Clinical outcomes in pediatric hydrocephalus patients treated with endoscopic third ventriculostomy and choroid plexus cauterization: a systematic review and meta-analysis

Abstract

OBJECTIVE Endoscopic third ventriculostomy and choroid plexus cauterization (ETV+CPC) is a novel procedure for infant hydrocephalus that was developed in sub-Saharan Africa to mitigate the risks associated with permanent implanted shunt hardware. This study summarizes the hydrocephalus literature surrounding the ETV+CPC intraoperative abandonment rate, perioperative mortality rate, cerebrospinal fluid infection rate, and failure rate. METHODS This systematic review and meta-analysis followed a prespecified protocol and abides by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search strategy using MEDLINE, EMBASE, PsychInfo, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus, and Web of Science was conducted from database inception to October 2019. Studies included controlled trials, cohort studies, and case-control studies of patients with hydrocephalus younger than 18 years of age treated with ETV+CPC. Pooled estimates were calculated using DerSimonian and Laird random-effects modeling, and the significance of subgroup analyses was tested using meta-regression. The quality of the pooled outcomes was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS After screening and reviewing 12,321 citations, the authors found 16 articles that met the inclusion criteria. The pooled estimate for the ETV+CPC failure rate was 0.44 (95% CI 0.37–0.51). Subgroup analysis by geographic income level showed statistical significance (p < 0.01), with lower-middle-income countries having a lower failure rate (0.32, 95% CI 0.28–0.36) than high-income countries (0.53, 95% CI 0.47–0.60). No difference in failure rate was found between hydrocephalus etiology (p = 0.09) or definition of failure (p = 0.24). The pooled estimate for perioperative mortality rate (n = 7 studies) was 0.001 (95% CI 0.00–0.004), the intraoperative abandonment rate (n = 5 studies) was 0.04 (95% CI 0.01–0.08), and the postoperative CSF infection rate (n = 5 studies) was 0.0004 (95% CI 0.00–0.003). All pooled outcomes were found to be low-quality evidence. CONCLUSIONS This systematic review and meta-analysis provides the most comprehensive pooled estimate for the ETV+CPC failure rate to date and demonstrates, for the first time, a statistically significant difference in failure rate by geographic income level. It also provides the first reported pooled estimates for the risk of ETV+CPC perioperative mortality, intraoperative abandonment, and CSF infection. The low quality of this evidence highlights the need for further research to improve the understanding of these critical clinical outcomes and their relevant explanatory variables and thus to appreciate which patients may benefit most from an ETV+CPC. Systematic review registration no.: CRD42020160149 (https://www.crd.york.ac.uk/prospero/)

Neuroendoscopic Techniques in the Treatment of Hydrocephalus

“…This complication is one of the more serious complications of ETV. Fukuhara et al identified central nervous system infection as an independent risk factor for ETV failure [28,58,59]. Despite the occurrence of infection, the prognosis is significantly better than that of patients with infection after shunt surgery, and in most cases, the infection can be controlled with targeted medical therapy [28,29,59].…”

Management and outcomes of myelomeningocele-associated hydrocephalus in low-income and middle-income countries: a systematic review and meta-analysis protocol

“…As such, the practice and outcomes of these techniques in LMICs warrant systematic review and meta-analysis. Previous work has examined the management and outcomes of hydrocephalus in HICs and LMICs13 14 although in unstratified medical subject headings age groups and aetiologies.…”

Management and outcomes of myelomeningocele-associated hydrocephalus in low- and middle-income countries: a systematic review and meta-analysis protocol

“…As such, the practice and outcomes of these techniques in LMICs warrant systematic review and meta-analysis. Previous work has examined the management and outcomes of hydrocephalus in HICs and LMICs (13, 14) albeit in unstratified medical subject headings (MeSH) age groups and aetiologies.…”