Ventriculocholecystic shunt. A mortality report

Ventriculo - Gallbladder shunt

INTRODUCTION

Permanent liquor diversion is associated with a high risk of failure and often requires re-intervention. The ventriculo-gallbladder shunt (VGS) has been recognized as a last-resort alternative for treating hydrocephalus when the peritoneum or other distal sites are no longer suitable for receiving shunts. This article aims to report a case from a neurosurgery referral service in Brazil and review the literature on this issue.

METHODS

A systematic literature review was conducted in accordance with the PRISMA statement. The PubMed, Embase, and Web of Science databases were searched for data screening and extraction. The reported case was conducted with ethical approval from the neurosurgical hospital's ethics committee.

RESULTS

G.B.S, male, 43 years old, no comorbidities, who has been dealing with a 12-year history of hydrocephalus, with post-surgical chronic fungal meningitis. Two years ago, he underwent a ventriculoatrial shunt (VAS) placement due to multiple ventriculoperitoneal shunt (VPS) failures. Endocarditis was suspected, and the VAS was removed. As an alternative, VGS was implanted 6 months ago, and since then, there has been no need for a new system review. The gallbladder has an absorptive capacity of 1500 cc of liquid daily, which is more than the normal daily production of cerebrospinal fluid (CSF). Therefore, it is a good alternative when the ventriculoperitoneal shunt is not feasible due to postsurgical peritoneal adhesions or when there are contraindications for ventriculoatrial shunts.

CONCLUSION

VGS is an alternative for patients who cannot undergo the most common surgical interventions, such as VPS.

Double ventriculo-gallbladder shunt in the treatment of giant suprasellar arachnoid cyst with secondary hydrocephalus

Ventriculo-gallbladder shunt is described as an effective alternative procedure in the treatment of hydrocephalus. We present the case of a 19-year-old patient diagnosed with suprasellar arachnoid cyst since his childhood and hydrocephalus, with a double shunt; ventriculo peritoneal and peritoneal cyst shunt. After several replacements due to peritoneal failure, he underwent ventriculoatrial shunt, with associated complications and subsequent repositioning to the peritoneum. After new valve dysfunction due to peritoneal complications, ventriculo-gallbladder shunt was proposed as an alternative treatment for this patient, which was safe and effective in resolving the patient's symptoms, and the patient was discharged, maintaining clinical stability in the follow-up more than 2 years later.

Minimally Invasive Ventriculo-Cholecystic Shunt Placement Utilizing Combined Ultrasound and Fluoroscopic Guidance

For the management of hydrocephalus with ventricular cerebrospinal fluid (CSF) shunting, multiple therapeutic options are available. Among these routes, the most commonly used are ventriculo-peritoneal, ventriculo-atrial, and ventriculo-pleural, while ventriculo-cholecystic is a less common option. Although ventriculo-peritoneal is accepted as the first option, ventriculo-cholecystic shunting may be performed in patients who are poor candidates for other routes of shunt placement. Open cholecystic shunt placement may be contraindicated in patients who have undergone previous surgeries or other comorbidities. Here, we present the case of a 25-year-old female with a complex medical history who presented with a posterior fossa intraparenchymal hemorrhage and subsequent hydrocephalus. She was unable to undergo a ventriculo-peritoneal, atrial, or pleural shunt placement, and thus, a cholecystic shunt placement was chosen. Due to a history of previous surgeries and comorbidities as well as a large volume of idiopathic and recurrent ascites, open placement was contraindicated in this patient. To the best of our knowledge, we present the first successful adult case of a minimally invasive ventriculo-cholecystic shunt placement under ultrasound and fluoroscopic guidance.

Ventriculosternal Shunt for the Treatment of Idiopathic Normal Pressure Hydrocephalus: A Case Report

Background: Conventional corticospinal fluid (CSF) diversion surgery for idiopathic normal pressure hydrocephalus (iNPH) includes ventriculoperitoneal shunt and ventriculoatrial shunt. Ventriculosternal (VS) shunt may be considered if both the abdominal cavity and atrium are not feasible.

Methods: A 76-year-old woman was admitted to our hospital with gait disturbance and urinary incontinence for 2 years, and the condition aggravated in the last 1 month. Based on clinical assessment and imaging findings, the patient was diagnosed with iNPH, with surgical indications. She was on peritoneal dialysis for chronic renal failure, and a cardiac Doppler echocardiogram showed enlargement of the left atrium and decreased diastolic function of the left ventricle. Due to these conditions, we chose the sternum as the vessel for CSF absorption and performed VS shunt.

Results: No swelling, exudation, and effusion were found in the suprasternal fossa. Gait disturbance and urinary incontinence improved significantly immediately and 1 week after surgery, respectively. No shunt-related complication was reported at 16 months follow-up.

Conclusion: This case demonstrated VS shunting as a feasible and alternative for the management of hydrocephalus.

Evaluation of the ventriculocholecystic shunt-an overview of present practice in adult and pediatric hydrocephalus

In the context of hydrocephalus, there are a multitude of therapeutic options that can be explored in order to improve patient outcomes. Although the peritoneum is the current elected clinical solution, various receptacles have been utilized when experiencing contraindications. Along with the ventriculoatrial or ventriculopleural, the ventriculocholecystic shunt was also described as an alternative. In order to make a decision on a place for drainage, the surgeon must be knowledgeable on details from modern literature. The main target of this review was to summarize the currently available information on this topic and assess the status of the gallbladder as a viable option for cerebrospinal fluid diversion.

Innovative approach to the difficult ventricular shunt using pleural access device for maintenance drainage: case report

Patients with complex medical problems and multiple failed ventricular shunts require continued innovation for hydrocephalus management. The authors report the case of a 4-year-old boy with refractory hydrocephalus and secondary reduced ability to absorb CSF in both the pleural and peritoneal cavities following renal transplantation. A novel management approach was devised with split shunting to pleural and peritoneal targets as well as prophylactic pleural port placement to provide a method for minimally invasive thoracentesis should symptomatic pleural effusions develop. Fluid was successfully aspirated via the pleural port with relief of symptoms over a period of 16 months without complication. The authors demonstrate that a previously undescribed approach to distal shunting can prevent neurological sequelae of shunt failure and permit noninvasive maintenance drainage for patients in whom symptomatic pleural effusion is a recurrent complication.

Thinking outside the shunt-sterile CSF malabsorption in pilocytic astrocytomas: case series and review of the literature

INTRODUCTION

Ventriculoperitoneal (VP) shunt insertion is the most common cerebrospinal fluid (CSF) diversionary procedure used for the treatment of chronic hydrocephalus. Sterile CSF ascites is a rare complication of VP shunt insertion. This can arise from either an overproduction of CSF or inadequate filtration of CSF at the level of the peritoneum. By either mechanism, the development of CSF ascites requires an intact VP shunt.

OBJECTIVE

The authors discuss two paediatric cases diagnosed with suprasellar pilocytic astrocytomas treated with platinum-based chemotherapy, who subsequently developed sterile CSF ascites. We review the literature with regard to CSF malabsorption and discuss it as a contributing factor to shunt malfunction.

CONCLUSION

CSF malabsorption with resultant ascites is a rare complication of VP shunting with many etiologies. Two common predisposing factors included the use of platinum-based chemotherapeutic agents, as well as the specific neuropathology. Further analysis of these two entities is needed in order to elucidate their role in contributing to the development of CSF ascites in this patient cohort.

Ventricular Shunts

Ventricular shunts are mechanical devices used in the treatment of hydrocephalus, by means of which cerebrospinal fluid (CSF) is diverted from the ventricles to other low-pressure body cavities. Over the last 50 years, mechanical shunting has become the cornerstone for the treatment of hydrocephalus with shunt valves evolving from simple differential valves to complex programmable valves. The chief complications of ventricular shunting include obstruction, infections, and overdrainage causing subdural hematomas and slit-ventricle syndrome. As the number of commercially available valve designs continues to grow, each new generation aims at reducing the likelihood of complications, especially those resulting from overdrainage. Several studies aimed at establishing the superiority of any valve design have been conducted. All have highlighted the advantages and shortcomings of most models without conclusively providing evidence for choosing one over another. As a result, choices still rest on individual and institutional preferences.

[Ventriculo-gallbladder shunt: An alternative for the treatment of hydrocephalus]

BACKGROUND

In the management of hydrocephalus, the ventriculo-gallbladder shunt is justified in situations where the ventriculo-peritoneal shunt is not useful due to peritoneal involvement and/or when the ventriculo-auricular and ventriculo-pleural shunts are contraindicated.

CLINICAL CASE

A 27 year-old female with hydrocephalus at birth, managed with ventricle-peritoneal shunt, modified 3 times throughout her life due to repeated infections and other different reasons. She was admitted due to colitis caused by Clostridium difficile, presenting concomitant signs of intracranial hypertension and neurological impairment. This led to a review and change of the ventriculo-peritoneal shunt system, with distal dysfunction due to peritoneal thickening. Atrial and pleural shunts were not indicated because the risk of infection. As an alternative, it was decided to place the distal end of the catheter in the gallbladder. The patient recovered her neurological functions after the surgery.

CONCLUSIONS

Drainage alternatives may be needed in 5% of patients with valvular shunt dysfunction. The ventriculo-gallbladder is a good and viable option because it has an absorptive capacity of 1500cc liquid daily, besides being an excellent drainage through the bile duct. The abdominal surgery is easy to perform, and it is an alternative option in the failure of the ventriculo-peritoneal shunt.

The ventriculocholecystic shunt: two case reports and a review of the literature

We describe the re-siting of ventriculoperitoneal shunts to the gallbladder in two children. The first child had a rare case of hydrocephalus associated with plasminogen deficiency. She had had multiple VP shunt revisions due to non-absorption of CSF from the peritoneum. The second had craniopharyngioma-related hydrocephalus with once again a non-absorbing peritoneum. We report no surgical complications in the revisions for both the cases, and there has been a subsequent follow-up of 46 and 28 months, respectively, without incident. A review of the relevant literature describing the use and the performance of ventriculocholecystic shunts in comparison with other ventricular shunts is considered.

The Ventriculo-Gallbladder Shunt in the Treatment of Refractory Hydrocephalus: A Review of the Current Literature

The ventriculo-gallbladder (VGB) shunt has been reported on several occasions for the alleviation of ventriculo-peritoneal (VP) –shunt-refractory hydrocephalus. There is little data regarding VGB shunts and a need for delineating appropriate surgical therapy when cerebrospinal fluid drainage to the peritoneum becomes infeasible. We report our experience with VGB shunt placement in three patients with chronic hydrocephalus. All three had a history of prior VP-shunt placements and revisions due to distal obstruction or infection, or contraindications to alternative forms of ventricular drainage. In one patient, the VGB shunt functioned well for 9 years but was revised due to contamination during an unrelated operation. Neither of the other two patients have experienced VGB shunt-related complications. VP shunts are presently regarded as the standard of care for uncomplicated hydrocephalus. When VP shunts fail, the most common alternatives have been ventriculo-atrial and ventriculo-pleural shunts. In five case series involving 59 patients with VGB shunts, the long-term success rate was 62.7 per cent. Infection (10.2%) and obstruction (10.2%) were the most common complications. Based on durability and a low incidence of complications, it is the current consensus that VGB shunts are a viable alternative with good outcomes in the case of failed VP shunts.

Ventriculogallbladder shunts in pediatric patients

OBJECT

The authors report a clinical protocol for the application of ventriculogallbladder (VGB) shunts in children who may be unable to maintain or receive ventriculoperitoneal (VP) shunts.

METHODS

Eighteen patients underwent placement of VGB shunts as an alternative to VP shunt therapy for the following reasons: malfunction of the VP shunt due to suspected failure of the peritoneum to absorb cerebrospinal fluid (17 cases) and multiple intraabdominal general surgical procedures (1 case). The patients ranged in age from 4 months to 17 years (mean 6.5 +/- 6.1 years [standard deviation {SD}]). All patients underwent preoperative imaging of the gall-bladder either by ultrasonography or computed tomography scanning. A team consisting of a pediatric neurological surgeon and a pediatric general surgeon performed all operative procedures. The procedures were conducted by open laparotomy to precisely place the appropriate length of distal catheter and to anchor it to the gallbladder wall.

RESULTS

There were 2 early shunt malfunctions, both obstructions due to "sludge" (1 in the biliary duct and 1 in the common bile duct). A late-onset (5-year) malfunction occurred secondary to gallbladder stones. In all 3 cases of malfunction, the devices were successfully converted to VP shunts. In 1 patient a conversion to a VP shunt was chosen following a general surgical intervention. There were 2 shunt infections (Staphylococcus epidermidis and Haemophilus influenzae). These were successfully treated. Two patients underwent conversion to a VGB shunt on 2 occasions. Thirteen patients had functional VGB shunts at the time of their last follow-up assessment. The follow-up for these 13 patients ranged from 1 to 8 years (mean 2.1 +/- 2.0 years [SD]).

CONCLUSIONS

Ventriculogallbladder shunts may be considered for the treatment of hydrocephalus in children when the peritoneal cavity cannot be used as a distal terminus.

A rare, delayed complication of a ventriculogallbladder shunt

✓The use of the gallbladder as an alternative cerebrospinal fluid diversion site has been previously described in cases in which all other body cavities, such as the peritoneal cavity, right atrium, or pleural cavity, have been exhausted. Various ventriculogallbladder (VG) shunt complications have been described as well. In the present paper, the authors report on a rare, delayed VG shunt complication. A distal obstruction developed in a previously inserted VG shunt because of a large, radiolucent bile calculus. The presence of the VG shunt could be implicated in the pathogenetic mechanism of the bile calculus formation. The authors also review the pertinent literature.

Case report of symptomatic cholelithiasis after ventricular cholecystic shunt

Hydrocephalus is a prevalent problem in the pediatric population, and patients with ventriculo-peritoneal shunts are often encountered. The use of ventricular cholecystic shunts is an option for patients who are unable to have a ventriculo-peritoneal shunt. This is a case report that describes a late complication of a ventricular cholecystic shunt. Eleven years after insertion of a ventricular cholecystic shunt, the patient developed cholelithiasis encrusted on shunt tubing. The shunt was revised, and 6 months follow-up has shown relief of symptoms and no further evidence of cholelithiasis.

Post-shunt ascites in infants with optic chiasmal hypothalamic astrocytoma: role of ventricular gallbladder shunt

INTRODUCTION

We report a series of infants with optic chiasmal hypothalamic astrocytomas (OCHAs) who developed abdominal ascites following ventriculo-peritoneal (VP) shunting. The mechanism of ascites development among these patients with OCHA remains speculative and unclear.

METHODS

We treated four infants with hypothalamic tumors who were shunted for hydrocephalus using standard VP shunts and who subsequently experienced symptomatic ascites.

RESULTS

In three patients the gallbladder proved an effective alternative site for shunting prior to conversion to other sites, and in one patient the gallbladder shunt remains functional and revision-free.

CONCLUSIONS

Several aspects of the gallbladder as a reservoir for CSF make this approach appealing. Ventricular gallbladder shunting provided an effective (at least temporarily) receptacle for CSF in these patients.

Ventriculo-gallbladder shunts in children

Ventriculoperitoneal shunts are the most common procedure for the treatment of hydrocephalus. Ventriculoatrial shunts are effective but are subject to a higher incidence of potentially serious complications. We report our experience with ventriculo-gallbladder shunts in children. Ventriculo-gallbladder shunts are safe, effective, and technically easy to perform. We recommend their use when ventriculoperitoneal shunts have failed or the peritoneal cavity is not adequate for shunting.

Ventricular gallbladder shunts: an alternative procedure in hydrocephalus

Hydrocephalus is a frequently encountered problem in infancy and is most commonly treated by placement of ventriculoperionteal (VP) or ventriculoatrial (VA) shunts. Other sites for insertion of the distal shunt have included the stomach, ureter, and fallopian tube. This report describes an experience with ventricular gallbladder shunts (VGB) in 25 children performed from 1970 to 1985. There were 13 girls and 12 boys ranging in age from 6 months to 16 years. Diagnosis included meningomyelocoele (7), congenital hydrocephalus (7), postmeningitic complications (5), intracranial tumor (4), and intraventricular hemorrhage (2). Indications for operation included VP shunt infection (15), massive ascites following VP shunt (3), VA shunt infection (4), and distal shunt malfunction due to fibrinous adhesions or cysts (secondary to infection; (3). Three patients had early shunt failure due to proximal obstruction (2) and gallbladder atony (1). Shunt revision was required in two and the atony was successfully treated with cholecystokinin in one. Fourteen shunts remain in place, two patients have been lost to follow-up, and three children died from unrelated causes. Seventy percent of the 20 patients available for long-term follow-up have functional shunts in place. The VGB shunt procedure remains an attractive alternative for patients with hydrocephalus in whom intraperitoneal and intravascular shunts are no longer feasible.