Uncommon complications of ventriculoperitoneal shunt surgery: review of four cases and literature review

Abstract

Background: Ventriculoperitoneal shunt is one of the most popular cerebrospinal fluid diversion procedures worldwide. Complications are common, but uncommon complications are rarely reported in the literature making a standardized guideline on management of unusual complications unavailable. We report this series of uncommon complications managed in our centre to share our experience and contribute to the pool of literature on the management of these weird complications of ventriculoperitoneal shunting. Case presentation: The first case was a 10-year-old girl who presented with headache, early morning vomiting and itching over the tract of the shunt in the neck. She has had ventriculoperitoneal shunt and excision and repair of encephalocele at the age of 3 months in our facility. On physical examination, she was conscious with a Glasgow coma score of 15, and shunt valve was hardened. She had removal of the shunt with intraoperative finding of calcified shunt tubing and the valve, and also cerebrospinal fluid was under high pressure that warranted re-insertion of another medium pressure shunt. She remained stable at last follow-up 3 months post-surgery. We managed two cases of shunt extrusion via the anus (a 1-year-old female infant and 9-year-old boy). None of the patients presented with evidence of peritonitis or shunt tract infection. The extruded shunts were removed under aseptic technique, and both patients had ventriculoperitoneal shunt re-inserted because of progression of hydrocephalus. They remained stable at last follow-up visits 6 months after surgery. The fourth case was a 9-month-old infant that presented with shunt extrusion via the abdominal wound site 3 weeks after ventriculoperitoneal shunt procedure. The child developed an abscess at the abdominal wound that ruptures spontaneously with extrusion of distal catheter, had no features of peritonitis and had shunt removed and re-inserted after 3 months. The child has remained stable. Conclusion: Although ventriculoperitoneal shunt calcification and extrusion are rare, they do occur. None of our patients had peritonitis. Shunt removal and subsequent reinsertion in the presence of raised intracranial pressure from hydrocephalus confirms an excellent outcome.

Management of trans-anal extrusion of distal ventriculoperitoneal shunt catheter in children

“…Most probably, there was the formation of the inflammatory tract around the VPS catheter that sealed it from the peritoneum and prevent the occurrence of peritonitis. 9,11,12,18,20,25 Few of the cases of VPS catheter extrusion through the anus also presented with the additional features of meningitis/ventriculitis. 26,27 In all the cases, the clinical diagnosis was obvious due to the presence of a distal VPS catheter protruding out through the anal canal.…”

“…Many of the authors suggested and safely managed their cases by removal of the entire VPS system with or without placement of the EVD, course of antibiotics, and delayed re-VPS insertion. 11,18,21,25 The exact etiology is not known, why there is perforation of the hollow viscera including colon/rectum by the peritoneal catheter of the VPS system. Various factors play a vital and contributory role in the occurrence of the perforation of the hollow viscera, followed by extrusion of the distal VPS catheter through the natural orifices, including the trans-anal extrusion.…”