• Journal of Korean Neurosurgical Society
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• v.29 no.9
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• pp.1204-1208
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• 2000

Objectives : At the closure of the transsphenoidal approach(TSA), the proper sellar floor reconstruction plays an important role in preventing postoperative complications. The septal cartilage, perpendicular plate of nasal septum, and the sphenoid sinus bone are usually used to repair the sellar floor as a bone splint. The authors evaluate the usefulness of a silicone plate as a substitute for bone splint to close a defect of the sellar floor. Materials and Methods : A silicone plate was used to repair the sellar floor in 7 patients with sellar lesions which included four pituitary adenomas, two Rathke's cleft cysts and one metastatic tumor. Among seven cases, five cases underwent a standard TSAs and two received a extended TSAs. The trajectories of the approach were sublabial in four cases and endonasal routes in three cases. The silicone plate for implantation was cut to a size of slightly larger than that of bone window and inserted with a three-pronged fork, and then adjusted precisely. Results : In six patients, there were no complications which related to sellar floor reconstruction. A postoperative cerebrospinal fluid(CSF) rhinorrhea was observed in one patient with pituitary macroadenoma. Conclusions : From the authors' experience, the advantages of the silicone plate are its simplicity of molding to fit any size of sellar floor defects, and easy detection of previously created bone window at reoperation.

• Journal of Korean Neurosurgical Society
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• v.50 no.6
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• pp.503-506
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• 2011

Objective : The aim of this study was to assess the safety and efficacy of radiation-sterilized allografts of iliac bone and fascia lata from cadaver specimens to repair skull base defects after transsphenoidal surgery. Methods : Between May 2009 and January 2010, 31 consecutive patients underwent endonasal transsphenoidal surgery and all patients received sellar reconstruction using allografts following tumor removal. The allografts were obtained from the local tissue bank and harvested from cadaver donors. The specimens used in our approach were tensor fascia lata and the flat area of iliac bone. For preparation, allografts were treated with gamma irradiation after routine screening by culture, and then stored at $-70^{\circ}C$. Results : The mean follow-up period after surgery was 12.6 months (range, 7.4-16 months). Overall, postoperative cerebrospinal fluid (CSF) leaks occurred in three patients (9.7%) and postoperative meningitis in one patient (3.2%). There was no definitive evidence of wound infection at the routine postoperative follow-up examination or during re-do surgery in three patients. Postoperative meningitis in one patient was improved with the use of antibiotics and prolonged CSF diversion. Conclusion : We suggest that allograft materials can be a feasible alternative to autologous tissue grafts for sellar reconstruction following transsphenoidal surgery under selected circumstances such as no or little intraoperative CSF leaks.

• Journal of Korean Neurosurgical Society
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• v.58 no.1
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• pp.36-42
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• 2015

Objective : Complete sellar floor reconstruction is critical to avoid postoperative cerebrospinal fluid (CSF) leakage during transsphenoidal surgery. Recently, the pedicled nasoseptal flap has undergone many modifications and eventually proved to be valuable and efficient. However, using these nasoseptal flaps in all patients who undergo transsphenoidal surgery, including those who had none or only minor CSF leakage, appears to be overly invasive and time-consuming. Methods : Patients undergoing endoscopic endonasal transsphenoidal tumor surgery within a 5 year-period were reviewed. Since 2009, we classified the intraoperative CSF leakage into grades from 0 to 3. Sellar floor reconstruction was tailored to each leak grade. We did not use any tissue grafts such as abdominal fat and did not include any procedures of CSF diversions such as lumbar drainage. Results : Among 200 cases in 188 patients (147 pituitary adenoma and 41 other pathologies), intraoperative CSF leakage was observed in 27.4% of 197 cases : 14.7% Grade 1, 4.6% Grade 2a, 3.0% Grade 2b, and 5.1% Grade 3. Postoperative CSF leakage was observed in none of the cases. Septal bone buttress was used for Grade 1 to 3 leakages instead of any other foreign materials. Pedicled nasoseptal flap was used for Grades 2b and 3 leakages. Unused septal bones and nasoseptal flaps were repositioned. Conclusion : Modified classification of intraoperative CSF leaks and tailored repair technique in a multilayered fashion using an en-bloc harvested septal bone and vascularized nasoseptal flaps is an effective and reliable method for the prevention of postoperative CSF leaks.

• Journal of Korean Neurosurgical Society
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• v.64 no.4
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• pp.619-630
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• 2021

Objective : The skull base reconstruction step, which prevents cerebrospinal fluid (CSF) leakage, is one of the most challenging steps in endoscopic skull base surgery (ESS). The purpose of this study was to assess the outcomes and complications of a reconstruction technique for immediate CSF leakage repair using multiple onlay grafts following ESS. Methods : A total of 230 consecutive patients who underwent skull base reconstruction using multiple onlay grafts with fibrin sealant patch (FSP), hydroxyapatite cement (HAC), and pedicled nasoseptal flap (PNF) for high-flow CSF leakage following ESS at three institutions were enrolled. We retrospectively reviewed the medical and radiological records to analyze the preoperative features and postoperative results. Results : The diagnoses included craniopharyngioma (46.8%), meningioma (34.0%), pituitary adenoma (5.3%), chordoma (1.6%), Rathke's cleft cyst (1.1%) and others (n=21, 11.2%). The trans-planum/tuberculum approach (94.3%) was the most commonly adapted surgical method, followed by the trans-sellar and transclival approaches. The third ventricle was opened in 78 patients (41.5%). Lumbar CSF drainage was not performed postoperatively in any of the patients. Postoperative CSF leakage occurred in four patients (1.7%) due to technical mistakes and were repaired with the same technique. However, postoperative meningitis occurred in 13.5% (n=31) of the patients, but no microorganisms were identified. The median latency to the diagnosis of meningitis was 8 days (range, 2-38). CSF leakage was the unique risk factor for postoperative meningitis (p<0.001). Conclusion : The use of multiple onlay grafts with FSP, HAC, and PNF is a reliable reconstruction technique that provides immediate and complete CSF leakage repair and mucosal grafting on the skull base without the need to harvest autologous tissue or perform postoperative CSF diversion. However, postoperative meningitis should be monitored carefully.

• Journal of Korean Neurosurgical Society
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• v.29 no.7
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• pp.929-934
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• 2000

Objective : The results of secondary transsphenoidal surgery(TSS) for either residual or recurring pituitary adenomas have been reported to be unfavorable. To evaluate the effectiveness of secondary TSS, we analyzed the surgical results of residual or recurred pituitary adenomas in patients who underwent secondary TSS from 1992 to 1998. Material and Methods : Among the 95 patients who underwent TSS during this period, 14(15%) received repeated TSS. Two of the 14 patients underwent three TSS. Among the 11 patients with pituitary adenomas, three had nonfunctioning tumors ; six prolachnomas ; two GH-secreting adenomas. The remaining three patieats had craniopharyngioma, pituitary abscess and hemangioendothelioma respectively. The interval between the two surgical procedures ranged from one week to 33 months(mean ; 12 months). Causes of the secondary TSS were tumor recurrence in 11 patients, intentional staged operation in three, persistent disease despite medical therapy and CSF leak after initial operation in one respectively. Treatments prior to secondary TSS were medical treatment only in eight patients. Results : During the repeated operationtss some adhesion was noted in septal mucous membrane. The sphenoid cavity was filled with fibrous tissue which correlated with the methods of reconstruction of the sellar floor at the previous operation. There was no statistically significant difference in success rate of surgery between the initial and the second TSS(86% vs 81%). The complication rate was similar between the two procedures. There was no statistically significant factors affecting the results of second TSS. Conclusion : Transsphenoidal reoperation was regarded as a suitable approach for treating recurrent pituitary adenomas in spite of some degree of operative difficulties. In patients with transsphenoidally resectable tumor residuals or recurrences confirmed by magnetic resonance imaging, remissions can be obtained with high probability, especially in secondary surgery after an staged decompression.