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Sanderfer VC, Arnold MR, Mulvaney GG, Wang H, McLanahan CS, Wait SD, Van Poppel MD, Cosper G, Schmelzer T, Schulman AM, Jernigan SC, Reinke CE. Outcomes of laparoscopic and open ventriculoperitoneal shunt placement. Am J Surg 2024; 227:123-126. [PMID: 37827869 DOI: 10.1016/j.amjsurg.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/29/2023] [Accepted: 10/01/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE Ventriculoperitoneal (VP) shunt placement requires a concurrent abdominal procedure. For peritoneal access laparoscopic or open approach may be utilized. Our aim was to compare patient/procedure characteristics and outcomes by peritoneal approach for VP shunts in children. METHODS NSQIP-Pediatric procedure targeted cerebral spinal fluid shunt Participant Use Data Files from 2016 to 2020 were queried. Patients were grouped into laparoscopic vs open abdominal approach. Patient demographics, procedure characteristics and 30-day outcomes were compared. RESULTS 7742 NSQIP-Pediatric patients underwent VP shunt placement. Patients undergoing laparoscopic approach were older and required less preoperative support. Mean operative time was longer with laparoscopy (mean(SD): 74.2(48.1) vs. 64.6(39) minutes, p < 0.0001) but had shorter hospital LOS. There was no difference in SSI, readmissions, or reoperation rates. CONCLUSION Patients undergoing laparoscopy for distal VP shunts are older with less support needs preoperatively. While laparoscopic approach had a shorter hospital LOS, there was no demonstratable difference in SSI, readmissions or reoperations between approaches. Further studies are needed to assess long-term outcomes.
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Affiliation(s)
| | - Michael R Arnold
- Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Graham G Mulvaney
- Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Huaping Wang
- Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | | | - Scott D Wait
- Carolina Neurosurgery & Spine Associates, Charlotte, NC, USA
| | | | | | | | | | | | - Caroline E Reinke
- Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
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Cooper DJ, Begley S, Zamor C, Schulder M. Laparoscopic Versus Open Ventriculoperitoneal Shunt Placement: A Non-inferiority Study. J Clin Neurosci 2023; 115:24-28. [PMID: 37459828 DOI: 10.1016/j.jocn.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 07/05/2023] [Indexed: 08/23/2023]
Abstract
Ventriculoperitoneal shunt (VPS) insertion into the abdominal cavity had been done for decades via an open approach. Recently, the laparoscopic insertion of the peritoneal portion of the shunt has become an option. The aim of this study is to compare outcomes between these two approaches. We performed a single institution retrospective review of 104 consecutive adult patients between 2015 and 2017. Patients had peritoneal catheters placed either via an open approach by the neurosurgical team, or laparoscopically by general surgeons. Patient demographics and outcomes were compared using a non-inferiority analysis. Independent variables in the analysis included patient age, gender, race, BMI, surgery performed, previous VPS placement, previous abdominal procedures, and VPS indication, while dependent variables included length of stay (LOS), estimated blood loss (EBL), occurrence of shunt failure, and postoperative complications. Cohort analysis included 62 open and 42 laparoscopic cases with similar baseline characteristics. In terms of patient outcomes, EBL and hospital stay duration were shown to be non-inferior in the open group as compared to the laparoscopic group. We could not prove non-inferiority based on risk for overall or distal shunt failure. Neurosurgeons may reasonably continue to place peritoneal shunt catheters using a "traditional" method.
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Affiliation(s)
- Dylan J Cooper
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell Health, 500 Hofstra Blvd, Hempstead, NY 11549, USA.
| | - Sabrina Begley
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell Health, 500 Hofstra Blvd, Hempstead, NY 11549, USA
| | - Chris Zamor
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell Health, 500 Hofstra Blvd, Hempstead, NY 11549, USA
| | - Michael Schulder
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell Health, 500 Hofstra Blvd, Hempstead, NY 11549, USA
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Greuter L, Ruf L, Guzman R, Soleman J. Open versus laparoscopic ventriculoperitoneal shunt placement in children: a systematic review and meta-analysis. Childs Nerv Syst 2023; 39:1895-1902. [PMID: 37225936 PMCID: PMC10290606 DOI: 10.1007/s00381-023-05966-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 04/16/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Ventriculoperitoneal shunt (VPS) surgery is the traditional method for treating hydrocephalus, remaining one of the most regularly used procedures in pediatric neurosurgery. The reported revision rate of VPS can reach up to 80% and significantly reduces the quality of life in the affected children and has a high socioeconomic burden. Traditionally, distal VPS placement has been achieved open via a small laparotomy. However, in adults several studies have shown a lower rate of distal dysfunction using laparoscopic insertion. As the data in children are scarce, the aim of this systematic review and meta-analysis was to compare open and laparoscopic VPS placement in children regarding complications. METHODS PubMed and Embase databases were searched using a systematic search strategy to identify studies comparing open and laparoscopic VPS placement up to July 2022. Two independent researchers assessed the studies for inclusion and quality. Primary outcome measure was distal revision rate. A fixed effects model was used if low heterogeneity (I2 < 50%) was present, otherwise a random effects model was applied. RESULTS Out of 115 screened studies we included 8 studies in our qualitative assessment and three of them in our quantitative meta-analysis. All studies were retrospective cohort studies with 590 analyzed children, of which 231 children (39.2%) received laparoscopic, and 359 children (60.8%) open shunt placement. Similar distal revision rates were observed between the laparoscopic and open group (3.75% vs. 4.3%, RR 1.16, [ 95% CI 0.48 to 2.79], I2 = 50%, z = 0.32, p = 0.74). There was no significant difference in postoperative infection rate between the two groups (laparoscopic 5.6% vs. open 7.5%, RR 0.99, (95% CI [0.53 to 1.85]), I2=0%, z = -0.03, p= 0.97). The meta-analysis showed a significantly shorter surgery time in the laparoscopic group (49.22 (±21.46) vs. 64.13 (±8.99) minutes, SMD-3.6, [95% CI -6.9 to -0.28], I2=99%m z= -2.12, p= 0.03) compared to open distal VPS placement. CONCLUSION Few studies are available comparing open and laparoscopic shunt placement in children. Our meta-analysis showed no difference in distal revision rate between laparoscopic and open shunt insertion; however, laparoscopic placement was associated with a significantly shorter surgery time. Further prospective trials are needed to assess possible superiority of one of the techniques.
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Affiliation(s)
- Ladina Greuter
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Linus Ruf
- Department of Pediatric Neurosurgery, University Children Hospital of Basel, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Department of Pediatric Neurosurgery, University Children Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Department of Pediatric Neurosurgery, University Children Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
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Ruf L, Greuter L, Guzman R, Soleman J. Distal shunt placement in pediatric ventriculoperitoneal shunt surgery: an international survey of practice. Childs Nerv Syst 2023; 39:1555-1563. [PMID: 36780037 DOI: 10.1007/s00381-023-05855-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 01/15/2023] [Indexed: 02/14/2023]
Abstract
OBJECTIVE Ventriculoperitoneal shunt (VPS) surgery is a common treatment for hydrocephalus in children and adults, making it one of the most common procedures in neurosurgery. Children being treated with a VPS often require several revisions during their lifetime with a lifetime revision rate of up to 80%. Several different techniques exist for inserting the distal catheter, while mini-laparotomy, trocar, or laparoscopy is traditionally used. As opposed to adults, only few studies exist, comparing the outcome of the different distal catheter placement techniques in children. This international survey aims to investigate the current daily practice concerning distal shunt placement techniques in children. MATERIAL AND METHODS An online questionnaire investigating the different techniques used to place the distal catheter in pediatric VPS surgery was distributed internationally. All results were analyzed using descriptive and comparative statistics. RESULTS A total of 139 responses were obtained. Mini-laparotomy was reported to be the most frequently used technique (n = 104, 74.8%) for distal shunt placement in children, while laparoscopic or trocar-assisted placements were only used by 3.6% (n = 5) and 21.6% (n = 30) of all respondents, respectively. Over half (n = 75, 54.0%) of all respondents do not believe that laparoscopic placement improves the outcome. CONCLUSION This international survey shows that mini-laparotomy is the most frequently used technique for distal VPS placement in children all over the world. Further randomized trials are needed to elucidate this matter.
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Affiliation(s)
- Linus Ruf
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Ladina Greuter
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Raphael Guzman
- Faculty of Medicine, University of Basel, Basel, Switzerland.,Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.,Division of Pediatric Neurosurgery, University Children's Hospital of Basel (UKBB), Spitalstrasse 21, 4031, Basel, Switzerland
| | - Jehuda Soleman
- Faculty of Medicine, University of Basel, Basel, Switzerland. .,Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland. .,Division of Pediatric Neurosurgery, University Children's Hospital of Basel (UKBB), Spitalstrasse 21, 4031, Basel, Switzerland.
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Mulvaney G, Arnold M, Reinke C, Wait S, Van Poppel M, McLanahan S, Schmelzer T, Cosper G, Schulman A, Jernigan S. Laparoscopic Co-surgeon Ventriculoperitoneal Shunt Placement Versus Single Surgeon Mini Laparotomy. Cureus 2022; 14:e26057. [PMID: 35747114 PMCID: PMC9209392 DOI: 10.7759/cureus.26057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction: Ventriculoperitoneal (VP) shunt placement is one of the most common treatments for pediatric hydrocephalus. However, device failures often occur, requiring operative revision of either the intraventricular or intraperitoneal shunt catheters. Historically, shunt placement was performed via laparotomy, but there has been a trend towards laparoscopic-assisted placement of the intraperitoneal portion of the shunt. We examined the outcomes of laparoscopic-assisted versus open VP shunt placement utilizing a local institutional retrospective review. Methods: Single institution 2012-2017 retrospective review of all cases was performed. Patients were divided into two groups - laparoscopic and open. Thirty-day outcomes, patient age, surgery performed, surgical control time (SCT), length of stay (LOS), and readmission were analyzed. Results: Cohort analysis inclusion criteria included 188 patients. The cohort analysis showed both decreased laparoscopic-assisted SCT (56.4 vs 32.1 min, p<0.0001) and postop complications (16.7% vs 7.1%, p<0.07). There was no significant difference in surgical site infection or readmission rates. Conclusion: Local analysis show advantages for laparoscopic-assisted VP shunt placement over open single surgeon techniques with decreased SCT, LOS, and unplanned interventions.
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De Jesus O, Rios-Vicil C, Pellot Cestero JE, Carro-Figueroa EF. Huge subcutaneous extraperitoneal pseudocyst after migration of the ventriculoperitoneal shunt catheter. BMJ Case Rep 2021; 14:e246681. [PMID: 34853048 PMCID: PMC8638129 DOI: 10.1136/bcr-2021-246681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 11/03/2022] Open
Abstract
The formation of an intraperitoneal pseudocyst as a complication of ventriculoperitoneal shunts is well known. However, the formation of a pseudocyst at the subcutaneous extraperitoneal abdominal space is unusual and likely secondary to the migration of the peritoneal catheter. We present a 53-year-old male who had placement of a ventriculoperitoneal shunt for hydrocephalus secondary to a vestibular schwannoma. Five months later, he presented with an enormously distended abdomen. Investigations showed the peritoneal catheter in the extraperitoneal space within a large right lower quadrant abdominal wall pseudocyst. The patient was taken to the operating theatre, and the shunt was externalised at the original abdominal incision. Approximately 3 L of cerebrospinal fluid were aspirated from the distal peritoneal catheter. After negative cultures, a new peritoneal catheter was placed intraperitoneally at the contralateral lower abdominal quadrant. The contralateral quadrant was utilised to prevent fluid accumulation into the old extraperitoneal cavity.
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Affiliation(s)
- Orlando De Jesus
- Neurosurgery, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico, Puerto Rico
| | - Christian Rios-Vicil
- Neurosurgery, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico, Puerto Rico
| | - Joel E Pellot Cestero
- Neurosurgery, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico, Puerto Rico
| | - Eric F Carro-Figueroa
- Neurosurgery, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico, Puerto Rico
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Abstract
Background Ventriculoperitoneal shunt surgery (VPS) is a simple solution to the problem of hydrocephalus. However, it is associated with significant complications. Meticulous attention to a variety of factors, techniques, and nuances in VPS can reduce these complications. Objective To review the various techniques and nuances during the different stages of VPS. Methods and Material PubMed search for original and review articles dealing with various techniques used during VPS. Results Thorough preoperative planning for VPS reduces operative time and complications. A standardized shunt surgery protocol significantly reduces shunt infection. Good and appropriate surgical technique can enhance the safety of the procedure. Anterior entry point is better than posterior entry point. Shunt tip should be away from choroid plexus, but the exact location is not vital for shunt survival. Proper placement of the shunt in the subgaleal and subcutaneous plane reduces wound and skin breakdown over the shunt. The trocar and laparoscopic methods to access the peritoneum are associated with fewer distal obstructions compared to mini-laparotomy. Perioperative antibiotic prophylaxis, use of antibiotic-impregnated shunts, and sutures are proven techniques to reduce shunt infection. Conclusions Preoperative planning, a standardized shunt surgery protocol, good surgical technique, gentle tissue handling, and short surgery duration are essential to reduce VPS complications. Specifically, use of anterior entry point, correct tunneling of the shunt in the subgaleal and subcutaneous plane, appropriate antibiotic prophylaxis, use of antibiotic-impregnated shunts, and meticulous skin closure using antimicrobial sutures can lead to a reduction in shunt malfunction and infection.
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Affiliation(s)
- Shibu V Pillai
- Department of Neurosurgery, Institute of Neurosciences, Mazumdar Shaw Medical Center, Narayana Health City, Hosur Road, Bangalore, Karnataka, India
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Dowlati E, Shashaty M, Carroll AH, Pivazyan G, Briscoe J, Patel N, Shahjouie S, Anaizi AN, Jackson PG, Nair MN. General surgery involvement with ventriculoperitoneal shunt insertions reduces revision rates. Clin Neurol Neurosurg 2020; 199:106263. [PMID: 33059316 DOI: 10.1016/j.clineuro.2020.106263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/20/2020] [Accepted: 09/29/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Ventriculoperitoneal shunts (VPS) are placed for a variety of etiologies. It is common for general surgery to assist with insertion of the distal portion in the peritoneum. OBJECTIVE To determine if there is a difference in revision rates in patients undergoing VPS placement with general surgery as well as those undergoing laparoscopic insertion. METHODS A retrospective review of all consecutive patients undergoing VPS placements was performed in a three-year period (2017-2019). Those that underwent placement with general surgery were compared to those without general surgery. Additionally, patients undergoing distal placement via mini-laparotomy versus laparoscopy were compared. Multivariable logistic regression was used to examine risk factors for distal VPS failure. RESULTS 331 patients were included. 202 (61.0 %) underwent VPS placement with general surgery. 121 (36.6 %) patients underwent insertion via laparoscopic technique. General surgery involvement reduced operative times, decreased length of stay, and lowered overall revision rates with distal revision rates being most significant (1.5 % vs 8.5 %; p = 0.0034). Patients undergoing VPS placement via laparoscopic technique had decreased operative time, length of stay, in-hospital complications and revision rates, with significant decrease in shunt infection (1.7 % vs 7.1 %; p = 0.0366). A history of prior shunt or abdominal surgery (OR 3.826; p = 0.0282) and lack of general surgery involvement (OR 20.98; p = 0.0314) are independent risk factors for distal shunt revision in our cohort. CONCLUSION The use of general surgeons in VPS insertion can be of benefit by decreasing operative time, length of stay, total revisions, and distal revision rates. Further prospective studies are warranted to determine true benefit.
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Affiliation(s)
- Ehsan Dowlati
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA.
| | | | | | - Gnel Pivazyan
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Jessica Briscoe
- Department of General Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Nirali Patel
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Shima Shahjouie
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA
| | - Amjad N Anaizi
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Patrick G Jackson
- Department of General Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Mani N Nair
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
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