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ORIGINAL ARTICLE
Year : 2009  |  Volume : 4  |  Issue : 2  |  Page : 66-69
 

Outcome of endoscopic third ventriculostomy and Chhabra shunt system in noncommunicating non-tumor childhood hydrocephalus


1 Department of Surgery, Neurological Surgery Unit, Surgery, Lagos State University College of Medicine and Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
2 Department of Anaesthesia, Lagos State University College of Medicine and Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
3 Department of Surgery, Lagos State University College of Medicine and Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria

Date of Web Publication29-Oct-2009

Correspondence Address:
O E Idowu
Neurological Surgery Division, Department of Surgery, Lagos State University College of Medicine, Ikeja, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1817-1745.57323

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   Abstract 

Background : Endoscopic third ventriculostomy (ETV) the main alternative to ventriculoperitoneal shunt (VPS) is just beginning to have a foothold in West Africa. It provides a great opportunity for a hydrocephalic child to be shunt free. The purpose of this paper is to compare outcome following ETV and VPS (using the cheap Chhabra shunt) in children with noncommunicating non-tumoral hydrocephalus in an environment where late presentation is the norm. Materials and Methods : Sixty-three pediatric patients (<6 years) with hydrocephalus who underwent a VPS or ETV at our hospital were included in this study. The study period was of 30 months (January 2006 till June 2008). Clinically successful outcome was defined as no event occurring during or after surgery that resulted in an alternate surgical procedure, or significant post-operative complication that includes death. All complications related to the procedures were also analyzed. Results : The outcome of surgical intervention was not significantly related to the gender, age of the patient at surgery, or type of surgery. The post-operative complication rate was similar in both groups. Conclusions : The clinical outcome of ETV is comparable to that of VPS, with the added benefit of no shunt-related problems; and being a short procedure, patient anesthesia and operation time, hospital stay, and cost are significantly reduced. We consider ETV to be the procedure of choice for the treatment of noncommunicating nontumoral hydrocephalus in the pediatric population.


Keywords: Children, endoscopic third ventriculostomy, hydrocephalus, outcome, ventriculoperitoneal shunt


How to cite this article:
Idowu O E, Falope L O, Idowu A T. Outcome of endoscopic third ventriculostomy and Chhabra shunt system in noncommunicating non-tumor childhood hydrocephalus. J Pediatr Neurosci 2009;4:66-9

How to cite this URL:
Idowu O E, Falope L O, Idowu A T. Outcome of endoscopic third ventriculostomy and Chhabra shunt system in noncommunicating non-tumor childhood hydrocephalus. J Pediatr Neurosci [serial online] 2009 [cited 2017 Dec 16];4:66-9. Available from: http://www.pediatricneurosciences.com/text.asp?2009/4/2/66/57323



   Introduction Top


Hydrocephalus is a common disease in the pediatric neurosurgical population. The advent of various cerebrospinal fluid (CSF) diversionary procedures has reduced significantly the associated neurological deficit and death. [1] Various studies have analyzed the treatment options and outcomes. [2],[3],[4],[5],[6],[7] However, its management remains a continuous challenge.

Conventional ventricular shunt hardwares used in developed countries, as well as the expertise to insert them, are not readily available to most children in the developing world. When available, these shunt hardwares are prohibitively expensive for use in most patients. The cost of a single shunt exceeds a months' income for most families with a hydrocephalic children in our subregion. Shunt cost is a financial obstacle not only to families but also to non-profit organizations that might choose to underwrite the care of affected children. This is one of the factors that promote the use of the relatively inexpensive alternative shunt hardware, the Chhabra shunt (CS), which is manufactured in India. This is readily available in Nigeria for about 90 US dollars.

In sub-Saharan Africa, apart from economic constraints, the management of hydrocephalus is further made difficult by the peculiar prevailing strong negative cultural taboos and religious beliefs. In the face of paucity of Neurosurgeons, these patients and their families also have to travel long distances to access neurosurgical care. [8] All these lead to significant delay prior to presentation and diagnosis with quite a number of children dying from active or passive euthanasia.

When the placement of a shunt is possible in our environment, it can pose a greater risk compared to the developed countries because complications of shunt malfunctions are less likely to be properly addressed in a timely fashion. Shunt complications are also responsible for most of the hydrocephalus-related deaths, excluding those directly dependent on some specific forms of hydrocephalus. [9],[10]

Endoscopic third ventriculostomy (ETV) the alternative to ventriculoperitoneal shunt (VPS) has increased in popularity because they provide the opportunity for the patient to be shunt free. In most centers, ETV has replaced VPS as a treatment for obstructive hydrocephalus. The availability of neuroendoscopy has added another option to the armamentarium of hydrocephalus management in our environment.

The purpose of this paper is to determine the outcome in our series of ETV and compare it with that of VPS in our patient population that usually present late.


   Materials and Methods Top


Sixty-three patients with hydrocephalus who underwent a VPS or ETV at our Hospital were included in this study. The study period was over 30 months (January 2006 till June 2008). Patients' records were analyzed retrospectively (first 15 patients who had VPS) and prospectively to obtain clinical data regarding the characteristics of patients (i.e., age, gender), neurological examination, computerized tomographic (CT) scan characteristics or magnetic resonance imaging (MRI) (noting etiology of hydrocephalus and Evans ratio), type of surgery, and surgical complications (intra-operative and post-operative) including death. In all patients, hydrocephalus was confirmed with a CT scan and/or MR images.

Routine follow-up consisted of clinical examination at 1, 3, and 6 months and yearly thereafter following the procedure. Clinically, successful outcome was defined as no event occurring during or after surgery that resulted in an alternate surgical procedure (shunt obstruction, persistent CSF leak, etc.), or significant post-operative complication (shunt sepsis, intracranial hematoma, death, etc.). All complications related to the procedures were also analyzed. The minimum follow-up was for 4 months (median 1 year; range 2-5 years).

The patients, who had VPS, had the Chhabra shunt placed via an occipital approach. Standards of practice that did not change during the study period included a 5-10 min skin preparation using cetrimide and povidone iodine. Tremendous care is taken to ensure that the skin incision site does not fall immediately over the burr hole sites. The shunt was tunneled subcutaneously between the scalp and abdominal incisions using a shunt passer. Durotomy was done after removing bone, when necessary, and the ventricular catheter was inserted and subsequently connected to the distal shunt catheter. Our ETV technique is as previously described. [11] Patients are discharged after ETV on the third day but on the seventh day after VPS.

The statistical analysis was performed by the two-tailed Student's t-test for paired data and by analysis of variance (ANOVA) where appropriate. The correlation between outcome (successful or unsuccessful) and variables such as gender, age, etiology, and type of surgery was submitted to univariate analysis performed with the chi-square or Fisher's exact test. Data are shown as mean ± standard error of mean (SEM). Significance was set at 5%. Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 14.


   Results Top


There were nine complications noted (post-ETV: four; post- VPS: 5); three of these complications were transient [Table 1].

Hydrocephalus was treated by VPS in 36 patients (males 21, females 15; one male had ETV initially) and ETV (males 16, females 13) in 29 patients (1 female patient initially had VPS). Their ages ranged from 3 weeks to 5 years. The median age for patients receiving Chhabra shunt was 8 months (mean = 15.4 months) and 7 months (mean = 10.4 months) for patients who had ETV. Comparing the ages and ER in the two groups, they were found to be quite similar [Table 2].

Hydrocephalus was due to congenital aqueductal stenosis (VPS: 14, ETV: 13) and Dandy Walker malformation (VPS: 7, ETV: 8) in most patients. Those with Dandy Walker tend to present at an older age compared with the other etiologies. The minimum age at presentation of the Dandy Walker patient was 6 months. The median surgical time for ETV was 20 min and for VPS 40 min.

Following ETV, two patients, both with Dandy Walker malformation, had cerebrospinal fluid leak, one was transient (3 days). The patient with transient CSF leak also had associated superficial surgical site infection, which subsided with daily dressing and oral antibiotics. The second patient had a repeat ETV done which demonstrated a patent ventriculostomy site. He subsequently had VPS to treat the persistent leak. A patient who represented with proximal shunt obstruction after VPS had ETV. This got complicated 3 months later with a huge chronic subdural hematoma [Figure 1]. One patient with myelomeningocoele associated with bilateral foramen of Monro stenosis had to have a VPS following failure of ETV. There was no death associated with ETV.

In the VPS group, there was a case each of transient CSF leak from the burr hole site and superficial surgical site infection in the VPS group. A patient also had proximal shunt obstruction that was treated by ETV. Two patients died from ventriculitis. The two patients had VPS 10 and 16 weeks earlier. By the time they presented, there was severe sepsis [Table 1].

The clinical outcome was not significantly related to the gender (P = 0.37), age of the patient at surgery (P = 0.41), or type of surgery (P = 0.78). The complication rate was similar in both groups (P = 0.99).


   Discussion Top


Hydrocephalus is still a management challenge in modern neurosurgery. Its surgical treatment is generally by CSF diversion with a shunt or ETV. The main advantage of CSF shunts is that they can be used in all types of hydrocephalus. In contrast, utilization ofETV in children has been considered to be limited by the characteristics of the CSF circulation and absorption in the first few months of life and by the prevalence of some specific types of hydrocephalus. A preferential absorption of CSF within the cerebral parenchyma rather than within the peripheral subarachnoid spaces has been propounded [12] and recent experiences appear to indicate that the percentage of success of ETV in infants is similar or only slightly inferior to that of the same procedure to older children. In favor of ETV is the possibility of avoiding all the early and late complications related to VPS insertion, the presence of a foreign body in the body, and the possible infective and mechanical failures of the VPS.

ETV has been successfully used in noncommunicating hydrocephalus. In our sires, the success rate of VPS (91.7%) was superior to that of ETV (89.7%), though not statistically significant (P= 0.78). This is in concordant with previously reported series. [3],[13] Success rate following ETV of 71%, 64%, and 85% was observed in other studies done in infants, compared to 89.7% in our series (youngest infant was 1 month); the success rate in other age group patients varied from 76% to 91.5%. [3],[13],[14],[15]

The causes of temporary CSF leak could be due to the failure of closure of dura, thinned out scalp, and thin cortical mantle in patients with gross hydrocephalus. Incidences of CSF leak after ETV have varied between 2% and 7%. [6],[16] The cause of persistent leak following ETV was probably nonpatent subarachnoid space in the face of a demonstrated open stoma on repeat ETV. After routinely closing the dura during ETV, the rate of CSF has been nil. In our ETV series, infection was not a major problem. Gorayeb et al. noted that 11% of infants developed infection, while 10% and 15% of patients developed infection in other series. [3],[13]

Shunt placement for treatment of hydrocephalus has not met all the desired expectations, despite continual development of new valve designs. It does not matter which shunt is used. A common cause of shunt failure is shunt infection, with a reported incidence of 5%-15%. [17],[18],[19] Staphylococcus aureus and coagulase-negative staphylococcus species, a variety of gram-negative rods, proprionibacterium species, and Enterococcus faecalis are important causes of shunt infection. [20],[21],[22] Staphylococcal species account for approximately 62- 75% of infections of shunt infections. [23] Even when patients receive appropriate care, CSF infections are associated with a substantial risk of morbidity, including seizure disorder, decreased intellectual capacity, and neurological deficit. [23] Shunt infection is associated with an increased risk of seizure disorder, decreased intellectual performance, and a 2-fold increase in the long-term mortality rate. [24],[25] It is potentially fatal especially if the patient presents late. This was the cause of the mortality we had in the VPS group (5.6% mortality rate). This was due to a delay for presentation after the patient developed sepsis. Delayed infection in our environment will most likely be fatal due to late presentation.

All the complications in the ETV patients occurred within 4 weeks including those with a follow-up greater than 6 months and more. But delayed complications including failure can occur and a longer follow up is desirable.

In conclusion, ETV is a simple, effective, and safe treatment option for noncommunicative nontumoral hydrocephalus. Its success rate is comparable to VPS with the added benefit of no shunt-related problems and short hospital stay. Chronic subdural hematoma as seen with VPS can occur. It can also be performed successfully in those who are previously shunted. Being a short procedure, patient anesthesia is significantly reduced. Overall, it is much more economical than a VPS. In the light of this, ETV should be the procedure of choice for the treatment of any noncommunicating notumoural hydrocephalus in our pediatric patient population

 
   References Top

1.Tuli S, Drake J, Lawless J, Wigg M, Lamberti-Pasculli M. Risk factors for repeated cerebrospinal shunt failures in pediatric patients with hydrocephalus. Neurosurg Focus 1999;4:7.  Back to cited text no. 1      
2.O'Brien DF, Hayhurst C, Pizer B, Mallucci CL. Outcomes in patients undergoing single-trajectory endoscopic third ventriculostomy and endoscopic biopsy for midline tumors presenting with obstructive hydrocephalus. J Neurosurg 2006;105:219-26   Back to cited text no. 2      
3.Javadpour M, Mallucci C, Brodbelt A, Golash A, May P. The impact of endoscopic third ventriculostomy on the management of newly diagnosed hydrocephalus in infants. Pediatr Neurosurg 2001;35:131-5.  Back to cited text no. 3      
4.Kestle J, Drake J, Milner R, Sainte-Rose C, Cinalli G, Boop F, et al. Long-term follow-up data from the shunt design trial. Pediatr Neurosurg 2000;33:230-6.  Back to cited text no. 4      
5.Mohanty A, Vasudev MK, Sampath S, Radhesh S, Sastry Kolluri VR. Failed endoscopic third ventriculostomy in children: Management options. Pediatr Neurosurg 2002;37:304-9.  Back to cited text no. 5      
6.Schroeder HW, Niendorf WR, Gaab MR. Complications of endoscopic third ventriculostomy. J Neurosurg 2002;96:1032-40.  Back to cited text no. 6      
7.Tamburrini G, Caldarelli M, Di Rocco C. Diagnosis and management of shunt complications in the treatment of childhood hydrocephalus. Rev Neurosurg 2002;1:3.  Back to cited text no. 7      
8.Warf BC. Comparison of 1-year outcomes for the Chhabra and Codman-Hakim Micro Precision shunt systems in Uganda: A prospective study in 195 children. J Neurosurg (Pediatrics 4) 2005;102:358-62.   Back to cited text no. 8      
9.Bryant MJ, McEniery J, Walker DG, Campbell R, Lister B, Sargent P, et al. Preliminary study of shunt related death in paediatric patients. J Clin Neurosci 2004;11:614-5.  Back to cited text no. 9      
10.Tuli S, Tuli J, Drake J, Spears J. Predictors of death in pediatric patients requiring cerebrospinal fluid shunts. J Neurosurg 2004;100:442-6.  Back to cited text no. 10      
11.Idowu O, Doherty A, Tiamiyu O. Initial experience with endoscopic third ventriculostomy in Nigeria, West Africa. Childs Nerv Syst 2008;24:253-5.  Back to cited text no. 11      
12.Oi S, Shimoda M, Shibata M, Honda Y, Togo K, Shinoda M, et al. Pathophysiology of long-standing overt ventriculomegaly in adults. J Neurosurg 2000;92:933-40.  Back to cited text no. 12      
13.Gorayeb RP, Cavalheiro S, Zymberg ST. Endoscopic third ventriculostomy in children younger than 1 year of age. J Neurosurg 2004;100:427-9.   Back to cited text no. 13      
14.Hopf NJ, Grunert P, Fries G, Resch KD, Perneczky A. Endoscopic third ventriculostomy: Outcome analysis of 100 consecutive procedures. Neurosurgery 1999;44:795-804.  Back to cited text no. 14      
15.Choi JU, Kim DS, Kim SH. Endoscopic surgery for obstructive hydrocephalus. Yonsei Med J 1999;40:600-7.  Back to cited text no. 15      
16.Kwiek SJ, Mandera M, Baowski P, Luszawski J, Duda I, Wolwender A, et al. Endoscopic third ventriculostomy for hydrocephalus: Early and late efficacy in relation to aetiology. Acta Neurochir (Wien) 2003;145:181-4  Back to cited text no. 16      
17.McGirt MJ, Leveque JC, Wellons JC 3 rd , Villavicencio AT, Hopkins JS, Fuchs HE, et al. Cerebrospinal fluid shunt survival and etiology of failures: A seven-year institutional experience. Pediatr Neurosurg 2002;36:248-55.  Back to cited text no. 17      
18.Kontny U, Hofling B, Gutjahr P, Voth D, Schwarz M, Schmitt HJ. CSF shunt infections in children. Infection 1993;21:89-92.  Back to cited text no. 18      
19.Horgan MA, Piatt JH Jr. Shaving of the scalp may increase the rate of infection in CSF shunt surgery. Pediatr Neurosurg 1997;26:180-4.  Back to cited text no. 19      
20.Pople IK, Bayston R, Hayward RD. Infection of cerebrospinal fluid shunts in infants: A study of etiological factors. J Neurosurg 1992;77:29-36.  Back to cited text no. 20      
21.Bayston R, Leung TS, Wilkins BM, Hodges B. Bacteriological examination of removed cerebrospinal fluid shunts. J Clin Pathol 1983;36:987-90.  Back to cited text no. 21      
22.Shapiro S, Boaz J, Kleiman M, Kalsbeck J, Mealey J. Origin of organisms infecting ventricular shunts. Neurosurgery 1988;22:868-72.  Back to cited text no. 22      
23.Fan-Havard P, Nahata MC. Treatment and prevention of infections of cerebrospinal fluid shunts. Clin Pharm 1987;6:866-80.  Back to cited text no. 23      
24.Chadduck W, Adametz J. Incidence of seizures in patients with myelomeningocele: A multifactorial analysis. Surg Neurol 1988;30:281-5.  Back to cited text no. 24      
25.Walters BC, Hoffman HJ, Hendrick EB, Humphreys RP. Cerebrospinal fluid shunt infection: Influences on initial management and subsequent outcome. J Neurosurg 1984;60:1014-21.  Back to cited text no. 25      


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]


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