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Laparoscopy Versus Mini-Laparotomy Peritoneal Catheter Insertion of Ventriculoperitoneal Shunts: a Systematic Review and Meta-Analysis

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Laparoscopy Versus Mini-Laparotomy Peritoneal Catheter Insertion of Ventriculoperitoneal Shunts: a Systematic Review and Meta-Analysis NEUROSURGICAL FOCUS Neurosurg Focus 41 (3):E7, 2016 Laparoscopy versus mini-laparotomy peritoneal catheter insertion of ventriculoperitoneal shunts: a systematic review and meta-analysis Mingliang He, MD, Leping Ouyang, MD, Shengwen Wang, PhD, Meiguang Zheng, MD, and Anmin Liu, PhD Department of Neurosurgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China OBJECTIVE Ventriculoperitoneal (VP) shunt treatment is the main treatment method for hydrocephalus. The traditional operative approach for peritoneal catheter insertion is mini-laparotomy. In recent years, laparoscopy-assisted insertion has become increasingly popular. It seems likely that use of an endoscope could lower the incidence of shunt malfunc- tion. However, there is no consensus about the benefits of laparoscopy-assisted peritoneal catheter insertion. METHODS A systematic search was performed using the PubMed, Embase, ScienceDirect, and Cochrane Library da- tabases. A manual search for reference lists was conducted. The protocol was prepared according to the interventional systematic reviews of the Cochrane Handbook, and the article was written on the basis of the PRISMA (Preferred Re- porting Items for Systematic Reviews and Meta-Analysis) guidelines. RESULTS Eleven observational trials and 2 randomized controlled trials were included. Seven operation-related outcome measures were analyzed, and 3 of these showed no difference between operative techniques. The results of the meta-analysis are as follows: in the laparoscopy group, the rate of distal shunt failure was lower (OR 0.41, 95% CI 0.25–0.67; p = 0.0003), the absolute effect is 7.11% for distal shunt failure, the number needed to treat is 14 (95% CI 8–23), operative time was shorter (mean difference [MD], -12.84; 95% CI -20.68 to -5.00; p = 0.001), and blood loss was less (MD -9.93, 95% CI -17.56 to -2.31; p = 0.01). In addition, a borderline statistically significant difference tending to laparoscopic technique was observed in terms of hospital stay (MD -1.77, 95% CI -3.67 to 0.13; p = 0.07). COncLUSIONS To some extent, a laparoscopic insertion technique could yield a better prognosis, mainly because it is associated with a lower distal failure rate and shorter operative time, which would be clinically relevant. http://thejns.org/doi/abs/10.3171/2016.5.FOCUS1637 KEY WORDS hydrocephalus; laparoscopy; mini-laparotomy; ventriculoperitoneal shunt; meta-analysis YDROCEPHALUS is a common disease that is treated occurrence of complications. Currently, a distal catheter by neurosurgeons.2 First described in 1908, ven- is inserted using a variety of techniques, including mini- triculoperitoneal (VP) shunt placement remains laparotomy and laparoscopy. The most frequently used ap- Ha mainstay of surgical therapy for hydrocephalus.2 Over proach for shunt insertion remains the mini-laparotomy.37 time, advances in design and materials of catheters as However, it has been reported that the distal catheter fail- well as valves have been achieved. However, complica- ure rate associated with mini-laparotomy ranges from 6% tions associated with VP shunts are still common. Typical to 28.7%,18,28 which seems to be higher than that for lapa- complications include infection, malposition, dislocation, roscopy (0%–15.7%).1,5,6,9,13,20,35,37 Moreover, many studies and obstruction. According to Patwardhan and Nanda, the have reported that patients undergoing laparoscopy benefit overall annual health care costs associated with VP shunts more from the shorter operative time, shorter hospital stay, in the US exceeds $1.1 billion.27 Notably, distal compli- and quicker recovery.7,24 Many analyses account for the cations account for as much as 30% of overall compli- benefits. One of the most important reasons is that, with cations.16 Thus, a properly working peritoneal catheter is the laparoscopic method, surgeons are able to place the very important for successful VP shunt treatment. The dis- peritoneal portion of the VP shunt in the peritoneal cavity tal insertion technique may play an important role in the and confirm its efficiency under direct vision.7,23 ABBREVIATIONS MD = mean difference; NNT = number needed to treat; RCT = randomized controlled trial; VP = ventriculoperitoneal. SUBMITTED January 29, 2016. ACCEPTED May 10, 2016. INCLUDE WHEN CITING DOI: 10.3171/2016.5.FOCUS1637. ©AANS, 2016 Neurosurg Focus Volume 41 • September 2016 1 Unauthenticated | Downloaded 09/26/21 07:35 AM UTC M. He et al. Overall, although many prospective and retrospective erative complication rate. The secondary outcomes were studies, RCTs, and case reports regarding the efficacy of operative time, hospital stay, and blood loss. Shunt failure the laparoscopic technique have been published, these is defined as any catheter-related problem that required studies have not reached a consensus. It is therefore the a return to surgery for management, such as shunt mal- aim of this systematic review and meta-analysis to evalu- function, displacement, misplacement, malposition, dislo- ate the efficacy of the laparoscopic method compared with cation, and obstruction. Intraoperative complication was the mini-laparotomy method from the included RCTs and defined as accidental injuries to viscera during operation. cohort studies up to July 2015. Studies were rated for the level of evidence according to criteria of the Centre for Evidence-Based Medicine in Ox- Methods ford and by using the GRADE tool (GRADEpro, version 3.2 for Windows). The quality of the RCTs was evaluated Before conducting this systematic review and meta- according to the Cochrane Collaboration’s tool, and bias analysis, we developed a detailed protocol that included was assessed using the method mainly established by Hig- literature search strategies, inclusion and exclusion crite- gins et al.12 ria, outcome measurements, selection and data extraction, quality assessment, and methods of statistical analysis. The protocol was prepared according to the Cochrane Statistical Analysis Handbook for Systematic Reviews of Interventions, and A meta-analysis was performed on the included studies the study was written according to PRISMA (Preferred using the software package RevMan (version 5.0, Cochrane Reporting Items For Systematic Reviews and Meta-Anal- Informatics & Knowledge Management Department). Di- yses) guidelines.12 chotomous variables are presented as ORs (laparoscopic vs mini-laparotomy) with 95% CIs. Random-effect models Literature Search Strategy were used, with significance set at p < 0.05. In addition, A literature search of laparoscopic and mini-laparoto- for outcomes that showed statistically significant treatment my techniques for VP shunt placement was performed by effects, we calculated absolute risk reduction and number 2 reviewers (L.O. and M.H.) on articles published between needed to treat (NNT). NNT was calculated using the January 1993 and July 2015. A computerized search of the absolute numbers and estimated using the control group event rate and OR with 95% CI obtained from the meta- PubMed, Embase, ScienceDirect, and Cochrane Library 2 databases was performed without restriction on the lan- analysis. Statistical heterogeneity was assessed using the I guage of publication. Keyword and free text searches used statistic, which describes the proportion of total variation combinations of the following keywords: laparoscopy, that is attributable to differences among trials rather than ventriculoperitoneal shunt, and hydrocephalus. A manual sampling error. An I2 value of < 25% was defined to rep- search for unpublished results of ongoing trials and pre- resent low heterogeneity, a value between 25% and 50% sentations at significant scientific meetings was conducted was defined as moderate heterogeneity, and > 50% was as a supplement. All reference sections of eligible studies defined as high heterogeneity between studies. Otherwise, and pertinent reviews were hand-reviewed for potentially the fixed-effects model was used. Moreover, a sensitivity relevant studies. When a study generated multiple publica- analysis was performed when the heterogeneity was high tions, the most current report was used. to find out the source of heterogeneity. Funnel plots were used to screen for potential publication biases. Literature Screening The decision on whether a study should be included Results was made independently by 2 authors (S.W. and M.Z.), and Figure 1 shows a flow diagram according to the disagreements were settled by the senior author (A.L.). PRISMA statement,22 with the total number of citations re- The inclusion criteria were as follows: 1) all available trieved using the search strategy and the number included RCTs and comparative studies (cohort studies: prospective in the systematic review. Thirteen studies met all of the in- and retrospective) that compared the laparoscopic method clusion criteria and were included in the analysis. In total, and mini-laparotomy method for all age groups; 2) need these studies included 3235 patients, of whom 1485 under- for a VP shunt for the treatment of hydrocephalus; and 3) went laparoscopic-assisted VP shunt placement and 1750 the percentage or crude data explicitly reported for both underwent mini-laparotomy method–assisted VP shunt the laparoscopic and mini-laparotomy methods. placement. Of these included studies, 2 are RCTs6,33 and The exclusion criteria were as follows: 1) insufficient 11 are cohort studies.3,4,7,8,23,24,26, 29,31, 32,40 As shown in Fig. 2, data or the lack of a comparison group; 2) substantial
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