Nasoseptal flap necrosis: a rare complication of endoscopic endonasal surgery

被引:47
作者
Chabot, Joseph D. [1 ]
Patel, Chirag R. [4 ]
Hughes, Marion A. [2 ]
Wang, Eric W. [3 ]
Snyderman, Carl H. [3 ]
Gardner, Paul A. [1 ]
Fernandez-Miranda, Juan C. [1 ]
机构
[1] Univ Pittsburgh, Med Ctr, Dept Neurosurg, Pittsburgh, PA USA
[2] Univ Pittsburgh, Dept Radiol, Med Ctr, Pittsburgh, PA 15260 USA
[3] Univ Pittsburgh, Dept Otolaryngol, Med Ctr, Pittsburgh, PA 15260 USA
[4] Loyola Univ, Sch Med, Dept Otolaryngol, Chicago, IL 60611 USA
关键词
nasoseptal flap; endoscopic endonasal; skull base reconstruction; complication; pituitary surgery; SKULL BASE RECONSTRUCTION; CEREBROSPINAL-FLUID LEAKS; ANTERIOR CRANIAL FOSSA; UPPER CERVICAL-SPINE; PEDICLED FLAPS; RISK-FACTORS; MENINGITIS; RESECTION; OUTCOMES; MORBIDITY;
D O I
10.3171/2017.2.JNS161582
中图分类号
R74 [神经病学与精神病学];
学科分类号
摘要
OBJECTIVE The vascularized nasoseptal flap (NSF) has become the workhorse for skull base reconstruction during endoscopic endonasal surgery (EES) of the ventral skull base. Although infrequently reported, as with any vascularized flap the NSF may undergo ischemic necrosis and become a nidus for infection. The University of Pittsburgh Medical Center's experience with NSF was reviewed to determine the incidence of necrotic NSF in patients following EES and describe the clinical presentation, imaging characteristics, and risk factors associated with this complication. METHODS The electronic medical records of 1285 consecutive patients who underwent EES at the University of Pittsburgh Medical Center between January 2010 and December 2014 were retrospectively reviewed. From this first group, a list of all patients in whom NSF was used for reconstruction was generated and further refined to determine if the patient returned to the operating room and the cause of this reexploration. Patients were included in the final analysis if they underwent endoscopic reexploration for suspected CSF leak or meningitis. Those patients who returned to the operating room for staged surgery or hematoma were excluded. Two neurosurgeons and a neuroradiologist, who were blinded to each other's results, assessed the MRI characteristics of the included patients. RESULTS In total, 601 patients underwent NSF reconstruction during the study period, and 49 patients met the criteria for inclusion in the final analysis. On endoscopic exploration, 8 patients had a necrotic, nonviable NSF, while 41 patients had a viable NSF with a CSF leak. The group of patients with a necrotic, nonviable NSF was then compared with the group with viable NSF. All 8 patients with a necrotic NSF had clinical and laboratory evidence indicative of meningitis compared with 9 of 41 patients with a viable NSF (p < 0.001). Four patients with necrotic flaps developed epidural empyema compared with 2 of 41 patients in the viable NSF group (p = 0.02). The lack of NSF enhancement on MR (p < 0.001), prior surgery (p = 0.043), and the use of a fat graft (p = 0.004) were associated with necrotic NSF. CONCLUSIONS The signs of meningitis after EES in the absence of a clear CSF leak with the lack of NSF enhancement on MRI should raise the suspicion of necrotic NSF. These patients should undergo prompt exploration and debridement of nonviable tissue with revision of skull base reconstruction.
引用
收藏
页码:1463 / 1472
页数:10
相关论文
共 51 条
[1]   Radiographic enhancement of the nasoseptal flap does not predict postoperative cerebrospinal fluid leaks in endoscopic skull base reconstruction [J].
Adappa, Nithin D. ;
Learned, Kim O. ;
Palmer, James N. ;
Newman, Jason G. ;
Lee, John Y. K. .
LARYNGOSCOPE, 2012, 122 (06) :1226-1234
[2]   Role of perioperative antibiotics in endoscopic skull base surgery [J].
Brown, Seth M. ;
Anand, Vijay K. ;
Tabaee, Abtin ;
Schwartz, Theodore H. .
LARYNGOSCOPE, 2007, 117 (09) :1528-1532
[3]   Delayed Nasoseptal Flaps for Endoscopic Skull Base Reconstruction: Proof of Concept and Evaluation of Outcomes [J].
Choby, Garret W. ;
Mattos, Jose L. ;
Hughes, Marion A. ;
Fernandez-Miranda, Juan C. ;
Gardner, Paul A. ;
Snyderman, Carl H. ;
Wang, Eric W. .
OTOLARYNGOLOGY-HEAD AND NECK SURGERY, 2015, 152 (02) :255-259
[4]   Pedicled flaps in endoscopic skull base reconstruction: review of current techniques [J].
Clavenna, Matthew J. ;
Turner, Justin H. ;
Chandra, Rakesh K. .
CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY, 2015, 23 (01) :71-77
[5]   The nasal floor pedicled flap: a novel technique for use in skull base reconstruction [J].
Daraei, Pedram ;
Oyesiku, Nelson M. ;
Patel, Zara M. .
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY, 2014, 4 (11) :937-943
[6]   NASAL MORBIDITY FOLLOWING ENDOSCOPIC SKULL BASE SURGERY: A PROSPECTIVE COHORT STUDY [J].
de Almeida, John R. ;
Snyderman, Carl H. ;
Gardner, Paul A. ;
Carrau, Ricardo L. ;
Vescan, Allan D. .
HEAD AND NECK-JOURNAL FOR THE SCIENCES AND SPECIALTIES OF THE HEAD AND NECK, 2011, 33 (04) :547-551
[7]   Endoscopic Endonasal Minimal Access Approach to the Clivus: Case Series and Technical Nuances [J].
Fraser, Justin F. ;
Nyquist, Gurston G. ;
Moore, Nicholas ;
Anand, Vijay K. ;
Schwartz, Theodore H. .
NEUROSURGERY, 2010, 67 (03) :150-158
[8]   Endoscopic endonasal resection of anterior cranial base meningiomas [J].
Gardner, Paul A. ;
Kassam, Amin B. ;
Thomas, Ajith ;
Snyderman, Carl H. ;
Carrau, Ricardo L. ;
Mintz, Arlan H. ;
Prevedello, Daniel M. .
NEUROSURGERY, 2008, 63 (01) :36-52
[9]   Outcomes following endoscopic, expanded endonasal resection of suprasellar craniopharyngiomas: a case series [J].
Gardner, Paul A. ;
Kassam, Amin B. ;
Snyderman, Carl H. ;
Carrau, Ricardo L. ;
Mintz, Arlan H. ;
Grahovac, Steven ;
Stefko, Susan .
JOURNAL OF NEUROSURGERY, 2008, 109 (01) :6-16
[10]   Endoscopic Endonasal Transethmoidal Transcribriform Transfovea Ethmoidalis Approach to the Anterior Cranial Fossa and Skull Base [J].
Greenfield, Jeffrey P. ;
Anand, Vijay K. ;
Kacker, Ashutosh ;
Seibert, Michael J. ;
Singh, Ameet ;
Brown, Seth M. ;
Schwartz, Theodore H. .
NEUROSURGERY, 2010, 66 (05) :883-892