Recurrent Leak Research Articles

Recurrent mitral paravalvular leak: benefits of leak site repair compared to re-replacement.

Mitral paravalvular leak (PVL) recurrence after surgical correction has not been well demonstrated. The aims of this study were to evaluate the long-term results of surgical mitral PVL correction, including recurrent PVL, and to elucidate the factors - including surgical technique - that affect the risk of recurrent PVL. Eighty-six patients who underwent surgical treatment for mitral PVL were enrolled in this study. Thirty-six patients underwent leak site repair (MVP group), and 50 patients underwent re-replacement (MVR group). Leak site repair was the preferred method and was performed whenever possible. The mean follow-up duration was 58.6±44.1 months (0.1-156.5 months). Operative mortality occurred in 7 patients (8.1%). There were no significant differences in operative mortality or postoperative complications between the groups. Overall survival rates at 5 and 10 years were 67.9% and 48.3%, respectively, without intergroup differences. Recurrent PVL without any evidence of infective endocarditis was found in 25 patients (29.1%). Five- and 10-year PVL-free rates were 69.9% and 18.3%, respectively. The mortality rate of reoperation for recurrent PVL was 35.2% (6/17). The risk factors of recurrent PVL were the MVR group (hazard ratio: 2.865, 95% CI: 1.077-7.619) and presence of extensive dehiscence (>25% of annulus: 2.861, 95% CI: 1.163-7.038). Recurrent PVL was not infrequent after surgical correction of mitral PVL, and reoperation may be a high-risk procedure. Leak site repair, if it could be performed, would be a good surgical option for mitral PVL because re-replacement was a risk factor for recurrence of PVL.

Sternocleidomastoid musculocutaneous flap: A viable option to seal off the post traumatic fistulas of neck

Introduction: Pharyngo/laryngo-cutaneous fistula in the neck is a troublesome complication after penetrating injuries. The objective of this report is to describe the utility of a sternocleidomastoid musculocutaneous flap as a viable tissue buttress for repairing a frank clinical fistula following penetrating injuries to the neck. Materials and Method: The procedure was done in three consecutive patients who clinically presented with fistulous communication of either pharynx or larynx. The etiology in all the patients was penetrating injury to the neck. Results: There was no recurrence of leakage in the postoperative period. All the patients had good aesthetic results and could take liquids & solids well. Conclusion: Sternocleidomastoid musculocutaneous flap is a good, locally available option to seal off the post traumatic fistula. Keywords: Sternocleidomastoid flap, Neck, Fistula, Traumatic

Mitral periprosthetic leakage: contemporary results of surgical correction at a single centre.

Mitral periprosthetic leakage (PPL) is a serious complication following valve replacement. Conflicting outcomes of surgical treatment have been reported in the presence of multiple previous cardiac operations and associated co-pathological conditions. Sixty-five symptomatic patients (37 women, mean age 64.8 years) underwent conventional operations at our hospital from 2006 to 2015. Mitral PPL was the leading surgical indication, although associated procedures were included. Previous transcatheter procedures and leaks involving multiple prostheses were excluded. The median number of past mitral operations was 2 (range 1-5). PPL recurrence was observed in 29% of cases. A previous operation on the aortic or tricuspid valve was performed in 31 patients. Mitral PPL involved one-, two- or three-quarters of the mitral perimeter in 46, 43 and 11% of cases. Prosthetic refixation or replacement was performed in 24 and 41 patients, respectively. Annular reconstruction was necessary in 17% of prosthetic replacements. Associated procedures were performed in 19 patients. The operation was executed through a right minithoracotomy (unclamped aorta) in 20% of patients. In-hospital deaths occurred in 3.1%. After a median follow-up of 60 months, freedom from all-cause mortality was 96.8, 91.5 and 88.8% at 1, 3 and 5 years. Lateral leaks [P = 0.03; hazard ratio (HR) = 4.57, 95% confidence interval (CI): 1.13-18.3] and PPL relapse (P = 0.03; HR = 4.33, 95% CI: 1.12-16.7) were independently associated with death. At follow-up, 4 patients had a >2+ recurrent leak and 2 were reoperated. A customized conventional mitral reoperation still represents a satisfactory and effective treatment option for PPL and should be considered even in patients with very complex issues.

Excavating meningoencephaloceles: A newly recognized entity.

Spontaneous cerebrospinal fluid (CSF) leaks are largely attributed to idiopathic intracranial hypertension and typically present as skull base defects with or without prolapse of intracranial contents. However, in our practice, we have encountered a distinct type of spontaneous CSF leak that presents in a different manner. To discuss a newly-classified, difficult to treat, subset of spontaneous CSF leaks that present as excavation of the bone of the skull base in a tunnel- or canal-like fashion by a meningocele or meningoencephalocele instead of as a localized area of bony dehiscence. A retrospective review was performed at a tertiary care rhinology practice to identify a subset of CSF leak patients with an excavating/canal-like skull base defect visualized radiographically on computed tomography (CT) scan or magnetic resonance imaging and/or endoscopically in the operating room. The cohort of patients consisted of 7 females and 1 male with an average age of 53.6 years and a self-reported race of 4:3:1 African-American:Caucasian:Indian. All patients presented with CSF rhinorrhea. The most common leak site was the cribriform and upper septum. Six of the 8 patients had multiple defects and/or progression of their skull base defects, and 5 patients required multiple and/or repeat repairs in the operating room. Seven of the 8 patients underwent a cisternogram because the excavating nature of the leaks made it difficult to identify the specific leak site on high-resolution CT scan alone. In spontaneous CSF leaks that are difficult to identify or recur soon after a proper repair, an excavating pattern should be considered. Failure to recognize this type of leak and all of its tributaries, to fully unroof the excavated bone to completely resect the meningocele, and to visualize and close the site of origin will likely result in failure and recurrence of CSF leak.

A Systematic Approach to the Evaluation and Management of the Failed Artificial Urinary Sphincter.

In men with post-prostatectomy incontinence, persistent or recurrent urinary leakage following artificial urinary sphincter placement is a frustrating complaint. Surgical failure can be classified as occurring early in the post-operative period vs. late-following a period of established continence-and should be managed according to the time course and severity of urinary leakage. We present a systematic approach for the evaluation and treatment of the failed artificial urinary sphincter. After considering the patient's individualized treatment goals and impact on quality of life, the clinician can more appropriately advise patients on a management strategy for their recurrent or persistent urinary incontinence following artificial urinary sphincter placement.

Analysis of Audiometric Outcomes following Combined Middle Cranial Fossa/Transmastoid Approaches for Spontaneous Cerebrospinal Fluid Otorrhea

Outcome Objectives To (1) explore audiometric outcomes following use of a combined transmastoid/middle cranial fossa (TM-MCF) approach in the treatment of spontaneous cerebrospinal fluid (CSF) otorrhea and (2) determine the influence of dehiscence location and reconstructive methodology on audiometric outcomes. Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods Adults with spontaneous CSF otorrhea were reviewed from 2007 to 2016 if they underwent combined TM-MCF. Definitive audiometric evaluations were performed at least 3 months postoperatively. The primary outcomes measures were pre- to postoperative changes in pure-tone average (PTA) and air-bone gap (ABG). Two subset analyses were performed for audiometric outcomes comparisons: first, patients with skull base dehiscences anterior to the ossicular chain were compared with those with posterior dehiscences. Second, patients undergoing skull base resurfacing plus abdominal fat graft mastoid obliteration (AFGMO) were compared with those undergoing resurfacing alone. Results A total of 28 patients and 31 ears were reviewed. There was 1 recurrent leak (3.5%). The cohort demonstrated significant improvement in mean postoperative ABG ( P = .008) but not PTA. On subset analysis, ears with posterior dehiscences demonstrated significant improvements in PTA ( P = .03) and ABG ( P = .05), while ears with anterior dehiscences did not. In addition, ears undergoing resurfacing plus AFGMO achieved significant improvements on all parameters ( P = .01). Only 3 of 15 ears undergoing resurfacing plus AFGMO experienced worsened postoperative hearing. Conclusion Use of the combined TM-MCF approach for treating spontaneous CSF otorrhea achieved good audiometric outcomes. Patients with skull base dehiscences posterior to the ossicles and those undergoing skull base resurfacing plus AFGMO achieved the most favorable results.

The fate of the bone graft in cerebrospinal fluid rhinorrhea endoscopic repair for idiopathic intracranial hypertension: a retrospective case series analysis.

Idiopathic intracranial hypertension (IIH) is a common cause of spontaneous cerebrospinal fluid (CSF) leaks necessitating surgical intervention, and grafting of septal, mastoid, or turbinate bone over the defect is increasingly performed to strengthen the repair of the primary defect. However, the postoperative fate of these grafted bone fragments is largely unknown. We performed a retrospective study of patients at the University of Pennsylvania undergoing repair of spontaneous CSF leaks secondary to IIH. Preoperative and postoperative CTs were analyzed to determine the integration status of the transplanted bone. Fourteen patients with IIH and spontaneous CSF leak were analyzed, with a mean postoperative imaging follow-up period of four years. Thirteen patients (93%) had bone present on CT imaging, with 11 of these patients displaying evidence of bone integration. Two patients (14%) had a recurrent CSF leak in the same area, including the patient with absence of bone on imaging follow-up. Bone grafts frequently incorporate when used for repair of spontaneous CSF leaks associated with IIH. The rate of incorporation is comparable to bone grafts used for other etiologies of CSF leak, despite the increased pressure on the repair site. Any rigid repair of the leak site should likely be accompanied by treatment of the underlying intracranial hypertension to avoid leak recurrence.

P3.04-042 2 Cases of Fast-Growing Emphysematous Bullae Following Lobectomy for Lung Cancer: Topic: Miscellaneous II

Emphysematous bullae usually grow gradually. We experienced 2 of those which came out and expanded in a few days after lobectomy for lung cancer. The first case: A 78-year-old man underwent right upper lobectomy for squamous cell carcinoma (cT1bN1M0). Air leak stopped in the morning of the 4th postoperative day (POD). Sever air leak recurred when he coughed during lunch on that day. Computed Tomography (CT) revealed a large bulla on the right S6 that we had never seen on his any preoperative imaging examinations neither in operation. The second case: A 66-year-old man had past medical history of infectious giant bulla on the left lung which was treated by surgery 10 years ago. This time, he had left upper lobectomy under diagnosis of adenocarcinoma (cT2aN0M0). Postoperative air leak almost stopped in the afternoon on the 3rd POD. In the evening on the same day, sever air leak relapsed after his coughing hard. CT revealed a large bulla on the left S6 that was recognized for the first time. In both cases we performed operation and found massive air leak coming out from holes on the bullae. We removed the bullae and stitched up leak points. We succeeded in reducing air leak at last. Their drains were removed in 2 weeks. Both of them are in good condition now. There are several similarities between these 2 cases. They had pulmonary emphysema but no bullae detected on preoperative CT. Recurrence of air leak after coughing triggered discovery of new occurring bullae, while postoperative air leak was being improved. It can be said that emphysema, improvement of air leak and coughing have something to do with onset of fast-growing bullae. We surgeons may have to keep in our mind the possibility of such occurrence, when we operate on similar patients as them.

КЛАССИФИКАЦИОННЫЕ КРИТЕРИИ ДИАГНОСТИКИ И ПРОГНОЗИРОВАНИЯ ИСХОДА ЦЕНТРАЛЬНОЙ СЕРОЗНОЙ ХОРИОРЕТИНОПАТИИ

Present concept of central serous chorioretinopathy classification does not reflect the true picture of the pathological process. The purpose of the study was the development of diagnostic criteria of central serous chorioretinopathy clinical forms and basing on that extend and optimize its classification with assessment of risk factors and prognosis of disease. Full ophthalmologic and somatic examination of 56men with central serous chorioretinopathy was made. Focal laser coagulation was performed in patients with fluorescein leakage and local injury of pigment epithelium by angiographic data (22patients). In the case of extended damage of pigment epithelium and diffuse leakage of fluorescein (23people) transpupillary thermotherapy of optical disk was conducted. Detailed expert evaluation of retinal changes by fluorescein angiographic data allowed dividing the patients into 3groups. The main criterion for the division was the damaged area of the pigment epithelium: group 1 – central serous chorioretinopathy with local injury of pigment epithelium (with leakage point); group 2 –central serous chorioretinopathy with extensive damage of pigment epithelium with diffuse leakage; group 3 –central serous chorioretinopathy with extensive damage of pigment epithelium combined with leakage point (recurrence of leakage).The results of our study brought us to the following conclusion. Development of new classification criteria of the disease allows to construct a more specific algorithm of therapeutic measures and to determine prognosis of central serous chorioretinopathy already at the stage of diagnostics.

Gastroesophageal stenting for the management of post sleeve gastrectomy leak. A single institution experience.

ObjectivesTo retrospectively evaluate the effectiveness of gastroesophageal stenting for post sleeve gastrectomy staple line leaks using removable self-expandable stents.MethodsBetween April 2012 and June 2015, 12 consecutive patients (6 males) with mean age of 34 years: (21-38 years) presented with staple line leak 1-8 weeks after the operation (mean 2.8 weeks). Patients underwent gastroesophageal stenting by interventional radiology. A total of 23 stents were deployed with mean length of 17.8 cm (7-24 cm) and mean diameter 25.6 mm (18-36 mm). Stent re-insertion was needed in 7 patients (9 procedure), while 6 patients required percutaneous collection drainage and 3 patients required endoscopic glue injection with clipping. Two stent removal procedures were carried out under endoscopic visualization after failed stent capture under fluoroscopy, while the remaining stents were successfully removed by interventional radiology.ResultsStent placement was technically successful in all patients. Stent migration occurred in 6 patients (50%). There is a tendency for stent migration with shorter stent length (R= -0.557, p=0.008). The mean duration of stenting was 60.5 days (14-137 days). All patients underwent stent removal and resumed oral intake with no recurrence of leak at a mean follow up time of 190 days (14-410 days). Complications included gastrointestinal bleeding (n=1), proximal esophageal stricture (n=1) and stent occlusion (n=1).ConclusionGastroesophageal stenting as a primary measure after diagnosis of early post sleeve gastrectomy leak appears to offer a safe and effective alternative option in obviating repeat surgical interventions. Minimally invasive interventions may still be required for the management of persistent leak.

Middle Cranial Fossa (MCF) Approach Without the Use of Lumbar Drain for the Management of Spontaneous Cerebral Spinal Fluid (CSF) Leaks.

To determine the efficacy and morbidity of repairing spontaneous cerebrospinal fluid (CSF) leaks with the middle cranial fossa (MCF) approach without the use of a lumbar drain (LD), as perioperative use of LD remains controversial. Retrospective review from 2003 to 2015. University of Iowa Hospitals and Clinics and Indiana University Health Center. Those with a confirmed lateral skull base spontaneous CSF leaks and/or encephaloceles. MCF approach for repair of spontaneous CSF leak and/or encephalocele without the use of lumbar drain. Assessment of patient age, sex, body mass index (BMI), and medical comorbidities. Spontaneous CSF leak patient characteristics (age, sex, BMI, obstructive sleep apnea) were collected. Length of stay (LOS), hospital costs, postoperative complications, CSF leak rate, and need for LD were calculated. Sixty-five operative MCF repairs were performed for spontaneous CSF leaks on 60 patients (five had bilateral CSF leaks). CSF diversion with LD was used in 15 of 60 patients, mostly before 2010. After 2010, only three of 44 patients (6.7%) had postoperative otorrhea requiring LD. The use of LD resulted in significantly longer LOS (3.6 ± 1.6 versus 8.7 ± 2.9 d) and hospital costs ($29,621). There were no postoperative complications in 77% (50 of 65) of cases. Three cases required return to the operating room for complications including frontal subdural hematoma (1), subdural CSF collection (1), and tension pneumocephalus (1). No patients experienced long-term neurologic sequelae or long-term CSF leak recurrence with an average length of follow-up of 19.5 months (range 3-137 mo). The average patient BMI was 37.5 ± 8.6 kg/m. The average age was 57.5 ± 11.4 years and 68% were female. Obstructive sleep apnea was present in 43.3% (26 of 60) of patients. The morbidity of the MCF craniotomy for repair of spontaneous CSF leaks is low and the long-term efficacy of repair is high. Universal use of perioperative lumbar drain is not indicated and significantly increases length of stay and hospital costs. Obesity and obstructive sleep apnea are highly associated with spontaneous CSF leaks.

Middle Ear Obliteration with Blind-Sac Closure of the External Auditory Canal for Spontaneous CSF Otorrhea.

Outcome Objectives To (1) identify unique features of patients who underwent middle ear/mastoid obliteration with blind-sac closure of the external auditory canal for spontaneous cerebrospinal fluid (CSF) otorrhea and (2) explore outcomes. Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods Adults treated for spontaneous cerebrospinal fluid otorrhea from 2007 through 2015 were reviewed and stratified into 2 groups based on the surgery performed: (1) 11 patients underwent middle ear/mastoid obliteration with blind-sac closure of the external auditory canal and (2) 26 patients underwent other procedures. Demographics, body mass index, revised cardiac risk index, Duke Activity Status Index scores, and anticoagulation use were documented. Audiologic data were gathered from pre- and postoperative visits. The primary outcome measure was leak recurrence. Complications were tabulated. Results Poor preoperative hearing was a relative indication for obliteration. Obliteration patients had higher body mass index (43.2 vs 34.9 kg/m2; P < .05), incidence of super-morbid obesity (45% vs 7.6%; P = .015), anticoagulation usage (36% vs 0%; P = .004), cardiac risk scores (1.2 vs 0.1 dB; P < .0004), and Duke Activity Status Index scores. There was 1 leak recurrence (9%). Major and minor complication rates were 9% and 36%, respectively. Mean follow-up was 30.8 ± 8.6 months. Conclusion Middle ear and mastoid obliteration with blind-sac closure of the external auditory canal is effective for treating spontaneous CSF otorrhea. The small cohort reviewed did not experience any major perioperative morbidity. The technique may be best suited for patients with poor hearing, the infirm, and those in whom craniotomy is contraindicated.

Efficacy of Perioperative Lumbar Drainage following Endonasal Endoscopic Cerebrospinal Fluid Leak Repair.

Objective Perioperative lumbar drain (LD) use in the setting of endoscopic cerebrospinal fluid (CSF) leak repair is a well-established practice. However, recent data suggest that LDs may not provide significant benefit and may thus confer unnecessary risk. To examine this, we conducted a meta-analysis to investigate the effect of LDs on postoperative CSF leak recurrence following endoscopic repair of CSF rhinorrhea. Data Sources A comprehensive search was performed with the following databases: Ovid MEDLINE (1947 to November 2015), EMBASE (1974 to November 2015), Cochrane Review, and PubMed (1990 to November 2015). Review Method A meta-analysis was performed according to PRISMA guidelines. Results A total of 1314 nonduplicate studies were identified in our search. Twelve articles comprising 508 cases met inclusion criteria. Overall, use of LDs was not associated with significantly lower postoperative CSF leak recurrence rates following endoscopic repair of CSF rhinorrhea (odds ratio: 0.89, 95% confidence interval: 0.40-1.95) as compared with cases performed without LDs. Subgroup analysis of only CSF leaks associated with anterior skull base resections (6 studies, 153 cases) also demonstrated that lumbar drainage did not significantly affect rates of successful repair (odds ratio: 2.67, 95% confidence interval: 0.64-11.10). Conclusions There is insufficient evidence to support that adjunctive lumbar drainage significantly reduces postoperative CSF leak recurrence in patients undergoing endoscopic CSF leak repair. Subgroup analysis examining only those patients whose CSF leaks were associated with anterior skull base resections demonstrated similar results. More level 1 and 2 studies are needed to further investigate the efficacy of LDs, particularly in the setting of patients at high risk for CSF leak recurrence.

Cancer of esophagus and GE junction– a long-term follow-up results

Background: Esophageal and GE Junction malignancies are diagnosed late and the long-term outcome is still suboptimal. We present our experience.Methods: 421 patients with mean age of 57.6 years with cancer of esophagus and GE Junction were evaluated with physical examination, CT chest and abdomen, gastroduodenoscopy and bronchoscopy. 254 (60.4%) patients underwent surgical treatment only and 167 (39.6%) underwent multimodality treatment. 295 patients underwent transthoracic approach, 88 – transhiatal approach and 58 patients underwent – abdominal approach only.Results: Upper, middle, GEJ type – I, GEJ type – II, GEJ type – III tumors were present in 5.7, 28.5, 36.8 and 1.9% cases, respectively. Anastomosis was placed at neck in 73.2% and in chest in 26.8% cases. Final stages were 0 (0.2%), Ia (0.5%), Ib (1.9%), IIa (10%), IIb (8.8%), IIIa (15.7%), IIIb (14.3%), IIIc (41.6%) and IV (7.1%). R0 resection was achieved in 91.5% cases. Postoperative mortality, recurrent laryngeal nerve injury, anastomotic leak and pneumonia were observed in 4.8%, 5.7%, 11.6% and 22.1%, respectively. Median overall survival was 28 months with 5-year overall survival of 21%. A subgroup of 70 patients (16.6%) who were subjected to preoperative chemoradiation followed by surgery showed response in 64.3% cases with a median and 5-year survival of 49 months and 30% in responders, and 15 months and 15% in non-responders.Conclusion: Patients presented mostly in stage III (78.7%), therefore a multimodality approach should be considered as a standard practice in Nepalese context in order to achieve better survival results.

The outcome of endoscopic management of bile leakage after hepatobiliary surgery.

Background/AimsDespite improvements in surgical techniques and postoperative patient care, bile leakage can occur after hepatobiliary surgery and may lead to serious complications. The aim of this retrospective study was to evaluate the efficacy of endoscopic treatment of bile leakage after hepatobiliary surgery.MethodsThe medical records of 20 patients who underwent endoscopic retrograde cholangiopancreatography because of bile leakage after hepatobiliary surgery from August 2009 to September 2014 were reviewed retrospectively. Endoscopic treatment included insertion of an endoscopic retrograde biliary drainage stent after endoscopic sphincterotomy.ResultsMost cases of bile leakage presented as percutaneous bile drainage through a Jackson-Pratt bag (75%), followed by abdominal pain (20%). The sites of bile leaks were the cystic duct stump in 10 patients, intrahepatic ducts in five, liver beds in three, common hepatic duct in one, and common bile duct in one. Of the three cases of bile leakage combined with bile duct stricture, one patient had severe bile duct obstruction, and the others had mild strictures. Five cases of bile leakage also exhibited common bile duct stones. Concerning endoscopic modalities, endoscopic therapy for bile leakage was successful in 19 patients (95%). One patient experienced endoscopic failure because of an operation-induced bile duct deformity. One patient developed guidewire-induced microperforation during cannulation, which recovered with conservative treatment. One patient developed recurrent bile leakage, which required additional biliary stenting with sphincterotomy.ConclusionsThe endoscopic approach should be considered a first-line modality for the diagnosis and treatment of bile leakage after hepatobiliary surgery.

Cerebrospinal fluid rhinorrhea secondary to idiopathic intracranial hypertension: Long-term outcomes of endoscopic repairs.

Endoscopic endonasal repair of cerebrospinal fluid (CSF) rhinorrhea secondary to idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri or benign intracranial hypertension, has varying success rates, from 25-87%, with minimal morbidity. However, often these series have a relatively short-term follow-up. Given the pathophysiology of IIH, long-term follow-up is necessary to identify true CSF leak recurrence rates. Our investigation aimed to evaluate long-term outcomes in endoscopically repaired CSF leaks. A retrospective chart review of all the patients with CSF rhinorrhea due to IIH who met inclusion criteria between 1996 and 2009. Outcome measures included the following: demographics, intracranial pressure, location of skull base defect, presence of encephalocele and/or meningoencephalocele, surgical repair technique, treatment with acetazolamide, whether a ventriculoperitoneal shunt was inserted, location of recurrence, history of meningitis or previous sinus surgery, and duration of follow-up. Thirty-two patients with a total of 44 skull base defects were reviewed over a mean follow-up of 10.2 years. The mean body mass index and intracranial pressure were 36.8 kg/m(2) and 27.7 cm H2O, respectively. Seven patients (18%) required revision surgery at the same site or a distant site. We found no statistical significance that identified the recurrence risk in the outcome measurements most likely due to our small failure rate. However, early recurrences were noted to recur at the same repair site, whereas late recurrences were noted to recur at a distant site along the skull base. IIH is an increasingly recognized entity treated by otorhinolaryngologists. We present the first long-term IIH CSF leak repair series. Long-term follow-up is necessary because delayed CSF leaks occur in this population.

A modification of endoscopic endonasal approach for management of encephaloceles in sphenoid sinus lateral recess.

Spontaneous cerebrospinal fluid leak with meningoencephaloceles in sphenoid sinus lateral recess is challenging. Transnasal visualization of this area is difficult, especially when large pneumatization is present. External approaches to this region involve aggressive surgery and are often associated with significant morbidity. The aim of this study is to assess the real effectiveness of a modification of the endoscopic endonasal approach for their management. This is a prospective case series study and was conducted at Otolaryngology department, Ain Shams University Hospitals, Cairo, Egypt. Seven patients with spontaneous cerebrospinal fluid leak with meningoencephaloceles in the sphenoid sinus lateral recess were included. Diagnosis was confirmed by: analysis for beta-2 transferrin and imaging. They were managed with endoscopic endonasal retrograde trans-sphenoid approach described in this study with multilayered reconstruction of the defect. Mean age of our patients was 40.14±8.35years; mean BMI was 36.37±2.59kg/m2. Primary empty sella was present and osteodural defect was identified in superior wall of sphenoid sinus lateral recess with punched out and regular smooth edges. Mean intra-cranial pressure was (26.42±3.87 mmH2O) and size of defect was less than 10mm, mean 7.85±1.34. Mean-operative time was 169.28±21.87min. The mean hospital stay was 7.42±1.39days. No cerebrospinal fluid leak recurrences were observed during follow-up period that ranged from 37 to 48months. Endoscopic endonasal retrograde trans-sphenoid approach provides a wide, safe, and direct route to the management of sphenoid sinus lateral recess cerebrospinal fluid leak.

Long-term outcomes of a transmastoid lateral semicircular canal approach to congenital CSF otorrhea in children associated with recurrent meningitis and severe inner ear malformation

ObjectiveTo investigate the long-term effectiveness of transmastoid lateral semicircular canal approach (TMLSCCA) to repair cerebrospinal fluid (CSF) leakage in children associated with recurrent meningitis and severe congenital inner malformation. MethodA retrospective study was conducted in a university hospital, academic medical center. Fifteen children with recurrent meningitis, secondary to severe congenital inner ear malformation, were included in the study. All of them had CSF associated otorrhea and treated using TLSCCA to repair CSF otorrhea by packing the vestibule with muscle and fascia. Observation of the status of postoperative CSF leakage, recurrence of meningitis and complication were conducted. ResultsNone of the cases had recurrent meningitis and CSF leakage after their TLSCCA procedure in the follow-up period of 1–8.5 years. One case presented with transient facial nerve paralysis and completely recovered 3 months later. ConclusionTLSCCA for CSF otorrhea in children with recurrent meningitis secondary to congenital inner ear malformation is an alternative approach that offers some advantages.

Purely endoscopic pterional extradural approach: A novel technique for repair of cerebrospinal fluid rhinorrhea.

Study Design:Retrospective descriptive study of an innovative surgical technique.Objective:To assess the feasibility and success of repair of transfrontal sinus cerebrospinal fluid (CSF) rhinorrhea through pterional transcranial extradural approach using endoscope.Summary of Background Data:Repair of CSF rhinorrhea has seen advancement with the evolution of endoscopic transnasal techniques. However, leaks from defect in the posterior wall of frontal sinus still remain a challenge for the skull base surgeons and requires conventional craniotomy more often. We describe a novel technique to repair these leaks by purely endoscopic pterional extradural (PEPE) approach thereby avoiding complications associated with conventional craniotomy and endoscopic transnasal approaches.Materials and Methods:Thirty-five patients with traumatic CSF rhinorrhea from the posterior wall of frontal sinus underwent repair with the present technique. They were followed up for 6–18 months and were evaluated for feasibility of procedure, recurrence of leak, and occurrence of the fresh neurological deficit.Results:Thirty-five patients underwent CSF rhinorrhea repair using the above technique. The procedure was accomplished in all patients without any intraoperative complications. There was no requirement of blood transfusion in any case. All patients had a cessation of CSF leak in the postoperative period, and there was no recurrence. There was no evidence of frontal lobe retraction injury in any of these patients, and no fresh neurological deficit was observed.Conclusion:This PEPE approach to repair CSF leak through the posterior wall of the frontal sinus is a novel technique in which we can avoid disadvantages associated with both conventional craniotomy as well as transnasal endoscopic approaches.

Principles in Skull Base Reconstruction following Expanded Endoscopic Approaches.

This study aims to describe the types of anterior skull base defects following expanded endoscopic approaches (EEA) and to outline the techniques involved in the repair of these defects. We retrospectively analyzed 63 cases of endoscopic skull base reconstruction (ESBR) following tumor excision, done from September 2011 to January 2015. These tumors consisted of 14 pituitary adenomas, 20 craniopharyngiomas, and 29 other miscellaneous tumors. The classification of skull base defects by Tabaee et al and the classification of cerebrospinal fluid (CSF) leaks by Esposito et al were considered during the ESBR. Recurrence of CSF leak was considered as failure of reconstruction. The 63 skull base defects included in this study occurred following EEA for tumor excision. Failure of reconstruction occurred in 6 six patients. All were successfully repaired, however, three patients in this series died due to tumor-related complications. The adherence to the general principles of reconstruction, appreciating the subtle differences in the nature of the various defects and the ability to adopt different strategies are the prerequisites for the successful closure of skull base defects.