Outcomes of ventriculoperitoneal shunt insertion in Sub-Saharan Africa

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Ventriculoperitoneal (VP) shunts in Sub-Saharan Africa are traditionally associated with high complication rates and poor outcomes. The aim of this study was to review one large institutional experience with VP shunts, to evaluate the feasibility of shunt insertion procedures with acceptable long-term outcomes in Africa, and to identify factors correlated with good and/or poor outcomes.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>A retrospective study was conducted by reviewing the charts of all children who underwent primary (93%) or subsequent VP shunt insertions at the Kijabe Hospital between November 2004 and March 2007. Epidemiological data, clinical investigations, etiology of the hydrocephalus, details of the VP shunt insertion, outcome at follow-up, and morbidity and mortality data were collected. Outcomes were graded as good, fair, or poor, according to visual, motor, and seizure criteria.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>The authors analyzed 593 VP shunt insertions in 574 patients. The sex distribution was 53% male and 47% female. The mean age at shunt insertion was 8.5 months (range 0–309 months). The commonest etiologies for hydrocephalus were spina bifida (43.4%) and postinfectious (27.7%). Follow-up was available in 76% of children, with a mean follow-up period of 8.9 months (range 2–30.5 months). The median patient age was 3.3 months. The overall shunt function rate at 2 years was 65%, and the complication rate per procedure was 20%, with infection encountered in 9.1% and shunt malfunction in 11%. Complications were significantly related to hydrocephalus etiology and to sex (p = 0.03 and p = 0.01, respectively). Overall outcomes were good in 40.2% and poor in 59.8%. Overall mortality in the group was 7.1%. Younger patients who survived had an overall good outcome (p = 0.0001). Only 10% of patients with a head circumference greater than 60 cm had a good outcome.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Despite limited resources, VP shunt procedures can be carried out in Sub-Saharan Africa with acceptable complication rates and fair long-term outcomes.</jats:p></jats:sec>

Global surgery for pediatric hydrocephalus in the developing world: a review of the history, challenges, and future directions

“…25 Postinfectious hydrocephalus, however, is not the leading etiology reported from all developing countries, with hydrocephalus secondary to neural tube defects being especially common, along with aqueductal stenosis and hemorrhage, in Kenya, Nigeria, Cameroon, Zambia, Zimbabwe, Malawi, and Saudi Arabia. 2,3,19,23,28,63,65 The spectrum of bacteria causing neonatal sepsis and postinfectious hydrocephalus also differs between developing and developed countries. 32,36 In developed countries, Group B Streptococcus, Escherichia coli, and Listeria monocytogenes most commonly cause neonatal sepsis.…”

“…18 In developing countries, risk factors for poor outcomes after VP shunt treatment include younger age, comorbidities like anemia and malnutrition, advanced presentation, and the absence of adequate diagnostic imaging. 23 Worldwide complication rates of VP shunts are reported to be between 1% and 40%, but developing countries face the greatest burden. 23,31 While the incidence of VP shunt infections ranges from 2% to 9% in developed countries, 15 in developing countries it reportedly occurs in 8.6%-50%.…”

“…23 Worldwide complication rates of VP shunts are reported to be between 1% and 40%, but developing countries face the greatest burden. 23,31 While the incidence of VP shunt infections ranges from 2% to 9% in developed countries, 15 in developing countries it reportedly occurs in 8.6%-50%. The preponderance of gram-negative and enteric bacteria in shunt infections may be related to poor hygiene, malnutrition, and the hospital environments in developing countries.…”

“…18,23 This treatment is effective, but is not without complications of shunt extrusion, breakage, overdrainage, obstruction, or infection and the potential for many revisions over a lifetime. 18 There is an especially high upfront burden of disease, with nearly half of all shunts failing in the first 2 years.…”

Bacteria causing ventriculoperitoneal shunt infections in a Kenyan population

“…3,4,12 Infection rates in African countries have been reported to be much higher: 9%-32%. 5,8,10 Most studies from developed countries report Staphylococcus epidermidis as the most common infectious agent, followed by Staphylococcus aureus. 1,13 Similarly, in a study from Chile, Pena et al documented the most common organism as coagulasenegative Staphylococcus, which accounted for 50% (13 of 26) of the infections.…”