Ventricular gallbladder shunts: an alternative procedure in hydrocephalus

Ventriculo-gallbladder shunt: case series and literature review

BACKGROUND

The ventriculoperitoneal shunt (VPS) is the gold-standard surgical technique to treat hypertensive hydrocephalus; however, it may fail in 20 to 70% of cases. The present study shows an alternative for patients with contraindications to VPS.

METHODS

A case series of nine patients. The medical records of all patients under 17 years of age who underwent ventriculo-gallbladder (VGB) shunt at a pediatric hospital from January 2014 to October 2022 were reviewed.

RESULTS

There were 6 (66.7%) males and 3 (33.3%) females. The average age of 73.6 months or 6.1 years at the time of surgery. They had undergone, on average, 5.1 VPS reviews before the VGB shunt. Five (55.5%) had complications of VGB shunt: infection (11.1%), atony (11.1%), hypodrainage (11.1%), and ventriculoenteric fistula (22.2%); all these patients got better at surgical reapproach, and in two of them, the VGB shunt was re-implanted.

CONCLUSION

This case series shows a lower risk of death and a similar risk of complications compared to other alternative shunts. This article spotlighted VGB as a viable alternative when VPS fails or has contraindications.

Ventriculo - Gallbladder shunt

INTRODUCTION

Permanent liquor diversion is associated with a high risk of failure and often requires re-intervention. The ventriculo-gallbladder shunt (VGS) has been recognized as a last-resort alternative for treating hydrocephalus when the peritoneum or other distal sites are no longer suitable for receiving shunts. This article aims to report a case from a neurosurgery referral service in Brazil and review the literature on this issue.

METHODS

A systematic literature review was conducted in accordance with the PRISMA statement. The PubMed, Embase, and Web of Science databases were searched for data screening and extraction. The reported case was conducted with ethical approval from the neurosurgical hospital's ethics committee.

RESULTS

G.B.S, male, 43 years old, no comorbidities, who has been dealing with a 12-year history of hydrocephalus, with post-surgical chronic fungal meningitis. Two years ago, he underwent a ventriculoatrial shunt (VAS) placement due to multiple ventriculoperitoneal shunt (VPS) failures. Endocarditis was suspected, and the VAS was removed. As an alternative, VGS was implanted 6 months ago, and since then, there has been no need for a new system review. The gallbladder has an absorptive capacity of 1500 cc of liquid daily, which is more than the normal daily production of cerebrospinal fluid (CSF). Therefore, it is a good alternative when the ventriculoperitoneal shunt is not feasible due to postsurgical peritoneal adhesions or when there are contraindications for ventriculoatrial shunts.

CONCLUSION

VGS is an alternative for patients who cannot undergo the most common surgical interventions, such as VPS.

Can we consider ventriculo-gallbladder shunt a first-line treatment in selected patients? Case report of a successful management

INTRODUCTION

Ventriculo-gallbladder shunt (VGS) has been recognized as a last-resort alternative to treat hydrocephalus when the peritoneum and/or other distal sites can no longer receive shunts. In some specific conditions, it may be conceded as a first-line treatment.

CASE PRESENTATION

We report the case of a 6-month-old girl with progressive post-hemorrhagic hydrocephalus who presented a concomitant chronic abdominal symptom. Specific investigations ruled out acute infection and led to the diagnosis of chronic appendicitis. Both problems were managed in a one-stage salvage procedure consisting of laparotomy sanctioning to treat the abdominal pathology and seize the opportunity to perform a VGS as a first option since the abdomen is prone to ventriculoperitoneal shunt (VPS) failure.

CONCLUSION

Only few cases have reported the use of VGS as the first option to handle uncommon complex cases due to abdominal or cerebrospinal fluid (CSF) conditions. We wish to draw attention to VGS as an effective procedure not only in children with multiple shunt failures but also as first-line management in some selected cases.

Double ventriculo-gallbladder shunt in the treatment of giant suprasellar arachnoid cyst with secondary hydrocephalus

Ventriculo-gallbladder shunt is described as an effective alternative procedure in the treatment of hydrocephalus. We present the case of a 19-year-old patient diagnosed with suprasellar arachnoid cyst since his childhood and hydrocephalus, with a double shunt; ventriculo peritoneal and peritoneal cyst shunt. After several replacements due to peritoneal failure, he underwent ventriculoatrial shunt, with associated complications and subsequent repositioning to the peritoneum. After new valve dysfunction due to peritoneal complications, ventriculo-gallbladder shunt was proposed as an alternative treatment for this patient, which was safe and effective in resolving the patient's symptoms, and the patient was discharged, maintaining clinical stability in the follow-up more than 2 years later.

Minimally Invasive Ventriculo-Cholecystic Shunt Placement Utilizing Combined Ultrasound and Fluoroscopic Guidance

For the management of hydrocephalus with ventricular cerebrospinal fluid (CSF) shunting, multiple therapeutic options are available. Among these routes, the most commonly used are ventriculo-peritoneal, ventriculo-atrial, and ventriculo-pleural, while ventriculo-cholecystic is a less common option. Although ventriculo-peritoneal is accepted as the first option, ventriculo-cholecystic shunting may be performed in patients who are poor candidates for other routes of shunt placement. Open cholecystic shunt placement may be contraindicated in patients who have undergone previous surgeries or other comorbidities. Here, we present the case of a 25-year-old female with a complex medical history who presented with a posterior fossa intraparenchymal hemorrhage and subsequent hydrocephalus. She was unable to undergo a ventriculo-peritoneal, atrial, or pleural shunt placement, and thus, a cholecystic shunt placement was chosen. Due to a history of previous surgeries and comorbidities as well as a large volume of idiopathic and recurrent ascites, open placement was contraindicated in this patient. To the best of our knowledge, we present the first successful adult case of a minimally invasive ventriculo-cholecystic shunt placement under ultrasound and fluoroscopic guidance.

Utility of ventriculogallbladder shunts in complex cases of hydrocephalus related to extreme prematurity

OBJECTIVE

The management of hydrocephalus resulting from intraventricular hemorrhage related to extreme prematurity remains demanding. Given the complexities of controlling hydrocephalus in this population, less commonly used procedures may be required. The authors examined the utility of ventriculogallbladder (VGB) shunts in a series of such children.

METHODS

The authors retrospectively reviewed the medical records of all children who underwent surgery for hydrocephalus in the period from 2011 through 2019 at Children's Healthcare of Atlanta. Six patients who underwent VGB shunt placement were identified among a larger cohort of 609 patients who had either a new shunt or a newly changed distal terminus site. The authors present an analysis of this series, including a case of laparoscopy-assisted distal VGB shunt revision.

RESULTS

The mean age at initial shunt placement was 5.1 months (range 3.0-9.4 months), with patients undergoing a mean of 11.8 shunt procedures (range 5-17) prior to the initial VGB shunt placement at a mean age of 5.3 years (range 7.9 months-12.8 years). All 6 patients with VGB shunt placement had hydrocephalus related to extreme prematurity (gestational age < 28 weeks). At the time of VGB shunt placement, all had complex medical and surgical histories, including poor venous access due to congenital or iatrogenic thrombosis or thrombophlebitis and a peritoneum hostile to distal shunt placement related to severe necrotizing enterocolitis. VGB complications included 1 case of shunt infection, identified at postoperative day 6, and 2 cases of distal shunt failure due to retraction of the distal end of the VGB shunt. In all, there were 3 conversions back to ventriculoperitoneal or ventriculoatrial shunts due to the 2 previously mentioned complications, plus 1 patient who outgrew their initial VGB shunt. Three of 6 patients remain with a VGB shunt, including 1 who underwent laparoscopy-assisted distal shunt revision 110.5 months after initial VGB shunt insertion.

CONCLUSIONS

Placement of VGB shunts should be considered in the armamentarium of procedures that may be used in the particularly difficult cohort of children with hydrocephalus related to extreme prematurity. VGB shunts show utility as both a definitive treatment and as a "bridge" procedure until the patient is larger and comorbid abdominal and/or vascular issues have resolved sufficiently to allow conversion back to ventriculoperitoneal or ventriculoatrial shunts, if needed.

Evaluation of the ventriculocholecystic shunt-an overview of present practice in adult and pediatric hydrocephalus

In the context of hydrocephalus, there are a multitude of therapeutic options that can be explored in order to improve patient outcomes. Although the peritoneum is the current elected clinical solution, various receptacles have been utilized when experiencing contraindications. Along with the ventriculoatrial or ventriculopleural, the ventriculocholecystic shunt was also described as an alternative. In order to make a decision on a place for drainage, the surgeon must be knowledgeable on details from modern literature. The main target of this review was to summarize the currently available information on this topic and assess the status of the gallbladder as a viable option for cerebrospinal fluid diversion.

Vegetation of Ventriculoatrial Shunt Managed via Multidisciplinary Surgical Approach

INTRODUCTION

The popularity of the ventriculoatrial shunt as a means for cerebrospinal fluid diversion was temporally limited, overcome by the success of the peritoneum as a site for distal drainage. Nevertheless, it remains an important tool for patients for whom ventriculoperitoneal shunting is not an option.

CLINICAL PRESENTATION

We present the case of a 9-year-old girl with a ventriculoatrial shunt, who had undergone multiple revisions. Ultimately, she suffered a wound dehiscence, resulting in infectious seeding of the bloodstream and formation of a thrombus, presumed granuloma, at the tip of the distal catheter in the right atrium. She underwent successful removal of the lesion via an open approach by our cardiothoracic colleagues.

DISCUSSION

Previous authors have noted a high number of mortalities as a result of these lesions. A collaborative approach resulted in a successful outcome for our patient. Although limited in utility today, the ventriculoatrial shunt remains a common procedure for neurosurgeons today.

CONCLUSION

Recognizing the potential for atrial thrombus formation and using a team approach can help avoid a poor outcome.

Management of ventriculo-gallbladder shunt in the presence of gallstones

Hydrocephalus is a prevalent health problem that is frequently encountered by paediatric neurosurgeons during infancy and childhood. We report a case of an 11-year-old boy with high cerebrospinal fluid protein hydrocephalus secondary to optic glioma that required a ventriculoperitoneal (VP) shunt. The patient had multiple failures of VP shunt and developed massive ascites. Alternatively, the hydrocephalus was treated by ventriculo-gallbladder (VG) shunt in the presence of sludge which was removed from the gallbladder before placement of the shunt. After VG shunt insertion, the patient expressed signs of infection with elevated liver profile, which emphasised the presence of gallstones. While the shunt was kept in its place without any complications, the gallstones were successfully removed by an endoscopic retrograde cholangiopancreatography. In conclusion, the presence of sludge is not a contraindication for VG shunt placement, and, if the VG shunt was complicated with gallstones, it could be treated without the need for cholecystectomy.

The ventriculo-cholecystic shunt: does CSF volume matter?

INTRODUCTION

The management of hydrocephalus in paediatric patients where the peritoneum has failed can be challenging. One option is to perform a ventriculo-cholecystic shunt. However, little is known about the capacity of the gall bladder to accommodate cerebrospinal fluid (CSF).

METHODS

A retrospective case series was performed to include all paediatric patients who received a ventriculo-cholecystic shunt at a single centre, Sheffield Children's Hospital.

RESULTS

We identified three patients who had a ventriculo-cholecystic shunt inserted. The shunt survived past 1 year in two patients, who had pre-operative external ventricular drain (EVD) outputs of 8 and 10 ml/h respectively. One patient shunt failed at day four post-op due to distal dysfunction, his pre-operative EVD was over 30 ml/h.

CONCLUSIONS

When considering a patient for a ventriculo-cholecystic shunt, caution should be taken if a high CSF output is known, for example, as per an EVD measurement.

Laparoscopy-assisted placement of a ventriculobiliary shunt: a technical note

PURPOSE

Hydrocephalus is a common condition in pediatric neurosurgeon's clinical practice. Peritoneal and atrial shunting is the treatment of choice in the immense majority of patients. Sometimes, there are complex cases that may need innovative solutions in order to implant the distal catheter of the shunt: in these situations, the gallbladder is a well-described option and it can be safely used.

METHODS

We report the case of a 4-month-old baby with a wide optic-chiasmal hypothalamic glioma generating hydrocephalus with high protein values in CSF. Ventriculobiliary shunting was decided, and the distal catheter was directed by the assistance of laparoscopic surgery.

RESULTS

The outcome was satisfactory.

CONCLUSIONS

As far as we know, laparoscopic placement of a distal catheter in the gallbladder has not been described in the literature; herein, we describe the tenets and the technical tips of this approach.

From the heart to the bladder-particularities of ventricular shunt topography and the current status of cerebrospinal fluid diversion sites

Hydrocephalus represents the pathological elevation of cerebrospinal fluid (CSF) levels as a consequence of various embryological or acquired defects. Although the classic method of treatment is by means of diverting the CSF from the ventricular system towards the peritoneum, there are other sites of diversion that have proven their efficiency through time, in the context of complications related to the more common option of intraperitoneal insertion. The aim of the review is to assess and organize a database of all the types of shunt locations from the oldest shunt attempts until present, using Pubmed and Medline and to underline the particularities related to technique, indications, complications and associated epidemiological background. Current literature reveals up to 36 sites of diversion of CSF with a diverse topography varying from cephalic regions such as venous sinuses or mastoid bone, thoracic elements such as the heart or the pleura and abdominopelvic segments such as the peritoneum or the urinary bladder. Several atypical locations were studied such as the fallopian and intestinal shunts. Although ventriculoperitoneal and ventriculoatrial shunts are the most commonly used shunts today, there are some systems such as the ventriculosinusal and ventriculolymphatic shunts that prove to be equally as efficient. The successful treatment of hydrocephalus requires a complete comprehension of the indications and therapeutic options and a reliable evaluation of the risks and possible complications. The profile of cerebral ventricular shunts is highly dynamic and the spectrum of cerebrospinal fluid diversion offers multiple solutions in the benefit of the patient.

Ventriculoatrial Shunts in Adults, Incidence of Infection, and Significant Risk Factors: A Single-Center Experience

BACKGROUND

In recent years, the number of ventriculoatrial (VA) shunt insertions has decreased worldwide, the major cause being the risk of shunt infection. VA shunts remain as an alternative option to ventriculoperitoneal shunts. We describe our 10-year experience with VA shunts by analyzing the incidence of shunt infections and predisposing cofactors.

METHODS

During a median follow-up of 15.3 months, 259 shunt insertions, performed on 255 patients, were analyzed. The infection rate was calculated and the predisposing cofactors age, gender, cause of the hydrocephalus, previous external ventricle drainage, antibiotic-impregnated catheters, the number of revisions, the educational level of the surgeons, and the duration of the operations were analyzed. Two observation times were stratified.

RESULTS

We found overall infections in 18 patients (7.1%), 16 deep infections (6.3%) including 1 shunt nephritis (0.4%) and 2 superficial infections (0.8%). Wound dehiscence occurred in 17 patients (6. 6%). Analyzing follow-up time, the infection rate was 3.65% (95% confidence interval, 0.9%-5.9%) at survival time 1, 3.38% (95% confidence interval, 1.1%-6.2%) at survival time 2. In the first 6 months, 95% of patients were free of infection. Only the number of revision procedures was associated with the number of infections (P value < 0.0005).

CONCLUSIONS

In our patient cohort, the infection rate related to VA shunt insertion is low; the only statistically significant risk factor was the number of revisions. If the VA shunt is applied following a standardized protocol, the infection risk does not represent an argument for reluctance towards the VA draining concept.

Ventricular Shunts

Ventricular shunts are mechanical devices used in the treatment of hydrocephalus, by means of which cerebrospinal fluid (CSF) is diverted from the ventricles to other low-pressure body cavities. Over the last 50 years, mechanical shunting has become the cornerstone for the treatment of hydrocephalus with shunt valves evolving from simple differential valves to complex programmable valves. The chief complications of ventricular shunting include obstruction, infections, and overdrainage causing subdural hematomas and slit-ventricle syndrome. As the number of commercially available valve designs continues to grow, each new generation aims at reducing the likelihood of complications, especially those resulting from overdrainage. Several studies aimed at establishing the superiority of any valve design have been conducted. All have highlighted the advantages and shortcomings of most models without conclusively providing evidence for choosing one over another. As a result, choices still rest on individual and institutional preferences.

[Ventriculo-gallbladder shunt: An alternative for the treatment of hydrocephalus]

BACKGROUND

In the management of hydrocephalus, the ventriculo-gallbladder shunt is justified in situations where the ventriculo-peritoneal shunt is not useful due to peritoneal involvement and/or when the ventriculo-auricular and ventriculo-pleural shunts are contraindicated.

CLINICAL CASE

A 27 year-old female with hydrocephalus at birth, managed with ventricle-peritoneal shunt, modified 3 times throughout her life due to repeated infections and other different reasons. She was admitted due to colitis caused by Clostridium difficile, presenting concomitant signs of intracranial hypertension and neurological impairment. This led to a review and change of the ventriculo-peritoneal shunt system, with distal dysfunction due to peritoneal thickening. Atrial and pleural shunts were not indicated because the risk of infection. As an alternative, it was decided to place the distal end of the catheter in the gallbladder. The patient recovered her neurological functions after the surgery.

CONCLUSIONS

Drainage alternatives may be needed in 5% of patients with valvular shunt dysfunction. The ventriculo-gallbladder is a good and viable option because it has an absorptive capacity of 1500cc liquid daily, besides being an excellent drainage through the bile duct. The abdominal surgery is easy to perform, and it is an alternative option in the failure of the ventriculo-peritoneal shunt.

Techniques that decrease or eliminate ionizing radiation for evaluation of ventricular shunts in children with hydrocephalus

Shunted hydrocephalus in children is a commonly seen diagnosis in hospitals throughout the world and is one of the most common chronic pediatric neurosurgical conditions. These children undergo numerous studies for routine surveillance as well as for evaluation of shunt malfunction, many of which are associated with significant radiation exposure over the child׳s lifetime. It is in the child׳s best interest to minimize the overall exposure to ionizing radiation so as to decrease the chance of the deleterious effects from occurring. The article outlines the epidemiology of ventricular shunt catheters, the typical indications and methods for shunt evaluation, and the preferred alternative imaging methods that eliminate or reduce radiation exposure.

Failure of peritoneal and gallbladder shunts in a child with craniopharyngioma

A 1-year-old girl with craniopharyngioma required external drainage of 40-50 mL/h of cerebrospinal fluid (CSF) after biopsy and cyst fenestration. She developed CSF ascites following insertion of a ventriculoperitoneal (VP) shunt and a distended painful gallbladder following ventriculogallbladder shunt insertion. Revision to a ventriculoatrial shunt was required. This is the first time a craniopharyngioma has been reported to cause increased CSF production. The potential mechanisms of CSF overproduction and the difficulties managing the large volume of CSF in a young child are discussed.

The ventriculocholecystic shunt: two case reports and a review of the literature

We describe the re-siting of ventriculoperitoneal shunts to the gallbladder in two children. The first child had a rare case of hydrocephalus associated with plasminogen deficiency. She had had multiple VP shunt revisions due to non-absorption of CSF from the peritoneum. The second had craniopharyngioma-related hydrocephalus with once again a non-absorbing peritoneum. We report no surgical complications in the revisions for both the cases, and there has been a subsequent follow-up of 46 and 28 months, respectively, without incident. A review of the relevant literature describing the use and the performance of ventriculocholecystic shunts in comparison with other ventricular shunts is considered.

Direct cardiac ventriculoatrial shunt: technical note

There are a number of choices for placement of the distal catheter during ventricular shunting for hydrocephalic patients. In very rare instances, patients with multiple revisions can no longer have their shunt placed in the routine locations. We describe the placement of the distal catheter into the atrium through direct cardiac access, a technique described decades ago but rarely needed in clinical practice. This can be a useful location in the limited number of patients who have exhausted other more routine locations.

The Ventriculo-Gallbladder Shunt in the Treatment of Refractory Hydrocephalus: A Review of the Current Literature

The ventriculo-gallbladder (VGB) shunt has been reported on several occasions for the alleviation of ventriculo-peritoneal (VP) –shunt-refractory hydrocephalus. There is little data regarding VGB shunts and a need for delineating appropriate surgical therapy when cerebrospinal fluid drainage to the peritoneum becomes infeasible. We report our experience with VGB shunt placement in three patients with chronic hydrocephalus. All three had a history of prior VP-shunt placements and revisions due to distal obstruction or infection, or contraindications to alternative forms of ventricular drainage. In one patient, the VGB shunt functioned well for 9 years but was revised due to contamination during an unrelated operation. Neither of the other two patients have experienced VGB shunt-related complications. VP shunts are presently regarded as the standard of care for uncomplicated hydrocephalus. When VP shunts fail, the most common alternatives have been ventriculo-atrial and ventriculo-pleural shunts. In five case series involving 59 patients with VGB shunts, the long-term success rate was 62.7 per cent. Infection (10.2%) and obstruction (10.2%) were the most common complications. Based on durability and a low incidence of complications, it is the current consensus that VGB shunts are a viable alternative with good outcomes in the case of failed VP shunts.

Ventriculogallbladder shunts in pediatric patients

OBJECT

The authors report a clinical protocol for the application of ventriculogallbladder (VGB) shunts in children who may be unable to maintain or receive ventriculoperitoneal (VP) shunts.

METHODS

Eighteen patients underwent placement of VGB shunts as an alternative to VP shunt therapy for the following reasons: malfunction of the VP shunt due to suspected failure of the peritoneum to absorb cerebrospinal fluid (17 cases) and multiple intraabdominal general surgical procedures (1 case). The patients ranged in age from 4 months to 17 years (mean 6.5 +/- 6.1 years [standard deviation {SD}]). All patients underwent preoperative imaging of the gall-bladder either by ultrasonography or computed tomography scanning. A team consisting of a pediatric neurological surgeon and a pediatric general surgeon performed all operative procedures. The procedures were conducted by open laparotomy to precisely place the appropriate length of distal catheter and to anchor it to the gallbladder wall.

RESULTS

There were 2 early shunt malfunctions, both obstructions due to "sludge" (1 in the biliary duct and 1 in the common bile duct). A late-onset (5-year) malfunction occurred secondary to gallbladder stones. In all 3 cases of malfunction, the devices were successfully converted to VP shunts. In 1 patient a conversion to a VP shunt was chosen following a general surgical intervention. There were 2 shunt infections (Staphylococcus epidermidis and Haemophilus influenzae). These were successfully treated. Two patients underwent conversion to a VGB shunt on 2 occasions. Thirteen patients had functional VGB shunts at the time of their last follow-up assessment. The follow-up for these 13 patients ranged from 1 to 8 years (mean 2.1 +/- 2.0 years [SD]).

CONCLUSIONS

Ventriculogallbladder shunts may be considered for the treatment of hydrocephalus in children when the peritoneal cavity cannot be used as a distal terminus.

Have we made progress in preventing shunt failure? A critical analysis

OBJECT

The goal of this study was to determine whether failure rates of hydrocephalus shunts have fallen over the years as a result of experience or technical improvements.

METHODS

A structured search was performed of the English language literature for case series reporting failure rates after shunt insertion. A metaanalytic model was constructed to pool data from multiple studies and to analyze failure rates statistically for temporal trends. Separate models were used for children (< 17 years old) and adults.

RESULTS

In children, the shunt failure rate was 31.3% for the 1st year and 4.5% per year thereafter. There were no significant changes in either rate over time. Although 1st-year failure rates in adults have fallen slightly over time, late failure rates have risen.

CONCLUSIONS

Progress in preventing shunt failures has not been made over the last several decades. Any improvements made in shunt materials or insertion techniques have been overshadowed by biological and other factors.

A rare, delayed complication of a ventriculogallbladder shunt

✓The use of the gallbladder as an alternative cerebrospinal fluid diversion site has been previously described in cases in which all other body cavities, such as the peritoneal cavity, right atrium, or pleural cavity, have been exhausted. Various ventriculogallbladder (VG) shunt complications have been described as well. In the present paper, the authors report on a rare, delayed VG shunt complication. A distal obstruction developed in a previously inserted VG shunt because of a large, radiolucent bile calculus. The presence of the VG shunt could be implicated in the pathogenetic mechanism of the bile calculus formation. The authors also review the pertinent literature.

Case report of symptomatic cholelithiasis after ventricular cholecystic shunt

Hydrocephalus is a prevalent problem in the pediatric population, and patients with ventriculo-peritoneal shunts are often encountered. The use of ventricular cholecystic shunts is an option for patients who are unable to have a ventriculo-peritoneal shunt. This is a case report that describes a late complication of a ventricular cholecystic shunt. Eleven years after insertion of a ventricular cholecystic shunt, the patient developed cholelithiasis encrusted on shunt tubing. The shunt was revised, and 6 months follow-up has shown relief of symptoms and no further evidence of cholelithiasis.

Post-shunt ascites in infants with optic chiasmal hypothalamic astrocytoma: role of ventricular gallbladder shunt

INTRODUCTION

We report a series of infants with optic chiasmal hypothalamic astrocytomas (OCHAs) who developed abdominal ascites following ventriculo-peritoneal (VP) shunting. The mechanism of ascites development among these patients with OCHA remains speculative and unclear.

METHODS

We treated four infants with hypothalamic tumors who were shunted for hydrocephalus using standard VP shunts and who subsequently experienced symptomatic ascites.

RESULTS

In three patients the gallbladder proved an effective alternative site for shunting prior to conversion to other sites, and in one patient the gallbladder shunt remains functional and revision-free.

CONCLUSIONS

Several aspects of the gallbladder as a reservoir for CSF make this approach appealing. Ventricular gallbladder shunting provided an effective (at least temporarily) receptacle for CSF in these patients.

Cerebral ventricular shunts

Cerebral ventricular shunts are siphoning devices used to treat hydrocephalus. They are placed within cerebral ventricles and peripheral cavities such as the ventricular atrium or peritoneal cavity. Complications include obstruction of cerebral spinal fluid (malfunction) and infection. Morbidity and mortality rates are high when shunt malfunction and infection are not treated emergently. This report summarizes the physical examination of patients with ventricular shunts, reviews the type of shunts commonly used, discusses shunt malfunctions (causing overshunting or undershunting of cerebrospinal fluid) and infections, and makes recommendations concerning empiric antibiotic therapy for shunt infection. The technique of tapping a shunt is presented for management of patients with elevated intracranial pressure that does not respond to non-invasive maneuvers to lower the pressure.

Ventricular cholecystic shunts in children

Hydrocephalus is a prevalent pediatric problem, and ventricular peritoneal shunting is the preferred procedure for surgical treatment. A system may become dysfunctional if the distal end of the catheter fails to drain because of intraabdominal adhesions, cerebral spinal fluid cysts, or peritonitis. Then additional revisions become necessary. Pediatric surgeons can come to the aid of their neurosurgical colleagues by placing the distal end of the catheter into the pleural space, cardiac atrium, ureter, stomach, or fallopian tube. These have all met with limited success. The ventricular cholecystic shunt has been used in some difficult-to-manage cases of hydrocephalus, and our experience with the procedure is described. In the complicated patient, we have had success placing the distal catheters in the gallbladder. Between 1986 and 1995 sixteen patients have had ventriculocholecystic shunts placed. The mean age was 10.8 years, ranging from 0.9 to 23 years. Prior shunting procedures averaged 4.1 (range 0 to 11). The follow-up period ranged from 4 weeks to 7.5 years, with a median follow-up of 3 years. No shunts were removed or revised specifically because of gallbladder complications such as infected bile, stones, or distal catheter occlusion. Seven patients experienced other shunt-related problems that were not caused by distal catheters, ie, staphylococcal infections and intracerebral problems. Eleven of the original shunts are still functioning. Two patients died of causes not related to the ventriculoperitoneal shunt. Because of their simplicity of placement, low incidence of complication, and similarity to ventriculoperitoneal shunts, the ventricular cholecystic shunt should be considered when other sites are unattainable.

Ventriculo-gallbladder shunts in children

Ventriculoperitoneal shunts are the most common procedure for the treatment of hydrocephalus. Ventriculoatrial shunts are effective but are subject to a higher incidence of potentially serious complications. We report our experience with ventriculo-gallbladder shunts in children. Ventriculo-gallbladder shunts are safe, effective, and technically easy to perform. We recommend their use when ventriculoperitoneal shunts have failed or the peritoneal cavity is not adequate for shunting.