The Evolution of Skull Base Reconstruction after Endoscopic Transnasal Transsphenoidal Surgery at a Large Academic Institution

Objective: To describe the evolution of the various methods of skull base reconstruction employed in the past decade and the impact on patient outcomes.

Methods: An institutional review board–approved retrospective review was performed identifying all patients who underwent an endoscopic transnasal transsphenoidal surgery between December 12, 2007, and August 16, 2019, at our institution. A total of 1,157 patients fit these criteria. Descriptive statistics were used to analyze the data.

Results: For mucosal reconstruction, there has been a significant decrease in the use of nasoseptal flaps (R = −0.83, p ≤ 0.001), especially in patients with no or low-grade CSF leaks, and a rise in free mucosal grafts (R = 0.89, p < 0.001; Figs. 1 and 2). Furthermore, the proportion of secondary rescue versus primary nasoseptal flaps has increased significantly (R = 0.88, p < 0.001) over the years. Other notable changes include an increase in the use of allografts (dural substitutes) for sellar floor reconstruction and in Helistat for intrasellar reconstruction, replacing the historically commonly used fat graft. The use of dural sealant has decreased significantly (R = −0.89, p < 0.001), especially for cases with no CSF leak (Fig. 3). Lastly, we note no significant changes in postoperative CSF leaks were noted in our large institutional series despite major changes in reconstruction techniques over the years.

Conclusion: Skull base reconstruction after endoscopic TNTS has evolved in many ways over the course of the last decade. Notably, we observed a drastic decrease in the use of nasoseptal flaps for no or low-grade CSF leaks, with a rise in free mucosal grafts in those cases. When a nasoseptal flap was used, a larger proportion are now rescue secondary flaps compared with primary pedicled flaps elevated prior to tumor resection during earlier years. Interestingly, there was a widespread use of dural sealant early on, followed by a notable decrease and more targeted use. Intrasellar filling has gradually transitioned from using fat grafts to Helistat or Gelfoam. These changes have not, however, significantly altered our institution's postoperative CSF leak rates.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
12 February 2021