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Meta-Analysis
. 2022 Feb;45(1):199-216.
doi: 10.1007/s10143-021-01590-6. Epub 2021 Jun 25.

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

Alessandro Boaro  1   2 , Bhargavi Mahadik  3 , Anthony Petrillo  3 , Francesca Siddi  4 , Sharmila Devi  4   5 , Shreya Chawla  4   5 , Abdullah M Abunimer  4 , Alberto Feletti  6 , Alessandro Fiorindi  7 , Pierluigi Longatti  8 , Francesco Sala  5 , Timothy R Smith  4 , Rania A Mekary  4   6
Affiliations
Meta-Analysis

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

Alessandro Boaro et al. Neurosurg Rev. 2022 Feb.

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.

Keywords: Complications; Efficacy; Endoscopic third ventriculostomy; Flexible neuroendoscopy; Hydrocephalus; Rigid neuroendoscopy.

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Conflict of interest statement

No conflict of interest or competing interests to report related to this work.

Figures

Fig. 1
Fig. 1
Study selection process of the identified articles
Fig. 2
Fig. 2
Forest plot for incidence of failure in adults stratified by endoscopy type. For flexible ETV: incidence of failure = 54%; number of studies = 2; P-heterogeneity = 0.001; I2 = 90.9%; for rigid ETV: incidence of failure: 20% number of studies = 16; P-heterogeneity = 0.002; I2 = 57.4%. Error bars represent the 95% CI. ETV: endoscopic third-ventriculostomy
Fig. 3
Fig. 3
Forest plot for incidence of failure in pediatric population stratified by endoscopy type. For flexible ETV: incidence of failure = 36%; number of studies = 2; P-heterogeneity = 0.14; I2 = 53.2%; for rigid ETV: incidence of failure = 32%; number of studies = 19; P-heterogeneity = 0.00; I2 = 85.2%. Error bars represent the 95% CI. ETV: endoscopic third-ventriculostomy
Fig. 4
Fig. 4
Forest plot for incidence of failure in mixed population stratified by endoscopy type. For flexible ETV: incidence of failure = 23%; number of studies = 7; P-heterogeneity = 0.00; I2 = 86%; for rigid ETV: incidence of failure = 22%; number of studies = 8; P-heterogeneity = 0.01; I2 = 61%. Error bars represent the 95% CI. ETV: endoscopic third-ventriculostomy
Fig. 5
Fig. 5
Funnel plots for incidence of failure in adult and pediatric populations undergoing rigid ETV. No evident signs of asymmetry are unveiled in adult (a) or pediatric (b) population. The Begg’s test confirmed these findings (adult p value 0.22, pediatric p value 0.55). ETV: endoscopic third-ventriculostomy
See this image and copyright information in PMC

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