Endoscopic third ventriculostomy versus ventriculoperitoneal shunt insertion for the management of pediatric hydrocephalus in African centers – A systematic review and meta-analysis
- Department of Neurosurgery, Surgery Interest Group of Africa, Abijo, Lagos, Nigeria.
- Department of Research, Surgery Interest Group of Africa, Abijo, Lagos, Nigeria.
Damilola Alexander Jesuyajolu Department of Neurosurgery, Surgery Interest Group of Africa, Abijo, Lagos, Nigeria.
DOI:10.25259/SNI_747_2022Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Damilola Alexander Jesuyajolu1, Abdulahi Zubair1, Armstrong Kpachi Nicholas2, Terngu Moti1, Osamagie Ehi Osarobomwen1, Israel Anyahaebizi1, Charles Okeke1, Samuel Olawale Davis1. Endoscopic third ventriculostomy versus ventriculoperitoneal shunt insertion for the management of pediatric hydrocephalus in African centers – A systematic review and meta-analysis. 14-Oct-2022;13:467
How to cite this URL: Damilola Alexander Jesuyajolu1, Abdulahi Zubair1, Armstrong Kpachi Nicholas2, Terngu Moti1, Osamagie Ehi Osarobomwen1, Israel Anyahaebizi1, Charles Okeke1, Samuel Olawale Davis1. Endoscopic third ventriculostomy versus ventriculoperitoneal shunt insertion for the management of pediatric hydrocephalus in African centers – A systematic review and meta-analysis. 14-Oct-2022;13:467. Available from: https://surgicalneurologyint.com/surgicalint-articles/11932/
Background: Ventriculoperitoneal shunt (VPS) insertion and endoscopic third ventriculostomy (ETV) are common surgical procedures used to treat pediatric hydrocephalus. There have been numerous studies comparing ETV and VPS, but none from an African perspective. In this study, we sought to compare outcomes from African neurosurgical centers and review the associated complications.
Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses were used in conducting this study. PubMed, Google Scholar, and African Journal Online were searched. Data on treatment successes and failures for ETV and VPS were pooled together and analyzed with a binary meta-analysis. A clinically successful outcome was defined as no significant event or complication occurring after surgery and during follow-up (e.g., infection, failure, CSF leak, malfunction, and mortality). Seven studies fully satisfied the eligibility criteria and were used in this review.
Results: There was no statistically significant difference between the outcomes of ETV and VPS (OR- 0.27; 95% CI −0.39–0.94, P = 0.42). After reviewing the rates of complications of ETV and VPS from the identified studies, four were recurrent. The infection rates of ETV versus VPS were 0.02% versus 0.1%. The mortality rates were 0.01% versus 0.05%. The reoperation rates were 0.05% versus 0.3%, while the rates of ETV failure and shunt malfunction were 0.2% versus 0.2%.
Conclusion: This study concludes that there is no significant difference between the outcomes of ETV and VPS insertion.
Keywords: Endoscopy, Infection, Malfunction, Ventriculostomy
There are not many neurosurgeons in Africa; it has the second highest neurosurgical workforce deficit reported globally.[
Hydrocephalus is an enlargement of the ventricles resulting from the inadequate passage or absorption of cerebrospinal fluid (CSF).[
Ventriculoperitoneal shunt (VPS) insertion and endoscopic third ventriculostomy (ETV) are common surgical procedures used to treat pediatric hydrocephalus. In emergency cases, however, external ventricular drainage can be used as a lifesaving procedure while a definitive treatment plan is arranged.[
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA guidelines) were used in conducting this study. A guide that included the review question, search strategy, eligibility criteria, and risk of bias assessment was established before the commencement of this review. Papers that compared ETV with VPS in the management of pediatric hydrocephalus in African surgical centers were included in this study. Studies that were not in the English language, from non-African countries and studies that did not compare ETV with VPS systems were excluded from the study. Reviews, meta-analyses, abstracts, conference presentations, commentaries, case reports, and letters to the editors were excluded from the study. Studies that reported data on ETV or VPS alone were excluded from the study. Studies that failed to report disaggregated data on ETV and VPS were also excluded from the study. To identify all eligible articles, a search was conducted from inception to August 2022. PubMed, Google Scholar, and African Journal Online were searched. During the screening process, the references of similar review articles were manually searched for studies that may have been missed by our initial search. The search strategy was jointly devised by the authors and is summarized in
To ensure consistency, two authors screened each article twice. Where conflicts existed, they were resolved by the third author. The search was broad and it aimed to identify all papers with information on ETV and VPS. The titles and abstracts were screened first, followed by a full-text screening. We extracted the following data: the author, publication year, country, study design, study arms, age, gender, cause of the hydrocephalus, period of follow-up, CSF leak, infection, mortality, reoperation, shunt malfunction, failure of ETV, and successful outcomes. For this meta-analysis, a clinically successful outcome was defined as no significant event or complication occurring after surgery and during follow-up (e.g., infection, failure, CSF leak, malfunction, and mortality). Failure was defined as the occurrence of a postoperative significant event (e.g., infection, failure, CSF leak, malfunction, shunt erosion, and mortality). The primary outcome was defined as the success or failure of the procedure. Raw data on clinically successful outcomes for ETV and VPS were pooled together and analyzed with a binary meta-analysis. All studies were first analyzed together, and then, all observational studies (6/7) were analyzed together. Subgroup analysis based on the risk of bias was also carried out. Tests of heterogeneity were also carried out with the Egger’s test and a funnel plot. The meta-analysis feature of IBM SPSS versus 28.0.1 was used. The analysis was carried out with inverse variance, and a random effects meta-analysis was used to account for the heterogeneity of studies. The level of significance was set at 0.05 with a 95% confidence interval.
Seven hundred and fifty papers were excluded after the titles and abstracts were screened, and 16 more studies were excluded after reading and assessing the full texts. Nine studies were excluded because they did not report the outcome of interest, two studies were excluded because they did not report disaggregated data on ETV and VPS, one study was excluded because the study was conducted in a non-African country, while four studies were excluded because the focus of their paper was on ETV alone. Seven articles fully satisfied the eligibility criteria and were used in this review and meta-analysis.[
The observational studies used in this review were evaluated with the Newcastle Ottawa Scale evaluation to determine the risk of bias. The studies are shown in
Five studies were of high quality while one study had a high risk. There was one RCT among the selected studies. For that study, we used the Cochrane tool. There was no statistically significant difference between the outcomes of ETV and VPS (OR- 0.27; 95% CI −0.39–0.94) P = 0.42) after analysis of the seven studies. As there were six observational studies and one RCT, we decided to exclude the RCT from the second analysis and see if there would be any substantial difference. After analysis, there was still no statistically significant difference (OR- 0.47; 95% CI −0.25–1.19) P = 0.20); the forest plot can be seen in the appendix as
We went further to do a subgroup analysis by including only high-quality observational studies (scores of 7–9 on the NOS scale – low risk of bias studies), and still, there was still no significant difference (OR−0.47; 95% CI −0.29 −1.24, P = 0.23). The forest plot can be seen in the appendix as
Our study included 580 African children who had procedures done in African centers. In this study, we sought to compare the successful outcomes between ETV and VPS insertion in the management of pediatric hydrocephalus. Although this subject has been widely published in the literature, we intended to compare these two from an African perspective while paying attention to the findings and experiences from neurosurgical centers across the continent. Interestingly, we found no statistically significant difference in the outcomes. Studies conducted in some African centers also found no significant difference in outcomes between ETV–CPC and ventriculoperitoneal shunting.[
In our study, the failure rates were consistently lower with ETV than they were with VPS. This finding is consistent with other studies in the published literature.[
The amount of existing research on this subject is exhaustive and many systematic reviews and meta-analyses have provided evidence on this topic. This study, however, is the first to look exclusively at the African literature, to generate evidence that may guide local practices. Regardless, more studies may need to be done on a geographic basis to generate locally relevant guidelines and practices that will improve patient care. Despite the comprehensive nature of this study, we had some limitations. The small sample size and the few African studies covered in this review make generalization difficult. Because we included articles only in the English language and searched three databases, we may have missed potentially relevant papers from nonanglophone countries. The heterogeneity of the studies in terms of how the complications were defined makes it hard to generalize the complications across the board.
This study concludes that there is no significant difference between the outcomes of ETV and VP shunt insertion. Considering the findings of this study, it would depend on other factors such as cost, accessibility, the skill, experience, and preference of the operating neurosurgeon when determining a surgical modality for the management of pediatric hydrocephalus. This paper contributes immensely to the African pediatric neurosurgical front and adds more evidence to local practices when managing pediatric hydrocephalus.
Data are available on reasonable request.
Ethical approval was not needed for this paper.
Patient’s consent not required as there are no patients in this study.
Care for All Foundation Research Grant (CFA 3262-22).
There are no conflicts of interest.
We would like to acknowledge the Care for All foundation for which D.J won a research grant award (CFA 3262-22).
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