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Lack of benefit of endoscopic ventriculoperitoneal shunt insertion: a multicenter randomized trial
John R W Kestle1, James M Drake, D Douglas Cochrane
1Division of Pediatric Neurosurgery, University of Utah, Primary Children's Medical Center, Salt Lake City, Utah 84113, USA. john.kestle@hsc.utah.edu
Insights
Endoscopic insertion of the initial ventriculoperitoneal (VP) shunt in children did not reduce shunt failure rates. This prospective trial found no significant difference in shunt survival between endoscopic and nonendoscopic procedures.
Area of Science:
- Pediatric Neurosurgery
- Hydrocephalus Management
- Surgical Innovation
Background:
- Endoscopic techniques for ventricular catheter placement have been anecdotally linked to reduced shunt failure.
- Uncontrolled series suggested improved outcomes with endoscopically assisted ventricular catheter placement.
Purpose of the Study:
- To prospectively evaluate the efficacy of endoscopic versus nonendoscopic ventricular catheter insertion for initial ventriculoperitoneal (VP) shunt placement in children.
- To determine if endoscopic assistance reduces shunt failure rates in pediatric hydrocephalus.
Main Methods:
- A prospective, multicenter, randomized trial involving 393 children under 18 years undergoing their first VP shunt placement.
- Patients were randomized to undergo either endoscopic or nonendoscopic ventricular catheter insertion.
- Shunt failure at 1 year was the primary outcome, assessed in a blinded fashion using an intention-to-treat analysis.
Main Results:
- The 1-year shunt failure incidence was 42% in the endoscopic group and 34% in the nonendoscopic group.
- Postoperative imaging revealed the ventricular catheter was in the choroid plexus in 67% of endoscopic cases versus 61% of nonendoscopic cases.
- No statistically significant difference in the time to first shunt failure was observed between the two groups (p = 0.09).
Conclusions:
- Endoscopic insertion of the initial ventriculoperitoneal (VP) shunt in pediatric hydrocephalus does not decrease the incidence of shunt failure.
- The study did not support the hypothesis that endoscopic assistance improves shunt survival in this patient population.
Object:
Endoscopically assisted ventricular catheter placement has been reported to reduce shunt failure in uncontrolled series. The authors investigated the efficacy of this procedure in a prospective multicenter randomized trial.
Methods:
Children younger than 18 years old who were scheduled for their first ventriculoperitoneal (VP) shunt placement were randomized to undergo endoscopic or nonendoscopic insertion of a ventricular catheter. Eligibility and primary outcome (shunt failure) were decided in a blinded fashion. An intention-to-treat analysis was performed. The sample size offered 80% power to detect a 10 to 15% absolute reduction in the 1-year shunt failure rate. The authors studied 393 patients from 16 pediatric neurosurgery centers between May 1996 and November 1999. Median patient age at shunt insertion was 89 days. The baseline characteristics of patients within each group were similar: 54% of patients treated with endoscopy were male and 55% of patients treated without endoscopy were male; 30% of patients treated with and 26% of those without endoscopy had myelomeningocele; a differential pressure valve was used in 51% of patients with and 49% of those treated without endoscopy; a Delta valve was inserted in 38% of patients in each group; and a Sigma valve was placed in 9% of patients treated with and 12% of those treated without endoscopy. Median surgical time lasted 40 minutes in the group treated with and 35 minutes in the group treated without endoscopy. Ventricular catheters, which during surgery were thought to be situated away from the choroid plexus, were demonstrated to be in it on postoperative imaging in 67% of patients who had undergone endoscopic insertion and 61% of those who had undergone nonendoscopic shunt placements. The incidence of shunt failure at 1 year was 42% in the endoscopic insertion group and 34% in the nonendoscopic group. The time to first shunt failure was not different between the two groups (log rank = 2.92, p = 0.09).
Conclusions:
Endoscopic insertion of the initial VP shunt in children suffering from hydrocephalus did not reduce the incidence of shunt failure.