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Lu VM, Brun JD, Niazi TN, Brun JD. Pediatric shunt failure in a resource limited Lower-Middle Income Country (LMIC) institution in La Paz, Bolivia. Childs Nerv Syst 2024:10.1007/s00381-024-06536-z. [PMID: 38985316 DOI: 10.1007/s00381-024-06536-z] [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: 04/09/2024] [Accepted: 07/05/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Shunt failure is an undesirable but common occurrence following neurosurgical shunting for pediatric hydrocephalus. Little is known about the occurrence of failure in lower-middle income country (LMIC) settings in South America. The objective of this study was to evaluate shunt failure in the sole publicly funded pediatric hospital in La Paz, Bolivia, with limited resources. METHODS A retrospective review of all patients at the Children's Hospital of La Paz, Bolivia (Hospital del Niño "Dr. Ovidio Aliaga Uria"), was conducted to identify all patients whose index surgical shunting for hydrocephalus was performed between 2019 and 2023. Categorical, continuous, and shunt failure data were statistically summarized. RESULTS A total of 147 unique pediatric patients underwent index ventriculoperitoneal shunting for hydrocephalus in the study period. There were 90 (61%) male and 57 (39%) female patients, with a median age of 2.2 months at index shunting procedure. The most common surgical indications were congenital hydrocephalus (n = 95, 65%), followed by hydrocephalus secondary to congenital defect (n = 25, 17%) and tumor (n = 18, 12%). A total of 18 (12%) of patients experienced inpatient failure during index admission requiring surgical revision at a median time of 12.5 days after index shunting. Postoperative imaging (OR 2.97, P = 0.037) and postoperative infection (OR 3.26, P = 0.032) during index admission both independently and statistically predicted inpatient failure. Of the 96 patients (65%) with postoperative follow-up, 16 (n = 16/96, 17%) patients experienced outpatient failure requiring readmission to hospital and surgical revision at a median time of 3.7 months after discharge. Kaplan-Meier estimations of overall inpatient and outpatient failure in this cohort were 23% (95% CI 14-37) and 28% (95% CI 15-49), respectively. CONCLUSIONS Both inpatient and outpatient shunt failures are significant complications in the management of pediatric hydrocephalus in La Paz, Bolivia. We identify multiple avenues to improve these outcomes which are institution-specific based on the review of these failures. Lessons learnt may be applicable to other similarly resourced institutions across South American LMICs.
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Affiliation(s)
- Victor M Lu
- Department of Neurological Surgery, Hospital del Niño "Dr. Ovidio Aliaga Uria", La Paz, Bolivia.
- Department of Neurological Surgery, University of Miami Miller School of Medicine, 1095 NW 14 Terrace, Miami, FL, 33136, USA.
- Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, FL, USA.
| | - Jorge Daniel Brun
- Department of Neurological Surgery, Hospital del Niño "Dr. Ovidio Aliaga Uria", La Paz, Bolivia
| | - Toba N Niazi
- Department of Neurological Surgery, University of Miami Miller School of Medicine, 1095 NW 14 Terrace, Miami, FL, 33136, USA
- Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, FL, USA
| | - Jorge David Brun
- Department of Neurological Surgery, Hospital del Niño "Dr. Ovidio Aliaga Uria", La Paz, Bolivia
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Lim JX, Han HP, Foo YW, Chan YH, Ng LP, Low DCY, Seow WT, Low SYY. Paediatric ventriculoperitoneal shunt failures: 12-year experience from a Singapore children's hospital. Childs Nerv Syst 2023; 39:3445-3455. [PMID: 37284980 DOI: 10.1007/s00381-023-06007-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 05/22/2023] [Indexed: 06/08/2023]
Abstract
PURPOSE Cerebrospinal fluid (CSF) shunt failures in children are devastating. The primary aims of this study are to, firstly, review our institutional series of ventriculoperitoneal shunt (VPS) insertions and identify factors associated with shunt failure. METHODS This is a single-institution, retrospective study conducted over a 12-year period. All patients under 18 years old with VPS inserted were included. Variables of interest such as patient characteristics, hydrocephalus aetiology, shunt implant details, and outcomes were subjected to statistical analyses. RESULTS A total of 214 VPS patients were selected for this study. The mean age at VPS insertion was 6 months with a mean follow-up duration of 44 months. The most common type of hydrocephalus was obstructive (n = 142, 66.4%), and the most frequent aetiology was tumour-related (n = 66, 30.8%). The 30-day shunt failure rate was 9.3%: 9 infections (4.2%), 7 occlusions (3.3%), and 4 others (1.9%). After multivariable analysis, only recent central nervous system (CNS) infection prior to VPS insertion remained significant (OR 15.4 (1.3-175), p = 0.028). CONCLUSION This is the first, large-scale local study focused on the shunt failure in Singaporean children. Significant findings in our study demonstrate that recently treated CNS infection is a factor associated with 30-day shunt failure while the values of CSF constituents were not contributory.
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Affiliation(s)
- Jia Xu Lim
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Hui Ping Han
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Yi Wen Foo
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Block MD11, Clinical Research Centre, #02-03 (c/o CBmE Office), 10 Medical Drive, Singapore, 117597, Singapore
| | - Lee Ping Ng
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - David Chyi Yeu Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
- Department of Neurosurgery, National Neuroscience Institute, 11, Jalan Tan Tock Seng, Singapore, 208433, Singapore
- SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11, Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Wan Tew Seow
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
- Department of Neurosurgery, National Neuroscience Institute, 11, Jalan Tan Tock Seng, Singapore, 208433, Singapore
- SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11, Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Sharon Yin Yee Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.
- Department of Neurosurgery, National Neuroscience Institute, 11, Jalan Tan Tock Seng, Singapore, 208433, Singapore.
- SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11, Jalan Tan Tock Seng, Singapore, 308433, Singapore.
- SingHealth Duke-NUS Paediatrics Academic Clinical Program, 100 Bukit Timah Road, Singapore, 229899, Singapore.
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Javeed F, Mohan A, Wara UU, Rehman L, Khan M. Ventriculoperitoneal Shunt Surgery for Hydrocephalus: One of the Common Neurosurgical Procedures and Its Related Problems. Cureus 2023; 15:e35002. [PMID: 36938269 PMCID: PMC10022834 DOI: 10.7759/cureus.35002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 02/17/2023] Open
Abstract
Objective This study was conducted to assess the outcome in patients with hydrocephalus who underwent ventriculoperitoneal (VP) shunt surgery. Methods This retrospective study was conducted at the neurosurgery department of a tertiary care hospital. The time frame was three years and five months from January 2017 to May 2020 with a follow-up of six months. Results This study included 1030 patients, out of whom 64.2% were male and 35.8% were female. While the majority of the patients were more than 11 years of age (466), age did not have any significant impact on the outcome of the ventriculoperitoneal shunt surgery. The most common cause of hydrocephalus was congenital (47.6%). A good outcome was seen in 63.4%, mortality was 10.6%, and complications were identified for 25.8%. The underlying pathology had a significant impact on the outcome in our study (p-value < 0.05) where the congenital cause of hydrocephalus showed a better outcome than any other cause. Conclusion Ventriculoperitoneal shunt is a good way to manage hydrocephalus, but there is always a high risk of complications.
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Affiliation(s)
- Farrukh Javeed
- Neurological Surgery, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Anmol Mohan
- Medicine, Karachi Medical and Dental College, Karachi, PAK
| | - Um Ul Wara
- Medicine and Surgery, Karachi Medical and Dental College, Karachi, PAK
| | - Lal Rehman
- Neurosurgery, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Maham Khan
- Radiation Oncology, Aga Khan University Hospital, Karachi, PAK
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Eliasi E, Cohen A, Wasser O, Oelsner G. A case of primary infertility and a patient with ventriculoperitoneal shunt. J Surg Case Rep 2022; 2022:rjac590. [PMID: 36540299 PMCID: PMC9760058 DOI: 10.1093/jscr/rjac590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022] Open
Abstract
Ventriculoperitoneal (VP) shunts are the main treatment modality for patients with hydrocephalus. The complications arising in patients with VP shunts are well documented. We present a case of infertility in a patient with a long-standing VP shunt. Her infertility is thought to be the result of pelvic adhesions due to factors related to the distal end of her VP shunt. A 22-year-old female with a 1-year history of infertility was referred due to bilateral hydrosalpinges. Diagnostic laparoscopy revealed multiple adhesions surrounding the distal end of the fallopian tubes. The distal portion of a VP shunt, which was placed over the course of her childhood, was found to be grossly inflamed and densely adherent to the pelvic viscera. VP shunts may produce abdominal adhesions and can cause mechanical infertility.
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Affiliation(s)
- Elior Eliasi
- Correspondence address. Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, 17 Povarsky Street, Bnei Brak, Israel. E-mail:
| | - Adiel Cohen
- Department of Obstetrics and Gynecology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Oren Wasser
- Hadassah-Hebrew University Medical School, Jerusalem, Israel
| | - Gabriel Oelsner
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Sackler School of Medicine, Tel Aviv University, Bnei Brak, Israel
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Rennert RC, Brandel MG, Srinivas S, Prajapati D, Al Jammal OM, Brown NJ, Diaz-Aguilar LD, Elster J, Gonda DD, Crawford JR, Levy ML. Palliative endoscopic third ventriculostomy for pediatric primary brain tumors: a single-institution case series. J Neurosurg Pediatr 2021; 28:387-394. [PMID: 34359046 DOI: 10.3171/2021.3.peds20952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 03/29/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Children with nonoperative brain tumors, such as diffuse intrinsic pontine gliomas (DIPGs), often have life-threatening hydrocephalus. Palliative shunting is common in such cases but can be complicated by hardware infection and mechanical failure. Endoscopic third ventriculostomy (ETV) is a minimally invasive alternative to treat hydrocephalus without implanted hardware. Herein, the authors report their institutional experience with palliative ETV for primary pediatric brain tumors. METHODS The authors conducted a retrospective review of consecutive patients who had undergone palliative ETV for hydrocephalus secondary to nonresectable primary brain tumors over a 10-year period at Rady Children's Hospital. Collected variables included age, sex, tumor type, tumor location, presence of leptomeningeal spread, use of a robot for ETV, complications, ETV Success Score (ETVSS), functional status, length of survival, and follow-up time. A successful outcome was defined as an ETV performed without clinically significant perioperative complications or secondary requirement for a new shunt. RESULTS Fifteen patients met the study inclusion criteria (11 males, 4 females; average age 7.9 years, range 0.8-21 years). Thirteen patients underwent manual ETV, and 2 patients underwent robotic ETV. Preoperative symptoms included gaze palsy, nausea/vomiting, headache, lethargy, hemiparesis, and seizures. Tumor types included DIPG (3), intraventricular/thalamic glioblastoma (2), and leptomeningeal spread of medulloblastoma (2), anaplastic oligo-/astrocytoma (2), rhabdoid tumor (2), primitive neuroectodermal tumor (1), ganglioglioma (1), pineoblastoma (1), and embryonal carcinoma (1). The mean preoperative ETVSS was 79 ± 8.8. There was 1 perioperative complication, a wound breakdown consistent with refractory hydrocephalus. The mean follow-up was 4.9 ± 5.5 months overall, and mean survival for the patients who died was 3.2 ± 3.6 months. Two patients remained alive at a mean follow-up of 15.7 months. Palliative ETV was successful in 7 patients (47%) and unsuccessful in 8 (53%). While patients with successful ETV were significantly older (11.9 ± 5.6 vs 4.4 ± 4.1 years, p = 0.010), there were no significant differences in preoperative ETVSS (p = 0.796) or postoperative survival (p = 0.476) between the successful and unsuccessful groups. Overall, functional outcomes were similar between the two groups; there was no significant difference in posttreatment Karnofsky Performance Status scores (68.6 ± 19.5 vs 61.3 ± 16.3, p = 0.454), suggesting that including ETV in the treatment algorithm did not worsen outcomes. CONCLUSIONS Palliative ETV is a safe and potentially efficacious treatment option in selected pediatric patients with hydrocephalus from nonoperative brain tumors. Close follow-up, especially in younger children, is required to ensure that patients with refractory symptoms receive appropriate secondary CSF diversion.
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Affiliation(s)
| | | | | | | | | | | | | | - Jennifer Elster
- 3Pediatrics, University of California San Diego, La Jolla; and
- 4Rady Children's Hospital, San Diego, California
| | - David D Gonda
- Departments of1Neurological Surgery and
- 2Neurosciences, and
| | - John R Crawford
- 2Neurosciences, and
- 3Pediatrics, University of California San Diego, La Jolla; and
| | - Michael L Levy
- Departments of1Neurological Surgery and
- 2Neurosciences, and
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Leu S, Halbeisen F, Mariani L, Soleman J. Intraoperative ultrasound-guided compared to stereotactic navigated ventriculoperitoneal shunt placement: study protocol for a randomised controlled study. Trials 2021; 22:350. [PMID: 34011396 PMCID: PMC8132376 DOI: 10.1186/s13063-021-05306-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 04/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ventriculoperitoneal shunt (VPS) placement is one of the most frequent neurosurgical procedures and the operation is performed in a highly standardised manner under maintenance of highest infection precautions. Short operation times are important since longer duration of surgery can increase the risk for VPS complications, especially infections. The position of the proximal ventricular catheter influences shunt functioning and survival. With freehand placement, rates of malpositioned VPS are still high. Several navigation techniques for improvement of shunt placement have been developed. Studies comparing these techniques are sparse. The aim of this study is to prospectively compare ultrasound (US) guided to stereotactic navigated shunt placement using optical tracking with the focus on operation time and efficiency. METHODS In this prospective randomised, single-centre, partially-blinded study, we will include all patients undergoing VPS placement in our clinic. The patients will be randomised into two groups, one group undergoing US-guided (US-G) and the other group stereotactic navigated VPS placement using optical tracking. The primary outcome will be the surgical intervention time. This time span consists of the surgical preparation time together with the operation time and is given in minutes. Secondary outcomes will be accuracy of catheter positioning, VPS dysfunction and need for revision surgery, total operation and anaesthesia times, and amount of intraoperative ventricular puncture attempts as well as complications, any morbidity and mortality. DISCUSSION To date, there is no prospective data available comparing these two navigation techniques. A randomised controlled study is urgently needed in order to provide class I evidence for the best possible surgical technique of this frequent surgery. TRIAL REGISTRATION Business Administration System for Ethical Committees (BASEC) 2019-02157, registered on 21 November 2019, https://www.kofam.ch/de/studienportal/suche/88135/studie/49552 ; clinicalTrials.gov: NCT04450797 , registered on 30 June 2020.
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Affiliation(s)
- Severina Leu
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Florian Halbeisen
- Basel Institute for Clinical Epidemiology & Biostatistics, University Hospital of Basel, Spitalstrasse 12, 4031, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.,Faculty of Medicine, University of Basel, Klingelbergstrasse 61, 4056, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.,Faculty of Medicine, University of Basel, Klingelbergstrasse 61, 4056, Basel, Switzerland
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Yeola Pate M, Singh K. Ventriculoperitoneal shunt presenting as umbilical CSF fistula. J Family Med Prim Care 2020; 9:6276-6278. [PMID: 33681077 PMCID: PMC7928099 DOI: 10.4103/jfmpc.jfmpc_814_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 06/14/2020] [Accepted: 09/28/2020] [Indexed: 12/02/2022] Open
Abstract
An umbilical cerebrospinal fluid (CSF) fistula following a ventriculoperitoneal (VP) shunt is an extremely rare complication. The shunt can get blocked and infected and present as purulent umbilical discharge. We report an 11-month-old female infant who presented with recurrent purulent umbilical discharge, 6 months after VP shunt operation for hydrocephalus. After relevant investigations, she underwent exploratory laparotomy which revealed an umbilical CSF fistula with a blocked VP shunt. VP shunt removal was done with excision of the fistulous tract. The post-op period was uneventful and umbilical discharge ceased. She is further planned for endoscopic third ventriculostomy. Umbilical discharge in a neonate may be due to several pathologies. The family physician is the first point of contact in the majority of the cases before they seek a specialist. Hence, recurrent umbilical discharge not responding to conservative management must be evaluated carefully, referred promptly, and the underlying pathology to be treated.
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Affiliation(s)
- Meenakshi Yeola Pate
- Department of Surgery, Acharya Vinobha Bhave Rural Hospital, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (M), Wardha, Maharashtra, India
| | - Kushagra Singh
- Department of Surgery, Acharya Vinobha Bhave Rural Hospital, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (M), Wardha, Maharashtra, India
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Global trends in the evaluation and management of cerebrospinal fluid shunt infection: a cooperative ISPN survey. Childs Nerv Syst 2020; 36:2949-2960. [PMID: 32519130 DOI: 10.1007/s00381-020-04699-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/21/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Ventriculoperitoneal shunts (VPS) is commonly performed by pediatric neurosurgeons and there is no consensus in management of VPS infection as it relates to diagnosis and treatment. OBJECTIVE We utilized an international practitioner-based survey to study the variability in VPS infection diagnostic and therapeutic measures. METHODS A survey gauging practice patterns of pediatric neurosurgeons regarding VPS and its complication management was distributed. Survey endpoints were analyzed by VPS case volume and pediatric-focused case volume regarding diagnostic measures, use of cerebrospinal fluid (CSF) profile, microbiology, and treatment. RESULTS A total of 439 surveys were distributed, with a response rate of 31%. Responders ranged from Americas (44.9%), European (31.4%), Asian (18.6%), African (2.5%), to Australian continents (2.5%). Practitioners were stratified based on number and percentage pediatric VPS performed. Institutions performing highest VPS and percentage pediatric case volumes had lower rate of VPS infection. Shunt tap was the most widely used diagnostic study. Overall CSF profile did not affect decision making towards VPS internalization, except for leukocyte count ≤ 20 × 109/L. Practitioners utilized 3 negative cultures prior to VPS internalization. Discrepancies in surgical management were noted amongst centers with high versus low VPS volume and proportion of pediatric-focused case volume. Practice patterns were not noted to be organism dependent. Antibiotic-impregnated shunts were utilized in the Americas and Europe over other regions but only in one third of all initial VPS or as a preventive strategy after a VPS infection has been resolved respectively. DISCUSSION Survey results from 6 continents in VPS management revealed patterns of lower infection in high-volume centers, 3 negative cultures prior to internalization and aggressive surgical VPS infection management in high-volume institutions.
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