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Published on: June 28, 2024
Endoscopic third ventriculostomy versus shunt for pediatric hydrocephalus: a systematic literature review and
Pavlos Texakalidis1, Muhibullah S Tora2, Jeremy S Wetzel2
1Department of Neurosurgery, Emory University School of Medicine, Suite 6204, 101 Woodruff Circle, Atlanta, GA, 30322, USA. ptexaka@emory.edu.
Insights
Endoscopic third ventriculostomy (ETV) shows lower infection risk than shunting for pediatric hydrocephalus. Reoperation rates were similar overall, but ETV was superior in Africa and Europe, warranting further research.
Area of Science:
- Neurosurgery
- Pediatric Medicine
- Medical Technology
Background:
- Pediatric hydrocephalus management is debated, with ventriculoperitoneal shunts as the current standard.
- Endoscopic third ventriculostomy (ETV) presents an alternative cerebrospinal fluid (CSF) diversion approach.
- Observational studies suggest ETV as a viable option.
Purpose of the Study:
- To compare the safety and efficacy of shunting versus ETV in pediatric hydrocephalus.
- To evaluate infection rates, mortality, CSF leaks, and reoperation rates for both procedures.
Main Methods:
- Systematic literature review following PRISMA guidelines.
- Searched PubMed and Cochrane databases up to October 2018.
- Conducted a random effects meta-analysis and assessed risk of bias.
Main Results:
- Analyzed 14 studies with 8419 pediatric hydrocephalus patients.
- ETV significantly reduced infection risk compared to shunts (OR: 0.19).
- Mortality, CSF leak, and overall reoperation rates were similar; however, ETV showed lower reoperation rates in Africa and Europe.
Conclusions:
- ETV is associated with a lower risk of infection in pediatric hydrocephalus compared to shunting.
- While overall reoperation rates are similar, geographic variations exist, with ETV showing better outcomes in Europe and Africa.
- Further randomized controlled trials are needed to confirm these findings and explore heterogeneity.
Background:
Optimized management of pediatric hydrocephalus remains the subject of debate. Ventriculoperitoneal shunt is largely considered the standard of care. However, the advancements and introduction of new cerebrospinal fluid (CSF) diversion approaches including the use of endoscopic third ventriculostomy (ETV) offer appealing alternatives that have been reported in numerous observational series.
Objective:
To evaluate the comparative safety and efficacy of shunting and ETV in pediatric hydrocephalus cases.
Methods:
This systematic literature review was performed according to the PRISMA guidelines. Eligible studies were identified through a search of PubMed (Medline) and Cochrane until October 2018. A random effects model meta-analysis was conducted and the I-square was used to assess heterogeneity. The ROBINS-1 tool and Cochrane tool were used to assess risk of bias in the observational and randomized studies, respectively.
Results:
Fourteen studies including 8419 patients were identified. Patients in the ETV group had a statistically significant lower risk of infection compared to shunt (OR: 0.19; 95% CI: 0.07-0.53; I2: 0%). All-cause mortality (OR: 0.77; 95% CI: 0.35-1.68; I2: 0%), post-operative CSF leak (OR: 1.53; 95% CI: 0.37-6.31; I2: 0%), and reoperation rates were similar between the two study groups (OR: 0.72; 95% CI: 0.39-1.32; I2: 93.5%). Subgroup analyses for re-operation demonstrated that ETV in Africa (OR: 0.13; 95% CI: 0.03-0.48; I2: 0%) and Europe (OR: 0.39; 95% CI: 0.30-0.52; I2:1.4%) was associated with significantly lower odds of re-operation compared to shunt, but not in USA/Canada (OR: 1.49; 95% CI: 0.85-2.63; I2:86.2%). Meta-regression analyses of age and duration of follow-up did not affect re-operation rates.
Conclusions:
ETV was associated with a statistically significant lower risk of procedure-related infection compared to shunt. All-cause mortality, CSF leak, and re-operation rates were similar between the study groups. Subgroup analysis based on the geographic region showed that ETV is associated with statistically significant lower odds for re-operation in Europe and Africa, but not in USA/Canada. Future RCTs are needed to validate the results of this study and elucidate the cause of this heterogeneity.
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