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Acta Neurochirurgica

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01-06-2020 | Pituitary Adenoma | Original Article - Pituitaries

Predicting post-operative cerebrospinal fluid (CSF) leak following endoscopic transnasal pituitary and anterior skull base surgery: a multivariate analysis

Authors: Cathal John Hannan, Hamad Almhanedi, Rafid Al-Mahfoudh, Maneesh Bhojak, Seamus Looby, Mohsen Javadpour

Published in: Acta Neurochirurgica | Issue 6/2020

Abstract

Background

Post-operative CSF leak is the major source of morbidity following endoscopic transsphenoidal surgery. The purpose of this study was to identify factors associated with post-operative CSF leak in patients undergoing this surgery and facilitate the prospective identification of patients at higher risk of this complication.

Methods

A review of a prospectively maintained database containing details of 270 endoscopic transsphenoidal operations performed by the senior author over a 9-year period was performed. Univariate analysis was performed using the Chi-squared and Fisher’s exact tests, as appropriate. A logistic regression model was constructed for multivariate analysis.

Results

The rate of post-operative CSF leak in this series was 9%. On univariate analysis, previous surgery, resection of craniopharyngiomas, adenomas causing Cushing’s disease and intra-operative CSF leaks were associated with an increased risk of post-operative CSF leak. The use of a vascularised nasoseptal flap and increasing surgical experience were associated with a decreased rate of CSF leak. On multivariate analysis, a resection of tumour for Cushing’s disease (OR 5.79, 95% CI 1.53–21.95, p = 0.01) and an intra-operative CSF leak (OR 4.56, 95% CI 1.56–13.32, p = 0.006) were associated with an increased risk of post-operative CSF leak. Increasing surgical experience (OR 0.14, 95% CI 0.04–0.46, p = 0.001) was strongly associated with a decreased risk of post-operative CSF leak.

Conclusions

Increasing surgical experience is a strong predictor of a decreased risk of developing post-operative CSF leak following endoscopic transsphenoidal surgery. Patients with Cushing’s disease and those who develop an intra-operative CSF leak should be managed with meticulous skull base repair and close observation for signs of CSF leak post-operatively.

Alalade AF, Venturini S, Dorward N, Thomas N (2019) Endoscopic skull base neurosurgical practice in the United Kingdom. Br J Neurosurg 33:508–513. https://doi.org/10.1080/02688697.2019.1606893 CrossRefPubMed

Berker M, Hazer DB, Yucel T, Gurlek A, Cila A, Aldur M, Onerci M (2012) Complications of endoscopic surgery of the pituitary adenomas: analysis of 570 patients and review of the literature. Pituitary 15:288–300. https://doi.org/10.1007/s11102-011-0368-2 CrossRefPubMed

Cappabianca P, Cavallo LM, Colao A, de Divitiis E (2002) Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg 97:293–298. https://doi.org/10.3171/jns.2002.97.2.0293 CrossRefPubMed

Carrau RL, Jho HD, Ko Y (1996) Transnasal-transsphenoidal endoscopic surgery of the pituitary gland. Laryngoscope 106:914–918. https://doi.org/10.1097/00005537-199607000-00025 CrossRefPubMed

Chandler WF, Barkan AL, Hollon T, Sakharova A, Sack J, Brahma B, Schteingart DE (2015) Outcome of transsphenoidal surgery for Cushing disease: a single-center experience over 32 years. Neurosurgery 78:216–223. https://doi.org/10.1227/neu.0000000000001011 CrossRef

Ciric I, Ragin A, Baumgartner C, Pierce D (1997) Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 40:225–236; discussion 236-227. https://doi.org/10.1097/00006123-199702000-00001 CrossRefPubMed

de Divitiis E, Cappabianca P, Cavallo LM, Esposito F, de Divitiis O, Messina A (2007) Extended endoscopic transsphenoidal approach for extrasellar craniopharyngiomas. Neurosurgery 61:219–227; discussion 228. https://doi.org/10.1227/01.neu.0000303220.55393.73 CrossRefPubMed

Dlouhy BJ, Madhavan K, Clinger JD, Reddy A, Dawson JD, O'Brien EK, Chang E, Graham SM, Greenlee JD (2012) Elevated body mass index and risk of postoperative CSF leak following transsphenoidal surgery. J Neurosurg 116:1311–1317. https://doi.org/10.3171/2012.2.Jns111837 CrossRefPubMedPubMedCentral

Dunn CJ, Alaani A, Johnson AP (2005) Study on spontaneous cerebrospinal fluid rhinorrhoea: its aetiology and management. J Laryngol Otol 119:12–15. https://doi.org/10.1258/0022215053222833 CrossRefPubMed

10.

Esposito F, Dusick JR, Fatemi N, Kelly DF (2007) Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery. Oper Neurosurg (Hagerstown) 60:295–303; discussion 303-294. https://doi.org/10.1227/01.Neu.0000255354.64077.66 CrossRef

11.

Frank G, Pasquini E, Doglietto F, Mazzatenta D, Sciarretta V, Farneti G, Calbucci F (2006) The endoscopic extended transsphenoidal approach for craniopharyngiomas. Neurosurgery 59:ONS75–ONS83; discussion ONS75-83. https://doi.org/10.1227/01.Neu.0000219897.98238.A3 CrossRefPubMed

12.

Fraser S, Gardner PA, Koutourousiou M, Kubik M, Fernandez-Miranda JC, Snyderman CH, Wang EW (2018) Risk factors associated with postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery. 128:1066. https://doi.org/10.3171/2016.12.Jns1694

13.

Grotenhuis JA (2005) Costs of postoperative cerebrospinal fluid leakage: 1-year, retrospective analysis of 412 consecutive nontrauma cases. Surg Neurol 64:490–493, discussion 493-494. https://doi.org/10.1016/j.surneu.2005.03.041 CrossRefPubMed

14.

Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, Mintz A (2006) A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 116:1882–1886. https://doi.org/10.1097/01.mlg.0000234933.37779.e4 CrossRefPubMed

15.

Hammer GD, Tyrrell JB, Lamborn KR, Applebury CB, Hannegan ET, Bell S, Rahl R, Lu A, Wilson CB (2004) Transsphenoidal microsurgery for Cushing’s disease: initial outcome and long-term results. J Clin Endocrinol Metab 89:6348–6357. https://doi.org/10.1210/jc.2003-032180 CrossRefPubMed

16.

Horiguchi K, Murai H, Hasegawa Y, Hanazawa T, Yamakami I, Saeki N (2010) Endoscopic endonasal skull base reconstruction using a nasal septal flap: surgical results and comparison with previous reconstructions. Neurosurg Rev 33:235–241. https://doi.org/10.1007/s10143-010-0247-8 CrossRefPubMed

17.

Ivan ME, Bryan Iorgulescu J, El-Sayed I, McDermott MW, Parsa AT, Pletcher SD, Jahangiri A, Wagner J, Aghi MK (2015) Risk factors for postoperative cerebrospinal fluid leak and meningitis after expanded endoscopic endonasal surgery. J Clin Neurosci 22:48–54. https://doi.org/10.1016/j.jocn.2014.08.009 CrossRefPubMed

18.

Karavitaki N, Cudlip S, Adams CBT, Wass JAH (2006) Craniopharyngiomas. Endocr Rev 27:371–397. https://doi.org/10.1210/er.2006-0002 CrossRefPubMed

19.

Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R (2005) Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus 19:E6PubMed

20.

Kassam AB, Prevedello DM, Carrau RL, Snyderman CH, Thomas A, Gardner P, Zanation A, Duz B, Stefko ST, Byers K, Horowitz MB (2011) Endoscopic endonasal skull base surgery: analysis of complications in the authors’ initial 800 patients. 114:1544. https://doi.org/10.3171/2010.10.Jns09406

21.

Koutourousiou M, Gardner PA, Fernandez-Miranda JC, Tyler-Kabara EC, Wang EW, Snyderman CH (2013) Endoscopic endonasal surgery for craniopharyngiomas: surgical outcome in 64 patients. 119:1194. https://doi.org/10.3171/2013.6.Jns122259

22.

Prosser JD, Vender JR, Alleyne CH, Solares CA (2012) Expanded endoscopic endonasal approaches to skull base meningiomas. J Neurol Surg B Skull Base 73:147–156. https://doi.org/10.1055/s-0032-1301391 CrossRefPubMedPubMedCentral

23.

Shiley SG, Limonadi F, Delashaw JB, Barnwell SL, Andersen PE, Hwang PH, Wax MK (2003) Incidence, etiology, and management of cerebrospinal fluid leaks following trans-sphenoidal surgery. Laryngoscope 113:1283–1288. https://doi.org/10.1097/00005537-200308000-00003 CrossRefPubMed

24.

Smith TR, Hulou MM, Huang KT, Nery B, de Moura SM, Cote DJ, Laws ER (2015) Complications after transsphenoidal surgery for patients with Cushing's disease and silent corticotroph adenomas. 38:E12. https://doi.org/10.3171/2014.10.Focus14705

25.

Solares CA, Ong YK, Snyderman CH (2010) Transnasal endoscopic skull base surgery: what are the limits? Curr Opin Otolaryngol Head Neck Surg 18:1–7. https://doi.org/10.1097/MOO.0b013e3283350035 CrossRefPubMed

26.

Soudry E, Turner J, Nayak J, Hwang P (2014) Endoscopic reconstruction of surgically created skull base defects: a systematic review. Otolaryngol Head Neck Surg 150:730–738. https://doi.org/10.1177/0194599814520685 CrossRefPubMed

27.

Sun I, Lim JX, Goh CP, Low SW, Kirollos RW, Tan CS, Lwin S, Yeo TT (2018) Body mass index and the risk of postoperative cerebrospinal fluid leak following transsphenoidal surgery in an Asian population. Singap Med J 59:257–263. https://doi.org/10.11622/smedj.2016159 CrossRef

28.

van Aken MO, de Marie S, van der Lely A-J, Singh R, de Marie S, van den Berge JH, Poublon RML, Fokkens WJ, Lamberts SWJ, de Herder WW (1997) Risk factors for meningitis after transsphenoidal surgery. Clin Infect Dis 25:852–856. https://doi.org/10.1086/515533 CrossRefPubMed

29.

Zwagerman NT, Wang EW, Shin SS, Chang YF, Fernandez-Miranda JC, Snyderman CH, Gardner PA (2018) Does lumbar drainage reduce postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery? A prospective, randomized controlled trial. J Neurosurg:1–7. https://doi.org/10.3171/2018.4.Jns172447

Title: Predicting post-operative cerebrospinal fluid (CSF) leak following endoscopic transnasal pituitary and anterior skull base surgery: a multivariate analysis
Authors: Cathal John Hannan
Hamad Almhanedi
Rafid Al-Mahfoudh
Maneesh Bhojak
Seamus Looby
Mohsen Javadpour
Publication date: 01-06-2020
Publisher: Springer Vienna
Keywords: Pituitary Adenoma
Craniopharyngioma
Published in: Acta Neurochirurgica / Issue 6/2020
Print ISSN: 0001-6268
Electronic ISSN: 0942-0940
DOI: https://doi.org/10.1007/s00701-020-04334-5

2024 ASCO Annual Meeting

Springer Medicine

Predicting post-operative cerebrospinal fluid (CSF) leak following endoscopic transnasal pituitary and anterior skull base surgery: a multivariate analysis

Abstract

Background

Methods

Results

Conclusions

2024 ASCO Annual Meeting

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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