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Lazarus JS, Ohonba E, Li YJ, Rohlwink UK, Figaji AA, Enslin JMN. Ventriculoperitoneal shunt failures at Red Cross War Memorial Children's Hospital. Childs Nerv Syst 2024; 40:2871-2881. [PMID: 38780622 PMCID: PMC11322230 DOI: 10.1007/s00381-024-06466-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Accepted: 05/14/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION Ventriculoperitoneal shunt (VP shunt) insertion is one of the mainstays of treatment of hydrocephalus and although very effective, a high rate of shunt failure persists globally. The purpose of the study was to quantify the ventriculoperitoneal shunt failure rate at Red Cross War Memorial Children's Hospital (RCWMCH) and assess potential factors contributing to shunt failures. METHODS A retrospective review of VP shunts done at RCWMCH between August 2015 through December 2019 was performed. Operative notes, discharge summaries and patient folders were reviewed to collect information about patient age, aetiology of hydrocephalus, index vs revision shunt, shunt system and other noticeable variables. Overall shunt failure was recorded. Univariate and multivariate models were used to determine causal relationship. RESULTS Four hundred and ninety-four VP shunt operations were performed on 340 patients with 48.8% being index shunts and 51.2% revision shunts. The average patient age was 3.4 months. The total VP shunt failure rate over the study period was 31.2%, with a 7.3% infection rate, 13.6% blockage and 3.6% disconnection rate. The most common aetiologies were post-infectious hydrocephalus 29.4%, myelomeningocele 19.7% and premature intraventricular haemorrhage 14.1%. Orbis-sigma II (OSVII), distal slit valves and antibiotic-impregnated catheters were used most frequently. Failure rates were highest in the revision group, 34.7% compared to 27.3% in index shunts. Sixty-five percent (65%) of the head circumferences measured were above the + 3 Z score (> 90th centile). CONCLUSION VP shunt failure occurs most commonly in revision surgery, and care should be taken at the index operation to reduce failure risk. Surgeon level, duration of surgery, aetiology of hydrocephalus and shunt system used did not influence overall failure rates. A closer look at larger head circumferences, their effect on shunt systems and the socio-economic factors behind late presentations should be investigated further in the future.
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Affiliation(s)
- J S Lazarus
- Department of Surgery, Division of Neurosurgery, University of Cape Town, Cape Town, South Africa.
- Division of Neurosurgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.
| | - E Ohonba
- Department of Surgery, Division of Neurosurgery, University of Cape Town, Cape Town, South Africa
- Division of Neurosurgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Y J Li
- Department of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - U K Rohlwink
- Department of Surgery, Division of Neurosurgery, University of Cape Town, Cape Town, South Africa
- Division of Neurosurgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - A A Figaji
- Department of Surgery, Division of Neurosurgery, University of Cape Town, Cape Town, South Africa
- Division of Neurosurgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - J M N Enslin
- Department of Surgery, Division of Neurosurgery, University of Cape Town, Cape Town, South Africa
- Division of Neurosurgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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Jakopin NE, Myong E, Bogucki T, Gray D, Gross P, McComb JG, Shannon CN, Tamber MS, Toyama M, van der Willigen T, Yazdani A, Hamilton MG, Koschnitzky JE. Establishing ranked priorities for future hydrocephalus research. J Neurosurg 2023; 139:492-501. [PMID: 36681979 DOI: 10.3171/2022.10.jns22753] [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: 03/31/2022] [Accepted: 10/25/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The aim of this initiative was to develop a ranked list of hydrocephalus research priorities as determined by the hydrocephalus patient community in conjunction with the healthcare and scientific community. METHODS Using the validated methodology published by the James Lind Alliance (JLA), the Hydrocephalus Association (HA) administered two surveys and hosted a final prioritization workshop. Survey One solicited open-ended responses from the community. From these responses, a long list of priority statements was developed. This list was then consolidated into a short list of research priority statements, which, after a nonsystematic literature review, were verified as being research uncertainties. Survey Two asked the community members to select their top 10 priorities from the short list. The final prioritization leading to a final ranked top 20 list of hydrocephalus research priorities took place at a virtual workshop led by a team of trained facilitators, by means of an iterative process of consensus building. RESULTS From Survey One, 3703 responses from 890 respondents were collected, leading to a long list of 146 priority statements. The consolidated short list contained 49 research priority statements, all of which were verified as uncertainties in hydrocephalus research. From an analysis of Survey Two responses, the top 21 research priority statements were determined. A consensus on these statements was reached at the virtual workshop, leading to a final ranked top 20 list of hydrocephalus research priorities, within which needs were apparent in several areas: development of noninvasive and/or one-time therapies, reduction of the burden of current treatments, improvement of the screening and diagnosis of hydrocephalus, improved quality of life, and improved access to care. CONCLUSIONS By gathering extensive input from the hydrocephalus community and using an iterative process of consensus building, a ranked list of the top 20 hydrocephalus research priorities was developed. The HA will use this ranked list to guide future research programs and encourages the healthcare and scientific community to do the same.
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Affiliation(s)
- Noriana E Jakopin
- 1Hydrocephalus Association, Bethesda, Maryland
- 2University of Maryland, College Park, Maryland
| | - Elliot Myong
- 1Hydrocephalus Association, Bethesda, Maryland
- 3University of Southern California, Los Angeles, California
| | | | - Diana Gray
- 1Hydrocephalus Association, Bethesda, Maryland
| | - Paul Gross
- 1Hydrocephalus Association, Bethesda, Maryland
- 4Cerebral Palsy Research Network, Greenville, South Carolina
| | | | - Chevis N Shannon
- 5Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Mandeep S Tamber
- 6Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | - Mark G Hamilton
- 8Department of Clinical Neurosciences, Division of Neurosurgery, Cumming School of Medicine, University of Calgary, Alberta, Canada
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Blazer-Yost BL. Consideration of Kinase Inhibitors for the Treatment of Hydrocephalus. Int J Mol Sci 2023; 24:ijms24076673. [PMID: 37047646 PMCID: PMC10094860 DOI: 10.3390/ijms24076673] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/07/2023] Open
Abstract
Hydrocephalus is a devastating condition characterized by excess cerebrospinal fluid (CSF) in the brain. Currently, the only effective treatment is surgical intervention, usually involving shunt placement, a procedure prone to malfunction, blockage, and infection that requires additional, often repetitive, surgeries. There are no long-term pharmaceutical treatments for hydrocephalus. To initiate an intelligent drug design, it is necessary to understand the biochemical changes underlying the pathology of this chronic condition. One potential commonality in the various forms of hydrocephalus is an imbalance in fluid–electrolyte homeostasis. The choroid plexus, a complex tissue found in the brain ventricles, is one of the most secretory tissues in the body, producing approximately 500 mL of CSF per day in an adult human. In this manuscript, two key transport proteins of the choroid plexus epithelial cells, transient receptor potential vanilloid 4 and sodium, potassium, 2 chloride co-transporter 1, will be considered. Both appear to play key roles in CSF production, and their inhibition or genetic manipulation has been shown to affect CSF volume. As with most transporters, these proteins are regulated by kinases. Therefore, specific kinase inhibitors are also potential targets for the development of pharmaceuticals to treat hydrocephalus.
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Affiliation(s)
- Bonnie L. Blazer-Yost
- Biology Department, Indiana University—Purdue University, 723 West Michigan Street, Indianapolis, IN 46202, USA
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Hochstetler A, Raskin J, Blazer-Yost BL. Hydrocephalus: historical analysis and considerations for treatment. Eur J Med Res 2022; 27:168. [PMID: 36050779 PMCID: PMC9434947 DOI: 10.1186/s40001-022-00798-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/22/2022] [Indexed: 11/18/2022] Open
Abstract
Hydrocephalus is a serious condition that affects patients of all ages, resulting from a multitude of causes. While the etiologies of hydrocephalus are numerous, many of the acute and chronic symptoms of the condition are shared. These symptoms include disorientation and pain (headaches), cognitive and developmental changes, vision and sleep disturbances, and gait abnormalities. This collective group of symptoms combined with the effectiveness of CSF diversion as a surgical intervention for many types of the condition suggest that the various etiologies may share common cellular and molecular dysfunctions. The incidence rate of pediatric hydrocephalus is approximately 0.1–0.6% of live births, making it as common as Down syndrome in infants. Diagnosis and treatment of various forms of adult hydrocephalus remain understudied and underreported. Surgical interventions to treat hydrocephalus, though lifesaving, have a high incidence of failure. Previously tested pharmacotherapies for the treatment of hydrocephalus have resulted in net zero or negative outcomes for patients potentially due to the lack of understanding of the cellular and molecular mechanisms that contribute to the development of hydrocephalus. Very few well-validated drug targets have been proposed for therapy; most of these have been within the last 5 years. Within the last 50 years, there have been only incremental improvements in surgical treatments for hydrocephalus, and there has been little progress made towards prevention or cure. This demonstrates the need to develop nonsurgical interventions for the treatment of hydrocephalus regardless of etiology. The development of new treatment paradigms relies heavily on investment in researching the common molecular mechanisms that contribute to all of the forms of hydrocephalus, and requires the concerted support of patient advocacy organizations, government- and private-funded research, biotechnology and pharmaceutical companies, the medical device industry, and the vast network of healthcare professionals.
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Affiliation(s)
- Alexandra Hochstetler
- Department of Biology, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA.
| | - Jeffrey Raskin
- Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA.,Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bonnie L Blazer-Yost
- Department of Biology, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA
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Limwattananon P, Kitkhuandee A. Ventriculoperitoneal shunt failure in pediatric patients: an analysis of a national hospitalization database in Thailand. J Neurosurg Pediatr 2021; 28:128-138. [PMID: 34087796 DOI: 10.3171/2021.1.peds20718] [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: 08/16/2020] [Accepted: 01/08/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Shunt failure is common among patients undergoing ventriculoperitoneal shunting for treatment of hydrocephalus. The present study examined long-term shunt failure and associated risk factors in pediatric patients by using a national hospitalization database of Thailand. METHODS Patients 17 years or younger who had been admitted to 71 public hospitals in 2012-2017 for first-time ventriculoperitoneal shunting for diseases with known etiology and discharged alive were followed through 2019 to ascertain shunt failure. Shunt survivals were calculated using Kaplan-Meier estimates and time to failure was analyzed to identify risk factors for the first failure by using Cox proportional hazards regression. Differences in risks of subsequent failures with respect to place in the order of failures (i.e., first, second, third) were determined using a cumulative hazard function. RESULTS Over a median follow-up of 29.9 months, shunt failure occurred in 33.7% of 2072 patients (median age 8.8 months), with a higher proportion in patients < 1 year than in patients 1-17 years (37.8% vs 28.9%, p < 0.001), and ranged from 26.1% of those having posttraumatic hydrocephalus to 35.9% of those having infectious diseases. The shunt failure rates at 3, 6, and 12 months were 11.5%, 19.0%, and 25.2%, respectively. Patients < 1 year had a higher risk of the first failure than patients 1-17 years (hazard ratio 1.45, 95% CI 1.20-1.76). Among those with shunt failure, 35.8% had multiple failures and 52.9% failed within 180 days after the index shunting. The cumulative hazard of subsequent failure was consistently higher than that of an earlier failure regardless of age and etiology, and the cumulative hazard of the second failure in the patients with 180-day failure was higher than that in the patients in whom shunts failed beyond 180 days. CONCLUSIONS Shunt failure occurred more frequently in younger pediatric patients. Much attention should be placed on the initial shunt operation so as to mitigate the failure risk. Close follow-up was crucial once patients had developed the failure, because the risk of subsequent failure was more likely than an earlier one among those with multiple failures.
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Coll G, Abed Rabbo F, de Schlichting E, Coste A, Chazal J, Garcier JM, Peyre H, Sakka L. Mechanical complications of cerebrospinal fluid shunt. Differences between adult and pediatric populations: myths or reality? Childs Nerv Syst 2021; 37:2215-2221. [PMID: 33768313 DOI: 10.1007/s00381-021-05125-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Shunt malfunctions seem more frequent in children (44 to 81%) than in adults (18 to 29%). Because of discrepancies between studies, it is not possible to affirm this disparity. The objective was to verify whether the incidence of cerebrospinal fluid (CSF) shunt malfunctions is higher in children than adults. METHODS We present a retrospective series of child and adult patients who underwent CSF shunt placement between 2000 and 2013 with a Sophysa SM8® valve. RESULTS 599 adults and 98 children (sex ratio 1.28) underwent CSF shunt placement. Age at first surgery ranged between 1 day of life and 90 years (mean of 55.8 years, SD 25.8, median 64.8 years). The mean follow-up was 4 years (SD 4.264, 0-16; median 3 years). The cumulative complication rate was 25.5% (178/697). Mechanical complications were disconnection (25.1%), migration (11.8%), intracranial catheter obstruction (8.9%) and malposition (8.4%). The mean delay for the first revision was 1.90 years (0-13.9), (SD 2.73, median 0.5). The probability of shunt failure was 65% at 10 years in the child group and 36% at 10 years in the adult group. Moreover, in the child group, 33% of revisions occurred during the first year after shunt placement versus 17% in the adult group. Thus, the probability of shunt failure was higher in children than in adults (log-rank test, p < 0.001). CONCLUSIONS This is the first retrospective study, comparing children and adults undergoing CSF shunt using the same valve, able to confirm the higher rate of complications in children.
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Affiliation(s)
- Guillaume Coll
- Service de Neurochirurgie B, Hôpital Gabriel Montpied, CHU Clermont-Ferrand, 58 rue Montalembert, F-63000, Clermont-Ferrand, France
| | - Francis Abed Rabbo
- Service de Neurochirurgie B, Hôpital Gabriel Montpied, CHU Clermont-Ferrand, 58 rue Montalembert, F-63000, Clermont-Ferrand, France. .,Laboratoire d'Anatomie et d'Organogenèse, Laboratoire de Biophysique Sensorielle, NeuroDol, faculté de médecine, Université Clermont Auvergne, F-63000, Clermont-Ferrand, France.
| | | | - Aurélien Coste
- Service de Neurochirurgie B, Hôpital Gabriel Montpied, CHU Clermont-Ferrand, 58 rue Montalembert, F-63000, Clermont-Ferrand, France
| | - Jean Chazal
- Service de Neurochirurgie B, Hôpital Gabriel Montpied, CHU Clermont-Ferrand, 58 rue Montalembert, F-63000, Clermont-Ferrand, France.,Laboratoire d'Anatomie et d'Organogenèse, Laboratoire de Biophysique Sensorielle, NeuroDol, faculté de médecine, Université Clermont Auvergne, F-63000, Clermont-Ferrand, France
| | - Jean-Marc Garcier
- Service de Radiologie Pédiatrique, CHU Clermont-Ferrand, F-63000, Clermont-Ferrand, France
| | - Hugo Peyre
- Service de Psychiatrie de l'Enfant et de l'Adolescent, Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris (AP-HP), F-75005, Paris, France
| | - Laurent Sakka
- Service de Neurochirurgie B, Hôpital Gabriel Montpied, CHU Clermont-Ferrand, 58 rue Montalembert, F-63000, Clermont-Ferrand, France.,Laboratoire d'Anatomie et d'Organogenèse, Laboratoire de Biophysique Sensorielle, NeuroDol, faculté de médecine, Université Clermont Auvergne, F-63000, Clermont-Ferrand, France
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Kim E, Cucchiaro G. Occipital Nerve Blocks for Relief of Headaches in Patients With Ventriculoperitoneal Shunts: A Case Series. J Child Neurol 2019; 34:674-678. [PMID: 31167597 DOI: 10.1177/0883073819853079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Pediatric patients with ventriculoperitoneal shunts commonly present with headaches. We report 7 children with ventriculoperitoneal shunts and occipital headaches who received occipital nerve blocks. Eighty-six percent of patients had a history of at least 1 ventriculoperitoneal shunt revision. Headaches improved in every patient after the block. Two patients (29%) were symptom free 11 and 12 months after the block. Four patients (57%) required repeat occipital nerve blocks. Two underwent pulsed radiofrequency ablation. No complications were noted. When patients with ventriculoperitoneal shunts present with headaches, a detailed physical examination is necessary. Persistent occipital headaches with tenderness and radiation in the path of the occipital nerves can be indicative of occipital neuralgia resulting from the shunt having crossed over the path of the greater or lesser occipital nerve. Occipital nerve blocks can help as both diagnostic and therapeutic interventions in these patients.
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Affiliation(s)
- Eugene Kim
- 1 Children's Hospital Los Angeles, Los Angeles, CA, USA
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Beuriat PA, Puget S, Cinalli G, Blauwblomme T, Beccaria K, Zerah M, Sainte-Rose C. Hydrocephalus treatment in children: long-term outcome in 975 consecutive patients. J Neurosurg Pediatr 2017; 20:10-18. [PMID: 28430083 DOI: 10.3171/2017.2.peds16491] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hydrocephalus remains one of the more common pathologies managed in pediatric neurosurgical units. Endoscopic third ventriculostomy (ETV) has an advantage over ventriculoperitoneal shunting as it enables patients to remain device free. Multiple shunt devices with various valve designs exist, with no one valve proven to be superior to another. The aim of this study was to describe the management of hydrocephalus and its long-term outcome. METHODS The authors retrospectively reviewed the medical records of all patients who had been treated for hydrocephalus at the Hôpital Necker-Enfants Malades in the period from 1985 to 1995. RESULTS Nine hundred seventy-five children had been treated for hydrocephalus. The mean follow-up was 11 ± 7.4 years (mean ± standard deviation). The most common cause of hydrocephalus was tumor related (32.3%), followed by malformative (24.5%) and inflammatory (20.9%) causes. Two hundred eighty patients underwent ETV as the first-line treatment. The procedure was effective in controlling hydrocephalus due to posterior fossa tumors and aqueductal stenosis. Six hundred ninety-five children had initial shunt insertion, with the majority receiving an Orbis-Sigma valve (OSV). The overall OSV shunt survival was 70% at 1 year, 58% at 10 years, and 49% at 20 years. The most common cause for mechanical shunt failure was obstruction (50.7%). Overall shunt survival was statistically different between the OSV and the differential-pressure valve (p = 0.009). CONCLUSIONS Endoscopic third ventriculostomy is effective in the management of childhood hydrocephalus. Its success is directly related to the underlying pathology. In the long term, the OSV has significantly higher event-free shunt survival than the classic differential-pressure valve systems.
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Affiliation(s)
| | - Stephanie Puget
- Department of Pediatric Neurosurgery, Hôpital Necker-Enfants Malades, Paris, France ; and
| | - Giuseppe Cinalli
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Napoli, Italy
| | - Thomas Blauwblomme
- Department of Pediatric Neurosurgery, Hôpital Necker-Enfants Malades, Paris, France ; and
| | - Kevin Beccaria
- Department of Pediatric Neurosurgery, Hôpital Necker-Enfants Malades, Paris, France ; and
| | - Michel Zerah
- Department of Pediatric Neurosurgery, Hôpital Necker-Enfants Malades, Paris, France ; and
| | - Christian Sainte-Rose
- Department of Pediatric Neurosurgery, Hôpital Necker-Enfants Malades, Paris, France ; and
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Burks JD, Conner AK, Briggs RG, Glenn CA, Bonney PA, Cheema AA, Chen S, Gross NL, Mapstone TB. Risk of failure in pediatric ventriculoperitoneal shunts placed after abdominal surgery. J Neurosurg Pediatr 2017; 19:571-577. [PMID: 28291419 DOI: 10.3171/2016.10.peds16377] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Experience has led us to suspect an association between shunt malfunction and recent abdominal surgery, yet information about this potential relationship has not been explored in the literature. The authors compared shunt survival in patients who underwent abdominal surgery to shunt survival in our general pediatric shunt population to determine whether such a relationship exists. METHODS The authors performed a retrospective review of all cases in which pediatric patients underwent ventriculoperitoneal shunt operations at their institution during a 7-year period. Survival time in shunt operations that followed abdominal surgery was compared with survival time of shunt operations in patients with no history of abdominal surgery. Univariate and multivariate analyses were used to identify factors associated with failure. RESULTS A total of 141 patients who underwent 468 shunt operations during the period of study were included; 107 of these 141 patients had no history of abdominal surgery and 34 had undergone a shunt operation after abdominal surgery. Shunt surgery performed more than 2 weeks after abdominal surgery was not associated with time to shunt failure (p = 0.86). Shunt surgery performed within 2 weeks after abdominal surgery was associated with time to failure (adjusted HR 3.6, 95% CI 1.3-9.6). CONCLUSIONS Undergoing shunt surgery shortly after abdominal surgery appears to be associated with shorter shunt survival. When possible, some patients may benefit from shunt placement utilizing alternative termini.
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Affiliation(s)
| | | | | | | | | | | | - Sixia Chen
- Biostatistics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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