Intra-abdominal cyst following revision of ventriculoperitoneal shunt--case report

Sheath formation around peritoneal tube: possible explanation for unknown cause of ventriculoperitoneal shunt failure

Ventriculoperitoneal (VP) shunt failures are common and are frequently associated with an obstruction of the peritoneal tube. This study aimed to explore the possible causes of peritoneal tube obstruction, which are largely unknown. From January 1981 to June 2018, we performed VP shunting in 646 patients with hydrocephalus. Among the procedures performed, 148 shunt revision procedures were performed in 98 patients with VP shunt failure. Of the study participants, 64 (43.2%) patients were diagnosed with peritoneal tube obstruction and five patients developed sheath formation that obstructed the end of the peritoneal tubes. Sheath formation around the peritoneal tube is a possible cause of VP shunt dysfunction.

Treatment of abdominal pseudocysts and associated ventricuoperitoneal shunt failure

PURPOSE

The purpose of this study was to determine whether drainage and revision are an effective treatment for abdominal pseudocyst associated ventriculoperitoneal (VP) shunt failure by estimating the total rate of secondary shunt failure.

METHODS

We performed a retrospective review of children with hydrocephalus diagnosed with and treated for an abdominal pseudocyst at the Children's Hospital, London Health Sciences Centre (LHSC) between January 1, 2000 and May 31, 2016 (ethics approval # 108136). Patients with a VP shunt were included if (i) the development of an abdominal pseudocyst at age 2 to 18 years was identified, (ii) treatment of the pseudocyst by either interventional radiology (IR) or surgical drainage, and (iii) revision of the VP shunt. Demographic data and details of pseudocyst formation/ treatment as well as subsequent failures were identified.

RESULTS

Twelve patients who had a VP shunt developed abdominal pseudocyst and met inclusion criteria. A 91% shunt failure rate after drainage and shunt revision was identified. Three patients had the pseudocyst drained in interventional radiology and then externalized due to shunt infection. Nine patients were treated by surgical revision. Ten patients experienced recurrent shunt failure following initial drainage of the pseudocyst: pseudocyst reoccurrence (n = 3), distal obstruction from adhesions (n = 1), and uncleared infection (n = 6).

CONCLUSION

The results suggest that pseudocyst drainage and shunt revision is ineffective in providing long-term resolution of shunt problems.

Fibrous encapsulation of the peritoneal catheter in peritoneal shunt: Case report

Background:

The authors report a case of fibrous encapsulation of the peritoneal catheter, which caused peritoneal shunt malfunction, and has not previously been researched well as a complication of peritoneal shunts.

Case Description:

A 69-year-old woman who had undergone a lumboperitoneal (LP) shunt for communicative hydrocephalus following subarachnoid hemorrhage caused by a ruptured aneurysm was identified with malfunction of the LP shunt system by dementia and gait disturbance. Hydrocephalus was revealed on computed tomography (CT). Under a laparoscopy, the intraabdominal peritoneal catheter was observed to be obstructed by fibrous encapsulation covering it like a long white stocking. Although the fibrous encapsulating tissue was excised by laparoscopy forceps, a ventriculoperitoneal shunt device was replaced with a new peritoneal catheter. The histopathological diagnosis of the surgically resected encapsulating tissue was the fibrous tissue with a few inflammation cells and a layer of lining cells surrounding some part of it. In the immunohistochemical study, a layer of lining cells surrounding the fibrous tissue showed immunohistochemically positive staining for calretinin.

Conclusion:

The fibrous encapsulation would be formed by peritoneal reaction to a peritoneal catheter as a foreign body by these histopathological and immunohistochemical analyses.

Fibrous capsule formation of the peritoneal catheter tip in ventriculoperitoneal shunt: Two case reports

Background:

A fibrous capsule formation of a peritoneal catheter tip has not previously been researched as a complication of ventriculoperitoneal (VP) shunts.

Case Description:

Two adult patients who had undergone a VP shunt for communicative hydrocephalus following subarachnoid hemorrhage caused by a ruptured aneurysm have been identified with malfunction of the VP shunt system by mild disturbance of consciousness and gait disturbance or loss of appetite. Hydrocephalus was diagnosed by computed tomography and the obstruction of the peritoneal catheter was revealed by shuntgraphy. Laparoscopy was performed and the peritoneal catheter tips were obstructed by fibrous white capsules that covered them. One was a thin membranous capsule like a stocking with two small endoluminal granulomas of the peritoneal catheter, and other one was a fibrous glossy white capsule like a sock. These fibrous capsules were excised by laparoscopy forceps without the conversion to a new peritoneal catheter. Following the procedure, the shunt functioned normally. The pathological diagnoses were peritoneum with foreign body reaction or hyalinization of membranous tissue surrounded by fibrous tissue.

Conclusion:

These fibrous capsules might be formed by the peritoneal reaction to cerebrospinal fluid as a foreign material. As such, a periodic medical check should be scheduled since a fibrous capsule of the peritoneal catheter tip might be formed again.

Laparoscopic assisted ventriculoperitoneal shunt revisions as an option for pediatric patients with previous intraabdominal complications

Multiple shunt failure is a challenge in pediatric neurosurgery practice and one of the most feared complications of hydrocephalus.

OBJECTIVE

To demonstrate that laparoscopic procedures for distal ventriculoperitoneal shunt failure may be an effective option for patients who underwent multiple revisions due to repetitive manipulation of the peritoneal cavity, abdominal pseudocyst, peritonitis or other situations leading to a "non reliable" peritoneum.

METHOD

From March 2012 to February 2013, the authors reviewed retrospectively the charts of six patients born and followed up at our institution, which presented with previous intra-peritoneal complications and underwent ventriculoperitoneal shunt revision assisted by video laparoscopy.

RESULTS

After a mean follow-up period of nine months, all patients are well and no further shunt failure was identified so far.

CONCLUSION

Laparoscopy assisted shunt revision in children may be, in selected cases, an effective option for patients with multiple peritoneal complications due to ventriculo-peritoneal shunting.

Abdominal cerebrospinal fluid pseudocyst: a comparative analysis between children and adults

PURPOSE

Abdominal cerebrospinal fluid (CSF) pseudocyst is a rare but important complication in patients with ventriculoperitoneal shunt (VPS). In addition to presenting our experience, we performed a comparative analysis between children and adults with this entity. To the author's knowledge, there are no studies in which this condition has been compared.

METHODS

The PubMed database was searched for all relevant reports published from 1954 to 2012. The differences were statistically compared, especially regarding clinical investigations, etiology of the hydrocephalus, shunt revision, CSF infection, treatment, and recurrence. Chi-square test or Fisher's exact test was used to find associations among the variables.

RESULTS

Compiled from literature, we found 393 cases of abdominal pseudocyst: 295 children, including our cases, and 55 adults, with age not informed in 43 cases. In children, 33 % of the patients have a positive culture on presentation, with higher incidence in children younger than 10 years. In contrast, only 15 % among adults were positive CSF culture. In total, 287 abdominal pseudocyst cases who underwent shunt revision have been reported; 78.4 % of children and 62.2 % of adults. The main occurrence of this complication according to the etiology of hydrocephalus in children was different from adults. The recurrence of pseudocyst occurred in 19.8 and 24.2 % of children and adults, respectively.

CONCLUSIONS

The differences between children and adults might represent distinct trends on the etiology and treatment of this entity. Hence, additional well-designed cohort studies will be necessary to strengthen our findings.

Laparotomy versus Laparoscopic Placement of Distal Catheter in Ventriculoperitoneal Shunt Procedure

OBJECTIVE

Traditionally, peritoneal catheter is inserted with midline laparotomy incision in ventriculoperitoneal (V-P) shunt procedures. Complications of V-P shunt is not uncommon and have been reported to occur in 5-37% of cases. The aim of this study is to compare the clinical outcomes and the operation time between laparotomy and laparoscopic groups.

METHODS

A total of 155 V-P shunt procedures were performed to treat hydrocephalic patients of various origins in our institute between June 2006 to January 2010; 95 of which were laparoscopically guided and 65 were not. We reviewed the operation time, surgery-related complications, and intraoperative and postoperative problems.

RESULTS

In the laparoscopy group, the mean duration of the procedure (52 minutes) was significantly shorter (p < 0.001) than the laparotomy group (109 minutes). There were two cases of malfunctions and one incidence of diaphragm injury in the laparotomy group. In contrast, there were neither malfunction nor any internal organ injuries in the laparoscopy group (p = 0.034). There were total of two cases of infections from both groups (p = 0.7).

CONCLUSION

Laparoscopically guided insertions of distal shunt catheter is considered a fast and safe method in contrast to the laparotomy technique. This method allows the exact localization of the peritoneal catheter and a confirmation of its patency.

Single Trocar Laparoscopically Assisted Placement of Central Nervous System–Peritoneal Shunts

BACKGROUND

Lumbar peritoneal and ventriculoperitoneal shunts are widely used for the treatment of hydrocephalus. In the past, the abdominal portion of these procedures required laparotomy. With the advent of minimally invasive techniques, laparoscopically assisted placement of the distal catheter has been tried.

MATERIALS AND METHODS

We performed 10 shunt procedures (3 lumbar peritoneal, 6 ventriculoperitoneal, and 1 meningomyelocele-peritoneal) in 10 patients (mean age 56; age range, 30-78 years). Four patients had undergone previous open shunt placement that failed. The abdominal portion of the procedure was performed using a 5-mm trocar and a 10Fr introducer for camera and catheter insertion. In 3 cases, an additional 5-mm port was necessary for lysis of adhesions. These access punctures did not require fascial closure and caused minimal pain and limitation.

RESULTS

No intra- or postoperative complications were encountered in this small patient group. At a median follow-up of 50 months (range, 3-56 months) all patients had functioning shunts.

CONCLUSION

Single trocar laparoscopically assisted placement of central nervous system-peritoneal shunts is safe and simple, and should be considered the procedure of choice. This technique is also suitable for repositioning migrated catheters and other catheter-tip manipulations.

Ventriculoperitoneal Shunt Dysfunction in Adults Secondary to Conditions Causing a Transient Increase in Intra-abdominal Pressure: Report of Three Cases

OBJECTIVE AND IMPORTANCE:

Ventriculoperitoneal (VP) shunts function because of the pressure differential between the intracranial space and the peritoneal cavity. The pressure in the peritoneal cavity is the lower of the two in a properly functioning shunt; thus, cerebrospinal fluid flows distally. Although not reported in the literature, adult constipation, ileus, or small bowel obstruction can alter this pressure balance and cause dysfunction. If not recognized as a transient, easily treated phenomenon, patients may be subjected to unnecessary shunt revisions. This study analyzed the occurrence of shunt malfunction in three adults secondary to transient increases in intra-abdominal pressure.

CLINICAL PRESENTATION:

Three patients with clinical symptoms and radiographic evidence of VP shunt malfunction at presentation were found to have transient conditions causing a significant increase in intra-abdominal pressure. These patients' records were evaluated with an emphasis on risk factors, treatments, and outcomes.

INTERVENTION:

After resolution of the patients' abdominal issues, clinical signs and symptoms of VP shunt dysfunction resolved within 24 hours. Radiographic evidence of the resolution of shunt failure also was observed.

CONCLUSION:

Shunt malfunction or dysfunction consumes many person-hours and healthcare dollars. This study provides anecdotal evidence that transient and easily reversible increases in the intra-abdominal pressure of adults with VP shunts can result in dysfunction. Although it may not be practical to delay shunt revision while attempting to correct constipation, ileus, or small bowel obstruction, clinicians treating patients with these abdominal conditions should be aware that they could cause transient VP shunt failure. It would seem prudent that patients with VP shunts be started on a prophylactic bowel regimen before surgical procedures to decrease the risk of this somewhat preventable result.