{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,11]],"date-time":"2026-09-11T07:05:59Z","timestamp":1789110359259,"version":"build-2803163510"},"reference-count":47,"publisher":"Public Library of Science (PLoS)","issue":"3","license":[{"start":{"date-parts":[[2021,3,15]],"date-time":"2021-03-15T00:00:00Z","timestamp":1615766400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Introduction<\/jats:title>\n<jats:p>Post-operative CSF leak still represents the main drawback of Endoscopic Endonasal Approach (EEA), and different reconstructive strategies have been proposed in order to decrease its rate.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Objective<\/jats:title>\n<jats:p>To critically analyze the effectiveness of different adopted reconstruction strategies in patients that underwent EEA.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Materials and methods<\/jats:title>\n<jats:p>Adult patients with skull base tumor surgically treated with EEA were retrospectively analyzed. Data recorded for each case concerned patient demographics, type of surgical approach, histotype, anatomical site of surgical approach, intra-operative CSF leak grade (no leak (INL), low flow (ILFL), high flow (IHFL)), reconstructive adopted strategy, Lumbar Drain positioning, post-operative CSF leak rate and intra\/post-operative complications.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Results<\/jats:title>\n<jats:p>A total number of 521 patients (January 2012-December 2019) was included. Intra-operative CSF leak grade showed to be associated with post-operative CSF leak rate. In particular, the risk to observe a post-operative CSF leak was higher when IHFL was encountered (25,5%; Exp(B) 16.25). In particular, vascularized multilayered reconstruction and fat use showed to be effective in lowering post-operative CSF leaks in IHFL (p 0.02). No differences were found considering INL and ILFL groups. Yearly post-operative CSF leak rate analysis showed a significative decreasing trend.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec005\">\n<jats:title>Conclusion<\/jats:title>\n<jats:p>Intra-operative CSF leak grade strongly affected post-operative CSF leak rate. Multilayer reconstruction with fat and naso-septal flap could reduce the rate of CSF leak in high risk patients. Reconstructive strategies should be tailored according also to the type and the anatomical site of the approach.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0245119","type":"journal-article","created":{"date-parts":[[2021,3,15]],"date-time":"2021-03-15T17:27:36Z","timestamp":1615829256000},"page":"e0245119","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":27,"title":["Skull base reconstruction: A question of flow? A critical analysis of 521 endoscopic endonasal surgeries"],"prefix":"10.1371","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7381-9194","authenticated-orcid":true,"given":"Giuseppe","family":"Di Perna","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Federica","family":"Penner","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fabio","family":"Cofano","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Raffaele","family":"De Marco","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bianca Maria","family":"Baldassarre","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Irene","family":"Portonero","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Diego","family":"Garbossa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luca","family":"Ceroni","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giancarlo","family":"Pecorari","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francesco","family":"Zenga","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2021,3,15]]},"reference":[{"key":"pone.0245119.ref001","article-title":"Skull base chordomas","author":"M Koutourousiou","year":"2011","journal-title":"Otolaryngologic Clinics of North America"},{"issue":"S3","key":"pone.0245119.ref002","first-page":"S145","article-title":"ICAR: endoscopic skull-base surgery","volume":"9","author":"EW Wang","year":"2019","journal-title":"International Forum of Allergy and Rhinology"},{"key":"pone.0245119.ref003","article-title":"Reconstruction after endoscopic surgery for skull base malignancies","volume":"0123456789","author":"CH Snyderman","year":"2020","journal-title":"Journal of neuro-oncology"},{"key":"pone.0245119.ref004","article-title":"Endoscopic transnasal skull base surgery: pushing the boundaries","author":"NT Zwagerman","year":"2016","journal-title":"Journal of Neuro-Oncology"},{"key":"pone.0245119.ref005","article-title":"Craniopharyngioma: A pathologic, clinical, and surgical review","author":"JC Fernandez-Miranda","year":"2012","journal-title":"Head and Neck"},{"key":"pone.0245119.ref006","article-title":"Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors: Part 2","author":"E de Divitiis","year":"2007","journal-title":"Neurosurgery"},{"key":"pone.0245119.ref007","doi-asserted-by":"crossref","first-page":"439","DOI":"10.1016\/j.wneu.2019.03.125","article-title":"The 3F (Fat, Flap, and Flash) Technique For Skull Base Reconstruction After Endoscopic Endonasal Suprasellar Approach","volume":"126","author":"LM Cavallo","year":"2019","journal-title":"World Neurosurgery"},{"issue":"01","key":"pone.0245119.ref008","doi-asserted-by":"crossref","first-page":"e50","DOI":"10.1055\/s-0035-1570388","article-title":"Nanofibrous Synthetic Dural Patch for Skull Base Defects: Preliminary Experience for Reconstruction after Extended Endonasal Approaches","volume":"77","author":"F Zenga","year":"2016","journal-title":"Journal of Neurological Surgery Reports"},{"key":"pone.0245119.ref009","article-title":"Surgical management of pituitary adenomas: does age matter?","author":"V Tardivo","year":"2019","journal-title":"Pituitary"},{"key":"pone.0245119.ref010","doi-asserted-by":"crossref","first-page":"e436","DOI":"10.1016\/j.wneu.2018.04.225","article-title":"Endoscopic Endonasal Reconstruction of Anterior Skull Base Defects: What Factors Really Affect the Outcomes?","volume":"116","author":"M Turri-Zanoni","year":"2018","journal-title":"World Neurosurgery"},{"issue":"1","key":"pone.0245119.ref011","first-page":"439","article-title":"Multilayered Closure of Cerebrospinal Fluid Rhinorrhea with Inlay Fascia Lata, Autologous Fat, and Outlay Fascia Lata: Our Experience","volume":"135","author":"CH Snyderman","year":"2019","journal-title":"World Neurosurgery"},{"issue":"1","key":"pone.0245119.ref012","doi-asserted-by":"crossref","first-page":"193","DOI":"10.1097\/SCS.0000000000004184","article-title":"A Stratified Algorithm for Skull Base Reconstruction with Endoscopic Endonasal Approach","volume":"29","author":"Z Li","year":"2018","journal-title":"Journal of Craniofacial Surgery"},{"key":"pone.0245119.ref013","article-title":"Different surgical approaches to the sellar region: Focusing on the \u201ctwo nostrils four hands technique.\u201d","author":"P Castelnuovo","year":"2006","journal-title":"Rhinology"},{"key":"pone.0245119.ref014","article-title":"Three-Dimensional Endoscopic Endonasal Approach and Outcomes in Sellar Lesions: A Single-Center Experience of 104 Cases","author":"V Pennacchietti","year":"2016","journal-title":"World Neurosurgery"},{"issue":"3","key":"pone.0245119.ref015","first-page":"643","volume":"50","author":"AC Sigler","year":"2017","journal-title":"Endoscopic Skull Base Reconstruction: An Evolution of Materials and Methods. Otolaryngologic Clinics of North America"},{"key":"pone.0245119.ref016","article-title":"Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery","author":"F Esposito","year":"2007","journal-title":"Neurosurgery"},{"key":"pone.0245119.ref017","article-title":"Evolution of reconstructive techniques following endoscopic expanded endonasal approaches","author":"A Kassam","year":"2005","journal-title":"Neurosurgical focus"},{"key":"pone.0245119.ref018","article-title":"Pitfalls of skull base reconstruction in endoscopic endonasal approach","author":"T Ogiwara","year":"2019","journal-title":"Neurosurgical Review"},{"key":"pone.0245119.ref019","article-title":"Endoscopic endonasal skull base surgery: Analysis of complications in the authors\u2019 initial 800 patients\u2014A review","author":"AB Kassam","year":"2011","journal-title":"Journal of Neurosurgery"},{"key":"pone.0245119.ref020","article-title":"Sellar repair in endoscopic endonasal transsphenoidal surgery: Results of 170 cases","author":"P Cappabianca","year":"2002","journal-title":"Neurosurgery"},{"issue":"5","key":"pone.0245119.ref021","doi-asserted-by":"crossref","first-page":"563","DOI":"10.1016\/j.wneu.2011.08.034","article-title":"Gasket seal closure for extended endonasal endoscopic skull base surgery: Efficacy in a large case series","volume":"80","author":"V Garcia-Navarro","year":"2013","journal-title":"World Neurosurgery"},{"key":"pone.0245119.ref022","article-title":"Cranial base repair using suturing technique combined with a mucosal flap for cerebrospinal fluid leakage during endoscopic endonasal surgery","author":"T. H","year":"2015","journal-title":"World Neurosurgery"},{"key":"pone.0245119.ref023","article-title":"Skull base reconstruction in the extended endoscopic transsphenoidal approach for suprasellar lesions","author":"LM Cavallo","year":"2007","journal-title":"Journal of Neurosurgery"},{"key":"pone.0245119.ref024","article-title":"Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap","author":"AB Kassam","year":"2008","journal-title":"Neurosurgery"},{"key":"pone.0245119.ref025","article-title":"Endoscopic endonasal resection of anterior cranial base meningiomas","author":"PA Gardner","year":"2008","journal-title":"Neurosurgery"},{"key":"pone.0245119.ref026","article-title":"The bath-plug closure of anterior skull base cerebrospinal fluid leaks","author":"PJ Wormald","year":"2003","journal-title":"American Journal of Rhinology"},{"key":"pone.0245119.ref027","article-title":"\u201cGasket-seal\u201d Watertight Closure in Minimal-access Endoscopic Cranial Base Surgery","author":"LZ Leng","year":"2008","journal-title":"Operative Neurosurgery"},{"key":"pone.0245119.ref028","article-title":"Anterior skull base reconstruction with fascia lata strip: The champagne cork technique","author":"M. A","year":"2012","journal-title":"Journal of Neurological Surgery, Part B: Skull Base"},{"key":"pone.0245119.ref029","article-title":"Endoscopy-assisted iliotibial tract harvesting for skull base reconstruction: Feasibility on a cadaveric model","author":"AB Villaret","year":"2011","journal-title":"Skull Base"},{"key":"pone.0245119.ref030","article-title":"Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery: Trends in repair failure and meningitis rates in 509 patients","author":"A Conger","year":"2019","journal-title":"Journal of Neurosurgery"},{"key":"pone.0245119.ref031","article-title":"Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations","author":"LM Cavallo","year":"2005","journal-title":"Neurosurgical focus"},{"key":"pone.0245119.ref032","article-title":"How to choose? Endoscopic skull base reconstructive options and limitations","author":"MR Patel","year":"2010","journal-title":"Skull Base"},{"key":"pone.0245119.ref033","article-title":"Endoscopic endonasal transsphenoidal surgery","author":"P Cappabianca","year":"2004","journal-title":"Neurosurgery"},{"issue":"3","key":"pone.0245119.ref034","doi-asserted-by":"crossref","first-page":"374","DOI":"10.3109\/02688697.2012.741739","article-title":"Extended endoscopic transplanum-transtuberculum approach for pituitary adenomas","volume":"27","author":"SA Barazi","year":"2013","journal-title":"British Journal of Neurosurgery"},{"key":"pone.0245119.ref035","article-title":"A novel reconstructive technique after endoscopic expanded endonasal approaches: Vascular pedicle nasoseptal flap","author":"G Hadad","year":"2006","journal-title":"Laryngoscope"},{"issue":"1","key":"pone.0245119.ref036","doi-asserted-by":"crossref","first-page":"136","DOI":"10.1016\/j.wneu.2012.08.011","article-title":"Long-term effectiveness of a reconstructive protocol using the nasoseptal flap after endoscopic skull base surgery","volume":"81","author":"ED McCoul","year":"2014","journal-title":"World Neurosurgery"},{"key":"pone.0245119.ref037","article-title":"Does lumbar drainage reduce postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery? A prospective, randomized controlled trial","author":"NT Zwagerman","year":"2019","journal-title":"Journal of Neurosurgery"},{"key":"pone.0245119.ref038","article-title":"Efficacy of the pedicled nasoseptal flap without cerebrospinal fluid (CSF) diversion for repair of skull base defects: Incidence of postoperative CSF leaks","author":"JA Eloy","year":"2012","journal-title":"International Forum of Allergy and Rhinology"},{"key":"pone.0245119.ref039","article-title":"Pure endoscopic endonasal approach for pituitary adenomas: Early surgical results in 200 patients and comparison with previous microsurgical series","author":"AR Dehdashti","year":"2008","journal-title":"Neurosurgery"},{"key":"pone.0245119.ref040","article-title":"Pneumocephalus patterns following endonasal endoscopic skull base surgery as predictors of postoperative CSF leaks","author":"MA Banu","year":"2014","journal-title":"Journal of Neurosurgery"},{"key":"pone.0245119.ref041","article-title":"External ventricular and lumbar drainage-associated meningoventriculitis: Prospective analysis of time-dependent infection rates and risk factor analysis","author":"S Scheithauer","year":"2010","journal-title":"Infection"},{"key":"pone.0245119.ref042","article-title":"Risk factors of cerebrospinal fluid rhinorrhea following transsphenoidal surgery","author":"H Nishioka","year":"2005","journal-title":"Acta Neurochirurgica"},{"key":"pone.0245119.ref043","article-title":"Nasoseptal flap reconstruction of high flow intraoperative cerebral spinal fluid leaks during endoscopic skull base surgery","author":"AM Zanation","year":"2009","journal-title":"American Journal of Rhinology and Allergy"},{"key":"pone.0245119.ref044","article-title":"Endoscopic endonasal approach for resection of cranial base chordomas: Outcomes and learning curve","author":"M Koutourousiou","year":"2012","journal-title":"Neurosurgery"},{"key":"pone.0245119.ref045","article-title":"Training in Neurorhinology: The Impact of Case Volume on the Learning Curve","author":"CH Snyderman","year":"2011","journal-title":"Otolaryngologic Clinics of North America"},{"key":"pone.0245119.ref046","doi-asserted-by":"crossref","first-page":"e277","DOI":"10.1016\/j.wneu.2019.10.039","article-title":"Outcome of Endoscopic Endonasal Surgery in Pediatric Craniopharyngiomas","volume":"134","author":"D Mazzatenta","year":"2020","journal-title":"World Neurosurgery"},{"key":"pone.0245119.ref047","article-title":"The awake endoscope-guided sealant technique with fibrin glue in the treatment of postoperative cerebrospinal fluid leak after extended transsphenoidal surgery: Technical note","author":"LM Cavallo","year":"2014","journal-title":"World Neurosurgery"}],"container-title":["PLOS ONE"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0245119","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,3,15]],"date-time":"2021-03-15T17:28:05Z","timestamp":1615829285000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0245119"}},"subtitle":[],"editor":[{"given":"Giovanni","family":"Cammaroto","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2021,3,15]]},"references-count":47,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2021,3,15]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0245119","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,3,15]]}}}