The postoperative leakage rate did not show significant differences by the reconstructive material used or by the type of flap employed. Grade 1 and grade 3 were significantly associated with postoperative leakage (p = 0.025, OR = 0.341 and p = 0.01, OR = 3.71, respectively). Postoperative CSF leakage was of grade 1 in 6 cases (4.4%), grade 2 in 7 (8.4%), and grade 3 in 8 (19%). Pituitary adenomas were associated with a significantly lower rate of postoperative leakage (4.3% p<0.001, OR = 0.202). In terms of pathology, craniopharyngiomas (36%) were associated with the highest repair failure rate (p<0.001, OR = 10.453). The postoperative leakage repair failure rate (28.6%) was higher than that of intraoperative leakage repair (p = 0.003, OR = 5.973).
Revision operations (14.9%) were associated with more leakage than primary operations (5.7%) (p = 0.017, odds ratio = 2.903). Leakage rate did not significantly differ by sex (p = 0.438). Postoperative CSF leakage developed in 21 (2.4% 8 males and 13 females Table 2) of the 869 cases, thus in 8.1% of the 260 cases exhibiting intraoperative leakage. Two Merocel tampons (Medtronic Xomed Surgical Products, Jacksonville, FL, USA) were packed into the bilateral nasal cavity. The sphenoid sinus was obliterated using Nasopore (Polyganics, Groningen, the Netherlands) (an absorbable packing material). Unused septal bone was inserted between the bilateral modified nasoseptal rescue flaps for use as a buttress should re-operation be required, and to strengthen the flaps. The Valsalva maneuver was performed to confirm the absence of CSF leakage, and then the sphenoid sinus was obliterated and a tissue sealant (Greenplast Green Cross Corp., Yongin, Korea) was applied. Next, more oxidative cellulose was added until the mucosa did not move. We were careful to not invert the mucosa because of the risk for a later mucocele. In the absence of leakage, the neurosurgeon filled the sellar resection cavity with oxidative cellulose (Surgicel/Ethicon Johnson & Johnson, Somerville, NJ, USA) and then the rhinology surgeon repositioned (reflected) the sphenoid sinus mucosa to cover the sellar floor. The neurosurgeon performed all grading the repair method varied by grade ( Fig 1). Grade 2 reflected moderate leakage combined with an obvious diaphragmatic defect grade 3 leakage was associated with a large diaphragmatic or dural defect. Absence of leakage (as confirmed by the Valsalva maneuver) was graded 0 and a small “weeping leak” without a visible diaphragmatic defect was graded 1. As previously reported, intraoperative CSF leakage was graded by reference to the size of the dural defect. The neurosurgeon performed intrasellar reconstruction and the rhinology surgeon reconstructed the outer portion of the sella.
After removing the tumor, both surgeons reconstructed the sellar defect.
After the bony portion of the sellar floor was exposed, a neurosurgeon drilled out the floor and opened the dura mater. A rhinology surgeon harvested bilateral modified nasoseptal rescue flaps. Surgical technique and repair of intraoperative CSF leakageĪll operations were performed using the two-nostrils/four-hands technique.
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