Shunts vs endoscopic third ventriculostomy in infants: are there different types and/or rates of complications?

Abstract

Our literature review shows that the advantages of ETV in terms of complications are almost all related to two factors: (a) the avoidance of a foreign body implantation and (b) the establishment of a 'physiological' cerebrospinal fluid (CSF) circulation. Both these kinds of achievements are particularly important in infants because of the relative high rate of some intraoperative (i.e. abdominal) and late (secondary craniosynostosis, slit-ventricle syndrome) shunt complications in this specific subset of patients. On the other side, the main factor which is claimed against ETV is the relatively high risk of immediate mortality and neurological complications. Clinical manifestations of neurological structure damage seem to be more frequent in infants, probably due to the more relevant effect of parenchymal and vascular damage in this age group; however, both the immediate mortality and neurological damage risk of ETV procedures should be weighted against the long-term mortality and the late neurological damage which is not infrequently described as a consequence of shunt malfunction and proximal shunt revision procedures. Infections are possible in both ETV and extrathecal CSF procedures, especially in infants. However, the incidence of infective complications is significantly lower in case of ETV (1-5% vs 1-20%). Moreover, different from shunting procedures, infections in children with third ventriculostomy have a more benign course, being generally controlled by antibiotic treatment alone.

Microscopic supraciliary approach for terminal laminotomy for treatment of hydrocephalus: a preliminary report of eight cases

“…(1) the avoidance of foreign body implantation and (2) the establishment of a "physiological" CSF circulation (9).…”

Surgical Treatment for Neonatal Hydrocephalus: Catheter-Based Cerebrospinal Fluid Diversion or Endoscopic Intervention?

“…Furthermore, outflow obstructions at the 4th ventricle foramina and above the level of the foramen magnum have a high success rate for endoscopic approaches [17]. In the three ventricles proximal of the mesencephalic stenosis the attempted, only with moderate success [18].…”

“…Compared to shunt placement, the most obvious advantage is prevention of foreign material implantation into the patient's body, avoiding the pitfalls of shunt obstruction or infection. Early studies showed the complication rates and the frequency of revisions to be lower and the long-term patency rates of CSF stomies to favor endoscopy [17] [43].…”

Global surgery for pediatric hydrocephalus in the developing world: a review of the history, challenges, and future directions

“…43 Endoscopic third ventriculostomy (ETV) offers freedom from hardware-related complications, and it seems especially appropriate in limited resource settings, where it offers a morbidity-reducing and cost-effective solution. 17,69 The addition of choroid plexus cauterization (CPC), with the goal of decreasing CSF production and changing CSF dynamics, was refined over the past decade through pioneering work in sub-Saharan Africa. 52,61,71,72,75 The success of ETV/CPC across all hydrocephalus etiologies ranges from 66% to 81.9% 9,60,61,63,70,71,74,75 and has been shown to be more efficacious than stand-alone ETV in children younger than 2 years.…”