Distal splenorenal shunt for decompression of portal hypertension in children with cystic fibrosis.

Apart from the sound physiologic basis for the distal splenorenal shunt as compared with the portacaval shunt and the conventional central splenorenal shunt, there are two important reasons why we think the use of this type of shunt is especially advantageous in children with portal hypertension secondary to cystic fibrosis. Firstly, the thick, fibrotic retroperitoneal area in the porta hepatis, where a portacaval shunt has to be constructed, can be avoided, which makes the distal splenorenal shunt the easier operation. Secondly, notwithstanding the relatively small-sized vessels, a wide anastomosis can be constructed with a high flow rate and, therefore, a minimal chance of shunt thrombosis.     

Liver abscess caused by an infected ventriculoperitoneal shunt.

Pyogenic liver abscess in Taiwan is most commonly due to Klebsiella pneumoniae infection in diabetic patients, and less frequently due to biliary tract infections. Liver abscess caused by ventriculoperitoneal (VP) shunt is very rare. We report a case of liver abscess caused by methicillin-resistant Staphylococcus aureus (MRSA), which developed as a complication of an infected VP shunt. A 53-year-old woman, who had shad a VP shunt implanted 3 months previously for hydrocephalus due to intracranial hemorrhage, presented with fever off and on, drowsiness and seizure attacks for 1 week. Computed tomography (CT) of the brain showed only mild right-sided hydrocephalus, and was negative for intracranial hemorrhage and intracranial mass. Analysis of cerebrospinal fluid showed significant pleocytosis and hypoglycorrhachia. CT scan of the abdomen disclosed a huge abscess in the right lobe of the liver. Cultures of both the cerebrospinal fluid and aspirated liver abscess isolated MRSA. The patient was treated with intraventricular and intravenous vancomycin, intravenous teicoplanin and oral rifampicin, followed by oral chloramphenicol and rifampicin. Percutaneous drainage of the liver abscess and externalization of the VP shunt were performed. The liver abscess had resolved almost completely on ultrasonography after 2 weeks of therapy. Liver abscess in patients with a VP shunt should be considered a possible abdominal complication of the VP shunt, and may be caused by unusual pathogens. Diagnosis requires CT scan and direct aspiration and culture of the liver abscess. Treatment requires management of both the liver abscess and the infected shunt.     

Peritoneovenous shunting for cirrhotic versus malignant ascites

The use of the peritoneovenous shunt in patients with cirrhosis is associated with a significantly higher complication rate than in patients with malignant ascites. Since many patients subsequently died due to the complications of shunt placement and the efficacy has never been clearly established by a randomized trial, it is difficult to recommend a procedure which may shorten the already brief life expectancy of the patient. We conclude that for the patients with ascites due to cirrhosis, the peritoneovenous shunt should be reserved for a carefully selected group, such as those patients with pending rupture of a hernia. However, for the patient with malignant ascites, the relatively low complication rate of peritoneovenous shunt placement and the lack of an adverse effect on survival time indicates that use of this successful palliative technique seems warranted in selected patients.     

Uterine perforation by a cystoperitoneal shunt, an unusual cause of recurrent vaginal discharge

BackgroundWe describe the first reported case of uterine perforation by a cystoperitoneal shunt. The mechanism of this unusual complication is unclear.CaseA 17-year-old patient had a cystoperitoneal shunt for a porencephalic cyst. She presented with recurrent watery vaginal discharge. A pelvic ultrasound examination showed that the uterus had been perforated by the distal tip of the shunt. The cystoperitoneal shunt was converted to a ventriculo-atrial shunt, and the vaginal discharge subsequently resolved.ConclusionThe appearance of light and clear vaginal discharge in a patient with a cystoperitoneal shunt raises the possibility of uterine perforation. This can be confirmed by ultrasound and analysis of the discharge. Removal of the shunt leads to spontaneous closure of the uterine defect.     

Evaluation and treatment of early hemorrhage of the alimentary tract after selective shunt procedures

The cause and treatment of early variceal bleeding in 15 patients who had undergone distal splenorenal shunt were reviewed. Eight of these patients were taken from a group of 91 who underwent selective shunts from July 1983 through June 1985 and had extensive preoperative and postoperative evaluation of shunt patency and pressure gradient. Seven patients operated upon before July 1983 were reviewed because they illustrate the cause, diagnosis, successful and unsuccessful management of bleeding after selective shunt. Urgent selective arteriography combined with shunt catheterization is the key diagnostic and therapeutic maneuver. Thrombosis of the shunt can be successfully managed by revising the anastomosis. Stenosis of the shunt can be successfully treated with balloon dilation or operative revision of the anastomosis. When renal vein hypertension (RVH) occurs, there might be inadequate decompression of the varices. A gradient of 10 millimeters of mercury or greater from left renal vein to vena cava is diagnostic. Measurements of 30 patients who had no bleeding and one patient with documented RVH show the gradient decreases over time. Treatment should be supportive until this adaptation occurs. Hemorrhage can also occur in patients with a patient shunt but without a significant pressure gradient. Inadequate decompression of the varices through the short gastric veins leading to the spleen has been proposed as one cause. Termed short gastric hypertension, this syndrome could be expected to parallel RVH because the venous collaterals will enlarge and eventually decompress the varices. Treatment should be aimed toward supporting the patient until this adaptation occurs. A small number of patients continue to bleed despite these therapeutic interventions but can sometimes be salvaged with a total shunt.     

Cholesterol pool sizes and turnover following portacaval shunt in the dog.

Portacaval shunt has been shown to be effective in lowering the plasma cholesterol level of both man and experimental animal. However, the primary mechanism which effects this reduction is unclear. We have measured the rapidly, and the slowly, miscible cholesterol pool sizes and the cholesterol production rate in mongrel dogs, with the animals in the cholesterol steady state, using 14C-cholesterol plasma decay curve analysis. Five control animals and three one year postoperative portacaval shunt animals with a 50 per cent plasma cholesterol level reduction were studied. No differences were demonstrated in either the cholesterol pool sizes or the production rate. These data have led us to postulate two hypotheses to explain the mechanism of the hypocholesterolemic effect of the portacaval shunt.     

Successful early in utero management of fetal hydrothorax in a twin pregnancy

We present a case of dichorionic diamniotic twin pregnancy in which one of the fetuses was found to have a major pleural effusion at 15 weeks of gestation. A single-needle pleural fluid aspiration was performed at 15 and 16 weeks, but the fluid reaccumulated quickly after each procedure and at 16 weeks, the fetus was found to become progressively hydropic. A shunt was then successfully inserted at 17 weeks, which is the earliest gestation reported so far in the literature for such a procedure to treat isolated hydrothorax. Because we felt that the fetus would be too small for a classical double-pigtail pleuroamniotic shunt, we used a multilength double-pigtail bladder stent (Harrison drain; Cook; Spencer; Indiana; USA) via a 13-gauge echo tip trocar. This shunt could be used for both singleton and twin pregnancies presenting with fetal pleural effusion from as early as 16 to 17 weeks to prevent the development of fetal hydrops and polyhydramnios and subsequent premature delivery. Treatment at this stage of gestation would also minimize the risk of lung hypoplasia, which is the main clinical issue when shunts are inserted after 24 weeks.     

Early experience with the selective splenocaval shunt for variceal bleeding

Selective variceal decompression is the operative method of choice in the definitive management of recurrent hemorrhage from gastroesophageal varices. The distal splenorenal shunt is the recommended procedure for selective variceal decompression, but its use may be limited in patients who have undergone left nephrectomy, in patients with an anatomically aberrant relationship between the splenic and left renal veins and in patients with preoperative visceral angiographic findings suggesting that they are at risk for development of the postoperative syndrome of renal vein hypertension. In these clinical situations, selective variceal decompression can be obtained with a splenocaval shunt, constructed by directly anastomosing the splenic vein to the infrarenal vena cava. Seven patients who have undergone the selective splenocaval shunt are reviewed in this report. Early experience with these patients demonstrates the use of the selective splenocaval shunt when an alternative to the distal splenorenal shunt is needed.     

In utero management of fetal lower urinary tract obstruction with a novel shunt: A landmark development in fetal therapy

Objective.?Fetal lower urinary tract obstruction occurs in ～1:3000 pregnancies. Standard vesicoamniotic shunting is fraught with malfunctioning in upto 60% of cases. We hereby report the development and application of a novel and reliable shunt.

Materials and methods.?Patients with lower urinary tract obstruction were offered the novel shunt among other standard management options. Shunting involved the placement of a double disk device with a standard double pig-tail catheter. All patients signed informed consent.

Results.?Four patients have been treated with the novel shunt. In three patients, shunting was conducted between the bladder and amniotic cavity. In one patient (dichorionic-discordant twins) with a prior dislodged shunt causing urinary ascites, shunting was conducted between the peritoneal and amniotic cavities (‘bridge shunt’). In all cases, correct and stable shunt placement was confirmed endoscopically and sonographically and in all patients, the fetal bladder remains effectively drained.

Conclusion.?Reliable and effective vesico or peritoneoamniotic shunting can be achieved with the novel shunt. This shunt cannot become dislodged into the peritoneal cavity or the amniotic cavity, and cannot be pulled out by the fetus. Further experience is necessary to determine the risks and benefits of this novel treatment for fetal lower urinary tract obstruction.     

The Denver type for peritoneovenous shunting of malignant ascites

Peritoneovenous shunts of the Denver type were inserted into 36 patients to control malignant ascites. The Denver system features a compressible pump chamber bearing a pressure sensitive valve. Initially, all the shunts functioned well. The shunt remained open until death in 21 patients, and at the beginning of the analysis, another two patients were still alive with an open shunt. Blockage of the shunt occurred in 13 patients before death. The cumulative survival time for patients after shunt insertion was 129 months and the cumulative shunt functioning time was 92 months. The over-all median survival time after shunt installation was 13 weeks, and calculated actuarially, the median shunt functioning time for long term survivors was 14 weeks. The cytologic state of the ascitic fluid did not make a statistically significant difference to the blockage-free interval (p = 0.99), neither did the type of primary tumor (p = 0.37). Complications were of a minor type. There was no laboratory or clinical evidence of disseminated intravascular coagulation. Tumor spread through the tubing was seen in one of the three autopsies performed. Denver type peritoneovenous shunting appears to provide effective palliation in the majority of patients. It should, however, only be performed as a last resort.     

23例脐静脉-门静脉-体静脉分流胎儿的产前诊断和产后随访分析

Objective?To investigate the current status of the prenatal diagnosis and postnatal follow-up of fetuses with umbilical-portal-system shunt (UPSVS). Methods?23 fetuses with UPSVS, diagnosed by Peking University People's Hospital from July 2013 to June 2020, were divided into three types according to the sonographic features: TypeⅠ, umbilical–systemic shunt (USS); TypeⅡ, ductus venosus–systemic shunt (DVSS); and TypeⅢ, portal–systemic shunt (PSS), which was divided into two subgroups: TypeⅢa, intrahepatic portal–systemic shunt (IHPSS); and TypeⅢb, extrahepatic portal–systemic shunt (EHPSS). Prenatal diagnosis and postnatal follow-up were analyzed retrospectively. Results?Compared with USS (2/23, 8.7%) and DVSS (4/23, 17.4%), PSS was the most common (17/23, 73.9%). The median follow-up time was 43 months(range 12-84). Three cases failed to be followed up. The rate of prenatal multi-disciplinary team (MDT) counselling was 15.0% (3/20). Fetal karyotyping was done at 35.0% (7/20). There were 11 cases opting to terminate the pregnancy, 9 cases with live born fetuses. Only 4 cases (4/9, 44.4%) had regular pediatric examination, compared with 2 cases with irregular examination and 3 cases without any examination. Conclusion?Prenatal MDT, genetic screening, and postnatal pediatric follow-up related to USPVS need to be further improved.     

Secondary infertility as a late complication of vesico-amniotic shunt therapy

OBJECTIVE: Vesico-amniotic shunting can be used for the treatment of fetal obstructive uropathy. However, the procedure is associated with a significant risk of complications. We report a case of a complicated vesico-amniotic placement, where a vesico-amniotic shunt ultimately resulted in, fortunately reversible, infertility. CASE: A 36-year-old multigravida was referred to our center at 13 weeks' gestation for the evaluation of fetal lower urinary obstruction. A vesico-amniotic shunt placement requiring several attempts was performed. A few weeks later premature rupture of the membranes occurred. At the request of the parents, the pregnancy was terminated at 22 weeks'gestation. The patient visited us again for secondary infertility, which turned out to be caused by a shunt left behind in the uterus, acting as an IUD. After hysteroscopic removal, she soon became pregnant again. CONCLUSION: This case illustrates the importance of careful documentation relating to each and every operation, of all materials used and what was retained in the patient. At delivery, obstetric staff should be completely aware of the prenatal treatment procedures performed, to ensure that no foreign objects are left by oversight, inside the patient's body.     

Interpretation of alveolar-arterial oxygen tension difference.

In this study, an assessment is given of errors resulting from the use of the alveolar-arterial oxygen difference determined on both room air and 100% oxygen in estimating changes in total shunt fraction of 41 patients hospitalized with long bone fractures. In 113 studies, changes in alveolar-arterial oxygen difference in 29 patients were in the opposite direction to changes in shunt fraction. Based upon these studies, changes of less than 45 millimeters in the arterial oxygen tension determined with a patient breathing 100% oxygen are not reliable indicators of direction of change in shunt fraction. In 126 studies, the shunt fraction determined from arterial and mixed venous oxygen contents in 71 patients was greater when determined on 100% oxygen than when determined on room air, a possible indication of the induction of alveolar or small airway collapse. The errors in estimation of shunt fraction due to assuming a value for arteriovenous oxygen content difference become larger as total shunt fraction increases; in particular, use of the alveolar-arterial oxygen difference as a guide to serial changes in pulmonary dysfunction can be particularly misleading when the alveolar-arterial oxygen tension difference is so large that the arterial hemoglobin is less than fully saturated on 100% oxygen. Use of mixed venous samples was found necessary, in these instances, to avoid large errors in estimation of total shunt fraction.     

Laparoscopic Resection of Endometriosis in a Patient with a Ventriculoperitoneal Shunt Using the LapDisc

The surgical approach in a patient with a ventriculoperitoneal shunt in need of abdominal surgery remains controversial. The risk of increased intracranial pressure with pneumoperitoneum in laparoscopy is still unresolved. We used the LapDisc (Ethicon, Inc., Somerville, New Jersey) to access the shunt and temporarily seal it, which enabled us to perform laparoscopic resection of endometriosis without subjecting the shunt to high intraabdominal pressure. The benefits of this approach are the ability to perform laparoscopy, less skin-to-shunt contact minimizing infection, and elimination of possible increased intracranial pressure secondary to pneumoperitoneum.With the progress made in the management of hydrocephalus, patients with ventriculoperitoneal (VP) shunts enjoy a longer lifespan. Therefore, the gynecologic laparoscopic surgeon can expect to treat a patient with a VP shunt in place.     

Intrathoracic dislodgement of pleuro-amniotic shunt. Three case reports with long -term follow-up

BACKGROUND: Intrathoracic shunt dislodgement is a rare, although significant, complication of pleuro-amniotic shunting. In a previously reported case, the abnormally located shunt caused constriction of the pulmonary hilum resulting in neonatal death. CASES: Three cases of severe fetal pleural effusion treated by pleuro-amniotic shunting at 33, 26 and 30 weeks of gestation and complicated by dislodgement of the shunt into the fetal chest are presented. These cases were collected from three fetal medicine referral centers, where 15 pleuro-amniotic shunts have been inserted in a total of 13 fetuses (11 unilateral and 2 bilateral procedures), giving prevalence for this complication of 20%. The indication for shunting was severe bilateral pleural effusions and hydrops in one case, and unilateral pleural effusion with marked mediastinal shift in 2 others. Intrathoracic dislodgement was diagnosed by ultrasound at 33, 29 and 39 weeks, and the infants were delivered at 35, 34 and 39 weeks of gestation, respectively. There were no complications associated with the malposition of the shunt within the fetal chest and clinical follow-up from 10 months to 2 years of age has demonstrated asymptomatic infants. CONCLUSION: The complication of intrathoracic dislodgement of a pleuro-amniotic shunt can be recognized prenatally by ultrasound. Prevention of this complication seems difficult, but if recognized, a conservative approach appears to be a sensible management option. Since the material of the shunt is inert, its presence within the pleural cavity is unlikely to be associated with an inflammatory foreign body response and, therefore, it should not cause long-term pulmonary complications.     

Risk Factors for Surgical Shunting in a Large Cohort With Ischemic Priapism

BackgroundIschemic priapism is treated with a stepwise algorithm, but some patients may benefit from immediate shunt placement.AimTo identify risk factors for surgical shunt placement in a large series of patients with ischemic priapism.MethodsWe identified all patients presenting to our institution with ischemic priapism from January 2010 to December 2018. Multivariable was performed to assess risk factors for surgical shunting. Receiver operating characteristic curve analysis (Youden Index) was used to assess which cutoff time for the duration of priapism was most predictive requiring shunting.OutcomesWe assess risk factors for surgical shunting and what duration of priapism was most predictive of requiring a shunt.ResultsWe identified a total of 169 ischemic priapism encounters from 143 unique patients, of which 26 (15%) encounters resulted in a surgical shunt. Patients treated with a shunt had longer priapism durations than those without (median 36 vs 10 hours, P < .001). Independent predictors of a surgical shunt on multivariate logistic regression were the duration of priapism in hours (odds ratio: 1.05, 95% confidence interval: 1.02–1.10; P < .001) and history of prior priapism (odds ratio: 3.15, 95% confidence interval: 1.03–9.60; P = .045). Receiver operating characteristic curve analysis using priapism duration to predict the need for shunt generated an area under curve of 0.83. A duration of 24 hours correlated to a sensitivity of 0.77 and specificity of 0.90.Clinical ImplicationsThese results can be used to counsel future patients and assist in the decision-making process for providers.Strengths & LimitationsThis is one of the largest series of priapism in the literature. Most (74%) of the priapism were due to intracavernosal injections so the results may not be generalizable to populations with different priapism etiologies.ConclusionIn this study of 169 priapism encounters, we found that the priapism duration and history of prior priapism were independent predictors of surgical shunt placement. These results can aid urologists in the counseling and decision-making process of these challenging cases.Zhao H, Dallas K, Masterson J, et al. Risk Factors for Surgical Shunting in a Large Cohort With Ischemic Priapism. J Sex Med 2020;17:2472–2477.     

Peritoneo-cystic shunt for malignant ascites

Peritoneo-venous shunting has been used extensively in the treatment of benign ascites and, to a limited extent, in the palliative management of malignant ascites. Acceptance of this therapy for malignant ascites has been slow because of concern over intravascular dissemination of disease. Recently a patient with advanced drug-resistant ovarian carcinoma was treated with peritoneo-cystic shunt. This patient's tumor had progressed on multiple chemotherapeutic agents. She continued to work 40 hr per week but her activity was limited by massive ascites. The Denver Shunt (Storz) was selected in preference to the strut-type shunt. The Denver Shunt has a miter valve which is less likely to become occluded by fibrinous and cellular debris, and manual compression of the pumping chamber allows flushing and control of flow. This patient's shunt remained patent for 5 months, until her death, documented by urine cytology and cystoscopy. Initial control of ascites was only fair, probably due to the virtual absence of a pressure gradient between the peritoneal cavity and the bladder. Without a pressure gradient, spontaneous flow would be expected to be nil. Though feasible and well tolerated, this technique is probably not useful in the management of malignant ascites. If modifications of the device could be made to increase the manual flow rate, then this technique might be acceptable.     

Infertility and ventriculoperitoneal shunt

Two women with a ventriculoperitoneal shunt had primary infertility. At laparoscopy they both had extensive peritoneal adhesions that made evaluation of pelvic organs impossible and increased the risk of bowel injury. History of ventriculoperitoneal shunt should be considered a contraindication of laparoscopy.     

Management of pregnancy and delivery of a patient with malfunctioning ventriculoperitoneal shunt

The use of ventriculoperitoneal shunts increased the life expectancy of many women with hydrocephalus who are able to reach childbearing age. It is believed that pregnancy may be associated with shunt malfunction and the management of pregnant women with a malfunctioning ventriculoperitoneal shunt is a challenging medical condition for the anaesthetist, the obstetrician and the neurosurgeon. We report on a case of a 35-year-old primiparous woman who underwent a scheduled caesarean delivery at 30 weeks' gestation due to deteriorating neurological condition during pregnancy. The patient had a history of astrocytoma resection in the past and placement of a ventriculoperitoneal shunt due to obstructive hydrocephalus. She had a normal life without neurological deficits until the 18th week of gestation, when the first neurological symptoms appeared. An MRI was done that showed significant dilatation of the fourth ventricle and it was believed that the shunt was not functioning properly so the patient's symptoms were present because of raised intracranial pressure. In the 30th week of gestation, she had a caesarean delivery under epidural anaesthesia and she gave birth to a live female infant. Her neurological condition started improving 48 h after delivery and the symptoms gradually regressed. At 20 days after surgery she was discharged from hospital. The presence of a ventriculoperitoneal shunt is not a contraindication for pregnancy. Maternal shunt dependency carries a relatively high incidence of complications for some patients, e.g. shunt malfunction due to raised intraabdominal pressure caused by the gravid uterus. The results of pregnancies and deliveries in women with pre-existing ventriculoperitoneal shunts are favourable if there is proper management.     

Diagnosis of the preterm patent ductus arteriosus: clinical signs, biomarkers, or ultrasound?

The current uncertainty in relation to treatment of the preterm patent ductus arteriosus reflects limitations to our understanding of the pathophysiology of ductal shunting, most particularly which ducts matter to which babies and when they matter. Doppler ultrasound offers a pragmatic tool with which to assess ductal patency and shunt significance and to allow prediction of spontaneous and therapeutic closure. Biomarkers, such as B-type natriuretic peptide, and clinical signs may have a diagnostic role where ultrasound is not available and also possibly as an adjunct to echocardiography in determining the pathophysiological impact of a ductal shunt in an individual baby.