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Late Onset of CSF Rhinorrhea in a Postoperative Transsphenoidal Surgery Patient Following Robotic-Assisted Abdominal Hysterectomy.

Dowdy JT, Moody MW, Cifarelli CP - J Investig Med High Impact Case Rep (2014)

Bottom Line: Direct closure with a combination of autologous fat, local bone, and/or synthetic grafts remains the standard of care for leaks encountered at the time of surgery as well as postoperatively.The development of the vascularized nasoseptal flap as a closure technique has increased the surgeon's capacity to correct even larger openings in the dura of the sella as well as widely exposed anterior skull base defects.We review the available literature regarding risk and pathophysiology of CSF leak following abdominal surgery and propose the need for increased vigilance in identification of such occurrences with the increasing acceptance and popularity of minimally invasive abdominal and pelvic surgeries as standards in the field.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.

ABSTRACT
Cerebrospinal fluid (CSF) leak is the most commonly encountered perioperative complication in transsphenoidal surgery for pituitary lesions. Direct closure with a combination of autologous fat, local bone, and/or synthetic grafts remains the standard of care for leaks encountered at the time of surgery as well as postoperatively. The development of the vascularized nasoseptal flap as a closure technique has increased the surgeon's capacity to correct even larger openings in the dura of the sella as well as widely exposed anterior skull base defects. Yet these advances in the technical nuances for management of post-transsphenoidal CSF leak are useless without the ability to recognize a CSF leak by physical examination, clinical history, biochemical testing, or radiographic assessment. Here, we report a case of a patient who developed a CSF leak 28 years after transsphenoidal surgery, precipitated by a robotic-assisted hysterectomy during which increased intra-abdominal pressure and steep Trendelenberg positioning were both factors. Given the remote nature of the patient's transsphenoidal surgery and relative paucity of data regarding such a complication, the condition went unrecognized for several months. We review the available literature regarding risk and pathophysiology of CSF leak following abdominal surgery and propose the need for increased vigilance in identification of such occurrences with the increasing acceptance and popularity of minimally invasive abdominal and pelvic surgeries as standards in the field.

No MeSH data available.


Related in: MedlinePlus

Coronal (A) and sagittal (B) views of the maxillofacial computed tomography prior to endoscopic repair show a small defect in the floor of the sella (arrow, A) and postoperative changes from the original transsphenoidal surgery. Coronal (C) and sagittal (D) post-contrast magnetic resonance images illustrate thick dural enhancement (white arrows, C and D) and the presence of subdural hygromas (black arrows, C) suggestive of intracranial hypotension.
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fig2-2324709614520982: Coronal (A) and sagittal (B) views of the maxillofacial computed tomography prior to endoscopic repair show a small defect in the floor of the sella (arrow, A) and postoperative changes from the original transsphenoidal surgery. Coronal (C) and sagittal (D) post-contrast magnetic resonance images illustrate thick dural enhancement (white arrows, C and D) and the presence of subdural hygromas (black arrows, C) suggestive of intracranial hypotension.

Mentions: The patient is a woman who underwent a sublabial transsphenoidal approach for resection of a pituitary adenoma at the age of 30. An autologous abdominal fat graft was applied at the sellar floor secondary to intraoperative observation of a CSF leak. She tolerated the procedure well and had an uneventful postoperative course. The pathology of the lesion was consistent with a nonfunctional pituitary macroadenoma. At the age of 58, the patient underwent a robotic-assisted total hysterectomy and oophorectomy due to persistent menorrhagia. During the procedure, the operative table was placed in extreme Trendelenberg position, noted to be approximately 45° from the floor (Figure 1). In the immediate postoperative period, the patient developed a clear nasal discharge that could be provoked with positional change. The working diagnosis for this postoperative drainage was allergic rhinitis versus an upper respiratory infection. Three months later, the patient returned to a local emergency department with severe headache, photophobia, nuchal rigidity, and continued positional nasal discharge. The nasal drainage was collected and tested positive for β-2 transferrin, confirming the presence of an active CSF fistula. Magnetic resonance imaging and computed tomography scan of the brain revealed a 2 to 3 mm defect located in the mid-floor of the sella with diffuse dural enhancement and bilateral subdural hygromas (Figure 2A-D). The patient underwent an endoscopic endonasal approach to the sphenoid sinus and sellar region. After bony decompression of the residual sphenoid rostrum, the mucosal elements at the sellar floor were removed via sharp dissection. A defect in the previous sellar floor reconstruction was easily identified with active extravasation of CSF (Figure 3). Reconstruction of the water-tight layer was accomplished by using a combination of autologous bone from the posterior nasal septum, a vascularized nasal septal flap, and a 1-square-inch piece of Duragen artificial dural implant (Integra LifeSciences, Plainsboro, NJ). The patient tolerated the procedure well and was able to be discharged home 2 days later on a course of intravenous antibiotics for meningitis. The patient was evaluated at a routine clinic visit 2 weeks after repair, where no further CSF rhinorrhea was reported or observed. Follow-up imaging at 16 months postoperatively demonstrated an intact vascularized closure and no evidence of persistent CSF leak (Figure 4A and B).


Late Onset of CSF Rhinorrhea in a Postoperative Transsphenoidal Surgery Patient Following Robotic-Assisted Abdominal Hysterectomy.

Dowdy JT, Moody MW, Cifarelli CP - J Investig Med High Impact Case Rep (2014)

Coronal (A) and sagittal (B) views of the maxillofacial computed tomography prior to endoscopic repair show a small defect in the floor of the sella (arrow, A) and postoperative changes from the original transsphenoidal surgery. Coronal (C) and sagittal (D) post-contrast magnetic resonance images illustrate thick dural enhancement (white arrows, C and D) and the presence of subdural hygromas (black arrows, C) suggestive of intracranial hypotension.
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License 1 - License 2 - License 3
Show All Figures
getmorefigures.php?uid=PMC4528865&req=5

fig2-2324709614520982: Coronal (A) and sagittal (B) views of the maxillofacial computed tomography prior to endoscopic repair show a small defect in the floor of the sella (arrow, A) and postoperative changes from the original transsphenoidal surgery. Coronal (C) and sagittal (D) post-contrast magnetic resonance images illustrate thick dural enhancement (white arrows, C and D) and the presence of subdural hygromas (black arrows, C) suggestive of intracranial hypotension.
Mentions: The patient is a woman who underwent a sublabial transsphenoidal approach for resection of a pituitary adenoma at the age of 30. An autologous abdominal fat graft was applied at the sellar floor secondary to intraoperative observation of a CSF leak. She tolerated the procedure well and had an uneventful postoperative course. The pathology of the lesion was consistent with a nonfunctional pituitary macroadenoma. At the age of 58, the patient underwent a robotic-assisted total hysterectomy and oophorectomy due to persistent menorrhagia. During the procedure, the operative table was placed in extreme Trendelenberg position, noted to be approximately 45° from the floor (Figure 1). In the immediate postoperative period, the patient developed a clear nasal discharge that could be provoked with positional change. The working diagnosis for this postoperative drainage was allergic rhinitis versus an upper respiratory infection. Three months later, the patient returned to a local emergency department with severe headache, photophobia, nuchal rigidity, and continued positional nasal discharge. The nasal drainage was collected and tested positive for β-2 transferrin, confirming the presence of an active CSF fistula. Magnetic resonance imaging and computed tomography scan of the brain revealed a 2 to 3 mm defect located in the mid-floor of the sella with diffuse dural enhancement and bilateral subdural hygromas (Figure 2A-D). The patient underwent an endoscopic endonasal approach to the sphenoid sinus and sellar region. After bony decompression of the residual sphenoid rostrum, the mucosal elements at the sellar floor were removed via sharp dissection. A defect in the previous sellar floor reconstruction was easily identified with active extravasation of CSF (Figure 3). Reconstruction of the water-tight layer was accomplished by using a combination of autologous bone from the posterior nasal septum, a vascularized nasal septal flap, and a 1-square-inch piece of Duragen artificial dural implant (Integra LifeSciences, Plainsboro, NJ). The patient tolerated the procedure well and was able to be discharged home 2 days later on a course of intravenous antibiotics for meningitis. The patient was evaluated at a routine clinic visit 2 weeks after repair, where no further CSF rhinorrhea was reported or observed. Follow-up imaging at 16 months postoperatively demonstrated an intact vascularized closure and no evidence of persistent CSF leak (Figure 4A and B).

Bottom Line: Direct closure with a combination of autologous fat, local bone, and/or synthetic grafts remains the standard of care for leaks encountered at the time of surgery as well as postoperatively.The development of the vascularized nasoseptal flap as a closure technique has increased the surgeon's capacity to correct even larger openings in the dura of the sella as well as widely exposed anterior skull base defects.We review the available literature regarding risk and pathophysiology of CSF leak following abdominal surgery and propose the need for increased vigilance in identification of such occurrences with the increasing acceptance and popularity of minimally invasive abdominal and pelvic surgeries as standards in the field.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.

ABSTRACT
Cerebrospinal fluid (CSF) leak is the most commonly encountered perioperative complication in transsphenoidal surgery for pituitary lesions. Direct closure with a combination of autologous fat, local bone, and/or synthetic grafts remains the standard of care for leaks encountered at the time of surgery as well as postoperatively. The development of the vascularized nasoseptal flap as a closure technique has increased the surgeon's capacity to correct even larger openings in the dura of the sella as well as widely exposed anterior skull base defects. Yet these advances in the technical nuances for management of post-transsphenoidal CSF leak are useless without the ability to recognize a CSF leak by physical examination, clinical history, biochemical testing, or radiographic assessment. Here, we report a case of a patient who developed a CSF leak 28 years after transsphenoidal surgery, precipitated by a robotic-assisted hysterectomy during which increased intra-abdominal pressure and steep Trendelenberg positioning were both factors. Given the remote nature of the patient's transsphenoidal surgery and relative paucity of data regarding such a complication, the condition went unrecognized for several months. We review the available literature regarding risk and pathophysiology of CSF leak following abdominal surgery and propose the need for increased vigilance in identification of such occurrences with the increasing acceptance and popularity of minimally invasive abdominal and pelvic surgeries as standards in the field.

No MeSH data available.


Related in: MedlinePlus