The burden of pediatric hydrocephalus is significant: hydrocephalus can affect development as well as the overall quality of life. Hydrocephalus affects a disproportionate number of children who are admitted to hospitals [17]. There are effective surgical treatments that can protect and improve quality of life; nevertheless, these do not come without risks and failures. The need for advancements in surgical interventions is generally recognized. It is recognized that, while hydrocephalus problems appear simple, they are highly complex [8]. Nonetheless, there is agreement that current management may result in frequent complications, low shunt survival rates, and poor patient quality of life, resulting in disappointing outcomes [31].
At present, we prefer shunt surgery as the first choice of surgical treatment in these patients. Given a choice between VA and VP, the authors still prefer VP. The reason was that VP (69.8%) had a much higher healing rate than VA (14.3%), even though the rate of surgery-associated complications was slightly higher in VP (25.6%) than in VA (12.9%), and the potential complications of VA are more serious [11], especially in those who are elderly and have multiple underlying diseases, heart-associated difficulties tend to be more dangerous. However, if the patient has contraindications to VP (such as ascites, cholecystitis), VA is undoubtedly an appropriate choice. In addition, patients who received both VP and VA had a higher percentage of patients who underwent more than one surgical treatment (18/38, 37.5%), and all of them healed, suggesting a shift to studies on the use of VP in combination with VA.
In the past 10 years, our experience with ETV has accumulated, and the procedure is currently considered safe and easy [10, 19]. In our observation, ETV showed the highest healing rate (76%) and the lowest rate of surgery-associated complications (9.1%) among the three surgical treatments we mainly used. The effectiveness and reliability of ETV suggest that we should make ETV a focus of future studies. Meanwhile, the combination of VP (VA) (11/50, 22%) after ineffective ETV treatment had a significant effect on patient healing, with all patients who had received ETV and VP (VA) sequentially healed. However, there is perhaps a greater risk of treatment with ETV after ineffective treatment with VP(VA) first, and the only death among 163 patients occurred in this case. For obstructive hydrocephalus, the efficiency of ETV is high, even up to 95% [15]. Nevertheless, even in obstructive hydrocephalus, successful ETV does not mean a cure. There are a great many reports of occlusion of the stoma [7, 15], and some of these patients suddenly deteriorated [1]. But ETV is not recommended for idiopathic NPH without considering its subtypes (e.g. InfinOH [12]). Clinicians should be careful not to settle for partial remission of symptoms after ETV and forgo treatment that might further improve symptoms.
The complications of surgery and their corresponding management are the issues we pay the most attention to. The most common complication is shunt-related peritonitis or abdominal abscess, abdominal end obstruction (17/163, 10.4%), followed by shunt-related cerebrospinal fluid infection or meningitis (6/163, 3.7%). We have summarized the common surgical complications and their corresponding management as follows (Table 4).
Intraoperative complications, which only refer to the incorrect placement of the primary catheter during the operation, mainly occur at the ventricular end of the shunt [30]. The authors concluded that CT and abdominal X-ray films should be reviewed promptly after shunt surgery. When the catheter is poorly positioned, the catheter position should be adjusted as early as possible while the patient is generally well.
Infections associated with shunts can be divided into three categories: shunt colony formation, shunt-associated cerebrospinal fluid infection or meningitis, and shunt-associated peritonitis or abdominal abscess. The appearance of colonies around the shunt comes from the following: 1. Direct contact between the skin and the shunt before or during shunting; 2. During the process, skin flora was inserted from the wound site [6], the skin protective film can prevent the former. At the same time, the latter can be avoided by increasing the speed of surgery, using some surgical techniques to reduce tissue damage, and applying the "principle of nonmaleficence" [24] (e.g. try to wait for the shunt to be used before opening the package).
In general, as soon as a shunt colony forms, cerebrospinal fluid infection is bound to occur sooner or later [22], so once there is sufficient reason to suspect shunt colony formation in our department, even if there is no cerebrospinal fluid infection, meningitis, or general infection symptoms, we will remove the shunt promptly and then observe the prognosis of the patient to decide whether to perform shunt surgery again. For hunt-related cerebrospinal fluid infection or meningitis, if this occurs, our treatment is to remove the shunt promptly, drain the ventricle ipsilaterally or contralaterally, and swiftly perform a bacteriological examination of the cerebrospinal fluid and the tip of the shunt. Once the bacterial infection is identified, systemic and intrathecal antibiotics should be promptly applied according to the drug sensitivity.
Postoperative complications mainly include inadequate shunt, excessive shunt, and shunt dysfunction. In such cases, we can clarify the specific cause by imaging and palpating the shunt function and then replacing the part of the shunt device according to the situation. In recent years, our department has been using programmable shunt valves. For patients with inadequate shunt and excessive shunt, we can adjust the pressure of the shunt valve first, and if the patient's symptoms still do not improve, it is necessary to look for other causes of shunt dysfunction carefully.
We can clarify their classification by preoperative CT, MRI, cerebrospinal fluid flow imaging, and cerebrospinal fluid tap tests for patients with hydrocephalus. For obstructive hydrocephalus, ETV is more efficient, safe, and easy [14]. However, ETV is not recommended for patients with NPH if they do not take their specific subtype (e.g., InfinOH) into consideration. The NPH occurs mainly in people aged 65 years or older, and its primary clinical features are ventricular enlargement (Evan's index ≥ 0.3) and Hakim's triad (walking instability, dementia, and urinary incontinence). Such patients can choose a lumbar puncture fluid release experiment for preoperative evaluation. Their surgical treatment is VP, and the shunting of cerebrospinal fluid is safe and effective, and about 75% of patients can be effective for a long time [13]. The best treatment outcome is achieved when the shunt is performed early in the disease [18]. In addition, we should not blindly insist on a single surgical method of bypass or fistula for different patients but should consider the best surgical option after the failure of the preferred surgery. Early detection, timely surgical intervention, standardized surgical operation, and regular follow-up of discharged patients should be conducted to treat unrelieved symptoms and related complications after ETV and shunt surgery.