A simplified technique for performing the ventriculo-peritoneal shunt. Technical note

[Placement of ventricle peritoneal shunt in the adult patient. A new protocol]

Introducción:

La colocación de un shunt ventrículo-peritoneal, a pesar de considerarse un procedimiento de baja complejidad, puede devenir en una serie de complicaciones. Nuestro equipo quirúrgico desarrolló e implementó a partir de junio de 2016 un nuevo protocolo. El objetivo del presente trabajo es: describir e ilustrar paso a paso la técnica quirúrgica utilizada y demostrar que el uso del “nuevo protocolo” disminuye significativamente las complicaciones asociadas al procedimiento.

Material y métodos:

Desde junio de 2014 a noviembre de 2017 se intervinieron 184 pacientes en relación a sistemas de derivación de LCR. Se realizó un estudio retrospectivo que incluyó los pacientes con colocación primaria de shunt ventrículo-peritoneal (n=114). El seguimiento promedio fue de 14,2 meses (rango 6-38). Para el análisis estadístico se dividió a la muestra en 2 grupos: “protocolo previo” (n=59) y “nuevo protocolo” (n=55). Para describir la técnica quirúrgica se utilizó el archivo fotográfico y los partes quirúrgicos.

Resultados:

Se describió la técnica quirúrgica en 7 fases. La cantidad de pacientes con alguna complicación fue significativamente menor luego de implementar el “nuevo protocolo” (20% versus 39% respectivamente; p=0,04). En el grupo “nuevo protocolo” no se registró infección alguna asociada a shunt.

Conclusión:

Se presentó e ilustró, de manera clara y detallada, la técnica de colocación de shunt ventrículo-peritoneal en 7 fases. Esta técnica, junto a una serie de normas, constituyen un “nuevo protocolo”. La aplicación de éste disminuyó significativamente las complicaciones asociadas al procedimiento. La tasa de infección “cero” no es una utopía.

Laparoscopically assisted ventriculoperitoneal shunt placement: a prospective randomized controlled trial

OBJECT

In ventriculoperitoneal (VP) shunt surgery, laparoscopic assistance can be used for placement of the peritoneal catheter. Until now, the efficacy of laparoscopic shunt placement has been investigated only in retrospective and nonrandomized prospective studies, which have reported decreased distal shunt dysfunction rates in patients undergoing laparascopic placement compared with mini-laparotomy cohorts. In this randomized controlled trial the authors compared rates of shunt failure in patients who underwent laparoscopic surgery for peritoneal catheter placement with rates in patients who underwent traditional mini-laparotomy.

METHODS

One hundred twenty patients scheduled for VP shunt surgery were randomized to laparoscopic surgery or mini-laparotomy for insertion of the peritoneal catheter. The primary endpoint was the rate of overall shunt complication or failure within the first 12 months after surgery. Secondary endpoints were distal shunt failure, overall complication/ failure, duration of surgery and hospitalization, and morbidity.

RESULTS

The overall shunt complication/failure rate was 15% (9 of 60 cases) in the laparoscopic group and 18.3% (11 of 60 cases) in the mini-laparotomy group (p = 0.404). Patients in the laparoscopic group had no distal shunt failures; in contrast, 5 (8%) of 60 patients in the mini-laparotomy group experienced distal shunt failure (p = 0.029). Intraoperative complications occurred in 2 patients (both in the laparoscopic group), and abdominal pain led to catheter removal in 1 patient per group. Infections occurred in 1 patient in the laparoscopic group and 3 in the mini-laparotomy group. The mean durations of surgery and hospitalization were similar in the 2 groups.

CONCLUSIONS

While overall shunt failure rates were similar in the 2 groups, the use of laparoscopic shunt placement significantly reduced the rate of distal shunt failure compared with mini-laparotomy.

Is there an ideal shunt? A panoramic view of 110 years in CSF diversions and shunt systems used for the treatment of hydrocephalus: from historical events to current trends

OBJECT

The goal of this study is to evaluate whether an "ideal shunt" exists.

METHODS

This is a retrospective analysis based on original papers in the field of Hydrocephalus and Shunts. Patients of all age groups, who had hydrocephalus, and underwent some form of CSF diversion were included. The study has been divided into four stages: from 1900 to 1949, 1950 to 1974, 1975 to 1999, and from 2000 to 2010.

RESULTS

In stage 1 (historical era): Saphenous vein grafts, rubber conduits, and other materials were used in CSF diversions. In 1949, the first implantable shunt tube was developed by Nulsen. In stage 2 (experimental stage): the Holter valve was developed. Newer innovations were developed in relation to the ventriculo-atrial shunt, which was the preferred CSF diversion. In stage 3 (developmental stage), a large number of different design shunt systems were developed, with the aim of reducing complications. The ventriculo-peritoneal shunt had become the preferred CSF diversion. Also, the programmable valve was born. In stage 4 (era of programmable valve, there is a preference for the use of programmable shunt systems. However, shunt failure rate at 1 year being around 25 to 40%, and shunt survival at 1 and 2 years are 50-70 and 47-53% in most series.

CONCLUSION

Every shunt is an ideal shunt provided the choice of the shunt used should be made by the matching performance of the shunt system to the altered profile of CSF dynamics of a given patient. The most important factor being the opening pressure.

Factors affecting surgical outcome of endoscopic third ventriculostomy in congenital hydrocephalus

Endoscopic third ventriculostomy (ETV) is an accepted modality of treatment for obstructive hydrocephalus, with good results in adult patients. However in the pediatric age group results vary from poor to similar to the adult population. This study evaluates the outcome of ETV in congenital hydrocephalus of both early and delayed presentation, and investigates factors that determine the outcome. Patients with congenital hydrocephalus who underwent ETV between January 2006 and December 2011 were retrospectively analyzed. Any conditions potentially influencing the need for redo surgery (persistent cerebrospinal fluid [CSF] leak not responding to local measures, tense fontanelle, increased ventricular size, recurrence of symptoms or radiological evidence of failure) were analyzed. A total of 102 patients with a mean age of 7.45years were included. Presenting features were increasing head circumference and delayed milestones. Ninety-eight patients had triventricular hydrocephalus due to aqueductal stenosis. Procedures performed were ETV only (n=74), ETV with aqueductoplasty (n=22), ETV with cystoventriculostomy (n=2) and aqueductoplasty only (n=2). Failure of ETV occurred in 11 patients and all were managed with a ventriculoperitoneal shunt. CSF leak in the perioperative period was the only factor that was significantly associated with failure of ETV. ETV is a safe procedure with a good success rate and can be offered to children with aqueductal stenosis. There is a higher chance of failure if there is a CSF leak in the early or late postoperative period.

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.

History of hydrocephalus and its treatments

Hydrocephalus has amazed and challenged clinicians throughout the history of medicine. In reviewing the treatment of hydrocephalus, the integral relationship between basic science and therapy is reaffirmed. As we embark into a new millennium, it is appropriate to reflect on the past studies of this disorder, review various attempted and currently used, and finally speculate on possible future directions in its treatment.

Peritoneal shunt tube placement performed using an endoscopic threaded imaging port. Technical note

The authors used an endoscopic threaded imaging port that originally was developed for laparoscopy to access the peritoneal cavity, and applied this device to the placement of a peritoneal shunt tube in patients suffering from hydrocephalus. Using this system, the peritoneum can be opened quickly under direct vision by using an endoscope through a small skin incision. The peritoneal cavity is secured by replacing the cannula with a polyvinyl chloride (PVC) tube. At the end of surgery, the terminal end of the shunt tube is inserted through the PVC tube, which serves as a guiding catheter. Only one or two skin stitches are needed for closure. This method has proved to be safe, quick, and less invasive than conventional minilaparotomy.

Laparoscopic removal of a displaced ventriculoperitoneal shunt

Detached catheters in the peritoneal cavity are among the complications following implantation of ventriculoperitoneal shunts. We present one case and discuss the value of a laparoscopic approach to retrieve this foreign body. Laparoscopic removal of these catheters is an effective and safe procedure and can be used in these ill patients, avoiding the possible complications of a laparotomy.

Laparoscopically assisted implantation of ventriculoperitoneal shunts

Laparoscopically-assisted minimally invasive procedures have been applied to a broad spectrum of abdominal interventions. Neurosurgeons performing ventriculoperitoneal shunt operations for hydrocephalus used to place the peritoneal catheter by performing an upper abdominal midline or subcostal incision. In this report, to reduce the patient's inconvenience caused by the laparotomy wound, three consecutive ventriculoperitoneal shunts were implanted, assisted by laparoscopy. By means of three incisions (one 10 mm supraumbilical for the camera and two 5 mm in the right hypochondric region for instrumentation) the peritoneal catheter was placed next to the epiploic foramen. After subcutaneous pull-through of the catheter to the right supraclavicular region, the operation was continued by the neurosurgeon. The postoperative course was uneventful in all cases. The patients were dismissed 3-7 days after surgery. Short time follow-up (212, 202, and 169 days after surgery) showed no complications and perfect function of the ventriculoperitoneal shunts.

A simplified technique for lengthening peritoneal catheters

Existing techniques for lengthening a peritoneal catheter require a formal laparotomy, and exploration for the catheter which is then extended by the addition of a necessary length. We describe a simplified technique which is quicker and which in co-operative patients can be done under local anaesthesia on an out-patient basis. In this technique the peritoneal catheter along with its fibrous sheath is dissected and after opening the sheath an additional length is added. The elongated catheter is replaced through the same tubular sheath into the peritoneal cavity.

A modified technique for placement of the peritoneal end of a shunt system: technical note

Infection and extrusion of the peritoneal catheter can complicate shunt surgery. We present a modification in the technique of peritoneal catheter placement which can help reduce the incidence of these complications, as it places the peritoneal catheter away from the abdominal wound. The subcutaneous passer is first introduced into the peritoneal cavity through the abdominal incision. It is then thrust superficially and manipulated into the subcutaneous plane, from where the procedure follows the conventional steps. We have followed this technique for 6 years without any additional hazard attributed to this procedure.

Avoidable factors that contribute to the complications of ventriculoperitoneal shunt in childhood hydrocephalus

A personal series of 80 consecutive children who underwent ventriculoperitoneal shunting for hydrocephalus has been followed up for a period of from 6 months to 6.5 years. Complications occurred in 8 patients; these included partial occlusion of the ventricular catheter in 2, infection in 2, peritoneal catheter-valve disconnection with migration of the catheter into the peritoneal cavity in 2, fracture of the peritoneal catheter just below the valve in 1, and failure of the peritoneal cavity to absorb cerebrospinal fluid in another. Analysis of the results in the present series showed that the complications result from the technique. The operative procedures responsible for a low complication rate in the present series are described. It is concluded that to avoid shunt complications, attention must be paid to the following factors: meticulous asepsis; good surgical technique, including testing of the shunt system to make certain that the correct opening pressure is present; elimination of contact between the shunt system and the patient's skin; placement of the valve under a pericranial flap; positioning the tip of the ventricular catheter just in front of the foramen of Monro and that of the peritoneal catheter in the pelvic peritoneal cavity.

Historical aspects of hydrocephalus

From early days on physicians took interest in hydrocephaly because of its grotesque appearance. Already Hippocrates recommended decompression-trepanation for the treatment of hydrocephalus. Only since anatomy and pathophysiology of hydrocephalus as well as production and absorption of the cerebrospinal fluid was clarified, more effective operative techniques could be developed. Conservative treatment was unsuccessful or was useful only as temporary or adjuvant therapy supporting surgical procedures. A great variety of operative methods was described since the middle of 19th century which yielded, however, unsatisfactory results in most instances. Results improved since the introduction of effective valve systems in combination with ventriculoatrial and ventriculoperitoneal shunts. Despite of improved results, the treatment of hydrocephalus remains problematic as is shown by the still high complication rate and the restless search for more effective ways of treatment.

Holoprosencephaly in neurosurgical practice

The clinical, angiographic, and pneumoencephalographic features of seven cases with holoprosencephaly are reported. Three of the alobar type in this series revealed the facial dysmorphia characteristic of the anomaly. In the other four cases (one alobar, one semilobar, and two lobar), such facial anomaly was absent, and the diagnosis was achieved only after contrast studies. An azygous anterior cerebral artery running over the cerebral surface due to a defective interhemispheric fissure is pathognomonic for alobar and semilobar holoprosencephaly. Dysgenesis of the deep venous system was found in alobar, semilobar, and lobar holoprosencephaly, a finding helpful in diagnosis, especially of the lobar type. Air study and computerized tomography scan revealed incomplete separation of the ventricular system. The basic nature of holoprosencephalization and its differentiation from non-holoprosencephalic malformation are discussed. Six of the seven patients reported had hydrocephalus.

Simulated testicular torsion in a neonate: complication of ventriculoperitoneal shunt

Ventriculoperitoneal shunts are a common form of cerebrospinal fluid diversion in treating hydrocephalus. With their use various complications have been noted. Herein is described a shunt complication which simulated an acute scrotal condition. The operative findings and treatment are discussed. A brief review of the literature is also given.

[Ventriculoperitoneal shunt in adults]

Apresentação de 18 pacientes adultos submetidos à derivação ventriculoperitoneal com válvula. Em 17 casos havia hipertensão intracraniana. Em 10 casos, com período de seguimento de 2 a 48 meses, os sistemas estão funcionando bem. Seis doentes faleceram, não sendo possível estabelecer as condições atuais dos 2 restantes. Em 2 pacientes necropsiados, foi verificada permeabilidade da derivação e ausência de aderências e de peritonite. Oclusão da extremidade peritoneal do cateter não ocorreu em caso algum.

[Ventriculo-peritoneal shunt with valve in the treatment of childhood hydrocephalus]

Uma série de 95 crianças hidrocefálicas foram submetidas à derivação ventriculoperitoneal (DVP) com válvula no período de dezembro de 1965 a novembro de 1969. Os resultados obtidos são analisados e comparados com os obtidos mediante derivação ventriculoatrial (DVA). Das crianças operadas, 54 estão vivas e com a hidrocefalia compensada, 9 faleceram, não sendo possível estabelecer as condições atuais das 32 restantes. Com a derivação para o peritônio foram evitadas as severas complicações vasculares e cardiopulmonares observadas com a derivação para a cvidade cardíaca. O número de revisões cirúrgicas é menor nos pacientes submetidos à DVP com válvula. Além disso, as infecções no sistema de drenagem ventriculoperitoneal provocam quadros menos graves e de mais fácil solução, que os observados na derivação ventriculoatrial. A análise das condições pré-operatórias, das complicações e dos resultados finais permitiram algumas conclusões: 1) o uso de válvula unidirecional, no sistema de derivação ventriculoperitoneal, dificulta a oclusão da extremidade distal do sistema de drenagem; 2) pode-se esperar bons resultados, sem necessidade de revisão cirúrgica, em cêrca de 42,35% das crianças hidrocefálicas submetidas à DVP com válvula; 3) as derivações ventriculoperitoneais com válvula, quando comparadas às derivações ventriculoatriais, considerando um grupo de crianças hidrocefálicas operadas nos mesmos Serviços, em condições semelhantes, com mesmo tempo de seguimento — foram as que proporcionaram melhores resultados; 4) os casos estudados permitem constatar, portanto, que a DVP com válvula, constitui atualmente a terapêutica cirúrgica mais apropriada da hidrocefalia infantil.

[Evaluation of the function of ventriculo-peritoneal shunts with valve by use of radioisotopes. Personal technical contribution]

Apresentação de um método pessoal de exame para avaliação do funcionamento da derivação ventrículo-peritoneal com válvula, consistente na injeção intra-ventricular de RIHSA, seguida da captação simultânea da atividade radioativa nos ventrículos e na cavidade peritoneal. Mapeamentos simultâneos das regiões cerebral e abdominal, feitos com intervalo de 18 a 24 horas completam o estudo.