|Ahead of print
Unusual complications of ventriculoperitoneal shunt surgery: Tertiary care experience
Mohd Faheem1, Manish Jaiswal2, Hanuman P Prajapati1, Raj Kumar3, Noor us Saba4, Bal K Ojha2
1 Department of Neurosurgery, Uttar Pradesh University of Medical Sciences, Saifai, Uttar Pradesh, India
2 Department of Neurosurgery, King George’s Medical University, Lucknow, Uttar Pradesh, India
3 Uttar Pradesh University of Medical Sciences, Saifai, Uttar Pradesh, India
4 Department of Anatomy, Jawahar Lal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
|Date of Submission||10-Jun-2020|
|Date of Decision||06-Aug-2020|
|Date of Acceptance||06-Aug-2020|
|Date of Web Publication||02-Jul-2021|
Department of Neurosurgery, King George’s Medical University, Lucknow 226003, Uttar Pradesh.
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Ventriculoperitoneal shunt (VP shunt) surgery is one of the most common procedures being performed in the pediatric age group in neurosurgical centers worldwide. Although considered a simple surgery, the complications have made it one of the most difficult procedures to manage in the long term. In this study, we describe our experiences in managing the unusual complications of this common procedure in children. Materials and Methods: This retrospective study enrolled 13 pediatric cases having unusual complications related to VP shunt who presented to us from August 2013 to August 2019. All the cases were evaluated for their demographic profile, type of complications, possible pathophysiology, outcome, and management. We had used only spring-valve-based Chhabra VP shunt in all of our cases. Results: The age group ranged between 2 and 18 years, with a male to female ratio of 9:4. Anal extrusion of distal shunt tube was observed in four cases, and two cases each of urethral and oral extrusion were also seen. Two cases developed extrusion of shunt tube through the anterior abdominal wall and one case developed umbilical fistula. Multiple extradural hematoma and intraventricular bleed with partial shunt coil were also seen in each of the cases, respectively. All cases were managed as per need. Conclusion: Unusual complications of VP shunt surgery are increasingly being observed nowadays. Prompt diagnosis and treatment of these complications result in an excellent outcome.
Keywords: Hydrocephalous, shunt extrusion, ventriculoperitoneal shunt
| Introduction|| |
Ventriculoperitoneal shunt (VP shunt) surgery is one of the commonest procedures being performed in children at every neurosurgical center. Numerous complications have been described in the literature including simple catheter obstruction, shunt infection, and distal catheter extrusion through the oral cavity, urethra, anal canal, abdominal wall, cervical region, etc.,, The reported incidence of distal catheter migration is 10%. Ventricular catheter can also cause rare complications such as intraventricular hemorrhage, pneumocephalus, subdural hematoma, and extradural hematoma.,
We report a study of 13 pediatric patients who presented to us with very rare complications of VP shunt surgery over a period of 6 years along with their pathophysiology and management.
| Materials and Methods|| |
The study was conducted from August 2013 to August 2019 at the Department of Neurosurgery, King George’s Medical University and Uttar Pradesh University of Medical Sciences, India. A total of 124 pediatric patients were admitted with the complications of VP shunt surgery, but only 13 patients were included in the present study as they had rare complications. Patients with common complications such as catheter obstruction, infection, drainage malfunction, and other similar complications were excluded from the study.
The ventricular end of the shunt was inserted at Keen’s point on the nondominant side in 12 cases whereas in one case right Kocher’s point was chosen. The lower end was placed at the level of umbilicus by open technique. Chhabra shunt having a spring-based pressure valve was placed in all the cases.
| Results|| |
All 13 pediatric cases were evaluated for their demographic profile, type of complications, possible pathophysiology, outcome, and management.
- Age and sex: Majority of the cases were of 0–5 years old (n = 9, 69.2%), and only 30.8% of the cases included 6–18 years old (n = 4). The ratio of male to female was 9:4 [[Table 1]].
- Type of complications: Of 13 pediatric patients, 11 patients had shunt extrusion (n = 84.6%) and 2 had complications related to the ventricular catheter (n = 15.4%) [[Table 2]].
- Anal extrusion: In four cases, distal shunt was extruded through the anal opening [[Figure 1]]. Two of them were operated for hydrocephalous secondary to tubercular meningitis, and two had congenital hydrocephalous. Three of the cases presented within 6 months, and the remaining one within 9 months after surgery. Previous incisions at the cranial and abdominal end were opened and the shunt was cut at the abdominal end. The lower end was pulled through the anal canal and the remaining portion through the abdominal incision after disconnecting it from the ventricular end [[Figure 2]]. A new shunt assembly was placed on the same side after confirming the sterility of cerebrospinal fluid (CSF) culture.
- Oral extrusion: Two of our cases had shunt extrusion through the oral cavity within 1 year of shunt insertion [[Figure 3]]. Both patients were operated for hydrocephalous secondary to lumbosacral meningomyelocele (LSMMC). The ventricular end was disconnected at the cranial incision and the whole of the shunt tube was retrieved through the abdominal end. Fresh shunt assembly was placed under aseptic conditions.
- Abdominal wall and umbilical region: Two of our pediatric patients had extrusion through the anterior abdominal wall (dehiscence of overlying skin in one and through the previous skin incision in another) [[Figure 4] and [Figure 5]]. Both these children were older than 5 years and operated for hydrocephalous secondary to posterior fossa tumor and craniopharyngioma, respectively. In the patient having skin dehiscence with an exposed shunt, the incision was made at the cranial and abdominal end, and the cut was made in the shunt tube at the site of the exposed shunt on the anterior abdominal wall. The upper part was retrieved through the chest wall and the remaining portion through the lower end. A new shunt assembly was placed from the opposite side. Patient with umbilical fistula was also dealt in a similar way.
- Urethral extrusion: Urethral extrusion was seen in two cases [[Figure 6]]. One of them was operated for hydrocephalous secondary to LSMMC and another for congenital hydrocephalous due to aqueduct stenosis. They presented to us at 6 months and 12 years after the shunt surgery, respectively. The shunt was removed in a similar way as that of anal extrusion. A new shunt system was placed in both the patients after the removal of the previous shunt.
- Intraventricular hemorrhage (IVH) with shunt coil: One of our patients developed IVH with partial coiling of the ventricular end. The child had a persistent headache after shunt surgery. The patient was observed for 2 weeks conservatively on cerebral dehydrants and IVH along hydrocephalous resolved completely in that period [[Figure 7]].
- Extradural hematoma (EDH): A unique complication of multiple EDH developed in a patient operated for hydrocephalous secondary to craniopharyngioma. Here, the shunt was placed at the right Kocher’s point as the patient had scalp infection at the Keen’s point. He developed bifrontal and biparietal EDH secondary to shunt placement. The patient was observed and EDH resolved slowly over a period of 3 months [[Figure 8]].
|Figure 2: Fecal discoloration of the distal end of VP shunt due to long-standing intraluminal bowel content exposure|
Click here to view
|Figure 5: VP shunt tube exposure due to skin necrosis over the chest wall|
Click here to view
|Figure 7: Intraventricular hemorrhage with partial coiling of ventricular end of VP shunt|
Click here to view
| Discussion|| |
Common complications of VP shunt surgery in pediatric patients have been extensively described in the literature. These complications include obstruction, infection, drainage-related malfunction such as over-drainage and under-drainage; however, there is a paucity of literature regarding the uncommon complications such as distal catheter extrusion through the oral cavity, anal opening, urethral opening, abdominal wall, and ventricular catheter-related complications, such as extradural hematoma, subdural hematoma, peritubal hematoma, IVH, shunt coiling within the ventricle, etc., of this commonly performed surgery. These complications are limited only to isolated case reports. In this study, we have described a series of cases with unusual complications along with their possible pathogenesis.,,,,,
Regarding distal catheter migration, bowel perforation resulting in anal extrusion is the commonest manifestation which was first described by Wilson and Bertrand in 1966. The incidence of bowel perforation is reported to be in the range of 0.1–0.7%.,, The exact pathogenesis cannot be ascertained, but it has been hypothesized that constant irritation and adherence of the catheter tip to the visceral wall generate local inflammatory response leading to the perforation of viscus. Anal extrusion is then facilitated by the peristaltic activity of the bowel. We had four pediatric patients who presented with extrusion through the anal canal.
Two of our patients had extrusion of the distal catheter through the oral cavity. The possible pathomechanism is the perforation of the stomach by constant irritation caused by the shunt tip. Once lying inside the stomach, reverse peristalsis caused by repeated vomiting may result in extrusion through the oral cavity. In two cases, the distal catheter came out through the urethral opening. It is a very rare occurrence as the bladder is an extraperitoneal structure. It is proposed that an inflammatory reaction to the foreign body within the peritoneal cavity leads to the fixation of the distal tube to the visceral surface. Now, the increased intraabdominal pressure during respiration and Valsalva manoeuver lead to perforation of the bladder wall and then extrusion through the urethral opening. Other predisposing factor includes trocar injury, previous abdominal surgery, and neurogenic bladder. One of our cases underwent abdominal surgery for anorectal malformation, so that could be one of the reasons for shunt extrusion.
Extrusion of the distal part of the shunt through the abdominal wall and umbilicus is extremely rare, and only a few cases have been reported in the literature. Etiology includes wound dehiscence, shunt tract infection, ischemic necrosis of overlying skin, poor nutrition, congenital anomaly at the umbilicus, and allergy to the shunt components. In one of our cases, overlying skin was necrosed and the shunt was exposed over the anterior chest wall, and in another case, the distal catheter came out from the previous incision site. It was prolapsed from the umbilicus in one of our patients and may be attributed to some congenital malformation at the umbilicus.,
Complications related to the distal catheter include subdural hematoma, extradural hematoma, and intraventricular bleed. It occurs due to the rapid decompression of the intracranial compartment leading to a sudden lowering of intracranial pressure. The reported incidence of epidural bleeding is 5.6% in the study of Driesen and Ellies. In our study, one case developed EDH at multiple locations (bilateral frontal and bilateral parietal regions) after the placement of VP shunt. To the best of our knowledge, this type of unique presentation is the only reported case in the literature. The other case had IVH and partial coiling of the proximal catheter. The reported incidence is 1.59% in the study of Gong et al. and it may be due to coexistent bleeding disorder, hemorrhage from occult vascular malformation, and repeated attempt to place VP shunt in the ventricle.
The proper management of all these complications includes prompt removal of shunt assembly, intravenous antibiotic as per CSF culture report, and then placement of fresh shunt assembly. External ventricular drain can be placed unless CSF culture becomes sterile on at least three successive samples. Fresh VP shunt is then planned depending upon the clinical status of the patient.
| Conclusion|| |
Apart from common complications of VP shunt surgery, uncommon complications are increasingly being observed in children nowadays. Neurosurgeons must acquaint themselves to deal with these rare complications. Prompt diagnosis and treatment of these uncommon complications result in an excellent outcome.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Paff M, Alexandru-Abrams D, Muhonen M, Loudon W. Ventriculoperitoneal VD complications: A review. Interdiscip Neurosurg 2018;13:66-70.
Wu Y, Green NL, Wrensch MR, Zhao S, Gupta N. Ventriculoperitoneal shunt complications in California: 1990 to 2000. Neurosurgery2007;61:557-62.
Vankipuram S, Jaiswal S, Jaiswal M, Bajaj A, Chandra A, Ojha BK. Spontaneous umbilical CSF fistula due to migration of the peritoneal end of VP shunt: a case report and review of pathogenesis. J Pediatr Neurosci 2017;12:285-7.
] [Full text]
Kast J, Duong D, Nowzari F, Chadduck WM, Schiff SJ. Time-related patterns of ventricular shunt failure. Childs Nerv Syst 1994;10:524-8.
Kalia KK, Swift DM, Pang D. Multiple epidural hematomas following ventriculoperitoneal shunt. Pediatr Neurosurg 1993;19:78-80.
Driesen W, Elies W. Epidural and subdural hematomas as a complication of internal drainage of cerebrospinal fluid in hydrocephalus. Acta Neurochir 1974;30:85-93.
Gong W, Xu L, Yang P, Yu Z, Wang Z, Chen G, et al
. Characteristics of delayed intracerebral hemorrhage after ventriculoperitoneal shunt insertion. Oncotarget 2017;8:42693-9.
Wilson CB, Bertan V. Perforation of the bowel complicating peritoneal shunt for hydrocephalus. Report of two cases. Am Surg 1966;32:601-3.
Snow RB, Lavyne MH, Fraser RA. Colonic perforation by ventriculoperitoneal shunts. Surg Neurol 1986;25:173-7.
Sathyanarayana S, Wylen EL, Baskaya MK, Nanda A. Spontaneous bowel perforation after ventriculoperitoneal shunt surgery: case report and a review of 45 cases. Surg Neurol 2000;54:388-96.
Ferreira PR, Bizzi JJ, Amantéa SL. Protrusion of ventriculoperitoneal shunt catheter through the anal orifice. A rare abdominal complication. J Pediatr Surg 2005;40:1509-10.
Thiong’o GM, Luzzio C, Albright AL. Ventriculoperitoneal shunt perforations of the gastrointestinal tract. J Neurosurg Pediatr2015;16:36-41.
Sridhar K, Karmarkar V. Peroral extrusion of ventriculoperitoneal shunt: case report and review of literature. Neurol India 2009;57:334-6.
] [Full text]
Ahmed A, Sandlas G, Kothari P, Sarda D, Gupta A, Karkera P, et al
. Outcome analysis of shunt surgery in hydrocephalus. J Indian Assoc Pediatr Surg2009;14:98-101.
] [Full text]
Silav G, Tun K, Dolgun H, Unlu A, Selcuki M. The spontaneous umbilical perforation of the distal end of ventriculoperitoneal shunt. Neurochirurgie 2002;48:128-30.
Turtas S, Orunesu G. Extrusion of peritoneal catheter through a thoracic skin fistula: report of a rare complication of ventriculoperitoneal shunt. Neurochirurgia (Stuttg) 1992;35:121-2.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2]