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Cerebrospinal fluid leaks in extended endoscopic transsphenoidal surgery: covering all the angles

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Abstract

Following extended endoscopic transsphenoidal approach (EETSA), cerebrospinal fluid (CSF) leak rate has been reported in the range of 5–50 %. Novel closure techniques, such as the nasoseptal flap and other multilayered repairs improved the outcomes significantly but took most of our focus. Little attention, however, was given to other aspects of the equation such as nasal support—to support the heavy weight of such repairs—and lumbar drains. These are important because they diminish the forces acting on both sides of the repair, hence covering all the angles. We reviewed data of 98 consecutive patients who underwent an EETSA between 1999 and 2014. We analyzed the rates of CSF leak throughout the years and with every modification added to our closure technique. Common pathologies encountered were invasive adenomas, meningiomas, chordomas, and craniopharyngiomas. CSF leak occurred overall in five patients (5.1 %). The nasoseptal flap decreased the rate of CSF leak but not significantly (P = 0.112), while placing a nasal trumpet to support our repair resulted in significant decrease in CSF leak rate (P = 0.0013). In the last 2 years of our series, when all modifications took place and all angles were covered, there was one leak in 35 cases (2.8 %). A protocol that covers all the angles by a good multilayered repair (regardless of its type and materials) while diminishing the forces acting on both sides of the repair leads to a minimal rate of CSF leak. No principle alone is effective individually.

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Abbreviations

EETSA:

Extended endoscopic transsphenoidal approach

CSF:

Cerebrospinal fluid

NS:

Nasoseptal

CT:

Computed tomography

MRI:

Magnetic resonance imaging

GTR:

Gross total resection

STR:

Subtotal resection

LD:

Lumbar drain

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Disclosure

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

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This is a retrospective study. For this type of study formal consent is not required.

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Correspondence to Hussein Fathalla.

Electronic supplementary material

Video 1

Video showing powerful CSF pulsations on closure prior to opening the lumbar drain (MP4 12,599 kb)

Video 2

Video showing the effect of lumbar drain in reducing the CSF pulsations (MP4 6570 kb)

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Fathalla, H., Di Ieva, A., Lee, J. et al. Cerebrospinal fluid leaks in extended endoscopic transsphenoidal surgery: covering all the angles. Neurosurg Rev 40, 309–318 (2017). https://doi.org/10.1007/s10143-016-0776-x

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  • DOI: https://doi.org/10.1007/s10143-016-0776-x

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