Step-wise Algorithm for Skull Base Reconstruction in Endoscopic Endonasal Surgery: From the Simple to the Complex
Eric Wang, Paul Gardner, Aldo Eguiluz-Melendez, Carl Snyderman, Philippe Lavigne, Vanessa Hernandez-Hernandez, Maria Belen Vega
Introduction: The most frequent complication of endoscopic endonasal surgery (EES) is postoperative cerebrospinal fluid (CSF) leak.
Objective: To develop a step-wise algorithm for EES reconstruction across the spectrum of skull base defects: from free mucosal graft for uncomplicated pituitary adenomas to free flaps in complex cases with recurrent leaks.
Methods: All patients with skull base pathologies who underwent EES between January 2017 and December 2018 were included and retrospectively analyzed. Tumor location, reconstruction method and postoperative CSF leak were reviewed and a step-wise algorithm based on size and location of defect was developed.
Results: Location of skull base defects was categorized as follows: anterior fossa, suprasellar, sellar and posterior fossa. For all sellar lesions we employed a free mucosal graft unless a high-flow CSF leak was present, in which case a single-layer reconstruction with nasoseptal flap (NSF) was performed. For all non-sellar sites, we performed a multilayer (collagen matrix +/- fascia lata +/- fat graft + vascularized flap) reconstruction. The NSF was the first choice for vascularized reconstruction when available. When the NSF was not available, alternative local and regional pedicled flaps were successful choices. When patients failed multiple attempts at repair, regional and microvascular free flaps were options.
Of 347 patients, 4.6% had a postoperative CSF leak. Of 158 patients with an intraoperative leak (45.5%), 10.1% developed a postoperative CSF leak: 7.8% for sellar/suprasellar defects and 13% for anterior/posterior fossa defects.
Conclusions: This algorithm provides a standardized, step-wise approach to the reconstruction of all skull base defects after EES based on location.