Viscus Perforation in Children caused by Peritoneal Shunt Catheters : Case series of 10 patients and review of literature Mohamad Bakhaidar Division of Neurological Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
Introduction Ventriculoperitoneal shunt (VPS) is a relatively common and easy procedure in neurosurgery nowadays. Despite its relatively easy installation, it may lead to few serious complications that increase mortality and morbidity.
Introduction Viscus perforation secondary to abdominal catheter of the VPS is a rare complication. Bowel perforation by a shunt catheter is estimated to be as low as 0.1 0.7%. (1,2) Other viscus as scrotum, heart, umbilicus; perforation of the abdominaperforationsl wall, vagina, uterus, bladder are even rarer with only a scattered case reports and small series in literature. 1. Janjua KJ, Ashraf AN, Sendi A (1995) Colonic perforation. Rare complication of CSF shunt. Br J Clin Pract 49:44 45 2. Park K-C, Wang C-K, Seo KJ, Cho K-B (2000) Transoral protrusion of a peritoneal catheter: a case report and literature review. Childs Nerv Syst 16:184-189
Material & methods We have retrospectively reviewed the medical records of all children (less than 14 years of age) with ventriculoperitoneal shunts treated at King Abdulaziz University Hospital and King Faisal Sepecialist Hospital, Jeddah, Saudi Arabia between july 1, 1998 to march 31, 2009. We have included all patients with a diagnosis of viscus perforation secondary to VPS.
Results We found 872 children who underwent 1500 shunt insertions and revisions in our medical records. We found 10 children, 7 females and 3 males, with a diagnosis of viscus perforation from distal end ventriculoperitoneal catheter.
Results Seven Patients had bowel perforations ( Three were extruded from anus and the other 4 without extrusion). The other three presented with a distal catheter protruding from other oragns. ( vulva, scrotum, urethra)
Results Seven Patients had bowel perforation ( Three were extruded from anus and the other 4 without extrusion). The other three presented with a distal catheter protruding from a viscus. ( vulva, scrotum, urethra)
Results Seven Patients had bowel perforation ( Three were extruded from anus and the other 4 without extrusion). The other three presented with a distal catheter protruding from a viscus. ( vulva, scrotum, urethra)
Results Seven Patients had bowel perforation ( Three were extruded from anus and the other 4 without extrusion). The other three presented with a distal catheter protruding from a viscus. ( vulva, scrotum, urethra)
Results The median age at presentation was 1.5 years. (6 months 3 years) The mean time of presentation from the last VP shunt insertion was 11.5 months ( 1 month 2.3 years)
Results No. Age/Sex Type of perforation Time of Presentation Cause of hydrocephalus Organism Outcome Final treatment 1 3 yr / F protrusion from the anus 28 months Dandy-Walker Malformation E. Coli Good Cysto-atrial shunt 2 6 months / M protrusion from the scrotum 1 month Postmeningetic hydrocephalus E. Coli & S. Aureus Good VAS 3 6 months / M protrusion from the anus 4 months Congenital hydrocephalus E. Coli Poor VAS 4 8 months/f protrusion from the urethra 3 months Congenital hydrocephalus and meningocele E.Coli Good VPS 5 2 yr /F Colon perforation 20 moths Congenital hydrocephalus and menigomyelocele E. Coli & Pseudomonas Died - 6 1 yr/ F Colon perforation 8 months Congenital hydrocephalus E. Coli Poor VPS 7 2 yr /M Colon perforation 2 months Congenital hydrocephalus E. Coli Good ETV 8 3 years/f Colon perforation 18 months Congenital hydrocephalus and menigomyelocele E. Coli Good VPS 9 2 years/f Protrusion from vulva 21 months Congenital hydrocephalus and menigomyelocele E.Coli Good VPS 10 1 yr/f protrusion from the anus 11 months Congenital hydrocephalus E.coli Good VPS
Bowel perforation Incidence is reported in literature : The incidence of intestinal perforation is reported to range between 0.1%-0.7% (1, 2) with a mortality rate as high as 15%.(2) The incidence of bowel perforation is our cases is 0.467% with a mortality rate of 14.2%. 1. Vuyyuru S, Ravuri SR, Tandra VR, Panigrahi MK. Anal extrusion of a ventriculo peritoneal shunt tube: Endoscopic removal. Journal of pediatric neurosciences. 2009;4(2):124. 2. Vinchon M, Baroncini M, Laurent T, Patrick D. Bowel perforation caused by peritoneal shunt catheters: diagnosis and treatment. Operative Neurosurgery. 2006;58(1):ONS-76-ONS-82.
Presentation Bowel perforation Almost half of the patients would present with an extrusion. (1) 42.8% of our patients presented with extrusion. Other presenting symptoms include: fever, neck rigidity, headache, decreased level of consciousness and abdominal symptoms as : pain, constipation, vomiting. Signs of meningitis and increase ICP can be seen in patients with malfunction shunt. 1. Sathyanarayana S, Wylen EL, Baskaya MK, Nanda A. Spontaneous bowel perforation after ventriculoperitoneal shunt surgery: case report and a review of 45 cases. Surgical neurology. 2000;54(5):388-96.
Presentation Scrotal/vulvar migration or perforation Most probably due to an unobliterated processus vaginalis (boys) or Canal of nuck ( Girls). Some case reports : only a scrotal swelling with symptoms and signs of malfunction.
Presentation Urethral extrusion Only a few case reports of bladder perforation and urethral extrusion. The location of the bladder extraperitoneally makes it a highly unlikely site of peritoneal catheter penetration.
Results No. Age/Sex Type of perforation Time of Presentation Cause of hydrocephalus Organism Outcome Final treatment 1 3 yr / F protrusion from the anus 28 months Dandy-Walker Malformation E. Coli Good Cysto-atrial shunt 2 6 months / M protrusion from the scrotum 1 month Postmeningetic hydrocephalus E. Coli & S. Aureus Good VAS 3 6 months / M protrusion from the anus 4 months Congenital hydrocephalus E. Coli Poor VAS 4 8 months/f protrusion from the urethra 3 months Congenital hydrocephalus and meningocele E.Coli Good VPS 5 2 yr /F Colon perforation 20 moths Congenital hydrocephalus and menigomyelocele E. Coli & Pseudomonas Died - 6 1 yr/ F Colon perforation 8 months Congenital hydrocephalus E. Coli Poor VPS 7 2 yr /M Colon perforation 2 months Congenital hydrocephalus E. Coli Good ETV 8 3 years/f Colon perforation 18 months Congenital hydrocephalus and menigomyelocele E. Coli Good VPS 9 2 years/f Protrusion from vulva 21 months Congenital hydrocephalus and menigomyelocele E.Coli Good VPS 10 1 yr/f protrusion from the anus 11 months Congenital hydrocephalus E. Coli Good VPS
Results No. Age/Sex Type of perforation Time of Presentation Cause of hydrocephalus Organism Outcome Final treatment 1 3 yr / F protrusion from the anus 28 months Dandy-Walker Malformation E. Coli Good Cysto-atrial shunt 2 6 months / M protrusion from the scrotum 1 month Postmeningetic hydrocephalus E. Coli & S. Aureus Good VAS 3 6 months / M protrusion from the anus 4 months Congenital hydrocephalus E. Coli Poor VAS 4 8 months/f protrusion from the urethra 3 months Congenital hydrocephalus and meningocele E.Coli Good VPS 5 2 yr /F Colon perforation 20 moths Congenital hydrocephalus and menigomyelocele E. Coli & Pseudomonas Died - 6 1 yr/ F Colon perforation 8 months Congenital hydrocephalus E. Coli Poor VPS 7 2 yr /M Colon perforation 2 months Congenital hydrocephalus E. Coli Good ETV 8 3 years/f Colon perforation 18 months Congenital hydrocephalus and menigomyelocele E. Coli Good VPS 9 2 years/f Protrusion from vulva 21 months Congenital hydrocephalus and menigomyelocele E.Coli Good VPS 10 1 yr/f protrusion from the anus 11 months Congenital hydrocephalus E.coli Good VPS
Discussion Pathophysiology is probably a chronic inflammatory process - Catheter attached to serosa with fibrosis fixed-point with repeated pressure may produce an ulcer with inflammation eventually perforation.
Management Externalization of shunt vs Removal of shunt with EVD on case-percase Obtain CSF samples. Distal catheter ideally should not be removed proximally. Try to pull it out if exposed or can be removed endoscopically (1). Start antibiotics covering the organisms Brown SR, Gourlay R, Battersby RDE (1996) Sigmoidoscopic neurosurgery? Treatment of an unusual complication of ventriculoperitoneal shunting. Br J Neurosurg 10:419 420
Management Bowel perforation is usually small and chronic and does not need any surgical interventions. Some authors suggest keeping patients fasting for two to three days. Small perforation usually heals faster. (1) If presented with acute abdomen: Involvement of pediatric surgery team Patients may need laparotomy if acute abdomen. 1. Brown SR, Gourlay R, Battersby RDE (1996) Sigmoidoscopic neurosurgery? Treatment of an unusual complication of ventriculoperitoneal shunting. Br J Neurosurg 10:419 420
Management Bladder perforation are also usually small and chronic. They possibly could got obliterated during contraction of the detrusor muscles. We kept a folley s catheter for 10 days to drain urine. Some authors suggest that 4-5 days is enough (1,2) 1. Prasad, V. S. S. V., A. M. Krishna, and P. K. Gupta. "Extrusion of peritoneal catheter of ventriculoperitoneal shunt through the urethra." British journal of neurosurgery 9.2 (1995): 209-210.
Management Revision of shunt should be modified case per case. Reinsertion of VP shunt can be done if controlled infection. Ventriculoarterial shunts and endoscopic third ventriculostomy are other options.
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