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NI FEATURE: THE EDITORIAL DEBATE III-- PROS AND CONS
Year : 2018  |  Volume : 66  |  Issue : 1  |  Page : 49--50

Is intraoperative lumbar subarachnoid drainage necessary for endoscopic endonasal pituitary surgery?

Kiyoshi Saito 
 Department of Neurosurgery, Fukushima Medical University, Hikarigaoka 1, Fukushima 960-1295, Japan

Correspondence Address:
Kiyoshi Saito
Department of Neurosurgery, Fukushima Medical University, Hikarigaoka 1, Fukushima 960-1295
Japan




How to cite this article:
Saito K. Is intraoperative lumbar subarachnoid drainage necessary for endoscopic endonasal pituitary surgery?.Neurol India 2018;66:49-50


How to cite this URL:
Saito K. Is intraoperative lumbar subarachnoid drainage necessary for endoscopic endonasal pituitary surgery?. Neurol India [serial online] 2018 [cited 2019 Jul 18 ];66:49-50
Available from: http://www.neurologyindia.com/text.asp?2018/66/1/49/222829


Full Text



Recent evolutions in the technique of endoscopic endonasal surgery (EES) have been of outstanding significance. For pituitary adenomas, EES has almost replaced microscopic transsphenoidal surgery.[1],[2],[3] The management of intraoperative cerebrospinal fluid (CSF) leakage has contributed to the development of extended EES. Nowadays, extended EES is the primary treatment for skull base chordomas. Many suprasellar craniopharyngiomas and some tuberculum sellae meningiomas can also be removed using extended EES.

A nasoseptal flap has an important function. For large skull base defects, it has dramatically decreased the risk of a postoperative CSF leak to less than 5%.[4] We have been using EES for pituitary adenomas for more than 20 years. Our standard procedure for closing the wound includes placement of an abdominal fat graft in the sella, suturing the incised dura of the sellar floor, and covering the sellar floor using a nasoseptal flap for managing a high-flow intraoperative CSF leakage. We do not use a lumber CSF drainage. Ishii Y et al., used a nasoseptal flap and an inlay fascial patch sutured to the edge of the dural defect for 42 extended EES. Overall, the incidence of CSF leakage was 7.1%.[5] Hara T et al., reported the effect of dural suturing technique.[6] They analyzed 194 EES. For managing a small or a moderate degree of CSF leakage, the autologous fat graft was anchored by dural suturing and covered with a sphenoidal sinus mucosal flap. For large CSF leakage, inlay sutured and onlay non-sutured fascial grafts were covered with a nasoseptal flap. Intraoperative CSF leakage was observed in 125 of 194 cases (64.4%) and postoperative CSF leak was encountered in 2 of 125 (1.6%) repaired cases. Both cases of CSF leakage were successfully treated with a lumber drainage. Amano K et al., proposed the use a sphenoid sinus mucosal flap.[7] They performed 500 EES for patients with pituitary or parasellar lesions and used a sphenoid sinus mucosal flap instead of a nasoseptal flap to cover the sellar floor. They encountered an intraoperative CSF leakage in 69.4% of the patients. The reoperation rate for postoperative CSF leak was 1.2%. They recommended the sphenoid sinus mucosal flap since it was effective, less invasive and easier to harvest. It also potentially reduced the donor site morbidity.

Many years ago, when we used a microscope to conduct trans-sphenoidal surgery, we proposed an injection of lactated Ringer solution or saline through a subarachnoid lumbar catheter to increase the volume of CSF and deliver the suprasellar tumor into the operative field.[8] We also proposed an open sella method and an intentional staged operation. After we changed to EES, we have never used the induced pressure method or the intentional staged operation since we could directly visualize the suprasellar tumor using the wide-angled endoscopic view. EES is superior to the microscopic transsphenoidal surgery in achieving gross total removal of macroadenomas.[1]

In this paper, Jonathan GE et al., performed a randomized controlled trial (RCT) utilizing the intraoperative lumbar drain insertion group versus the lumbar drain non-insertion group, to determine the role of lumbar CSF drainage in patients with pituitary adenomas.[9] This is a valuable paper since RCTs for surgical techniques are usually difficult to perform. The results were unequivocal. As expected, lumbar CSF drainage significantly reduced the incidence of intraoperative CSF leak from 46.7% to 3.3%. It prevented the bulging of suprasellar arachnoid into the operative field and reduced the incidence of arachnoidal laceration. However, there were no significant differences in the incidence of postoperative CSF rhinorrhea and in the extent of resection between the two groups. Overall, the mean resection rate in this paper was 94.7%. There was only one patient who developed a postoperative CSF leak. This data is an indication of the high quality of surgeries performed by the authors. I believe they successfully removed the adenomas and prevented the occurrence of postoperative CSF leakage even in the surgeries in which an intraoperative lumbar CSF drainage was not used.

My conclusions are the following. Controlled intraoperative lumbar CSF drainage significantly reduces the incidence of intraoperative CSF leak during EES for pituitary adenomas. However, institution of an intraoperative lumbar CSF drainage is not a necessary step to remove the macroadenoma, or to prevent postoperative CSF rhinorrhea during EES for a pituitary adenoma that is performed by an experienced surgeon.

References

1Nishioka H. Recent evolution of endoscopic endonasal surgery for treatment of pituitary adenomas. Neurol Med Chir (Tokyo) 2017;57:151-8.
2Sharma BS, Sawarkar DP, Suri A. Endoscopic pituitary surgery: Techniques, tips and tricks, nuances, and complication avoidance. Neurol India 2016;64:724-36.
3Sankhla SK, Jayashankar N, Khan GM. Endoscopic endonasal transplanum transtuberculum approach for retrochiasmatic craniopharyngiomas: Operative nuances. Neurol India 2015;63:405-13.
4Pinheiro-Neto CD, Snyderman CH. Nasoseptal flap. Adv Otorhinolaryngol 2013;74:42-55.
5Ishii Y, Tahara S, Teramoto A, Morita A. Endoscopic endonasal skull base surgery: Advantages, limitations, and our techniques to overcome cerebrospinal fluid leakage: Technical note. Neurol Med Chir (Tokyo) 2014;54:983-90.
6Hara T, Akutsu H, Yamamoto T, Tanaka S, Takano S, Ishikawa E, Matsuda M, Matsumura A. Cranial base repair using suturing technique combined with a mucosal flap for cerebrospinal fluid leakage during endoscopic endonasal surgery.
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8Saito K, Kuwayama A, Yamamoto N, Sugita K. The transsphenoidal removal of nonfunctioning pituitary adenomas with suprasellar extensions: The open sella method and intentionally staged operation. Neurosurgery 1995;36:668-76.
9Jonathan GE, Sarkar S, Singh G, Mani S, Thomas R, Ari George Chacko AG. A randomized controlled trial to determine the role of intraoperative lumbar cerebrospinal fluid drainage in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas. Neurol India 2018;66:133-8.