title: Cerebrospinal fluid leaks in extended endoscopic transsphenoidal surgery: covering all the angles.
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.
authors: Department of Surgery, Division of Neurosurgery, St. Michaels Hospital, University of Toronto, Toronto, ON, Canada. sehs.fathalla@gmail.com.|Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8s, Canada. sehs.fathalla@gmail.com.|Division of Neurosurgery, Cairo University Hospitals (Kasr El Aini), Cairo University, Cairo, Egypt. sehs.fathalla@gmail.com.
authors: Hussein
authors: H
authors: Fathalla
authors: Department of Surgery, Division of Neurosurgery, St. Michaels Hospital, University of Toronto, Toronto, ON, Canada.|Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8s, Canada.
authors: Antonio
authors: A
authors: Di Ieva
authors: Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8s, Canada.|Department of Surgery, Division of Head and Neck Surgery, St. Michaels Hospital, University of Toronto, Toronto, ON, Canada.
authors: John
authors: J
authors: Lee
authors: Department of Surgery, Division of Head and Neck Surgery, St. Michaels Hospital, University of Toronto, Toronto, ON, Canada.
authors: Jennifer
authors: J
authors: Anderson
authors: Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8s, Canada.
authors: Rowan
authors: R
authors: Jing
authors: Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8s, Canada.
authors: Michael
authors: M
authors: Solarski
authors: Department of Surgery, Division of Neurosurgery, St. Michaels Hospital, University of Toronto, Toronto, ON, Canada.|Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8s, Canada.
authors: Michael D
authors: MD
authors: Cusimano
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001932:Brain Neoplasms / Q000601:surgery*; D065634:Cerebrospinal Fluid Leak / Q000209:etiology / Q000601:surgery*; D002648:Child; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009300:Nasal Septum / Q000601:surgery*; D044583:Neuroendoscopy / Q000009:adverse effects*; D019291:Skull Base / Q000601:surgery*; D013524:Surgical Flaps; D055815:Young Adult
keywords: CSF leak; CSF leak endoscopic skull base surgery; Extended endoscopic transsphenoidal approach; Nasoseptal flap; Perioperative lumbar drain