Previous Ventriculoperitoneal Shunt Research Articles

Successful laparoscopic cholecystectomy in a patient with ventriculoperitoneal shunt: a case report

With advances in medical care there is a significant increase in life expectancy of patients with hydrocephalus. Many patients survive and live a meaningful life even after a decade of ventriculoperitoneal (VP) shunt placement. In this scenario, there are all the chances that these patients may need abdominal surgeries for pathologies unrelated to VP shunt. Laparoscopic cholecystectomy is one of the most common abdominal surgeries being performed. In patients with VP shunt in situ, before performing laparoscopic cholecystectomy factors such as type of shunt, shunt function, presence of shunt infection and possibility of shunt malfunction needs to be assessed. Laparoscopic cholecystectomy in a patient with previous VP shunt is not a well answered question. Some authors favor this while the others disagree. With proper anesthetic management and monitoring it is safe to perform laparoscopic cholecystectomy in these patients, even though literature gives little information about it. So, this case report is our sincere effort to strengthen the available data and stabilize a ground that can we can safely perform laparoscopic cholecystectomy in patient with VP shunt.

Laparoscopic Versus Open Ventriculoperitoneal Shunt Placement: A Non-inferiority Study

Ventriculoperitoneal shunt (VPS) insertion into the abdominal cavity had been done for decades via an open approach. Recently, the laparoscopic insertion of the peritoneal portion of the shunt has become an option. The aim of this study is to compare outcomes between these two approaches. We performed a single institution retrospective review of 104 consecutive adult patients between 2015 and 2017. Patients had peritoneal catheters placed either via an open approach by the neurosurgical team, or laparoscopically by general surgeons. Patient demographics and outcomes were compared using a non-inferiority analysis. Independent variables in the analysis included patient age, gender, race, BMI, surgery performed, previous VPS placement, previous abdominal procedures, and VPS indication, while dependent variables included length of stay (LOS), estimated blood loss (EBL), occurrence of shunt failure, and postoperative complications. Cohort analysis included 62 open and 42 laparoscopic cases with similar baseline characteristics. In terms of patient outcomes, EBL and hospital stay duration were shown to be non-inferior in the open group as compared to the laparoscopic group. We could not prove non-inferiority based on risk for overall or distal shunt failure. Neurosurgeons may reasonably continue to place peritoneal shunt catheters using a “traditional” method.

Evaluation of Connecting a Fourth Ventricular Catheter with Y Connector to a Previous Ventriculoperitoneal Shunt, as a Treatment Option for Patients with Symptomatic Trapped Fourth Ventricle

Evaluation of Connecting a Fourth Ventricular Catheter with Y Connector to a Previous Ventriculoperitoneal Shunt, as a Treatment Option for Patients with Symptomatic Trapped Fourth Ventricle

Comparison of treatment modalities regarding the entity of the trapped fourth ventricle: A 20-year retrospective analysis of our clinical experience

Introduction: The entity of the trapped fourth ventricle represents a clinical challenge, as it is a rare entity associated with a wide spectrum of underlying pathologic conditions and the proposed treatment options are restricted and frequently associated with complications and unfavorable long-term outcome. The majority of the affected individuals report a medical history of previous ventriculo-peritoneal shunt infection, as well as a precipitating factor for the entrapment (central nervous system infection, intraventricular hemorrhage, trauma). They come to clinical attention due to symptomatology attributed to mass effect that is exerted by the ballooned fourth ventricle on the brainstem and cerebellum. Materials and Methods: We present our results, extracted from data derived from our medical center 20 years surgical experience and relevant outcomes in 120 pediatric patients diagnosed and managed with entrapped fourth ventricle. They were treated either with fourth ventricle-peritoneal shunt insertion or with an endoscopic approach. The relative efficacy of both techniques was recorded one year and five years after the initial operation and the data underwent statistical analysis. All patients who failed the initial therapeutic option were managed again with the aforementioned techniques, and their long-term results were recorded. Conclusions: We recorded that after one year of follow-up, there were no significant differences in outcome when these two techniques were compared. However, when the results of five-year follow-up were compared between two groups, there was superiority, regarding the functional outcome, of the procedure involving the insertion of a fourth ventricular-peritoneal shunt. The outcome of patients that underwent a salvage procedure of any type did not seem to be different after a one-year follow-up period, being unable to verify the superiority of one technique over the other. However, there seems to be a superiority of the shunt procedure over the endoscopic technique regarding the functional outcome of these patients, five years after their second operation. Nevertheless, these results are only indicative and our data are insufficient to establish a statistical level of significance, probably due to the restricted number of patients that were incorporated in our survey.

Endoscopic Third Ventriculostomy for the Treatment of Hydrocephalus in a Pediatric Population with Myelomeningocele.

Hydrocephalus develops in up to 90% of patients born with myelomeningocele. Although endoscopic third ventriculostomy (ETV) is currently considered the preferred treatment for obstructive hydrocephalus, its results have been inconsistent in patients with myelomeningocele. This study focuses on clinical and radiologic outcomes of ETV in children with hydrocephalus related to myelomeningocele. Medical records of 18 pediatric patients with myelomeningocele treated with ETV from 1998 to 2015 at the Centro Hospitalar São João (Porto, Portugal) were reviewed retrospectively. Patients' caregivers were contacted to evaluate their clinical manifestations before and after surgery regarding signs and symptoms of hydrocephalus and Chiari malformation. Control neuroradiologic imaging of 9 patients was obtained and analyzed. Success of ETV was defined by clinical resolution and radiologic confirmation. ETV was successful in 8 of 18 cases (44.4%). Groups of patients were compared according to age at the time of surgery, with a 40% (2/5) success rate in newborns and a 50% success rate (3/6) in children older than 1 year. Eight patients underwent ETV as a first option, with a 37.5% success rate. Ten patients underwent the procedure after previous ventriculoperitoneal shunt (VPS), 5 for malfunction and 5 for VPS infection with 60% and 40% success rates, respectively. Early postoperative complications occurred in 2 patients. ETV can be performed in patients with myelomeningocele and hydrocephalus with success rates of almost 50%. Prior VPS or VPS malfunction or infection do not contraindicate ETV. If possible, the procedure should be delayed until the patient is at least 1 month old.

Incidence of and Risk Factors for Pediatric Metachronous Contralateral Inguinal Hernia: Analysis of a 17-Year Nationwide Database in Taiwan.

BackgroundPrevious prospective, retrospective, and meta-analysis studies revealed that the overall incidence of metachronous contralateral inguinal hernia (MCIH) ranges from 5.76% to 7.3%, but long-term follow-up postoperative data are scant. We identified the incidence and risk factors of MCIH in pediatric patients during the follow-up using the Taiwan National Health Insurance Research Database (NHIRD).MethodsBetween 1996/01/01 and 2008/12/31, all pediatric patients with primary unilateral inguinal hernia repair who were born after 1996/01/01 were collected via ICD-9 diagnostic and procedure codes recorded in NHIRD. Patients with another operation during the same admission, complicated hernia, or laparoscopic procedure were excluded. Several reported risk factors, including age, sex, preterm birth, low body weight, and previous ventriculoperitoneal shunt placement, were used for analysis. The primary endpoint was the repairmen of MCIH following the initial surgery. All patients were followed until 2013/12/31 or withdrawal from national health insurance.ResultsA total of 31,100 pediatric patients underwent unilateral inguinal hernia repair, and 111.76 months of median follow-up data were collected. The overall rate of MCIH was 12.3%. Among the 31,100 patients who had the hernia repair, 63.6% had MCIH within 2 years and 91.5% had MCIH within 5 years. After initial surgery, the incidence of MCIH gradually and significantly decreased with age up to approximately 6 years. Multivariable analysis showed that age <4 y and girls were risk factors for subsequent MCIH.ConclusionsAfter 17 years of follow-up, the overall MCIH rate was 12.3%, and 91.7% of patients needed repair for MCIH within the first 5 years after initial surgery. Age <4 years and girls were risk factors for MCIH. The contralateral exploration for inguinal hernia should be considered among these patients.

Endoscopic re-opening of third ventriculostomy: Case series and review of literature

ObjectivesEndoscopic third ventriculostomy (ETV) emerged as an effective alternative to shunting devices in patients with obstructive hydrocephalus. When ETV fails, neurosurgeons must choose between applying a shunting device or performing a repeat ETV (re-ETV) and attempt a shunt independent outcome. In this series, clinical, surgical and follow-up data from six patients who underwent a second ETV were reviewed. Patients and methodsBetween January 2005 and June 2015, six patients underwent re-ETV, with four being children. Causes of obstructive hydrocephalus included idiopathic aqueduct stenosis, congenital aqueduct stenosis, neonatal intraventricular haemorrage, hypothalamic glioma and post-meningitis aqueductal stenosis. Success of the procedure was defined by clinical improvement and shunt independence. ResultsOverall success rate of this series was 83.3%, with re-ETV being effective in five of the six patients. The single case of re-ETV failure was observed in the pediatric population and was due to late stoma obstruction by tumoral growth, with a ventriculo-peritoneal shunt (VPS) being placed 6 months after re-ETV. In this series, no mortality and no major permanent morbidity were observed following re-ETV. ConclusionRepeat ETV is a safe and effective procedure and should be an option for treatment of recurrent obstructive hydrocephalus if stoma closure or obstruction is present. Younger age and the presence of a previous VPS should not discourage this procedure.

Endoscopic Third Ventriculostomy for Patients with Previous Ventriculoperitoneal Shunt Insertion

Background Definitive treatment of hydrocephalus has many options including treatment of the cause, choroid plexus cauterization, ventriculoperitoneal (VP) shunt insertion, and endoscopic third ventriculostomy (ETV). The last two are the most commonly used. In cases of repeated VP shunt complications, ETV is suggested as an alternative option with some doubts regarding the effect of shunt dependency.

Herniation of Meckel's diverticulum into a ventriculoperitoneal shunt tract

We report a case of a 22-month old girl who presented with a ventriculoperitoneal shunt (VPS) infection, secondary to herniation of a perforated Meckel's diverticulum through a ventral abdominal wall defect from a previous VPS revision. This is the first description of the kind in the pediatric or surgical literature.

Laparoscopic versus open insertion of the peritoneal catheter in ventriculoperitoneal shunt placement: review of 810 consecutive cases

Traditional ventriculoperitoneal (VP) shunt surgery involves insertion of the distal catheter by minilaparotomy. However, minilaparotomy may be a significant source of morbidity during shunt surgery. Laparoscopic insertion of the distal catheter is an alternative technique that may simplify and improve the safety of shunt surgery. The authors performed a retrospective review of hospital records of all patients undergoing new VP shunt insertion at a tertiary care center between 2004 and 2009. Patient characteristics and outcomes were compared between patients undergoing open or laparoscopic insertion of the distal catheter. Independent variables in the analysis included age, sex, race, body mass index, surgical technique, previous VP shunt placement, previous abdominal procedures, American Society of Anesthesiology (ASA) score, and indication for shunt placement. Dependent variables included the occurrence of shunt failure, cause of shunt failure, complications, length of stay (LOS), LOS after shunt placement, estimated blood loss, and operative time. The authors identified 810 patients who met the inclusion criteria; open or laparoscopic distal catheter insertion was performed in 335 and 475 patients, respectively. There were no significant differences between the groups regarding age, race, ASA score, or indication for shunt placement. The most common indication was hydrocephalus due to subarachnoid hemorrhage, followed by tumor-associated hydrocephalus, normal pressure hydrocephalus (NPH), and hydrocephalus due to trauma. The incidence of shunt failure was not statistically different between cohorts, occurring in 20.0% of laparoscopic and 20.9% of open catheter placement cases (p = 0.791). With analysis of causes of shunt failure, shunt obstruction occurred significantly more often in the open surgery cohort (p = 0.012). In patients with a known cause shunt obstruction, distal obstruction occurred in 35.7% of the open cohort obstructions and 4.8% of the laparoscopic cohort obstructions (p = 0.014). The relative risk of distal obstruction in open cases compared with laparoscopic cases was 7.50. Infections occurred in 8.2% of laparoscopic cases compared with 6.6% of open cases (p = 0.419). Within the NPH subgroup, the laparoscopically treated patients had significantly more overdrainage (p = 0.040), whereas those in the open cohort experienced significantly more shunt obstructions (p = 0.034). Laparoscopically treated patients had shorter operative times (p < 0.0005), inpatient LOS (p < 0.001), and inpatient LOS after VP shunt placement (p = 0.01) as well as less blood loss (p = 0.058). To our knowledge this is the largest reported comparison of distal VP shunt catheter insertion techniques. Compared with minilaparotomy, the laparoscopic approach was associated with decreased time in the operating room and a decreased LOS. Moreover, laparoscopy was associated with fewer distal shunt obstructions. Laparoscopic shunt surgery is a viable alternative to traditional shunt surgery.

Radical surgery for a ventricular septal defect associated with trisomy 18

Congestive heart failure is one of the major causes of early death of patients with trisomy 18. Ventricular septal defect (VSD) is the most common heart defect in patients with trisomy 18, and closure of the VSD may elongate the lifespan of the patient. Morphological characteristics of these patients, such as thoracic deformity, prominent right ventricular hypertrophy, and dysplastic tricuspid valve may complicate closure of the VSD. We report our initial experience of VSD closure in patients with trisomy 18 and estimate the feasibility of the surgical procedure. Between June 2005 and September 2007, five female patients with trisomy 18 and VSD underwent radical operations. Four of them had undergone previous palliative surgery entailing pulmonary artery banding. All patients survived surgery. The average cardiac arrest time during surgery was 74 +/- 22 min. No early death occurred within 30 days of surgery. One patient with hydrocephalus treated by a previous ventriculoperitoneal shunt died in hospital owing to postoperative intracranial hypertension. Four of five patients were discharged from the hospital. Of the four discharged patients, a girl who underwent primary radical operation died of pneumonia. Another patient died of sudden cardiopulmonary arrest. The average survival of the patients in this study was 815 +/- 389 days at data acquisition, with two patients still alive. Closure of VSDs in patients with trisomy 18 was found feasible and was associated with extended survival.

Laparoscopic-Assisted Placement of Ventriculo-Peritoneal Shunt Tips in Children with Multiple Previous Open Abdominal Ventriculo-Peritoneal Shunt Surgeries

Placing a ventriculo-peritoneal shunt in children with hydrocephalus is the standard of care. Many of these children will require revision of this portion of the shunt for a variety of reasons. Previously, it was thought that in a child with multiple previous ventriculo-peritoneal shunt (VPS) revisions, laparoscopy was contraindicated. This study aims to show that laparoscopy can be used safely and effectively in children with multiple previous ventriculo-peritoneal shunt surgeries. Laparoscopically assisted placement of the peritoneal portion of the ventriculo-peritoneal shunt in children with multiple previous VPS revisions was performed in 8 consecutive children (4 female) with ages ranging from 7 months to 18 years between May 2003 and September 2007. All eight children had undergone more than two previous VPS operations. All shunts were placed in areas free of adhesions and flow was observed under direct visualization. All of the procedures were successful; none needed conversion to the standard mini-laparotomy approach. No obvious or occult injury to the abdominal components was noted during hospitalization or during follow-up. Six of 8 patients required lysis of adhesions at the time of the revision. Average length of hospital stay was 2.6 days and no revisions of the abdominal portion of the VPS have been required by any of the 8 patients after laparoscopic revision. Previously unknown complications of shunt surgery were corrected in 1 of 8 children. Laparoscopic placement of the peritoneal portion of a ventriculo-peritoneal shunt can be done safely and effectively in children with multiple previous VPS revisions due to improved visualization and placement of the shunt tip in a virgin area of the abdomen. Additionally, any known or unknown complications from previous VPS surgeries can be corrected with the laparoscopic approach. When combined with the reduction in pain, shorter hospital stay, and fewer immediate and future complications, this is the procedure of choice for patients requiring revision VPS surgeries in our hospital.

Laparoscopic versus open approach for implantation of the peritoneal catheter during ventriculoperitoneal shunt placement

Ventriculoperitoneal shunt (VPS) is the mainstay of therapy for hydrocephalus. The aim of this study is to compare outcomes of laparoscopic (LVPS) versus open (OVPS) techniques for placement of distal VPS catheters. All patients undergoing new VPS placement at a tertiary care center between January 2004 and August 2007 were included. Univariate analysis was performed. Wilcoxon rank-sum, chi-square, and Fisher's exact tests were used to make comparisons between LVPS and OVPS groups. Stepwise backward logistic regression was performed to predict complications requiring operative intervention. A Kaplan-Meier estimate of the survival function was calculated for shunt survival. All data is presented as median and range unless otherwise specified. Five hundred thirty-five consecutive patients underwent 579 VPS (258 LVPS, 321 OVPS). Median age (52.0 years) and American Society of Anesthesiologists (ASA) score (3) were similar in LVPS and OVPS groups. Body mass index (BMI) [27.8 (17.0-64.9) kg/m(2) versus 25.9 (12.3-44.4) kg/m(2), p = 0.007], previous operations [0.8 +/- 0.9 versus 0.6 +/- 0.7, p = 0.004 (mean +/- standard deviation)], estimated blood loss (EBL) [20 (0-175) ml versus 25 (0-500) ml, p < 0.001], operating room (OR) time [37.5 (17.0-152.0) min versus 52.0 (20.0-197.0) min, p < 0.001], and length of stay (LOS) [11 (1-77) days versus 14 (1-225) days, p = 0.016] were statistically different between the LVPS and OVPS groups, respectively. LVPS abdominal complication rate of 5.8% and OVPS rate of 6.9% were similar (p = 0.611). Previous abdominal operation [odds ratio (OR) 1.673, 95% confidence interval (CI) 1.100-2.543, p = 0.016] and previous VPS (OR 1.929, 95% CI 1.147-3.243, p = 0.016) were significant predictors of complications requiring operative intervention. Kaplan-Meier analysis demonstrated no difference in survival between LVPS and OVPS groups (p = 0.538), with overall shunt survival of 86.4% at 6 months and 83.0% at 1 year. LVPS is associated with decreased OR time, less blood loss, and shorter LOS with no difference in complication rate when compared OVPS. The laparoscopic approach for VPS is a safe, effective, and readily reproducible alternative to the traditional open approach.

Obstetrical anesthesia for a parturient with a ventriculoperitoneal shunt and third ventriculostomy

To describe the anesthetic considerations for a primiparous woman whose history included four neurosurgeries: ventriculoperitoneal (VP) shunt insertion, evacuation of a subdural hematoma, shunt revision, and third ventriculostomy for hydrocephalus secondary to aqueductal stenosis. A 37-yr-old GI, P0 woman with a VP shunt and third ventriculostomy was assessed in the Obstetrical Anesthesia Clinic at 36 wk. gestation to consider analgesic options for labour and delivery and review anesthetic management in the event that an operative delivery was required. A third ventriculostomy had been performed when increased intracranial pressure and neurological symptoms reappeared despite the previous VP shunt. Pregnancy was uneventful and vaginal delivery was anticipated. She presented in spontaneous labour at 40 wk. gestation. She declined analgesia throughout her four and a half hour labour A mediolateral episiotomy was performed to facilitate spontaneous delivery of a 4,182 g female infant. Mother and baby were discharged home without incident after two days. She denied any problems, including headaches, on follow up at two and four weeks. A review of the literature concerning pregnant patients with shunts found that both regional and general anesthesia has been used with no reports of complications directly related to anesthesia. No published cases describing labour analgesia for patients with third ventriculostomy were found. Two neurosurgeons advised that regional anesthesia was not contraindicated in such patients and that analgesia should be based on obstetrical considerations and the neurological status of the patient.