Graded Reconstruction Strategy Using a Multi-Layer Technique without Lumbar Drainage After Endoscopic Endonasal Surgery

Abstract Objective Sellar reconstruction following endoscopic endonasal surgery (EES) requires modification based on the degree of cerebrospinal fluid (CSF) leak. For high-flow (grade II or III according to Esposito et al., 2007) intraoperative CSF leak, lumbar drainage (LD), in addition to the multi-layer closing technique, is generally recommended. However, LD has complications occasionally, including post-puncture headache, over-drainage symptoms, and increased length of stay (LOS). We retrospectively evaluated the outcome of our graded reconstruction strategy using a multi-layer technique with a novel material, without LD, after EES. Methods Ninety-seven patients who underwent EES with grade II or III intraoperative CSF leak between June 2020 and March 2021 were retrospectively reviewed. For grade II CSF leak, fibrin sealant and a nasoseptal flap (NSF) were placed; for grade III CSF leak, a multi-layer technique was utilized in combination with collagen matrix, an acellular dermal graft, injectable hydroxyapatite (HXA), and an NSF. Postoperatively, routine LD was not performed. Results This study included 48 (49.5%) grade II and 49 (50.5%) grade III CSF leaks. Upon follow-up period (mean, 8.7 months), no patient showed postoperative CSF leak in either group. No HXA-associated complications occurred. Conclusions A graded surgical repair strategy after EES could avoid postoperative CSF leak. Combined use of injectable HXA and acellular dermal grafts for high-flow CSF leak can limit LD requirement, without significant risks.