2025 Proffered Presentations
S050: GRADED SKULL BASE RECONSTRUCTION AFTER ENDOSCOPIC PITUITARY SURGERY
Claudio A Callejas, MD1; Kyle K VanKoevering, MD2; Kyle C Wu, MD2; Kathleen Kelly, MD2; Lucas P Carlstrom, MD, PhD3; Daniel M Prevedello, MD, MBA2; Ricardo L Carrau, MD, MBA2; 1The Queen Elizabeth Hospital; 2The Ohio State University; 3Southern California Permanente Medical Group
Introduction: There is no universally accepted method for skull base reconstruction following endoscopic pituitary surgery. Different teams worldwide adopt techniques that work best for them based on their experience. We describe our current graded approach to skull base reconstruction after endoscopic pituitary surgery and presents our results with this approach.
Methods: Based primarily on the presence and magnitude of an intraoperative CSF leak, assessed using the grading system described by Esposito et al. (2007), we classified the risk of a postoperative CSF leak as low (grades 0 and 1), moderate (grade 2), or high (grade 3). Collagen matrix was used as first layer of reconstruction to lift and support the pituitary gland and diaphragm, preventing diaphragm tears and stalk stretching caused by significant diaphragm descent. A second layer of autologous tissue was used in all cases. For a low risk of postoperative CSF leak, a free mucoperiosteum graft or sphenoid mucosa was used. For a moderate risk of postoperative CSF leak, a free mucoperiosteum graft with a non-reabsorbable nasal packing as a firm bolster to buttress the reconstruction or a nasoseptal flap without a non-reabsorbable nasal packing was used. Finally, for a high risk of postoperative CSF leak, a nasoseptal flap with a non-reabsorbable nasal packing to buttress the reconstruction was used. Non-reabsorbable nasal packing was removed at day 5-7 post op. Seventy consecutive patients with pituitary tumors were retrospectively collected at our institution between 7/12/23 and 6/14/24. Patients with Rathke's cleft cyst were not included.
Results: The postoperative CSF leak rate was 1.42% (1/70). We had 1 case of postoperative central nervous system infection (meningitis). The intraoperative CSF leak rate was 37% (26/70), corresponding to 18 grade 1, 5 grade 2, and 3 grade 3 CSF leaks. Collagen matrix was used for reconstruction in all cases. Free grafts were used in 60 cases (54 from middle turbinate mucoperiosteum and 6 from nasal floor mucoperiosteum), with nasoseptal flap used in 6 cases and sphenoid mucosa in 4 cases. Neither fat nor biologic glue were used.
Conclusion: The described graded approach to skull base reconstruction after pituitary surgery has enabled us to achieve excellent outcomes while minimizing patient morbidity. Minimizing the rate of intraoperative CSF leak without compromising tumor resection is key to reduce morbidity associated with reconstruction.