Elsevier

World Neurosurgery

Volume 84, Issue 3, September 2015, Pages 677-680.e1
World Neurosurgery

Original Article
The Impact of Endoscopic Third Ventriculostomy on Shunt Revision Rate: A 14-Year Experience at a Single Institution

https://doi.org/10.1016/j.wneu.2015.04.037Get rights and content

Background

Shunt-related procedures in the treatment of hydrocephalus are often associated with malfunction and revision resulting in significant patient morbidity and financial impact on the health care system. The increased utilization of endoscopic third ventriculostomy (ETV) as an alternative treatment paradigm for obstructive hydrocephalus carries the theoretical expectation of concomitant decreased numbers of shunt procedures. The objective of the present study was to determine the impact of ETV on shunt-related procedures within a 14-year interval (1998–2011), during which ETV has gained wider acceptance and greater utilization.

Methods

This retrospective chart review describes the annual rate of pediatric patients who underwent either ETV or shunt-related procedures at New York Presbyterian Hospital Weill-Cornell Medical Center. Statistical analyses were done to analyze possible correlation between relative rates of these cases.

Results

During the 14-year study period, 954 procedures were performed for the treatment of hydrocephalus (159 ETVs and 795 shunt-related procedures). Of the shunts, 356 were initial insertions and 439 were revisions. The number of ETVs increased from 8 procedures in 1998/1999 to 34 in 2010/2011, whereas the total number of annual shunt-related procedures decreased from 146 to 99. The relative ratios of ETVs and shunt-related procedures to the total number of cases demonstrate an inverse relationship over time (Spearman correlation coefficient rs = −1.0; P = 0.0004).

Conclusions

Based on prior cost-effectiveness analyses, the observed trend of the inverse correlation between ETVs and shunt-related procedures may contribute to financial savings and improvement in patient outcomes. Further study is required to define the impact on morbidity and associated success rates.

Introduction

Shunt-related procedures in the treatment of hydrocephalus have historically accounted for nearly 50% of pediatric neurosurgical procedures (7). Shunt malfunctions and revisions result in significant morbidity for patients as well as financial impact on the health care system 1, 11. The increased utilization of endoscopic third ventriculostomy (ETV) as an alternative treatment paradigm for obstructive hydrocephalus carries the theoretical expectation of a concomitant decrease in shunt-related procedures. During the past 2 decades, shunt-free success rates for certain forms of hydrocephalus have increased from 50% to >80% 4, 9, 12, 13, 15. ETV has therefore emerged as the preferred treatment for noncommunicating hydrocephalus in select patients 16, 17, 19. However, the impact of ETV on the overall case distribution, as it relates to shunt-related procedures, has not yet been formally and specifically evaluated.

In an effort to better understand the impact of increasing ETV utilization on shunt-related procedures, we determined the annual rate of each procedure during a 14-year period (1998–2011), during which ETV has gained wider acceptance and greater utilization. All procedures for ETV, shunt insertion, and shunt revision were included. Although not directly calculated, these findings suggest an important decrease in the economic burden of shunt-related procedures and on-the-call burden of the pediatric neurosurgical workforce.

Section snippets

Methods

During a 14-year interval from 1998 to 2011, pediatric patients who underwent either ETV or shunt-related procedures at New York Presbyterian Hospital Weill-Cornell Medical Center were included in a retrospective chart review.

The review was limited to patients between 0 and 18 years of age who had undergone ETV, ETV revision, ventriculoperitoneal shunt, ventriculopleural shunt, ventriculoatrial shunt insertion, shunt removal, and shunt revision. All surgeries in this patient cohort were

Results

During the 14-year study period, 954 procedures were performed for the treatment of hydrocephalus. Of these, there were 159 ETVs and 795 shunt-related procedures. Of the shunts, 356 were initial insertions and 439 were revisions. The number of ETVs increased over time from 8 procedures in 1998/1999, when it was first introduced at this institution by M.M.S., to 34 in 2010/2011 (Table 1). Concomitantly, the total number of annual shunt-related procedures decreased from 146 to 99 during the same

Discussion

Shunt-related procedures in the treatment of hydrocephalus comprise a large percentage of cases performed by pediatric neurosurgeons (7). The susceptibility of shunts to malfunction and necessary revision contributes to significant morbidity for the patient. The use of ETV has, therefore, emerged as a safe and effective alternative to shunt placement and revision in specific patient populations 2, 5, 6. In an effort to better understand the evolution of ETV and its impact on shunt-related

Conclusions

Although other factors in addition to increased utilization of ETV may affect our case numbers, a clear shift toward higher relative rates of ETV versus shunt revisions is demonstrated. Based on prior cost-effectiveness analyses, the decrease in cumulative rate of shunt-related procedures is likely to contribute to cost savings and improvement in patient outcomes. Further study is required to define the impact on patient morbidity of the relative rates and associated success rates and long-term

References (19)

  • A.L. Albright et al.

    Outcome data and analysis in pediatric neurosurgery

    Neurosurgery

    (1999)
  • J. Baldauf et al.

    Value of endoscopic third ventriculostomy instead of shunt revision

    Min Invas Neurosurg

    (2010)
  • P. Barlow et al.

    An economic argument in favour of endoscopic third ventriculostomy as a treatment for obstructive hydrocephalus

    Min Invas Neurosurg

    (1997)
  • J. Boschert et al.

    Endoscopic third ventriculostomy for shunt dysfunction in occlusive hydrocephalus: long-term follow up and review

    J Neurosurg

    (2003)
  • N. Buxton et al.

    Endoscopic third ventriculostomy: outcome analysis of 100 consecutive procedures

    Neurosurgery

    (1999)
  • G. Cinalli et al.

    The role of endoscopic third ventriculostomy in the management of shunt malfunction

    Neurosurgery

    (1998)
  • D. Cochrane et al.

    Model for the cost analysis of shunted hydrocephalic children

    Pediat Neurosurg

    (1995)
  • D.D. Cochrane et al.

    Ventricular shunting for hydrocephalus in children: patients, procedures, surgeons and institutions in English Canada, 1989-2001

    Eur J Pediat Surg

    (2002)
  • H. Feng et al.

    Endoscopic third ventriculostomy in the management of obstructive hydrocephalus: an outcome analysis

    J Neurosurg

    (2004)
There are more references available in the full text version of this article.

Cited by (4)

  • Endoscopic Third Ventriculostomy in Cases of Ventriculoperitoneal Shunt Malfunction: Does Shunt Duration Play a Role?

    2019, World Neurosurgery
    Citation Excerpt :

    Shunt failure during a patient's life is a common event.1,2 Endoscopic third ventriculostomy (ETV) is theoretically less invasive than shunt revision and has progressively gained a consensus for managing ventriculoperitoneal shunt (VPS) malfunctions.1,3-6 ETV performed after a VPS failure is commonly termed secondary ETV.1,2,5,7,8

Supplementary digital content available online.

Conflict of interest statement: Mark M. Souweidane serves as a paid consultant and member of the NeuroEndoscopy Advisory Board for Aesculap. The other authors have no known conflicts of interest or significant financial support associated with this publication to declare.

View full text