Ostomy closure and the role of repeat endoscopic third ventriculostomy (re-ETV) in failed ETV procedures

Endoscopic third ventriculostomy (ETV) has replaced shunt surgery for several indications. Failure of ETV secondary to restenosis can result in recurrence of symptoms of raised intracranial pressure.

To analyze the rates of restenosis due to ostomy closure and factors resulting in failures and to assess the role of re-ETV in such cases.

Re-ETV was performed after counselling and obtaining informed consent. The technique of re-ETV was essentially the same as in primary ETV. Video analysis of primary ETV was performed before selecting a patient for re-ETV. Factors analyzed included age, gender, etiology of hydrocephalus, cerebrospinal fluid (CSF) findings, presence of shunt tube and adequacy of ETV and bleeding at the time of ETV.

Thirty-two patients underwent re-ETV. The mean interval between the first ETV and re-ETV was 1.4 years (3 days to 2.9 years). Overall failure of ETV due to restenosis was 8.78%. The technical success rate of performing re-ETV was 93.2%. The overall clinical recovery following surgery was observed in 89% of the patients, three from early and 25 from delayed ETV failures. The radiological recovery was seen in 20 (63%) patients. The good flow of CSF via the re-ETV site was documented with cine mode magnetic resonance imaging (MRI) in seven patients. Unlike primary ETV, the success of re-ETV in children aged less than 2 years was 90% (P < 0.005). There were 56.25% failure of ETV in patients with previous infection or foreign body within the ventricle (P < 0.001). While the chances of restenosis were high in the procedure with some infections, the outcome was equally better. Gender of the patients and CSF findings had no influence on ostomy closure.

re-ETV can be considered in carefully selected patients of failed ETV. It is more useful in delayed ETV failures and can be offered before a patient is advised VP shunt.