Cerebrospinal Fluid Leak in Transnasal Transsphenoidal Surgery for Pituitary Adenoma and its Management

Introduction Over the past few decades endoscopic transnasal transsphenoidal (ETNTS) approach has been practised for excision of pituitary tumours which has minimised the rate of complications and morbidity. However, cerebrospinal fluid (CSF) leak remains a frequent complication requiring efficient management. Various skull-base repair techniques have been described in the literature all along, but there is no universal protocol for the same. Our study aims to determine an ideal strategy for skull-base repair following ETNTS surgery and suggest a protocol at the tertiary centre for the same. Materials and Methods In this prospective study, patients with pituitary adenoma undergoing ETNTS excision from January 2017 to May 2019 were included. Data were collected based on the intraoperative findings of grade of CSF leak following excision, surgical method for skull-base repair, biomaterials used, and recurrence of CSF leak postoperatively and its management. Results A total of 141 patients between 10 to 74 years of age (mean age 42.6) underwent ETNTS excision of pituitary adenoma. Intraoperative CSF leak was observed in 30.5% patients with 14.1% of grade I, 8.5% of grade II and 7.8% of grade III and repair was done with fat closure, multilayer closure and with naso-septal flap, respectively. Postoperative recurrence of CSF leak was found in 2.83% of total cases and 9.3% of patient with intraoperative leak, which were managed appropriately. Overall closure rate was 100% with no further recurrence of CSF leak. Conclusion Surgical repair of skull-base in CSF leak is challenging and requires management in careful and graded fashion for favourable outcome.