Efficacy and safety of flexible versus rigid endoscopic third ventriculostomy in pediatric and adult populations: a systematic review and meta-analysis

Abstract

Endoscopic third ventriculostomy (ETV) is a well-established surgical procedure for hydrocephalus treatment, but there is sparse evidence on the optimal choice between flexible and rigid approaches. A meta-analysis was conducted to compare efficacy and safety profiles of both techniques in pediatrics and adults. A comprehensive search was conducted on PubMED, EMBASE, and Cochrane until 11/10/2019. Efficacy was evaluated comparing incidence of ETV failure, while safety was defined by the incidence of perioperative complications, intraoperative bleedings, and deaths. Random-effects models were used to pool the incidence. Out of 1365 studies, 46 case series were meta-analyzed, yielding 821 patients who underwent flexible ETV and 2918 who underwent rigid ETV, with an age range of [5 days–87 years]. Although flexible ETV had a higher incidence of failure in adults (flexible: 54%, 95%CI: 22–82% vs rigid: 20%, 95%CI: 22–82%) possibly due to confounding due to etiology in adults treated with flexible, a smaller difference was seen in pediatrics (flexible: 36%, pediatric: 32%). Safety profiles were acceptable for both techniques, with a certain degree of variability for complications (flexible 2%, rigid 18%) and death (flexible 1%, rigid 3%) in pediatrics as well as complications (rigid 9%, flexible 13%), death (flexible 4%, rigid 6%) and intra-operative bleeding events (rigid 6%, flexible 8%) in adults. No clear superiority in efficacy could be depicted between flexible and rigid ETV for hydrocephalus treatment. Safety profiles varied by age but were acceptable for both techniques. Well-designed comparative studies are needed to assess the optimal endoscopic treatment option for hydrocephalus.

Late-onset obstructive hydrocephalus associated with occipital encephalocele with large skull defect successfully treated by endoscopic third ventriculostomy: A case report

“…Regarding the ETV in this case, a slightly modi ed location of the burr hole was needed, considering the patient's speci c abnormalities. Concerning this modi cation, we used a exible neuroendoscope with a higher degree of mobility to access the targeted ventricle in a non-linear manner [14][15][16][17].…”

Carbon Dots in Treatment of Pediatric Brain Tumors: Past, Present, and Future Directions

“…Panobinostat Histone deacetylase (HDAC) inhibitor, Partial rescue of H3K27M hypomethylation [82] Entinostat HDAC inhibitor, well tolerated in phase I study in pediatric patients, no dose-limiting toxicity [83] Vorinostat HDAC inhibitor, well-tolerated in children in combination with temozolomide, dose-limiting myelosuppression [84] Valproic Acid Histone hyperacetylation inducer, well tolerated in children with no dose-limiting toxicity [85] 5-aza-2′-deoxycytidine DNMT methylation inhibitor (demethylating agent), proposed to suppress intratumoral heterogeneity [86] Pediatric neurosurgeons have recently implemented endoscopy to access difficult-toreach lesions in the brain and spinal canal [87,88]. Though flexible scopes permit tortuous courses to be taken to the target tissue, the use of both rigid and flexible endoscopes has been shown to be safe in endoscopic third ventriculostomy in both pediatric and adult populations [89]. Endoscopy enables the surgeon to minimize the size of the and craniotomy, in some cases to a singular burr hole, thereby limiting surgical morbidity.…”

Evaluation of the precision of navigation-assisted endoscopy according to the navigation tool setup and the type of endoscopes

“…Its main advantage over open procedures resides in its minimal invasiveness with less postoperative morbidity, especially to reach deep-seated brain lesions, skull base surgery or to open basal cisterns in case of hydrocephalus [4,6,23,25]. In some selected neurosurgical indications, straight rigid and flexible endoscopes were reported to be suitable to, for example, perform ventriculocisternostomies and present the same rate of complications [2,19]. These two techniques, however, harbor certain limitations in surgical and anatomical visualization: the surgeon has to work with a non-stereoscopic view and a lack of depth perception during endoscope-assisted procedures [20,28], despite novel high-definition cameras [12].…”