An Algorithm for the Use of Free Tissue Graft Reconstruction in the Endoscopic Endonasal Approach for Pituitary Tumors

OBJECTIVE: To identify factors associated with suc-cessful use of free tissue grafting versus vascularized reconstruction after resection of pituitary tumors.METHODS: A retrospective chart review of 2 tertiary academic medical centers over 3.5 years was conducted. Variables assessed included age, sex, body mass index, pathology, extent of surgical exposure, cavernous sinus or suprasellar extension, intraoperative cerebrospinal fluid (CSF) leak, grade of leak, previous radiation, and previous surgery. Reconstructive techniques were divided into no reconstruction, free tissue grafts, and vascularized flaps.RESULTS: A total of 485 patients were included. Free grafts were used in 299/485 cases (61.6%) and were more commonly used with smaller approaches (P < 0.001). Larger exposure size and CSF leak grades 2 and 3 were associ-ated with vascularized flap use (P < 0.001 and P = 0.012, respectively). Using multivariate regression, type of reconstruction could be predicted by increasing extent of approach, intraoperative CSF leak grade, and suprasellar extension (odds ratio [OR], 2.014, P< 0.001, 95% confidence interval [CI], 1.335-3.039; OR, 1.636, P = 0.025, 95% CI, 1.064-2.517; OR, 1.975, P < 0.001, 95% CI, 1.554-2.510, respectively). Postoperative CSF leak occurred in 9 of 173 patients (5.2%) with intraoperative leak and was not associated with any factors on analysis.CONCLUSIONS: We propose an algorithm whereby grade 1 CSF leaks in sellar and parasellar resections can be successfully reconstructed with a free graft. Vascular-ized flaps may be reserved for grade 2 or 3 intraoperative CSF leaks, extended approaches, or tumors with supra-sellar extension.