Texakalidis Pavlos, Tora Muhibullah S, Wetzel Jeremy S, Chern Joshua J
Department of Neurosurgery, Emory University School of Medicine, Suite 6204, 101 Woodruff Circle, Atlanta, GA, 30322, USA.
Children's Healthcare of Atlanta, Department of Neurosurgery, Egleston Hospital, Atlanta, GA, USA.
Childs Nerv Syst. 2019 Aug;35(8):1283-1293. doi: 10.1007/s00381-019-04203-2. Epub 2019 May 25.
Optimized management of pediatric hydrocephalus remains the subject of debate. Ventriculoperitoneal shunt is largely considered the standard of care. However, the advancements and introduction of new cerebrospinal fluid (CSF) diversion approaches including the use of endoscopic third ventriculostomy (ETV) offer appealing alternatives that have been reported in numerous observational series.
To evaluate the comparative safety and efficacy of shunting and ETV in pediatric hydrocephalus cases.
This systematic literature review was performed according to the PRISMA guidelines. Eligible studies were identified through a search of PubMed (Medline) and Cochrane until October 2018. A random effects model meta-analysis was conducted and the I-square was used to assess heterogeneity. The ROBINS-1 tool and Cochrane tool were used to assess risk of bias in the observational and randomized studies, respectively.
Fourteen studies including 8419 patients were identified. Patients in the ETV group had a statistically significant lower risk of infection compared to shunt (OR: 0.19; 95% CI: 0.07-0.53; I: 0%). All-cause mortality (OR: 0.77; 95% CI: 0.35-1.68; I: 0%), post-operative CSF leak (OR: 1.53; 95% CI: 0.37-6.31; I: 0%), and reoperation rates were similar between the two study groups (OR: 0.72; 95% CI: 0.39-1.32; I: 93.5%). Subgroup analyses for re-operation demonstrated that ETV in Africa (OR: 0.13; 95% CI: 0.03-0.48; I: 0%) and Europe (OR: 0.39; 95% CI: 0.30-0.52; I:1.4%) was associated with significantly lower odds of re-operation compared to shunt, but not in USA/Canada (OR: 1.49; 95% CI: 0.85-2.63; I:86.2%). Meta-regression analyses of age and duration of follow-up did not affect re-operation rates.
ETV was associated with a statistically significant lower risk of procedure-related infection compared to shunt. All-cause mortality, CSF leak, and re-operation rates were similar between the study groups. Subgroup analysis based on the geographic region showed that ETV is associated with statistically significant lower odds for re-operation in Europe and Africa, but not in USA/Canada. Future RCTs are needed to validate the results of this study and elucidate the cause of this heterogeneity.
小儿脑积水的优化管理仍是一个有争议的话题。脑室腹腔分流术在很大程度上被视为治疗的标准方法。然而，包括使用内镜下第三脑室造瘘术（ETV）在内的新的脑脊液（CSF）分流方法的进展和引入提供了有吸引力的替代方案，这些方案已在众多观察性系列研究中有所报道。
评估分流术和ETV在小儿脑积水病例中的相对安全性和有效性。
本系统文献综述按照PRISMA指南进行。通过检索PubMed（Medline）和Cochrane数据库，直至2018年10月，确定符合条件的研究。进行随机效应模型的荟萃分析，并使用I²来评估异质性。分别使用ROBINS-1工具和Cochrane工具评估观察性研究和随机对照研究中的偏倚风险。
共纳入14项研究，涉及8419例患者。与分流术相比，ETV组患者感染风险在统计学上显著降低（OR：0.19；95%CI：0.07 - 0.53；I²：0%）。两组的全因死亡率（OR：0.77；95%CI：0.35 - 1.68；I²：0%）、术后脑脊液漏（OR：1.53；95%CI：0.37 - 6.31；I²：0%）和再次手术率相似（OR：0.72；95%CI：0.39 - 1.32；I²：93.5%）。再次手术的亚组分析表明，在非洲（OR：0.13；95%CI：0.03 - 0.48；I²：0%）和欧洲（OR：0.39；95%CI：0.30 - 0.52；I²：1.4%），与分流术相比，ETV再次手术的几率显著降低，但在美国/加拿大并非如此（OR：1.49；95%CI：0.85 - 2.63；I²：86.2%）。年龄和随访时间的meta回归分析对再次手术率没有影响。
与分流术相比，ETV与手术相关感染风险在统计学上显著降低相关。两组的全因死亡率、脑脊液漏和再次手术率相似。基于地理区域的亚组分析表明，在欧洲和非洲，ETV与再次手术几率在统计学上显著降低相关，但在美国/加拿大并非如此。未来需要进行随机对照试验来验证本研究结果并阐明这种异质性的原因。
