A novel safe approach to laparoscopic colorectal cancer resection in patients with ventriculoperitoneal shunt: report of two cases and literature review

A novel safe approach to laparoscopic colorectal cancer resection in patients with... There is ongoing challenges regarding the safety of performing laparoscopic surgery with the presence of ventriculoperito- neal (VP) shunts, especially in patients treated for cancer disease. To date, only one case has been reported in the English lit- erature. Herein, we report an additional two cases of patients with previous insertion of a VP shunt, diagnosed with colon cancer. Both our patients underwent successful laparoscopic colectomies, without clamping or removal of the VP shunt, with no reported perioperative complications or postoperative neurological deficits. Laparoscopic bowel resection for cancer, in patients with a pre-existing VP shunt, could be considered a potentially safe and feasible procedure. Furthermore, due to the increasing number of patients with VP shunts, additional case reports and investigations are warranted to further con- firm safety of this procedure. INTRODUCTION VP shunts, especially in patients treated for cancer disease. To our knowledge only one previous case was reported [2]. Ventriculoperitoneal (VP) shunts are silicone catheters placed We herein present two cases of adult colon cancer patients from the lateral brain ventricle through a subcutaneous tunnel with VP shunts that underwent laparoscopic surgery. into the peritoneal cavity, in order to drain excess cerebrospinal fluids. Since laparoscopic surgery has become the standard approach in many abdominal operations, several cases have high lightened the potential hazards of this technique, in patients CASE PRESENTATION with VP shunts. The primary concerns in laparoscopic surgery in Case 1 patients with VP shunt are a clinically significant increase in intra- A 71-year-old man was referred to our colon and rectum clinic, cranial pressure (ICP) and retrograde shunt failure. Nonetheless, an increase in ICP has never shown to be clinically significant, following diagnosis with right hepatic flexure colon cancer, which was detected by colonoscopy, due to abdominal pain moreover, ICP monitoring likely outweighs the risk of adverse events [1]. Other concerns include the development of severe thor- and recent change in bowel habits. Medical history included diagnosis with hydrocephalus 18 years earlier. He received a VP acic subcutaneous emphysema with compromised ventilation leading to increase in ICP. There is ongoing controversy regarding shunt that was routed subcutaneously, through the right thor- acic region into the abdominal cavity, at the epigastric region. the safety of performing laparoscopic surgery with the presence of Received: May 22, 2017. Accepted: December 26, 2017 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx264/4822189 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 S. Fuad et al. The current procedure, laparoscopic right hemicolectomy important issues should be taken under careful consideration, was performed using standard 4 port technique. No clamping such as the influence of a pneumoperitoneum on iatrogenic of the catheter was done. The postoperative course was spread of cancer cells, port-site metastasis, which seem to be uneventful with no neurological deficit. The patient was dis- characteristic to laparoscopic surgery. Furthermore, pneumo- charged 6 days postoperatively. peritoneum by CO insufflation might encourage VP shunt- related subcutaneous seeding of cancer cells. Otani et al. reported a rare case of pancreatic cancer diagnosed by the Case 2 detection of skin metastases along the VP shunt catheter, as an A 78-year-old woman was referred to our colon and rectum unfortunate consequence of its presence [8]. Magtibay et al. [9] clinic following diagnosis of left colon cancer, which was also reported a very rare case, in which the VP shunt served as detected by colonoscopy, due to rectal bleeding. Medical history a conduit for the spread of malignant medulloblastoma cells to included four previous abdominal operations: appendectomy, the peritoneum. Nonetheless, the reported incidence of port- open cholecystectomy and two caesarian sections, and an site metastasis following laparoscopic colon cancer surgery is insertion of VP shunt through left thoracic region into the low. Moreover, when port-site metastasis develops, it tends to abdominal cavity. occur in patients with advanced disease, such as large and The current procedure, her fifth abdominal surgery, laparo- locally advanced tumors or Dukes’ C cancers [10]. Therefore, scopic left hemicolectomy was performed using standard 4 port laparoscopic surgery for clinical stage T4 tumors with serosal technique. Unusual dense adhesions were found. No clamping involvement, as Dukes’ C cancers should be used with caution, of the catheter was done. The postoperative course demon- especially in patients with a VP shunt, as it might encourage VP strated a slow recovery with mild wound infection treated with shunt-related skin metastases. drainage and orally antibiotics only. No neurological deficit was detected. The patient was discharged 11 days postoperatively. CONCLUSIONS Laparoscopic bowel resection for cancer, in patients with a pre- DISCUSSION existing VP shunt, could be considered a potentially safe and To our knowledge, there is only one previously published case feasible procedure. Furthermore, due to the increasing number report in the English literature of a cecal cancer patient with of patients with VP shunts, additional reports and investiga- previous history of a VP shunt that was treated by laparoscopic tions are warranted to further confirm safety of this procedure. right colon resection [2]. Herein we report an additional two cases of patients with previous insertion of a VP shunt, diagnosed with colon cancer. CONFLICT OF INTEREST STATEMENT Both our patients underwent successful laparoscopic hemico- None declared. lectomies, without clamping or removal of the VP shunt, with no reported perioperative complications or postoperative neurological deficits. Our decision to leave the VP shunt in REFERENCES place was in contrast to the aforementioned case report, which involved manipulating and clamping of the shunt prior to 1. Jackman SV, Weingart JD, Kinsman SL, Docimo SG. insufflation of carbon dioxide, to prevent adverse effects from the Laparoscopic surgery in patients with ventriculoperitoneal pneumoperitoneum. shunts: safety and monitoring. J Urol 2000;164:1352–4. Barina et al. was the first to report on the clinical course, in 2. Torigoe T, Koui S, Uehara T, Arase K, Nakayama Y, adults with VP shunts in place, during open appendectomy for Yamaguchi K. Laparoscopic cecal cancer resection in a appendicitis. Similar to our report, they also demonstrated, in patient with a ventriculoperitoneal shunt: a case report. Int general, no shunt-related complications, such as malfunction J Surg Case Rep 2013;4:330–3. or infection [3]. Wadhwa et al. [4] were the first to report a retro- 3. Barina AR, Virgo KS, Mushi E, Bahadursingh AM, Johnson spective review of curative-intent open surgery for gastrointes- FE. Appendectomy for appendicitis in patients with a prior tinal cancers in adult patients with VP shunts. In this study the ventriculoperitoneal shunt. J Surg Res 2007;141:40–4. authors demonstrated that the presence of VP shunt did not 4. Wadhwa S, Hanna GK, Barina AR, Audisio RA, Virgo KS, increase the risk of postoperative complications, such as Johnson FE. Gastrointestinal cancer surgery in patients with increased ICP, pneumocephalus and infectious meningitis. a prior ventriculoperitoneal shunt: the department of veter- They did recommend intraoperative isolation of the shunt away ans affairs experience. Gastrointest Cancer Res 2012;5:125–9. from the operative field to prevent contamination. 5. Kerwat RM, Murali Krishnan VP, Appadurai IR, Rees BI. Kerwat et al. [5] showed that performing laparoscopic chole- Laparoscopic cholecystectomy in the presence of a lumbo- cystectomy, with no externalization of the shunt catheter, to be peritoneal shunt. J Laparoendosc Adv Surg Tech A 2001;11: a safe procedure. Furthermore, Jakman et al. [1] found no clinic- 37–9. ally significant increase in ICP, in patients with VP shunts, with 6. Fraser JD, Aguayo P, Sharp SW, Holcomb IG, Ostlie DJ St, insufflations pressure of 16 mmHg and average of 3 h operative Peter SD. The safety of laparoscopy in pediatric patients time. Moreover, other studies demonstrated no increase in air with ventriculoperitoneal shunts. J Laparoendosc Adv Surg embolism, shunt infectious and retrograde failure of the valve Tech A 2009;19:675–8. system [6], although conversion to open surgery was reported 7. Allam E, Patel A, Lewis G, Mushi E, Audisio RA, Virgo KS, to be higher with the presence of a VP shunt, mostly due to et al. Cholecystectomy in patients with prior ventriculoperi- dense adhesions [7]. toneal shunts. Am J Surg 2011;201:503–7. Nonetheless there is controversy regarding safety of per- 8. Nawashiro H, Otani N, Katoh H, Ohnuki A, Ogata S, Shima forming laparoscopic surgery with the presence of VP shunts, K. Subcutaneous seeding of pancreatic carcinoma along a especially in patients treated for cancer disease. Thus, some VP shunt catheter. Lancet Oncol 2002;3:683. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx264/4822189 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Laparoscopic bowel resections in patients with VP shunts 3 9. Magtibay PM, Friedman JA, Rao RD, Buckner JC, Cliby WA. 10. Jayne DG, Guillou PJ, Thorpe H, Quirke P, Copeland J, Unusual presentation of adult metastatic peritoneal Smith AM, et al. Randomized trial of laparoscopic- medulloblastoma associated with a ventriculoperitoneal assisted resection of colorectal carcinoma: 3-year results shunt: a case study and review of the literature. Neuro Oncol of the UK MRC CLASICC Trial Group. J Clin Oncol 2007;25: 2003;5:217–20. 3061–8. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx264/4822189 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

A novel safe approach to laparoscopic colorectal cancer resection in patients with ventriculoperitoneal shunt: report of two cases and literature review

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Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018.
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Abstract

There is ongoing challenges regarding the safety of performing laparoscopic surgery with the presence of ventriculoperito- neal (VP) shunts, especially in patients treated for cancer disease. To date, only one case has been reported in the English lit- erature. Herein, we report an additional two cases of patients with previous insertion of a VP shunt, diagnosed with colon cancer. Both our patients underwent successful laparoscopic colectomies, without clamping or removal of the VP shunt, with no reported perioperative complications or postoperative neurological deficits. Laparoscopic bowel resection for cancer, in patients with a pre-existing VP shunt, could be considered a potentially safe and feasible procedure. Furthermore, due to the increasing number of patients with VP shunts, additional case reports and investigations are warranted to further con- firm safety of this procedure. INTRODUCTION VP shunts, especially in patients treated for cancer disease. To our knowledge only one previous case was reported [2]. Ventriculoperitoneal (VP) shunts are silicone catheters placed We herein present two cases of adult colon cancer patients from the lateral brain ventricle through a subcutaneous tunnel with VP shunts that underwent laparoscopic surgery. into the peritoneal cavity, in order to drain excess cerebrospinal fluids. Since laparoscopic surgery has become the standard approach in many abdominal operations, several cases have high lightened the potential hazards of this technique, in patients CASE PRESENTATION with VP shunts. The primary concerns in laparoscopic surgery in Case 1 patients with VP shunt are a clinically significant increase in intra- A 71-year-old man was referred to our colon and rectum clinic, cranial pressure (ICP) and retrograde shunt failure. Nonetheless, an increase in ICP has never shown to be clinically significant, following diagnosis with right hepatic flexure colon cancer, which was detected by colonoscopy, due to abdominal pain moreover, ICP monitoring likely outweighs the risk of adverse events [1]. Other concerns include the development of severe thor- and recent change in bowel habits. Medical history included diagnosis with hydrocephalus 18 years earlier. He received a VP acic subcutaneous emphysema with compromised ventilation leading to increase in ICP. There is ongoing controversy regarding shunt that was routed subcutaneously, through the right thor- acic region into the abdominal cavity, at the epigastric region. the safety of performing laparoscopic surgery with the presence of Received: May 22, 2017. Accepted: December 26, 2017 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx264/4822189 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 S. Fuad et al. The current procedure, laparoscopic right hemicolectomy important issues should be taken under careful consideration, was performed using standard 4 port technique. No clamping such as the influence of a pneumoperitoneum on iatrogenic of the catheter was done. The postoperative course was spread of cancer cells, port-site metastasis, which seem to be uneventful with no neurological deficit. The patient was dis- characteristic to laparoscopic surgery. Furthermore, pneumo- charged 6 days postoperatively. peritoneum by CO insufflation might encourage VP shunt- related subcutaneous seeding of cancer cells. Otani et al. reported a rare case of pancreatic cancer diagnosed by the Case 2 detection of skin metastases along the VP shunt catheter, as an A 78-year-old woman was referred to our colon and rectum unfortunate consequence of its presence [8]. Magtibay et al. [9] clinic following diagnosis of left colon cancer, which was also reported a very rare case, in which the VP shunt served as detected by colonoscopy, due to rectal bleeding. Medical history a conduit for the spread of malignant medulloblastoma cells to included four previous abdominal operations: appendectomy, the peritoneum. Nonetheless, the reported incidence of port- open cholecystectomy and two caesarian sections, and an site metastasis following laparoscopic colon cancer surgery is insertion of VP shunt through left thoracic region into the low. Moreover, when port-site metastasis develops, it tends to abdominal cavity. occur in patients with advanced disease, such as large and The current procedure, her fifth abdominal surgery, laparo- locally advanced tumors or Dukes’ C cancers [10]. Therefore, scopic left hemicolectomy was performed using standard 4 port laparoscopic surgery for clinical stage T4 tumors with serosal technique. Unusual dense adhesions were found. No clamping involvement, as Dukes’ C cancers should be used with caution, of the catheter was done. The postoperative course demon- especially in patients with a VP shunt, as it might encourage VP strated a slow recovery with mild wound infection treated with shunt-related skin metastases. drainage and orally antibiotics only. No neurological deficit was detected. The patient was discharged 11 days postoperatively. CONCLUSIONS Laparoscopic bowel resection for cancer, in patients with a pre- DISCUSSION existing VP shunt, could be considered a potentially safe and To our knowledge, there is only one previously published case feasible procedure. Furthermore, due to the increasing number report in the English literature of a cecal cancer patient with of patients with VP shunts, additional reports and investiga- previous history of a VP shunt that was treated by laparoscopic tions are warranted to further confirm safety of this procedure. right colon resection [2]. Herein we report an additional two cases of patients with previous insertion of a VP shunt, diagnosed with colon cancer. CONFLICT OF INTEREST STATEMENT Both our patients underwent successful laparoscopic hemico- None declared. lectomies, without clamping or removal of the VP shunt, with no reported perioperative complications or postoperative neurological deficits. Our decision to leave the VP shunt in REFERENCES place was in contrast to the aforementioned case report, which involved manipulating and clamping of the shunt prior to 1. Jackman SV, Weingart JD, Kinsman SL, Docimo SG. insufflation of carbon dioxide, to prevent adverse effects from the Laparoscopic surgery in patients with ventriculoperitoneal pneumoperitoneum. shunts: safety and monitoring. J Urol 2000;164:1352–4. Barina et al. was the first to report on the clinical course, in 2. Torigoe T, Koui S, Uehara T, Arase K, Nakayama Y, adults with VP shunts in place, during open appendectomy for Yamaguchi K. Laparoscopic cecal cancer resection in a appendicitis. Similar to our report, they also demonstrated, in patient with a ventriculoperitoneal shunt: a case report. Int general, no shunt-related complications, such as malfunction J Surg Case Rep 2013;4:330–3. or infection [3]. Wadhwa et al. [4] were the first to report a retro- 3. Barina AR, Virgo KS, Mushi E, Bahadursingh AM, Johnson spective review of curative-intent open surgery for gastrointes- FE. Appendectomy for appendicitis in patients with a prior tinal cancers in adult patients with VP shunts. In this study the ventriculoperitoneal shunt. J Surg Res 2007;141:40–4. authors demonstrated that the presence of VP shunt did not 4. Wadhwa S, Hanna GK, Barina AR, Audisio RA, Virgo KS, increase the risk of postoperative complications, such as Johnson FE. Gastrointestinal cancer surgery in patients with increased ICP, pneumocephalus and infectious meningitis. a prior ventriculoperitoneal shunt: the department of veter- They did recommend intraoperative isolation of the shunt away ans affairs experience. Gastrointest Cancer Res 2012;5:125–9. from the operative field to prevent contamination. 5. Kerwat RM, Murali Krishnan VP, Appadurai IR, Rees BI. Kerwat et al. [5] showed that performing laparoscopic chole- Laparoscopic cholecystectomy in the presence of a lumbo- cystectomy, with no externalization of the shunt catheter, to be peritoneal shunt. J Laparoendosc Adv Surg Tech A 2001;11: a safe procedure. Furthermore, Jakman et al. [1] found no clinic- 37–9. ally significant increase in ICP, in patients with VP shunts, with 6. Fraser JD, Aguayo P, Sharp SW, Holcomb IG, Ostlie DJ St, insufflations pressure of 16 mmHg and average of 3 h operative Peter SD. The safety of laparoscopy in pediatric patients time. Moreover, other studies demonstrated no increase in air with ventriculoperitoneal shunts. J Laparoendosc Adv Surg embolism, shunt infectious and retrograde failure of the valve Tech A 2009;19:675–8. system [6], although conversion to open surgery was reported 7. Allam E, Patel A, Lewis G, Mushi E, Audisio RA, Virgo KS, to be higher with the presence of a VP shunt, mostly due to et al. Cholecystectomy in patients with prior ventriculoperi- dense adhesions [7]. toneal shunts. Am J Surg 2011;201:503–7. Nonetheless there is controversy regarding safety of per- 8. Nawashiro H, Otani N, Katoh H, Ohnuki A, Ogata S, Shima forming laparoscopic surgery with the presence of VP shunts, K. Subcutaneous seeding of pancreatic carcinoma along a especially in patients treated for cancer disease. Thus, some VP shunt catheter. Lancet Oncol 2002;3:683. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx264/4822189 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Laparoscopic bowel resections in patients with VP shunts 3 9. Magtibay PM, Friedman JA, Rao RD, Buckner JC, Cliby WA. 10. Jayne DG, Guillou PJ, Thorpe H, Quirke P, Copeland J, Unusual presentation of adult metastatic peritoneal Smith AM, et al. Randomized trial of laparoscopic- medulloblastoma associated with a ventriculoperitoneal assisted resection of colorectal carcinoma: 3-year results shunt: a case study and review of the literature. Neuro Oncol of the UK MRC CLASICC Trial Group. J Clin Oncol 2007;25: 2003;5:217–20. 3061–8. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx264/4822189 by Ed 'DeepDyve' Gillespie user on 16 March 2018

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Journal of Surgical Case ReportsOxford University Press

Published: Jan 1, 2018

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