Cerebrospinal fluid leaks in extended endoscopic transsphenoidal surgery: covering all the angles

Following extended endoscopic transsphenoidal approach (EETSA), cerebrospinal fluid (CSF) leak rate has been reported in the range of 5–50 %. Novel closure techniques, such as the nasoseptal flap and other multilayered repairs improved the outcomes significantly but took most of our focus. Little attention, however, was given to other aspects of the equation such as nasal support—to support the heavy weight of such repairs—and lumbar drains. These are important because they diminish the forces acting on both sides of the repair, hence covering all the angles. We reviewed data of 98 consecutive patients who underwent an EETSA between 1999 and 2014. We analyzed the rates of CSF leak throughout the years and with every modification added to our closure technique. Common pathologies encountered were invasive adenomas, meningiomas, chordomas, and craniopharyngiomas. CSF leak occurred overall in five patients (5.1 %). The nasoseptal flap decreased the rate of CSF leak but not significantly (P = 0.112), while placing a nasal trumpet to support our repair resulted in significant decrease in CSF leak rate (P = 0.0013). In the last 2 years of our series, when all modifications took place and all angles were covered, there was one leak in 35 cases (2.8 %). A protocol that covers all the angles by a good multilayered repair (regardless of its type and materials) while diminishing the forces acting on both sides of the repair leads to a minimal rate of CSF leak. No principle alone is effective individually.