Practice patterns of Canadian neurosurgeons for initial placement of ventriculoperitoneal shunts – a Delphi study on the benefits and challenges of implementing laparoscopic approaches

Practice patterns of Canadian neurosurgeons for initial placement of ventriculoperitoneal shunts

U of A ethics approval: Pro00128728

Second round of the study

Principal Investigator(s) (Supervisor(s)) (Primary Contact:

Dr. Kim

Assistant Professor

Faculty of Medicine and Dentistry

University of Alberta

Edmonton, AB

(780) 407-1165

mjkim@ualberta.ca

Co-investigator(s) (Student(s)): Dr. Chow

Clinical Associate Professor

Faculty of Medicine and Dentistry

University of Alberta

Edmonton, AB

(780) 407-1428

Dr. Heppner

Resident

Faculty of Medicine and Dentistry

University of Alberta

Edmonton, AB

(306) 717-3141

jmheppne@ualberta.ca

Invitation to Participate:

Our sincere thanks to those who have participated in the first round of the Delphi survey! You will find that there is a summary of the results from the first round included in some of the questions here. This is the second round wherein we have included ideas and issues not present in the first round, and we aim to close in on consensus through refined versions of the prior questions. It is expected that at least one more subsequent survey will be needed after this one to identify consensus on the issues of discussion.

Please note that in addition, we will be asking for the center at which you practice so that we can assess the extent to which we are capturing the overall Canadian Neurosurgical perspective. This is very important towards our goal of obtaining consensus of opinion. Aside from this, all data entered continues to be anonymous, and no other personal information is required.

As before:

You are again invited to participate in this research study about utilization of laparoscopy in the placement of primary ventriculoperitoneal (VP) shunts in Canada, because as a practicing Neurosurgeon you may have experience in placement of VP shunts. You are receiving this invitation through the Canadian Neurosurgical Society database of members. Eligibility entails anyone who is currently a practicing neurosurgeon in Canada.

Purpose of the Study: From this research we wish to learn what current experience, opinion, and practice exists in the Canadian Neurosurgical community regarding utilization of laparoscopy for the placement of the abdominal catheter in VP shunt procedures. While there is evidence in the literature supporting the possible benefits of this approach, there have been no definitive evidence-based position statements made either in favor or against this alternative to the classic mini-laparotomy. Furthermore, none of the published trials comparing laparoscopic to the mini-laparotomy approach have included Canada.

Thank you in advance for your ongoing time and participation in our research.

Question Title

* 1. Most respondents in the initial survey have experience with laparoscopic assistance (65.5%), very few use it exclusively for de novo shunts.

IF you do not have experience with laparoscopic placement, what is the limiting factor(s) or barriers at your center that may limit this? Please choose all that apply.

a. Access to General Surgery personnel

a. Personal preference

a. Lack of experience

a. Concerns of personnel in the OR relating to infection risk (i.e. local shunt protocol)

Other (please specify)

Question Title

* 2. Most participants in the previous survey felt that there is no bias for or against laparoscopic assistance at their center (72.4%). Only 3.45% feel their center has a negative opinion about laparoscopic assistance.

Have you ever felt pressure from your center or colleagues to utilize laparoscopic assistance when you might not have otherwise wanted to do so?

Yes

Question Title

* 3. IF there are barriers to utilization of laparoscopic assistance at your center, what you believe is the major barrier?

Lack of access

Lack of experience

Superiority of the mini-laparotomy

Non-inferiority of the mini-laparotomy

Non-superiority of laparoscopic assistance

Other (please specify)

Question Title

* 4. If you were to estimate the frequency of complications following a de novo VP shunt for all comers, what number would you quote a patient based on local practice? Please keep in mind that we recognize this is a subjective assessment for each respondent. We aim to identify differences in institutional experiences that may differ nationally and from the literature values. We acknowledge that the numbers you provide are purely a ballpark estimate which should represent the relative likelihood of each complication.

	0-5%	6-10%	11-15%	16-20%	>20%
Infection	Infection 0-5%	Infection 6-10%	Infection 11-15%	Infection 16-20%	Infection >20%
Distal catheter obstruction	Distal catheter obstruction 0-5%	Distal catheter obstruction 6-10%	Distal catheter obstruction 11-15%	Distal catheter obstruction 16-20%	Distal catheter obstruction >20%
Proximal catheter obstruction	Proximal catheter obstruction 0-5%	Proximal catheter obstruction 6-10%	Proximal catheter obstruction 11-15%	Proximal catheter obstruction 16-20%	Proximal catheter obstruction >20%
Post-operative pain that cannot be adequately managed	Post-operative pain that cannot be adequately managed 0-5%	Post-operative pain that cannot be adequately managed 6-10%	Post-operative pain that cannot be adequately managed 11-15%	Post-operative pain that cannot be adequately managed 16-20%	Post-operative pain that cannot be adequately managed >20%
Misplacement of the distal catheter	Misplacement of the distal catheter 0-5%	Misplacement of the distal catheter 6-10%	Misplacement of the distal catheter 11-15%	Misplacement of the distal catheter 16-20%	Misplacement of the distal catheter >20%
Intra-abdominal adhesion creation	Intra-abdominal adhesion creation 0-5%	Intra-abdominal adhesion creation 6-10%	Intra-abdominal adhesion creation 11-15%	Intra-abdominal adhesion creation 16-20%	Intra-abdominal adhesion creation >20%
Incisional hernia	Incisional hernia 0-5%	Incisional hernia 6-10%	Incisional hernia 11-15%	Incisional hernia 16-20%	Incisional hernia >20%
Intra-abdominal pseudocyst	Intra-abdominal pseudocyst 0-5%	Intra-abdominal pseudocyst 6-10%	Intra-abdominal pseudocyst 11-15%	Intra-abdominal pseudocyst 16-20%	Intra-abdominal pseudocyst >20%
Visceral injury	Visceral injury 0-5%	Visceral injury 6-10%	Visceral injury 11-15%	Visceral injury 16-20%	Visceral injury >20%
Over-shunting	Over-shunting 0-5%	Over-shunting 6-10%	Over-shunting 11-15%	Over-shunting 16-20%	Over-shunting >20%
Under-shunting	Under-shunting 0-5%	Under-shunting 6-10%	Under-shunting 11-15%	Under-shunting 16-20%	Under-shunting >20%
CSF leak	CSF leak 0-5%	CSF leak 6-10%	CSF leak 11-15%	CSF leak 16-20%	CSF leak >20%
Intracerebral hemorrhage	Intracerebral hemorrhage 0-5%	Intracerebral hemorrhage 6-10%	Intracerebral hemorrhage 11-15%	Intracerebral hemorrhage 16-20%	Intracerebral hemorrhage >20%
Intraventricular hemorrhage	Intraventricular hemorrhage 0-5%	Intraventricular hemorrhage 6-10%	Intraventricular hemorrhage 11-15%	Intraventricular hemorrhage 16-20%	Intraventricular hemorrhage >20%
Scalp complication including infection and hematoma	Scalp complication including infection and hematoma 0-5%	Scalp complication including infection and hematoma 6-10%	Scalp complication including infection and hematoma 11-15%	Scalp complication including infection and hematoma 16-20%	Scalp complication including infection and hematoma >20%
Catheter fracture	Catheter fracture 0-5%	Catheter fracture 6-10%	Catheter fracture 11-15%	Catheter fracture 16-20%	Catheter fracture >20%

Question Title

* 5. A consensus emerged in the previous survey that in patients undergoing revision of VP shunt, infection was the most important complication (29.1%). This was followed by roughly equivalent importance of issues with proximal or distal catheter, and misplacement of the distal catheter.

In your opinion, is laparoscopic assistance likely superior in revision surgeries for a VP shunt where both the proximal and distal catheters are possibly in need of revision?

Yes

Maybe (please specify)

Question Title

* 6. No one in the previous survey felt that laparoscopic assistance would help prevent proximal catheter misplacement. Otherwise for all other complications there were respondents who disagreed to some degree whether laparoscopic assistance could reduce specific complication incidence.

93% felt that laparoscopic assistance WOULD reduce distal catheter misplacement.

73% felt that laparoscopic assistance WOULD reduce incisional hernia.

64% felt that laparoscopic assistance WOULD reduce post-operative pain.

75% felt that laparoscopic assistance would NOT reduce the chance of infection.

67.8% felt that laparoscopic assistance would NOT reduce the chance of intra-abdominal pseudocyst.

60.7% felt that laparoscopic assistance would NOT reduce the chance of intra-abdominal adhesions.

What is the expected likelihood of laparoscopic assistance to REDUCE the incidence of the following complications? We acknowledge that the numbers you provide are purely a ballpark estimate which should represent the relative likelihood with respect to each complication in your experience and at your center.

	0%	1-9%	10-19%	20-29%	30-50%	>50%
Distal catheter misplacement	Distal catheter misplacement 0%	Distal catheter misplacement 1-9%	Distal catheter misplacement 10-19%	Distal catheter misplacement 20-29%	Distal catheter misplacement 30-50%	Distal catheter misplacement >50%
Incisional hernia	Incisional hernia 0%	Incisional hernia 1-9%	Incisional hernia 10-19%	Incisional hernia 20-29%	Incisional hernia 30-50%	Incisional hernia >50%
Infection	Infection 0%	Infection 1-9%	Infection 10-19%	Infection 20-29%	Infection 30-50%	Infection >50%
Post-operative pain	Post-operative pain 0%	Post-operative pain 1-9%	Post-operative pain 10-19%	Post-operative pain 20-29%	Post-operative pain 30-50%	Post-operative pain >50%
Intra-abdominal pseudocyst	Intra-abdominal pseudocyst 0%	Intra-abdominal pseudocyst 1-9%	Intra-abdominal pseudocyst 10-19%	Intra-abdominal pseudocyst 20-29%	Intra-abdominal pseudocyst 30-50%	Intra-abdominal pseudocyst >50%
Intra-abdominal adhesions	Intra-abdominal adhesions 0%	Intra-abdominal adhesions 1-9%	Intra-abdominal adhesions 10-19%	Intra-abdominal adhesions 20-29%	Intra-abdominal adhesions 30-50%	Intra-abdominal adhesions >50%
Visceral injury	Visceral injury 0%	Visceral injury 1-9%	Visceral injury 10-19%	Visceral injury 20-29%	Visceral injury 30-50%	Visceral injury >50%
Distal catheter obstruction	Distal catheter obstruction 0%	Distal catheter obstruction 1-9%	Distal catheter obstruction 10-19%	Distal catheter obstruction 20-29%	Distal catheter obstruction 30-50%	Distal catheter obstruction >50%
Over-shunting	Over-shunting 0%	Over-shunting 1-9%	Over-shunting 10-19%	Over-shunting 20-29%	Over-shunting 30-50%	Over-shunting >50%
Under-shunting	Under-shunting 0%	Under-shunting 1-9%	Under-shunting 10-19%	Under-shunting 20-29%	Under-shunting 30-50%	Under-shunting >50%
CSF leak	CSF leak 0%	CSF leak 1-9%	CSF leak 10-19%	CSF leak 20-29%	CSF leak 30-50%	CSF leak >50%
Intracerebral hemorrhage	Intracerebral hemorrhage 0%	Intracerebral hemorrhage 1-9%	Intracerebral hemorrhage 10-19%	Intracerebral hemorrhage 20-29%	Intracerebral hemorrhage 30-50%	Intracerebral hemorrhage >50%
Intraventricular hemorrhage	Intraventricular hemorrhage 0%	Intraventricular hemorrhage 1-9%	Intraventricular hemorrhage 10-19%	Intraventricular hemorrhage 20-29%	Intraventricular hemorrhage 30-50%	Intraventricular hemorrhage >50%
Scalp complication not including infection or hematoma	Scalp complication not including infection or hematoma 0%	Scalp complication not including infection or hematoma 1-9%	Scalp complication not including infection or hematoma 10-19%	Scalp complication not including infection or hematoma 20-29%	Scalp complication not including infection or hematoma 30-50%	Scalp complication not including infection or hematoma >50%
Catheter fracture	Catheter fracture 0%	Catheter fracture 1-9%	Catheter fracture 10-19%	Catheter fracture 20-29%	Catheter fracture 30-50%	Catheter fracture >50%

Question Title

* 7. Would you expect that operative times for laparoscopic VP shunt placement would eventually decrease or be similar to open shunt placement as experience and protocols develop and are refined?

Yes

Question Title

* 8. Most in the previous survey felt that length of hospital stay following VP shunt would be about the same with or without laparoscopic assistance (79.3%). 13.8% felt laparoscopic assistance could reduce length of stay.

What is the most frequent cause of increased length of stay for patient receiving a de novo VP shunt?

Infection

Post-operative pain (cranial or neck)

Post-operative pain (abdominal)

Over-shunting

Under-shunting

Unrelated comorbidities

Other (please specify)

Question Title

* 9. Please specify the center at which you primarily currently perform shunt surgeries.

Dalhousie University

Greater Toronto Area acute care centres (including University of Toronto, Sunnybrook Hospital, Hamilton Hospital, London Hospital, Kingston Hospital, Windsor Hospital, and McMaster University)

Kamloops Hospital

Kelowna Hospital

Ottawa Hospital

University of Alberta (including Royal Alexandra Hospital)

University of British Columbia ((including Lions Gate hospital)

University of Calgary

University of Manitoba

University of Regina

University of Saskatchewan

University of Sherbrooke

Thunder Bay Hospital

Victoria Hospital

CHUM

McGill

Laval University

University of Montreal

The Scared Heart Hospital

Maisonneuve-Rosemont Hospital

Sainte-Justine Hospital

MUHC

Charles-Lemoyne Hospital

Chicoutimi Health and Social Service Centre

Trois-Rivieres Hospital

Gatineau Health and Social Service Centre