Endoscopic third ventriculostomy versus ventriculoperitoneal shunt in pediatric patients: a decision analysis

Uncertainty persists on the best treatment for patients with obstructive hydrocephalus: endoscopic third ventriculostomy (ETV) or shunt, particularly in the younger age groups. We performed decision analysis for quality of life (QOL) outcomes comparing these two procedures. Frequency of outcome events for ETV was obtained from the Canadian Pediatric Neurosurgery Study Group (368 patients) and for shunts from two prospective randomized trials, the Shunt Design Trial and the Endoscopic Shunt Insertion Trial (647 patients combined). Quality-adjusted life year (QALY) estimates for various outcomes were obtained from the literature. Decision analysis was performed at 1 year of follow-up for specific age groups, e.g., < 1 month, 1-6 months, etc. Failure from cerebrospinal fluid (CSF) diversion from either procedure was a function of age with higher failures rates in younger patients. Expected QALY at 1 year were marginally higher for ETV for all age groups, but the outcomes were similar enough to be regarded as equivalent. The results, however, were highly sensitive to the assigned health utility value estimates for patients who are well with a functioning ETV or shunt and the severe complication rate from ETV. Age is a major determinant of outcome from CSF diversion with worse outcomes in young patients. QALY estimates for either ETV or shunt are similar at 1 year.