Ascites and abdominal pseudocysts following ventriculoperitoneal shunt surgery: variations of the same theme

Reconversion to ventriculoperitoneal shunt following ventriculoatrial shunt malfunction in children

PURPOSE

To analyze the long-term efficacy of the ventriculoatrial shunt (VAS) in pediatric patients with hydrocephalus, focusing on the atrial catheter and suitable revision procedures of the distal catheter following VAS malformation performed at our institution.

METHODS

The authors retrospectively analyzed data of 28 pediatric patients under the age of 10 years who were treated with VAS for hydrocephalus and who had a follow-up period of at least 5 years.

RESULTS

A total of 42 atrial tube revision procedures were performed in 28 patients during the study period. The median atrial tube survival time due to atrial tube obstruction was 2.32 years (n = 31, range: 0.4-8.08 years). Atrial tube survival time was shorter in younger children (p < 0.0001) and in children who were shorter in height (p = 0.0001). As a revision procedure following atrial tube malfunction, 22 (78.6%) out of the 28 patients who had an inserted VAS had the VAS reconversion into a VPS at the last follow-up.

CONCLUSIONS

VAS can be a useful alternative to VPS, but it requires frequent atrial tube revisions, especially in younger children. Reconversion to VPS after VAS malfunction is a reasonable option and is associated with longer shunt survival time despite its previously observed difficulties.

Abdominal complications in patients with a ventriculoperitoneal shunt: proposal for management recommendations from a single pediatric tertiary center

PURPOSE

The aim of this study was to describe our experience in the management of patients with ventriculoperitoneal shunt-related complications (abdominal pseudocyst, bowel-related complications, and ascites) and to propose treatment recommendations.

MATERIAL AND METHODS

A retrospective descriptive study was conducted in patients with ventriculoperitoneal shunt-related abdominal complications seen between 2009 and 2019 at a tertiary-care pediatric center. Patients were classified according to their diagnosis into the following: group A (abdominal pseudocyst), group B (bowel-related complications), and group C (ascites). The following variables were studied in all three groups: age, sex, etiology of hydrocephalus, history of pyogenic ventriculitis, history of abdominal surgery, clinical presentation, presence of ventricular enlargement on computed tomography scan, abdominal ultrasonography, shunt series X-ray, cerebrospinal fluid cultures, urgent as well as elective surgical interventions, antibiotic treatment, length of hospital stay, follow-up, and outcome.

RESULTS

Overall, 48 patients were analyzed: group A, n=29; group B, n=15; and group C, n=4. In all cases, surgical decision-making was based on symptom severity at the time of diagnosis, presence of ventricular enlargement on computed tomography scan, and cerebrospinal fluid culture results. In patients with positive cultures, the shunt system was removed, and an external ventricular drain was placed. In oligosymptomatic patients, cerebrospinal fluid culture results were awaited to define long-term treatment and in patients with ventricular enlargement or clinically difficult-to-treat symptoms, the distal catheter was exteriorized at the thoracic level.

CONCLUSION

In patients with shunt-related abdominal complications, surgical management depends on symptom severity and/or whether infection is present at the time of diagnosis.

Abdominal Complications Related to Ventriculoperitoneal Shunt Placement: A Comprehensive Review of Literature

Ever since the shunt device became the gold standard treatment for hydrocephalus, complications due to infections and mechanical problems have increased while lives have been saved. In addition, abdominal complications have become an important issue as the peritoneum is now the main place to insert the distal catheter. The most common complications were abdominal pseudocyst, distal catheter migration, inguinal hernia, catheter disconnection, and intestinal obstruction. The pediatric population is more prone to develop most of these complications due to their rapidly growing body, weaker abdominal musculature, and increased intraabdominal pressure. The goal of this review was to study the main aspects associated with abdominal complications after ventriculoperitoneal shunt (VPS) insertion, including the pathophysiology, epidemiological aspects, as well as the rationale for management and prevention according to the current “state-of-the-art.” It is paramount to recognize the risk factors associated with various types of complications to manage them properly.

Huge abdominal cerebrospinal fluid pseudocyst following ventriculoperitoneal shunt: a case report

Introduction

Abdominal pseudocysts comprising cerebrospinal fluid are an uncommon but significant complication in patients with ventriculoperitoneal shunt. We present a successfully treated 12-year-old boy with a history of ventriculoperitoneal shunting and a huge abdominal cerebrospinal fluid pseudocyst.

Case presentation

A12-year-old Japanese boy presented with a deteriorated consciousness and a palpable and elastic large lower abdominal mass. Computed tomography of his abdomen demonstrated a collection of homogenous low-density fluid near the catheter tip of the ventriculoperitoneal shunt. Cerebral computed tomography revealed an increased ventricular size. Based on the clinical diagnosis of abdominal pseudocyst, the peritoneal shunt catheter was secured and divided into two parts by cutting it on the chest; then, the proximal side of the peritoneal shunt catheter was externalized for extraventricular drainage. The cyst was percutaneously aspirated with ultrasound guidance, and the distal side of the peritoneal shunt catheter was removed. The distal side of the peritoneal shunt catheter was reinserted in another position into his abdomen after 3-week extraventricular drainage management.

Conclusion

Emergency physicians should know about this potential complication as an important differential diagnosis resulting from acute abdominal complaints in patients with ventriculoperitoneal shunts.

TB Meningitis and TB Peritonitis: Abdominal Pseudocyst and VP-Shunt Link

TB meningitis (TBM) carries high morbidity and mortality and is a relatively common extrapulmonary TB in the third world countries. TBM as thick exudative disease manifests on MRI and CT as nodular basal leptomeningitis, hydrocephalus, basal infarcts, and tuberculomas. Hydrocephalus is treated with ventriculoperitoneal shunting (VPS). Shunt malfunction and revision are common. We report a case of multidrug-resistant TBM with spinal involvement and dissemination of the disease via VPS causing TB peritonitis (TBP). TBP presented as a large abdominal pseudocyst around the catheter tip with shunt malfunction. There was no evidence for any other site of extra-CNS disease. TBP per se is relatively less common. This is the first case reporting VPS as a means of TB spread.

The Neuroimaging Studies in Children with Ventriculoperitoneal Shunt Complications: A 10 Years Descriptive Sudy in Tehran

Background

Any mismatch between the production and absorption of CSF results in hydrocephalus. In most cases, the selected choice of treatment is the ventriculoperitoneal shunt insertion. Although, the surgery could have complications such as infection, shunt malfunction, subdural hematoma, seizure and Shunt immigration; so, the early and proper detection of these complications could result in better prognosis. The aim of this study was to evaluate and compare the efficacy of CT scan, CSF analysis and X-ray radiography in detection of shunt complications and problems in shunt placement and further follow-up in hospitalized children.

Methods

The medical records of children in Rasul Akram hospital in Tehran were reviewed retrospectively in the last 10 years, from 2006 to 2016. All data were recorded in the prepared form including the age, sex, shunt complication, CT scan and CSF characteristics.

Results

The total number of 95 patients were interfered in this study including 56 males (58.9%) and 39 females (41.1%). The mean age at the onset of complications were 2.8±2.2 years-old. The shunt obstruction (60%) and infection (25.3%) were the most common complications. The CT scan was able to detect 36.5% of shunt complications. The CT scan had the sensitivity and specificity of 50 and 87%, respectively in detection of shunt obstruction. The all cases of brain hematoma and hemorrhage were revealed by CT scan. On the other hand, the CT scan had 20% of sensitivity and 60% of specificity in the detection of shunt infection. The CSF evaluation in shunt infection revealed 92% hypoglycemia, 87.5% pleocytosis, and 62.5% positive CSF culture. CSF had the sensitivity, specificity, positive predictive value and negative predictive value of 92, 82, 63 and 97%, respectively. The patient's symptoms and signs were helpful in obtaining higher test accuracy.

Conclusion

The CT scan was not a good sensitive and specific study in the detection of shunt obstruction and infection, but it was very accurate in detection of hemorrhage and hematoma. On the other hand, CSF evaluation was a reliable test in shunt infection disclosure.

Abdominal Pseudocysts and Peritoneal Catheter Revisions: Surgical Long-Term Results in Pediatric Hydrocephalus

OBJECTIVE

An abdominal pseudocyst (APC) is a distal catheter site-specific failure in patients treated with ventriculoperitoneal shunts. Few studies with more than 10 patients have been reported. The aim of this study was to analyze causes of peritoneal catheter revisions with special emphasis on revisions because of an APC.

METHODS

Pediatric patients with first shunt operation between 1982 and 1992 were included, and time, cause, and modality of peritoneal catheter revision were determined retrospectively.

RESULTS

One hundred thirty-eight patients were treated for hydrocephalus, and 112 patients received a peritoneal catheter during the follow-up. An APC was diagnosed in 14 (12.5%) patients, and 28 revisions were needed for its treatment. The rate of shunt infection in patients with APC was 50%, but bacterial examination of the pseudofluid culture revealed infection in only 3 patients. Age at first surgical procedure, type of first surgical procedure, and etiology of hydrocephalus were not associated with APC diagnosis. APC recurred in 4 patients. These patients had a catheter repositioning directly into the peritoneum as first surgical treatment. No recurrences were observed in patients with shunt externalization or replacement of the peritoneal catheter.

CONCLUSIONS

An APC is a major long-term complication after ventriculoperitoneal shunt treatment. Although a sterile inflammatory response cannot be excluded completely, our results favor the hypothesis of low-level shunt infection. In both cases, the surgical consequences are the same. An infected APC should be treated as a shunt infection. Uninfected patients can be treated with shunt externalization and replacement of only the peritoneal catheter.

Ventriculo-ureteral shunt insertion using percutaneous nephrostomy: a novel minimally invasive option in a patient with chronic hydrocephalus complicated by multiple distal ventriculoperitoneal shunt failures

The management of ventriculoperitoneal (VP) shunt failure is a common problem in neurosurgical practice. On occasion, extraperitoneal sites for CSF diversion are required when shunting to the peritoneal cavity has failed after multiple attempts. The authors report a novel minimally invasive procedure allowing cannulation of the ureter for the purpose of ventriculo-ureteral (VU) shunting. Sixteen years prior to presentation, this 46-year-old woman had contracted tuberculous meningitis and had chronic hydrocephalus, with multiple distal shunt failures in recent months. A percutaneous nephrostomy was used to pass the distal catheter based on intraoperative retrograde pyelography. Following successful placement of the VU shunt, the patient's hydrocephalus stabilized and she returned to her regular functional status. The only long-term complication noted within 36 months of follow-up was a transient episode of electrolyte disturbance and dehydration associated with a diarrheal illness that responded to adequate hydration and salt supplementation. By its minimally invasive nature, this approach offers a reasonable extraperitoneal alternative after multiple distal shunt catheter failures have occurred.

Ventriculo-ureteral shunt insertion using percutaneous nephrostomy: a novel minimally invasive option in a patient with chronic hydrocephalus complicated by multiple distal ventriculoperitoneal shunt failures

The management of ventriculoperitoneal (VP) shunt failure is a common problem in neurosurgical practice. On occasion, extraperitoneal sites for CSF diversion are required when shunting to the peritoneal cavity has failed after multiple attempts. The authors report a novel minimally invasive procedure allowing cannulation of the ureter for the purpose of ventriculo-ureteral (VU) shunting. Sixteen years prior to presentation, this 46-year-old woman had contracted tuberculous meningitis and had chronic hydrocephalus, with multiple distal shunt failures in recent months. A percutaneous nephrostomy was used to pass the distal catheter based on intraoperative retrograde pyelography. Following successful placement of the VU shunt, the patient's hydrocephalus stabilized and she returned to her regular functional status. The only long-term complication noted within 36 months of follow-up was a transient episode of electrolyte disturbance and dehydration associated with a diarrheal illness that responded to adequate hydration and salt supplementation. By its minimally invasive nature, this approach offers a reasonable extraperitoneal alternative after multiple distal shunt catheter failures have occurred.

Hourly oral sodium chloride for the rapid and predictable treatment of hyponatremia

Hypertonic NaCl is first-line therapy for acute, severe and symptomatic hyponatremia; however, its use is often restricted to the intensive care unit (ICU). A 35-year-old female inpatient with an optic chiasm glioma and ventriculoperitoneal shunt for hydrocephalus developed acute hyponatremia (sodium 122 mEq/l) perhaps coinciding with haloperidol treatment. The sum of her urinary sodium and potassium concentrations was markedly hypertonic vis-à-vis plasma; it was inferred that serum sodium concentration would continue to fall even in the complete absence of fluid intake. Intravenous (i.v.) 3% NaCl was recommended; however, a city-wide public health emergency precluded her transfer to the ICU. She was treated with hourly oral NaCl tablets in a dose calculated to deliver the equivalent of 0.5 ml/kg/h of 3% NaCl with an objective of increasing the serum sodium concentration by 6 mEq/l. She experienced a graded and predictable increase in serum sodium concentration. A slight overshoot to 129 mEq/l was rapidly corrected with 0.25 l of D5W, and she stabilized at 127 mEq/l. We conclude that hourly oral NaCl, in conjunction with careful monitoring of the serum sodium concentration, may provide an attractive alternative to i.v. 3% NaCl for selected patients with severe hyponatremia.

Intraabdominal Pseudocyst Developed after Ventriculoperitoneal Shunt: A Case Report

Abdominal pseudocyst is a rare complication developing after ventriculoperitoneal shunt treatment. It is more commonly seen particularly in children. The underlying pathogenesis may be associated with repeat revisions or infections. Morphologically, it has no complete cyst wall, presenting only with a pseudocapsule among the intestinal loops, around the lower shunt tip. The principal problem appears to be the reduced peritoneal absorption capacity. The treatment is complicated and difficult. In this report, we present an 8-year-old abdominal pseudocyst case with a history of many shunt revisions.

Brain metastases as a cause of malignant cerebrospinal fluid ascites: case report and review of the literature

The development of cerebrospinal fluid ascites after a ventriculo-peritoneal shunt operation is an extremely rare complication. There have been only sporadic case reports and small series reviews published in regards to this condition. They are usually found in the context of primary brain tumors, usually affecting the pediatric population. We present an unusual case of a patient with known metastatic breast carcinoma to the brain who develops malignant cerebrospinal fluid ascites after a ventriculo-peritoneal shunt insertion. This is the first known adult case of a metastatic breast primary to the brain causing tumor dissemination via a ventriculo-peritoneal shunt.

Factors affecting ventriculoperitoneal shunt survival in adult patients

Background:

Ventriculoperitoneal (VP) shunt insertion remains the mainstay of treatment for hydrocephalus despite a high rate of complications. The predictors of shunt malfunction have been studied mostly in pediatric patients. In this study, we report our 11-year experience with VP shunts in adult patients with hydrocephalus. We also assess the various factors affecting shunt survival in a developing country setting.

Methods:

A retrospective chart analysis was conducted for all adult patients who had undergone shunt placement between the years 2001 and 2011. Kaplan–Meier curves were used to determine the duration from shunt placement to first malfunction and log-rank (Cox–Mantel) tests were used to determine the factors affecting shunt survival.

Results:

A total of 227 patients aged 18–85 years (mean: 45.8 years) were included in the study. The top four etiologies of hydrocephalus included post-cranial surgery (23.3%), brain tumor or cyst (22.9%), normal pressure hydrocephalus (15%), and intracranial hemorrhage (13.7%). The overall incidence of shunt malfunction was 15.4% with the median time to first shunt failure being 120 days. Etiology of hydrocephalus (P = 0.030) had a significant association with the development of shunt malfunction. Early shunt failure was associated with age (P < 0.001), duration of hospital stay (P < 0.001), Glasgow Coma Scale (GCS) score less than 13 (P = 0.010), excision of brain tumors (P = 0.008), and placement of extra-ventricular drains (P = 0.033).

Conclusions:

Patients with increased age, prolonged hospital stay, GCS score of less than 13, extra-ventricular drains in situ, or excision of brain tumors were more likely to experience early shunt malfunction.

Hepatic cerebrospinal fluid pseudocyst: A rare complication of ventriculoperitoneal shunt

Background:

Ventriculoperitoneal (VP) shunts are among the most frequently performed operations in the management of hydrocephalus. Hepatic cerebrospinal fluid (CSF) pseudocyst is a rare but important complication in patients with a VP shunt insertion. In addition to presenting our own case, we performed a PubMed search to comprehensively illustrate the predisposing factors, clinical picture, diagnostic methods, and surgical treatment. This article represents an update for this condition.

Case Description:

A 40-year-old male was admitted to a hospital complaining of fever, abdominal distention, and pain. He had undergone a VP shunt for communicating hydrocephalus caused by a head trauma one year earlier. Laboratory studies showed liver enzymes alterations, and imaging studies demonstrated a well-defined intraaxially hepatic cyst with the shunt catheter placed inside. Staphylococcus epidermis was cultured via CSF. After removing the VP shunt and an adequate antibiotic treatment, the complication of hepatic CSF pseudocyst was resolved.

Conclusion:

Hepatic CSF pseudocyst is a rare complication of a VP shunt. Once the diagnosis is verified and if the CSF is sterile, just simply remove the peritoneal catheter and reposition a new one in the abdomen. We believe that it is not necessary to remove or aspirate the hepatic intraaxial pseudocyst, because of the risk of bleeding. In case of CSF infection, the VP shunt can be removed and/or an external derivation can be made, and after treatment with antibiotics, a new VP shunt is placed in the opposite side of the peritoneum.

Abdominal cerebrospinal fluid pseudocyst occurring 21 years after ventriculoperitoneal shunt placement: a case report

Background

Ventriculoperitoneal shunt (VPS) placement is an established procedure for the treatment of hydrocephalus of diverse etiologies in children and adults. Abdominal cerebrospinal fluid pseudocyst, which is potentially life threatening, is a rare complication and usually occurs during childhood. However, with increasing longevity following successful treatment, it can also occur in adults.

Case presentation

Here we describe a 22-year-old man who was admitted to our hospital because of diffuse abdominal distention. A VPS was placed 21 years earlier to treat hydrocephalus secondary to spina bifida. Abdominal computed tomography (CT) revealed a homogeneous low-density fluid collection adjacent to the VPS catheter tip, causing stomach obstruction. Thus a peritoneal pseudocyst around VPS was suspected and emergency laparotomy was performed. The large mass was localized in the left upper abdomen between the stomach and mesentery of the transverse colon, exactly at the omental bursa. The cystic mass was opened and 1500 ml of clear fluid was drained; the distal end of the VPS was repositioned outside the mass. Thus, an abdominal cerebrospinal fluid pseudocyst as a complication of VPS was diagnosed.

Conclusion

Gastroenterological surgeons should be aware of this possible complication, and this complication should be considered during differential diagnosis of an acute abdomen complaint.

Abdominal cerebrospinal fluid pseudocyst mimicking full-term pregnancy

Abdominal cerebrospinal fluid pseudocysts (APC) are a relatively uncommon complication of ventriculoperitoneal (VP) shunts, and most frequently occur in the pediatric population. Pediatric patients most often present with neurological sequelae, however, adults may present with abdominal complaints. Here we report a case of a nineteen year-old female with a VP shunt who presented with only abdominal distension suggestive of a full-term pregnancy. Abdominal CT studies subsequently established a diagnosis of APC. A total of 12.7L of fluid was drained laparoscopically, and the VP shunt was eventually revised into a ventriculo-atrial shunt. Because adult patients often present years after their VP shunt procedures with only abdominal complaints, the diagnosis of APC relies on detailed history taking and a strong clinical suspicion. The aetiology, presentation, diagnosis and treatment of APC are also reviewed.

Hydrocephalic holoprosencephaly: An oxymoron? Insights into etiology and management

Holoprosencephaly is usually associated with microcephaly, although macrocephaly is not uncommonly seen. However, the cause of hydrocephalus in holoprosencephaly remains ill-defined. Here, the authors report a case of CSF ascites following ventriculoperitoneal shunt placement in a five month-old child with alobar holoprosencephaly, and hypothesize that the excessive CSF production which occurs in this condition may be responsible for the formation of CSF ascites. Further research is required to assess whether the gene responsible for holoprosencephaly is also responsible for upregulating CSF production in patients with concomitant hydrocephalus.

Staphylococcus warneri ventriculoperitoneal shunt infection: failure of diagnosis by ventricular CSF sampling

BACKGROUND

The definite diagnosis of hydrocephalus valve infection is generally made by cerebrospinal fluid (CSF) sampling via the valve reservoir, which is considered to be more dependable than that of the CSF obtained by lumbar puncture.

CASE REPORT

We treated a 17-year-old boy with an intra-abdominal pseudocyst due to ventriculoperitoneal shunt infection caused by Staphylococcus warneri whose ventricular CSF, obtained via the valve reservoir, was repeatedly sterile thus causing a considerable delay in the management of the complication.

DISCUSSION AND CONCLUSIONS

S. warneri constitutes an emergent contaminant of catheters and prostheses. We found only a detailed report of S. warneri infection of a ventriculoatrial shunt. If manifestations of peritoneal involvement in shunted patients would occur, the attention should be shifted to the distal component of the shunt hardware, even in the presence of a normal ventricular CSF as happened in our case to avoid unnecessary delay in diagnosis and management.

Acute cholecystitis complicating ventriculo-peritoneal shunting: report of a case and review of the literature

CASE

A 3-year-old boy underwent emergency external ventricular drainage and excision of a fourth ventricle anaplastic ependymoma. A week later, the child was given a ventriculo-peritoneal shunt. Fourteen days after shunting, the child developed a subphrenic abscess and acute cholecystitis that required surgery.

RESULTS

A Staphylococcus epidermidis was isolated both from the ventricular catheter and CSF and from the subphrenic abscess and the gallbladder. To our knowledge, this is the first report of cholecystitis evolving as a descending shunt infection. The current literature related with this unique complication is briefly reviewed.

Severe constipation: an under-appreciated cause of VP shunt malfunction: a case-based update

BACKGROUND

Increased intra-abdominal pressure has been reported to result in raised intracranial pressure in a variety of conditions such as obesity and pregnancy, and it also constitutes an infrequent cause of ventriculoperitoneal (VP) shunt malfunction. Patients with neurological deficits, as those with myelomeningocele or cerebral palsy, are prone to developing a neurogenic bowel and to suffer chronic constipation. Although previously recognized, VP shunt failure attributed to constipation has only recently been described. We briefly review the etiopathogenesis, diagnosis and management of severe constipation leading to VP shunt malfunction. Our aim is to draw the attention of pediatric neurosurgeons towards severe constipation as a possible cause of VP shunt failure thus avoiding unnecessary surgical valve revisions, to which children with hydrocephalus are often submitted to.

ILLUSTRATIVE CASES

We report two children that developed transient VP shunt failure because of intense constipation that caused exacerbation of previously shunted hydrocephalus. One of the patients constitutes the first description of this complication associated with an anteriorly placed anus and the other with intestinal paresis after ileostomy. Conservative treatment aimed at alleviating the increased intra-abdominal pressure resulted in complete resolution of the children's manifestations of VP shunt failure, without having to resort to surgical revision of the VP shunt.