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Endoscopic endonasal skull base reconstruction using a nasal septal flap: surgical results and comparison with previous reconstructions

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Abstract

The objective of this study is to evaluate the usefulness and reliability of endoscopic endonasal skull base reconstructions using a nasal septal flap. This study is designed as a retrospective review. Between April 2005 and November 2009, we performed 32 endoscopic endonasal skull base reconstructions for closure of large dural defects. Eleven patients underwent reconstructions using fat grafts or the fascia lata (non-flap group). Twenty one patients underwent reconstructions using a nasal septal flap with a balloon catheter (flap group). Incidence of postoperative cerebrospinal fluid (CSF) leaks and perioperative insertion rate of external lumbar drain (ELD) were compared between the two groups. Postoperative CSF leaks occurred in two patients (9.5%) in the flap group. Three patients (27.3%) presented CSF leaks in the non-flap group. The rate of insertion of ELD was 81.8% in the non-flap group. In the flap group, one patient (4.8%) should be placed with ELD postoperatively. The incidence of postoperative CSF leaks in the flap group was lower than in the non-flap group, whereas the rate of insertion of ELD in the non-flap group was higher than in the flap group. Endoscopic endonasal skull base reconstruction using a nasal septal flap without ELD seems to be useful and reliable for ventral skull base defects after endoscopic endonasal approaches as compared with our previous single-layer reconstructions using free fat grafts or fascia lata. The long-term effectiveness of nasal septal flaps to prevent intracranial complications should be confirmed.

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References

  1. Arita K, Kurisu K, Tominaga A, Ikawa F, Iida K, Hama S, Watanabe H (1999) Size-adjustable titanium plate for reconstruction of the sella turcica: technical note. J Neurosurg 91:1055–1057

    Article  CAS  PubMed  Google Scholar 

  2. Bien AG, Bowdino B, Moore G, Leibrock L (2007) Utilization of preoperative cerebrospinal fluid drain in skull base surgery. Skull Base 17:133–139

    Article  PubMed  Google Scholar 

  3. Cappabianca P, Cavallo LM, Mariniello G, de Divitiis O, Romero AD, de Divitiis E (2001) Easy sellar reconstruction in endoscopic endonasal transsphenoidal surgery with polyester-silicone dural substitute and fibrin glue: technical note. Neurosurgery 49:473–476

    Article  CAS  PubMed  Google Scholar 

  4. Cappabianca P, Cavallo LM, Esposito F, Valente V, de Divitiis E (2002) Sellar repair in endoscopic endonasal transsphenoidal surgery: results of 170 cases. Neurosurgery 51:1365–1371

    Article  PubMed  Google Scholar 

  5. Carrau RL, Snyderman CH, Kassam AB (2005) The management of cerebrospinal fluid leaks in patients at risk for high-pressure hydrocephalus. Laryngoscope 115:205–212

    Article  PubMed  Google Scholar 

  6. Casiano RR, Jassir D (1999) Endoscopic cerebrospinal fluid rhinorrhea repair: is a lumber drain necessary? Otolaryngol Head Neck Surg 121:745–750

    Article  CAS  PubMed  Google Scholar 

  7. Castelnuovo PG, Delu G, Locatelli D, Padoan G, Bernardi FD, Pistochini A, Bignami M (2006) Endonasal endoscopic duraplasty: our experience. Skull Base 16:19–23

    Article  PubMed  Google Scholar 

  8. Cavallo LM, Messina A, Esposito F, de Divitiis O, Dal Fabbro M, de Divitiis E, Cappabianca P (2007) Skull base reconstruction in the extended endoscopic transsphenoidal approach for suprasellar lesions. J Neurosurg 107:713–720

    Article  PubMed  Google Scholar 

  9. 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 40:225–237

    Article  CAS  PubMed  Google Scholar 

  10. Cook SW, Smith Z, Kelly DF (2004) Endonasal transsphenoidal removal of tuberculum sellae meningiomas: technical note. Neurosurgery 55:239–246

    Article  PubMed  Google Scholar 

  11. Couldwell WT, Weiss MH, Rabb C, Liu JK, Apfelbaum RI, Fukushima T (2004) Variations on the standard transsphenoidal approach to the sellar region, with emphasis on the extended approaches and parasellar approaches: surgical experience in 105 cases. Neurosurgery 55:539–550

    Article  PubMed  Google Scholar 

  12. de Divitiis E, Cavallo LM, Cappabianca P, Esposito F (2007) Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors: part 2. Neurosurgery 60:46–58

    PubMed  Google Scholar 

  13. de Divitiis E, Cappabianca P, Cavallo LM, Esposito F, de Divitiis O, Messina A (2007) Extended endoscopic transsphenoidal approach for extrasellar craniopharyngiomas. Neurosurgery 61(Suppl 2):219–228

    Article  PubMed  Google Scholar 

  14. Dusick JR, Esposito F, Kelly DF, Cohan P, DeSalles A, Becker DP, Martin NA (2005) The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J Neurosurg 102:832–841

    Article  PubMed  Google Scholar 

  15. El-Banhawy OA, Halaka AN, Altuwaijiri MA, Ayad H (2008) Long-term outcome of endonasal endoscopic skull base reconstruction with nasal turbinate graft. Skull Base 18:297–308

    Article  PubMed  Google Scholar 

  16. El-Sayed IH, Roediger FC, Goldberg AN, Parsa AT, McDermott MW (2008) Endonasal reconstruction of skull base defects with the nasal septal flap. Skull Base 18:385–394

    Article  PubMed  Google Scholar 

  17. Esposito F, Dusick JR, Fatemi N, Kelly DF (2007) Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery. Neurosurgery 60:295–304

    Article  PubMed  Google Scholar 

  18. Frank G, Pasquini E, Doglietto F, Doglietto F, Mazzatenta D, Sciarretta V, Farneti G, Calbucci F (2006) The endoscopic extended transsphenoidal approach for craniopharyngiomas. Neurosurgery 59(Suppl 1):ONS75–ONS83

    PubMed  Google Scholar 

  19. Frank G, Sciarretta V, Calbucci F, Farneti G, Mazzatenta D, Pasquini E (2006) The endoscopic transnasal transsphenoidal approach for the treatment of cranial base chordomas and chondrosarcomas. Neurosurgery 59(Suppl 1):ONS50–ONS57

    PubMed  Google Scholar 

  20. Fortes FS, Carrau RL, Snyderman CH, Prevedello D, Vescan A, Mintz A, Gardner P, Kassam AB (2007) The posterior pedicle inferior turbinate flap: a new vascularized flap for skull. Laryngoscope 117:1329–1332

    Article  PubMed  Google Scholar 

  21. 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

    Article  PubMed  Google Scholar 

  22. Harvey RJ, Nogueira JF, Schlosser RJ, Patel SJ, Vellutini E, Stamm AC (2009) Closure of large skull base defects after endoscopic transnasal craniotomy. J Neurosurg 111:371–379

    Article  PubMed  Google Scholar 

  23. Kaptain GJ, Vincent DA, Laws ER Jr (2001) Cranial base reconstruction after transsphenoidal surgery with bioabsorbable implants. Neurosurgery 48:232–234

    Article  CAS  PubMed  Google Scholar 

  24. 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:E6

    PubMed  Google Scholar 

  25. Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL (2005) Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus 19:E3

    PubMed  Google Scholar 

  26. Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL (2005) Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum. Neurosurg Focus 19:E4

    PubMed  Google Scholar 

  27. Kassam AB, Gardner PA, Snyderman CH, Carrau RL, Mintz AH, Prevedello DM (2008) Expanded endonasal approach, a fully endoscopic transnasal approach for the resection of midline suprasellar craniopharyngiomas: a new classification based on the infundibulum. J Neurosurg 108:715–728

    Article  PubMed  Google Scholar 

  28. Kassam AB, Thomas A, Carrau RL, Snyderman CH, Vescan A, Prevedello D, Mintz A, Gardner P (2008) Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 63(Suppl 1):ONS44–ONS53

    Article  PubMed  Google Scholar 

  29. Kato T, Sawamura Y, Abe H, Nagashima M (1998) Transsphenoidal-transtuberculum sellae approach for supradiaphragmatic tumors: technical note. Acta Neurochir 140:715–719

    Article  CAS  Google Scholar 

  30. Kitano M, Taneda M (2004) Subdural patch graft technique for watertight closure of large dural defects in extended transsphenoidal surgery. Neurosurgery 54:653–661

    Article  PubMed  Google Scholar 

  31. Kobayashi S, Sugita K, Matsuo K, Inoue T (1981) Reconstruction of the sellar floor during transsphenoidal operations using alumina ceramic. Surg Neurol 15:196–197

    Article  CAS  PubMed  Google Scholar 

  32. Kouri JG, Chen MY, Watson JC, Oldfield EH (2000) Resection of suprasellar tumors by using a modified transsphenoidal approach. Report of four cases. J Neurosurg 92:1028–1035

    Article  CAS  PubMed  Google Scholar 

  33. Laws ER, Kanter AS, Jane JA Jr, Dumont AS (2005) Extended transsphenoidal approach. J Neurosurg 102:825–828

    Article  PubMed  Google Scholar 

  34. Leng LZ, Brown S, Anand VK, Schwartz TH (2008) “GASKET-SEAL” watertight closure in minimal access endoscopic cranial base surgery. Neurosurgery 62(ONS Suppl 2):ONSE342–ONSE343

    Article  PubMed  Google Scholar 

  35. Locatelli D, Rampa F, Acchiardi I, Bignami M, De Bernardi F, Castelnuovo P (2006) Endoscopic endonasal approaches for repair of cerebrospinal fluid leaks: nine-year experience. Neurosurgery 58(Suppl 2):ONS246–ONS257

    Google Scholar 

  36. Oliver CL, Hackman TG, Carrau RL, Snyderman CH, Kassam AB, Prevedello DM, Gardner P (2008) Palatal flap modifications allow pedicled reconstruction of the skull base. Laryngoscope 118:2102–2106

    Article  PubMed  Google Scholar 

  37. Pinheiro-Neto CD, Prevedello DM, Carrau RL, Snyderman CH, Mintz A, Gardner P, Kassam A (2007) Improving the design of the pedicled nasoseptal flap for skull base reconstruction: a radioanatomic study. Laryngoscope 117:1560–1569

    Article  PubMed  Google Scholar 

  38. Saeki N, Murai H, Hasegawa Y, Horiguchi K, Hanazawa T, Fukuda K (2009) Endoscopic endonasal surgery for exrasellar tumors: case presentation and its future perspective (in Japanese). No Shinkei Geka 37:229–246

    PubMed  Google Scholar 

  39. Seiler RW, Mariani L (2000) Sellar reconstruction with resorbable vicryl patches, gelatin foam, and fibrin glue in transsphenoidal surgery: a 10-year experience with 376 patients. J Neurosurg 93:762–765

    Article  CAS  PubMed  Google Scholar 

  40. Shah RN, Surowitz JB, Patel MR, Huang BY, Snyderman CH, Carrau RL, Kassam AB, Germanwala AV, Zanation AM (2009) Endoscopic pedicled nasoseptal flap reconstruction for pediatric skull base defects. Laryngoscope 119:1067–1075

    Article  PubMed  Google Scholar 

  41. Snyderman CH, Janecka IP, Sekhar LN, Sen CN, Eibling DE (1990) Anterior cranial base reconstruction: role of galeal and pericranial flaps. Laryngoscope 100:607–614

    Article  CAS  PubMed  Google Scholar 

  42. Snyderman CH, Kassam AB, Carrau R, Mintz A (2007) Endoscopic reconstruction of cranial base defects following endonasal skull base surgery. Skull Base 17:73–78

    Article  PubMed  Google Scholar 

  43. Tabaee A, Anand VK, Brown SM, Lin JW, Schwartz TH (2007) Algorithm for reconstruction after endoscopic pituitary and skull base surgery. Laryngoscope 117:1133–1137

    Article  PubMed  Google Scholar 

  44. Van Aken MO, Feelders RA, de Marie S, van de Berge JH, Dallenga AH, Delwel EJ, Poublon RM, Romijn JA, van der Lely AJ, Lamberts SW, de Herder WW (2004) Cerebrospinal fluid leakage during transsphenoidal surgery: postoperative external lumber drainage reduces the risk for meningitis. Pituitary 7:89–93

    Article  PubMed  Google Scholar 

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Acknowledgements

This work was performed in collaboration with the Departments of Otorhinolaryngology and Bioenvironmental Medicine at Chiba University Graduate School of Medicine.

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Authors and Affiliations

  1. Department of Neurosurgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana Chuoku, Chiba, 260-8670, Japan

    Kentaro Horiguchi, Hisayuki Murai, Yuzo Hasegawa, Iwao Yamakami & Naokatsu Saeki

  2. Department of Otorhinolaryngology, Chiba University Graduate School of Medicine, Chiba, Japan

    Toyoyuki Hanazawa

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  1. Kentaro Horiguchi
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  2. Hisayuki Murai
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  3. Yuzo Hasegawa
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  4. Toyoyuki Hanazawa
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  6. Naokatsu Saeki
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Correspondence to Kentaro Horiguchi.

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Comments

Luigi Maria Cavallo, Paolo Cappabianca, Naples, Italy

This is an interesting article coming from a country that has a long tradition in the field of transsphenoidal surgery and, furthermore, from a group leaded by dr. Saeki who has already established in Japan as a relevant surgeon in performing pure endoscopic pituitary surgery.

This work follows a series of articles that recently have proved the efficacy of the nasoseptal flap in the reconstruction of skull base defects after extended endoscopic endonasal transsphenoidal surgery, thus helping in resolving a problem which was considered the Achille’s heel of such procedures.

Moreover it is clear as craniopharyngiomas and above all those expanding into the third ventricle are still exposed to an increased risk of post-operative CSF-leak for such reason requiring a special attention during the reconstruction phase of the surgical procedure.

In our experience, in those cases we have obtained a successfully reconstruction using a thin film of fibrin glue inside the intradural space and at the level of the skull base defect; this manoeuvre allowed the sealing of the sub-arachnoidal space which represents the source from which the CSF comes out. In this way a first, valid, watertight barrier against the CSF is realized.

This little trick, together with the routinary use of the nasoseptal flap, in our experience has really minimized, even in case of large oste-dural defects, the rate of post-operative CSF leak.

Miguel A. Arraez, Malaga, Spain

This article from Horiguchi and colleagues has several points of interest, regarding the best way to seal a dural defect after midbase neoplasms resection. Although the endoscopic approach is being used more and more for the approach of complex skull base lesions, some problems are still unsolved. One of the big troubles is reconstruction after dural opening and, as a matter of fact, the risk of persistent postoperative CSF fistula is considered for many authors the main drawback when comparing endoscopy with microsurgery to resect intradural lesions. Several techniques (with different tissues and materials) have been used to avoid such a complication, but those techniques eluding the principle of autologous pedicled and vascularized tissue may be condemned to fail if the dural defect is not small. Several publications have pointed out the usefulness of the nasal septum pedicled flap for the closure of midbase defects after endoscopic approaches. The paper from Horiguchi and colleagues states in that way. According to their experience, this kind of reconstruction is more effective than the multilayer (“non flap”) technique. Although the authors are wondering about the long-term results of the pedicled flap and the inherent surgical difficulties, the low incidence of postoperative ELD and CSF fistula merits the pedicled flap as the most reliable way to undertake the sealing of a complex dural defect after endoscopy. Another complementary aspect to congratulate the authors is the original design of the “sinus compression ballon”, that is supposed to distribute more properly the pressure inside the sphenoidal sinus in accordance to the needs of the flap.

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

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