Cavallo Luigi M, Solari Domenico, Somma Teresa, Savic Dragan, Cappabianca Paolo
Department of Neurological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy.
Department of Neurological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy.
World Neurosurg. 2014 Sep-Oct;82(3-4):e479-85. doi: 10.1016/j.wneu.2013.01.017. Epub 2013 Jan 8.
The introduction of extended endoscopic endonasal approaches for the management of midline skull base lesions has brought again the focus on the problem of postoperative cerebrospinal fluid (CSF) leak management. Notwithstanding the improvements in reconstruction techniques that have reduced the rate of postoperative CSF leakage, no technique has proven to be thoroughly effective.
Nine patients complaining of postoperative CSF leaking after extended endoscopic endonasal surgery for different suprasellar lesions were managed without reoperation by means of repeated endoscopic endonasal fibrin glue injections in the sphenoid sinus cavity while they were awake in the outpatient operating room. Only a few patients required light sedation with benzodiazepine. To help the healing process, lumbar CSF diversion was used in four patients who complained of moderate and severe leaks,
We achieved an effective and resilient closure of the skull-base defect in all cases who underwent the endoscope-guided fibrin glue injection for the management of postoperative CSF leak after endoscopic endonasal surgery. Of the four patients presenting a "weeping" leak, one patient required a single injection, whereas three required two procedures; no lumbar drainage was used. Two patients with "moderate" leaks received four injections and in both a lumbar drain also was positioned. In the other two patients, three (in this case a lumbar drain was used) and two injections were performed, respectively. We managed the patient with severe leaking by performing an injection five times, and lumbar drainage was placed. No complications related to procedure or to the use of this material were observed (mean follow-up, 26.6 months; range, 5-63).
An endoscope-guided sealant technique with fibrin glue used while the patient is awake has proven, in our experience, to be effective in reducing the rate of reoperations in the management of postoperative CSF leaking after endoscopic endonasal approaches for the treatment of intradural skull base lesions. This technique, which needs larger case series to be validated, could be considered in the spectrum of possibilities to manage selected postoperative CSF leakages.
扩大经鼻内镜入路用于治疗中线颅底病变，再次使人们将焦点集中在术后脑脊液漏的处理问题上。尽管重建技术有所改进，降低了术后脑脊液漏的发生率，但尚无技术被证明是完全有效的。
9例因鞍上不同病变接受扩大经鼻内镜手术后出现脑脊液漏的患者，在门诊手术室清醒状态下，通过在蝶窦腔内反复经鼻内镜注射纤维蛋白胶进行处理，无需再次手术。只有少数患者需要使用苯二氮䓬类药物进行轻度镇静。为促进愈合过程，4例主诉中重度漏液的患者采用了腰大池脑脊液引流。
在内镜引导下注射纤维蛋白胶处理经鼻内镜手术后脑脊液漏的所有病例中，我们均实现了颅底缺损的有效且持久的封闭。4例出现“渗液”漏的患者中，1例患者只需单次注射，而3例需要进行两次操作；未使用腰大池引流。2例“中度”漏液的患者接受了4次注射，且均放置了腰大池引流。另外2例患者分别进行了3次（此次使用了腰大池引流）和2次注射。我们对严重漏液的患者进行了5次注射，并放置了腰大池引流。未观察到与操作或该材料使用相关的并发症（平均随访26.6个月；范围5 - 63个月）。
根据我们的经验，患者清醒状态下使用纤维蛋白胶的内镜引导封闭技术，在处理经鼻内镜入路治疗硬脑膜内颅底病变术后脑脊液漏时，可有效降低再次手术率。该技术尚需更多病例系列进行验证，在处理特定术后脑脊液漏时可作为一种选择。
