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The use of dehydrated amniotic membrane allograft for augmentation of dural repair in transsphenoidal endoscopic endonasal resection of pituitary adenomas

  • Original Article - Brain Tumors
  • Published:
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Abstract

Background

In transsphenoidal endoscopic endonasal surgery (TEES), watertight separation of the sinonasal cavity and intracranial compartment is the primary goal of closure. However, even when meticulous closure technique is implemented, cerebrospinal fluid (CSF) leaks, dural scarring, and meningitis may result. Particularly when intraoperative CSF leak occurs, materials that facilitate the creation of a watertight seal that inhibits disease transition and minimizes inflammatory response after durotomy are sought. Dehydrated amniotic membrane (DAM) allograft appears to confer these attributes as studies have shown it augments epithelialization, facilitates wound healing, and minimizes and impedes bacterial growth. We detail the use of DAM allograft to augment sellar closures after TEES.

Methods

We conducted a feasibility study, retrospectively reviewing our institution’s database of TEES for resection of pituitary adenomas in which DAM was utilized to supplement sellar closure.

Results

One hundred twenty transsphenoidal surgery cases with DAM were used during sellar closure, with a 49.2% intraoperative CSF leak rate. Of this cohort, two patients experienced postoperative CSF leak (1.7%), and no patients developed meningitis. CSF leak rate for TEES-naïve patients was 0.9%.

Conclusions

This feasibility study demonstrates that dehydrated amniotic membrane allograft can be safely utilized as an adjunct during sellar closures for TEES for pituitary adenoma resection with very low rates of CSF leak and meningitis.

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Abbreviations

TEES:

Transsphenoidal endoscopic endonasal surgery

CSF:

Cerebrospinal fluid

DAM:

Dehydrated amniotic membrane

FDA:

Food and Drug Administration

NSF:

Nasoseptal flap

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Acknowledgments

The authors would like to thank Linda Alberga for manuscript preparation, and Roberto Suazo for video editing.

Author information

Authors and Affiliations

  1. Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, 33125, USA

    Daniel G. Eichberg, Angela M. Richardson, Simon S. Buttrick, Ashish H. Shah & Ricardo J. Komotar

  2. Department of Neurological Surgery, University of Miami School of Medicine, 1095 NW 14th Terrace (D4-6), Miami, FL, 33136, USA

    Daniel G. Eichberg

  3. University of Miami Miller School of Medicine, Miami, FL, 33125, USA

    G. Damian Brusko

  4. College of Osteopathic Medicine, Nova Southeastern University, 3200 South University Drive, Ft. Lauderdale, FL, 33328, USA

    Sheikh C. Ali

  5. Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, FL, 33125, USA

    Elie S. Alam & Zoukaa B. Sargi

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  1. Daniel G. Eichberg
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Corresponding author

Correspondence to Daniel G. Eichberg.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

“For this type of study, formal consent is not required.”

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Comments

The utilization of amniotic membranes in trans-sphenoidal surgery is a relatively new technique. It was first described by the authors for dural repair after craniotomies in a previous publication.

In this retrospective non randomized study, the same group of authors reports their outcomes using the same product in transnasal pituitary procedures.

The introduction makes an argument for the use of amniotic membranes in closure of pituitary adenoma resections as there currently is no consensus for CSF resistant closure in TEES. While this may be true, to demonstrate the appropriateness for DAM use, the authors simply describe the outcome data for a large series of TEES patients that underwent closure with DAMs (as well as other materials) and then compared those outcomes to non-risk-stratified data in existing literature.

The data shows an intraoperative CSF leak rate in half of their patients with postoperative rate of 1.7% in complex cases and 0.9% in naive patients but does not show statistically significant superiority. While intraoperative rate of CSF leak is a bit high, they consider the postoperative rate an improvement from published rates of CSF leak at 1.9–4%.

The authors believe very strongly in the superiority of DAMs, as laid out in the discussion. However, this conclusion could have been better supported if the study included a control group of different materials used for dural repair.

A. Samy Youssef

CO, USA

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Eichberg, D.G., Richardson, A.M., Brusko, G.D. et al. The use of dehydrated amniotic membrane allograft for augmentation of dural repair in transsphenoidal endoscopic endonasal resection of pituitary adenomas. Acta Neurochir 161, 2117–2122 (2019). https://doi.org/10.1007/s00701-019-04008-x

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