Ellenbogen Yosef, Brar Karanbir, Yang Kaiyun, Lee Yung, Ajani Olufemi
1Michael G. DeGroote School of Medicine, McMaster University, Hamilton.
2Faculty of Medicine, University of Toronto; and.
J Neurosurg Pediatr. 2020 Jul 3;26(4):371-378. doi: 10.3171/2020.4.PEDS19720. Print 2020 Oct 1.
Pediatric hydrocephalus is a significant contributor to infant morbidity and mortality, particularly in developing countries. The mainstay of treatment has long been shunt placement for CSF diversion, but recent years have seen the rise of alternative procedures such as endoscopic third ventriculostomy (ETV), which provides similar efficacy in selected patients. The addition of choroid plexus cauterization (CPC) to ETV has been proposed to increase efficacy, but the evidence of its utility is limited. This systematic review and meta-analysis aimed to determine the efficacy and safety of ETV+CPC in comparison to ETV alone for the treatment of pediatric all-cause hydrocephalus.
MEDLINE, Embase, Cochrane CENTRAL, ClinicalTrials.gov, and ICRCTN databases were searched from conception through to October 2018 for comparative studies including both ETV+CPC and ETV in a pediatric population. The primary outcome was success rate, defined as no secondary procedure required for CSF diversion; secondary outcomes included time to failure, mortality, and complications. Data were pooled using random-effects models of meta-analysis, and relative risk (RR) was calculated.
Five studies were included for final qualitative and quantitative analysis, including 2 prospective and 3 retrospective studies representing a total of 963 patients. Overall, there was no significant difference in success rates between ETV and ETV+CPC (RR 1.24, 95% CI 0.88-1.75, p = 0.21). However, a subgroup analysis including the 4 studies focusing on African cohorts demonstrated a significant benefit of ETV+CPC (RR 1.38, 95% CI 1.08-1.78, p = 0.01). There were no notable differences in complication rates among studies.
This systematic review and meta-analysis failed to find an overall benefit to the addition of CPC to ETV; however, a subgroup analysis showed efficacy in sub-Saharan African populations. This points to the need for future randomized clinical trials investigating the efficacy of ETV+CPC versus ETV in varied patient populations and geographic locales.
小儿脑积水是导致婴儿发病和死亡的一个重要因素，在发展中国家尤为如此。长期以来，治疗的主要方法一直是进行分流术以引流脑脊液，但近年来，诸如内镜下第三脑室造瘘术（ETV）等替代手术不断兴起，该手术在部分患者中具有相似的疗效。有人提出在ETV基础上加用脉络丛烧灼术（CPC）以提高疗效，但其效用证据有限。本系统评价和荟萃分析旨在确定与单纯ETV相比，ETV+CPC治疗小儿各种病因脑积水的疗效和安全性。
检索MEDLINE、Embase、Cochrane CENTRAL、ClinicalTrials.gov和ICRCTN数据库，检索时间从建库至2018年10月，查找在儿科人群中比较ETV+CPC和ETV的对照研究。主要结局为成功率，定义为无需进行脑脊液分流的二次手术；次要结局包括失败时间、死亡率和并发症。采用随机效应荟萃分析模型汇总数据，并计算相对危险度（RR）。
纳入5项研究进行最终定性和定量分析，包括2项前瞻性研究和3项回顾性研究，共963例患者。总体而言，ETV和ETV+CPC的成功率无显著差异（RR 1.24，95%CI 0.88-1.75，p = 0.21）。然而，一项纳入4项针对非洲队列研究的亚组分析显示ETV+CPC具有显著益处（RR 1.38，95%CI 1.08-1.78，p = 0.01）。各研究的并发症发生率无显著差异。
本系统评价和荟萃分析未能发现ETV加用CPC有总体益处；然而，亚组分析显示其在撒哈拉以南非洲人群中有效。这表明未来需要进行随机临床试验，以研究ETV+CPC与ETV在不同地理区域的疗效。
