Perspectives Commentary on: Combined Use of a Gasket Seal Closure and a Vascularized Pedicle Nasoseptal Flap Multilayered Reconstruction Technique for High-Flow Cerebrospinal Fluid Leaks After Endonasal Endoscopic Skull Base Surgery by Hu et al. World Neurosurg 2014 http://dx.doi.org/10.1016/j.wneu.2014.06.004
Paolo Cappabianca, M.D. Professor and Chairman of Neurological Surgery Department of Neurosciences & Reproductive and Odontostomatological Sciences Division of Neurosurgery Università degli Studi di Napoli Federico II
Gutta Cavat Lapidem: The Reconstruction of the Skull Base After Endoscopic Endonasal Surgery Michelangelo de Angelis and Paolo Cappabianca
n the last 2 decades, the evolution of endoscopic endonasal transsphenoidal surgery along with the development of a specific paradigm for skull base reconstruction (1, 7, 8) and improvement of the materials and reconstruction techniques has resulted in a marked reduction of postoperative cerebrospinal fluid (CSF) leak rate in the standard transsphenoidal approach. However, the widespread use of extended endoscopic endonasal approaches for the removal of skull base lesions (2) has led to the reemergence of postoperative CSF leak as a major issue for this kind of surgery.
I
techniques (4, 6, 9-13, 15-21). There is also a wide choice of synthetic, autologous, or heterologous materials, such as turbinate mucoperichondrium, fascia lata, periumbilical fat tissue, nasoseptal flap, bovine or equine pericardium, collagen sponge, titanium mesh, and polylactic acid, that can be used in different approaches individually or combined in a multilayer fashion to repair the large skull base defect resulting from endoscopic transnasal craniotomy. The use of vascularized mucosal pedicled flaps has been a significant advancement in the reconstruction of major endoscopic skull base defects (12, 14).
Reconstruction of the skull base defect in the extended transsphenoidal approach presents problems different from those associated with standard transsphenoidal surgery, related to either the local anatomy (5) or the materials for reconstruction (10). In extended or expanded endonasal surgery, the procedure differs from standard transsphenoidal surgery because skull base surgery is performed. Removal of the lesion usually requires an extensive opening of the arachnoid cisterns and sometimes (e.g., in case of craniopharyngiomas) of the third ventricle, increasing the risk of air passage in the intradural space, with subsequent pneumocephalus and risk of infection. As a consequence, different reconstruction techniques and materials are required to obtain a watertight reconstruction to rebuild the natural intradural and extradural compartments and to prevent postoperative CSF leak.
In their study, Hu et al. compared the vascularized pedicle nasoseptal flap multilayered reconstruction technique used alone or in combination with gasket seal closure, and their results are in favor of the combined technique, supporting the more recent contribution of other authors (18). Hu et al. also described their experience in using NasoPore (Polyganics, Rozenburglaan 15a, 9727 DL Groningen, The Netherlands) instead of a balloon to hold the reconstruction materials with encouraging results that in our opinion could be corroborated with future studies.
The increased CSF leakage rate reported following extended approaches compared with standard approaches led to the development of a large variety of skull base reconstruction
Key words Endonasal endoscopic approach - Gasket seal closure - High-flow CSF leaks - Multilayered reconstruction - Skull base reconstruction - Vascularized pedicle nasoseptal flap -
Abbreviations and Acronyms CSF: Cerebrospinal fluid
WORLD NEUROSURGERY - [-]: ---, MONTH 2014
One other question that emerges from this interesting article regards the use of a lumbar drain. The use of this invasive CSF diversion device is controversial because of the rare complications associated with its use, including subarachnoid hemorrhage, meningitis, intracranial hypotension, tension pneumocephalus, cerebral herniation syndromes, and retained catheters (9, 22). Hu et al. show how rational use and management of the lumbar drain does not increase the risk of infection, and their complication rate is
Department of Neurosciences & Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy To whom correspondence should be addressed: Paolo Cappabianca, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2014). http://dx.doi.org/10.1016/j.wneu.2014.06.050
www.WORLDNEUROSURGERY.org
1
PERSPECTIVES
very low. All studies concerning the use of a lumbar drain after extended endoscopic endonasal approaches are retrospective without a control group; a prospective randomized controlled study is needed to provide reliable evidence. In conclusion, endoscopic reconstruction of the osteodural defect created after extended approaches remains problematic. Because there is no unequivocal agreement regarding which material or combination of materials and which method can be considered the perfect remedy, the choice of adequate
REFERENCES 1. Cappabianca P, Cavallo LM, Esposito F, Valente V, de Divitiis E: Sellar repair in endoscopic endonasal transsphenoidal surgery: results of 170 cases. Neurosurgery 51:1365-1371 [discussion 13711372], 2002. 2. Cappabianca P, Cavallo LM, Esposito F, de Divitiis O, Messina A, de Divitiis E: Extended endoscopic endonasal approach to the midline skull base: the evolving role of transsphenoidal surgery. Adv Tech Stand Neurosurg 33:151-199, 2008. 3. Cappabianca P, Esposito F, Magro F, Cavallo LM, Solari D, Stella L, de Divitiis O: Natura Abhorret a Vacuo—use of fibrin glue as a filler and sealant in neurosurgical “dead spaces.” Technical note. Acta Neurochir (Wien) 152:897-904, 2010. 4. Castelnuovo P, Dallan I, Bignami M, Battaglia P, Mauri S, Bolzoni Villaret A, Bizzoni A, Tomenzoli D, Nicolai P: Nasopharyngeal endoscopic resection in the management of selected malignancies: ten-year experience. Rhinology 48:84-89, 2010. 5. Cavallo LM, de Divitiis O, Aydin S, Messina A, Esposito F, Iaconetta G, Talat K, Cappabianca P, Tschabitscher M: Extended endoscopic endonasal transsphenoidal approach to the suprasellar area: anatomic considerations—part 1. Neurosurgery 61:ONS24-ONS34, 2007. 6. Cavallo LM, Messina A, Esposito F, de Divitiis O, Dal Fabbro M, de Divitiis E, Cappabianca P: Skull base reconstruction in the extended endoscopic transsphenoidal approach for suprasellar lesions. J Neurosurg 107:713-720, 2007. 7. de Divitiis E, Cavallo LM, Cappabianca P, Esposito F: Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors: part 2. Neurosurgery 60:46-58 [discussion 58-59], 2007.
technique and materials to be used is still addressed in each case according to the surgeon’s experience and the features of the case (20). The use of a vascularized flap covering a multilayer reconstruction seems to be an effective solution for the problem (3, 19). Nevertheless, future developments are expected to come from collaboration between surgeons, the scientific research community, and industry to increase the effectiveness and the safety of the extended transsphenoidal procedure, with further improvement and better outcomes for patients.
surgery for pituitary adenomas. Minim Invasive Neurosurg 46:289-292, 2003.
62(5 Suppl 2):ONSE342-ONSE343, 2008 [discussion ONSE343].
9. Eloy JA, Kuperan AB, Choudhry OJ, Harirchian S, Liu JK: Efficacy of the pedicled nasoseptal flap without cerebrospinal fluid (CSF) diversion for repair of skull base defects: incidence of postoperative CSF leaks. Int Forum Allergy Rhinol 2: 397-401, 2012.
18. Mascarenhas L, Moshel YA, Bayad F, Szentirmai O, Salek AA, Leng LZ, Hofstetter CP, Placantonakis DG, Tsiouris AJ, Anand VK, Schwartz TH: The transplanum transtuberculum approaches for suprasellar and sellar-suprasellar lesions: avoidance of cerebrospinal fluid leak and lessons learned. World Neurosurg 2013 Feb 9 [Epub ahead of print].
10. Esposito F, Dusick JR, Fatemi N, Kelly DF: Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery. Neurosurgery 60(4 Suppl 2):295-303 [discussion 303-304], 2007. 11. Garcia-Navarro V, Anand VK, Schwartz TH: Gasket seal closure for extended endonasal endoscopic skull base surgery: efficacy in a large case series. World Neurosurg 80:563-568, 2013. 12. Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, Mintz A: A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 116:1882-1886, 2006. 13. Jane JA Jr: “Gasket-seal” closure for cerebrospinal fluid leaks. World Neurosurg 80:491-492, 2013. 14. Kassam AB, Thomas A, Carrau RL, Snyderman CH, Vescan A, Prevedello D, Mintz A, Gardner P: Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 63: ONS44-ONS52 [discussion ONS52-ONS53], 2008. 15. Kassam AB, Prevedello DM, Carrau RL, Snyderman CH, Thomas A, Gardner P, Zanation A, Duz B, Stefko ST, Byers K, Horowitz MB: Endoscopic endonasal skull base surgery: analysis of complications in the authors’ initial 800 patients. J Neurosurg 114:1544-1568, 2011. 16. Laws ER, Kanter AS, Jane JA Jr, Dumont AS: Extended transsphenoidal approach. J Neurosurg 102:825-827 [discussion 827-828], 2005.
19. McCoul ED, Anand VK, Singh A, Nyquist GG, Schaberg MR, Schwartz TH: Long-term effectiveness of a reconstructive protocol using the nasoseptal flap after endoscopic skull base surgery. World Neurosurg 81:136-143, 2014. 20. Patel MR, Stadler ME, Snyderman CH, Carrau RL, Kassam AB, Germanwala AV, Gardner P, Zanation AM: How to choose? Endoscopic skull base reconstructive options and limitations. Skull Base 20:397-404, 2010. 21. Sciarretta V, Mazzatenta D, Ciarpaglini R, Pasquini E, Farneti G, Frank G: Surgical repair of persisting CSF leaks following standard or extended endoscopic transsphenoidal surgery for pituitary tumor. Minim Invasive Neurosurg 53: 55-59, 2010. 22. 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: Cerebrospinal fluid leakage during transsphenoidal surgery: postoperative external lumbar drainage reduces the risk for meningitis. Pituitary 7:89-93, 2004.
Citation: World Neurosurg. (2014). http://dx.doi.org/10.1016/j.wneu.2014.06.050 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com
8. El-Banhaawy OA, Halaka AN, El-Dien AE-HS: Sellar floor reconstruction with nasal turbinate tissue after endoscopic endonasal transsphenoidal
2
www.SCIENCEDIRECT.com
17. Leng LZ, Brown S, Anand VK, Schwartz TH: “Gasket-seal” watertight closure in minimal-access endoscopic cranial base surgery. Neurosurgery
1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2014.06.050
Paolo Cappabianca, M.D. Professor and Chairman of Neurological Surgery Department of Neurosciences & Reproductive and Odontostomatological Sciences Division of Neurosurgery Università degli Studi di Napoli Federico II
Gutta Cavat Lapidem: The Reconstruction of the Skull Base After Endoscopic Endonasal Surgery Michelangelo de Angelis and Paolo Cappabianca
n the last 2 decades, the evolution of endoscopic endonasal transsphenoidal surgery along with the development of a specific paradigm for skull base reconstruction (1, 7, 8) and improvement of the materials and reconstruction techniques has resulted in a marked reduction of postoperative cerebrospinal fluid (CSF) leak rate in the standard transsphenoidal approach. However, the widespread use of extended endoscopic endonasal approaches for the removal of skull base lesions (2) has led to the reemergence of postoperative CSF leak as a major issue for this kind of surgery.
I
techniques (4, 6, 9-13, 15-21). There is also a wide choice of synthetic, autologous, or heterologous materials, such as turbinate mucoperichondrium, fascia lata, periumbilical fat tissue, nasoseptal flap, bovine or equine pericardium, collagen sponge, titanium mesh, and polylactic acid, that can be used in different approaches individually or combined in a multilayer fashion to repair the large skull base defect resulting from endoscopic transnasal craniotomy. The use of vascularized mucosal pedicled flaps has been a significant advancement in the reconstruction of major endoscopic skull base defects (12, 14).
Reconstruction of the skull base defect in the extended transsphenoidal approach presents problems different from those associated with standard transsphenoidal surgery, related to either the local anatomy (5) or the materials for reconstruction (10). In extended or expanded endonasal surgery, the procedure differs from standard transsphenoidal surgery because skull base surgery is performed. Removal of the lesion usually requires an extensive opening of the arachnoid cisterns and sometimes (e.g., in case of craniopharyngiomas) of the third ventricle, increasing the risk of air passage in the intradural space, with subsequent pneumocephalus and risk of infection. As a consequence, different reconstruction techniques and materials are required to obtain a watertight reconstruction to rebuild the natural intradural and extradural compartments and to prevent postoperative CSF leak.
In their study, Hu et al. compared the vascularized pedicle nasoseptal flap multilayered reconstruction technique used alone or in combination with gasket seal closure, and their results are in favor of the combined technique, supporting the more recent contribution of other authors (18). Hu et al. also described their experience in using NasoPore (Polyganics, Rozenburglaan 15a, 9727 DL Groningen, The Netherlands) instead of a balloon to hold the reconstruction materials with encouraging results that in our opinion could be corroborated with future studies.
The increased CSF leakage rate reported following extended approaches compared with standard approaches led to the development of a large variety of skull base reconstruction
Key words Endonasal endoscopic approach - Gasket seal closure - High-flow CSF leaks - Multilayered reconstruction - Skull base reconstruction - Vascularized pedicle nasoseptal flap -
Abbreviations and Acronyms CSF: Cerebrospinal fluid
WORLD NEUROSURGERY - [-]: ---, MONTH 2014
One other question that emerges from this interesting article regards the use of a lumbar drain. The use of this invasive CSF diversion device is controversial because of the rare complications associated with its use, including subarachnoid hemorrhage, meningitis, intracranial hypotension, tension pneumocephalus, cerebral herniation syndromes, and retained catheters (9, 22). Hu et al. show how rational use and management of the lumbar drain does not increase the risk of infection, and their complication rate is
Department of Neurosciences & Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy To whom correspondence should be addressed: Paolo Cappabianca, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2014). http://dx.doi.org/10.1016/j.wneu.2014.06.050
www.WORLDNEUROSURGERY.org
1
PERSPECTIVES
very low. All studies concerning the use of a lumbar drain after extended endoscopic endonasal approaches are retrospective without a control group; a prospective randomized controlled study is needed to provide reliable evidence. In conclusion, endoscopic reconstruction of the osteodural defect created after extended approaches remains problematic. Because there is no unequivocal agreement regarding which material or combination of materials and which method can be considered the perfect remedy, the choice of adequate
REFERENCES 1. Cappabianca P, Cavallo LM, Esposito F, Valente V, de Divitiis E: Sellar repair in endoscopic endonasal transsphenoidal surgery: results of 170 cases. Neurosurgery 51:1365-1371 [discussion 13711372], 2002. 2. Cappabianca P, Cavallo LM, Esposito F, de Divitiis O, Messina A, de Divitiis E: Extended endoscopic endonasal approach to the midline skull base: the evolving role of transsphenoidal surgery. Adv Tech Stand Neurosurg 33:151-199, 2008. 3. Cappabianca P, Esposito F, Magro F, Cavallo LM, Solari D, Stella L, de Divitiis O: Natura Abhorret a Vacuo—use of fibrin glue as a filler and sealant in neurosurgical “dead spaces.” Technical note. Acta Neurochir (Wien) 152:897-904, 2010. 4. Castelnuovo P, Dallan I, Bignami M, Battaglia P, Mauri S, Bolzoni Villaret A, Bizzoni A, Tomenzoli D, Nicolai P: Nasopharyngeal endoscopic resection in the management of selected malignancies: ten-year experience. Rhinology 48:84-89, 2010. 5. Cavallo LM, de Divitiis O, Aydin S, Messina A, Esposito F, Iaconetta G, Talat K, Cappabianca P, Tschabitscher M: Extended endoscopic endonasal transsphenoidal approach to the suprasellar area: anatomic considerations—part 1. Neurosurgery 61:ONS24-ONS34, 2007. 6. Cavallo LM, Messina A, Esposito F, de Divitiis O, Dal Fabbro M, de Divitiis E, Cappabianca P: Skull base reconstruction in the extended endoscopic transsphenoidal approach for suprasellar lesions. J Neurosurg 107:713-720, 2007. 7. de Divitiis E, Cavallo LM, Cappabianca P, Esposito F: Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors: part 2. Neurosurgery 60:46-58 [discussion 58-59], 2007.
technique and materials to be used is still addressed in each case according to the surgeon’s experience and the features of the case (20). The use of a vascularized flap covering a multilayer reconstruction seems to be an effective solution for the problem (3, 19). Nevertheless, future developments are expected to come from collaboration between surgeons, the scientific research community, and industry to increase the effectiveness and the safety of the extended transsphenoidal procedure, with further improvement and better outcomes for patients.
surgery for pituitary adenomas. Minim Invasive Neurosurg 46:289-292, 2003.
62(5 Suppl 2):ONSE342-ONSE343, 2008 [discussion ONSE343].
9. Eloy JA, Kuperan AB, Choudhry OJ, Harirchian S, Liu JK: Efficacy of the pedicled nasoseptal flap without cerebrospinal fluid (CSF) diversion for repair of skull base defects: incidence of postoperative CSF leaks. Int Forum Allergy Rhinol 2: 397-401, 2012.
18. Mascarenhas L, Moshel YA, Bayad F, Szentirmai O, Salek AA, Leng LZ, Hofstetter CP, Placantonakis DG, Tsiouris AJ, Anand VK, Schwartz TH: The transplanum transtuberculum approaches for suprasellar and sellar-suprasellar lesions: avoidance of cerebrospinal fluid leak and lessons learned. World Neurosurg 2013 Feb 9 [Epub ahead of print].
10. Esposito F, Dusick JR, Fatemi N, Kelly DF: Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery. Neurosurgery 60(4 Suppl 2):295-303 [discussion 303-304], 2007. 11. Garcia-Navarro V, Anand VK, Schwartz TH: Gasket seal closure for extended endonasal endoscopic skull base surgery: efficacy in a large case series. World Neurosurg 80:563-568, 2013. 12. Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, Mintz A: A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 116:1882-1886, 2006. 13. Jane JA Jr: “Gasket-seal” closure for cerebrospinal fluid leaks. World Neurosurg 80:491-492, 2013. 14. Kassam AB, Thomas A, Carrau RL, Snyderman CH, Vescan A, Prevedello D, Mintz A, Gardner P: Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 63: ONS44-ONS52 [discussion ONS52-ONS53], 2008. 15. Kassam AB, Prevedello DM, Carrau RL, Snyderman CH, Thomas A, Gardner P, Zanation A, Duz B, Stefko ST, Byers K, Horowitz MB: Endoscopic endonasal skull base surgery: analysis of complications in the authors’ initial 800 patients. J Neurosurg 114:1544-1568, 2011. 16. Laws ER, Kanter AS, Jane JA Jr, Dumont AS: Extended transsphenoidal approach. J Neurosurg 102:825-827 [discussion 827-828], 2005.
19. McCoul ED, Anand VK, Singh A, Nyquist GG, Schaberg MR, Schwartz TH: Long-term effectiveness of a reconstructive protocol using the nasoseptal flap after endoscopic skull base surgery. World Neurosurg 81:136-143, 2014. 20. Patel MR, Stadler ME, Snyderman CH, Carrau RL, Kassam AB, Germanwala AV, Gardner P, Zanation AM: How to choose? Endoscopic skull base reconstructive options and limitations. Skull Base 20:397-404, 2010. 21. Sciarretta V, Mazzatenta D, Ciarpaglini R, Pasquini E, Farneti G, Frank G: Surgical repair of persisting CSF leaks following standard or extended endoscopic transsphenoidal surgery for pituitary tumor. Minim Invasive Neurosurg 53: 55-59, 2010. 22. 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: Cerebrospinal fluid leakage during transsphenoidal surgery: postoperative external lumbar drainage reduces the risk for meningitis. Pituitary 7:89-93, 2004.
Citation: World Neurosurg. (2014). http://dx.doi.org/10.1016/j.wneu.2014.06.050 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com
8. El-Banhaawy OA, Halaka AN, El-Dien AE-HS: Sellar floor reconstruction with nasal turbinate tissue after endoscopic endonasal transsphenoidal
2
www.SCIENCEDIRECT.com
17. Leng LZ, Brown S, Anand VK, Schwartz TH: “Gasket-seal” watertight closure in minimal-access endoscopic cranial base surgery. Neurosurgery
1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2014.06.050
