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Repair and prevention of cerebrospinal fluid leakage in transsphenoidal surgery: a sphenoid sinus mucosa technique

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Abstract

Cerebrospinal fluid (CSF) leakage is a common but sometimes serious complication after transsphenoidal surgery (TSS). To avoid this postsurgical complication, we usually repair the CSF leaking area using an autologous material, such as fat, fascia, or muscle graft and sometimes nasonasal septal flap. In this report, we propose a technique using a novel autologous material, sphenoid sinus mucosa (SSM), to repair intraoperative CSF leakage or prevent it postoperatively. On 26 February 2007, we introduced the technique of using SSM to repair or prevent CSF leakage in TSS. Until 30th of June 2014, we performed 500 TSSs for patients with pituitary or parasellar lesions. They were 195 men and 305 women with a mean age of 48.5 years (range, 5–85 years). We used SSM for patching or suturing the arachnoid laceration or dural defect, in lieu of fat or fascia harvested from abdomen or thigh, or made pedicle flap of SSM instead of nasonasal septal flap to cover the sellar floor. Comparing the previous 539 cases not using these techniques before 26 February 2007, intraoperative CSF leakage increased from 49 to 69.4 % (p < 0.0001) due to more aggressive surgical technique, mainly related to more extensive approaches and lesion removals, but the rate of using fat was reduced significantly from 35.5 to 19.4 % (p = 0.00021) in small or moderate CSF leaks during TSS without increasing the reoperation rate for postoperative CSF leaks (1.86 vs 1.2 %, p = 0.45). The technique of using SSM to repair intraoperative CSF leaks or prevent them postoperatively in TSS was considered useful, effective, less invasive, easier for graft harvesting (same surgical field), and providing natural anatomical reconstruction, without potential donor site morbidity. We can recommend it as a standard method for CSF leaks repair and prevention in TSS.

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Abbreviations

CSF:

Cerebrospinal fluid

SSM:

Sphenoid sinus mucosa

TSS:

Transsphenoidal surgery

MRI:

Magnetic resonance image

T1WIGd:

T1-weighed image with gadolinium enhancement

CT:

Computed tomography

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Acknowledgments

We would like to thank Dr. Kostadin Karagiozov for his review of this manuscript and Dr. Atsushi Watanabe for providing statistical analyses.

Conflict of interest

The authors report no conflict of interest concerning the materials or methods in this study or the findings specified in this paper.

Consent

Written informed consent was obtained from the patient for the publication of this report and any accompanying images.

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Authors and Affiliations

  1. Department of Neurosurgery, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan

    Kosaku Amano, Tomokatsu Hori, Takakazu Kawamata & Yoshikazu Okada

Authors
  1. Kosaku Amano
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  2. Tomokatsu Hori
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  3. Takakazu Kawamata
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  4. Yoshikazu Okada
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Corresponding author

Correspondence to Kosaku Amano.

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Comments

Dorian Chauvet, Paris, France

I congratulate the authors for this well-illustrated article, describing their experience of sphenoid sinus mucosa (SSM) graft, in order to repair CSF leaks. The statistics do not seem dramatic, but the concept is quite innovative and totally included in a mini invasive perspective. Two main techniques are nicely described: free flap SSM (patching or suturing) and pedicle flap SSM patching, which appears particularly relevant to me. Indeed, the SMM should be more often considered for sellar reconstruction and/or dural repair, as it is easily harvested in the same surgical field, without any clinical consequence for the patient (on the contrary of nasoseptal flap). However, one must notice that this study is a single surgeon work that mucosa cannot be always used because of its fragility and that wide laceration cannot be strongly repaired by SSM. Moreover, suturing techniques in this deep-seated area, with a very thin flap, can present many difficulties. To conclude with a touch of provocation, SSM techniques presented by Amano et al. are very encouraging, just because it would be a pity not to use this autologous material.

Juan Antonio Ponce-Gómez and Luis Alberto Ortega-Porcayo, Mexico City, Mexico

This is an interesting paper, for which the authors presented their single center experience using either a free flap of sphenoid sinus mucosa or a vascular pedicle sphenoid mucosal flap to prevent CSF leakage after transsphenoidal surgery.

During the last years, multiple reconstruction techniques with autologous and synthetic materials using vascularized or free flaps have been used with promising results. Even though the results are getting better, most of these techniques added an extra morbidity obtaining the fat and fascia and postoperative nasal complications. This well-described technique is a promising option for sellar floor reconstruction. They showed an impressive CSF leak rate of 1.2 % (6/500 cases), decreasing grafts from the abdomen or thigh, nasoseptal flap dissection, and avoiding prophylactic lumbar drain postoperatively. Reproducibility of the same technique in different centers around the world with the same results will give this technique the proper place in neurosurgery.

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Amano, K., Hori, T., Kawamata, T. et al. Repair and prevention of cerebrospinal fluid leakage in transsphenoidal surgery: a sphenoid sinus mucosa technique. Neurosurg Rev 39, 123–131 (2016). https://doi.org/10.1007/s10143-015-0667-6

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