Increased intracranial pressure is often relieved by a ventriculoperitoneal shunt. The shunt has a one-way valve which can withstand pressures of 300 mmHg and prevent reflux of intraabdominal fluid. We have utilized laparoscopy for cholecystectomy in four patients with VP shunts. In all patients the peritoneal cavity was free of adhesions. When CO2 insufflation pressure was as high as 10-15 mmHg cerebrospinal fluid was still noted to flow from the end of the shunts. In three patients the entire procedure was performed laparoscopically. In the fourth patient the procedure was converted to an open cholecystectomy because of extensive inflammation surrounding a gangrenous gallbladder. Postoperatively the shunts remained intact and functional. There were no central nervous system sequelae. None of the shunts became infected. Elective laparoscopic cholecystectomy in patients with VP shunts can be done safely without a need for clamping or other manipulation of the shunt.

Percutaneous endoscopic gastrostomy (PEG) has been popular since it was introduced in 1980. Gastrostomy tubes left in place for long periods often result in unusual complications. Complications may also result from simply replacing a long-term indwelling tube. Five patients who had gastrostomy tubes in place for as long as 4 years are presented and their complications reviewed. Various methods used in treating these complications are discussed, and suggestions for their prevention are given. Gastrointestinal erosion and jejunal perforation following migration of the gastrostomy tube, persistent abdominal wall sinus tracts, and separation of the flange head with small bowel obstruction were encountered. Reinsertion of a gastrostomy tube through a tract prior to adequate maturation was also noted to lead to complications. Complications may result from gastrostomy tubes left in place for extended periods of time and during replacement procedures. Awareness of such complications along with education of caregivers and timely intervention by the endoscopist may prevent such occurrences. In some cases one can only hope to minimize morbidity.

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Two patients with sinus tracts from retained T-fasteners following PEG tube placement are reported. Both patients had the PEG tubes subsequently removed and presented with purulent discharge and granulations near well-healed gastrostomy sites. The management of this complication and a possible method of prevention are discussed.