Introduction: The endoscopic endonasal transsphenoidal approach (EETSA) is increasingly being used to treat pituitary adenomas and other sellar/suprasellar pathologies. One important complication of the transsphenoidal approach is cerebrospinal fluid (CSF) leakage, which occurs in 0.4 to 9% of cases. We report our experience with EETSA and describe the methods that we use to prevent CSF leakage.

Methods: A single surgeon performed EETSA on 170 consecutive patients between Feb 2004 and Apr 2011. Patients were divided into three groups based on their CSF leakage status as follows: no CSF leakage, minor CSF leakage, and major CSF leakage. Sellar floor reconstruction was performed according to this classification. In the no-CSF leakage group, sellar floor reconstruction was performed with oxidative cellulose (Surgicel®) only. In the second group (minor CSF leakage), sellar floor reconstruction was performed using autologous fat and bone grafts. Patients in the third group (major CSF leakage) underwent an additional reconstructive procedure of the skull base using the pedicled septal mucosal flap.

Results: Of 170 patients, 30 (17.6%) showed CSF leakage in the operation field; 24 (14.1%) were classified as having minor CSF leakage and 6 (3.5%) patients were classified as having major CSF leakage. Post-operative CSF leakage occurred in only two cases.

Conclusions: CSF leakage, though relatively common in the operation field, can be prevented effectively with adequate reconstruction techniques. Assignment of patients to one of three groups based on their CSF leakage in the operation field and sellar floor reconstruction based on this classification resulted in favorable postoperative outcomes.

Patient Care: This method can prevent CSF leakage efficiently after endonasal endoscopic transsphenoidal approach.

Learning Objectives: The endoscopic endonasal transsphenoidal approach (EETSA) is increasingly being used to treat pituitary adenomas and other sellar/suprasellar pathologies. One important complication of the transsphenoidal approach is cerebrospinal fluid (CSF) leakage, which occurs in 0.4 to 9% of cases. We report our experience with EETSA and describe the methods that we use to prevent CSF leakage.

References: 1. Black PM, Zervas NT, Candia GL: Incidence and management of complications of transsphenoidal operation for piyuitary adenomas. Neurosurgery 20(6) : 920-924, 1987 2. Capabianca P, Cavallo LM, Esposito F, Valente V, de Divitiis E: Sellar repair in endoscopic endonasal transsphenoidal durgery : results of 170 cases. Neurosurgery 51(6) : 1365-1372, 2002 3. Cappabianca P, Cavallo LM, Mariniello G, de Divitiis O, Romero AD et al.: Easy sellar reconstruction in endoscopic endonasal transsphenoidal surgery with polyester-silicone dural substitute and fibrin glue: technical note. Neurosurgery 49:473–476,2001 4. Charalampaki P, Reisch R, Ayad A, Conrad J, Welschehold S, Perneczky A, et al.: Endoscopic endonasal pituitary surgery : Surgical and outcome analysis of 50 cases. J Clin Neurosci 14 : 410-415, 2007 5. Ciric I, Ragan A, Baumgartner C, Pierce D: Complications of transsphenoidal surgery : results of national survey, review of the literature, and personal experience. Neurosurgery 40(2) : 225-237, 1997 6. Ciric I, Rosenblatt s, Zhao J-Ch: Transsphenoidal microsurgery (operative nuances). Neurosurgery 51(1) : 161-169, 2002 7. Cook SW, Smith Z, Kelly DF: Endonasal transsphenoidal removal of tuberculum sellae meningiomas: technical note. Neurosurgery 55:239–246, 2004 8. Dehdashti AR, Ganna A, Karabatsou K, Gentili F: Pure endoscopic endonasal approach for pituitary adenomas: Early surgical results in 200 patients and comparison with previous microsurgical series. Neurosurgery 62 : 1006-1017, 2008 9. Dusick JR, Esposito F, Kelly DF, Cohan P, DeSalles A, Becker DP, et al.: The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J Neurosurg 102:832–841, 2005 10. Frank G, Pasquini E, Doglietto F, Mazzatenta D, Sciarretta V, Farneti G, et al.: The endoscopic extended transsphenoidal approach for craniopharyngiomas. Neurosurgery 59: (1 Suppl 1): ONS75–ONS83, 2006 11. Gondin JA, Schops M, de Almeida JPC, de Albuquerque LAF, Gomes E, Ferraz T, et al. : Endoscopic endonasal transsphenoidal surgery: surgical results of 228 pituitary adenomas treated in a pituitary center. Pituitary 13 : 68-77, 2010 12. Guiot G: Transsphenoidal approach in surgical treatment of pituitary adenomas. General principles and indications in nonfunctioning adenomas in Kolher PO, Ross GT(eds) : Diagnosis and treatment of pituitary tumors, Amsterdam : Excepta Media Congress Series, 1973, Vol 303, p159-178 13. H. Nishioka, J. Haraoka, Y. Ikeda: Risk factors of cerebrospinal fluid rhinorrhea following transsphenoidal surgery. Acta Neurochir (Wien) 147: 1163–1166, 2005 14. Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, et al.: A Novel Reconstructive Technique After Endoscopic Expanded Endonasal Approaches: Vascular Pedicle Nasoseptal Flap. Laryngoscope 116(10) : 1882-1886, 2006 15. Hardy J : Transsphenoidal microsurgery of the normal and pathological pituitary. Clin Neurosurg 16 : 185-217, 1969 16. Hirsch O: Successful closure of cerebrospinal fluid rhinorrhea by endonasal surgery. Arch Otolaryngol : 56:1–12, 1952 17. Jane JA Jr, Thapar K, Kaptain GJ, Martens N, Laws ER Jr.: Pituitary surgery: transsphenoidal approach (operative nuances). Neurosurgery 51(2) : 435-444, 2002 18. Jankovsky R, Auque J, Simon CMJC, Hepner H, Wayoff M: Endoscopic pituitary surgery. Laryngoscope 102 : 198-202, 1992 19. Jho HD: Endoscopic transsphenoidal surgery. J Neurooncol 54 : 187-195, 2001 20. Jho HD, Carrau RL: Endoscopic endonasal transsphenoidal surgery : experience with 50 patients. J Neurosurg 87 : 44-51, 1997