Laparoscopic-Assisted Ventriculoperitoneal Shunt Placement and Reduction in Operative Time and Total Hospital Charges

Journal Pre-proof Laparoscopic-assisted ventriculoperitoneal shunt placement and reduction in operative time and total hospital charges Joshua S. Catapano, MD, Andrew W. Mezher, BS, Derrick J. Wang, BS, Alexander C. Whiting, MD, Michael A. Mooney, MD, Michael A. Bohl, MD, John P. Sheehy, MD, Joseph D. DiDomenico, MD, Christina E. Sarris, MD, Kris A. Smith, MD, Michael T. Lawton, MD, Joseph M. Zabramski, MD PII:

S1878-8750(19)33115-8

DOI:

https://doi.org/10.1016/j.wneu.2019.12.086

Reference:

WNEU 13933

To appear in:

World Neurosurgery

Received Date: 13 September 2019 Revised Date:

13 December 2019

Accepted Date: 15 December 2019

Please cite this article as: Catapano JS, Mezher AW, Wang DJ, Whiting AC, Mooney MA, Bohl MA, Sheehy JP, DiDomenico JD, Sarris CE, Smith KA, Lawton MT, Zabramski JM, Laparoscopic-assisted ventriculoperitoneal shunt placement and reduction in operative time and total hospital charges, World Neurosurgery (2020), doi: https://doi.org/10.1016/j.wneu.2019.12.086. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Inc. All rights reserved.

Laparoscopic-assisted ventriculoperitoneal shunt placement and reduction in operative time and total hospital charges

Joshua S. Catapano, MD Andrew W. Mezher, BS Derrick J. Wang, BS Alexander C. Whiting, MD Michael A. Mooney, MD Michael A. Bohl, MD John P. Sheehy, MD Joseph D. DiDomenico, MD Christina E. Sarris, MD Kris A. Smith, MD Michael T. Lawton, MD Joseph M. Zabramski, MD

Correspondence: Joseph M. Zabramski, MD c/o Neuroscience Publications; Barrow Neurological Institute St. Joseph’s Hospital and Medical Center 350 W. Thomas Rd.; Phoenix, AZ 85013 Tel: 602.406.3593; Fax: 602.406.4104 E-mail: [email protected]

DISCLOSURES: None FINANCIAL SUPPORT: None ACKNOWLEDGMENTS: The authors thank the Neuroscience Publications staff at Barrow Neurological Institute for help with manuscript preparation.

SUBMISSION CATEGORY: Original Article

Catapano JS et al. 1 ABSTRACT Objective: In ventriculoperitoneal shunt (VPS) placement, distal placement of the peritoneal catheter is typically performed by a neurosurgeon. More recently, laparoscopic-assisted (LA) placement of the distal peritoneal catheter by general surgeons has become common. This study examined whether LA placement of VPS (LAVPS) is associated with reduced operative time, lower hospital cost, and fewer distal revisions. Methods: A retrospective review was performed for all patients who received a new VPS at our institution between 2013 and 2016. Age, sex, diagnosis, previous abdominal surgeries, operative time, anesthesia grade, 30-day shunt failures, and total hospital charges were analyzed. Results: Six hundred and eighty patients underwent first-time VPS placement, including 199 with LAVPS and 481 with non-LA VPS placement (non-LAVPS). The mean age of LAVPS patients was significantly higher than that of non-LAVPS patients (64.1 vs. 59.3 years; P=.002). Mean operative time was shorter in the LAVPS group than in the non-LAVPS group (55 vs. 75 minutes; P<.001). Distal shunt revision within 30 days occurred more often among non-LAVPS patients (6 of 481 [1.2%]) than among LAVPS patients (0 of 199 [0%]). A subset analysis of patients with normal pressure hydrocephalus found decreased total hospital charges in the LAVPS group ($67,124 vs. $80,890; P=.009). Conclusions: Compared with non-LAVPS, LAVPS is associated with significantly shorter operative times and fewer distal shunt revisions within 30 days. Subset analysis supports a decrease in total hospital charges. Additional studies are needed, but these data suggest that LAVPS is a safer, less expensive alternative to non-LAVPS.

RUNNING TITLE: Laparoscopic-assisted VPS and reduced charges

Catapano JS et al. 2 KEYWORDS: Hospital charges; laparoscopic-assisted ventriculoperitoneal shunt placement; normal pressure hydrocephalus; operative time

ABBREVIATIONS: ASA, American Society of Anesthesiologists; CI, confidence interval; CSF, cerebrospinal fluid; LA, laparoscopic-assisted; LAVPS, laparoscopic-assisted ventriculoperitoneal shunt placement; non-LAVPS, non–laparoscopic-assisted ventriculoperitoneal shunt placement; NPH, normal pressure hydrocephalus; OR, odds ratio; VPS, ventriculoperitoneal shunt

Catapano JS et al. 3 INTRODUCTION Hydrocephalus is a condition characterized by a disruption of the normal cerebrospinal fluid (CSF) flow dynamics that results in accumulation of CSF.1, 2 Surgical management of symptomatic hydrocephalus with ventriculoperitoneal shunt (VPS) placement aims to restore equilibrium between CSF production and outflow. The typical VPS placement involves cannulating one of the lateral ventricles,2 followed by tunneling of the distal peritoneal tubing to an abdominal incision. The ventricular and peritoneal tubing are connected with an intervening shunt valve, and after assuring flow of CSF, the distal tubing is advanced into the peritoneal cavity. In the past, the abdominal portion of the procedure has typically been performed by neurosurgeons. More recently, however, laparoscopic-assisted (LA) peritoneal catheter placement by general surgeons has become increasingly common. Despite more than 60 years of technical advances since the first VPS, the complication rate associated with the procedure remains high.3-7 Infection, shunt obstruction, and catheter migration are among the leading complications that require operative revision or removal of the shunt, which is a major source of patient and financial burden.8-11 LA placement of the distal catheter may help reduce the risk of distal shunt malfunction. In a retrospective study of 810 patients, Naftel et al.12 found that distal shunt obstruction occurred more often among patients treated with open approaches than among those treated with LA approaches. Because of the prevalence of VPS-associated complications, we investigated the effect of LA VPS placement (LAVPS) of the distal catheter by general surgeons, compared with non-LA VPS placement (non-LAVPS), among patients who received new shunts. We retrospectively analyzed all cases of new VPS placement at our institution between 2013 and 2016. Patients were placed into one of two cohorts on the basis of whether LA was used for the procedure. We

Catapano JS et al. 4 then compared the two groups with respect to demographic characteristics, diagnosis, severity of illness, surgical history, operative time, 30-day shunt failure rate, and total hospital charges. We hypothesized that LAVPS would reduce operative time, lower hospital cost, and decrease distal revisions.

MATERIALS AND METHODS The study was approved by the institutional review board at St. Joseph’s Hospital and Medical Center in Phoenix, AZ and was granted a waiver for patient consent due to the retrospective nature of the study. All VPS placements performed at our high-volume tertiary center from July 1, 2013, to May 31, 2016, were retrospectively reviewed. Exclusion criteria included (1) prior VPS placement, (2) age less than 18 years, (3) and nonperitoneal placement of the distal catheter. Charts were reviewed for patient age, sex, treatment, treatment date, comorbidities, prior abdominal surgical procedures, reason for shunt, shunt failures within 30 days, reason for shunt failure, emergency department visits within 30 days, hospital admissions within 30 days, total hospital charges for patients, length of stay, and operative time. Two cohorts were compared, LAVPS vs. non-LAVPS. The non-LAVPS cohort included both patients who underwent minilaparotomy (n=397) and patients treated with use of trocar (n=84). A second analysis was performed that included only patients with normal pressure hydrocephalus (NPH) and compared total hospital charges between the two cohorts. The subgroup of NPH patients are a more uniform group; patients with NPH share a common cause of hydrocephalus and are typically treated on an elective basis. Statistical analysis was performed with SPSS, version 24 (IBM), and included means, standard deviations, percentages, independent t-tests, and χ2 analysis.

Catapano JS et al. 5

RESULTS A total of 680 patients were found to meet the inclusion criteria during the 34-month study period. Patient characteristics for the LAVPS cohort (N=199) and the non-LAVPS cohort (N=481) are summarized in Table 1. The mean (standard deviation) age of LAVPS patients (64.1 [18] years) was significantly greater than the mean age of non-LAVPS patients (59.3 [17.4] years; P=.002). The LAVPS cohort had more patients 65 years of age or older than the nonLAVPS cohort (61.3% vs. 45%; P<.001). The cohorts had similar sex distributions. Overall, the American Society of Anesthesiologists (ASA) scores were higher in the non-LAVPS cohort than in the LAVPS cohort (ASA score >3, 16% vs. 6.5%; P<.001). The three most common attributed diagnoses for both cohorts were NPH, a tumor or cyst, or a vascular lesion (aneurysm, arteriovenous malformation, or arteriovenous fistula). However, NPH was more prevalent among patients in the LAVPS cohort (111 of 199 [56%] vs. 142 of 481 [30%]), whereas patients in the non-LAVPS cohort were more likely to receive a diagnosis of a tumor or cyst (40 [20%] vs. 151 [31%]) or a vascular lesion (16 [8%] vs. 86 [18%]; P<.001). Patients in the LAVPS and non-LAVPS cohorts had similar rates of idiopathic intracranial hypertension (7% vs. 5%) and other causes of hydrocephalus related to prior infection (2% vs. 4%), trauma (3% vs. 4%), and cerebrovascular accident (2% vs. 5%). The LAVPS and non-LAVPS cohorts had similar rates of previous abdominal surgery (53% vs. 47%; P=.15) and history of more than one abdominal surgery (18% vs. 14%; P=.53). The LAVPS and non-LAVPS cohorts had similar rates of hernia repair (13% vs. 11%); appendectomy (16% vs. 12%); cesarean delivery (7%, 4%); bariatric surgery (4%, 2%); exploratory laparotomy (2% vs. 1%); hysterectomy (14% vs. 12%); tubal ligation,

Catapano JS et al. 6 oophorectomy, and/or salpingectomy (2% vs. 4); renal, bladder, aortic, and/or adrenal surgery (4% vs. 2%); and splenectomy, liver, and/or pancreatic surgery (1% vs. 0.8%). However, the LAVPS cohort had a significantly higher rate of previous bowel surgery compared with the nonLAVPS cohort (4% vs. 1%; P=.03). Table 2 compares the outcomes for the LAVPS and non-LAVPS cohorts. Mean procedure duration was significantly shorter for the LAVPS cohort compared with the nonLAVPS cohort (54.6 vs. 75 minutes; P<.001). Of the LAVPS procedures, 47 (23%) were longer than 60 minutes, compared with 305 (63%) of the non-LAVPS procedures (P <.001; odds ratio [OR], 5.6; 95% confidence interval [CI], 3.8–8.2). No difference was observed when comparing the LAVPS and non-LAVPS cohorts with respect to 30-day rate of return to the emergency department (15% vs. 12%; P=.32) or 30-day rate of readmission (10% vs. 12%; P=.5). However, data analysis revealed a significantly higher rate of repeat shunt surgery for non-LAVPS cases compared with LAVPS cases (35 of 481 [7%] vs. 3 of 199 [2%]; P=.002; OR, 5; 95% CI, 1.6–17). The need for repeat shunt surgery due to valve malfunction (2 [1%] vs. 11 [2.3%]) or proximal failure (1 [0.5%] vs. 5 [1%]) was similar in the LAVPS and non-LAVPS cohorts. In contrast, none of the repeat surgeries in the LAVPS cohort were due to distal shunt failure, whereas 6 patients (1.2%) in the non-LAVPS cohort required revision due to distal failure. Among the non-LAVPS cases, 84 shunt procedures were performed using the trocar method. The rate of repeat surgery in these cases was equivalent to that in the remainder of the non-LAVPS group; 7 (8.3%) of the non-LAVPS cases using a trocar method required repeat shunt surgery with distal shunt failure reported in 1.3%. Of interest, the mean surgical time for

Catapano JS et al. 7 the trocar method cases was shorter, measuring 56.1 minutes versus 79.1 minutes in all other non-LAVPS cases (P<.001). Table 3 presents analysis of individual risk factors for repeat shunt surgery due to distal shunt failure within 30 days after VPS surgery. Individual risk factors analyzed, including age of at least 65 years (P=.22), female sex (P=.70), procedure duration greater than 60 minutes (P=.69), ASA score >3 (P=.57), and previous abdominal surgery (P=.69), were not found to be significant risk factors for repeat shunt surgery to treat distal shunt failure. Two risk factors that were almost statistically significant for repeat surgery secondary to distal shunt failure were undergoing non-LAVPS procedures (P=.19; OR, 1; 95% CI, 1–1.023) and a history of gastric bariatric surgery (P=.16; OR, 7.3; 95% CI, 0.8–65.6).

NPH Subset Analysis Patients with a diagnosis of NPH in the LAVPS (n=111) and non-LAVPS (n=142) cohorts were compared with respect to patient characteristics, surgical and postoperative outcomes, and costs. The mean age of patients with NPH was similar between the LAVPS and non-LAVPS subcohorts (74.8 years vs. 74.9 years; P=.88) (Table 4). Similarly, no significant difference was observed for the number of patients with an ASA score >3 (2 of 111 [1.8%] vs. 8 of 142 [5.6%]; P=.19). The mean operative time for shunt placement among patients with NPH was significantly shorter in the LAVPS group than in the non-LAVPS group (48.3 vs. 65.8 minutes; P<.001). Postoperatively, the NPH LAVPS subcohort had a shorter mean length of hospital stay than the NPH non-LAVPS subcohort, although this difference was not statistically significant (73 vs. 101 hours; P=.16). Comparison of the hospital charges between the two groups revealed that mean costs were approximately $13,750 less per case in the LAVPS cohort

Catapano JS et al. 8 than in the non-LAVPS cohort ($67,124.11 vs. $80,890.35; P=.009). None of the NPH LAVPS subcohort patients experienced distal shunt failure in the 30 days after surgery, while there was one patient in the NPH non-LAPVS cohort who experienced distal shunt failure within 30 days (P=.56).

DISCUSSION VPS surgery is the most frequent CSF diversionary procedure used in the management of hydrocephalus.2 Given the high rate of associated complications and frequency of shunt revision following primary VPS placement, investigations into optimizing patient outcomes are warranted. Few studies have been published that directly compare the outcomes of LA and nonLA VPS procedures for the treatment of hydrocephalus. We compared two cohorts of patients treated with either LA or non-LA VPS placement for the treatment of hydrocephalus due to various causes. We found a significant reduction in mean procedure time for the LAVPS group. LA procedures took a mean of 20.4 minutes less than non-LA VPS procedures. Similarly, only 23% of LAVPS procedures took more than an hour to perform, compared with 63% of non-LAVPS procedures. This is likely attributable to the presence of two surgical teams operating simultaneously in the LAVPS procedures, whereas a single surgical team performs non-LAVPS procedures. In the NPH subcohorts, there was a similar significant reduction in mean operative time among LAVPS cases. Our data agree with previously reported findings of reduced operative times among patients who undergo LA placement of VPS, compared with patients who undergo open procedures. Naftel et al.12 reported that laparoscopy reduced operative time by a mean of 12

Catapano JS et al. 9 minutes, whereas a smaller study of 155 patients by Park et al.13 found a 57-minute difference in mean procedure time. In addition to measuring differences in surgical parameters and complication rates between the LAVPS and non-LAVPS cohorts, we sought to compare associated costs. Our cost analysis was limited to patients with NPH. Patients with NPH are relatively similar with respect to comorbidities and complications, resulting in better matched groups for comparing costs associated with LA versus non-LA placement of VPS. The mean hospital cost for the patients with NPH in the LAVPS cohort was approximately $13,750 less than that for patients with NPH in the non-LAVPS cohort (P=.009). Although no statistically significant difference was found in the mean length of stay, there was an association between longer hospital stays and patients undergoing non-LAVPS placement, which possibly contributed to the cost difference. The shorter duration of LAVPS procedures may also help reduce costs associated with staffing the operating room and maintaining general anesthesia. The mean cost associated with the 142 patients with NPH in the non-LAVPS cohort collectively added nearly two million dollars to hospital charges. For large-volume institutions that perform many VPS procedures a year, using laparoscopic approaches would likely reduce hospital costs by a significant extent. To compare risks of postoperative complications, we analyzed rates of return to the emergency department, readmission, and repeat shunt surgery within the first 30 days. We found similar emergency department return and readmission rates for the two groups. However, the incidence of repeat shunt surgery within 30 days was found to be significantly greater among the non-LAVPS cohort. Because we were interested in assessing the effect of LA on VPS outcomes, we subsequently analyzed the independent complications that necessitated shunt revision surgery. Distal shunt failure was not a cause for revision surgery in the LAVPS cohort but

Catapano JS et al. 10 accounted for 6 of 35 repeat surgery cases in the non-LAVPS cohort. The data in Table 3 summarize the analysis of several variables as independent risk factors for distal shunt failure. None of the variables were statistically significant risk factors for distal shunt failure. However, the absolute increase in observed surgical revision secondary to distal shunt failure in the nonLAVPS cohort suggests inferiority. The retrospective nature of this study limits the interpretation of the results. We predict that a larger sample size would appropriately demonstrate a significant reduction in distal shunt failure among patients with LAVPS compared with non-LAVPS. Previously, Phan et al.5 published a meta-analysis that reviewed previously reported trials comparing laparoscopic and open approaches to VPS placement. Ten studies were included in the analysis. Their results demonstrated that, relative to non-LAVPS, LAVPS reduced operative time by a mean of approximately10 minutes (P<.001) and significantly reduced the rate of distal shunt obstruction (P=.03) and abdominal malposition and distal obstruction (P=.001).5 This analysis additionally noted no significant difference in proximal shunt failure (P=.61) or overall shunt complication and failure rate (P=.35). Although these findings were limited by the observational nature of several of the studies, the large sample sizes for each cohort (LAVPS, 1373 cases; non-LAVPS, 1388 cases) allowed reasonable support for the conclusions drawn. Additionally, He et al.14 published a meta-analysis that compared laparoscopy and minilaparotomy approaches for distal VPS catheter insertion. Thirteen studies were included in their analysis: two randomized control studies and eleven observational studies. LA was used in 1485 VPS cases, and an open technique was used in an additional 1750 cases. In agreement with the meta-analysis published by Phan et al.,5 He et al.14 found that LAVPS was associated with a lower rate of distal shunt failure

Catapano JS et al. 11 (P<.001), a reduction in operative time by a mean of approximately 13 minutes (P<.001), and reduced blood loss (P=.01).

CONCLUSION VPS placement is the mainstay of treatment for hydrocephalus requiring CSF diversion. Although surgical techniques and device development continue to evolve, the complication rate associated with VPS remains high, often requiring operative shunt revision. Distal shunt obstruction is a major contributor to postoperative all-cause shunt failure. With the increase in minimally invasive surgical strategies, the use of laparoscopy to assist in VPS procedures has grown in popularity. Our data suggest that LAVPS may be a cost-saving alternative to the nonLAVPS approach and support the finding that LA reduces distal shunt failure rates. Further analysis, including larger prospective randomized control trials of the two approaches, would better elucidate the differences.

Catapano JS et al. 12 REFERENCES 1. Scarff JE. Treatment of hydrocephalus: an historical and critical review of methods and results. J Neurol Neurosurg Psychiatry. Feb 1963;26:1-26. 2. Greenberg M. Handbook of Neurosurgery 8th ed. New York: Thieme Medical Publisher; 2016. 3. Pudenz RH. The surgical treatment of hydrocephalus--an historical review. Surg Neurol. Jan 1981;15(1):15-26. 4. Rachel RA. Surgical treatment of hydrocephalus: a historical perspective. Pediatr Neurosurg. Jun 1999;30(6):296-304. 5. Phan S, Liao J, Jia F, Maharaj M, Reddy R, Mobbs RJ, Rao PJ, Phan K. Laparotomy vs minimally invasive laparoscopic ventriculoperitoneal shunt placement for hydrocephalus: A systematic review and meta-analysis. Clin Neurol Neurosurg. Jan 2016;140:26-32. 6. Wu Y, Green NL, Wrensch MR, Zhao S, Gupta N. Ventriculoperitoneal shunt complications in California: 1990 to 2000. Neurosurgery. Sep 2007;61(3):557-562; discussion 562-553. 7. Paff M, Alexandru-Abrams D, Muhonen M, Loudon W. Ventriculoperitoneal shunt complications: a review. Interdisciplinary Neurosurgery. 2018;13:66-70. 8. Patwardhan RV, Nanda A. Implanted ventricular shunts in the United States: the billiondollar-a-year cost of hydrocephalus treatment. Neurosurgery. 2005;56(1):139-144; discussion 144-135. 9. Vinchon M, Lemaitre MP, Vallee L, Dhellemmes P. Late shunt infection: incidence, pathogenesis, and therapeutic implications. Neuropediatrics. Aug 2002;33(4):169-173.

Catapano JS et al. 13 10. Mwachaka PM, Obonyo NG, Mutiso BK, Ranketi S, Mwang'ombe N. Ventriculoperitoneal shunt complications: a three-year retrospective study in a Kenyan national teaching and referral hospital. Pediatr Neurosurg. 2010;46(1):1-5. 11. Baird C, O'Connor D, Pittman T. Late shunt infections. Pediatr Neurosurg. Nov 1999;31(5):269-273. 12. Naftel RP, Argo JL, Shannon CN, Taylor TH, Tubbs RS, Clements RH, Harrigan MR. Laparoscopic versus open insertion of the peritoneal catheter in ventriculoperitoneal shunt placement: review of 810 consecutive cases. J Neurosurg. Jul 2011;115(1):151158. 13. Park YS, Park IS, Park KB, Lee CH, Hwang SH, Han JW. Laparotomy versus laparoscopic placement of distal catheter in ventriculoperitoneal shunt procedure. J Korean Neurosurg Soc. Oct 2010;48(4):325-329. 14. He M, Ouyang L, Wang S, Zheng M, Liu A. Laparoscopy versus mini-laparotomy peritoneal catheter insertion of ventriculoperitoneal shunts: a systematic review and meta-analysis. Neurosurg Focus. Sep 2016;41(3):E7.

Catapano JS et al. 14 Table 1. Patient demographic and clinical characteristics with placement of first-time ventriculoperitoneal shunt stratified by laparoscopic-assisted versus non–laparoscopic-assisted placement Non– Laparoscopic- LaparoscopicAssisted Assisted Placement Placement Characteristic (N= 199) (N=481) P value Age Mean (SD), years

64.1 (18)

59.3 (17.4)

.002

≥65 years

122 (61.3)

214 (45)

<.001

115 (58)

261 (54)

.45

Male sex ASA score

<.01

1

1 (0.5)

2 (0.4)

2

29 (14.6)

48 (10.0)

3

156 (78.4)

352 (73.2)

4

13 (6.5)

72 (15.9)

5

0 (0)

4 (0.8)

Not charted

0 (0)

3 (0.6)

13/199 (6.5)

76/478 (16)

ASA score >3 Diagnosis

.001 <.001

NPH

111 (56)

142 (30)

Tumor/cyst

40 (20)

151 (31)

Aneurysm/AVM/AVF

16 (8)

86 (18)

IIH

14 (7)

26 (5)

Infectious

4 (2)

20 (4)

Trauma

6 (3)

21 (4)

CVA

3 (2)

25 (5)

Other

5 (3)

10 (2)

Previous abdominal surgery

105 (53)

224 (47)

.15

>1 Abdominal surgery

36 (18)

68 (14)

.53

26 (13)

54 (11)

.51

Type of abdominal surgery Hernia

Catapano JS et al. 15 Appendectomy

31 (16)

60 (12)

.32

Cesarean delivery

14 (7)

21 (4)

.18

Cholecystectomy

31 (16)

59 (12)

.26

Bowel surgery

8 (4)

6 (1)

.03

Gastric/bariatric

7 (4)

12 (2)

.45

Exlap

3 (2)

7 (1)

>.99

Hysterectomy

27 (14)

60 (12)

.71

Tubal ligation/oophorectomy/salpingectomy 4 (2)

21 (4)

.18

Renal/bladder/aorta/adrenal

7 (4)

10 (2)

.29

Splenectomy/liver/pancreas

2 (1)

4 (.8)

>.99

ASA, American Society of Anesthesiologists; AVF, arteriovenous fistula; AVM, arteriovenous malformation; CVA, cerebrovascular accident; Exlap, exploratory laparotomy; IIH, idiopathic intracranial hypertension; NPH, normal pressure hydrocephalus; SD, standard deviation.

Catapano JS et al. 16 Table 2. Ventriculoperitoneal shunt outcomes comparing patients with laparoscopic-assisted placement versus non–laparoscopic-assisted placement Non– LaparoscopicLaparoscopicAssisted Assisted Placement (N= Placement P value (OR [95% Characteristic 199) (N=481) CI]) Duration of procedure, min Mean (SD)

54.6 (22.4)

75 (45)

<.001

>60

47 (23)

305 (63)

<.001 (5.6 [3.8-8.2])

Return to emergency department within 30 days

30 (15)

59 (12)

.32 (0.8 [0.5-1.3])

Readmitted within 30 days

20 (10)

57 (12)

.5 (1.2 [0.7-2.1])

Repeat shunt surgery

3 (2)

35 (7)

.002 (5 [1.6-17])

Distal shunt failure

0 (0)

6 (1.2)

Valve

2 (1)

11 (2.3)

Proximal shunt failure

1 (0.5)

5 (1)

Infection

0 (0)

8 (1.7)

Hematoma

0 (0)

5 (1)

Repeat shunt surgery reason

Data are no. (%) of patients unless otherwise indicated. CI, confidence interval; OR, odds ratio; SD, standard deviation

Catapano JS et al. 17 Table 3. Risk factors for repeat shunt surgery for distal shunt failure within 30 days Repeat Shunt Risk Factor Surgery, no. (%) OR (95% CI) P Value Age ≥ 65 years

.22

Yes (n=336)

1 (0.3)

No (n=344)

5 (1.5)

0.202 (0.02, 1.7)

Female sex

.70

Yes (n=304)

2 (0.7)

No (n=376)

4 (1.1)

0.62(0.1-3.3)

Non–laparoscopic-assisted placement

.19

Yes (n=481)

6 (1.2)

No (n=199)

0 (0)

1 (1, 1.023)

Procedure duration >60 min

.69

Yes (n=352)

4 (1.1)

No (n=328)

2 (0.6)

1.9 (0.34, 10.3)

ASA score > 3

.57

Yes (n=89)

1 (1.1)

No (n=588)

5 (0.9)

1.3 (0.15, 11.5)

Previous abdominal surgery

.69

Yes (n=329)

2 (0.6)

No (n=351)

4 (1.1)

0.5 (0.097, 2.9)

Gastric/bariatric prior surgery

.16

Yes (n=19)

1 (5.3)

No (n=661)

5 (0.8)

7.3(0.8-65.6)

Diagnosis: vascular bleed

.36

Yes (n=192)

3 (1.6)

No (n=488)

3 (0.6)

3.4 (1.8, 6.6)

ASA, American Society of Anesthesiologists; CI, confidence interval; OR, odds ratio.

Catapano JS et al. 18 Table 4. Characteristics, outcomes, and results for patients with normal pressure hydrocephalus who received laparoscopic-assisted versus non–laparoscopic-assisted ventriculoperitoneal shunt placement LaparoscopicNon–Laparoscopic-Assisted Assisted Placement Characteristic (N= 111) Placement (N=142) P value Age, mean (SD), years

74.8 (8.7)

74.9 (8.4)

.88

Length of hospital stay, mean (SD), hours

73 (116)

101 (182)

.16

Charges, mean (SD), US$

67,124.11 (23,987)

80,890.35 (50,555)

.009

Distal shunt failure within 30 days

0 (0)

1 (0.7)

.56

Total duration of surgery, mean (SD), min

48.3 (13.5)

65.8 (19.6)

<.001

ASA score >3

2 (1.8)

8 (5.6)

.19

Data are no. (%) unless otherwise indicated. ASA, American Society of Anesthesiologists; SD, standard deviation.

Table 1. Patient demographic and clinical characteristics with placement of first-time ventriculoperitoneal shunt stratified by laparoscopic-assisted versus non–laparoscopic-assisted placement Non– Laparoscopic- LaparoscopicAssisted Assisted Placement Placement Characteristic (N= 199) (N=481) P value Age Mean (SD), years

64.1 (18)

59.3 (17.4)

.002

≥65 years

122 (61.3)

214 (45)

<.001

115 (58)

261 (54)

.45

Male sex ASA score

<.01

1

1 (0.5)

2 (0.4)

2

29 (14.6)

48 (10.0)

3

156 (78.4)

352 (73.2)

4

13 (6.5)

72 (15.9)

5

0 (0)

4 (0.8)

Not charted

0 (0)

3 (0.6)

13/199 (6.5)

76/478 (16)

ASA score >3 Diagnosis

.001 <.001

NPH

111 (56)

142 (30)

Tumor/cyst

40 (20)

151 (31)

Aneurysm/AVM/AVF

16 (8)

86 (18)

IIH

14 (7)

26 (5)

Infectious

4 (2)

20 (4)

Trauma

6 (3)

21 (4)

CVA

3 (2)

25 (5)

Other

5 (3)

10 (2)

Previous abdominal surgery

105 (53)

224 (47)

.15

>1 Abdominal surgery

36 (18)

68 (14)

.53

26 (13)

54 (11)

.51

Type of abdominal surgery Hernia

Appendectomy

31 (16)

60 (12)

.32

Cesarean delivery

14 (7)

21 (4)

.18

Cholecystectomy

31 (16)

59 (12)

.26

Bowel surgery

8 (4)

6 (1)

.03

Gastric/bariatric

7 (4)

12 (2)

.45

Exlap

3 (2)

7 (1)

>.99

Hysterectomy

27 (14)

60 (12)

.71

Tubal ligation/oophorectomy/salpingectomy 4 (2)

21 (4)

.18

Renal/bladder/aorta/adrenal

7 (4)

10 (2)

.29

Splenectomy/liver/pancreas

2 (1)

4 (.8)

>.99

ASA, American Society of Anesthesiologists; AVF, arteriovenous fistula; AVM, arteriovenous malformation; CVA, cerebrovascular accident; Exlap, exploratory laparotomy; IIH, idiopathic intracranial hypertension; NPH, normal pressure hydrocephalus; SD, standard deviation.

Table 2. Ventriculoperitoneal shunt outcomes comparing patients with laparoscopic-assisted placement versus non–laparoscopic-assisted placement Non– LaparoscopicLaparoscopicAssisted Assisted Placement (N= Placement P value (OR [95% Characteristic 199) (N=481) CI]) Duration of procedure, min Mean (SD)

54.6 (22.4)

75 (45)

<.001

>60

47 (23)

305 (63)

<.001 (5.6 [3.8-8.2])

Return to emergency department within 30 days

30 (15)

59 (12)

.32 (0.8 [0.5-1.3])

Readmitted within 30 days

20 (10)

57 (12)

.5 (1.2 [0.7-2.1])

Repeat shunt surgery

3 (2)

35 (7)

.002 (5 [1.6-17])

Distal shunt failure

0 (0)

6 (1.2)

Valve

2 (1)

11 (2.3)

Proximal shunt failure

1 (0.5)

5 (1)

Infection

0 (0)

8 (1.7)

Hematoma

0 (0)

5 (1)

Repeat shunt surgery reason

Data are no. (%) of patients unless otherwise indicated. CI, confidence interval; OR, odds ratio; SD, standard deviation

Table 3. Risk factors for repeat shunt surgery for distal shunt failure within 30 days Repeat Shunt Risk Factor Surgery, no. (%) OR (95% CI) P Value Age ≥ 65 years

.22

Yes (n=336)

1 (0.3)

No (n=344)

5 (1.5)

0.202 (0.02, 1.7)

Female sex

.70

Yes (n=304)

2 (0.7)

No (n=376)

4 (1.1)

0.62(0.1-3.3)

Non–laparoscopic-assisted placement

.19

Yes (n=481)

6 (1.2)

No (n=199)

0 (0)

1 (1, 1.023)

Procedure duration >60 min

.69

Yes (n=352)

4 (1.1)

No (n=328)

2 (0.6)

1.9 (0.34, 10.3)

ASA score > 3

.57

Yes (n=89)

1 (1.1)

No (n=588)

5 (0.9)

1.3 (0.15, 11.5)

Previous abdominal surgery

.69

Yes (n=329)

2 (0.6)

No (n=351)

4 (1.1)

0.5 (0.097, 2.9)

Gastric/bariatric prior surgery

.16

Yes (n=19)

1 (5.3)

No (n=661)

5 (0.8)

7.3(0.8-65.6)

Diagnosis: vascular bleed

.36

Yes (n=192)

3 (1.6)

No (n=488)

3 (0.6)

3.4 (1.8, 6.6)

ASA, American Society of Anesthesiologists; CI, confidence interval; OR, odds ratio.

Catapano JS et al. 1 Table 4. Characteristics, outcomes, and results for patients with normal pressure hydrocephalus who received laparoscopic-assisted versus non–laparoscopic-assisted ventriculoperitoneal shunt placement LaparoscopicNon–Laparoscopic-Assisted Assisted Placement Characteristic (N= 111) Placement (N=142) P value Age, mean (SD), years

74.8 (8.7)

74.9 (8.4)

.88

Length of hospital stay, mean (SD), hours

73 (116)

101 (182)

.16

Charges, mean (SD), US$

67,124.11 (23,987)

80,890.35 (50,555)

.009

Distal shunt failure within 30 days

0 (0)

1 (0.7)

.56

Total duration of surgery, mean (SD), min

48.3 (13.5)

65.8 (19.6)

<.001

ASA score >3

2 (1.8)

8 (5.6)

.19

Data are no. (%) unless otherwise indicated. ASA, American Society of Anesthesiologists; SD, standard deviation.

ABBREVIATIONS: ASA, American Society of Anesthesiologists; CI, confidence interval; CSF, cerebrospinal fluid; LA, laparoscopic-assisted; LAVPS, laparoscopic-assisted ventriculoperitoneal shunt placement; non-LAVPS, non–laparoscopic-assisted ventriculoperitoneal shunt placement; NPH, normal pressure hydrocephalus; OR, odds ratio; VPS, ventriculoperitoneal shunt

AUTHOR CONTRIBUTIONS: 1) The conception and design of the study-Dr. Catapano, Dr. Smith, Dr. Lawton and Dr. Zabramski 2) Acquisition of data-Derrick Wang, Dr. Catapano Dr. Mooney, Dr. Whiting, Dr. Bohl, Dr. Sheehy, Dr. Sarris 3) Analysis and interpretation of data-Dr Catapano and Dr. Whiting 4) Drafting the article-Dr. Catapano, Andrew Mezher and Dr. DiDomenico 5) Revising it critically for important intellectual content-Dr. Zabramski, Dr. Smith, and Dr. Lawton 6) Final approval of the version to be submitted-Dr. Zabramski

DISCLOSURES: None FINANCIAL SUPPORT: None