PEG hydrogel sealant versus fibrin glue in posterior fossa surgery: an economic comparison across five European countries.

Aim: Posterior cranial fossa (PCF) surgery is associated with complications, including cerebrospinal fluid (CSF) leakage. Dural sealants such as polyethylene glycol (PEG)-based hydrogels and fibrin glue can prevent CSF leaks, with evidence suggesting PEG hydrogels may outperform fibrin glue. However, the budget impact of using PEG hydrogels in PCF surgeries in Europe is unclear. Materials & methods: A decision tree was developed based on a previous US model, to assess the budget impact of switching from fibrin glue to PEG hydrogel in PCF surgery across five European countries. Input costs were derived from published sources for the financial year 2022/2023. Health outcomes, including CSF leaks, were considered. Results: The model predicted that using PEG hydrogel instead of fibrin glue in PCF surgery can lead to cost savings in five European countries. Cost savings per patient ranged from EUR 419 to EUR 1279, depending on the country. Sensitivity analysis showed that the incidence of CSF leaks and pseudomeningoceles had a substantial impact on the model's results. Conclusion: PEG hydrogels may be a cost-effective alternative to fibrin glue in PCF surgery. The model predicted that cost savings would be mainly driven by a reduction in the incidence of postoperative CSF leaks, resulting in reduced reliance on lumbar drains, reparative surgery and shortened hospital stays.

Lower airway disease and pituitary surgery: Is there an association with postoperative cerebrospinal fluid leak?

OBJECTIVES/HYPOTHESIS: To explore the relationship between lower airway disease and postoperative cerebrospinal fluid (CSF) rhinorrhea among patients undergoing pituitary surgery STUDY DESIGN: Retrospective review. METHODS: A retrospective review of the Healthcare Cost and Utilization Project's 2013 National Inpatient Sample was conducted to characterize the hospital stay and surgical outcomes of patients undergoing pituitary surgery. Patients with lower airway disease (including chronic obstructive pulmonary disease and asthma) were compared to a disease-free population identifying demographics and complications over-represented in the lower airway group. RESULTS: The majority of hypophysectomies (92.1%) were performed via a transsphenoidal approach. Among transsphenoidal patients, individuals with asthma (92.8% of the lower airway disease cohort) harbored a greater postoperative CSF leak rate (4.7% vs. 2.7%, P = .022), and were more likely to develop postoperative diabetes insipidus (6.2% vs. 4.1%, P = .024) and neurological complications (13.0% vs. 9.6%, P = .010) when compared to a lower airway disease-free cohort. Patients with CSF rhinorrhea had longer lengths of stay (7.8 days vs. 4.5 days, P < .001) and higher discharge costs ($148,309 vs. $76,246, P < .001). A binary logistic regression model identified having asthma (P = .042), being female (P = .011), and having gastroesophageal reflux disease (P = .006) as independent predictors of postoperative CSF rhinorrhea. CONCLUSIONS: Several patient comorbidities including asthma are associated with a greater risk of postoperative CSF rhinorrhea. Perioperative lower airway assessment and disease control may potentially decrease one's risk of this complication, although further inquiry is urgently needed to identify optimal preventive strategies. LEVEL OF EVIDENCE: 2c. Laryngoscope, 127:1543-1550, 2017.

[CLOSURE OF NASOCRANIAL FISTULAS WITH "BATH-PLUG" TECHNIQUE AND MULTILAYER RECONSTRUCTION]. / NASOCRANIALIS FISTULÁK ZÁRÁSA "KÁDDUGÓ" TECHNIKÁVAL ÉS TÖBBRÉTEGU REKONSTRUKCIÓVAL.

BACKGROUND AND PURPOSE: In case of dehiscenses developing on the anterior scull base, complete closure resulting in the cessation of the communication between the nasal cavity and the intracranial space is mandatory as soon as possible, in order to prevent serious complications. With the development of the endoscopic techniques, the endonasal management for the reconstruction has become available in recent decades. METHODS: We aim to present the reconstruction techniques applied in our department in the cases of two patients recently operated at our institute. The choice of methods primarily depends on the size and the localization of the defect. Dehiscenses under 5 mm of diameter can be closed with the so called "bath-plug" technique, while bigger defects, where the required closure of the plug is not possible, can be solved with multilayer reconstruction. We use autogenous fascia, fat and muco-periosteum in both cases. RESULTS: Our patient, who underwent the aforementioned "bath-plug" procedure, could be discharged after a few days of uneventful postoperative period. During a ten-month follow-up period new fistula formation was not observed. In the case of a patient who underwent multilayer reconstruction, meningitis occurred postoperatively, which was resolved after antibiotic therapy. During a 17-month follow-up period recurrent liquorrhoea did not occur. CONCLUSION: With suitable technical background and appropriate endoscopic skills the surgeries of the anterior skull base cerebrospinal fluid fistulas can be performed efficiently and with low complication rate. These are minimally invasive procedures accompanied by less surgical trauma, morbidity and shorter hospitalization, hence these techniques are considered to be cost-effective and well-tolerated for the patients.

Assessment of quality-of-life outcomes after surgery for nasal polyposis with the DyNaChron questionnaire.

This prospective study assesses outcomes at 6 weeks and 7 months after radical ethmoid surgery in 65 patients with nasal polyposis using a new and detailed instrument, the DyNaChron questionnaire, which was filled in the day prior to surgery and at 6 weeks and 7 months after surgery at follow-up visits. Before surgery, the leading bothersome symptoms were olfactory disturbances (7.74 ± 2.81) and nasal obstruction (6.66 ± 2.28). After surgery (6th week and 7th month), there was a clear improvement of all symptoms including nasal obstruction, olfactory disturbances, anterior rhinorrhea, postnasal discharge, facial pain/headache and cough in comparison to baseline (p < 0.0001). Nasal obstruction was the most improved symptom (effect size of 2.24). At 7th post-operative month, the sense of smell continued to improve slightly. By contrast, the postnasal discharge score that was significantly improved at 6th post-operative week tended to worsen at 7 months (p = 0.0045). Before surgery, strong psychosocial impacts were observed in association with nasal obstruction and anterior rhinorrhea. The physical impacts of each symptom were proportionally correlated to the symptom score before and after surgery. The quality of life (QOL) related to each symptom was clearly better at 6 weeks and remained steady at 7 months after surgery. In conclusion, olfactory disorders and postnasal rhinorrhea were the main remaining symptoms after sinus surgery despite a global improvement of symptoms and quality of life. The earlier time point to stabilize QOL outcomes of endoscopic sinus surgery could be suggested at 6 weeks after surgery.

Physician accountability in iatrogenic cerebrospinal fluid leak litigation.

BACKGROUND: The potentially severe complications resulting from cerebrospinal fluid (CSF) leak makes iatrogenic injury a medicolegal area of concern for otolaryngologists and neurosurgeons. The objectives of this analysis were to study legal outcomes as well as medical and nonmedical elements affecting malpractice litigation. METHODS: Public court records available in the Westlaw legal database (Thomson Reuters, New York, NY) were searched for medical malpractice litigation related to iatrogenic CSF leak. Of the 18 jury verdicts and settlements included, outcomes and awards, patient demographic data, and other factors instrumental in determining legal responsibility were recorded for comparison. RESULTS: Ten (55.6%) cases were resolved in the defendant's favor, 2 (11.1%) resulted in damages awarded by a jury, and 6 (33.3%) were settled out of court before resolution of trial. Mean damages awarded were $1.1 million, while out of court settlements averaged $966,887. Malpractice stemming from patients who underwent endoscopic sinus surgery comprised 77.8% of cases analyzed. The most frequent alleged factors cited for litigation included having to undergo additional surgery (88.9%), developing meningitis (50.0%), and failing to recognize complications in a timely manner (44.4%). Perceived deficits in informed consent were alleged in one-third of cases. CONCLUSION: Although a slight majority of cases were resolved in the defendant's favor, payments made were considerable, averaging approximately $1 million. Strategies to decrease liability and allow patients to make more informed decisions should include clear communication with patients that explicitly states potential risks, such as meningitis, and possible need to undergo additional reparative surgery.

Pharmacoeconomical consequences of postoperative CSF leaks after intracranial surgery--a prospective analysis.

Cerebrospinal fluid (CSF) leaks are well-known and frequent complications of intracranial procedures with their clinical aspects covered by numerous studies. Little, however, is known about the pharmacoeconomical aspects of this specific complication. 545 patients with a variety of intracranial procedures (elective and trauma) were recruited for a multicenter, prospective, observational study over a 13-month period. A specific pharmacoeconomic analysis was performed in 168 of these patients from the institution of the first author covering all clinical and pharmaco-economical aspects of this specific complication. Of all patients, 5.36% developed a postoperative CSF leak. Treatment of the leak required numerous diagnostic and therapeutic procedures such as reoperations (n = 6), lumbar punctures (n = 11) or lumbar drainages (n = 4). Costs for these procedures and prolonged hospital stays nearly doubled the costs per case (€14079/case without a fistula vs. €25499/case with a fistula). Reimbursement for the hospital covered these extra costs, but net earnings per case were diminished by €565 in cases with a CSF leak. The authors conclude that the presence of a CSF leak after an intracranial operation - although not influencing outcome in general - results in additional diagnostic and therapeutic procedures for the patient, an enormous increase in costs for the community, and a financial loss for the hospital. Strategies to lower this complication rate should therefore urgently be developed both from a clinical and a pharmacoeconomical point of view.

Endoscopic transnasal transethmosphenoidal approach for pituitary tumors: assessment of technique and postoperative findings of nasal and paranasal cavities.

OBJECTIVE: Transnasal endoscopic surgery is the most common approach to removal of pituitary tumors. This study evaluated the transnasal transethmosphenoidal approach (TTES) in terms of its operative manipulability and the postoperative status of the paranasal cavities. METHODS: A total of 132 patients with pituitary tumors underwent surgery by one of the following three approaches: (1) bilateral TTES, in which the surgical procedures were performed via the bilateral paranasal cavities, (2) unilateral TTES, in which the procedures were performed via one side only, and (3) unilateral TTES and resection of the posterior portion in the nasal septum approach (RPS), which is a modification of approach (2) and enables performance of the procedures from both sides. RESULTS: The degree of freedom for the surgical procedures with each of the approaches decreased in the following order: bilateral TTES, unilateral TTES and RPS, and unilateral TTES. The postoperative CT images and endoscopic findings were good with each of the surgical approaches, but the incidences of olfactory disturbance and nasal dryness were significantly higher with the bilateral TTES compared with the unilateral TTES and RPS and the unilateral TTES. CONCLUSION: The unilateral TTES and RPS was for us most suitable approach of the three methods. In the case of advanced tumors, the bilateral TTES should be selected because it permits superior operative manipulability. Finally, the unilateral TTES is most appropriate for removal of tumors that are deviated to one side and localized within the sella.

[Experiences with assessment of frontobasal defects, a diagnostic concept]. / Erfahrungen mit der Abklärung von Frontobasisdefekten, ein diagnostisches Konzept.

BACKGROUND: Cerebrospinal fluid (CSF) rhinorrhea presents not only a therapeutic challenge, but a diagnostic challenge as well. This is especially true in the case of atraumatic spontaneous leakage, which is often only minimal in quantity and can occur intermittently. The purpose of this paper is to compare the current methods of evaluation of CSF Rhinorrhea (beta 2-Transferrin assay, high resolution computed tomography [HRCT], and computotomographic cisternography [CTC]) and develop a diagnostic protocol. METHOD: A retrospective analysis was performed of 61 patients who underwent operation for CSF rhinorrhea between 1988 and 1996 comparing the method of preoperative diagnosis and intraoperative findings. RESULTS: beta 2-transferrin-determination in the nasal discharge had a sensitivity of 79% (33/42), HRCT correctly identified the defect in 84% (48/57) of cases, and CTC correctly localized the pathology in 72% (18/25) of the patients. CONCLUSION: The sensitivity of each CSF rhinorrhea diagnosis method is less than 90%. It is our opinion that with the current level of technology a combined approach is optimal with two or more of the above studies. A diagnosis scheme is presented to manage step by step this challenging and potentially lethal problem.

Incidence and management of complications of transsphenoidal operation for pituitary adenomas.

Two hundred fifty-five consecutive transsphenoidal procedures for pituitary adenomas were reviewed to evaluate complications and their management. There were no operative deaths. Cerebrospinal fluid (CSF) rhinorrhea was the most common complication, occurring in 2.7% of cases; diabetes insipidus was next, lasting less than 1 year in 1.6% of patients and over a year in 0.4%. Sinusitis occurred in 1.2% of patients, and delayed epistaxis occurred in 0.8%. Postoperative hematomas, meningitis, hydrocephalus, and deep venous thrombosis each occurred in 0.4% of cases. These results are discussed in the context of previous reports, including an international survey of pituitary surgeons. Although transsphenoidal surgery has a low morbidity and mortality, it is nevertheless associated with potentially serious difficulties that should be expeditiously recognized and managed.

Transsphenoidal surgery following unsuccessful prior therapy. An assessment of benefits and risks in 158 patients.

The authors report the results of a retrospective study conducted in an effort to define the results and risks of transsphenoidal surgery for patients whose prior therapy had failed. In a series of 1210 patients undergoing transsphenoidal surgery during a 10-year period, 158 had received prior therapy: 127 for pituitary adenoma, 20 for craniopharyngioma, and 11 for other lesions. Prior therapy was considered "direct" when it consisted of craniotomy or transsphenoidal surgery (either open or stereotaxic), and "indirect" when it consisted of radiation therapy, adrenalectomy, or bromocriptine therapy. The current transsphenoidal operation was performed for persistent hyperfunctioning endocrinopathy in 63 patients, for visual loss in 72 patients, and for cerebrospinal fluid (CSF) rhinorrhea in 21 patients. Success rates were as follows: normalization of endocrinopathy was achieved in 35% of cases; improvement or stabilization of vision in 59%; and successful repair of CSF rhinorrhea in 74%. The risks associated with repeat transsphenoidal surgery are significantly greater than the same procedure in a previously untreated patient.