Multi-factor analysis of sellar floor dural suture, bone reconstruction and pedicled nasoseptal flap in skull base reconstruction / 西安交通大学学报(医学版)

【Objective】 To evaluate the efficacy and weight of sellar floor repair techniques such as different dura suture, bone reconstruction, and pedicled nasoseptal flap (PNSF) on the skull base reconstruction of medium and high flow cerebrospinal fluid leakage during endonasal endoscopic pituitary adenoma surgery. 【Methods】 We collected the data of Grade 2-3 cerebrospinal fluid leakage (Kelly grade) during endonasal endoscopic pituitary adenoma resection in our hospital from January 2015 to April 2021. Multiple reconstruction techniques such as dura suture, bone reconstruction and PNSF, and related factors such as age, sex, body mass index (BMI), diabetes, tumor size and diameter of diaphragmatic defect were recorded and introduced to multivariate regression to analyze the effects of the above factors on the duration of postoperative cerebrospinal fluid rhinorrhea and bed rest time, with a special focus on the weight priority of dura suture, bone reconstruction, and PNSF. 【Results】 A total of 281 patients were included, with the average age of (47±12.6) years, males accounting for 52.6%. There were 93 cases of PNSF, 268 cases of bone reconstruction, 109 cases of dura anchor suture, 50 cases of patch suture, and 122 cases without suture. The results of multivariate analysis indicated that the application of PNSF, bone reconstruction, and dura suture significantly reduced postoperative rhinorrhea time [reduced by 18.524, 35.876, and 16.983/19.791 (anchor suture/patch suture) hours, respectively; all PPNSF>bone reconstruction [Standard β=0.211/0.207 (anchor suture/patch suture)>0.200>0.165]. The weight of reducing bed time was bone reconstruction >dura suture > PNSF [Standard β=0.239>0.206/0.210 (anchor suture/patch suture) >0.164]. After stabilizing the learning curve in 25-30 cases, the average time for bone reconstruction was (3.9±0.4) minutes. After stabilizing learning curve in 30-40 cases, the dura suture technique took an average of (3.7±0.3) minutes per stitch, (3.7±1.0) stitches per case, and (13.6±2.7) minutes of total time consumption per case. 【Conclusion】 Dural anchoring and patching suture can both effectively shorten the duration of cerebrospinal fluid rhinorrhea and bed rest time. Bone reconstruction significantly improves the stability of reconstruction, especially in prompting patients’ early disengagement of bed rest. Moreover, the learning curves of the above two methods are economical and reasonable, and their weight is close to or even exceeds that of PNSF. Therefore, they can be an effective supplement or even substitute for PNSF.

Application of bone-mucosa embedding reconstruction with naso-sphenoidal in-situ autologous material on medium-flow cerebral spinal fluid leak during endoscopic endonasal surgery of pituitary adenoma / 西安交通大学学报(医学版)

【Objective】 To introduce the repair application in medium-flow cerebrospinal fluid leakage during transsphenoidal pituitary tumor resection by using autologous material from the surgical site in situ， combined with dural suture and bone-mucosa embedding technique， and evaluate its effect. 【Methods】 We conducted a retrospective case analysis of medium-flow cerebrospinal fluid leakage during endoscopic transsphenoidal approach pituitary tumor resection in our hospital from September 2016 to March 2020. All the collected cases were divided into two groups. In situ material harvest group： dural suture + in situ bone-mucosa embedding， avoiding additional trauma to the thigh and nasal cavity， referred to as in situ group. Traditional multi-layer reconstruction group： fat + fascia lata + pedicled nasoseptal flap （PNSF）， referred to as traditional group. The important indexes related to repair were compared and analyzed between the two groups. 【Results】 The in situ group and the traditional group consisted of 108 and 63 cases， respectively. The baseline data of the two groups were comparable. For the incidence of postoperative cerebrospinal fluid leakage ［（1/108， 0.9%） vs. （1/63， 1.6%）， P>0.05］ and intracranial infection rate ［（2/108， 1.9%） vs. （2/63， 3.2%）， P>0.05］， no statistical difference was shown between the groups. While compared with that in the traditional group， the mean postoperative bed stay time ［（3.7±1.6） vs. （4.4±1.5） days， P<0.001］ and the mean postoperative hospital stay ［（5.8±1.8） vs. （6.5±1.7） days， P<0.001］ of the in situ group were significantly shorter. The in situ group had significantly lower incidences of postoperative olfactory disturbance ［（0/108， 0%） vs. （3/63， 4.8%）， P<0.05］ and nasal discomfort ［（3/108， 2.8%） vs. （7/63， 11.1%）， P<0.05］. Follow-up imaging and endoscopic examination showed that the reconstructed structure of the in situ group was stable， and there was no delayed cerebrospinal fluid leakage. 【Conclusion】 This technique showed a reliable effect in repairing medium-flow leaks during transsphenoidal pituitary tumor resection by restoring the anatomical structure while avoiding the additional trauma. It is beneficial to shortening bed stay and hospitalization time and improving the subjective experience of patients， thus having a great value in clinical application.

Analysis of risk factors for intracranial infection after endoscopic transnasal pituitary adenoma resection and strategies for reconstructing skull base defects / 中国肿瘤临床

To investigate the risk factors for the occurrence of intracranial infection (ICI) after endoscopic transnasal resection of a pituitary adenoma and to select the best strategy for reconstructing skull base defects. Method: The clinical data of 162 patients with pituitary adenoma admitted into First Hospital of Shanxi Medical University between December 2016 and December 2019 were analyzed retrospectively. The incidence rate of ICI after surgery was analyzed. According to the occurrence of ICI, patients were stratified into ICI and non-ICI groups. The infected and non-infected groups of clinical data were collected and the independent risk factors for ICI after surgery were analyzed. Result: Among the 162 patients, 11 patients (6.79%) developed ICI, whereas 151 patients (93.21%) did not develop ICI. Body mass index (BMI), intraoperative cerebrospinal fluid leakage, postoperative cerebrospinal fluid leakage, and Kelly grades were significantly higher in the ICI group than in the non-ICI group (P<0.05). Logistic regression analysis showed that BMI, intraoperative cerebrospinal fluid leakage, postoperative cerebrospinal fluid leakage, and Kelly grades were independent risk factors for ICI after surgery (P<0.05). Conclusions: The incidence of ICI after endoscopic endonasal surgery is related to BMI, intraoperative cerebrospinal fluid leakage, postoperative cerebrospinal fluid leakage, and Kelly grades. Furthermore, reasonable strategies for skull-base reconstruction should be developed according to the Kelly grading system.

Application of modified pedicled nasal septum mucosa flap on cerebrospinal fluid leakage in transsphenoidal pituitary surgery / 中国医师进修杂志

Objective@#To explore the therapeutic effect of modified pedicled nasal septum mucosa flap on cerebrospinal fluid leakage in transsphenoidal pituitary surgery.@*Methods@#The clinical data of 28 patients treated with modified pedicled nasal septal mucosa flap during endoscopic transsphenoidal resection of pituitary adenoma in Dalian Central Hospital from August 2017 to December 2018 were analyzed retrospectively. Seven cases of high-flow cerebrospinal fluid leakage occurred during the operation. Skull base reconstruction was performed with modified pedicled nasal septum mucosal flap. Modified pedicled nasal septum mucosal flap was repositioned in 21 cases.@*Results@#Seven cases of modified pedicled nasal septum mucosal flap for skull base reconstruction had no postoperative cerebrospinal fluid leakage and 1 case had hypoolusia. Postoperative cerebrospinal fluid leakage occurred in One of the 21 patients with mucosal flap replacement, and stopped after 8 d of continuous lumbar drainage. One case had hypoolusia.@*Conclusions@#Modified pedicled nasal septum mucosal flap is a safe and reliable technique. It can not only achieve the effect of pedicled nasal septum mucosal flap in skull base reconstruction, but also avoid nasal complications caused by excessive application of mucosal flap.

Therapeutic effect of pedicled nasal septum mucosal flap on cerebrospinal fluid leakage in transsphenoidal approach / 中国医师进修杂志

Objective To explore the therapeutic effect of pedicled nasal septum mucosal flap on high-flow cerebrospinal fluid leakage in transsphenoidal approach. Methods The clinical data of 31 patients with high-flow cerebrospinal fluid leakage during neuroendoscope transsphenoidal approach from January 2012 to April 2018 were analyzed retrospectively. Among them, skull base of 18 patients was reconstructed with pedicled nasal septum mucosal flap technique (observation group), and skull base of 13 patients was reconstructed with the'sandwich'method (control group). The postoperative cerebrospinal fluid leakage and complications were compared between 2 groups. Results Postoperative cerebrospinal fluid leakage occurred in 6 cases in control group, and 1 case in observation group, and there was statistical difference between 2 groups (P<0.05). Postoperative olfactory loss occurred in 2 cases in control group, and 3 cases in observation group, and there was no statistical difference between 2 groups (P>0.05). Conclusions Multilayer skull base reconstruction with pedicled nasal septum mucosal flap can significantly reduce the incidence of cerebrospinal fluid leakage after transsphenoidal tumor resection, and is a safe and reliable method to treat the high flow cerebrospinal fluid leakage in operation.

Application of modified pedicled nasal septum mucosa flap on cerebrospinal fluid leakage in transsphenoidal pituitary surgery / 中国医师进修杂志

explore the therapeutic effect of modified pedicled nasal septum mucosa flap on cerebrospinal fluid leakage in transsphenoidal pituitary surgery. Methods The clinical data of 28 patients treated with modified pedicled nasal septal mucosa flap during endoscopic transsphenoidal resection of pituitary adenoma in Dalian Central Hospital from August 2017 to December 2018 were analyzed retrospectively. Seven cases of high-flow cerebrospinal fluid leakage occurred during the operation. Skull base reconstruction was performed with modified pedicled nasal septum mucosal flap. Modified pedicled nasal septum mucosal flap was repositioned in 21 cases. Results Seven cases of modified pedicled nasal septum mucosal flap for skull base reconstruction had no postoperative cerebrospinal fluid leakage and 1 case had hypoolusia. Postoperative cerebrospinal fluid leakage occurred in One of the 21 patients with mucosal flap replacement, and stopped after 8 d of continuous lumbar drainage. One case had hypoolusia. Conclusions Modified pedicled nasal septum mucosal flap is a safe and reliable technique. It can not only achieve the effect of pedicled nasal septum mucosal flap in skull base reconstruction, but also avoid nasal complications caused by excessive application of mucosal flap.

Sphenoid greater wing dysplasia associated with neurofibromatosis type Ⅰ: a case report and review of the literature / 中华整形外科杂志

Objective@#To discuss the etiology, pathogenesis, clinical manifestation, diagnosis and therapy of sphenoid wing dysplasia(SWD) associated with neurofibromatosis type Ⅰ(NF-Ⅰ).@*Methods@#We retrospectively reviewed its clinical manifestations, imaging, surgical treatment, complications and postoperative outcome of one NF-Ⅰ patient with SWD.@*Results@#A 14 years-old girl presented with pulsating exophthalmos, loss of vision and café au lait spots. Radiological studies showed right-side orbital enlargement and complete absence of the greater wing of the sphenoid. Titanium mesh was tailored intraoperatively to close the defect as a barrier between the orbital cavity and the cranium and then covered by periosteum.The patient developed postoperative infectious which was controlled by after antibiotic treatment and proper drainage. Proptosis improved significantly after surgery within a month. Ocular pulsation subsided and clinical symptoms improved at 28-month follow-up.@*Conclusions@#Sphenoid greater wing dysplasia associated with neurofibromatosis type Ⅰ is a rare inherited autosomal dominant disorders. The treatment should be customized to each patient. Titanium mesh reconstruction is patients with symptomatic sphenoid dysplasia. It can correct the proptosis and pulsating exophthalmos without the risk of bone resorption and recurrence.However, high risk of infection is associated with the procedure.

Endoscopic Endonasal Skull Base Repair with Nasoseptal Flap / 대한이비인후과학회지

Endoscopic endonasal approach (EEA) for the skull base surgery has been widely accepted since the advent of image guidance system and new reconstruction method. EEA has the advantage of being non-invasive approach with low morbidity. Among many reconstructive methods nasoseptal flap is the method of choice because of the proximity to the skull base and hypervascularity as a pedicled flap. In this review, the authors introduce the indication, surgical techniques and postoperative complications of nasoseptal flap.

Long Term Follow-Up after Skull Base Reconstrucion

Skull base tumors have been determined inoperable because it is difficult to accurately diagnose the extent of the involvement and to approach and excise the tumor safely. However, recently, the advent of sophisticated diagnostic tools such as computed tomography and magnetic resonance imaging as well as the craniofacial and neurosurgical advanced techniques enabled an accurate determination of operative plans and safe approach for tumor excision. Resection of these tumors may sometimes result in massive and complex extirpation defects that are not amenable to local tissue closure. The purpose of this study is to analyze experiences of skull base reconstruction and to evaluate long term survival rate and complications. All cranial base reconstructions performed from July 1993 to September 2000 at Department of Plastic and Reconstructive Surgery of the Seoul National University Hospital were observed. The medical records were reviewed and analysed to assess the location of defects, reconstruction method, existence of the dural repair, history of preoperative radiotherapy and chemotherapy, complications and causes of death of the expired patients. There were 12 cases in region II, 8 cases in region I and 1 case in region III according to the Irish classification of skull base. Cranioplasty was performed in 4 patients with a bone graft and microvascular free tissue transfer was selected in 17 patients to reconstruct the cranial base and/or mid-facial defects. Among them, 11 cases were reconstructed with a rectus abdominis musculocutaneous free flap, 2 with a latissimus dorsi muscluocutaneous free flap, 1 with a fibular osteocutaneous free flap, 2 with a scapular osteocutaneous free flap, and 1 with a forearm fasciocutaneous free flap, respectively. During over 3 years follow-up, 5 patients were expired and 8 lesions were relapsed. Infection(3 cases) and partial flap loss(2 cases) were the main complications and multiorgan failure(3 cases) by cancer metastasis and sepsis(2 cases) were causes of death. Statistically 4-years survival rate was 68%. A large complex defects were successfully reconstructed by one-stage operation and, the functional results were also satisfactory with acceptable survival rates.