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Dr. Prakash Paudel

Written By Dr. Prakash Paudel

Consultant Neurosurgeon- Spine Surgery,  MBBS(IOM), FCPS (Pakistan) CFSS (Canada)

Pediatric hydrocephalus presents a formidable challenge to healthcare systems worldwide, and nowhere is this more evident than in resource-limited regions like Nepal. In these settings, the standard treatment often involves ventriculoperitoneal (VP) shunt surgery, a procedure that offers hope but also comes with its share of risks. Imagine the plight of a young child in Nepal diagnosed with hydrocephalus, whose journey towards recovery hinges on the success of this surgery. Now, let’s delve deeper into the complexities of this treatment landscape and explore how healthcare providers in Nepal are navigating these challenges to ensure the best possible outcomes for their patients.

Hydrocephalus, characterized by the abnormal accumulation of cerebrospinal fluid in the brain, can result from various underlying causes such as infection, bleeding, tumors, or congenital anomalies. In Nepal, where healthcare resources are scarce, the management of pediatric hydrocephalus poses unique challenges. Access to specialized care, post-operative support, and long-term follow-up are crucial factors that influence the trajectory of a child’s recovery journey.

The cornerstone of treatment for pediatric hydrocephalus in Nepal is VP shunt surgery, a procedure aimed at alleviating symptoms and improving the quality of life for affected children. However, this surgery is not without risks. Complications such as infection and shunt malfunction can occur, posing significant hurdles to successful outcomes. The lack of comprehensive data on complication rates and associated risk factors in low-resource settings like Nepal further complicates the picture.

To shed light on this issue, the author; principal investigator and colleagues from Bir Hospital embarked on a journey to analyze a cohort of pediatric hydrocephalus patients who underwent VP shunt surgery at a prominent hospital in Kathmandu between 2014 and 2017. Through meticulous data collection and analysis, we sought to identify key determinants of complication rates and inform strategies for improving the safety and efficacy of VP shunt surgery in resource-limited settings. During this retrospective analysis, a total of 133 children who underwent VP shunt surgery at the hospital were included in the study. We meticulously examined the medical records and follow-up data of these patients to gather comprehensive information on patient demographics, surgical variables, and postoperative outcomes.

The inclusion criteria for the study comprised pediatric patients aged 15 years or younger who underwent their first VP shunt surgery at the hospital within the specified time frame. This ensured a focused analysis on patients undergoing the initial intervention for hydrocephalus. To ensure consistency and accuracy in data collection, researchers utilized a standardized data collection form. This form likely included fields for recording patient demographics (such as age and gender), details of the surgical procedure (such as duration and surgeon experience), characteristics of the VP shunt (such as type and material), and postoperative outcomes (including complications such as infection and shunt malfunction).

Statistical analyses were then performed on the collected data to identify factors associated with complication rates following VP shunt surgery. These analyses likely included chi-square tests to assess the association between categorical variables (e.g., surgeon experience) and complication rates, as well as Cox proportional hazards regression to evaluate the impact of time-related factors (e.g., surgery duration) on complication rates.

The findings of the study revealed several key insights into the factors influencing complication rates in pediatric hydrocephalus patients undergoing VP shunt surgery in Nepal. For example, the overall complication rate was found to be 26.7%, with shunt malfunction being more common (21.7%) than infection (5%). Factors such as longer surgery times (>1 hour), surgeries performed by less experienced surgeons, and surgeries classified as urgent were associated with higher complication rates. However, demographic factors, tube characteristics, and hospital-related factors did not significantly affect complication rates.

Findings were both enlightening and sobering. Of the children who underwent VP shunt surgery during the study period, a significant proportion experienced complications, with shunt malfunction emerging as a predominant issue. Factors such as longer surgery times, surgeries performed by less experienced surgeons, and urgent procedures were associated with higher complication rates. These insights underscored the critical role of surgical expertise and efficient perioperative management in mitigating adverse outcomes.

However, amidst the challenges, there were also glimmers of hope. The relatively low rate of infection suggested that current antibiotic protocols and wound care practices may be effective in reducing postoperative infections. This finding speaks to the resilience and resourcefulness of healthcare providers in Nepal who are working tirelessly to optimize patient care despite limited resources.

But the journey does not end here. The road ahead is fraught with obstacles, yet filled with opportunities for innovation and improvement. By leveraging the insights gleaned from this study and embracing a holistic approach to care that addresses not only the medical but also the social and economic determinants of health, healthcare providers in Nepal can continue to make strides towards better outcomes for pediatric hydrocephalus patients.

In conclusion, navigating the landscape of pediatric hydrocephalus treatment in Nepal is a journey filled with challenges, but also with hope and resilience. By understanding the complexities of this treatment landscape, healthcare providers can better tailor interventions to meet the unique needs of their patients and ultimately improve the quality of life for children affected by this condition. Together, we can chart a course towards a brighter future for pediatric hydrocephalus care in Nepal and beyond.

Take away: This study investigated the complication rates and risk factors of VP shunt surgery in children with hydrocephalus in Nepal. We found that younger age, longer surgery duration, and lower surgeon experience increased the risk of complications, such as infection and shunt malfunction. These findings suggest that improving surgical skills, reducing operative time, and selecting appropriate candidates for VP shunt surgery may enhance the outcomes of pediatric hydrocephalus patients in Nepal. This study provides valuable insights for healthcare providers and policymakers in low-resource settings, where VP shunt surgery is a common and critical intervention for pediatric hydrocephalus. Future research should explore the role of other factors, such as shunt quality, postoperative care, and follow-up, in determining the long-term outcomes of VP shunt surgery in Nepal.