Predicting shunt failure in children: should the global shunt revision rate be a quality measure?

Abstract

<jats:sec> <jats:title>OBJECT</jats:title> <jats:p>Ventricular shunts for pediatric hydrocephalus continue to be plagued with high failure rates. Reported risk factors for shunt failure are inconsistent and controversial. The raw or global shunt revision rate has been the foundation of several proposed quality metrics. The authors undertook this study to determine risk factors for shunt revision within their own patient population.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>In this single-center retrospective cohort study, a database was created of all ventricular shunt operations performed at the authors’ institution from January 1, 2010, through December 2013. For each index shunt surgery, demographic, clinical, and procedural variables were assembled. An “index surgery” was defined as implantation of a new shunt or the revision or augmentation of an existing shunt system. Bivariate analyses were first performed to evaluate individual effects of each independent variable on shunt failure at 90 days and at 180 days. A final multivariate model was chosen for each outcome by using a backward model selection approach.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>There were 466 patients in the study accounting for 739 unique (“index”) operations, for an average of 1.59 procedures per patient. The median age for the cohort at the time of the first shunt surgery was 5 years (range 0–35.7 years), with 53.9% males. The 90- and 180-day shunt failure rates were 24.1% and 29.9%, respectively. The authors found no variable—demographic, clinical, or procedural—that predicted shunt failure within 90 or 180 days.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>In this study, none of the risk factors that were examined were statistically significant in determining shunt failure within 90 or 180 days. Given the negative findings and the fact that all other risk factors for shunt failure that have been proposed in the literature thus far are beyond the control of the surgeon (i.e., nonmodifiable), the use of an institution’s or individual’s global shunt revision rate remains questionable and needs further evaluation before being accepted as a quality metric.</jats:p></jats:sec>

Shunt complications and revisions in children: A retrospective single institution study

“…Shunting and ventriculostomy are the two permanent treatment methods of CSF diversion. Unfortunately, shunting in the pediatric population is associated with high shunt failure rates/revisions rates ranging from 20% to 85% (Berry et al., 2008 ; Bir et al., 2016 ; Gupta et al., 2007 ; Merkler et al., 2017 ; Reddy et al., 2014 ; Riva‐Cambrin et al., 2016 ; Rossi et al., 2016 ; Stein & Guo, 2008 ; Stone et al., 2013 ; Wu et al., 2007 ). Complication rates in terms of revision surgery have frequently been examined and the literature is extensive.…”

Ventriculoperitoneal shunt failure in pediatric patients: an analysis of a national hospitalization database in Thailand

“…In the United States, a single-center university study (n = 341) by Shannon et al reported relatively lower rates of 15% and 21% at 6 and 24 months, respectively, and another study in a children's hospital (n = 466) by Rossi et al reported relatively higher rates of 24.1% and 29.9% at 3 and 6 months, respectively. 17,21 In the United Kingdom, a multicenter database study (n = 1615) by Al-Tamimi et al and a single-center teaching hospital study (n = 321) by Anderson et al reported relatively higher rates at 12 months of 28.8% and 26.0%, respectively. 10,12 Our shunt failure trend showing high failure rates within the first year followed by lower rates over time is consistent with published literature.…”

“…11 Evidence on specific etiology associated with shunt failure was mixed. 12,21,27,33 Many studies have identified congenital hydrocephalus as a significant risk factor for initial shunt failure. 11,20,22 In general, patients with hydrocephalus caused by congenital abnormalities are more likely to undergo shunt placement earlier when compared to patients with other etiologies, which may coincide with the notion that younger patients have a higher failure rate.…”

Intradural spine surgery may not carry an increased risk of shunt revision compared with extradural spine surgery in pediatric patients with myelomeningocele

“…Similarly, Rossi et al report a 90-day shunt failure rate of 24.1% and a 180-day shunt failure rate of 29.9%. 22 Notably, these rates are for shunts placed for any indication, and may not accurately represent the population of MMC patients with shunted hydrocephalus. Overall, the risk for shunt failure in MMC is highest within the 1st year of life, with declining risk thereafter, except for a spike in the early teenage years.…”