Recurrent perforations of viscus due to ventriculoperitoneal shunt in a hydrocephalic child

Migration of the distal ventriculoperitoneal shunt catheter into the stomach with or without trans-oral extrusion: A systematic literature review and meta-analysis

BACKGROUND

Intra-gastric migration of the distal ventriculoperitoneal shunt (VPS) catheter clinically presenting with or without trans-oral extrusion is one of the rare complications of VPS catheter insertion.

AIM

To identify the demographics, clinical presentation, clinical findings, and results of surgical therapy offered for the treatment of intra-gastric migration of the distal VPS catheter, clinically presented with or without trans-oral extrusion.

METHODS

An online search was performed for the extraction/retrieval of the published/ available literature pertaining to the above-mentioned VPS complication. Manuscripts were searched from PubMed, PMC (PubMed Central), ResearchGate, and Google Scholar databases using various terminology relating to the VPS complications. The first case of migration of a VPS catheter into the stomach was reported in the year 1980, and the data were retrieved from 1980 to December 2022. Cases were categorized into two groups; Group A: Cases who had migration of the distal VPS catheter into the stomach and clinically presented with trans-oral extrusion of the same, and Group B: Cases who had migration of the distal VPS catheter into the stomach, but presented without trans-oral extrusion.

RESULTS

A total of n = 46 cases (n = 27; 58.69% male, and n = 19; 41.3% females) were recruited for the systematic review. Group A included n = 32, and Group B n = 14 cases. Congenital hydrocephalus was the indication for the primary VPS insertion for approximately half of the (n = 22) cases. Approximately sixty percent (n = 27) of them were children ≤ 5 years of age at the time of the diagnosis of the complication mentioned above. In seventy-two percent (n = 33) cases, this complication was detected within 24 mo after the VPS insertion/last shunt revision. Clinical diagnosis was evident for the entire group A cases. Various diagnostic modalities were used to confirm the diagnosis for Group B cases. Various surgical procedures were offered for the management of the complication in n = 43 cases of both Groups. In two instances, intra-gastric migration of the distal VPS catheter was detected during the autopsy. This review documented four deaths.

CONCLUSION

Intra-gastric migration of the peritoneal end of a VPS catheter is one of the rare complications of VPS catheter implantation done for the treatment of hydrocephalus across all age groups. It was more frequently reported in children, although also reported in adults and older people. A very high degree of clinical suspicion is required for the diagnosis of a case of an intra-gastric migration of the distal VPS catheter clinically presenting without trans-oral extrusion.

Migration of the distal catheter of the ventriculoperitoneal shunt in hydrocephalus: A Comprehensive Analytical Review from an Anatomical Perspective

There have been many reports on migration of the distal catheter of the ventriculoperitoneal shunt (VPS) since this phenomenon was recognized 50 years ago. However, there have been no attempts to analyze its different patterns or to assess these patterns in terms of potential risk to patients. We comprehensively reviewed all reports of distal VPS catheter migration indexed in PubMed and identified three different anatomical patterns of migration based on catheter extension and organs involved: (1) internal, when the catheter invades any viscus inside the thoracic, abdominal, or pelvic cavity; (2) external, when the catheter penetrates through the body wall either incompletely (subcutaneously) or completely (outside the body); and (3) compound, when the catheter penetrates a hollow viscus and protrudes through a pre-existing anatomical orifice. We also analyzed the association between each migration type and several key factors. External migration occurred mostly in infants. In contrast, internal migration occurred mostly in adults. A body wall weakness was not a risk factor for catheter protrusion. Shunt duration was a critical factor in the migration pattern, as most newly-replaced shunts tended to migrate externally. Clinicians must pay close attention to cases of large bowel perforation, since they were most often associated with intracranial infections. The organ involved in compound migration could determine the route of extrusion, as the bowel was involved in all trans-anal migrations and the stomach in most trans-oral cases. Clin. Anat. 30:821-830, 2017. © 2017Wiley Periodicals, Inc.

Anal extrusion of migrated ventriculo-peritoneal shunt catheter: An unusual complication and review of literature

Authors present an unusual case of anal extrusion of peritoneal end of ventriculo-peritoneal shunt in a 2-year-old male child. Pertinent literature is reviewed regarding this rare complication of a very commonly performed neurosurgical procedure.

Laparoscopic retrieval of disconnected shunt catheters from the peritoneal cavity as a day-case procedure in children--early feasibility report

PURPOSE

The aim of this study was to report our experience with laparoscopic retrieval of disconnected shunt catheters in children.

METHODS

Demographic data, indications for shunt insertion, time to disconnection, symptomatology, time to retrieval, operative details, length of stay and complications were recorded retrospectively. Laparoscopy was performed using two 5-mm ports and 10-12-mmHg CO(2) pneumoperitoneum.

RESULTS

Seven children (five boys, two girls) had laparoscopic retrieval of disconnected ventriculoperitoneal (VP; n = 6) and lumboperitoneal (n = 1) shunt catheters between 2006 and 2008. Median age was 8 (5-15) years. The indications for shunt insertion were hydrocephalus (n = 4), traumatic subdural haematoma (n = 1), pinealoblastoma (n = 1) and idiopathic intracranial hypertension (n = 1). Median interval from insertion to disconnection was 3 (range 1-10) years. Presenting symptoms were headache (n = 3) and neck swelling (n = 1). Three children were asymptomatic. Median referral-to-procedure time was 69 (range 2-224) days. One child underwent emergency removal of disconnected shunt with laparoscopic-assisted VP shunt insertion under the same anaesthetic. One child had a laparotomy as the catheter tip had penetrated the sigmoid mesocolon close to the bowel and could not be safely removed laparoscopically. Of the remaining five children, four had the procedure performed as day cases. There was no intra- or post-operative morbidity or subsequent shunt infections.

CONCLUSIONS

Peritoneally migrated shunt catheters have a risk of viscus injury, particularly bowel perforation. In our experience, laparoscopic retrieval of migrated shunt catheters was safe both as an emergency procedure and electively, when it was performed as a day-case basis in selected patients with excellent outcome.

Bowel perforation secondary to ventriculoperitoneal shunt: case report and clinical analysis

Bowel perforation is an unusual complication of ventriculoperitoneal shunting. This article describes a case of bowel perforation associated with a ventriculoperitoneal shunt inserted in an 8-month-old male infant for meningocoele and hydrocephalus. Ten months after insertion of the shunt the infant presented with the shunting tube protruding through the anus. There were no signs of meningitis or peritonitis. At laparotomy the tube was seen to enter the transverse colon and was encapsulated by the greater omentum. The tube was cut and the distal end removed via the anus. The transverse colon was repaired. The catheter continued to function effectively and the patient remained asymptomatic. The literature on this rare complication is reviewed and the therapeutic options are discussed.

Bowel perforation caused by peritoneal shunt catheters: diagnosis and treatment

OBJECTIVE

The peritoneum is the preferred site for insertion of shunts used for the treatment of hydrocephalus. Bowel perforation by peritoneal catheters (BPPC) is a rare but devastating complication. Its pathophysiology, diagnosis, and treatment are debated.

METHODS

Retrospective review of cases of BPPC in a series of 1956 patients having a peritoneal catheter followed up for a mean duration of 10.0 years.

RESULTS

Nineteen observations of BPPC, representing 1.0% of the total series. Nine of 19 patients were nonambulatory, and nine of 19 had a previous history of meningeal infection. At the time of diagnosis, only three of the 19 patients had anal extrusion of the catheter, 14 had fever, nine had abdominal signs and symptoms, and six had cutaneous signs of infection. Radiological investigations were often negative or inconclusive. In seven of the patients, the initial diagnosis was shunt failure, and BPPC was diagnosed only during shunt revision. Once the correct diagnosis was made, the treatment was total shunt removal, external drainage, and antibiotic therapy for 2 weeks. Three patients, all severely impaired before BPPC, died, one of meningeal sepsis, the others of multiorgan failure related to spastic tetraparesis. Three were considered shunt-independent, two had a ventriculoatrial shunt, and the others had a new shunt with a peritoneal catheter without complication.

CONCLUSION

BPPC is a neurosurgical emergency. Anal extrusion is present in only a minority of patients; the diagnosis of BPPC is often difficult, delayed, and its incidence is likely underestimated. The majority of patients can be treated with a new peritoneal shunt after cure of the infection.

Peritoneal Shunt Tube Migration Into the Stomach-Case Report-

A 47-year-old man presented with repeated headache and feverishness 3.5 years after undergoing ventriculoperitoneal shunt surgery for normal pressure hydrocephalus secondary to subarachnoid hemorrhage. Abdominal computed tomography revealed that the peritoneal catheter was encased by fibrous tissue and the distal end of the catheter had migrated into the stomach. The diagnosis was spontaneous gastric perforation by the ventriculoperitoneal shunt. The fibrous tissue was expected to seal the very small gastric perforation, so the catheter was successfully extracted through a scalp incision without abdominal surgical intervention.

[Unusual abdominal complication of ventriculoperitoneal shunt]

The most common complications after CSF shunting to treat hydrocephalus are shunt infection and obstruction. Although ventriculoperitoneal (VP) diversion of the CSF using artificial shunt devices is an accepted method for the management of hydrocephalus, high rates of various complications have been reported, ranging from 24% to 47%. Among these, abdominal complications account for approximately 25%. The incidence of bowel perforation by shunt-catheter is known to be as low as 0.1-0.7%. We describe a case of migration af a peritoneal catheter through a congenital hernia of Morgagni.

Unexpected childhood death due to a rare complication of ventriculoperitoneal shunting

A 10-year-old boy with Arnold-Chiari malformation, spina bifida, and a ventriculoperitoneal shunt for hydrocephalus died unexpectedly, having appeared to be only mildly unwell with fever on the night before death. At autopsy, the shunt was partially obstructed with an associated enterococcal meningitis. The tip of the shunt was located within the transverse colon, which was embedded in a mass of fibrous adhesions resulting from previous abdominal surgery. Blood cultures were sterile. Intestinal perforation is a rare complication of ventriculoperitoneal shunting that may be associated with the development of meningitis and unexpected death. The autopsy assessment of children with such indwelling devices requires examination of the functional state of the shunt, full septic workup, and determination of the precise location of the tip of the catheter within the peritoneal cavity.

Spontaneous bowel perforation after ventriculoperitoneal shunt surgery: case report and a review of 45 cases

BACKGROUND

Ventriculoperitoneal shunt surgery is the most widely used procedure in the treatment of hydrocephalus. However, this invasive procedure has been associated with several delayed abdominal complications. Perforation of the bowel is a very rare complication occurring in less than 0.1% of cases. Although infrequent, this delayed complication can be fatal if it goes unrecognized.

CASE DESCRIPTION

This report presents an adult patient who had undergone ventriculoperitoneal shunt surgery and later presented with rectal protrusion of the shunt tube after asymptomatic perforation of the bowel wall. The shunt was removed without complication and the patient remained asymptomatic.

CONCLUSIONS

Forty-five similar cases have been reported in the literature. The information provided within this report examines the case at hand, as well as provides an analysis of the literature as it relates to bowel perforation through symptomatic presentation, diagnosis, cultures, management with or without laparotomy, and outcome.

Pneumocephalus secondary to colonic perforation by ventriculoperitoneal shunt catheter

We present a case of colonic perforation as a complication arising from ventriculoperitoneal shunt catheter. A 58-year-old woman with a ventriculoperitoneal shunt catheter inserted for obstructive hydrocephalus was admitted to hospital with signs and symptoms of meningitis. CT showed an air-fluid level within both lateral ventricles, raising the possibility of colonic perforation since no other aetiology for the pneumocephalus could be found. The CT demonstration of the colonic perforation played a crucial role in patient management.