Bilateral scrotal migration of abdominal catheters: a rare complication of ventriculoperitoneal shunt

Shunt Migration in Children: A Patient Level Systematic Review of Risk Factors and Outcome

Ventriculoperitoneal shunt insertion is one of the most common pediatric neurosurgical procedures performed. Shunt migration is one of the infrequent complications of shunt insertion and often requires a change of the shunt system. The objective of the study is to systematically review the sites of shunt migration and factors associated with mortality in children. Comprehensive search and review of the literature were done according to the PRISMA guidelines. Citations were selected using the following inclusion criteria: 1. Shunt migration in ventriculoperitoneal shunts was the primary inclusion criteria, 2. Age of the study participants <18 years, and 3. Patient-level data available in the study. Exclusion criteria were 1. Age >18 years, 2. Patient-level data not available, 3. Full text of the article not available, and 4. Article not in the English language. Sites of migration and risk factors for mortality were assessed. In total, 111 studies out of 161 studies were included in the final analysis. The scrotum was the most common site of shunt migration (30.67%), followed by anal migration, migration into the bowel, chest wall/thoracic migration, and intracranial/subgaleal migration. Univariate analysis showed the presence of infection and site of migration to be significantly associated with mortality. Multivariate analysis showed the presence of infection and age at presentation to be significant predictors of mortality. This study highlights that presence of infection is a significant predictor of mortality in cases of shunt migration. Infection should be managed expeditiously for optimum management of shunt migration.

Scrotal migration of a ventriculoperitoneal shunt in an adult. A case report and literature review

Introduction

Scrotal migration of a ventriculoperitoneal shunt (VPS) catheter is a rare complication of VPS. Scrotal migrations usually manifest in the first year post-operatively, usually in the pediatric population, due to processus vaginalis patency and increased abdominal pressure.

Research question

To review cases of scrotal migration of a VPS catheter that occur in the adult population, and its recommended management.

Material and methods

A case report and review of the literature.

Results

A 75-year-old male with a ventriculoperitoneal shunt for normal pressure hydrocephalus, presented with testicular swelling. Imaging revealed that the distal shunt catheter had migrated into his scrotum. He required an emergency shunt revision, with a truncation of the catheter, and involvement of the general surgical team for hernia management. He remained well at one year follow-up.

Discussion and conclusion

To the best of our knowledge, this is the fifth case in an adult. This case serves as a reminder to take a thorough clinical history, imaging of the entire VPS pathway, and to consider unusual reasons for VPS failures. Emergency intervention for distal shunt revision is required to prevent further neurological or urological morbidity. Treatment includes not only catheter revision and reinsertion, but the catheter should be truncated, to avoid testicular migration recurrence. Hernia repair can be done either as an emergency or elective case, depending on the patient's clinical status and presentation.

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Ventriculoperitoneal catheter migration to the scrotum can occur in adults, as well as more commonly in paediatrics.

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This is the fifth adult case of scrotal distal cather shunt migration.

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This can cause a hydrocele and result in shunt failure.

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This can necessitate shunt revision and involvement of the general surgical team.

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In shunt failure, or scrotal swelling, thorough work-up must be done to diagnose rare, potentially fatal, conditions.

The "SHIFT" technique: Suprahepatic IntraFalciform tubing for placement of ventriculoperitoneal shunts

Ventriculoperitoneal (VP) shunts in pediatric patients are an important aspect of management for patients with hydrocephalus and are fraught with complications. Surgical revision rates for VP shunts in the pediatric population are currently high, which necessitates innovation in operative techniques for placing VP shunts in attempt to decrease complication risks. Here we describe a novel approach for placement of VP shunts that we hypothesize can reduce potential morbidity among pediatric patients. By utilizing the falciform ligament of the liver and the suprahepatic recess to suspend and maintain the shunt, outcomes may portend fewer iatrogenic intra-abdominal injuries, enhanced ease of shunt removal, provide a large surface area for absorption of drained cerebrospinal fluid, and result in fewer adhesions secondary to device placement. We are referring to the operative technique as the "SupraHepatic IntraFalciform Tubing" (SHIFT) technique. In summary, the SHIFT shunt is fashioned by creating a window through the falciform ligament, inserting the shunt, and placing tubing in the suprahepatic recess.

Treatment Options for Scrotal Migration of Ventriculoperitoneal Shunts: Case Illustration and Systematic Review of 48 Cases

BACKGROUND

Scrotal migration of intact or disconnected tubing is a rare complication of ventriculoperitoneal shunts. While some illustrative case reports can be found in the literature, a systematic review on treatment options is lacking.

OBJECTIVE

To propose the first literature-based treatment algorithm on scrotal shunt migration.

METHODS

We conducted a literature search using the keywords: "VP," "ventriculoperitoneal," "shunt," and "scrotum." We identified 36 publications with 48 cases reported including our index case.

RESULTS

Median age at presentation was 13.5 mo (3 d to 65 yr) which was 4 mo (3 d to 72 mo) after last shunt-related surgery. All patients had scrotal swelling, 39 (81%) patients presented without other symptoms, 4 (8%) had additionally local pain, and 4 (8%) patients presented with symptoms of shunt dysfunction. Treatment was surgically in all but one case where spontaneous resolution without repeat migration occurred. In 3 of 4 patients who had either subcutaneous shortening or abdominal repositioning of the shunt without hernia repair, scrotal shunt migration recurred within the following month. Whereas the surgical treatment with reposition of the migrated catheter back into the peritoneal cavity via a groin incision plus hernia repair yielded a definite treatment in all 26 performed cases, the revision rate was significantly higher in the shunt revision without hernia repair cohort (P = .0009).

CONCLUSION

Scrotal shunt migration is a rare shunt complication with good recovery when treated surgically. We recommend hernia repair in addition to either manual or surgical repositioning of migrated tubing.

Mechanisms and Major Sites of Distal Catheter Migration in Ventriculoperitoneal Shunting Maneuvers: A Review Article

A ventriculoperitoneal shunt (VPS) is a medical device used to deflect cerebrospinal fluid from cerebral ventricles to the peritoneal cavity. Since 1908, ventriculoperitoneal shunts have been considered the best option in hydrocephalus management. Manifestation related to VPS may arise anywhere whilst tunneling the VPS from the ventricle to the peritoneal cavity, but complications associated with the distal catheter are especially common and a leading cause of revision surgeries. Among the many complications associated with peritoneal shunts, migration of the catheter into other parts of the body is still common. Scrotal migration mainly takes place in children aged 4 days to 5 years. Patent processus vaginalis, formation of an inguinal hernia, and increased intraabdominal pressure are leading risk factors associated with migration of the peritoneal catheter into the scrotum. Thoracic migration of peritoneal catheters predominantly occurs in adult patients. Important mechanisms in thoracic migration include (1) iatrogenic perforation of the external or internal jugular veins by the surgeon during tunneling and (2) gradual destruction of the venous structures by the catheter due to routine extension and flexion of the neck. After entering the vessel, negative intrathoracic pressure combined with positive intraabdominal pressure aids migration into the thoracic cavity. Sharp tips or shunt types contribute to intraabdominal migration and perforation.

Migration of the Distal Catheter of Ventriculoperitoneal Shunts in Pediatric Age Group: Case Series

BACKGROUND

Ventriculoperitoneal (VP) shunting is the most commonly performed procedure in the treatment of hydrocephalus. VP shunt migration can occur at different sites. The aim of the study was to present different sites of abnormal distal shunt location, pathophysiology, and the management in each situation.

METHODS

Between 2014 and 2017, all patients with hydrocephalus in the Department of Neurosurgery, Cairo University, were gathered prospectively. All pediatric patients below the age of 12 years with shunt migration of the distal end of the VP shunt were identified.

RESULTS

Of 1092 patients operated on by the VP shunt between 2014 and 2017, 15 presented with shunt dysfunction because of distal shunt migration (6 anal, 3 scrotal, 1 colon, 1 peroral, 1 upper lumbar extrusion, 1 paraspinal, 1 penile, and 1 umbilical). Especially upper lumbar extrusion and paraspinal shunt location are extremely rare. All the 15 patients were treated successfully with VP shunts and prospectively followed until they presented with complications on different occasions.

CONCLUSIONS

Peritoneal complications are among the most common causes of VP failure. We present a rare complication where the shunt migrates outside the peritoneal cavity elsewhere with ambiguous pathogenesis. Special considerations have to be appointed during the shunt revision surgeries of these cases.

Choroid Plexus Hyperplasia with Intractable Ascites and a Resulting Communicating Hydrocele following Shunt Operation for Hydrocephalus

Choroid plexus hyperplasia/papilloma and resulting hyperproduction of cerebrospinal fluid is a rare cause of hydrocephalus. In these patients, intractable ascites can occur after a ventriculoperitoneal (VP) shunting operation. However, shunt-related hydrocele is a rare complication of VP shunting. Previous reports have indicated catheter-tip migration to the scrotum as a cause of hydrocele. Here, we present the first documented case of choroid plexus hyperplasia that led to intractable ascites after shunting and a resulting hydrocele without catheter-tip migration into the scrotum.

Rare complication of ventriculoperitoneal shunt. Early onset of distal catheter migration into scrotum in an adult male: Case report and literature review

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Cases of scrotal migration of distal catheter in adults are rare.

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There have been no reports for scrotal migration in adults at an early onset.

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Early detection of migration of distal catheter prevents shunt malfunction.

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Prompt surgical management of catheter repositioning is recommended.

Introduction

The role of shunt placement is to divert cerebrospinal fluid from within the ventricles to an alternative location in the setting of hydrocephalus. One of the rare shunt complications is distal catheter migration, and various body sites have been reported, including the scrotum. Although cases of scrotal migration of distal catheter have been reported in pediatric patients, cases in adult patients are rare due to obliterated processus vaginalis. Furthermore, there has not been a case reported for scrotal migration in an adult at an early onset.

Presentation of case

65-year-old male underwent shunt placement for normal-pressure hydrocephalus-like symptoms. On post-operative day seven patient developed right testicular edema, for which ultrasound was performed, revealing hydrocele along with the presence of distal catheter in the scrotum. On post-operative day nine patient underwent distal catheter trimming via laparoscopic approach with general surgery, with post-operative imaging showing satisfactory location of distal catheter in the peritoneal cavity.

Discussion/Conclusion

Early onset of distal catheter migration into scrotum in an adult male is a unique case, as most cases are reported in pediatric patients, and it is the first case reported in the English literature to have occurrence at an early onset during the peri-operative period. As our case demonstrates, early occurrence and detection of scrotal migration of the distal catheter prevent shunt malfunction. Prompt surgical management of catheter repositioning is therefore recommended to avoid the risk of further complications.

Scrotal migration of lumboperitoneal shunt catheter in an adult--case report

A 57-year-old man presented with recurrent parasagittal anaplastic meningioma of frontoparietal region. The tumor was extensively removed, and the dura was repaired with Gore-Tex surgical membrane. After the operation, subcutaneous cerebrospinal fluid (CSF) collection was observed in the fronto-parietal area and a lumboperitoneal shunt was placed. Four weeks after the shunt procedure, he complained of right scrotal swelling and recurrence of the CSF collection. Radiography revealed the coiled catheter in the scrotum. The catheter was surgically removed through a small incision in the skin of the scrotum under local anesthesia. Lumboperitoneal shunt is a simple and useful procedure to control CSF pressure, but catheter migration has been reported in infants and children. Shunt catheter can migrate into the scrotum even in an adult, as the vaginal process, through which the catheter seemed to have entered the scrotum, is patent in 5% of the adult population. In these cases, direct removal through a small incision is appropriate to remove the catheter.

Scrotal migration of the peritoneal catheter of a ventriculoperitoneal shunt in a 5-year-old male. Case report

A 5-year-old male presented with scrotal migration of the catheter from a ventriculoperitoneal shunt manifesting as left scrotal swelling 4 months after implantation. Surgical obliteration of the patent peritoneal processus vaginalis that forms a corridor from the peritoneum to the scrotum was performed to avoid shunt malfunction. Review of the 26 reported cases including the present case revealed that most patients were up to 18 months old. Our patient was the oldest. Migration tended to occur within 6 months after implantation (mean 3.8 months, median 1.0 month). Involvement of the right side of the scrotum was prevalent (23 of 26 cases). Patent processus vaginalis and small peritoneal cavity probably contribute to scrotal catheter migration.

Nonfunctional abdominal complications of the distal catheter on the treatment of hydrocephalus: an inflammatory hypothesis? Experience with six cases

INTRODUCTION

The peritoneal cavity is the most common site of cerebrospinal fluid absorption in hydrocephalus treatment. Many distal catheter complications are the result of this type of treatment, and these have been extensively described in the neurosurgical literature.

MATERIALS AND METHODS

In our study, six cases of distal catheter migration with visceral perforation and/or extrusion are presented: three through the umbilicus, two through the scrotum, and one through the anus. An extensive review of the literature was performed.

RESULTS

The studies of peritoneal dialysis models for the treatment of chronic renal failure patients provide important data about solute absorption in the peritoneal cavity and reactivity of the peritoneal membrane.

CONCLUSION

This model, when compared to distal catheter complications on a ventriculoperitoneal (VP) shunt, presents similarities that could help understand the mechanism of the nonfunctional complications of the distal VP catheter (complication with functional shunt), providing valuable data to support an inflammatory mechanism.

Hydrocele of the canal of Nuck as a result of a rare ventriculoperitoneal shunt complication

Patients with ventriculoperitoneal (VP) shunts may have multiple complications. Migration of the peritoneal catheter into some anatomical or congenitally open cavities can cause inguinal or genitourinary manifestations such as hernia, hydrocele or acute scrotum, and these are common in male infants. We report a very rare complication of VP shunt encountered in a female infant, manifesting as hydrocele of the canal of Nuck, the female counterpart of hydrocele of the spermatic cord. It is emphasized that VP shunts may also cause clinical inguinal manifestations in female infants, and groin or external genital organ swelling in these patients may be an important sign of shunt malfunction.

The incidence of inguinal complications after ventriculoperitoneal shunt for hydrocephalus

AIM

This study outlines the incidence of acquired clinical inguinal manifestations (CIM) in infants undergoing ventriculoperitoneal (VP) shunt procedures, and the possible underlying mechanisms in the development of these pathologies.

MATERIAL AND METHODS

The charts of children who had undergone VP shunt procedures for hydrocephalus between 1992 and 2002 were reviewed. All patients were contacted by a telephone interview, and they were invited to be examined in the outpatient clinic of paediatric surgery for the development of groin manifestation.

RESULTS

Eighty-eight patients responded to the inquiry. Twenty-one (23.8%) patients developed a CIM. Three of them were premature infants. The mean interval between the shunt procedure and the diagnosis of CIM was 5.3 months (20 days to 48 months). Nineteen of the patients who developed a CIM were in the 0- to 12-month age group when the VP shunt procedures were initially performed. Ten CIM occurred on the right (47%), 7 on the left (33%) and 4 were bilateral (20%). The rate of bilateral patency as an operative finding was 76%. There was one recurrence (4.8%).

CONCLUSION

The younger the age at which the VP shunt was performed, the higher the incidence of CIM. Bilateral manifestations were higher than in the normal population. Increased intra-abdominal pressure by accumulation of fluid in combination with the high patency rate of processus vaginalis possibly plays a role in the development of CIM in VP shunt patients. Bilateral repair should be considered even when CIM is unilateral. Special care should be given to repair procedures since the recurrence rate is relatively high.

Father of neurosurgery in Hong Kong

Neurosurgery in Hong Kong had its origins as a division of General Surgery and became a subspecialty only 46 years ago with the arrival of Hsiang-Lai Wen. For well over a decade, Wen would be the only neurosurgeon in the colony. His contributions to neurosurgery included the ventriculosuperior sagittal sinus shunt and the application of acupuncture in anesthesia, pain ablation, and drug detoxification. A pilot with the China National Aviation Corporation during World War II, he played an active part in the Allied war effort. As a diplomate of the American Board of Neurological Surgery, Wen sought to improve the standard of neurosurgery in Hong Kong and southern China with the establishment of the Hong Kong Neurosurgical Society in 1981 and the Research Institute of Neurosciences in Guangzhou in 1988. Wen was acknowledged as Hong Kong's "father of neurosurgery," and his work paved the way for the development of modern neurosurgery in the region.

Extrusion of the peritoneal catheter of a VP shunt system through a gastrostomy wound

BACKGROUND

A variety of complications can occur following ventriculoperitoneal shunt. We report a case of extrusion of the catheter tip through the old scar of the percutaneous endoscopic gastrostomy (PEG) wound.

CASE DESCRIPTION

A 70-year-old male suffered from an intracerebral hemorrhage and then developed hydrocephalus. He required a ventriculoperitoneal shunt. This patient required a PEG for gastroenteric feeding. The PEG was removed 4 years after the insertion because of infection. The tip of the distal shunt tube extruded through the scar of the PEG wound 2 years later.

CONCLUSION

The catheter end of VP shunt can extrude through the weak point of an old PEG scar. This kind of complication should be brought to mind while performing abdominal surgery in patients with VP shunts.

A ventriculoperitoneal shunt masquerading as a paratesticular tumor

A 3-year-old boy with hydrocephalus was observed to have a painless 2.0-cm right scrotal mass. Abdominal radiograph showed ventriculoperitoneal shunt tubing in the right scrotal sac. Removal of a detached shunt catheter and inguinal hernia repair resolved the problem.

Delayed intrapleural migration of a ventriculoperitoneal shunt

We report a case of delayed intrapleural migration of the peritoneal catheter of a ventriculoperitoneal shunt. This is an unusual but life-threatening complication of peritoneal shunting for the treatment of hydrocephalus. A method of treatment and abbreviated review of shunt complications is included.

CSF hydrocele--unusual complication of V-P shunt

CSF hydrocele as a complication of migration or extrusion of the peritoneal end of the V-P shunt has rarely been reported. Here the case of a 6 month old infant, born at 28 weeks gestational age, is reported. The baby was noted to have scrotal swelling, exacerbated by crying, two months after insertion of ventriculoperitoneal shunt. The hydrocele resolved following revision of the shunt. Possible pathophysiological causes are discussed.