- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT03448614
Skull Base Reconstruction After Endonasal Cranio-endoscopic Resection Using Autologus Grafts
Study Overview
Status
Conditions
Detailed Description
Type of the study:
A prospective clinical study will be conducted in the period between January 2018 and January 2020.
Study Setting:
Otolaryngology Department, Alexandria University Hospital. Otolaryngology Department, Assiut University Hospital.
Study tools :
Preoperative evaluation:
- Personal history: age, sex, marital status, occupation, number of children, and endocrinal history in case pituitary tumors.
- Presentation: endocrine, visual, oculomotor and/or a headache.
- Therapeutic history.
- Past history: trans-sphenoidal surgery, trauma and nasal diseases and/or surgery.
- General examination: including gross features of Cushing's disease or acromegaly.
- Full ENT examination including assessment of the nasal cavity, nasal septum for deviation, perforation and/or adhesions) and nasal turbinates; including nasal endoscopic examination and dental assessment.
- Neurosurgical consultation.
- Ophthalmological assessment: visual acuity, visual field, fundus examination and color vision.
Radiological assessment:
- MRI of the brain: A complete protocol including at least, T1- and T2-weighted images and T1-weighted post-contrast (gadolinium) images, in the three orthogonal planes at max 3 mm sections: for assessment of tumor site, size and extension, and involvement of large blood vessels and nerves.
- Multi-slice CT scan of the nose and paranasal sinuses (bone window, high resolution, with intravenous contrast, in the three orthogonal planes, with three-dimensional reconstruction and at maximum 3 mm sections): for assessment of nasal cavity abnormalities including the nasal septum, sinus pathology, type of sphenoid sinus pneumatization, etc.
Assessment of the general condition of the patient:
- Complete blood count: to assess for anemia or other hematological abnormalities.
- Serum electrolytes: mainly sodium and potassium.
- Fasting and postprandial blood glucose level.
- ECG and echocardiography.
Operative techniques:
After cranio-endoscopic resection and complete removal of the lesion skull base defect will be repaired according to the following scheme (modified from Sigler et al) No leak →No repair or single layer Low-flow leak → Multilayer repair Autograft (fascia Lata, fat, bone, mucosa) High-flow leak →Multilayer repair Autograft (fascia Lata, fat, bone, mucosa)+ Intranasal vascularized flap.
Modifying factors (factors that indicate the need for a vascularized flap regardless of leak type): Cushing disease, morbid obesity, craniopharyngioma, meningioma, extended skull base approach, large defect, revision surgery, history of or future need for radiation treatment.
So repair technique after extensive dural and bony resection or high flow leak will include multiple layers of fascia lata with pieces of fatty tissue in between. After that, a nasoseptal flap (or other vascularized flap, e.g., posterior pedicled inferior turbinate, posterior pedicled middle turbinate, bipedicled anterior septal, anterior inferior turbinate) will be harvested and applied according to local vascularity.
Then a separator will be applied; to prevent future accidental dislodgement of grafts during Merocel® removal, followed by placement of a moderately inflated Foley balloon catheter; to support the reconstruction.
At the end of the procedure, when hemostasis will be achieved, irrigation will be performed to remove any bone residuals or blood clots from the choanae and the nasopharynx. Then, the middle turbinates will be gently repositioned medially. At last, nasal Merocel® (polyvinyl alcohol) sponges will be placed in the nasal cavity on either side and hydrated with saline to expand.
Repair of low flow leak will be the same as the previous technique with the replacement of the vascularized flap with free mucosal graft and no need for Foley catheter.
Early postoperative management:
For the next twenty-four hours, the patient will be monitored in the intensive care unit, particularly for diabetes insipidus (after pituitary surgery), visual deterioration, any CSF leak, manifestations of meningitis or any hemorrhage.
Inspection for CSF leak will be a part of the routine evaluation of every patient, both in the recovery room and in the days after surgery. If persistent CSF leak became evident, a lumbar drainage was tried before re-exploration under general anesthesia. Analgesics will be routinely prescribed. Prophylaxis against postoperative nausea and vomiting will be achieved by an intraoperative intravenous administration of a single dose of an antiemetic, ondansetron 4 mg, as well as a throat pack to prevent intraoperative bleeding from draining into the stomach.
An intravenous third-generation cephalosporin will be started with anesthesia induction and continued until removal of the nasal packing. Then, patients will be kept on a five days course of an oral antibiotic; for safety.
Nasal packs will be removed on the third or fifth postoperative day. Then, the patient will be examined under endoscopic guidance.
Follow up:
I. Otorhinolaryngologic assessment: The first office visit will be scheduled after a week following the surgery. After application of topical anesthesia (lidocaine 10%), any blood clots will be endoscopically removed and any synechiae will be released. The examination will be for any bleeding or CSF leakage. The patient will be seen on a weekly basis for the first three weeks and then every three weeks for the next two appointments. Healing usually occurs three to six weeks. Further appointments will be scheduled as necessary II. Neuro-radiological assessment: Early MRI will be obtained on the first or second postoperative day to assess the extent of resection, the location of the fat graft if one is present, and the presence of any hematoma. Serial imaging was done after six months and then annually.
III. Endocrinal assessment: in case of hypophysectomy. IV. Ophthalmological assessment: serial visual field, visual acuity, and fundus examinations will be done for every patient, especially those with a pre-operative visual loss.
Study Type
Enrollment (Anticipated)
Contacts and Locations
Study Locations
-
-
-
Assiut, Egypt, 71515
- Assiut University
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
- ADULT
- OLDER_ADULT
- CHILD
Accepts Healthy Volunteers
Genders Eligible for Study
Sampling Method
Study Population
Description
Inclusion Criteria:
- All patients undergoing endonasal cranio-endoscopic resection
Exclusion Criteria:
- Unfit patient for surgery.
- Patient refusal to participate in this study.
Study Plan
How is the study designed?
Design Details
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Head CT scan
Time Frame: within 1month preoperative
|
bone window axial, coronal and sagittal cuts to measure preoperative skull base defect size
|
within 1month preoperative
|
brain MRI: with and without contrast
Time Frame: within1 week post operative
|
Coronal, axial and sagittal MRI in T1 and T2 signals measures postoperative tumor, to assess the repaired defect after the surgery
|
within1 week post operative
|
brain MRI: with and without contrast
Time Frame: 3 monthes post operative
|
Coronal, axial and sagittal MRI in T1 and T2 signals to assess the repaired defect after the surgery
|
3 monthes post operative
|
brain MRI: with and without contrast
Time Frame: 6monthes postoperative
|
Coronal, axial and sagittal MRI in T1 and T2 signals to assess the repaired defect after the surgery, recurrence of tumor
|
6monthes postoperative
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
estimation of incidence of sinonasal, orbital &/or intracranial complications
Time Frame: within 90 days following surgery
|
identification of possible complication that will occur during resection of skull base and removal of tumors
|
within 90 days following surgery
|
the incidence of CSF leakage
Time Frame: within 90 days postoperative
|
history of CSF leakage confirmed by endoscopic examination
|
within 90 days postoperative
|
CSF leakage related surgical intervention
Time Frame: within 90 days postoperative
|
second surgical intervention to explore the grafted defect
|
within 90 days postoperative
|
Endonasal endoscopic evaluation of the grafted defect
Time Frame: within 1 month postoperative, 3monthes postoperative
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using 4 mm 0-degree endoscope to measure graft condition and visualize any CSF fistula
|
within 1 month postoperative, 3monthes postoperative
|
Brain MRI: with and without contrast
Time Frame: within 1 month preoperative
|
Coronal, axial and sagittal MRI in T1 and T2 signals measures preoperative tumor size
|
within 1 month preoperative
|
type of pathology
Time Frame: within 1 week post operative
|
identification of the type of the pathology
|
within 1 week post operative
|
Collaborators and Investigators
Sponsor
Investigators
- Principal Investigator: ahmed G sholkamy, Msc, Assiut University
Publications and helpful links
General Publications
- Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus. 2005 Jul 15;19(1):E3.
- Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum. Neurosurg Focus. 2005 Jul 15;19(1):E4.
- Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R. Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus. 2005 Jul 15;19(1):E6.
- Kassam A, Carrau RL, Snyderman CH, Gardner P, Mintz A. Evolution of reconstructive techniques following endoscopic expanded endonasal approaches. Neurosurg Focus. 2005 Jul 15;19(1):E8.
- Snyderman CH, Kassam AB, Carrau R, Mintz A. Endoscopic Reconstruction of Cranial Base Defects following Endonasal Skull Base Surgery. Skull Base. 2007 Feb;17(1):73-8. doi: 10.1055/s-2006-959337.
- Sigler AC, D'Anza B, Lobo BC, Woodard TD, Recinos PF, Sindwani R. Endoscopic Skull Base Reconstruction: An Evolution of Materials and Methods. Otolaryngol Clin North Am. 2017 Jun;50(3):643-653. doi: 10.1016/j.otc.2017.01.015. Epub 2017 Mar 31.
- Villaret AB, Schreiber A, Battaglia P, Bignami M. Endoscopy-assisted iliotibial tract harvesting for skull base reconstruction: feasibility on a cadaveric model. Skull Base. 2011 May;21(3):185-8. doi: 10.1055/s-0031-1275260.
- Zanation AM, Thorp BD, Parmar P, Harvey RJ. Reconstructive options for endoscopic skull base surgery. Otolaryngol Clin North Am. 2011 Oct;44(5):1201-22. doi: 10.1016/j.otc.2011.06.016.
- Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, Mintz A. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope. 2006 Oct;116(10):1882-6. doi: 10.1097/01.mlg.0000234933.37779.e4.
- El-Sayed IH, Roediger FC, Goldberg AN, Parsa AT, McDermott MW. Endoscopic reconstruction of skull base defects with the nasal septal flap. Skull Base. 2008 Nov;18(6):385-94. doi: 10.1055/s-0028-1096202.
Study record dates
Study Major Dates
Study Start (ACTUAL)
Primary Completion (ANTICIPATED)
Study Completion (ANTICIPATED)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (ACTUAL)
Study Record Updates
Last Update Posted (ACTUAL)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Keywords
Additional Relevant MeSH Terms
Other Study ID Numbers
- skull base reconstruction
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
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