ETV/CPC and Ventriculoperitoneal Shunt Outcomes by a Pediatric General Surgeon in Tanzania: A Case for Task-Shifting to Meet Global Neurosurgical Need?

Abstract

Object: In low- and middle-income countries, hydrocephalus is one of the most common congenital birth defects. Traditionally, shunt placement has been the major intervention for hydrocephalus. More recently, Endoscopic Third Ventriculostomy with Choroid Plexus Cauterization (ETV/CPC) was introduced as a low-cost, effective alternative. This study seeks to characterize hydrocephalus and its neurosurgical outcomes in Tanzania and to assess the feasibility of training a pediatric general surgeon in performing ETV/CPC. Methods: Part 1 of this combined prospective/retrospective cohort study characterizes hydrocephalus and its treatment in Arusha, Tanzania. Measured variables include etiologies of hydrocephalus, ages and demographics at treatment, severity of disease, numbers of patients, 30-day morbidity and mortality of shunt placement, and rates of shunt failure/infection (based on Kaplan-Meier method). In part 2 of this study, a pediatric general surgeon from Tanzania was provided with ETV/CPC training. We allowed a 3-month latency period for her to become familiarized with the procedure. Then, we prospectively collected data from a consecutive cohort of 9 months of patients with hydrocephalus. Our main variables of interest were failure rate, failure reason, and 30-day mortality. We used the Kaplan-Meier method to determine if there was a significant difference in neurosurgical outcomes for hydrocephalus between VPS and ETV. Results: Part 1: Of 136 patients studied, average age of hydrocephalus onset was 2.98 months, average age of first illness was 1.81 months, and average age at treatment was 11.22 months. The most common etiologies were myelomeningocele (32 percent), congenital idiopathic (30 percent), post-infectious (26 percent), and encephalocele (4 percent). Overall, the VPS failure rate was 39.2 percent with an average time to failure of 8.18 months and average number of failures as 1.84. Most common reasons for failure included shunt malfunction (78 percent), shunt infection (16 percent), and wound dehiscence (6 percent). The 30-day mortality rate was 3.1 percent. Kaplan-Meier analyses showed no significant survival or VPS failure differences based on identified patient characteristics. Part 2: Of 32 patients evaluated for ETV, 23 ETV surgeries were attempted and 17 (73.9 percent) were successful. 6 were converted to VPS for reasons of technical issues (33.3 percent), scarred third ventricle floor (33.3 percent), and poor visualization (33.3 percent). The etiologies of hydrocephalus were 38 percent PIH and 62 percent NPIH. After a median follow-up of 57 days, the VPS failure rate was 37.5 percent and ETV failure rate was 5.9 percent (p=0.3192). The direction of revisions were as follows: prior VPS to new VPS (n=2), prior VPS to new ETV (n=1), and prior ETV to new VPS (n=1). There were no deaths during our follow-up period. Kaplan-Meier analyses showed no significant survival or VPS failure differences based on patient characteristics or surgery. There was a significantly shorter treatment delay in part 2 compared to part 1 (0.31 vs. 8.2 months, p= 0.0276). 3 Conclusion: Overall, these analyses in Tanzania show that (1) etiologies of hydrocephalus are evenly split between myelomeningocele, congenital idiopathic, and post-infectious, (2) neurosurgical outcomes based on shunt placement showed high shunt failure rates within one year, most commonly due to shunt malfunction, and (3) early outcomes of ETV by a pediatric general surgeon were not significantly different from VPS outcomes, with results limited by small sample size. A determination of equivalence or superiority between these surgical approaches by a pediatric general surgeon requires further research