Surgical resource utilization after initial treatment of infant hydrocephalus: comparing ETV, early experience of ETV with choroid plexus cauterization, and shunt insertion in the Hydrocephalus Clinical Research Network

Jonathan Pindrik; Jay Riva-Cambrin; Abhaya V Kulkarni; Jessica S Alvey; Ron W Reeder; Ian F Pollack; John C Wellons; Eric M Jackson; Curtis J Rozzelle; William E Whitehead; David D Limbrick; Robert P Naftel; Chevis Shannon; Patrick J McDonald; Mandeep S Tamber; Todd C Hankinson; Jason S Hauptman; Tamara D Simon; Mark D Krieger; Richard Holubkov; John R W Kestle; Hydrocephalus Clinical Research Network

doi:10.3171/2020.4.PEDS19632

Surgical resource utilization after initial treatment of infant hydrocephalus: comparing ETV, early experience of ETV with choroid plexus cauterization, and shunt insertion in the Hydrocephalus Clinical Research Network

J Neurosurg Pediatr. 2020 Jun 19;26(4):337-345. doi: 10.3171/2020.4.PEDS19632.

Authors

Jonathan Pindrik¹, Jay Riva-Cambrin², Abhaya V Kulkarni³, Jessica S Alvey⁴, Ron W Reeder⁴, Ian F Pollack⁵, John C Wellons⁶, Eric M Jackson⁷, Curtis J Rozzelle⁸, William E Whitehead⁹, David D Limbrick¹⁰, Robert P Naftel⁶, Chevis Shannon⁶, Patrick J McDonald¹¹, Mandeep S Tamber¹¹, Todd C Hankinson¹², Jason S Hauptman¹³, Tamara D Simon¹³, Mark D Krieger¹⁴, Richard Holubkov¹⁵, John R W Kestle⁴; Hydrocephalus Clinical Research Network

Affiliations

¹ 1Division of Pediatric Neurosurgery, Department of Neurological Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio.
² 2Section of Pediatric Neurosurgery, Division of Neurosurgery, Alberta Children's Hospital, University of Calgary, Alberta, Canada.
³ 3Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada.
⁴ 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah.
⁵ 5Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
⁶ 6Division of Pediatric Neurosurgery, Department of Neurosurgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee.
⁷ 7Department of Neurosurgery, Johns Hopkins Children's Center, Johns Hopkins University School of Medicine, Baltimore, Maryland.
⁸ 8Division of Pediatric Neurosurgery, Department of Neurosurgery, Children's of Alabama, University of Alabama School of Medicine, Birmingham, Alabama.
⁹ 9Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.
¹⁰ 10Division of Pediatric Neurosurgery, Departments of Neurological Surgery and Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, Missouri.
¹¹ 11Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada.
¹² 12Departments of Neurosurgery and Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado.
¹³ 13Division of Pediatric Neurosurgery, Department of Neurosurgery, Seattle Children's Hospital, University of Washington, Seattle, Washington.
¹⁴ 14Department of Surgery, Children's Hospital of Los Angeles, California; and.
¹⁵ 15Hydrocephalus Clinical Research Network Data Coordinating Center, Department of Pediatrics, University of Utah, Salt Lake City, Utah.

PMID: 32559741
DOI: 10.3171/2020.4.PEDS19632

Abstract

Objective: Few studies have addressed surgical resource utilization-surgical revisions and associated hospital admission days-following shunt insertion or endoscopic third ventriculostomy (ETV) with or without choroid plexus cauterization (CPC) for CSF diversion in hydrocephalus. Study members of the Hydrocephalus Clinical Research Network (HCRN) investigated differences in surgical resource utilization between CSF diversion strategies in hydrocephalus in infants.

Methods: Patients up to corrected age 24 months undergoing initial definitive treatment of hydrocephalus were reviewed from the prospectively maintained HCRN Core Data Project (Hydrocephalus Registry). Postoperative courses (at 1, 3, and 5 years) were studied for hydrocephalus-related surgeries (primary outcome) and hospital admission days related to surgical revision (secondary outcome). Data were summarized using descriptive statistics and compared using negative binomial regression, controlling for age, hydrocephalus etiology, and HCRN center. The study population was organized into 3 groups (ETV alone, ETV with CPC, and CSF shunt insertion) during the 1st postoperative year and 2 groups (ETV alone and CSF shunt insertion) during subsequent years due to limited long-term follow-up data.

Results: Among 1090 patients, the majority underwent CSF shunt insertion (CSF shunt, 83.5%; ETV with CPC, 10.0%; and ETV alone, 6.5%). Patients undergoing ETV with CPC had a higher mean number of revision surgeries (1.2 ± 1.6) than those undergoing ETV alone (0.6 ± 0.8) or CSF shunt insertion (0.7 ± 1.3) over the 1st year after surgery (p = 0.005). At long-term follow-up, patients undergoing ETV alone experienced a nonsignificant lower mean number of revision surgeries (0.7 ± 0.9 at 3 years and 0.8 ± 1.3 at 5 years) than those undergoing CSF shunt insertion (1.1 ± 1.9 at 3 years and 1.4 ± 2.6 at 5 years) and exhibited a lower mean number of hospital admission days related to revision surgery (3.8 ± 10.3 vs 9.9 ± 27.0, p = 0.042).

Conclusions: Among initial treatment strategies for hydrocephalus, ETV with CPC yielded a higher surgical revision rate within 1 year after surgery. Patients undergoing ETV alone exhibited a nonsignificant lower mean number of surgical revisions than CSF shunt insertion at 3 and 5 years postoperatively. Additionally, the ETV-alone cohort demonstrated significantly fewer hospital admission days related to surgical management of hydrocephalus within 3 years after surgery. These findings suggest a time-dependent benefit of ETV over CSF shunt insertion regarding surgical resource utilization.

Keywords: HCRN; Hydrocephalus Clinical Research Network; cerebrospinal fluid; choroid plexus cauterization; endoscopic third ventriculostomy; resource utilization; shunt.