Successful repair of intraoperative cerebrospinal fluid leaks improves outcomes in endoscopic skull base surgery

Arash Shahangian; Zachary M Soler; Andrew Baker; Sarah K Wise; Shruthi K Rereddy; Zara M Patel; Nelson M Oyesiku; John M DelGaudio; Constantinos G Hadjipanayis; Bradford A Woodworth; Kristen O Riley; John Lee; Michael D Cusimano; Satish Govindaraj; Mohemmed N Khan; Alkis Psaltis; Peter J Wormald; Stephen Santoreneos; Raj Sindwani; Samuel Trosman; Janalee K Stokken; Troy D Woodard; Pablo F Recinos; W Alexander Vandergrift 3rd; Caitlin Boling; Rodney J Schlosser

doi:10.1002/alr.21845

Successful repair of intraoperative cerebrospinal fluid leaks improves outcomes in endoscopic skull base surgery

Int Forum Allergy Rhinol. 2017 Jan;7(1):80-86. doi: 10.1002/alr.21845. Epub 2016 Aug 31.

Authors

Arash Shahangian¹, Zachary M Soler¹, Andrew Baker¹, Sarah K Wise², Shruthi K Rereddy^{2

3}, Zara M Patel⁴, Nelson M Oyesiku⁵, John M DelGaudio², Constantinos G Hadjipanayis^{5

6}, Bradford A Woodworth⁷, Kristen O Riley⁸, John Lee⁹, Michael D Cusimano¹⁰, Satish Govindaraj¹¹, Mohemmed N Khan¹¹, Alkis Psaltis¹², Peter J Wormald¹², Stephen Santoreneos¹³, Raj Sindwani¹⁴, Samuel Trosman¹⁴, Janalee K Stokken¹⁵, Troy D Woodard¹⁴, Pablo F Recinos¹⁴, W Alexander Vandergrift 3rd¹⁶, Caitlin Boling¹, Rodney J Schlosser¹

Affiliations

¹ Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, SC.
² Department of Otolaryngology-Head & Neck Surgery, Emory University, Atlanta, GA.
³ Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Philadelphia, PA.
⁴ Department of Otolaryngology-Head & Neck Surgery, Stanford University, Stanford, CA.
⁵ Department of Neurosurgery, Emory University, Atlanta, GA.
⁶ Department of Otolaryngology-Head & Neck Surgery, Mount Sinai Beth Israel, New York City, NY.
⁷ Division of Otolaryngology-Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, AL.
⁸ Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL.
⁹ Department of Otolaryngology-Head & Neck Surgery, University of Toronto, St. Michael's Hospital, Toronto, ON, Canada.
¹⁰ Department of Neurosurgery University of Toronto, St. Michael's Hospital, Toronto, ON, Canada.
¹¹ Department of Otolaryngology-Head & Neck Surgery, Mount Sinai Hospital, New York City, NY.
¹² Department of Otolaryngology-Head & Neck Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia.
¹³ Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, SA, Australia.
¹⁴ Section of Rhinology, Head and Neck Institute and the Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH.
¹⁵ Department of Otolaryngology-Head & Neck Surgery, Mayo Clinic, Rochester, MN.
¹⁶ Department of Neurosurgery, Medical University of South Carolina, Charleston, SC.

PMID: 27579523
DOI: 10.1002/alr.21845

Abstract

Background: The impact of failed cerebrospinal fluid leak (CSF) leak repair in endoscopic skull base surgery has not been adequately studied.

Methods: In this investigation we reviewed patients who had undergone endoscopic skull base surgery between 2002 and 2014 at 7 international centers. Demographic variables, comorbidities, tumor characteristics, and repair techniques were evaluated to determine association with successful repair of CSF leak. Postoperative complications and length of stay were compared among groups.

Results: Data were collected on 2097 patients who were divided into 3 groups: (1) those with no intraoperative leak (n = 1533); (2) those with successful repair of their intraoperative leak (n = 452); and (3) those with failed repair (n = 112). Compared with successful repair, failed repair was associated with an increased risk of intracranial infection (odds ratio [OR], 5.6; 95% confidence interval [CI], 5.3-13.15), pneumocephalus (OR, 16; 95% CI, 5.8-44.4), 30-day readmission (OR, 8.4; 95% CI, 5.3-13.5), reoperation (OR, 115.4; 95% CI, 56.3-236.8), and prolonged hospital stay (14.9 vs 7.0 days, p < 0.01). Outcomes in patients who had successful repairs of intraoperative leaks were similar to those who never had leakage. Intraoperative use of pedicled nasoseptal flaps was associated with successful repair (OR, 0.60; 95% CI, 0.34-0.92).

Conclusion: Intraoperative CSF leaks are a frequent and expected occurrence during endoscopic skull base surgery. Failed CSF leak repair has a significant impact on patient outcomes, with increased rates of postoperative pneumocephalus, intracranial infections, reoperation, deep vein thrombosis, readmission, and prolonged hospital stay. Recognition and repair of intraoperative CSF leaks reduces postoperative complications. Use of pedicled nasoseptal flaps improves outcomes in reconstructing defects at higher risk for postoperative leak.

Keywords: complication; intraoperative leak; postoperative leak; skull base reconstruction; skull base tumor.

MeSH terms

Adolescent
Adult
Aged
Aged, 80 and over
Brain Neoplasms / surgery
Cerebrospinal Fluid Leak / surgery*
Child
Child, Preschool
Chordoma / surgery
Encephalocele / surgery
Endoscopy / adverse effects*
Female
Head and Neck Neoplasms / surgery
Humans
Infant
Length of Stay
Male
Middle Aged
Patient Readmission
Plastic Surgery Procedures* / adverse effects
Pneumocephalus / etiology
Postoperative Complications / etiology
Postoperative Complications / surgery*
Reoperation
Skull Base / surgery*
Treatment Outcome
Young Adult