Endoscopic third ventriculostomy versus ventriculoperitoneal shunt placement in children with obstructive hydrocephalus

Background: Uncertainty persists on the best treatment for patients with obstructive hydrocephalus: endoscopic third ventriculostomy (ETV) or ventriculoperitoneal shunt (VPS), particularly in the younger age groups. The author investigated and compared 1-year outcomes for ETV and VPS treatment categories at Zewditu Memorial Hospital (ZMH), Ethiopia.
Methods: This was a retrospective, hospital-based study. The study reviewed 259 paediatric patients with hydrocephalus in whom VPS or ETV with or without choroid plexus cauterisation (CPC) was done as a primary treatment, between January 2013 and January 2016 at ZMH. Patients’ medical records, operative notes, and neural tube database records were used to complete a structured questionnaire. The difference in proportions was examined using the chi-square test.
Results: Sixty-seven (25.9%) children initially underwent ETV and 192 (74.1%) underwent VPS placements. The median age was 5 months (range 3 days-168 months). Children who underwent VPS placement rather than ETV had a statistically significant higher risk of postoperative infection (27.0% vs 6.1%; P = 0.001), complications (27.0% vs 12.2%; P = 0.025), and a higher but insignificant operative failure rate at 1 year (45.3% vs 38.8%; P = 0.27). Sex and age were not associated with the occurrence of complications, while VPS and myelomeningocele or encephalocele (MMC/EC) were strongly associated. Complication and infection were significantly and negatively associated with complication-free 1-year survival rate (P < 0.001 each), while gender, age, procedure, and cause of hydrocephalus did not show any association with survival. There was a significant reduction of VPS success rate from 76.9% at 6 months postsurgery to 54.7% at 1 year (P < 0.001), while ETV success rate remained constant during the same period (66.7% and 61.2%, respectively). Mortality frequencies for ETV and VPS insertion were 3 (4.5%) and 9 (4.7%), respectively, for a combined total of 12 deaths (4.6%).
Conclusions: Sex and age were not associated with complications, while VPS and MMC/EC were strongly associated. Children who underwent VP shunt placement rather than ETV had a higher risk of postoperative infection and complications, but there was no difference in operative failure or success rate and mortality rates between the procedures. ETV failure rate was less likely after 6 months.

Keywords
obstructive hydrocephalus; endoscopic third ventriculostomy; ventriculoperitoneal shunt; children; paediatric surgery; neurosurgery; Ethiopia