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Introduction: Surgical techniques for sellar reconstruction include no reconstruction, use of synthetic materials, autologous grafts, and/or vascularized flaps. The aim of this study was to conduct a multi-center study comparing the efficacy and postoperative morbidity associated with different sellar reconstruction techniques., Methods: A retrospective chart review of patients who underwent endoscopic transsphenoidal surgery for pituitary tumors from five participating sites between January 2021 and March 2023 was performed. The variables included demographics, tumor characteristics, reconstruction technique, postoperative cerebrospinal fluid leak (CSF) leak, and 22-item Sino-Nasal Outcome Test (SNOT-22) scores. Comparisons of postoperative complications, SNOT-22 scores, and duration of surgery by type of onlay reconstruction were evaluated using Fisher's exact test, analysis of variance, and Kruskal‒Wallis test., Results: Five hundred and one patients were identified. The median tumor size was 2.1 cm, and 64% were non-functioning. Intraoperative CSF leak was identified in 38% of patients. A total of 89% of patients underwent onlay reconstruction: 49% were reconstructed with mucosal grafts, 35% with nasoseptal flaps, and 5% with other onlay techniques. Nasoseptal flaps were utilized more frequently in the setting of giant pituitary adenomas (>3 cm), medial cavernous sinus wall resection, and high-flow intraoperative CSF leaks. Cases who utilized mucosal grafts had an overall shorter operating time (median: 183 min vs. 240 min; p < 0.001). Five postoperative CSF leaks were identified, and therefore, statistical analysis could not be performed for this complication., Conclusion: The effectiveness and morbidity of different sellar reconstruction techniques are comparable. Vascularized flaps were utilized more frequently in the setting of larger tumors and high-flow intraoperative CSF leaks., (© 2024 ARS‐AAOA, LLC.)

Objective: Nonfunctioning pituitary adenomas (NFPAs) present at a wide range of ages; it is possible that variable outcomes are based on patient age at presentation. This study aimed to explore long-term outcomes of patients with NFPAs following endonasal transsphenoidal surgery (ETS), considering age stratification., Methods: This retrospective study included 228 patients with NFPAs who underwent ETS, with a median follow-up period of 63 months. The outcomes included progression-free survival (PFS) rates and neurological and endocrinological outcomes. Age-stratified Kaplan-Meier and Cox proportional hazards analyses were performed. Patients were classified into four age groups: ≤ 49, 50-59, 60-69, and ≥ 70 years., Results: Age-stratified analysis showed a significant correlation between age and PFS in NFPAs (5-year PFS rates: 63.0% in those ≤ 49 years, 76.7% in those 50-59 years, 85.0% in those 60-69 years, and 88.1% in those ≥ 70 years; p = 0.001, log-rank test). Bivariate (HR 1.03, 95% CI 1.01-1.05; p = 0.001) and multivariable (HR 1.03, 95% CI 1.02-1.05; p = 0.001) analyses demonstrated that older age was significantly associated with longer PFS. Multivariable analysis also demonstrated that smaller maximum tumor diameter (HR 0.77, 95% CI 0.60-0.99; p = 0.036) and gross-total resection (HR 8.55, 95% CI 3.90-18.75; p = 0.001) were significantly associated with longer PFS. Multivariable logistic regression analysis demonstrated that only younger age was associated with postoperative improvement of male hypogonadism (HR 0.91, 95% CI 0.84-0.99; p = 0.019). Other postoperative neurological and endocrinological outcomes were not significantly associated with age., Conclusions: Older patients with NFPAs treated with ETS demonstrated a longer PFS. Of endocrinological outcomes studied, only male hypogonadism improvement was associated with younger patient age.

Purpose: The anatomy of the medial wall of the cavernous sinus (MWCS) and parasellar ligaments (PLs) has acquired increasing importance in endoscopic endonasal (EE) surgery of the cavernous sinus (CS), including resection of the MWCS in functioning pituitary adenomas (FPAs). Although anatomical studies have been published, it represents a debated topic due to their complex morphology. The aim is to offer a description of the PLs that originate from the MWCS and reach the lateral wall of the cavernous sinus (LWCS), proposing the "candy wrapper" model. The relationships between the neurovascular structures and histomorphological aspects were investigated., Methods: Forty-two CSs from twenty-one human heads were studied. Eleven specimens were used for EE dissection; five underwent a microscopic dissection. Five specimens were used for histomorphological analysis., Results: Two groups of PLs with a fan-shaped appearance were encountered. The anterior group included the periosteal ligament (55% sides) and the carotico-clinoid complex (100% sides), formed by the anterior horizontal and the carotico-clinoid ligaments. The posterior group was formed by the posterior horizontal (78% sides), and the inferior hypophyseal ligament (34% sides). The periosteal ligament originated inferiorly from the MWCS, reaching the periosteal dura. The anterior horizontal ligament was divided in a superior and inferior branch. The superior one continued as the carotid-oculomotor membrane, and the inferior branch reached the CN VI. The carotico-clinoid ligament between the middle and anterior clinoid was ossified in 3 sides. The posterior horizontal ligament was related to the posterior genu and ended at the LWCS. The inferior hypophyseal ligament followed the homonym artery. The ligaments related to the ICA form part of the adventitia., Conclusion: The "candy wrapper" model adds further details to the previous descriptions of the PLs. Understanding this complex anatomy is essential for safe CS surgery, including MWCS resection for FPAs., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Background: Cerebrospinal fluid (CSF) leak is a common complication after surgeries involving sellar reconstruction. Various techniques, including the nasoseptal flap, have been developed to limit postoperative CSF leak. However, the nasoseptal flap causes complications owing to donor site morbidity. A free mucosal graft may be just as effective in reducing CSF leaks as well as reducing postoperative nasal discomfort. This study aimed to assess operative outcomes of free mucosal graft after pituitary resection., Methods: A retrospective chart review was performed for patients who underwent endoscopic endonasal resection of pituitary adenomas. The following data were collected: demographic data, intraoperative CSF leak, postoperative CSF leak, other complications, and mucosal graft healing at 1 month. Also, the Sinonasal Outcome Test-22 was administered preoperatively and 1 month and 3 months postoperatively., Results: Charts of 158 patients were reviewed, including patients who underwent no mucosal reconstruction, free mucosal graft reconstruction, and nasoseptal flap reconstruction. There was a 7.4% postoperative CSF leak rate in patients who underwent no reconstruction (n = 27), whereas postoperative CSF leak rate was 0.82% in patients undergoing free mucosal graft reconstruction (n = 122) (P < 0.05). Sinonasal Outcome Test-22 scores for patients with free mucosal graft reconstruction showed no significant worsening postoperatively., Conclusions: The free mucosal graft is a simple and effective means of sellar reconstruction in patients undergoing endonasal endoscopic pituitary resection, and its efficacy is similar to nasoseptal flaps. The free mucosal graft technique does not worsen sinonasal morbidity postoperatively., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Postoperative cerebrospinal fluid leak after endoscopic pituitary surgery ranges from 1.9% to 10% in different series. Vascularized flaps have reduced the incidence of leak; however, this carries nasal morbidity. This study presents a technique for sellar reconstruction with free mucosal graft from the nasal cavity floor including inferior meatus mucosa. This technique aims to standardize sellar reconstruction without the use of the nasoseptal flap and to keep the advantage of mucosal coverage of the defect in all cases., Methods: Fifty consecutive patients who had endoscopic surgery for pituitary tumors and reconstruction with nasal cavity floor free mucosal graft were retrospectively reviewed. There were a total of 50 patients with postoperative follow-up from 3 to 16 months. Collagen dural graft was used inlay and free mucosal graft overlay to cover the sellar defect. No fat grafts or lumbar drains were used. A Sinonasal Outcome Test-22 (SNOT-22) was performed before, 1 and 3 months after surgery., Results: There were 40% detected intraoperative leaks and no postoperative leaks. Nasal endoscopy performed at 1 month follow-up showed complete healing of the graft to the skull base and near total or complete mucosalization of the donor site. No significant difference was found in the SNOT-22 comparing the total preoperative and 1-month scores., Conclusions: The nasal cavity floor free mucosal graft is an easy and safe technique, with minimal nasal morbidity. There were no postoperative cerebrospinal fluid leaks, despite aggressive tumor resection. No lumbar drains or fat graft were used. The harvest of mucosal graft does not worsen the quality of life measured with the SNOT-22 test., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Endoscopic endonasal transsphenoidal surgery (EETS) is a widely accepted technique for sellar tumors. Common findings during preoperative assessment include septal deviations and turbinate hypertrophy. This study evaluated quality of life changes after concurrent septoplasty and/or inferior turbinoplasty during EETS., Methods: A retrospective review was performed of a prospectively collected database including all patients undergoing EETS at our institution during a 10-month period between 2015 and 2016. Patients were divided into a septoplasty/inferior turbinoplasty group and a no septoplasty/inferior turbinoplasty group. The Sino-Nasal Outcome Test (SNOT-22) was used to evaluate quality of life. Mean preoperative scores were compared with 1- and 3-month postoperative scores within each cohort. The SNOT-22 was also reorganized into 5 distinct subdomains. Average subdomain scores were calculated, and preoperative and 1- and 3-month postoperative subdomain scores were compared within each cohort. A paired Student t test was used. P values < 0.05 were considered statistically significant., Results: All 24 patients met inclusion criteria by completing preoperative and postoperative SNOT-22 surveys. In the septoplasty/inferior turbinoplasty group, preoperative and 3-month postoperative scores showed a clinically significant difference (P = 0.047). The septoplasty/inferior turbinoplasty group specifically showed a significant difference in the psychiatric and sleep SNOT-22 subdomains when comparing preoperative with 3-month postoperative scores (P = 0.03, P = 0.01)., Conclusions: Patients who underwent concurrent septoplasty and/or turbinoplasty with EETS had a significantly improved quality of life compared with preoperative assessment, specifically regarding psychological and sleep symptoms., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives/hypothesis: Blood supply to the Hadad-Bassagasteguy pedicled nasoseptal flap may be interrupted by surgery of the pterygopalatine fossa, posterior septectomy, or large sphenoidotomies. This would preclude its use for reconstruction of skull base defects after expanded endonasal approaches (EEA). We present a novel method to ascertain the patency of the nasoseptal artery after prior surgery, and consequently the availability of the nasoseptal flap, using acoustic Doppler sonography., Study Design: Retrospective clinical review., Methods: Four patients who underwent EEAs were evaluated intraoperatively with acoustic Doppler sonography. The mucosa that covers the inferior aspect of the rostrum of the sphenoid sinus was scanned with the tip of the probe. Reflection of sound waves representing intravascular blood flow was assessed., Results: In three patients, the artery was identified in at least one side. One remaining patient showed no acoustic signal suggesting loss of the nasoseptal artery bilaterally, therefore necessitating the use of a fat graft for the reconstruction., Conclusions: Acoustic Doppler sonography seems to be a feasible and effective way to ascertain the availability of the nasoseptal artery. It is a relatively inexpensive and simple technique that can be performed by any endoscopic surgeon.