LONG-TERM RESULTS OF A SECOND ENDOSCOPIC THIRD VENTRICULOSTOMY IN CHILDREN: RETROSPECTIVE ANALYSIS OF 40 CASES. Commentaries

OBJECTIVE: To evaluate retrospectively the operative findings and long-term results of a repeat endoscopic third ventriculostomy(ETV) in pediatric hydrocephalic patients readmitted after the first procedure with symptoms and/or signs of intracranial hypertension and/or radiological evidence of increased ventricular dilationand/or occluded stomaon follow-up radiological examinations. METHODS: We analyzed a series of 482 ETVs in pediatric patients from 2 Italian departments of pediatric neurosurgery. The clinical charts of 40 patients undergoing a second ETV were selected and reviewed retrospectively. The pre- and postoperative radiological findings and operative films were analyzed retrospectively. RESULTS: Forty patients underwent a total of 82 ETVs. Thirty-eight patients were operated on twice and 2 were operated on 3 times. During the second procedure, the stomawas found to be closed in 28 patients without underlying adhesions, to be open but with significant arachnoidadhesions in the prepontine cisternin 8 patients, to be open without adhesions in 2 patients, to have a pinhole orifice in 1 patient, and to be closed with underlying adhesions in 1 patient. The second procedure allowed reopening of the stomaor lysis of the arachnoidadhesions in 35 patients and was abandoned in 3 patients because of extensive arachnoidadhesions or because the stomawas found to be wide open (2 patients). In 30 patients (75%), the second ETV was effective, and the 2 patients who underwent a third ETV remained shunt free. In 10 patients (25%), a ventriculoperitoneal shunt was eventually placed. Age younger than 2 years at the time of the first procedure and arachnoidadhesions in the subarachnoid cisternsobserved during the second procedure are the main negative prognostic factors for the success of a second ETV. CONCLUSION: A second ETV can be performed with a reasonable chance of restoring patency of the stomaand avoiding placement of an extrathecal shunt. Every effort should be made to detect subarachnoid adhesions in the cisternon preoperative imaging study to select potential candidates and avoid unnecessary procedures.