary tumor resection. Between January 1997 and January 2008, 665 patients underwent either transnasal transsphenoidal endoscopic or extended transsphenoidal surgery for pituitary tumors. In patients without intraoperative CSF leak, we prefer to pack the surgical cavity with absorbable material, such as collagen sponge (Gelfoam), or, in the case of thin diaphragma sellae and postoperative risk of rupture with abdominal fat. In patients with minimal CSF oozing, but without any visible diaphragma sellae defect or only a small dural defect with leak, we pack the surgical cavity with abdominal fat. In case of a leak from an anterior face of the diaphragma sellae defect we prefer to reconstruct the defect by means of mucoperiosteum taken from the resected middle turbinate. Patients with larger sellar or supradiaphragmatic defects were treated with a multilayer reconstruction. 529 patients (79.5%) did not require any repair besides a packing of the surgical cavity with absorbable material such as collagen sponge, while 128 patients (19.2%) required an endoscopic skull base repair at the end of the procedure for an overt CSF leak. 8 patients (1.2%) required repair because of overt thin diaphragma sellae without a visible CSF leak but with a postoperative risk of rupture. Out of the latter two groups (n = 136) only 11 patients (8 %) developed persistent postoperative CSF leaks requiring revision multilayer reconstruction. More complex defects after pituitary surgery should be repaired with a multilayer technique, using autologous materials such as fat, fascia lata, bone and mucoperiosteum taken from the middle turbinate. This type of autologous material is generally reliable in more complex defects, and it appears to be easy to harvest and handle for repair.