Sellar Reconstruction with Free Mucosal Graft after Resection of Large Pituitary Tumors

Introduction: Large pituitary adenomas, often described as tumors greater than 3 cm, present a unique surgical challenge due to the enormous tumor size and adjacent critical structures. Surgical resection, with increasing utilization of the endoscopic endonasal approach, is the mainstay of treatment. Postoperative cerebrospinal fluid (CSF) leak is a potential complication of endoscopic resection of large pituitary adenomas. The rate of intraoperative CSF leak in patients undergoing resection for large pituitary tumors ranges from 8.0 to 42.8%, while the postoperative CSF leak rate ranges from 0.0 to 28.6%. A free mucosal graft (FMG) of the nasal floor can be a robust and viable method for performing sellar reconstruction. It has been shown to have ease of harvest, minimal nasal morbidity and does not worsen sinonasal quality of life compared with the nasoseptal flap. However, there is limited literature on the use of FMG following endoscopic endonasal resection of large (>3 cm) pituitary adenomas.

Objective: The aim of this study is to assess outcomes of sellar reconstruction with a free mucosal graft of the nasal cavity floor after resection of large pituitary tumors, focusing particularly on the rate of CSF leak and other complications.

Methods: A retrospective chart review of patients who underwent endoscopic endonasal resection of large (>3 cm) pituitary adenomas with FMG reconstruction was completed (Group A). The following outcomes were recorded and measured: intraoperative CSF leak, postoperative CSF leak, intraoperative and postoperative complications, mucosal graft healing at one month postoperatively, and length of follow-up. All patients included in the study were followed for at least 3 months postoperatively. These results were compared with patients who received no reconstruction or oxidized cellulose polymer for reconstruction following resection of pituitary adenomas of any size (Group B).

Results: Fifty-three patients were included in the study: 29 patients in Group A and 24 patients in Group B. In Group A, 6/29 patients had tumors greater than 4 cm. Twenty-six out of 29 patients received gross-total resection of tumor. The intraoperative and postoperative CSF leak rate was 27.6 and 0%, respectively. In Group B, 5/24 patients had tumors greater than 3 cm in size. The gross-total resection rate was 23/24 (95.8%). The intraoperative and postoperative CSF leak rates were 29.2 and 8.3%, respectively. In both groups, there were no complications aside from CSF leak, and all grafts were completely healed 1 month postoperatively.

Conclusion: The free mucosal graft is a successful reconstruction technique for patients with large pituitary adenomas with and without intraoperative CSF leak and is associated with a reduced rate of postoperative CSF leak compared with no reconstruction.

Fig. 1 T1-weighted sagittal MRI demonstrating large 5.5-cm pituitary adenoma.

Fig. 2 T1-weighted sagittal MRI 6 months following endoscopic endonasal pituitary resection with free mucosal graft. Residual tumor is present.