Successful treatment for intractable chylous ascites in a child using a peritoneovenous shunt

Intractable post-operative chylous ascites had been managed successfully using a peritoneovenous shunt (PVshunt). A 4-year-old girl with neuroblastoma originated from the right adrenal gland was admitted to our hospital. Following the preoperative chemotherapy, tumor resection, and lymph node dissection of the abdominal paraaortic region were carried out. Post-operative radiation therapy 9.6 gray to the tumor bed and to the paraaortic region and a high dose chemotherapy supported by auto bone marrow transplantation were completed. Three months later some enlarged lymph nodes along the duodeno-hepatic ligament were detected and these had gradually increased in size. Lymph node dissection along the hepatic artery and the abdominal aorta was carried out. Pathological examination of the specimen showed reactive lymph node swelling. Chylous ascites developed several days after surgery. Despite the medium-chain triglycerides meal or total parental nutrition, the ascites persisted for more than 80 days. Multiple paracenteses were mandatory. A PV shunt was implanted and the ascites was resolved by the fourth post-operative day. Thirty months later, the vascular end tube of the shunt was ligated. As ascites had not accumulated for 2 weeks, the PV shunt was removed. The patient has been doing well without recurrence of ascites or neuroblastoma for 12 years. As PV shunts were mostly used for long lasting disease, it has not been referred as to how to know when the shunt should be removed. If the shunt is inserted for transient management of ascites, less invasive methods of investigation to know when to remove the shunt need to be developed.     

Transoral protrusion of a peritoneal catheter: a rare complication of ventriculoperitoneal shunt

Ventriculoperitoneal (VP) shunt surgery is the most used technique for the treatment of hydrocephalus. This procedure is associated with a large amount of complications. Bowel perforation caused by a peritoneal shunt catheter is one of these complications, sometimes fatal, and is usually difficult to recognize, except when protrusion of the peritoneal catheter through a natural orifice occurs. This report presents the case of a 2-year-old boy who had undergone a VP shunt and later presented with protrusion of the peritoneal catheter through his mouth. The shunt device was removed and an external shunt procedure was achieved, using the original ventricular catheter kept in place. The diagnosis of bacterial meningitis was retained and an antibiotic therapy was started. The evolution was fatal in 15 days secondary to a bacterial ventriculitis. Through the reported cases of bowel perforation, many risk factors were individualized, such as age, congenital etiology of the hydrocephalus, silicon allergy or the length of the peritoneal catheter. Bowel perforation is a serious complication of VP shunt surgery, leading sometimes to a fatal outcome.     

Results of portasystemic shunts in cirrhosis in children

A surgical porto-systemic shunt was carried out in 37 children and adolescents (age: 2 yrs-18 yrs) who presented with cirrhosis and portal hypertension. All patients were classified "A" or "B" according to Child's criteria. Proof of the patency of the shunt was obtained by endoscopy and/or angiography in 31 children. Two children died in the early postoperative period. Thrombosis of the shunt occurred in 4 children. With a follow-up of 6 months to 11 years, none of the 31 children operated on successfully presented with gastro-intestinal bleeding due to portal hypertension. Nine presented with one or several episodes of porto-systemic encephalopathy. Five of these were transient allowing for a normal diet to be resumed later. These results indicate that porto-systemic shunts are effective to prevent gastro-intestinal bleeding, even in young children with cirrhosis. However, in addition to Child's criteria, indications for shunt surgery must take into account the degree of hemorrhage risk and the possible need for a liver transplantation later.     

Neuropathological findings in a child with slit ventricle syndrome

The histopathological changes in shunted hydrocephalic children with slit ventricle syndrome have never been described. Periventricular gliosis is presumed to be an important feature. A girl who was shunted in infancy following meningitis developed headaches at 10 years of age and suffered a respiratory arrest, from which she was resuscitated. CT scan of the head showed very small ventricles. A diagnosis of slit ventricle syndrome was made. She died 33 h later. Autopsy revealed a large head and brain, small ventricles with glial adhesions, obstruction of the cerebral aqueduct, complete obstruction of the shunt catheter and reactive astroglia in the periventricular white matter. The latter change was no more severe than in hydrocephalic children with enlarged ventricles who have died following shunt failure. Periventricular astrogliosis may not necessarily be the major determinant of the slit ventricle syndrome.     

Origin of the right pulmonary artery from the ascending aorta

A 19-day old female infant presented with congestive cardiac failure. Cardiac catheterization and angiography demonstrated the right pulmonary artery to originate from the ascending aorta, and an atrial septal defect with a left to right shunt of 40%. At the age of six months anastomosis of the right pulmonary artery to the main pulmonary artery was performed with hypothermic arrest and cardioplegia. The postoperative course was complicated by respiratory distress but later the patient's condition improved. Four years later control cardiac catheterization and angiography visualized operative repair and only a small left to right shunt of 20% at atrial level.     

Massive ascites formation due to unabsorbed cerebrospinal fluid following abdominal surgery in ventriculoperitoneal shunt. A case report

A 15-year-old girl with a congenital heart disease (pulmonary stenosis and aortic insufficiency), who had a ventriculoperitoneal shunt operation because of hydrocephalus internus at the age of two years, 12 years later underwent colectomy because of juvenile colonic polyposis. After this operation, enormous production of ascites began which, because of progressive development, finally required ventriculoatrial shunt operation. A total volume of 17 liters of fluid was removed in two ascites drainages before and during the latter operation. Postoperatively the ascites production stopped completely.     

Acute Inferior Cardiac Inflow Obstruction Resulting from Inadvertent Surgical Closure of a Prominent Eustachian Valve Mistaken for an Atrial Septal Defect

A 5-month-old boy with a VACTERL syndrome underwent cardiac surgery for correction of a common arterial trunk and closure of an atrial septal defect. A prominent Eustachian valve was mistaken for the atrial septum and surgically closed. Thirty months later, after gradual shrinking of the foramen ovale with associated reduction of the right-to-left shunt, the boy presented with acute symptoms of a lower inflow obstruction, characterized by hepatomegaly and engorged abdominal vein pattern (Medusa's head). The boy was reoperated successfully after the condition had been recognized.     

An unusual complication of tapping a ventriculoperitoneal shunt.

A case is reported describing a complication of an unsuccessful attempt to aspirate the reservoir of a ventriculoperitoneal shunt system with a suspected shunt infection. This arose due to a misunderstanding of the anatomy of the shunt and resulted in an intracerebral haematoma. The complications of cerebrospinal fluid shunting and the difficulty in the diagnosis thereof are outlined. We discuss the role and method of shunt tapping in diagnosing shunt problems before reviewing the literature describing the rationale. The variation in shunt design is emphasized. Guidelines are then proposed not to dissuade physicians from tapping shunts but to ensure that the procedure is performed safely and in collaboration with neurosurgical units.     

Neonatal ventricular haemorrhage: treatment by puncture

Transfontanellar ventricular puncture and intermittent lumbar punctures were carried out in 10 patients affected by intraventricular haemorrhage during the period between 1980 and 1983. In only three of them was later a shunt necessary for treatment of hydrocephalus. Six children developed normally, in two severe mental retardation ensued, and two died later, one of heart failure after cardiac surgery and one of ventriculitis following shunt implantation. Puncture therapy can be recommended for intraventricular haemorrhage of the neonate.     

Spinal cord tumor-associated syrinx mimicking abdominal epilepsy: a rare cause of childhood abdominal pain

A 10-year-old child presented with recurrent abdominal pain. Abdominal epilepsy was suspected as conventional criteria for the diagnosis were met, including an apparent therapeutic response to anticonvulsant medication. Seven months later the patient developed recurrent abdominal pain, a gait disorder, and atrophy of the right thigh and calf. Magnetic resonance imaging of the spine revealed a thoracic syringomyelia. Anticonvulsant medications were discontinued and a syringoperitoneal shunt was placed with resolution of symptoms. This appears to be a previously undescribed presentation for syringomyelia and emphasizes the importance of considering alternative central nervous system disorders before the diagnosis of abdominal epilepsy is made.     

Rapid evaluation of ventriculoperitoneal shunt function in a pediatric patient using emergency ultrasound

A 9-year-old girl with a ventriculoperitoneal shunt presents to the emergency department with progressive positional headaches, vomiting, fatigue, and pain over her shunt tract. Emergency ultrasound was used to diagnose discontinuity in the cervical portion of the shunt allowing for expedited care while waiting for confirmatory testing. She underwent urgent shunt replacement with good outcome.     

Growth pattern in children with congenital heart disease

Summary Growth study of 25 acyanotic children with left-to-right shunt and 5 cyanotic children with right-to-left shunt (tetralogy of Fallot) is reported. Data were collected at the time of operation and on followup 4 1/2–12 months later. No significant differences in the two measurements were seen. Weight was more impaired at the time of operation than height. The literature is reviewed. From the Child Development Unit, Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky, U.S.A.     

Cerebral and Abdominal Arterial Hemodynamics in Preterm Infants with Patent Ductus Arteriosus

Using Doppler echocardiography we evaluated the effect of ductal shunt flow on the cerebral and abdominal arterial blood flow in 25 preterm infants. Eligible for inclusion in this study were healthy preterm newborn infants. They were divided into two groups based on their gestational age: group A, 33-36 weeks (15 infants) and group B, 28–32 weeks (10 infants). Two-dimensional Doppler echocardiograms were obtained in each infant during the first 8 hours of life and repeated every 6–12 hours until no ductal shunt flow could be detected. Flow in the ductus arteriosus, the basilar artery and the coeliac artery were examined. Closure of the ductus arteriosus occurred significantly later(p< 0.05) in group B than in group A. Pulsatility indices of flow in the basilar and coeliac arteries were high when the ductus was patent, decreasing to a fixed level with closure. This study suggests that a shunt of the patent ductus arteriosus (PDA) adversely influences the cerebral and abdominal blood flow in preterm infants.     

Modified Blalock Taussig shunt anastomosis in a three month old child with pulmonary stenosis: Embolization therapy

A case of transcatheter occlusion of a modified Blalock-Taussig (BT) shunt with a detachable balloon is described. A three month old boy with pulmonary atresia with intact ventricular septum had a repair consisting in valvotomy and a modified BT. This palliative aorticopulmonary shunt created congestive heart failure. As an alternative to surgery, a detachable balloon was used to occlude the BT shunt.     

Treatment of cerebrospinal fluid shunt infections: a decision analysis

BACKGROUND: Cerebrospinal fluid shunts transfer cerebrospinal fluid (CSF) from the lateral ventricles in the brain to the peritoneum (ventriculoperitoneal shunt) or the right atrium (ventriculoatrial shunt) via subcutaneous Silastic tubing. As with any implanted foreign body, infection is a serious complication. Although there are several therapeutic modalities currently used for the treatment of shunt infections, controversy remains as to which is best given that there has been only one randomized trial comparing their effectiveness. OBJECTIVE: To determine which treatment modality is most effective by using decision analysis to compare three approaches with regard to cure rate, morbidity and mortality. METHODS: We constructed a decision tree to map out the different treatment modalities and assigned probability values obtained from previously published studies. A utility value was assigned to each treatment outcome, ranging from 0 to 1.0, with a higher score indicating a more favorable outcome. Calculations were performed using Decision Analysis TreeAge computer software. RESULTS: The removal of an infected shunt with establishment of external ventricular drainage or ventricular taps and administration of antibiotics leads to the highest expected value, 0.86. Removal of an infected shunt followed by immediate replacement and administration of antibiotics is less effective, with an expected value of 0.76. The use of antibiotics alone results in the lowest expected value, 0.61. Sensitivity analysis showed the above findings to be robust with respect to clinically relevant changes for the baseline probabilities and utility values. CONCLUSION: A protocol of shunt removal, external ventricular drainage placement or ventricular taps and antibiotics, followed by creation of a new shunt when CSF sterility is achieved, is the most effective method of treatment for CSF shunt infection.     

Successful treatment of a brain abscess with antibiotics and drainage puncture in an 11-year-old boy with a complex cyanotic heart defect

A Blalock-Taussig-anastomosis was performed at the age of 2 years in a boy with transposition of the great arteries, ventricular septal defect, and pulmonary atresia. Nine years later he developed a transient aphasia. Cranial computed tomography (CT-scan) revealed a structure compatible with brain abscess. The boy was conscious and no neurological deficit was found. Initial therapy consisted of Ampicillin, Tobramycin, and Metronidazole, 12 days later an acute hemiplegia developed. 30 ml of pus were aspirated from the brain abscess, and the boy's condition dramatically improved. Streptococcus milleri was found bacteriologically and antibiotic therapy was continued over six weeks. Serial CT-scans during and after therapy demonstrated disappearance of the brain abscess. The presented case shows that after a shunt procedure in cyanotic heart disease right-to-left-shunting and therefore chronic oxygen desaturation and polycythemia are still present as facilitating factors for focal encephalomalacia, cerebritis, and brain abscess. In case of short duration of neurological symptoms and a size of abscess less than 4 cm in diameter antibiotic therapy without total excision may eliminate the infection.     

西地那非抑制高肺血流肺动脉高压大鼠肺血管重构和上调肺血管Kv1.5mRNA表达

目的 观察高肺血流肺动脉高压大鼠肺血管结构重建和肺血管电压依从钾通道Kv1.5mRNA表达变化,探讨口服西地那非对高肺血流肺动脉高压大鼠肺血管重构及肺血管电压依从钾通道Kv1.5mRNA表达的影响.方法 将27只雄性SD大鼠随机分为对照组(n=9)、分流组(n=9)、分流+西地那非组(n=9).后两组大鼠通过腹主动脉一下腔静脉分流术建立高肺血流肺动脉高压动物模型.对分流+西地那非组大鼠每天灌胃枸橼酸西地那非10 mg·kg-1·d-1,对照组和分流组每天灌胃等量生理盐水.11周后,测定肺动脉平均压(mPAP)及肺动脉收缩压(sPAP);观察右室肥厚程度,计算右室重量/(左室+室间隔)重量比值,以[RV/(LV+S)]表示;计算肺中、小血管肌型动脉相对中膜厚度(RMT);采用实时荧光RT-PCR定量法观察大鼠肺血管电压依从钾通道Kv1.5mRNA表达.结果 与对照组比较,分流组大鼠mPAP、sPAP、RV/(Lv+S)比值显著增高(P<0.01),RMT显著增加(P<0.01),肺血管Kv1.5mRNA表达水平显著降低(P<0.01).与分流组相比,分流+西地那非组mPAP、sPAP、RV/(LV+S)比值显著低于分流组(P<0.01),RMT显著降低(P<0.01),肺血管Kv1.5mRNA表达水平显著升高(P<0.01).分流+西地那非组mPAP、sPAP、RV/(Lv+S)比值和RMT与对照组比较,差异均无显著性意义(P>0.05);两组大鼠Kv1.5 mRNA表达水平也无显著性差异(P>0.05).结论 高肺血流肺高压大鼠肺血管发生重构并且其肺血管Kv1.5mRNA表达下降,而口服枸橼酸西地那非抑制高肺血流肺高压大鼠肺血管重构和上调肺血管Kv1.5mRNA表达.     

A case of infertility in a patient with a ventriculoperitoneal shunt

OBJECTIVE AND IMPORTANCE: Complications arising from the placement of ventriculoperitoneal (VP) shunts are well documented. A case of infertility is presented that was thought to result from factors related to the distal end of a VP shunt residing within a patient's abdomen. CLINICAL PRESENTATION: A 30-year-old female with a 3-year history of infertility was referred for fallopian tube blockage. An exploratory laparoscopy revealed multiple adhesions adjoining the distal end of her fallopian tubes. The distal portion of a VP shunt placed at childhood (with subsequent revisions) was found entangled among grossly inflamed and densely adhesive pelvic viscera. INTERVENTION: Laparoscopic adhesiolysis was performed and the patient's fallopian tubes were reconstituted. The distal portion of the VP shunt was freed from the surrounding viscera and was not revised. CONCLUSION: VP shunts may produce adhesive disease and complicate fertility via mechanical, chemical, and/or infectious processes.     

Massive hematuria due to portal hypertension in a child with bladder augmentation for vesical exstrophy

We report a case of a 17-year-old patient with severe hematuria from an ileocystoplasty-augmented bladder for vesical exstrophy, with associated cirrhosis secondary to autoimmune hepatitis, diagnosed years later. Varix development and further bleeding from ectopic varices, related to cirrhosis and portal hypertension, are a rare cause of hematuria in patients with surgically augmented bladder volume. This child was successfully treated with a transjugular intrahepatic portosystemic shunt procedure as a bridge to hepatic transplantation.     

Silent bowel perforation and transanal prolapse of a ventriculoperitoneal shunt

A 2-year-old hydrocephalic child presenting with ventriculitis following intestinal perforation by a ventriculoperitoneal (VP) shunt is reported. The peritoneal end of the shunt had extruded through the anus without causing any abdominal signs. Removal of the shunt, external ventriculostomy, and antibiotics were effective treatment. Accepted: 23 March 1999