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首页> 外文期刊>Journal of neurosurgery. Pediatrics. >Shunt survival after failed endoscopic treatment of hydrocephalus: Clinical article
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Shunt survival after failed endoscopic treatment of hydrocephalus: Clinical article

机译：内镜治疗脑积水失败后分流存活：临床文章

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Object. It is not known whether previous endoscopic third ventriculostomy (ETV) affects the risk of shunt failure. Different epochs of hydrocephalus treatment at the CURE Children's Hospital of Uganda (CCHU) - initially placing CSF shunts in all patients, then attempting ETV in all patients, and finally attempting ETV combined with choroid plexus cauterization (CPC) in all patients - provided the opportunity to assess whether prior endoscopic surgery affected shunt survival. Methods. With appropriate institutional approvals, the authors reviewed the CCHU clinical database to identify 2329 patients treated for hydrocephalus from December 2000 to May 2007. Initial ventriculoperitoneal (VP) shunt placement was performed in 900 patients under one of three circumstances: 1) primary nonselective VP shunt placement with no endoscopy (255 patients); 2) VP shunt placement at the time of abandoned ETV attempt (with or without CPC) (370 patients); 3) VP shunt placement subsequent to a completed but failed ETV (with or without CPC) (275 patients). We analyzed time to shunt failure using the Kaplan-Meier method to construct survival curves, Cox proportional hazards regression modeling, and risk-adjusted analyses to account for possible confounding differences among these groups. Results. Shunt failure occurred in 299 patients, and the mean duration of follow-up for the remaining 601 was 28.7 months (median 18.8, interquartile range 4.1-46.3). There was no significant difference in operative mortality (p = 0.07 by log-rank and p = 0.14 by Cox regression adjusted for age and hydrocephalus etiology) or shunt infection (p = 0.94, log-rank) among the 3 groups. There was no difference in shunt survival between patients treated with primary shunt placement and those who underwent shunt placement at the time of an abandoned ETV attempt (adjusted hazard ratio [HR] 1.14, 95% CI 0.86-1.51, p = 0.35). Those who underwent shunt placement after a completed but failed ETV (with or without CPC) had a lower risk of shunt failure (p = 0.008, log-rank), with a hazard ratio (adjusted for age at shunting and etiology) of 0.72 (95% CI 0.53-0.98), p = 0.03, compared with those who underwent primary shunt placement without endoscopy; but this was observed only in patients with postinfectious hydrocephalus (PIH) (adjusted HR 0.55, 95% CI 0.36-0.85, p = 0.007), and no effect was apparent for hydrocephalus of noninfectious etiologies (adjusted HR 0.98, 95% CI 0.64-1.50, p = 0.92). Improved shunt survival after failed ETV in the PIH group may be an artifact of selection arising from the inherent heterogeneity of ventricular damage within that group, or a consequence of the timing of shunt placement. The anticipated benefit of CPC in preventing future ventricular catheter obstruction was not observed. Conclusions. A paradigm for infant hydrocephalus involving intention to treat by ETV with or without CPC had no adverse effect on mortality or on subsequent shunt survival or infection risk. This study failed to demonstrate a positive effect of prior ETV or CPC on shunt survival.
机译：目的。尚不知道以前的内镜第三脑室造口术（ETV）是否会影响分流失败的风险。乌干达CURE儿童医院（CCHU）进行脑积水治疗的不同时期-首先在所有患者中放置CSF分流器，然后在所有患者中尝试ETV，最后在所有患者中尝试ETV结合脉络丛烧灼（CPC）-提供了机会评估以前的内窥镜手术是否影响分流存活。方法。经适当的机构批准，作者审查了CCHU临床数据库，确定了2000年12月至2007年5月接受治疗的2329例脑积水患者。在以下三种情况之一的情况下，对900例患者进行了最初的室腹膜（VP）分流：1）原发性非选择性VP分流无内镜放置（255例）; 2）放弃ETV尝试时（有或​​无CPC）时的VP分流放置（370例患者）; 3）在完成但失败的ETV（有或无CPC）后进行VP分流（275例）。我们使用Kaplan-Meier方法构建生存曲线，Cox比例风险回归模型和风险调整分析来分析分流失败的时间，以解决这些组之间可能混淆的差异。结果。 299例患者发生了分流衰竭，其余601例患者的平均随访时间为28.7个月（中位值为18.8，四分位间距为4.1-46.3）。在三组中，手术死亡率（对数秩为p = 0.07，经年龄和脑积水病因校正的Cox回归为p = 0.14）或分流感染（对数秩为p = 0.94）无显着差异。在一次ETV尝试中，接受一次分流术的患者与接受分流术的患者的分流存活率无差异（危险比[HR] 1.14，95％CI 0.86-1.51，p = 0.35）。在完成但未完成ETV（有或无CPC）后接受分流放置的患者，发生分流失败的风险较低（p = 0.008，对数秩），危险比（根据分流和病因年龄进行调整）为0.72（ 95％CI（0.53-0.98），p = 0.03，与那些未经内镜行初次分流术的患者相比;但这仅在感染后脑积水（PIH）患者中观察到（校正后的HR 0.55，95％CI 0.36-0.85，p = 0.007），对于非感染性病因的脑积水没有明显影响（校正后的HR 0.98，95％CI 0.64-）。 1.50，P = 0.92）。 PIH组ETV失败后分流存活率的提高可能是该组内心室损伤固有的异质性或分流放置时间的结果所引起的选择人工。没有观察到CPC预防未来心室导管阻塞的预期益处。结论。婴幼儿脑积水的范式涉及在有或无CPC的情况下接受ETV治疗，对死亡率或随后的分流存活或感染风险均无不利影响。这项研究未能证明先前的ETV或CPC对分流存活率有积极作用。

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