Dewan Michael C, Lim Jaims, Shannon Chevis N, Wellons John C
Division of Pediatric Neurosurgery, Department of Neurological Surgery, Vanderbilt University Medical School, Nashville, Tennessee.
J Neurosurg Pediatr. 2017 May;19(5):578-584. doi: 10.3171/2017.1.PEDS16536. Epub 2017 Mar 10.
OBJECTIVE Up to one-third of patients with a posterior fossa brain tumor (PFBT) will experience persistent hydrocephalus mandating permanent CSF diversion. The optimal hydrocephalus treatment modality is unknown; the authors sought to compare the durability between endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) therapy in the pediatric population. METHODS The authors conducted a systematic review of articles indexed in PubMed between 1986 and 2016 describing ETV and/or VPS treatment success/failure and time-to-failure rate in patients < 19 years of age with hydrocephalus related to a PFBT. Additionally, the authors conducted a retrospective review of their institutional series of PFBT patients requiring CSF diversion. Patient data from the systematic review and from the institutional series were aggregated and a time-to-failure analysis was performed comparing ETV and VPS using the Kaplan-Meier method. RESULTS A total of 408 patients were included from 12 studies and the authors' institutional series: 284 who underwent ETV and 124 who underwent VPS placement. The analysis included uncontrolled studies with variable method and timing of CSF diversion and were subject to surgeon bias. No significant differences between cohorts were observed with regard to age, sex, tumor grade or histology, metastatic status, or extent of resection. The cumulative failure rate of ETV was 21%, whereas that of VPS surgery was 29% (p = 0.105). The median time to failure was earlier for ETV than for VPS surgery (0.82 [IQR 0.2-1.8] vs 4.7 months [IQR 0.3-5.7], p = 0.03). Initially the ETV survival curve dropped sharply and then stabilized around 2 months. The VPS curve fell gradually but eventually crossed below the ETV curve at 5.7 months. Overall, a significant survival advantage was not demonstrated for one procedure over the other (p = 0.21, log-rank). However, postoperative complications were higher following VPS (31%) than ETV (17%) (p = 0.012). CONCLUSIONS ETV failure occurred sooner than VPS failure, but long-term treatment durability may be higher for ETV. Complications occurred more commonly with VPS than with ETV. Limited clinical conclusions are drawn using this methodology; the optimal treatment for PFBT-related hydrocephalus warrants investigation through prospective studies.
高达三分之一的后颅窝脑肿瘤（PFBT）患者会出现持续性脑积水，需要永久性脑脊液分流。最佳的脑积水治疗方式尚不清楚；作者试图比较小儿人群中内镜下第三脑室造瘘术（ETV）和脑室腹腔分流术（VPS）治疗的持久性。方法：作者对1986年至2016年间在PubMed上索引的文章进行了系统回顾，这些文章描述了19岁以下与PFBT相关的脑积水患者的ETV和/或VPS治疗的成功/失败情况以及失败时间率。此外，作者对其机构系列中需要脑脊液分流的PFBT患者进行了回顾性研究。将系统回顾和机构系列中的患者数据汇总，并使用Kaplan-Meier方法进行ETV和VPS的失败时间分析。结果：12项研究和作者的机构系列共纳入408例患者：284例行ETV，124例行VPS置入术。该分析包括脑脊液分流方法和时机各异的非对照研究，且存在外科医生偏倚。在年龄、性别、肿瘤分级或组织学、转移状态或切除范围方面，各队列之间未观察到显著差异。ETV的累积失败率为21%，而VPS手术的累积失败率为29%（p = 0.105）。ETV的中位失败时间早于VPS手术（0.82 [四分位间距0.2 - 1.8]对4.7个月[四分位间距0.3 - 5.7]，p = 0.03）。最初，ETV生存曲线急剧下降，然后在2个月左右趋于稳定。VPS曲线逐渐下降，但最终在5.7个月时低于ETV曲线。总体而言，一种手术方式相对于另一种手术方式未显示出显著的生存优势（p = 0.21，对数秩检验）。然而，VPS术后并发症（31%）高于ETV（17%）（p = 0.012）。结论：ETV失败比VPS失败更早发生，但ETV的长期治疗持久性可能更高。VPS比ETV更容易发生并发症。使用该方法得出的临床结论有限；PFBT相关脑积水的最佳治疗方法值得通过前瞻性研究进行调查。
