Risk of failure in pediatric ventriculoperitoneal shunts placed after abdominal surgery

Ventriculoperitoneal shunt failure due to raised intra-abdominal pressure: A case report and review of the literature

Background:

Ventriculoperitoneal (VP) shunt implantation is the standard neurosurgical procedure to treat hydrocephalus for various reasons. Its function depends on the differential pressure between the ventricular space and the peritoneal cavity. Correct functioning of cerebrospinal fluid (CSF) valves requires a gradient of pressure between the ventricular and the abdominal cavity. Any reason that disrupts this balance can result in dysfunction of the system. Increased intra-abdominal pressure (IAP) may be a reason to induce shunt failure by decreasing CSF drainage from the ventricular system to the peritoneal cavity.

Case Description:

We report a case of repeated VP shunt failure because of constipation and successful conservative management by lowering IAP without surgical revision of the VP shunt system and reviewed the relevant literature.

Conclusion:

Increased IAP for a variety of reason should always be considered as a possible reason for shunt failure that can often be treated conservatively and therefore can reduce unnecessary shunt revision surgery.

Optimal timing and sequence of ventriculoperitoneal shunt and gastrostomy placement

Background: The optimal timing of ventriculoperitoneal shunt (VPS) and gastrostomy placement, relative to the safety of simultaneous versus staged surgery, has not been clearly delineated in the literature.Objective: To study the optimal inter-procedural timing relative to distal VPS infection and pertinent reoperation.Methods: A fifteen-year, retrospective, single-center study was conducted on adults undergoing VPS and gastrostomy within 30-days. Patients were grouped according to inter-procedural interval: 0-24 hr (immediate), 24 hr-7 days (early), and 7-30 days (delayed). The primary endpoint of the study was VPS infection and distal shunt complications requiring reoperation. Potential predictors of the primary end point (baseline cohort characteristics, procedural factors) were examined with standard statistical methods.Results: A total of 188 patients met inclusion criteria. The average interval between procedures was 7 ± 6 days, with 43.1% undergoing VPS prior to gastrostomy. Primary endpoint was encountered in 5 patients (2.7%): 1 (5.9%) of 17 patients undergoing immediate placement, 3 (2.8%) of 107 with early placement, and 1 (1.6%) of 64 with delayed placement. Although not statistically significant, 3.7% of patients undergoing VPS first had the primary endpoint, compared to 1.9% of those with gastrostomy. There were no statistically significant associations between the primary outcome and peri-operative CSF counts, gastrostomy modality, hydrocephalus etiology, chronic steroid use, or extended antibiotic administration.Conclusion: Although the low overall event rate in this cohort precludes definitive determination regarding differential safety, the data generally support a practice of performing the procedures >24-hours apart, with placement of gastrostomy prior to VPS.

Laparoscopically Assisted Ventriculoperitoneal Shunt Placement Is not Cost-Effective nor Preventive for Distal Shunt Malfunction

BACKGROUND

Laparoscopy for ventriculoperitoneal shunt creation might offer smaller incisions and more reliable placement. We assessed the reliability and cost-effectiveness of this technique compared with mini-laparotomy shunt placement.

METHODS

All patients undergoing ventriculoperitoneal shunt creation between November 2013 and September 2017 at a single academic institution were evaluated. Individual cases were assessed for the use of laparoscopy for peritoneal shunt placement (laparoscopy) versus mini-laparotomy for peritoneal shunt placement (open). The direct hospital costs for the laparoscopy and open groups were compared for elective shunt placement from the Vizient database. These direct costs were the proportion of the admission cost attributed to surgery. The primary endpoints included costs and revision of the peritoneal catheter within 12 months of the index procedure.

RESULTS

A total of 68 patients met the inclusion criteria. Most cases (n = 40; 58.8%) had been performed with laparoscopy, with 28 performed using an open peritoneal approach. Three patients had required ≥1 distal shunt revision: 2 laparoscopy patients (5.0%; 1 had required a second revision) and 1 open patient (3.6%). No statistically significant differences were found for the patients requiring distal shunt revision between the 2 groups (P = 1.000; Fisher's exact test). The direct cost ($9461) of ventriculoperitoneal shunt creation with laparoscopy was greater than that with an open approach ($8247; P = 0.033).

CONCLUSIONS

Both laparoscopy and open peritoneal shunt creation are safe procedures, with a 12-month distal revision rate in the present series of ~4%. Laparoscopy provided no relative improvement in safety or complication avoidance but had resulted in a mean increase in costs of >$1200 per patient.

Intradural spine surgery may not carry an increased risk of shunt revision compared with extradural spine surgery in pediatric patients with myelomeningocele

OBJECTIVE Patients with myelomeningocele are often affected by scoliosis and tethered cord syndrome, and frequently require spine surgery. Intradural spine surgeries may carry an inherently higher risk of inducing shunt malfunction due to entry into the subarachnoid space. In this study, the authors sought to compare rates of shunt malfunction after intradural and extradural spine surgeries among pediatric patients with myelomeningocele. METHODS The authors reviewed records of the National Spina Bifida Program Registry for Children's Hospital of Alabama. The Exago reporting function was used to identify patients who had received at least one of the following procedures: shunt revision, tethered cord release (TCR), or spinal fusion for deformity. The registry records were reviewed for all identified patients to determine if a shunt revision was performed within the 1st year after TCR or spinal fusion. RESULTS Final analyses included 117 patients, of whom 39 underwent spinal fusion and 78 underwent TCR. Among patients who underwent spinal fusion, shunt revision was performed within 30 days in 2 patients (5.1%), within 60 days in 2 (5.1%), within 90 days in 4 (10.3%), and within 1 year in 5 (12.8%). Among patients who underwent TCR, shunt revision was performed within 30 days in 7 patients (9.0%), within 60 days in 10 (12.8%), within 90 days in 11 (14.1%), and within 1 year in 17 (21.8%). Using the log-rank test, there was no significant difference in Kaplan-Meier curves between intradural and extradural groups (p = 0.59). CONCLUSIONS In a review of single-institution registry data, the authors found no statistically significant difference in the risk of shunt malfunction after intradural and extradural spine surgeries.