title: Sellar reconstruction algorithm in endoscopic transsphenoidal pituitary surgery: experience with 240 cases.
abstract: BACKGROUND
  Proposing a strategy for sellar reconstruction in endoscopic transsphenoidal transsellar approachfor pituitary adenoma.
  
  
  METHODS
  240 patients with pituitary adenoma underwent pure endoscopic endonasal transsphenoidal surgery.Intra-operative CSF leaks were classified as grade 0, no observable leak; grade 1, CSF dripping through anarachnoid membrane defect of less than 1 mm; and grade 2, CSF flowing through an arachnoid defect of morethan 1 mm. Sellar reconstruction was performed according to our staging system; in stage I, the defect was coveredwith oxidized cellulose and sphenoid sinus filled up with Gelfoam. In stage II, a layer of fat was appliedon the defect and fascia lata placed epidurally. In stage III, one or two layers of fascia were used with addingsurgical glue and/or lumbar drainage. Mucosa of sphenoid sinuses was kept intact as much as possible and approximatedat the end of procedure.
  
  
  RESULTS
  intra-operative CSF leaks grade 0, 1 and 2 resulted in 133(55.4%), 78 (32.5%) and 29(12.1%) patients,respectively. Stage I of reconstruction was used in 126 patients (52.5%) with no intra-operative CSF leak orsever prolapse of arachnoid membrane. Stage II was performed in 80 patients (33.3%) with either leak grade 1(73 patients) or grade 0 with severe prolapse of the suprasellar components induced in the sella (2 cases) or inwhom extra-pseudocapsular dissection performed (5 cases). Stage III was performed in 34 cases (14.2%) witheither CSF leak grade 2 (29 patients) or grade 1 with simultaneous severe destruction or removal of sellar floorlaterally, superiorly or inferiorly (5 patients) which made it impossible to place the fascia underlay to the bone.A minimum of 18 months follow-up showed development of 2 CSF leaks (0.8%), one pneumocephalus (0.4%)and 2 meningitis (0.8%) cases.
  
  
  CONCLUSIONS
  Given the low postoperative CSF leak rate, we demonstrated that our adopted sellar reconstructionstrategy focusing mostly on the adopted intra-operative CSF leak grading system is safe and useful forovercoming devastating complications like postoperative CSF leaks.
authors.affiliation: Assistant Professor of ENT- Head and Neck Surgery, Endoscopic Pituitary and Skull Base Surgery Unit, ENT-Head and Neck Surgery Research Center and Department, Rasool Akram Hospital, Iran University of Medical Sciences, Tehran, Iran. jalessimd@gmail.com.
authors.forename: Maryam
authors.initials: M
authors.lastname: Jalessi
authors.affiliation: Associate Professor of Neurosurgery, Endoscopic Pituitary and Skull Base Surgery Unit, ENT-Head and Neck Surgery Research Center and Department, Rasool Akram Hospital, Iran University of Medical Sciences, Tehran, Iran, and Neurosurgery Department, Loghman Hakim Hospital, Shaheed Beheshti University of Medical Sciences, Tehran, Iran. gsharifimd@gmail.com.
authors.forename: Guive
authors.initials: G
authors.lastname: Sharifi
authors.affiliation: MD, School of Medicine, Iran University of Medical Sciences, Tehran, Iran. mirfallahi@gmail.com.
authors.forename: Mohammad Rasool
authors.initials: MR
authors.lastname: Mirfallah Layalestani
authors.affiliation: Assistant Professor of ENT- Head and Neck Surgery, ENT-Head and Neck Surgery Research Center and Department, Rasool Akram Hospital, Iran University of Medical Sciences, Tehran, Iran. amintehran@ent-hns.org.
authors.forename: Ebrahim
authors.initials: E
authors.lastname: Amintehran
authors.affiliation: MD, Endoscopic Pituitary and Skull Base Surgery Unit, ENT-Head and Neck Surgery Research Center and Department, Rasool Akram Hospital, Iran University of Medical Sciences, Tehran, Iran. parinyazdanifard@yahoo.com.
authors.forename: Parin
authors.initials: P
authors.lastname: Yazdanifard
authors.affiliation: Professor of Neurosurgery, Neurosurgery Department, Loghman Hakim Hospital, Shaheed Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Omidvar
authors.initials: O
authors.lastname: Rezaee Mirghaed
authors.affiliation: Professor of ENT- Head and Neck Surgery, Endoscopic Pituitary and Skull Base Surgery Unit, ENT-Head and Neck Surgery Research Center and Department, Rasool Akram Hospital, Iran University of Medical Sciences, Tehran, Iran. Farhadi@ent-hns.org.
authors.forename: Mohammad
authors.initials: M
authors.lastname: Farhadi
keywords: Endoscopic transsphenoidal surgery; cerebrospinal fluid leak; reconstruction