Multicenter Study of Sellar Reconstruction after Endoscopic Transsphenoidal Resection of Pituitary Tumors

Introduction: Surgical techniques for sellar reconstruction vary from no reconstruction of the sella, use of synthetic materials, autologous grafts and/or vascularized flaps. This study is the first comprehensive multicenter study that attempts to identify the most efficient and least morbid surgical approach to sellar reconstruction. The aim of this study was to conduct a multicenter study comparing the efficacy and postoperative morbidity associated with different sellar reconstruction techniques.

Methods: A retrospective chart review of patients who underwent endoscopic transsphenoidal surgery for pituitary tumors from 5 participating sites between January 2021 and March 2023 was performed. Variables included patient demographics, tumor characteristics, intraoperative findings, reconstruction technique, postoperative CSF leak, and 22-item Sino-Nasal Outcome Test (SNOT-22) scores. Onlay techniques included: no reconstruction, mucosal grafts, nasoseptal flaps, or other techniques. SNOT-22 scores were gathered preoperatively and at 1, 3 and 6 months postoperatively. Comparisons of duration of surgery, postoperative complications and SNOT-22 scores by type of onlay reconstruction were evaluated using analysis of variance and Kruskal–Wallis, two-sample t, Wilcoxon’s rank-sum, chi-square, and Fisher exact test.

Results: A total of 507 patients from 5 participating sites were identified. Average tumor size was 2.1 cm, and 64% were nonfunctioning. Intraoperative CSF leak was identified in 38% of patients (2/3 low-flow, 1/3 high-flow). Eighty-nine percent underwent onlay reconstruction; 49% were reconstructed with mucosal grafts, 35% with nasoseptal flap, 5% with other onlay techniques. There were only 6 postoperative CSF leaks identified, and therefore statistical analysis could not be performed on this data. No significant differences in postoperative complications and SNOT-22 outcomes were identified based on the type of onlay reconstruction. Nasoseptal flaps were utilized more frequently in the setting of giant pituitary adenomas (>3 cm), medial cavernous sinus wall resection and high-flow intraoperative CSF leaks. Cases that utilized mucosal grafts versus nasoseptal flaps had an overall shorter operating time (183 vs. 240 minutes, p < 0.001).

Conclusion: The effectiveness and morbidity of different sellar reconstruction techniques are comparable, though operative times were longer in cases using nasoseptal flaps. Vascularized flaps were utilized more frequently in the setting of larger tumors and high-flow intraoperative CSF leaks. Low postoperative CSF leak rate was detected in this cohort.

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

Publication History

Article published online:
05 February 2024