内镜颅底肿瘤切除术中高流量脑脊液鼻漏修补失败原因及处理
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摘要
目的探讨内镜颅底肿瘤切除术中高流量脑脊液鼻漏修补失败原因及处理方法。方法5例患者均为2012年12月至2016年6月经鼻蝶和唇下-上颌窦入路行内镜颅底肿瘤切除术中发生高流量脑脊液鼻漏并首次颅底重建失败而行二次修补的病例,通过自体脂肪片+自体鼻中隔黏膜瓣、自体脂肪片+自体阔筋膜+自体鼻中隔黏膜瓣、自体脂肪片+自体阔筋膜等修补材料重建颅底。结果二次修补术分别采用硬膜下覆盖自体脂肪片+自体鼻中隔黏膜瓣(1/5例)、硬膜下覆盖自体脂肪片+硬膜外覆盖自体阔筋膜(1/5例),以及硬膜下覆盖自体脂肪片+硬膜外覆盖自体阔筋膜+自体鼻中隔黏膜瓣(3/5例)修补漏口,颅底创面愈合良好;平均随访20个月,无脑脊液鼻漏复发。结论高流量脑脊液鼻漏修补和颅底重建是内镜颅底肿瘤切除术成败之关键。修补失败原因包括人工硬膜完全吸收、未以脂肪组织封堵术区残腔或脂肪片液化、中鼻甲黏膜瓣与硬脑膜愈合不佳、未以阔筋膜封堵硬脑膜缺损、阔筋膜移位或鼻中隔黏膜瓣缺血坏死。多层组织重建联合带蒂组织瓣的修复方式安全、可靠,术前制定详细的手术方案、术中严格按照手术规程操作,可避免修补失败。
Objective To investigate the reasons and management of repair failure of high-flow cerebrospinal fluid rhinorrhea(HFCSFR) after endoscopic resection of skull base tumors. Methods We retrospectively reviewed 5 patients with repair failure of HFCSFR after endoscopic removal of skull base tumors in our center from December 2012 to June 2016. The patients underwent reoperations for skull base repair. The reasons of repair failure and management strategies were analyzed. Results The reconstruction methods of skull base in the reoperation for HFCSFR included autologous fat inlay and autologous pedicled nasal septal flap onlay in one patient, autologous fat inlay and autologous fascia lata onlay in one patient, and autologous fat inlay and autologous fascia lata onlay and autologous pedicled nasal septal flap in 3 patients. The skull base was reconstructed well in 5 patients. The mean follow-up period was 20 months, and no HFCSFR reoccurred in 5 patients. Conclusions Repair of HFCSFR and reconstruction of skull base are the key to endoscopic removal of skull base tumors. The reasons of repair failure included improperly employing synthetic dura mater, failing to obliterate the dead space left behind by removal of tumors with fat grafts or fat liquefaction, non-healing of middle turbinate and dura mater,failing to cover the dural defect onlay with fascia lata, displacement of the repair grafts, ischemia and necrosis of nasal septal flap. The surgeons should pay more attention to the repairment of HFCSFR after endoscopic removal of skull base tumors. Reconstruction with multilayer grafts and vascularized autologous flaps is an effective and safe strategy. Formulating detailed operation plan and strictly following surgical procedure could avoid repair failure.
Objective To investigate the reasons and management of repair failure of high-flow cerebrospinal fluid rhinorrhea(HFCSFR) after endoscopic resection of skull base tumors. Methods We retrospectively reviewed 5 patients with repair failure of HFCSFR after endoscopic removal of skull base tumors in our center from December 2012 to June 2016. The patients underwent reoperations for skull base repair. The reasons of repair failure and management strategies were analyzed. Results The reconstruction methods of skull base in the reoperation for HFCSFR included autologous fat inlay and autologous pedicled nasal septal flap onlay in one patient, autologous fat inlay and autologous fascia lata onlay in one patient, and autologous fat inlay and autologous fascia lata onlay and autologous pedicled nasal septal flap in 3 patients. The skull base was reconstructed well in 5 patients. The mean follow-up period was 20 months, and no HFCSFR reoccurred in 5 patients. Conclusions Repair of HFCSFR and reconstruction of skull base are the key to endoscopic removal of skull base tumors. The reasons of repair failure included improperly employing synthetic dura mater, failing to obliterate the dead space left behind by removal of tumors with fat grafts or fat liquefaction, non-healing of middle turbinate and dura mater,failing to cover the dural defect onlay with fascia lata, displacement of the repair grafts, ischemia and necrosis of nasal septal flap. The surgeons should pay more attention to the repairment of HFCSFR after endoscopic removal of skull base tumors. Reconstruction with multilayer grafts and vascularized autologous flaps is an effective and safe strategy. Formulating detailed operation plan and strictly following surgical procedure could avoid repair failure.
引文
[1] Paluzzi A, Gardner P, Fernandez-Miranda JC, Snyderman C.The expanding role of endoscopic skull base surgery[J]. Br J Neurosurg, 2012, 26:649-661.
[2] Esposito F, Dusick JR, Fatemi N, Kelly DF. Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery[J]. Neurosurgery, 2007, 60(4 Suppl 2):295-303.
[3] Conger A, Zhao F, Wang X, Eisenberg A, Griffiths C, Esposito F, Carrau RL, Barkhoudarian G, Kelly DF. Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery:trends in repair failure and meningitis rates in 509 patients[J]. J Neurosurg, 2018.[Epub ahead of print]
[4] Sigler AC, D'Anza B, Lobo BC, Woodard TD, Recinos PF,Sindwani R. Endoscopic skull base reconstruction:an evolution of materials and methods[J]. Otolaryngol Clin North Am, 2017,50:643-653.
[5] Ogiwara T, Nagm A, Hasegawa T, Hanaoka Y, Ichinose S, Goto T,Hongo K. Pitfalls of skull base reconstruction in endoscopic endonasal approach[J]. Neurosurg Rev, 2018.[Epub ahead of print]
[6] Meng XL, Hu K, Ji X, Kong JX, Zhou XS, Wan JH. Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors[J]. Zhongguo Er Bi Yan Hou Lu Di Wai Ke Za Zhi,2016, 22:100-104.[孟肖利,胡珂,计晓,孔建新,周先申,万经海.内镜经扩大鼻蝶入路切除鞍上肿瘤的临床分析[J].中国耳鼻咽喉颅底外科杂志,2016, 22:100-104.]
[7] Meng X, Feng X, Wan J. Endoscopic endonasal transsphenoidal approach for the removal of optochiasmatic cavernoma:case report and literature review[J]. World Neurosurg, 2017, 106:E11-14.
[8] Tang B, Xie SH, Huang GL, Zeng EM, Hong T. Treatment of high-flow cerebrospinal fluid leak after endoscopic endonasal resection of skull base tumor[J]. Zhongguo Nei Jing Za Zhi,2016, 22:78-83.[唐斌,谢申浩,黄观林,曾而明,洪涛.内镜下经鼻切除颅底肿瘤术中高流量脑脊液漏的处理[J].中国内镜杂志,2016, 22:78-83.]
[9] Li Z, Ji T, Huang GD, Guo J, Yang JH, Li WP. A stratified algorithm for skull base reconstruction with endoscopic endonasal approach[J]. J Craniofac Surg, 2018, 29:193-198.
[10] Wu YX, Zhao TZ, Zheng T, Lu WH, Zhao LF, Xue YF, Wang Y, He SM. Comparative analysis of outcomes following craniotomy and expanded endoscopic endonasal transsphenoidal resection of craniopharyngioma[J]. Zhonghua Shen Jing Wai Ke Za Zhi,2017, 33:990-995.[邬迎喜,赵天智,郑涛,吕文海,赵兰夫,薛亚飞,王元,贺世明.神经内镜扩大经鼻蝶切除术与开颅术治疗颅咽管瘤的疗效[J].中华神经外科杂志,2017,33:990-995.]
[11] Metwali H,Gerganov V, Nery B, Aly A, Avila-Cervantes R,Samii M. Efficiency and safety of autologous fat grafts in reconstructing skull base defects after resection of skull base meningiomas[J]. World Neurosurg, 2018, 110:249-255.
[12] Sunaga A, Sugawara Y, Katsuragi-Tomioka Y, Kobayashi E.The fate of nonvascularized fat grafts:histological and bioluminescent study[J]. Plast Reconstr Surg Glob Open, 2013,1:E40.
[13] Liu JK, Schmidt RF, Choudhry OJ, Shukla PA, Eloy JA. Surgical nuances for nasoseptal flap reconstruction of cranial base defects with high-flow cerebrospinal fluid leaks after endoscopic skull base surgery[J]. Neurosurg Focus, 2012, 32:E7.
[14] Zuniga MG, Turner JH, Chandra RK. Updates in anterior skull base reconstruction[J]. Curr Opin Otolaryngol Head Neck Surg,2016, 24:75-82.
[15] Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A,Snyderman CH, Mintz A. A novel reconstructive technique after endoscopic expanded endonasal approaches:vascular pedicle nasoseptal flap[J]. Laryngoscope, 2006, 116:1882-1886.
[16] Kassam AB, Thomas A, Carrau RL, Snyderman CH, Vescan A,Prevedello D, Mintz A, Gardner P. Endoscopic reconstruction of the cranial base using apedicled nasoseptal flap[J].Neurosurgery, 2008, 63(1 Suppl 1):ONS44-52.
[17] Zanation AM, Carrau RL, Snyderman CH, McKinney KA,Wheless SA, Bhatki AM, Gardner PA, Prevedello DM, Kassam AB. Nasoseptal flap takedown and reuse in revision endoscopic skull base reconstruction[J]. Laryngoscope, 2011, 121:42-46.
[18] Patel MR, Taylor RJ, Hackman TG, Germanwala AV, SasakiAdams D, Ewend MG, Zanation AM. Beyond the nasoseptal flap:outcomes and pearls with secondary flaps in endoscopic endonasal skull base reconstruction[J]. Laryngoscope, 2014,124:846-852.
[19] Ivan ME, Iorgulescu JB, El-Sayed I, McDermott MW, Parsa AT,Pletcher SD, Jahangiri A, Wagner J, Aghi MK. Risk factors for postoperative cerebrospinal fluid leak and meningitis after expanded endoscopic endonasal surgery[J]. J Clin Neurosci,2015, 22:48-54.
[20] Hsu AK, Singh A, Bury S, Schwartz TH, Anand VK, Kacker A.Endoscopic cerebrospinal fluid leak closure in an infected field[J]. Am J Rhinol Allergy, 2015, 29:305-308.
[2] Esposito F, Dusick JR, Fatemi N, Kelly DF. Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery[J]. Neurosurgery, 2007, 60(4 Suppl 2):295-303.
[3] Conger A, Zhao F, Wang X, Eisenberg A, Griffiths C, Esposito F, Carrau RL, Barkhoudarian G, Kelly DF. Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery:trends in repair failure and meningitis rates in 509 patients[J]. J Neurosurg, 2018.[Epub ahead of print]
[4] Sigler AC, D'Anza B, Lobo BC, Woodard TD, Recinos PF,Sindwani R. Endoscopic skull base reconstruction:an evolution of materials and methods[J]. Otolaryngol Clin North Am, 2017,50:643-653.
[5] Ogiwara T, Nagm A, Hasegawa T, Hanaoka Y, Ichinose S, Goto T,Hongo K. Pitfalls of skull base reconstruction in endoscopic endonasal approach[J]. Neurosurg Rev, 2018.[Epub ahead of print]
[6] Meng XL, Hu K, Ji X, Kong JX, Zhou XS, Wan JH. Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors[J]. Zhongguo Er Bi Yan Hou Lu Di Wai Ke Za Zhi,2016, 22:100-104.[孟肖利,胡珂,计晓,孔建新,周先申,万经海.内镜经扩大鼻蝶入路切除鞍上肿瘤的临床分析[J].中国耳鼻咽喉颅底外科杂志,2016, 22:100-104.]
[7] Meng X, Feng X, Wan J. Endoscopic endonasal transsphenoidal approach for the removal of optochiasmatic cavernoma:case report and literature review[J]. World Neurosurg, 2017, 106:E11-14.
[8] Tang B, Xie SH, Huang GL, Zeng EM, Hong T. Treatment of high-flow cerebrospinal fluid leak after endoscopic endonasal resection of skull base tumor[J]. Zhongguo Nei Jing Za Zhi,2016, 22:78-83.[唐斌,谢申浩,黄观林,曾而明,洪涛.内镜下经鼻切除颅底肿瘤术中高流量脑脊液漏的处理[J].中国内镜杂志,2016, 22:78-83.]
[9] Li Z, Ji T, Huang GD, Guo J, Yang JH, Li WP. A stratified algorithm for skull base reconstruction with endoscopic endonasal approach[J]. J Craniofac Surg, 2018, 29:193-198.
[10] Wu YX, Zhao TZ, Zheng T, Lu WH, Zhao LF, Xue YF, Wang Y, He SM. Comparative analysis of outcomes following craniotomy and expanded endoscopic endonasal transsphenoidal resection of craniopharyngioma[J]. Zhonghua Shen Jing Wai Ke Za Zhi,2017, 33:990-995.[邬迎喜,赵天智,郑涛,吕文海,赵兰夫,薛亚飞,王元,贺世明.神经内镜扩大经鼻蝶切除术与开颅术治疗颅咽管瘤的疗效[J].中华神经外科杂志,2017,33:990-995.]
[11] Metwali H,Gerganov V, Nery B, Aly A, Avila-Cervantes R,Samii M. Efficiency and safety of autologous fat grafts in reconstructing skull base defects after resection of skull base meningiomas[J]. World Neurosurg, 2018, 110:249-255.
[12] Sunaga A, Sugawara Y, Katsuragi-Tomioka Y, Kobayashi E.The fate of nonvascularized fat grafts:histological and bioluminescent study[J]. Plast Reconstr Surg Glob Open, 2013,1:E40.
[13] Liu JK, Schmidt RF, Choudhry OJ, Shukla PA, Eloy JA. Surgical nuances for nasoseptal flap reconstruction of cranial base defects with high-flow cerebrospinal fluid leaks after endoscopic skull base surgery[J]. Neurosurg Focus, 2012, 32:E7.
[14] Zuniga MG, Turner JH, Chandra RK. Updates in anterior skull base reconstruction[J]. Curr Opin Otolaryngol Head Neck Surg,2016, 24:75-82.
[15] Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A,Snyderman CH, Mintz A. A novel reconstructive technique after endoscopic expanded endonasal approaches:vascular pedicle nasoseptal flap[J]. Laryngoscope, 2006, 116:1882-1886.
[16] Kassam AB, Thomas A, Carrau RL, Snyderman CH, Vescan A,Prevedello D, Mintz A, Gardner P. Endoscopic reconstruction of the cranial base using apedicled nasoseptal flap[J].Neurosurgery, 2008, 63(1 Suppl 1):ONS44-52.
[17] Zanation AM, Carrau RL, Snyderman CH, McKinney KA,Wheless SA, Bhatki AM, Gardner PA, Prevedello DM, Kassam AB. Nasoseptal flap takedown and reuse in revision endoscopic skull base reconstruction[J]. Laryngoscope, 2011, 121:42-46.
[18] Patel MR, Taylor RJ, Hackman TG, Germanwala AV, SasakiAdams D, Ewend MG, Zanation AM. Beyond the nasoseptal flap:outcomes and pearls with secondary flaps in endoscopic endonasal skull base reconstruction[J]. Laryngoscope, 2014,124:846-852.
[19] Ivan ME, Iorgulescu JB, El-Sayed I, McDermott MW, Parsa AT,Pletcher SD, Jahangiri A, Wagner J, Aghi MK. Risk factors for postoperative cerebrospinal fluid leak and meningitis after expanded endoscopic endonasal surgery[J]. J Clin Neurosci,2015, 22:48-54.
[20] Hsu AK, Singh A, Bury S, Schwartz TH, Anand VK, Kacker A.Endoscopic cerebrospinal fluid leak closure in an infected field[J]. Am J Rhinol Allergy, 2015, 29:305-308.
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