Elsevier

World Neurosurgery

Volume 84, Issue 2, August 2015, Pages 240-245
World Neurosurgery

Original Article
Sellar Floor Reconstruction with the Medpor Implant Versus Autologous Bone After Transnasal Transsphenoidal Surgery: Outcome in 200 Consecutive Patients

https://doi.org/10.1016/j.wneu.2015.02.025Get rights and content

Objective

The Medpor porous polyethylene implant provides benefits to perform sellar floor reconstruction when indicated. This material has been used for cranioplasty and reconstruction of skull base defects and facial fractures. We present the most extensive use of this implant for sellar floor reconstruction and document the safety and benefits provided by this unique implant.

Methods

The medical charts for 200 consecutive patients undergoing endonasal transsphenoidal surgery from April 2008 through December 2011 were reviewed. Material used for sellar floor reconstruction, pathologic diagnosis, immediate inpatient complications, and long-term complications were documented and analyzed. Outpatient follow-up was documented for a minimum of 1-year duration, extending in some patients up to 5 years.

Results

Of the 200 consecutive patients, 136 received sellar floor cranioplasty using the Medpor implant. Postoperative complications included 6 complaints of sinus irritation or drainage, 1 postoperative cerebrospinal fluid leak requiring operative re-exploration, 1 event of tension pneumocephalus requiring operative decompression, 1 case of aseptic meningitis, 1 subdural hematoma, and 1 case of epistaxis. The incidence of these complications did not differ from the autologous nasal bone group in a statistically significant manner.

Conclusions

Sellar floor reconstruction remains an important part of transsphenoidal surgery to prevent postoperative complications. Various autologous and synthetic options are available to reconstruct the sellar floor, and the Medpor implant is a safe and effective option. The complication rate after surgery is equivalent to or less frequent than other methods of reconstruction and the implant is readily incorporated into host tissue after implantation, minimizing infectious risk.

Introduction

The transnasal, transsphenoidal approach for removal of lesions in the sella, planum sphenoidale, and clivus is a safe and effective route with a very low morbidity and mortality rate 2, 6, 22. Postoperatively, sellar floor reconstruction is often warranted and there are several methods to address this need. Surgical complications can arise if this task is neglected or improperly performed. Mechanical complications reported in the literature relating to this approach include chiasmal herniation syndrome, empty sella syndrome, intrasellar hematoma, intrasellar abscess, cerebrospinal fluid (CSF) leakage, and resultant meningitis 13, 18.

Options to reconstruct the sellar floor include autologous and synthetic materials. Autologous nasal bone, cartilage, or a large piece of bone from the sphenoid rostrum or sellar floor can sometimes be used to reconstruct the floor of the sella if a large enough piece is available at the time of surgery. Synthetic options include bioabsorbable implants, titanium mesh, dural substitute, fibrin glue alone, and the Medpor implant (Stryker; Kalamazoo, MI) 1, 5, 14, 21. The use of these substances obviates the need to harvest native tissue. Ideally, the implant would not present an increased infectious risk, would not pose a significant impediment to repeat surgery, and would incorporate to form a seal with the native tissues to help prevent CSF leak.

The Medpor polyethylene implant has been used in various roles in craniofacial reconstruction. Examples include frontal sinus fractures, facial fractures, sellar floor reconstruction, orbital floor reconstruction, cranioplasty, repair of skull base defects after surgery, and external ear reconstruction 4, 7, 15, 18, 19. We present the most extensive experience with use of the Medpor implant to reconstruct the sellar floor documented to date in the literature and compare results with the use of autologous bone during the same time period.

Section snippets

Patient Population

The surgical records and medical charts for 200 consecutive patients undergoing endonasal transsphenoidal surgery performed by the senior author from April 2008 through December 2011 were reviewed in accordance with Institutional Review Board project #00012119 of Houston Methodist Hospital. All cases were performed at Houston Methodist Hospital in the same operative suite. Material used for sellar floor reconstruction, the pathology of sellar mass, immediate complications in the postoperative

Results

Of the 200 consecutive cases of transsphenoidal explorations, 136 received a sellar floor cranioplasty using the Medpor implant, and 61 received an autologous nasal bone cranioplasty. Re-explorations and removal of previously placed implants, decision not to reconstruct altogether, and other reasons, mentioned later, account for discrepancy of 197 total sellar floor reconstruction events in 200 patients. Of the 136 Medpor implants, the final pathology of 114 were pituitary adenomas of varying

Discussion

The transnasal transsphenoidal approach has become the preferred approach to access intrasellar pathology, particularly pituitary tumors. This is secondary to the relative safety and direct access this operative corridor provides the surgeon. Visualization of sellar pathology is further aided because the endoscope and the operative microscope can be used during surgery. Mortality rates attributable to the procedure are very low, but the rate of complications quoted in the literature is not

Conclusion

Sellar floor reconstruction is an important part of transsphenoidal surgery after resection of sellar lesions for a number of reasons. Various autologous and synthetic options are available to reconstruct the sellar floor. The Medpor implant is a safe and effective option to use. The rate of complications after surgery are equivalent to or less frequent than other methods of sellar floor reconstruction including the use of autologous bone, and the implant is readily incorporated into host

References (23)

  • P. Cappabianca et al.

    Easy sellar reconstruction in endoscopic endonasal transsphenoidal surgery with polyester-silicone dural substitute and fibrin glue: technical note

    Neurosurgery

    (2001)
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      The porous nature of high-density polyethylene implants allows vascular and soft tissue ingrowth, which is thought to enhance stabilization of the implant and promote resistance to infection [2]. Reconstruction of the sellar floor with autologous bone compared to MEDPOR has been previously studied without significant differences in complication rates [3]. Regardless, all foreign bodies have the potential to extrude or act as a nidus for infection.

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      Most authors use a bone graft to prevent cerebral herniation. However, autologous bone graft reconstruction is not always possible [5] and, depending on the size of the defect, several materials may be used, such as bone substitute (hydroxyapatite), titanium plates or porous polyethylene (Medpor®) [6]. These techniques are generally used for small defects not requiring solid material, while our technique can be used to reconstruct larger anterior skull base defects.

    • Anterior skull base reconstruction after tumor resection using the posterior wall of the frontal sinus

      2019, Annales Francaises d'Oto-Rhino-Laryngologie et de Pathologie Cervico-Faciale
    • The Challenge of Skull Base Closure: Methods for Reducing Postoperative Cerebrospinal Fluid Leak

      2019, World Neurosurgery
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      Porous polyethylene (MEDPOR [Stryker Corp, Kalamazoo, Michigan, USA]) also acts as a rigid support, but is easier to trim to the necessary size and is more malleable. Disadvantages of MEDPOR placement are device extrusion in the early postoperative period and local tissue integration, making future MEDPOR removal more difficult if reoperation is necessary.53 Absorbable gelatin sponges (Gelfoam [Pfizer Inc, New York, New York, USA]) may be used over the reconstruction to stabilize the other layers.

    • Development of Chronic Sphenoid Sinusitis After Sellar Reconstruction with Medpor Porous Polyethylene Implant

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      Porous polyethylene implants theoretically may be favorable in that its high-density pores have been shown to induce rapid fibrovascular and soft tissue ingrowth, which allow for incorporation into the surrounding tissue and increased implant stability. This fibrovascular tissue ingrowth is believed to allow cellular products to permeate the implant early on, ameliorating the risk of infection.14,19,22 In addition, the rapid soft tissue integration of the implant allows for increased stabilization rate, reducing the risk of implant migration and extrusion.19,23

    • Application of Fibrin Rich in Leukocytes and Platelets in the Reconstruction of Endoscopic Approaches to the Skull Base

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      On the other hand, the use of synthetic41,42 or heterologous (bovine, equine) materials36,43 is described mainly as the application of membranes produced from collagen or cellulose, or the use of dural sealants.24,44-48 Some hemostatic products are commonly used as adjuvant in combined reconstruction techniques.1,49-51 Also, cadaveric allograft has been proposed.40,52

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    Conflict of interest statement: The authors thank and acknowledge the support from The Veralan Foundation, The Taub Foundation, The Blanche Green Estate Fund of the Pauline Sterne Wolff Memorial Foundation, The Methodist Hospital Foundation, and the very generous support of Donna and Kenneth Peak.

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