Role of endoscopic third ventriculostomy in children in a high-burden resource-limited setting: A prospective study.

BACKGROUND

Endoscopic third ventriculostomy (ETV) is an established alternative to ventriculoperitoneal shunting for pediatric hydrocephalus, but its success in younger children remains variable, particularly in resource-limited settings.

METHODS

We conducted a prospective observational study (July 2019-June 2024) at a tertiary pediatric surgical center in Northern India, including children aged 3-60 months undergoing ETV. Demographics, etiology, intraoperative findings, complications, and outcomes were analyzed. Primary outcome was 6-month ETV success (alive, clinically well, shunt-free). Long-term outcomes were assessed by Kaplan-Meier shunt-free survival analysis.

RESULTS

Ninety-six children (median age 14 months; 62 % boys) underwent ETV. Fourteen (14.6 %) were excluded from crude 6-month outcomes due to early loss to follow-up. Among 82 evaluable patients, 59 (72.0 %) achieved 6-month success. Success rates by age were: 54.5 % (3-6 months), 66.7 % (6-12 months), 79.5 % (1-2 years), and 70.6 % (2-5 years) (p≈0.11). By etiology, aqueductal stenosis and myelomeningocele had comparable outcomes (70.0 % vs. 77.3 %, p > 0.05). CSF leak occurred in 16.7 % (highest in 6-12 months; p = 0.001), with 62.5 % of these requiring shunting. Other complications included seizures (10.4 %), transient deficits (7.2 %), and infections (4.1 %). Kaplan-Meier analysis showed actuarial shunt-free survival of 74.3 % at 6 months, which plateaued through 5 years. Cine MRI flow studies correlated stoma patency with clinical success.

CONCLUSION

ETV provides effective and durable shunt-free survival in young children, with outcomes comparable to international series. Age < 6 months and postoperative CSF leak are key predictors of failure. Careful selection, meticulous technique, and structured follow-up are essential to optimize safety and success in resource-constrained environments.