Journal of Indian Association of Pediatric Surgeons
Journal of Indian Association of Pediatric Surgeons
                                                   Official journal of the Indian Association of Pediatric Surgeons                           
Year : 2017  |  Volume : 22  |  Issue : 3  |  Page : 155--157

Pediatric ventriculoperitoneal shunts and their complications: An analysis


Nitin Agarwal1, Ram Mohan Shukla1, Deepika Agarwal2, Kaustubh Gupta3, Rohtash Luthra3, Jalaj Gupta3, Sunny Jain3,  
1 Department of Pediatric Surgery, R.D. Gardi Medical College, Ujjain, Madhya Pradesh, India
2 Department of Anesthesiology, R.D. Gardi Medical College, Ujjain, Madhya Pradesh, India
3 Department of Surgery, R.D. Gardi Medical College, Ujjain, Madhya Pradesh, India

Correspondence Address:
Kaustubh Gupta
R-5 G.S.V.M Medical College Campus, Kanpur - 208 002, Uttar Pradesh
India

Abstract

Introduction: Ventriculoperitoneal (VP) shunt is the most commonly utilized shunting procedure because of the capacity of the peritoneum to resorb fluid. Initial and subsequent peritoneal catheter placements can be done with relative ease. They are associated with a variety of complications. Materials and Methods: The total number of patients operated in the study period was 96. We studied 41 operated patients of VP shunt who had various shunt-related complications and analyzed the predisposing risk factors and spectrum of complications. Results: The mean age was 28 ± 32 months out of which 28 were males and 13 females. The etiology of hydrocephalus was aqueductal stenosis in 18, Arnold Chiari malformation in 10, Dandy–Walker malformation in 2, postmeningitis in 8 (pyogenic in 5 and tubercular in 3), postintraventricular hemorrhage in 2 patients and postencephalocele surgery in 1. Conclusion: With this retrospective review of complications of VP shunts, age at initial shunt insertion and the interval between the age of initial shunt placement and onset of complications were the most important patient-related predictors of shunt failure. The different predominant etiological factors responsible for early and late shunt failure were infective and mechanical complications, respectively.



How to cite this article:
Agarwal N, Shukla RM, Agarwal D, Gupta K, Luthra R, Gupta J, Jain S. Pediatric ventriculoperitoneal shunts and their complications: An analysis.J Indian Assoc Pediatr Surg 2017;22:155-157


How to cite this URL:
Agarwal N, Shukla RM, Agarwal D, Gupta K, Luthra R, Gupta J, Jain S. Pediatric ventriculoperitoneal shunts and their complications: An analysis. J Indian Assoc Pediatr Surg [serial online] 2017 [cited 2020 Oct 23 ];22:155-157
Available from: https://www.jiaps.com/text.asp?2017/22/3/155/207624


Full Text

 Introduction



Hydrocephalus is the final result of impaired cerebrospinal fluid (CSF) resorption or obstructed CSF flow. Ventriculoperitoneal (VP) shunt placement is a common procedure undertaken for hydrocephalus but as with all other procedures is associated with many complications.

The complications of VP shunt surgery may be broadly divided into (1) mechanical complications and (2) infective complications.

Mechanical complications include obstruction, disconnection or migration of any components of a shunt system either at the ventricular or peritoneal end.

Infective complications include shunt tract abscess, skin necrosis overlying the shunt device and most importantly ventriculitis. Other complications are seizures, subdural collection, craniosynostosis, inguinal hernia and hydrocele, ascites, pseudocyst formation, perforation of a viscus or extrusion of the shunt and intestinal volvulus and obstruction.[1] We studied 41 operated patients of VP shunt who presented with various shunt-related complications and analyzed the predisposing risk factors and spectrum of complications.

 Materials and Methods



The present study includes 41 patients of hydrocephalus in which VP shunts were placed and had complications. These patients presented to our institute between January 2006 and December 2012. The total number of patients who underwent VP shunt surgery during this period was 96.

All patients who underwent VP shunt (medium pressure Chhabra's silastic shunt) for hydrocephalus and presented with various complications due to causes other than intracranial masses were included in this study. All patients who presented with various shunt-related complications were thoroughly analyzed by clinical examination, laboratory tests, and imaging studies (plain skiagram to establish shunt location, computed tomography [CT] head and ultrasonography and CT abdomen).

Early and late shunt complications were defined according to the duration between the initial shunt placement and appearance of first shunt malfunction. Those occurring within 2 years were early and later than 2 years were late complications.[2]

 Results



A total of 41 patients who had undergone VP shunt and had complications were analyzed. The mean age was 28 ± 32 months, 28 were males and 13 were females. The etiology of hydrocephalus has been enumerated in [Table 1].{Table 1}

Forty-one of the 96 patients (42.71%) suffered from complications. Among 41 patients, 35 had single complication and the rest had more than one complication.

Two patients had convulsions; two had CSF leak from an abdominal wound, one had extrusion of shunt through umbilicus, one had scrotal swelling, and five had erythema and abscess formation along the shunt tract. In the two patients with wound infection, one (known case of meningitis with seizures) had skin breakdown with exposure of shunt behind the ear. After failure of secondary suturing in this patient, a rotational flap was done but this also failed, and revision of shunt was then planned, but the patient was lost to follow-up. The other one (follow-up case of encephalocele) went into septicemia and succumbed.

Ten patients had a history of shunt revision in the past, out of which seven had undergone revision of shunt once, one had undergone revision twice, and two patients had undergone multiple shunt revisions. On examination, peritoneal end malfunction was seen in 20 whereas 12 patients had ventricular end malfunction. Some patients had both ventricular and peritoneal end malfunction.

In this study, the majority of patients who had shunt failure were re-shunted during initial 2 years of age.

Number of early and late infective complications was 12 and 3, respectively. Furthermore, numbers of early and late mechanical complications were 12 and 20, respectively. On analyzing the nature of complication with respect to shunt-complication interval, 34.14% of patients with shunt related complications presented within 6 months of shunt placement and 51.21% presented within 2 years of shunt placement. There was a reduction in complications with higher interval between shunt placements to complication.

Mean shunt complication interval in patients with infective complications was 12.84 ± 23.34 months compared to 45.61 ± 37.81 months in patients with mechanical complications.

On analyzing relation of mechanical complication to shunt–complication interval, in early shunt failure, ventricular end, and peritoneal end malfunction was identified in 29.03% and 9.67%, respectively. In late shunt failure, ventricular end, and peritoneal end malfunction was identified in 12.9% and 48.38%, respectively.

In 8 patients, i.e., 19.51% response with conservative management was noted.

Nine patients, i.e., 21.95% had complete shunt replacement on opposite side, while local repositioning was done in 19 patients, i.e., 46.34%.

Five patients underwent abdominal exploration, 1 for ileal perforation and 4 for CSF pseudocyst. Patients with CSF pseudocyst required abdominal exploration with marsupialization of cyst and replacement of shunt into generalized peritoneal cavity.

Two patients underwent shunt exteriorization followed by peritoneal end revision in one and complete shunt replacement in the other patient. The overall mortality rate in our study was four (4.17%); three were due to ventriculitis, and one went into DIC.

 Discussion



Placement of VP shunts for hydrocephalus is a well-known procedure but with its own set of complications. Shunt malfunction can occur anywhere, from hours to years after the placement of the shunt system. Overall shunt infection rate is 5%–8% in English literature.[1] In our study, it was 15.63% which is on the higher side.

The role of, age at the time of shunt insertion has been evaluated previously in several observational studies. Di Rocco et al.[2] inferred increased shunt failures in patients who had undergone shunt placement at age <6 months. Piatt and Carlson [3] had similar results in patients <2 years of age. Similar observation was made by Liptak and McDonald [4] in children <1 year of age. The present study also revealed that patient age at the time of shunt placement is an important predictor of shunt function. In our study, the majority of patients who had shunt failure were shunted during initial 2 years of age.

On the other hand, there are some studies showing no effect of age on the incidence of shunt infection.[5] In the study by Braga et al., a higher incidence of infections was observed in children older than 2 years.[6]

In our series, 33.33% were mechanical, and 15.63% were infective complications. Similar findings were seen in the study by Kinasha et al. with 32% shunt blockage and 24.6% infection, whereas, Lee et al. had 12.2% shunt blockage and 4.1% infection.[5],[7] Peacock and Currer in their study found a shunt blockage rate of 20%.[8]

In our study, 34.14% of patients with shunt related complications presented within 6 months of shunt placement and 51.21% presented within 2 years of shunt placement. On literature review, event-free survival at 1 year ranged from 62% to 80%[9],[10] and at 10 years from 35% to 48%.[9],[11]

The most common pathogen isolated in our culture sensitivity reports was staphylococcus epidermidis followed by methicillin-resistant Staphylococcus aureus as mentioned in literature.[12],[13]

The shunt related mortality was 20% in the study by Kinasha et al.[5] whereas in our series, it was 4.17%. The different studies available in English literature show a mortality rate (in nontumoral hydrocephalus) ranging from 8.6%[14] to 13.7%.[15] The figure varies as per the duration of follow-up in these studies.[14],[15] We are trying further to decrease the postoperative mortality by improving the infrastructure and other facilities available in our rural setup.

 Conclusion



This retrospective review on complications of VP shunts suggests that age at shunt placement and the interval between the age at shunt placement and onset of complications were the most important predictors of shunt failure. The different predominant etiological factors responsible for early and late shunt failure were infective and mechanical complications respectively. Superficial wound infections are efficiently managed with local wound dressings. However, in deep wound infections revision of shunt on the opposite side would be a more viable option. It is necessary to decrease the infection rate in our set up by increasing the awareness among the hospital staff for maintaining strict asepsis in hospital settings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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