Marano Paul J, Stone Scellig S D, Mugamba John, Ssenyonga Peter, Warf Ezra B, Warf Benjamin C
Harvard Medical School, Boston, Massachusetts;
J Neurosurg Pediatr. 2015 Apr;15(4):399-405. doi: 10.3171/2014.10.PEDS14250. Epub 2015 Feb 6.
The role of reopening an obstructed endoscopic third ventriculostomy (ETV) as treatment for ETV failure is not well defined. The authors studied 215 children with ETV closure who underwent successful repeat ETV to determine the indications, long-term success, and factors affecting outcome.
The authors retrospectively reviewed the CURE Children's Hospital of Uganda database from August 2001 through December 2012, identifying 215 children with failed ETV (with or without prior choroid plexus cauterization [CPC]) who underwent reopening of an obstructed ETV stoma. Treatment survival according to sex, age at first and second operation, time to failure of first operation, etiology of hydrocephalus, prior CPC, and mode of ETV obstruction (simple stoma closure, second membrane, or cisternal obstruction from arachnoid scarring) were assessed using the Kaplan-Meier survival method. Survival differences among groups were assessed using log-rank and Wilcoxon methods and a Cox proportional hazards model.
There were 125 boys and 90 girls with mean and median ages of 229 and 92 days, respectively, at the initial ETV. Mean and median ages at repeat ETV were 347 and 180 days, respectively. Postinfectious hydrocephalus (PIH) was the etiology in 126 patients, and nonpostinfectious hydrocephalus (NPIH) in 89. Overall estimated 7-year success for repeat ETV was 51%. Sex (p = 0.46, log-rank test; p = 0.54, Wilcoxon test), age (< vs > 6 months) at initial or repeat ETV (p = 0.08 initial, p = 0.13 repeat; log-rank test), and type of ETV obstruction (p = 0.61, log-rank test) did not affect outcome for repeat ETV (p values ≥ 0.05, Cox regression). Those with a longer time to failure of initial ETV (> 6 months 91%, 3-6 months 60%, < 3 months 42%, p < 0.01; log-rank test), postinfectious etiology (PIH 58% vs NPIH 42%, p = 0.02; log-rank and Wilcoxon tests) and prior CPC (p = 0.03, log-rank and Wilcoxon tests) had significantly better outcome.
Repeat ETV was successful in half of the patients overall, and was more successful in association with later failures, prior CPC, and PIH. Obstruction of the original ETV by secondary arachnoid scarring was not a negative prognostic factor, and should not discourage the surgeon from proceeding. Repeat ETV may be a more durable solution to failed ETV/CPC than shunt placement in this context, especially for failures at more than 3 months after the initial ETV. Some ETV closures may result from an inflammatory response that is less robust at the second operation.
重新打开受阻的内镜下第三脑室造瘘术（ETV）作为治疗ETV失败的作用尚未明确界定。作者研究了215例ETV闭合的儿童，这些儿童接受了成功的重复ETV手术，以确定其适应证、长期成功率以及影响预后的因素。
作者回顾性分析了乌干达CURE儿童医院2001年8月至2012年12月的数据库，确定了215例ETV失败（有或无先前脉络丛烧灼术[CPC]）且接受了受阻ETV造瘘口重新开放手术的儿童。采用Kaplan-Meier生存法评估根据性别、首次和第二次手术时的年龄、首次手术失败时间、脑积水病因、先前的CPC以及ETV梗阻方式（单纯造瘘口闭合、第二膜或蛛网膜瘢痕导致的脑池梗阻）的治疗生存率。使用对数秩检验、Wilcoxon检验和Cox比例风险模型评估组间生存差异。
初始ETV时，有125名男孩和90名女孩，平均年龄和中位年龄分别为229天和92天。重复ETV时的平均年龄和中位年龄分别为347天和180天。126例患者的病因是感染后脑积水（PIH），89例为非感染后脑积水（NPIH）。重复ETV的总体估计7年成功率为51%。性别（对数秩检验p = 0.46；Wilcoxon检验p = 0.54）、初始或重复ETV时的年龄（< vs > 6个月）（初始时对数秩检验p = 0.08，重复时p = 0.13）以及ETV梗阻类型（对数秩检验p = 0.61）均不影响重复ETV的预后（p值≥0.05，Cox回归）。初始ETV失败时间较长者（> 6个月为91%，3 - 6个月为60%，< 3个月为42%，p < 0.01；对数秩检验）、感染后病因（PIH为58% vs NPIH为42%，p = 0.02；对数秩检验和Wilcoxon检验）以及先前的CPC（p = 0.03，对数秩检验和Wilcoxon检验）预后明显更好。
总体而言，重复ETV在一半的患者中取得成功，并且在与较晚失败、先前CPC以及PIH相关时更成功。继发性蛛网膜瘢痕导致的原ETV梗阻不是不良预后因素，不应阻碍外科医生继续进行手术。在这种情况下，重复ETV可能比分流置入术更持久地解决ETV/CPC失败问题，特别是对于初始ETV后超过3个月的失败情况。一些ETV闭合可能是由炎症反应引起的，而第二次手术时这种炎症反应较弱。
