Background: Over the years various multilayered skull base reconstruction methods have been explored for patients who have underwent endoscopic transsphenoidal surgery. Autologous fat graft is currently being widely used to reinforce dural closure and obliterate dead spaces. Although reported to be fairly safe, complications such as fat necrosis and lipoid meningitis have been previously reported. This study aimed to evaluate whether the use of fat graft or additional measures such as pre/post-operative lumbar drain insertion is necessary to prevent post-operative cerebrospinal fluid (CSF) leakage in pituitary adenoma patients with grade 0, 1 or 2 intra-operative CSF leak grade.
Methods: This study is a retrospective review of pituitary adenoma patients from a single neurosurgeon in a tertiary hospital setting who have underwent endoscopic transsphenoidal surgery. A total of 238 pituitary adenoma cases from 2017 to 2022 were reviewed. Intra-operative CSF leak grade, skull base reconstruction method, presence of post-operative CSF leak and previously reported risk factors for post-operative CSF leak (ex. higher BMI) were identified.
Results: There were 161 grade 0 (68%), 36 grade 1 (15%), 25 grade 2 (11%) and 16 (7%) grade 3 intra-operative CSF leak cases. Grade 3 cases were excluded from further review. Skull base for grade 0, 1 and 2 cases were all reconstructed by applying fibrin sealant patches to the dural defect and enforcing it with hydrogel sealant. Additional nasoseptal flap was used in 6 grade 2 cases. There were no cases where fat was used for skull base reconstruction. Moreover, there were no cases where pre/post-operative lumbar drain was used. There were no cases of post-operative CSF leak and 2 cases (0.9%) of post-operative infection.
Conclusions: The use of fat graft for skull base reconstruction in pituitary adenoma patients with grade 0, 1 and 2 intra-operative CSF leak does not seem necessary. Fibrin sealant patches and hydrogel sealant were sufficient without the need to obliterate sphenoid dead space with autologous fat graft. Furthermore, pre/post-operative lumbar drain insertion was also not needed. The use of nasoseptal flap seem to be effective when an additional reinforcing layer is needed during skull base reconstruction, especially in grade 2 cases with larger diaphragmatic defect.