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.     

The acute abdomen in patients with ventriculoperitoneal shunts.

A rationale for management of the patient with an acute adbomen and a ventriculoperitoneal shunt is presented in relation to eight patients. In two patients peritonitis was due to perforation of an abdominal viscus, not shunt related, and six were due to infections of ventriculoperitoneal shunts. Resolution of abdominal symptomatology occurs within six hours after the distal end of the shunt catheter is removed from the abdomen and placed in a drainage bottle. In four of these six, infection was limited to the peritoneal end of the catheter. The ventricular fluid was sterile.     

Peritoneal catheter placement into the suprahepatic space: a report of 2 cases with abdominal complications of ventriculoperitoneal shunts

Complications arising from the placement of ventriculoperitoneal shunts are common. These complications may be related to a number of causes and present with various symptoms. Of these, abdominal complications such as formation of intraperitoneal pseudocysts and abdominal abscesses possibly recur, but, alternative sites for placing the peritoneal catheter of ventriculoperitoneal shunts are limited. We present two cases of ventriculoperitoneal shunt malfunctioning due to repeated abdominal complications. The location of the peritoneal end of the shunt was successfully revised to the suprahepatic space in the peritoneal cavity. We describe the clinical course of these two cases in this report, along with a precise technique of placing the peritoneal end of the shunt into the suprahepatic space. In addition, we will discuss the validity of this space as an alternative site for the placement of the peritoneal end of the ventriculoperitoneal shunt.     

Laparoscopic versus non-laparoscopic-assisted ventriculoperitoneal shunt placement in adults. A retrospective analysis

BACKGROUND: Ventriculoperitoneal shunts and distal shunt revisions bear a high risk of distal malfunction, especially in patients with previous abdominal pathologies as well as in obese patients. We performed laparoscopy-guided distal shunt placement or revision for patients with and without a positive abdominal history. We review the indications, techniques, complications, and long-term outcomes of these cases and compare the results to those of patients operated without laparoscopic guidance. METHODS: A total of 211 distal shunt procedures were performed in our institute between January 2001 and December 2005, 59 of which were laparoscopically guided, and 152 were not. Of the 211 procedures, 177 were placement of new shunt systems, and 34 were distal revisions. A total of 33 procedures were performed in 25 patients with a history of abdominal surgery or inflammatory bowel disease; 15 procedures were operated with laparoscopic guidance. RESULTS: The short-term complication and outcome rates were similar between the laparoscopy group and the other patients. Among the patients with new shunts, the long-term distal malfunction rate was lower in the laparoscopy group compared with the nonlaparoscopy group (4% vs 10.3%, respectively; P = .17). No patients in the laparoscopy group and 6 patients operated by other techniques had distal malfunction. There was 1 laparoscopy-related mortality and no morbidity. CONCLUSIONS: Laparoscopy is not routinely indicated in distal shunt placement or revision. However, a laparoscopy-guided procedure may lower the rate of distal malfunction in patients with previous abdominal surgeries.     

Laparoscopic-assisted lumboperitoneal shunt: a simplified technique.

OBJECTIVES: Lumboperitoneal shunt has been advocated as a better alternative to ventriculoperitoneal shunt in communicating hydrocephalus. To minimize the morbidity of subcutaneous tunneling or an open abdominal wound, we developed a simplified technique for laparoscopy-assisted placement of lumboperitoneal shunts. METHODS: Patients deemed candidates for lumboperitoneal shunts underwent laparoscopy-assisted lumboperitoneal shunt placement. Using a Tuohy needle, the neurosurgeon obtains access to the lumbar subthecal space. Simultaneously, the laparoscopist obtains access to the peritoneal cavity with two 5-mm ports for the take down of the descending colon, clearing the way for the passage of the shunt passer from the back into the peritoneal cavity. RESULTS: Over the last 5 years, 45 patients have undergone laparoscopy-assisted lumboperitoneal shunt placement. Patients have been followed with neuropsychiatric examinations, imaging studies, and repeated neurological examinations. No complications related to the laparoscopy have occurred. Neurosurgical complications included postural headaches caused by overdrainage in 4 patients requiring laparoscopic modification of the shunt slit and in 1 patient with acquired Arnold-Chiari I malformation. CONCLUSION: Laparoscopy-assisted lumboperitoneal shunt offers many advantages over percutaneous ventriculoperitoneal or laparoscopic transabdominal lumboperitoneal shunts. The procedure can be performed in less than 30 minutes by any practicing laparoscopist.     

Laparoscopic management of ventriculoperitoneal and lumboperitoneal shunt complications.

BACKGROUND AND OBJECTIVES: Minimally invasive approaches for the initial placement of ventriculoperitoneal (VP) and lumboperitoneal (LP) shunts have been well described. A laparoscopic approach has multiple advantages over open techniques, including decreased morbidity, more rapid recovery, and ability to visually assess catheter function. However, few series have addressed the role of laparoscopy in the management of VP and LP shunt complications. METHODS: We present here the largest published series of laparoscopic treatment of VP and LP shunt complications in adults, by retrospectively reviewing all cases performed in a 1-year interval by a single surgeon. RESULTS: Ten patients presented with complications of previous shunting; all were managed laparoscopically. Eighty percent of these patients had a successful single laparoscopic intervention. One patient developed a cerebrospinal fluid leak from the lumbar wound, and 2 patients required additional laparoscopic shunt revisions. CONCLUSIONS: We conclude that laparoscopy has great utility in the assessment of shunt function. Laparoscopic techniques should be considered not only for placement of peritoneal catheters, but also for the management of distal shunt malfunction and diagnosis of abdominal pain in these patients.     

Laparoscopic guidance or revision of ventriculoperitoneal shunts in children.

BACKGROUND: Ventriculoperitoneal shunt is the preferred treatment for hydrocephalus. Known complications include infection, obstruction, and disconnection with the fractured fragment migrating in the peritoneal cavity. We report 17 cases of laparoscopic evaluation and revision of ventriculoperitoneal shunts in children. METHODS: From January 2000 through October 2002, we retrospectively reviewed our experience with laparoscopy and ventriculoperitoneal shunts. RESULTS: Laparoscopy was performed in 17 children with a malfunctioning shunt, presumed shunt dislodgment or disconnection, reinsertion of a shunt after externalization, and primary shunt placement. Six patients (35%) were converted to an open laparotomy due to dense adhesions. Eleven patients (65%) underwent successful laparoscopic-assisted ventriculoperitoneal shunt placement: 5/11 (45%) had lysis of adhesions or pseudocyst marsupialization with repositioning of a functional shunt, or both; 3/11 (27%) had successful retrieval of a disconnected catheter with reinsertion of a new catheter; 2/11 (18%) had laparoscopic confirmation of satisfactory placement and function, requiring no revision; 1/11 (9%) had an initial shunt placed with laparoscopic guidance due to the obesity. Operative time for the laparoscopic procedure ranged from 30 minutes to 60 minutes. All laparoscopic procedures used 1-mm or two 5-mm ports. Perioperatively, no adverse neurological sequelae occurred due to the pneumoperitoneum. CONCLUSIONS: Laparoscopic guidance or revision of ventriculoperitoneal shunts permits (1) direct visualization of catheter insertion within the peritoneal cavity, (2) satisfactory positioning, (3) lysis of adhesions or marsupialization with catheter repositioning, or both, and (4) retrieval of fractured catheters.     

Peritoneography in the assessment of peritoneal cerebrospinal fluid absorption potential for distal ventriculoperitoneal shunt catheter placement: technical case report

OBJECTIVE AND IMPORTANCE: Distal ventriculoperitoneal shunt failure has been associated with absorption failure secondary to previous peritonitis. This assumption has caused surgeons to seek alternate sites for distal catheter placement. We propose that the absorptive potential of the peritoneal cavity should be assessed before that site is discounted for catheter placement. CLINICAL PRESENTATION: The case of a 14-month-old male patient is presented, demonstrating multiple ventriculoperitoneal shunt placement procedures and a diagnostic dilemma with respect to distal shunt placement. Peritoneography was performed to demonstrate peritoneal fluid absorption, allowing subsequent placement of a new distal shunt catheter with good clinical results. TECHNIQUE: Using aseptic technique, a 24-gauge spinal needle was inserted in the midline of the abdomen and water-soluble contrast material was instilled. Delayed radiographs delineated peritoneal adhesions and demonstrated renal excretion of the contrast material, confirming peritoneal absorption. CONCLUSION: The peritoneal cavity remains the site of choice for distal shunt catheter placement. If failure of peritoneal cerebrospinal fluid absorption is suspected as a cause of shunt failure, then peritoneography with water-soluble contrast material may be safely used to demonstrate the adequacy of fluid absorption before a secondary site is chosen.     

Intraperitoneal cerebrospinal fluid pseudocyst. A rare complication of ventriculoperitoneal shunt

The abdominal intraperitoneal cerebrospinal fluid pseudocyst is a rare but important complication in patients with ventriculoperitoneal shunts. We report a case of a 31-year-old female, in which a large abdominal pseudocyst was developed 1 year after insertion of a ventriculoperitoneal shunt for hydrocephalus. The abdominal CT scan and the ultrasonographical evaluation of the abdomen showed a well defined, cystic mass lesion with a volume of 50 cm3, in the recessus hepato-renal. The peritoneal tip of the shunt was located within the mass lesion. A distal externalization of the peritoneal catheter without excision of the pseudocyst was performed. Cerebrospinal fluid culture demonstrated a Staphylococcus epidermis infection and adequate antibiotic treatment was administrated. The previous symptoms improved 4 weeks later and a new catheter was placed intraperitoneally in a different quadrant. The postoperative course was uneventful. We suggest that chronic inflammation or subclinical peritonitis is a predisposing factor for this complication.     

Laparoscopy-assisted ventriculoperitoneal shunt surgery: personal experience and review of the literature

Ventriculoperitoneal shunting is a widely accepted technique for the treatment of hydrocephalus. The standard procedure to insert the peritoneal catheter requires an abdominal incision, muscle dissection, and opening of the peritoneum. A number of complications related to the abdominal surgical phase have been reported. Laparoscopy-assisted ventriculoperitoneal shunting is a valid alternative procedure that reduces surgical trauma. We describe our experience and review the literature. A total of 30 laparoscopically guided ventriculoperitoneal shunting procedures were performed between January 2007 and June 2008, in collaboration with a general surgeon experienced in laparoscopy. Of these procedures, 25 were new shunt placements and 5 were revisions. Data about operative time, outcome, and complications were registered and compared with a group of 30 patients treated by means of standard laparotomy in the period 2005–2007. Laparoscopic shunt placement was successful in all patients. Operative duration, complications, and postoperative pain were all lower in patients treated by laparoscopy as compared to the laparotomy. In the laparoscopic group, an earlier peristalsis, quicker mobilization, and better cosmetic results were also noted. Laparoscopy in both ventriculoperitoneal shunt placement and revision is a safe, effective, and minimally invasive technique. It ensures proper abdominal placement of the distal catheter under direct vision allowing confirmation of its patency.     

Laparoscopic ventriculoperitoneal shunts: benefits to resident training and patient safety

Background and Objectives:

Symptomatic hydrocephalus is a surprisingly common clinical condition. Neurosurgeons are expert at ventriculostomy, but minimally invasive peritoneal access is outside the realm of their current training. We have adopted a multidisciplinary approach, with general surgeons positioning the distal shunt. Our objective was to review this recent experience.

Methods:

All distal shunts were placed by a single surgeon with resident assistance. After ventriculostomy, the shunt tubing was tunneled onto the anterior abdominal wall. A Veress needle was placed through the tunnel incision and the abdomen insufflated. A 5-mm optical access trocar and camera were introduced via a separate stab incision. The shunt tubing was then directed into the abdominal cavity using a Hickman introducer kit, with flow confirmed visually.

Results:

Study patients who had between 0 and 10 previous abdominal operations received 111 consecutive shunts. There was one intraoperative complication, a colon injury during trocar placement. In this case, the colotomy was repaired and the shunt placed in the pleural space. There were no conversions to the open abdominal approach. Postoperatively, there were no wound infections, no cases of shunt malpositioning, and there were no deaths.

Conclusions:

Laparoscopic placement of ventriculoperitoneal shunts is feasible, safe, and carries a low rate of complications. The value to resident education in the practice of this procedure has not been previously emphasized. In the era of increased awareness of patient safety, laparoscopic VP shunting serves as a model for accomplishing both goals of improved outcomes and quality surgical education.     

Minimally invasive implantation of the peritoneal catheter in ventriculoperitoneal shunt placement for hydrocephalus: analysis of data in 151 consecutive adult patients

OBJECT: The authors report on their experience with laparoscopy-guided implantation of a peritoneal catheter in ventriculoperitoneal shunt placement procedures in adults. METHODS: In performing the conventional method of shunt placement in 2001, 8% of the cases resulted in malposition and dislocation of the distal catheter; therefore, the authors together with personnel from the Department of General Surgery decided to utilize an interdisciplinary approach involving laparoscopy-guided implantation of the catheter. Between October 2001 and January 2005, 202 ventriculoperitoneal shunt placement procedures were conducted in adult patients for hydrocephalus of various origins. In 152 patients, laparoscopy-guided implantation of the distal catheter was performed. In all except one of these patients, implantation was successful. Laparoscopy and the cranial part of the surgery were performed simultaneously. There was an 8% rate of malposition of the distal catheter in the nonlaparoscopy group. In contrast, there was no dislocation or malposition of the distal catheter in the laparoscopy group. Two cases (1.3%) of shunt infection occurred in the laparoscopy group. CONCLUSIONS: Laparoscopic implantation of a distal catheter is a simple, minimally invasive, and easy procedure to perform and allows exact localization of the peritoneal catheter and confirmation of its patency.     

Accurate placement of the distal end of a ventriculoatrial shunt with the aid of real-time transesophageal echocardiography. Technical note

OBJECTIVE: Ventriculoatrial (VA) shunts remain a valid option for the treatment of hydrocephalus, especially in patients in whom ventriculoperitoneal (VP) shunts fail. Correct positioning of the distal end of the catheter in the right atrium is of paramount importance for maintaining shunt patency and reducing the incidence of VA shunt-associated morbidity. The authors present their experience with real-time transesophageal echocardiography (TEE) monitoring for the accurate placement of the distal catheter of a VA shunt. METHODS: Four patients underwent conversion of a VP shunt to a VA shunt under the guidance of intraoperative fluoroscopy and TEE between May 2003 and December 2004. After induction of general anesthesia, the TEE transducer was advanced into the esophagus. A cervical incision was made and the external jugular vein was visualized. An introducer was passed through an opening in the jugular vein and a guidewire was placed through the introducer. Under continuous TEE guidance, the guidewire was carefully advanced into the superior vena cava. A distal shunt catheter overlying a J-wire was then passed to the superior vena cava, again under TEE guidance. The catheter was advanced to the right atrium after removing the guidewire. Final visualization with TEE and fluoroscopy revealed a good position of the catheter in the right atrium in all four cases. The mean duration of the operation was 91 minutes (range 65-120 minutes) and the mean operative blood loss was 23 ml (range 10-50 ml). No procedure-related complication was noted. CONCLUSIONS: Real-time TEE is a safe and simple technique for the accurate placement of the distal catheter of a VA shunt.     

Laparoscopically assisted ventriculoperitoneal shunt placement using 2-mm instrumentationrid=""id=""Presented in poster format at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), San Antonio, Texas, USA, 24–27 March 1999

Background: Laparoscopy has potential benefit in the placement of ventriculoperitoneal shunts. In patients who have undergone multiple shunt revisions or other abdominal operations, laparoscopy may be particularly beneficial when finding of a suitable area in which to place the shunt is a concern. The purpose of this study was to evaluate the safety and effectiveness of laparoscopically assisted ventriculoperitoneal shunt placement, with an emphasis on using 2-mm instrumentation. Methods: Laparoscopically assisted ventriculoperitoneal shunt placement using 2-mm instrumentation was performed in eight adult hydrocephalus patients from August 1996 to September 1998. All eight patients had undergone 1 to 18 prior shunt revisions. The procedures were performed with two 2-mm trocars. The instrumentation consisted of a 2-mm laparoscope, a 2-mm grasper, and 2-mm scissors. All shunts were placed in an area free of adhesions and checked for flow under direct vision. Four of the patients required a lysis of adhesions to create a space adequate for catheter placement. Results: All of the procedures were successful, with no operative complications. The operative times ranged from 29 to 99 min, (mean, 63 min). The blood loss in all of the procedures was minimal. At this writing, none of the patients have required subsequent distal shunt revisions. No conversions to larger instruments or an open procedure were required. Conclusions: Laparoscopically assisted ventriculoperitoneal shunt placement using 2-mm instrumentation is safe and effective, offering several advantages over the open procedure. This procedure is ideal for the use of 2-mm instruments. Received: 19 March 1999/Accepted: 23 June 1999/Online publication: 10 April 2000     

A retrospective analysis of laparoscopically assisted ventriculoperitoneal shunts

Background: During the last two years, laparoscopy has been utilized to facilitate the rapid, safe and direct placement of the abdominal component of ventriculoperitoneal shunts. This study was undertaken to review the feasibility, benefits, technique, and clinical application of laparoscopically assisted ventriculoperitoneal (LAVP) shunt placement. Methods: A retrospective analysis of the records of six patients who underwent LAVP shunt placement was undertaken. The sex, age, technique, indication for surgery, comorbid conditions, complications operative time, results, and mortality were noted. Results: All patients underwent successful shunt placement. This included placement in the face of previous abdominal surgery, including a percutaneous gastrostomy. The one major complication, hemothorax, was not associated with the laparoscopic portion of the procedure. Conclusions: Using basic laparoscopic skills and nonspecialized equipment, laparoscopic assistance in ventriculoperitoneal shunt placement offers easy, direct placement of the intraabdominal portion of the catheter in most situations and provides definite patient benefits.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Orlando, Florida, USA, 11–14 March 1995     

Percutaneous endoscopic gastrostomy in patients with ventriculoperitoneal shunts

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) may be required in neurosurgical patients with a persistently depressed neurological status or severe lower cranial nerve palsies. Such patients may have a coexisting hydrocephalus requiring cerebrospinal fluid (CSF) diversion. Despite the risk of infection resulting from exposure to oropharyngeal flora by the pull-through PEG technique and the secondary pneumoperitoneum seen in one-third of patients, simultaneous peritoneal placement of CSF shunt catheters with PEG is the current practice. The aim of the study was to determine the frequency of CSF diversionary procedures in neurosurgical patients undergoing PEG insertion and the occurrence of infective complications in patients with simultaneous placement of a PEG and a ventriculoperitoneal (VP) shunt. METHODS: This was a retrospective review of all neurosurgical patients undergoing PEG. The presence of hydrocephalus, mode of CSF diversion and the development of subsequent infection in those having coexistent distal peritoneal catheter placement and PEG were determined. RESULTS: PEGs were placed in 42 neurosurgical patients (9.3 per cent of all PEGs inserted), of whom 21 had a coexisting hydrocephalus. Eight of 16 shunts with distal catheter placement in the peritoneal cavity developed infection requiring revision. Infections occurred with greater frequency in patients with a tracheostomy. There were no shunt infections requiring revision in a second group of 21 patients who had a coexisting shunt and tracheostomy without PEG. CONCLUSION: Simultaneous placement of a PEG and a VP shunt should be avoided in the acute phase of a patient's hospital admission.     

Laparoscopic fundoplication in children with previous abdominal surgery

BACKGROUND/PURPOSE: In our institution, many children requiring antireflux surgery for gastroesophageal reflux have had previous abdominal surgery, usually gastrostomy tube or ventriculoperitoneal (VP) shunt placement. The authors review their laparoscopic Nissen fundoplication (LNF) experience in children with previous abdominal surgery assessing surgical outcome. METHODS: A total of 82 consecutive LNFs performed at our institution between January 1996 and September 1998 were reviewed. Follow-up ranged from 1 month to 32 months (average, 8.9 months). LNF was performed without dividing short gastric vessels (Rosetti modification) through a standard 5-port technique. RESULTS: A total of 26 of 82 patients (31.7%) had previous abdominal surgery and were divided into 2 groups: gastrostomy (n = 17) and VP shunt (n = 11) with 2 crossovers. A total of 14 of 17 (82.3%) in the gastrostomy group had percutaneous endoscopic gastrostomy (PEG) placement versus 3 of 17 (17.6%) by open technique (open). Four patients in the VP group had multiple surgeries (range, 1 to 10, average, 2.3). LNF was completed in 25 of 26 (96.2%). One operation was converted to an open procedure because of severe adhesions. In 13 of 17 (76.5%) the previous gastrostomy was not taken down. In 4 of 17 (23.5%), the gastrostomy was taken down to complete the procedure: 2 of 3 (66.7%) of the open group versus 2 of 14 (14.3%) of the PEG group. All 11 (100%) of the VP group had successful LNF. Two of 11 (18.2%) had shunt dysfunction at 2 months (shunt infection) and 4 months (clogged distal shunt), respectively. There have been no cases of recurrent reflux, and all gastrostomies and VP shunts were functional at the time of this report. CONCLUSIONS: Previous abdominal surgery is common in children with gastroesophageal reflux disease requiring an antireflux procedure. The authors conclude from these preliminary results that laparoscopic Nissen fundoplication can be performed safely with minimal morbidity and excellent functional results in children with gastrostomies or ventriculoperitoneal shunts.     

Laparoscopic management of distal ventriculoperitoneal shunt complications

BACKGROUND: The traditional management of hydrocephalus still is the placement of ventriculoperitoneal (VP) shunts. However, the majority of patients require one or more revisions over their lifetime. Revisions may be required for infections, proximal site malfunction, or distal catheter complications. The authors present their experience with distal catheter complications managed laparoscopically. METHODS: Patients with recurrent symptoms of increased intracranial pressure or abdominal complaints were evaluated for shunt malfunction. Similar radiographic imaging was performed for all the patients, including computed tomography (CT) of the head and abdomen, shunt series, and/or ultrasound of the distal catheter. RESULTS: From April 2003 to July 2005, 13 patients with distal VP shunt complications were managed laparoscopically. On the basis of preoperative cerebrospinal fluid (CSF) cultures, all the patients were determined not to have an infection. Radiographic imaging showed the patients to have distal catheter problems. Preoperatively, five abdominal CT scans, six shunt series, and four abdominal ultrasounds were obtained. All studies singly and positively identified the appropriate abdominal catheter defect except in three patients who required multiple sequential radiographic studies for final determination of the diagnosis. In four patients (30.8%), the distal catheter was found to be in the extraperitoneal space. Another four patients (30.8%) had intraabdominal CSF pseudocysts. Five patients (38.4%) had issues with the position of the intraabdominal catheter: four of them subdiaphragmatic and one on the dome of the bladder. Laparoscopic repositioning was successful for all 13 patients. CONCLUSION: Regardless of the patient's presenting symptoms, appropriate imaging studies should be obtained preoperatively in a sequential manner. Distal VP shunt complications can be safely and effectively managed laparoscopically. This approach allows the intraabdominal portion of the catheter to be assessed and problems to be managed, thereby salvaging the existing shunt and avoiding the potential morbidity associated with additional VP shunt placement.     

Cerebral fluid edema: a rare complication of ventriculoperitoneal shunt

Physiopathologic knowledge of hydrocephalus allows progress in the conception of modern shunts. With better controlled surgical techniques, shunting has revolutionized the prognosis of hydrocephalus. However, peritoneal or atrial shunting is not harmless, as illustrated by the large number of reported complications. We describe here an unusual complication of ventriculoperitoneal shunt dysfunction revealed by focal cerebral edema in a 60-year-old patient. Preoperative cerebral CT scan showed the focal brain edema with diffusion of cerebrospinal fluid around the trajectory of the ventricular catheter. Abdominal CT scan demonstrated distal shunt dysfunction. Clinical and radiological outcome was good after surgical revision of the shunt, confirming the diagnosis.     

Infectious risk to ventriculo-peritoneal shunts from gastrointestinal surgery in the pediatric population

Purpose

The infectious implication of abdominal surgeries on ventriculo-peritoneal (VP) shunts, including simultaneous shunt placement and management of shunt infections, has been ill defined in children.

Methods

We conducted a 9-year retrospective review of pediatric patients with VP shunts who underwent abdominal surgeries.

Results

Forty-two patients fit criteria. The median age at shunt placement was 1.75 years, and the median time between shunt placement and abdominal surgery was 24 days. The most common procedures included gastrostomy (17), fundoplication (15), and appendectomy (3). Seven patients had simultaneous abdominal surgery and shunt placement. All patients received preoperative antibiotics. Two children developed shunt infections, both occurred after appendectomy. Both were treated with antibiotics, with one requiring shunt removal. Median length of stay was 24 days but 28 days for those with infections. Thirty-eight patients were discharged home, 3 to chronic care facilities, and 1 died.

Conclusions

Infections did not occur in children with VP shunts undergoing elective abdominal procedures or procedures simultaneously with shunt insertion. Infections were seen only with emergent appendectomies, suggesting that performing gastrointestinal procedures at the time of VP shunt insertion is safe. Children with VP shunts undergoing emergent surgery for peritoneal infection warrant close observation for shunt infection.