Closure Strategy in Endoscopic Pituitary Surgery: Experience from 3,015 Patients

Introduction

The closure step in endoscopic pituitary surgery is crucial and requires an effective strategy to minimize postoperative complications. Numerous surgical techniques have been described, but no clear consensus has been established.

Methods

Between January 2006 and March 2022, 3,015 adult patients with pituitary adenomas were operated on by an expert neurosurgical team using a mononostril endoscopic endonasal approach. The closure strategy was tailored based on preoperative risk factors and intraoperative findings. Risk factors for closure failure included body mass index (BMI) > 40, sellar floor lysis, more than two previous surgeries, large skull base destruction, and prior radiotherapy. Patients treated with an expanded endonasal approach were excluded from the study.

Results

Most patients were female (F/M ratio: 1.4), with a median age of 50 years (range: 18–89). An intraoperative cerebrospinal fluid (CSF) leak requiring specific surgical management was observed in 10.6% of patients (319/3,015). In patients with intraoperative leaks, closure was managed according to predictive risk factors: a Foley balloon catheter was used for sellar floor lysis or BMI > 40, while a multilayer repair strategy with a vascularized nasoseptal flap was used in other cases.

Postoperative CSF leaks occurred in 1% of patients (29/3,015), while meningitis was reported in 0.8% of cases (24/3,015). Among patients with intraoperative CSF leaks, closure failure was observed in 3.4% of cases (11/319).

Conclusion

With 16 years of experience and over 3,000 patients, our closure strategy in endoscopic pituitary surgery has proven to be reliable and reproducible. A planned and stepwise approach optimizes this critical step, ensuring a very low failure rate while adapting to each patient’s specific needs.

source: https://www.frontiersin.org/journals/oncology/articles/10.3389/fonc.2022.1067312/full