Endoscopic third ventriculostomy in children with a fiber optic neuroendoscopy

Wenjun Shen,Tadanori Tomita,Hasan R Syed,Gurpreet Gandhoke,Roxanna Garcia,Tatiana Pundy

doi:10.1007/s00381-017-3679-4

Abstract

ObjectiveEndoscopic third ventriculostomy (ETV) provides a shunt-free treatment for obstructive hydrocephalus children. With rapidly evolving technology, the semi-rigid fiber optic neuroendoscopy shows a potential application in ETV by blunt fenestration. A retrospective analysis of our experience is reviewed.MethodsThe authors review infants and children who underwent ETV using this technique from June 2004 to June 2016 with radiological and clinical follow-up done by a single surgeon. Patients who underwent ETV with channel scope were excluded. Demographic variables and operative reports were collected. Improvement of preoperative symptoms and avoidance of additional cerebrospinal fluid (CSF) diversion procedures were considered a success. The ETV success score (ETVSS) was used to correlate with clinical outcomes.ResultsA total of 79 patients were included with a mean age of 8.3 ± 5.5 years, and 40.5% were female. The mean clinical and radiographic follow-up was 38.6 ± 40.9 months. The overall complication rate was 6.3%, while 73.4% were considered successful. The ETV failure cases received conversion to ventriculoperitoneal shunt or redo of ETV with a median time of 2 months. The mean ETV success score was 74.3 ± 11.8 with positive correlation between success rate (P < 0.05). Kaplan-Meier failure-free survival rates of 30-day, 90-day, 6-month, 1-year, and 2-year were 89.9, 83.5, 78.5, 75.9, and 74.6%. Eight patients required redo ETV, and five of these patients required eventual shunt placements. Approximately 61.9% of failure occurred within 3 months. Patients with post-intraventricular hemorrhage (IVH) /infection, and age younger than 12 months had the poorest outcome (P < 0.05).ConclusionsBlunt dissection of the third ventricle floor under endoscopic vision with the stylet tip of a fiber optic neuroendoscopy is safe and requires less equipment in the pediatric population. This technique is successful with an optimistic long-term outcome except for infants and the post-IVH and infectious subgroups.

Highlights

Endoscopic third ventriculostomy (ETV) is the most commonly performed endoscopic procedure in neurosurgery for obstructive hydrocephalus [1]
We present our results with the flexible neuroendoscope and blunt dissection technique for ETV in 85 patients
Success of ETV was determined on the basis of the last follow-up: the improvement of preoperative symptoms with or without reduction of ventricular size on radiological examination was considered a success, while the need for insertion of a VP shunt/redo of ETV or radiographic progression of hydrocephalus were considered a failure

Summary

Introduction

Endoscopic third ventriculostomy (ETV) is the most commonly performed endoscopic procedure in neurosurgery for obstructive hydrocephalus [1] It provides a more physiological restoration of cerebrospinal fluid (CSF) between ventricular. Rigid lens scopes with working channel provide the advantage of better visualization of anatomical structures, but are burdened by larger instrument size at the time of ventriculostomy. These rigid lens scopes with working channel are placed into the ventricle through a peel away catheter or trocar of 12.5 Fr. to 19 Fr. In all of the abovementioned techniques, a working channel is required to allow for the use of the instrumentation These techniques need larger burr hole for instrumentation, and leave larger needle tract. The use of instrumentation under endoscopic guidance claims to be safer because of the direct visualization of the instruments, vascular damage can occur [2, 6]

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Results

Conclusion