title: Reopening of an obstructed third ventriculostomy: long-term success and factors affecting outcome in 215 infants.
abstract: OBJECTIVE
  The role of reopening an obstructed endoscopic third ventriculostomy (ETV) as treatment for ETV failure is not well defined. The authors studied 215 children with ETV closure who underwent successful repeat ETV to determine the indications, long-term success, and factors affecting outcome.
  
  
  METHODS
  The authors retrospectively reviewed the CURE Children's Hospital of Uganda database from August 2001 through December 2012, identifying 215 children with failed ETV (with or without prior choroid plexus cauterization [CPC]) who underwent reopening of an obstructed ETV stoma. Treatment survival according to sex, age at first and second operation, time to failure of first operation, etiology of hydrocephalus, prior CPC, and mode of ETV obstruction (simple stoma closure, second membrane, or cisternal obstruction from arachnoid scarring) were assessed using the Kaplan-Meier survival method. Survival differences among groups were assessed using log-rank and Wilcoxon methods and a Cox proportional hazards model.
  
  
  RESULTS
  There were 125 boys and 90 girls with mean and median ages of 229 and 92 days, respectively, at the initial ETV. Mean and median ages at repeat ETV were 347 and 180 days, respectively. Postinfectious hydrocephalus (PIH) was the etiology in 126 patients, and nonpostinfectious hydrocephalus (NPIH) in 89. Overall estimated 7-year success for repeat ETV was 51%. Sex (p = 0.46, log-rank test; p = 0.54, Wilcoxon test), age (< vs > 6 months) at initial or repeat ETV (p = 0.08 initial, p = 0.13 repeat; log-rank test), and type of ETV obstruction (p = 0.61, log-rank test) did not affect outcome for repeat ETV (p values ≥ 0.05, Cox regression). Those with a longer time to failure of initial ETV (> 6 months 91%, 3-6 months 60%, < 3 months 42%, p < 0.01; log-rank test), postinfectious etiology (PIH 58% vs NPIH 42%, p = 0.02; log-rank and Wilcoxon tests) and prior CPC (p = 0.03, log-rank and Wilcoxon tests) had significantly better outcome.
  
  
  CONCLUSIONS
  Repeat ETV was successful in half of the patients overall, and was more successful in association with later failures, prior CPC, and PIH. Obstruction of the original ETV by secondary arachnoid scarring was not a negative prognostic factor, and should not discourage the surgeon from proceeding. Repeat ETV may be a more durable solution to failed ETV/CPC than shunt placement in this context, especially for failures at more than 3 months after the initial ETV. Some ETV closures may result from an inflammatory response that is less robust at the second operation.
authors: Harvard Medical School, Boston, Massachusetts;
authors: Paul J
authors: PJ
authors: Marano
authors: Scellig S D
authors: SS
authors: Stone
authors: John
authors: J
authors: Mugamba
authors: Peter
authors: P
authors: Ssenyonga
authors: Ezra B
authors: EB
authors: Warf
authors: Benjamin C
authors: BC
authors: Warf
mesh_terms: D001099:Arachnoid / Q000473:pathology; D002425:Cautery / Q000009:adverse effects; D002648:Child; D002675:Child, Preschool; D002831:Choroid Plexus / Q000601:surgery; D005260:Female; D006801:Humans; D006849:Hydrocephalus / Q000601:surgery*; D007223:Infant; D053208:Kaplan-Meier Estimate; D008297:Male; D044583:Neuroendoscopy; D016016:Proportional Hazards Models; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D020542:Third Ventricle / Q000601:surgery*; D016896:Treatment Outcome; D014454:Uganda; D014696:Ventriculostomy / Q000379:methods
keywords: Africa; CI = confidence interval; CPC = choroid plexus cauterization; CURE Children's Hospital of Uganda; ETV = endoscopic third ventriculostomy; HR = hazard ratio; NPIH = nonpostinfectious hydrocephalus; PIH = postinfectious hydrocephalus; children; choroid plexus cauterization; endoscopic third ventriculostomy; failure; hydrocephalus; outcome; repeat ETV