and E.M.H.S.) independently screened titles and abstracts for eligibility, after which full-texts of all potentially eligible studies were assessed for inclusion. <30) were excluded, as these were not considered strong evidence due to the risk of publication bias and selected populations. Studies including CSF fistula repairs or biopsies were excluded. The timeframe 2015 to 2020 was chosen with the aim to provide an up-to-date analysis of CSF leak after TSS and to expand on the existing literature on this topic.Įxtended procedures and use of dural sealants were no restriction for inclusion. , for the search strings per database).Īrticles reporting original studies published since 2015 on the adult population reporting CSF leak rates after TSS written in English or Dutch were included. A combination of free, controlled, and Mesh/Emtree terms for TSS and CSF leak, such as “Transsphenoidal” OR “Endoscopic endonasal” AND “Cerebrospinal fluid leak” OR “Cerebrospinal fluid rhinorrhea,” was used to form a search string ( We performed a literature search in the PubMed, Embase, and Cochrane Library databases for articles reporting CSF leak after TSS until April 1, 2020. The objectives of this study are to benchmark the prevalence of CSF leak after TSS in the adult population in the past 5 years, and to define variables affecting this risk. TSS has been an evolving field over the last decades, therefore complication rates should be investigated in recent literature and frequently updated as advancements in the surgical technique continue. However, techniques of closure have been significantly improved by using a vital nasoseptal mucosal flap, the use of sealing materials, and improved neurosurgical techniques. However, the exact risk of this complication and variables of influence are not clearly defined and reported prevalence rates vary widely (0–40%).ĬSF leak rates among patients undergoing TSS are regarded to be higher than for transcranial neurosurgical procedures due to additional risk factors, such as gravity and a lack of anatomical barriers provided by watertight dural closure and subcutaneous and cutaneous closure. The prevalence of postoperative CSF leak seems increased in patients with an elevated body mass index (BMI) and/or increased intracranial pressure. Grotenhuis reports an additional cost of €10.243 per patient with postoperative CSF leak for transsphenoidal procedures. These complications often lead to additional health care costs and substantial morbidity as they may require prolonged hospitalization, reoperation, and external lumbar drainage (ELD). CSF leak is associated with various complications including meningitis, intracranial infection, and CSF hypotension syndrome. ![]() Intraoperative CSF leak and cavernous sinus invasion appear to be significant risk factors for postoperative CSF leak.Ĭerebrospinal fluid (CSF) leak is still widely recognized as a commonly occurring postoperative complication of transsphenoidal surgery (TSS). The overall recent prevalence of CSF leak after TSS in adults is 3.4%. Previous TSS and microscopic surgery are not significantly associated with postoperative CSF leak. Patients with cavernous sinus invasion (OR 3.0, 95% CI 1.1–8.7) and intraoperative CSF leak (OR 5.9, 95% CI 3.8–9.0) have increased risk of postoperative CSF leak. The prevalence of CSF leak found in patients undergoing pituitary adenoma resection was 3.2% (95% CI 2.5–4.2%), whereas patients who underwent TSS for another indication had a CSF leak prevalence rate of 7.1% (95% CI 3.0–15.7%) (odds ratio 2.3, 95% CI 0.9–5.7). ![]() The overall prevalence of postoperative CSF leak was 3.4% (95% confidence interval or CI 2.8–4.0%). These studies yielded 24,979 patients who underwent a total of 25,034 transsphenoidal surgeries. We identified 2,408 articles through the database search, of which 70, published since 2015, were included in this systematic review. For two between-group comparisons a generalized linear mixed model was applied. Meta-analysis was performed using the Untransformed Proportion metric in OpenMetaAnalyst. The PubMed, Embase, and Cochrane Library databases were searched for articles reporting CSF leak after TSS in the adult population. The authors followed the PRISMA guidelines. The primary objective of this study is to benchmark the current prevalence of CSF leak after TSS in the adult population. Cerebrospinal fluid (CSF) leak is widely recognized as a challenging and commonly occurring postoperative complication of transsphenoidal surgery (TSS).
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