Background: Shunting of cerebrospinal fluid (CSF) has reduced the morbidity and mortality of hydrocephalus. Ventriculoperitoneal (VP) shunt is the most commonly used procedure for shunting, but it has potential complications that may need multiple surgical interventions. Methods: It is a clinical retrospective observational study that was conducted on 30 patients of both genders with different ages who presented with signs and symptoms of shunt malfunction between 2012 and 2016. A complete clinical assessment was done, a final diagnosis was made, and a treatment of individual patients was planned accordingly. Patients were followed up within 1 week and 1 month post-operatively. Data was analyzed using the SPSS (version 16.0). Results: VP shunt was inserted for 205 patients. Thirty (14.6%) patients had various forms of complications. Fifteen (50%) patients had complications related to the proximal catheter and the reservoir while 15 (50%) patients had complications related to distal catheter. The most common complications were exposure of the shunt 23.3% (13.3% exposed shunt reservoir and 10% exposed distal catheter) followed by shunt obstruction 13.3% (6.66% proximal and 6.66% distal). Twenty- eight (93.3%) patients were managed surgically, 24 (85%) patients of them showed marked improvement at the end of the first month postoperatively, while four (15%) patients needed another surgical intervention. Conclusions: Insertion of V-P shunt is routinely done by all neurosurgeons. A great care should be taken during insertion of the shunt system starting from scrubbing to avoid complications. Despite complications, the VP shunt remains the main surgical procedure used for hydrocephalus management. Keywords: Hydrocephalus, Cerebrospinal fluid shunts, Ventriculoperitoneal shunt, Ventriculoperitoneal shunt complications Background procedure, complication rates in adults are poorly estab- Hydrocephalus is an excess of cerebrospinal fluid (CSF) lished with a reported range from 17 to 33% [2, 4–10]. in the ventricular system due to the imbalance between Children demonstrated a higher rate of shunt complica- formation and absorption of CSF which is referred to (i) tions than did adults at 5 years (48 versus 27%, P < 0.0001) obstruction of the CSF pathways, (ii) over production of . The advent of endoscopic third ventriculostomy has CSF, and(iii)impairedvenousdrainage. Hydrocephalus gained popularity due to the high complication and failure is the second most common congenital brain malforma- rates of ventriculoperitoneal shunt . The major disad- tion . To date, the standard treatment of hydrocephalus vantage of VPS is the fact that it constitutes a foreign body is ventriculoperitoneal shunt. The technique of using the and prone to complications such as mechanical blockage, peritoneal cavity for CSF absorption in ventriculoperitoneal shunt infection, shunt migration, and rarely shunt protru- shunting (VPS) was developed by Kausch in 1908 . Al- sion . If a shunt system fails to be operated correctly, though VPS insertion is a common neurosurgical the patient’s life and cognitive functions are placed at risk. Thus, an urgent revision must be done . Although de- veloping countries face the problem of shunt complica- Correspondence: firstname.lastname@example.org; tions more than other countries, much research is ongoing email@example.com but still remains a common problem . Neurosurgery Department, Qena Faculty of Medicine, South Valley University, Qena, Egypt © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Hamdan Egyptian Journal of Neurosurgery (2019) 33:8 Page 2 of 8 Methods Table 1 Demographic data, clinical presentations, frequencies, and classifications of complications of ventriculoperitoneal This is a retrospective observational study that was shunts conducted at the Department of Neurosurgery, Qena Item Frequency Percentage University Hospital, South Valley University for a period of 5 years from January 2012 to December 2016. An Age groups informed signed consent was taken from the parents and Infant 22 73.3 guardians of patients before enrolling them into the study Child 6 20 after the approval of the ethical committee of the Faculty Adult 2 6.66 of Medicine, South Valley University. During the study Age (years), mean (standard deviation) 3.6 ± 6.64 period, a complete clinical assessment including a detailed Sex history and examination with a particular emphasis on neurological examination was done for all patients after Female 8 26.6 admission. A medium-pressure PS medical valve systems Male 22 73.3 were inserted for all patients. Patients with VP shunt Clinical presentations complications operated at Qena University Hospital Bulged anterior fontanelle 22 73.3 were included while patients operated before the study Sleepiness 21 70 period were excluded. The investigations performed for Frequent vomiting 20 66.7 all patients were complete blood count (CBC), erythro- cyte sedimentation rate (ESR), complete urine analysis, Enlarged head 17 56.66 X-ray chest, and brain computed tomography (CT) scan Tense anterior fontanelle 12 40 or MRI. Specific investigations such as CSF analysis, CSF Agitation and irritability 11 36.7 culture and sensitivity, blood culture and sensitivity, urine Inflammation around distal tube 9 30 culture and sensitivity, pus culture and sensitivity, ultra- Fever 6 20 sound of abdomen, shunt series X-rays, and MRI of the Headache 7 23.33 brain were also performed when indicated. A final diagno- sis was made on the basis of clinical findings, and investi- Exposure of shunt reservoir 4 13.66 gations and treatment of individual patients were planned CSF leak from distal wound 3 10 accordingly. All patients with VP shunts who had one or Swelling around reservoir 2 6.66 more complications were included in the study. Swelling around distal tube 2 6.66 Scrotal swelling 1 3.33 Statistical analysis Complications Data was recorded and analyzed using the Statistical Package of Social Sciences (SPSS) version 16. Descriptive A Related to proximal catheter and reservoir 15 50 statistics were presented as frequencies, percentages, Exposure of the reservoir 4 13.33 means, and standard deviations. Misplaced catheter 3 10 Ventriculitis 2 6.66 Results Proximal obstruction by debris 2 6.66 Two hundred and five patients for whom VP shunt CSF collection around reservoir 2 6.66 was inserted by consultant and senior neurosurgeons, thirty (14.6%) patients had complications. Both gen- CSF overdrainage (CSDH) 2 6.66 ders were included [22 (73.3%) males and 8 (26.6%) fe- B Related to distal catheter 15 50 males]. All ages were also included [22 (73.3%) infants, 6 Exposure of skin overlying the tube 3 10 (20%) children, and 2 (6.6%) adults] with a mean age (3.60 Infection around the tube 2 6.66 ± 6.64) as shown in Table 1. Clinically, 22 (73.3%) patients CSF collection around distal tube 2 6.66 presented with bulged anterior fontanelle, 21 (70%) with Fracture of the tube 2 6.66 sleepiness, 20 (66.7%) patients with frequent vomiting, 17 (56.66%) patients with enlarged head, 12 (40%) patients Extrusion through anus 2 6.66 with tense anterior fontanelle, 11 (36.7%) patients with agi- Obstruction by pseudocyst 2 6.66 tations and irritability, nine (30%) patients with inflamma- Extra peritoneal placement 2 6.66 tion around distal tube, seven (23.33%) patients with Hydrocele 1 3.33 headache, six (20%) patients with fever, four (13.66%) patients with exposure of the shunt reservoir, three (10%) patients with CSF leak from the distal wound, two (6.66%) patients with swelling around the reservoir, Hamdan Egyptian Journal of Neurosurgery (2019) 33:8 Page 3 of 8 two (6.66%) patients with swelling around distal tube, and one (3.33%) patient with scrotal swelling as shown in Fig. 1 and Table 1. The documented complications were classified ac- cording to site into two categories: (i) complications re- lated to proximal catheter and reservoir and (ii) complications related to distal catheter as presented in Table 1. Concerning proximal catheter and reservoir complications, they appeared in 15 patients. The skin erosion over the shunt reservoir was the most common complication which was documented in four (13.3%) pa- tients as shown in Fig. 2. Misplaced catheter was noted in three (10%) patients; ventriculitis was presented in two (6. 7%) patients as shown in Fig. 3. Obstruction of proximal catheter by debris was noted in two (6.7%) patients, and CSF leak making collection around the reservoir was doc- umented in two (6.7%) patients as shown in Fig. 4.Over- Fig. 2 Photograph of a 6-month-old infant showing complete ex- drainage of the ventricles may lead to unilateral or posure of the shunt reservoir bilateral chronic subdural hematoma (CSDH), and this was presented in two (6.7%) patients as shown in Fig. 5. Regarding distal catheter complications, they also oc- prominences. In our study, two (6.66%) patients were doc- curred in15 patients. Exposure of skin overlying the tube umented to have a fracture and, hence, distal tube migra- occurred in three (10%) patients (hyperemia with superfi- tion as shown in Fig. 8. Extrusion of the distal end of cial ulceration or complete exposure) as shown in Fig. 6. distal catheter through anus was also reported in two Infection around the distal catheter was reported in two (6.66%) patients as shown in Fig. 9. Two (6.66%) patients (6.7%) patients. Two (6.66%) patients showed poor peri- had a distal failure due to obstruction of the distal end of toneal absorption which leaded to distal failure and CSF the distal catheter by pseudo cyst causing closed narrow collection under the skin surrounding the distal catheter space for CSF drainage causing VP shunt malfunctioning as shown in Fig. 7. Fracture can occur at any site along as shown in Fig. 10. Other complications were noted as the course of the distal tube especially near bony extraperitoneal placement of the distal catheter and hydrocele, each of them noted in only one patient for each (3.33%). It was noted that complications tend to occur more frequently in case of proximal catheter insertion in occipital horn (posterior parietal shunt) than in frontal horn (frontal VP shunts). Such complications occurred within 26 out of 162 patients for whom occipitoparietal Fig. 3 CT brain axial view of a 16-month-old female patient showing Fig. 1 Clinical presentations of shunt complications left-sided VP shunt causing picture of ventriculitis Hamdan Egyptian Journal of Neurosurgery (2019) 33:8 Page 4 of 8 Fig. 4 Photograph of an 8-month-old infant showing CSF collection around the shunt reservoir Fig. 6 Photograph of a 16-year-old male patient showing CSF leak VP shunt was done. The remaining 43 patients for whom (white arrows) through ulceration of the skin over the distal catheter frontal VP shunt was done showed complications related of left VP shunt at the abdomen to four patients only. Thus, the incidence of complications with occipitoparietal VP shunt is 86.67 and 13.33% with the frontal type out of the total number of complications. congenital, 10 patients were post meningitic, four patients VP shunts were inserted for treatment of hydrocephalus were post subarachnoid hemorrhage, and three patients caused by any etiology such as congenital, post menin- were tumor-induced hydrocephalus. Out of 30 patients gitic, post subarachnoid hemorrhage, and tumor who had various types of VP shunt complications, 28 (93. obstructing CSF pathway. In the current study, out of 205 33%) patients complained of congenital hydrocephalus, one patients operated with VP shunt, 188 patients were (3.33%) patient complained of post meningitic Fig. 5 a Plain CT brain of an 18-month-old infant showing bilateral chronic subdural hematoma due to right-sided VP shunt overdrainage. b Plain CT brain of a 1-year-old infant showing right-sided chronic subdural hematoma due to right-sided VP shunt overdrainage Hamdan Egyptian Journal of Neurosurgery (2019) 33:8 Page 5 of 8 Fig. 7 Photograph of a 30-month-old male child showing CSF sub- Fig. 9 Photograph of a 13-month-old male infant showing extrusion cutaneous collection surrounding the distal catheter near its inser- of the distal end of the distal catheter through the anus with CSF tion at the abdomen drainage out hydrocephalus, and one (3.33%) patient complained of post conservatively while 28 (93.3%) patients were managed subarachnoid hydrocephalus. No patient who had tumor- surgically. Surgeries included proximal revision, distal induced hydrocephalus complained of shunt complications revision, debridement, redirection of misdirected catheter, (see Table 2). repositioning of the distal catheter, new VP shunt on the Patients were followed up after 1 week and 1 month other side, changing the shunt pressure to higher one postoperatively. Two (6.66%) patients were managed in case of CSDH, or closure of hernia sac as shown in Fig. 8 a Plain X-ray AP view on the skull and upper chest of a 17-year-male patient showing a fracture of distal tube of right VP shunt at the neck region (b arrow). b Plain X-rays AP view on the pelvis migrated disconnected distal catheter (c arrow) Hamdan Egyptian Journal of Neurosurgery (2019) 33:8 Page 6 of 8 Discussion Although VP shunt is an effective treatment of hydro- cephalus, it is plagued by shunt-related complications . As VP shunt is lifelong commitment, multiple surgical procedures may be required during life time . The incidence of VP shunt complications was reported by most studies to be slightly higher in males than females , which was consistent with the current study as males represent 73.3%. Among 30 patients who were operated by ventriculoperitoneal shunt, infants and children represented 93.3% whereas adults represented 6.6%. This is consistent with Abdul Munam et al. who conducted their study on 40 VP shunt complicated patients where children represented 85% . In neonates, scalp necrosis is actually a common complication associated with VP shunts which is due to the inherent skin fragility and the superficial nature of the shunt [20, 21]. In agreement with this current study scalp, necrosis was presented in four (13.3%) patients. Lee et al. found shunt blockage in 12.2% of 246 shunt procedures in Seoul, Korea, and their infection rate was 4.1%. Shunt infection was found together with blockage in most instances in their series indicating that shunt malfunction could have been caused by infection in these patients . Vanaclocha et al. observed that shunt malfunction occurred in infected shunts where some of which were clinically undetectable. Fig. 10 a CT abdomen axial view of a 13-year-old male patient showing They argued that the incidence of shunt infection might be right hypochondrial cyst (a arrow). b Abdominal ultrasonography done higher than generally reported and that negative cultures for the same patient, and right hypochondrial cyst was found (b arrow). of CSF taps did not exclude shunt infection in malfunc- c Ultrasonic-guided aspiration was done from this cyst, and the aspirate tioning shunts . Peacock and Currer found shunt was clear CSF blockage to be 20% in their series of 440 patients . Mwan’gombe and Omulo reported an infection rate of 24.6% among children operated for non-tumor hydro- Fig. 11. At the end of the first month, two (6.66%) patients cephalus in Nairobi . In the current study, shunt with infection around the distal tube were managed con- obstruction was reported in approximately 13.4% of servatively by good antiseptics and highly sensitive antibi- patients (6.7% proximal obstruction by debris and 6.7% otics according to culture and sensitivity tests showing distal obstruction by pseudo cyst). Infection was also marked improvement. Out of the 28 surgically treated reported in 13.4% of patients. Hamada and Abou Zeid patients, 24 (85%) patients showed marked improvement found that misdirection of proximal catheter was founded while four (15%) patients needed other surgical in two (7.1%) patients of their shunt malfunction series interventions. which is approximately near to the result of this current Table 2 Incidence of VP shunt complications in relation to site and etiology Site of VP shunt patients No. of VP shunt (total = 205) No. of complicated shunts (total = 30) Percentage of complicated shunts Occipitoparietal 162 26 86.67 Frontal 43 4 13.33 Etiology No. of patient’s shunts (total = 205) Complicated shunt Percentage of complicated shunts No. of patients Congenital 188 28 93.33 Post meningitic 10 1 3.33 Post S.A.H 4 1 3.33 Tumors 3 0 0 Hamdan Egyptian Journal of Neurosurgery (2019) 33:8 Page 7 of 8 study where two patients were reported with a VP shunt distal catheter per rectum without any complications in the form of obstruction or peritonitis. Previous studies reported that age and principal diagnosis (etiology) are independent contributors to the risk of initial shunt failure [32–34]. In agreement with these studies, the current study demon- stratedthatage andetiologywere significantly associated with shunt revision where 28 (93.33%) patients with VP shunt complications were congenital. Accordingly, there was a higher rate of complications related to congenital etiology. Conclusions Insertion of VP shunt is routinely done by all neurosur- geons. Great care and precautions should be taken during insertion of the shunt system starting from scrubbing to avoid complications such as infection. Implantation of VP shunt system should be done by well-qualified neurosur- Fig. 11 Photograph of a 9-month-old male infant showing hydrocele geons in order to limit or avoid shunt complications. Des- (b arrow) who was operated to close surgically the hernia sac (arrow a) pite complications, the VP shunt remains the main surgical procedure used for hydrocephalus management. study as proximal catheter misdirection was founded in three (10%) patients . Aldrich and Harmann found Abbreviations CBC: Complete blood count; CSDH: Chronic subdural hematoma; that shunt disconnection and fracture accounted for 15% CSF: Cerebrospinal fluid; CT: Computed tomography; ESR: Erythrocyte of their shunt malfunctions and that occipitally placed sedimentation rate; MRI: Magnetic resonance imaging; No: Number; shunts had a higher tendency to dislocate than frontally S.A.H: Subarachnoid hemorrhage; SPSS: Statistical Package of Social Sciences; VP: Ventriculoperitoneal; VPS: Ventriculoperitoneal shunt placed shunts . In agreement with this study, Shunt fracture was noted in 6.66% of shunt complication for oc- Acknowledgements cipitally placed shunts. Bierbauer et al. found no advantage I would like to thank Dr. Mohammed A. Abdelsamea, an assistant professor of anteriorly placed shunts over posteriorly placed shunts at Qena Faculty of Education, South Valley University, Egypt, and a postdoctoral research associate at College of Education and Human in terms of shunt malfunction or infection . However, Development, University of Minnesota, USA, for his help in editing and in the current study, there was an advantage of anteriorly proofreading the English language of the final version of the manuscript. placed VP shunts over posteriorly placed shunts in terms of malfunction and infection. It was also noted that Availability of data and materials The data and materials of this manuscript are available for sharing. complications tend to occur more with occipitoparietal than with frontal VP shunts. In more details, incidence of Author’s contributions complications with occipitoparietal VP shunt was 10.4% The data collection and the scientific writing were done by the corresponding and with frontal type was 6%. author himself. The author read and approved the final manuscript. Abdominal complications of VP shunt are not rare Ethics approval and consent to participate and the main causes of distal catheter failure are related An informed signed consent was taken from all the patients and guardians to extra peritoneal retraction of the catheter and sub- of patients before enrolling them into the study after approval of the ethical cutaneous or intra-abdominal cerebrospinal fluid (CSF) committee of the Faculty of Medicine, South Valley University. The present study has been performed in accordance with the Declaration collections . In the current study, intra-abdominal of Helsinki and after approval of Ethical Committee, Qena Faculty of pseudo cyst was reported in two (6.66%) patients and Medicine, South Valley University. extra peritoneal catheter in one (3.33%) patient. A higher incidence of unobliterated processus vaginalis Consent for publication A written consent has been obtained from every included patients and in pediatric patients than in adult patients leads to a guardians of the patients regarding publishing their details and images. higher likelihood of VP shunt distal catheter migration into the scrotum . In the current study, one infant Competing interests presented with scrotal swelling due to patent processus The author declares that he has no competing interests. vaginalis (see Fig. 11) and this is consistent with the previous study. 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Egyptian Journal of Neurosurgery
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Published: Jun 1, 2018