Our next Late Breaking Abstract is Dr. Gernsback, the Shunting Holy Grail, Decreasing Shunt Revisions. So I would like to thank everyone for the opportunity to be here. I will talk about the Holy Grail of Pediatric Neurosurgery, Decreasing Shunt Revisions. I have no disclosures. So how did we get here? Forty percent of shunts will fail within the first year. Shunts are highly error prone. How can we get this better? We can avoid shunts altogether by doing ETVs, as is evident by Dr. Worf's group. That's a great approach, but not everyone has the anatomy for that. Much work has been done on new valves and differential technology that way. I'm not an engineer, not really my bucket. So what about other things? There has been data coming out of the HCRN that shows that if you keep the proximal end of a catheter surrounded by CSF, that may decrease shunt revisions. We sort of took this and ran with it and said, can we decrease shunt revisions by keeping the ventricles larger? So what we did is most of our patients get either a non-programmable valve with their first shunt or a programmable valve, and we started with a group of our patients with the adjustable valves to sequentially turn those valves up to try and artificially inflate the ventricle size while still allowing the child room for their brain to develop. And we were curious to see whether this would have any effect on shunt revisions. So we looked at 81 children who were treated over eight years, ventriculo-abdominal shunts treated with one of these two types of valves, not including other valves. Interestingly, the group one, the non-programmable, belonged primarily to one surgeon, but not exclusively. The other two groups, the programmable valves that were adjusted or those that were not adjusted, belonged primarily to the other surgeons, again, not exclusively. So we went back and analyzed all of these children. Baseline characteristics were not significantly different across the groups. Again, we had a large number of preterm infants with IVH, as is common in probably most institutions in this day and age. We also looked at a number of comorbid conditions. And since we do subscribe somewhat to the Ben Whorf School of doing ETVs, we looked at whether or not the patients had had prior ETVs. We looked at their ages. We did note that the group one patients were somewhat younger than the other groups. Unclear why exactly that is, but it was interesting to note. We looked at the shunt revisions by group. The group three, these are the kids that we put in an adjustable shunt and turned up the pressure. They had the lowest number of shunt revisions as compared to the non-adjustable and those with an adjustable shunt that was not adjusted. This was significant on ANOVA testing with a p-value of about .31. Age at shunt placement. It's well known that if you can get a child older and bigger, they will have a better chance of keeping that shunt patent. We found this to be true, again, with a p-value of .022 for older children not requiring a revision at two years versus those requiring a revision. Likewise, the older children needed zero or one revisions, whereas younger children needed more than one revisions. Again, this was significant at less than .02. The age at surgery. So our initial follow-up point was two years. We also followed these children as long as sort of possible. So some of them we actually have six and seven year follow-up on them. And again, age at surgery, older children are less likely to need a revision even at the time of final follow-up, years later. This might not be surprising. Children with abdominal anomalies, developmental anomalies, not necrotizing enterocolitis surprisingly, are more likely to need revisions. Obviously a lot of people avoid going into the belly in children with belly issues, and there's probably a good reason to do that. Proportional hazards model, little statistics refresher. This is a way to look at whether or not an event occurs and the time to occur. So ETVs, if you had had a prior ETV, you were less likely to need a shunt revision. And if you did need one, you needed it later. Likewise, group three, those adjusted sequentially shunts, were less likely to need a revision and would need them later than the other two groups. And finally, we did look at the environment that the catheter tip was in and found that a catheter tip in CSF was much more likely than one in brain to need revision. Again, kind of intuitive. So conclusions, sequential pressure increases with a shunt valve may decrease revisions, which is what we're all trying to do, fewer shunt revisions. Having had a prior ETV may be productive of needing a shunt revision as well. And somewhat logically, older children and those without abdominal abnormalities are less likely to need revisions and will need them later. Unfortunately, this is a single institution study. It is retrospective and there may be some selection bias given that most of one type of shunt valve belonged to one surgeon. So this suggests that a multicenter prospective randomized trial would be in order. So if anyone from the HCRN is interested, let me know. Any questions? Thank you.

pediatric neurosurgery

shunt revisions

endoscopic third ventriculostomy

adjustable shunt valves

multicenter prospective randomized trial