Factors Influencing Intraoperative Cerebrospinal Fluid Leak and Methods of Sella Turcica Closure

Introduction: The purposes of this study were to identify factors that effect intraoperative cerebrospinal fluid leak and to assess the efficiency of the new multilayer sella turcica closure technique as compared with the previously used techniques in the presence of intraoperative cerebrospinal fluid leak. Methods: Between 1995 and 2006, 346 patients (225 women and 121 men) with pituitary adenomas were operated on by the transsphenoidal route at the Department of Neurosurgery of the Kaunas Medical University Hospital. The total number of operations on these patients was 382. The interseptal route was used in 245 cases and the sublabial route in 17 cases; 120 operations were performed using the direct transnasal approach. A microadenoma was found in 82 (21.5%) cases, and a macroadenoma was found in 300 (78.5%). Results: In surgeries for microadenomas, total removal was achieved in 78 (95.1%) cases; in those for macroadenomas 134 (44.7%) cases achieved total removal. Operations were performed for 171 (44.8%) nonfunctioning adenomas, 95 (24.9%) for prolactinomas, 87 (22.3%) for somatotrophic hormone (STH) secreting adenomas, 22 (5.8%) for ACTH-secreting adenomas, and 7 (1.8%) for other hormone-secreting adenomas. The number who experienced intraoperative CSF leaks was 62 (16.2%). To find out the signs pointing to a higher risk of this complication, we made a statistical analysis of signs. It has been found that removal of an STH-producing adenoma is an independent factor that predicts an almost twofold higher risk of intraoperative CSF leak. When such a complication was noted, the sella turcica was closed by 1 of the 2 following techniques: (1) single-layer technique, which is followed by packing the sella turcica and sphenoidal sinus with fat, and (2) a new multilayer sellar closure technique using Surgicel and TachoSil. When the conventional technique was used to close sella turcica, 3 cases of postoperative CSF leak were noted. With the new multilayer sellar closure technique, no cases of postoperative CSF leak were noted, and the total number of postoperative complications was also significantly lower ( P = 0.02). Conclusions: The risk of intraoperative leakage of CSF was almost twofold higher in the removal of somatotrophic hormone-secreting adenomas than in the removal of nonsecreting or other hormone-secreting pituitary adenomas. In the presence of intraoperative leakage of CSF, the multilayer technique of sella turcica closure was more effective tha