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Complications of CSF Shunting in Hydrocephalus pp 187–202Cite as

Complications of Peritoneal Shunts

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Abstract

Abdominal complications related to VP shunting may present a diversity of causes and include different clinical manifestations, ranging from mild to quite severe conditions. Complications related to distal catheter migration and visceral perforation and/or extrusion, ascites, and peritoneal pseudocysts have been recognized and treated in neurosurgical practice, and all of them can be grouped and named as “nonfunctional abdominal complication of distal catheter.”

Sterile ascites is defined by CSF accumulation in the peritoneal cavity without loculation and proved negative viral and bacterial cultures and Gram stains from the ascitic fluid. It is a rare complication of VP shunts and can lead to shunt malfunction. In the majority of cases, pseudocysts develop after infection and subsequent peritonitis causes the pathological accumulation of CSF ascites inside a cyst. In sterile ascites, however, no known infective cause is found. Treatment usually consists of changing the cavity of CSF diversion from peritoneum to jugular/atrial or pleural spaces after excluding infective causes or immune responses to silicone tubing.

Pseudocysts are loculated intra-abdominal fluid collections developing around the peritoneal catheter. Although in some cases, fluid inside the cyst is sterile the majority of CSF pseudocysts are associated with shunt infections. Infected fluid requires shunt removal, external ventricular drain insertion, and antibiotics. Then, a new cavity is usually chosen for the insertion of the peritoneal catheter. Alternatives include ventriculo-jugular/atrial shunt, pleural diversion, or omental bursa.

Anal extrusion of the distal peritoneal catheter is a rare complication of VP shunts. Granulomatous reaction to a foreign body or preexisting conditions including maldevelopment of bowel anatomy could be linked to some other cases. Trauma during the operation, with unnoticed perforation of a hollow viscus should also be taken into consideration.

Other rare complications of VP shunt surgery including allergic reaction, migration, intestinal volvulus, abdominal wall perforation, or VPS-related abdominal metastases originating from brain tumors are discussed in detail and bibliography reviewed.

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References

  1. Acharya R, Ramachandran CS, Singh S (2001) Laparoscopic management of abdominal complications in ventriculoperitoneal shunt surgery. J Laparoendosc Adv Surg Tech A 11(3):167–170

    Article  CAS  PubMed  Google Scholar 

  2. Adegbite AB, Khan M (1982) Role of protein content in CSF ascites following ventriculoperitoneal shunting. Case report. J Neurosurg 57(3):423–425

    Article  CAS  PubMed  Google Scholar 

  3. Adeolu AA, Komolafe EO, Abiodun AA, Adetiloye VA (2006) Symptomatic pleural effusion without intrathoracic migration of ventriculoperitoneal shunt catheter. Childs Nerv Syst 22:186–188

    Article  CAS  PubMed  Google Scholar 

  4. Aras M, Altaş M, Serarslan Y, Akçora B, Yılmaz A (2013) Protrusion of a peritoneal catheter via abdominal wall and operated myelomeningocele area: a rare complication of ventriculoperitoneal shunt. Childs Nerv Syst 29:1199–1202

    Article  Google Scholar 

  5. Barami K, Sood S, Ham S, Canady A (1998) Chemical meningitis from bile reflux in a lumbar-gallbladder shunt. Pediatr Neurosurg 29:328–330

    Article  CAS  PubMed  Google Scholar 

  6. Barker GM, Läckgren G, Stenberg A, Arnell K (2006) Distal shunt obstruction in children with myelomeningocele after bladder perforation. J Urol 176:1726–1728

    Article  CAS  PubMed  Google Scholar 

  7. Berger MS, Baumeister B, Geyer JR, Milstein J, Kanev PM, LeRoux PD (1991) The risks of metastases from shunting in children with primary central nervous system tumors. J Neurosurg 74:872–877

    Article  CAS  PubMed  Google Scholar 

  8. Bernstein RA, Hsueh W (1985) Ventriculocholecystic shunt: a mortality report. Surg Neurol 23:31–37

    Article  CAS  PubMed  Google Scholar 

  9. Bhasin RR, Chen MK, Pincus DW (2007) Salvaging the “lost peritoneum” after ventriculoatrial shunt failures. Childs Nerv Syst 23:483–486

    Article  PubMed  Google Scholar 

  10. Boch AL, Hermelin E, Sainte-Rose C, Sgouros S (1998) Mechanical dysfunction of ventriculoperitoneal shunts caused by calcification of the silicone rubber catheter. J Neurosurg 88:975–982

    Article  CAS  PubMed  Google Scholar 

  11. Britz GW, Kim DK, Loeser JD (1996) Hydrocephalus secondary to diffuse villous hyperplasia of the choroid plexus. Case report and review of the literature. J Neurosurg 85(4):689–691

    Article  CAS  PubMed  Google Scholar 

  12. Brownlee JD, Brodkey JS, Schaefer IK (1998) Colonic perforation by ventriculoperitoneal shunt tubing: a case of suspected silicone allergy. Surg Neurol 49:21–24

    Article  CAS  PubMed  Google Scholar 

  13. Campbell AN, Chan HSL, Becker LE, Daneman A, Park TS, Hoffman HJ (1984) Extracranial metastases in childhood primary intracranial tumors. A report of 21 cases and review of the literature. Cancer 53:974–981

    Article  CAS  PubMed  Google Scholar 

  14. Casey KF, Vries JK (1989) Cerebral fluid overproduction in the absence of tumor or villous hypertrophy of the choroid plexus. Childs Nerv Syst 5(5):332–334

    Article  CAS  PubMed  Google Scholar 

  15. Chen TH, Lin MS, Kung WM, Hung KS, Chiang YH, Chen CH (2011) Combined ventriculoperitoneal shunt blockage, viscus perforation with migration into urethra, presenting with repeated UTI. Ann R Coll Surg Engl 93:151–153

    Article  Google Scholar 

  16. Chidambaram B, Balasubramaniam V (2000) CSF ascites: a rare complication of ventriculoperitoneal shunt surgery. Neurol India 48(4):378–380

    CAS  PubMed  Google Scholar 

  17. Dean D, Keller I (1972) Cerebrospinal fluid ascites: a complication of ventriculoperitoneal shunt. J Neurol Neurosurg Psychiatry 35:474–476

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  18. de Aquino HB, Carelli EF, Borges Neto AG, Pereira CU et al (2006) Nonfunctional abdominal complications of the distal catheter on the treatment of hydrocephalus: an inflammatory hypothesis? Experience with six cases. Childs Nerv Syst 22:1225–1230

    Article  PubMed  Google Scholar 

  19. De Jong L, Van Der Aa F, De Ridder D, Van Calenbergh F (2011) Extrusion of a ventriculoperitoneal shunt catheter through an appendicovesicostomy. Br J Neurosurg 25:115–116

    Article  PubMed  Google Scholar 

  20. DiLuna ML, Johnson ML, Bi WL, Chiang VL, Duncan CC (2006) Sterile ascites from a ventriculoperitoneal shunt: a case report and review of the literature. Childs Nerv Syst 22:1187–1193

    Article  PubMed  Google Scholar 

  21. Di Rocco C (1987) Complications unique to peritoneal shunts. In: The treatment of infantile hydrocephalus, vol 2. CRC Press, Boca Raton, pp 129–139

    Google Scholar 

  22. Di Rocco C, Marchese E, Velardi F (1994) A survey of the first complication of newly implanted CSF devices for the treatment of nontumoral hydrocephalus. Childs Nerv Syst 10:321–327

    Article  PubMed  Google Scholar 

  23. Dodge HW, Remine WH, Leaens MD (1957) The treatment of hydrocephalus by spinal subarachnoid-omental bursa shunt. Minn Med 40:227–230

    PubMed  Google Scholar 

  24. Dominguez CJ, Tyagi A, Hall G, Timothy J, Chumas PD (2000) Subgaleal coiling of the proximal and distal components of a ventriculo-peritoneal shunt. An unusual complication and proposed mechanism. Childs Nerv Syst 16:493–495

    Article  CAS  PubMed  Google Scholar 

  25. Eichler I (1986) Complications following implantation of ventriculo–atrial and ventriculoperitoneal shunts. Zentralbl Neurochir 47(2):161–166

    CAS  PubMed  Google Scholar 

  26. Ersahin Y, Mutluer S, Tekeli G (1996) Abdominal cerebrospinal fluid pseudocysts. Childs Nerv Syst 12:755–758

    Article  CAS  PubMed  Google Scholar 

  27. Ferreira PR, Bizzi JJ, Amantea SL (2005) Protrusion of ventriculoperitoneal shunt catheter through the anal orifice. A rare abdominal complication. J Pediatr Surg 40:1509–1510

    Article  PubMed  Google Scholar 

  28. Gattuso P, Carson HJ, Attal H, Castelli MJ (1995) Peritoneal implantation of meningeal melanosis via ventriculoperitoneal shunt: a case report and review of the literature. Diagn Cytopathol 13:257–259

    Article  CAS  PubMed  Google Scholar 

  29. Gaskill SJ, Marlin AE (1989) Pseudocysts of the abdomen associated with ventriculoperitoneal shunts: a report of twelve cases and a review of the literature. Pediatr Neurosci 15:23–27

    Article  CAS  PubMed  Google Scholar 

  30. Gaudio R, De Tommasi A, Occhiogrosso M, Vailati G (1988) Respiratory distress caused by migration of ventriculoperitoneal shunt catheter into the chest cavity: report of a case and review of the literature. Neurosurgery 23:768–769

    Article  CAS  PubMed  Google Scholar 

  31. Goldblum RM, Pyron D, Shenoy M (1998) Modulation of IgG binding to silicone by human serum albumin. FASEB J 12(Part II):5967

    Google Scholar 

  32. Grosfeld JL, Cooney DR, Smith J, Campbell RL (1974) Intra- abdominal complications following ventriculoperitoneal shunt procedures. Pediatrics 54:791–796

    CAS  PubMed  Google Scholar 

  33. Harsh GR III (1954) Peritoneal shunt for hydrocephalus: utilizing the fimbria of the fallopian tube for entrance to the peritoneal cavity. J Neurosurg 11:284–294

    Article  PubMed  Google Scholar 

  34. Hashimoto M, Yokota A, Urasaki E, Tsujigami S, Shimono M (2004) A case of abdominal CSF pseudocyst associated with silicone allergy. Childs Nerv Syst 20:761–764

    PubMed  Google Scholar 

  35. Kataria R, Sinha VD, Chopra S, Gupta A, Vyas N (2013) Urinary bladder perforation, intra-corporeal knotting, and per-urethral extrusion of ventriculoperitoneal shunt in a single patient: case report and review of literature. Childs Nerv Syst 29:693–697

    Article  PubMed  Google Scholar 

  36. Ketoff J, Klein R, Maukkassa K (1997) Ventricular cholecystic shunts in children. J Pediatr Surg 32:181–183

    Article  CAS  PubMed  Google Scholar 

  37. Khosrovi H, Kaufman HH, Hrabovsky E, Bloomfield SM, Prabhu V, el-Kadi HA (1998) Laparoscopic-assisted distal ventriculoperitoneal shunt placement. Surg Neurol 49(2):127–134 (discussion 134–125)

    Article  CAS  PubMed  Google Scholar 

  38. Kimura N, Namiki T, Wada T, Sasano N (1984) Peritoneal implantation of endodermal sinus tumor of the pineal region via a ventriculo-peritoneal shunt. Cytodiagnosis with immunocytochemical demonstration of alpha-fetoprotein. Acta Cytol 28:143–147

    CAS  PubMed  Google Scholar 

  39. Klykken PC (2005) Abdominal CSF pseudocyst. Childs Nerv Syst 21:1018–1019

    Article  PubMed  Google Scholar 

  40. Krediet RT (1999) The peritoneal membrane in chronic peritoneal dialysis. Kidney Int 55:341–356

    Article  CAS  PubMed  Google Scholar 

  41. Kubo S, Ueno M, Takimoto H, Karasawa J, Kato A, Yoshimine T (2003) Endoscopically aided retroperitoneal placement of a lumboperitoneal shunt. Technical note. J Neurosurg 98:430–433

    Article  PubMed  Google Scholar 

  42. Kurschel S, Eder HG, Schleef J (2005) CSF shunts in children: endoscopically-assisted placement of the distal catheter. Childs Nerv Syst 21(1):52–55

    Article  PubMed  Google Scholar 

  43. Longstreth GF, Buckwalter NR (2001) Sterile cerebrospinal fluid ascites and chronic peritonitis. N Engl J Med 345(4):297–298

    Article  CAS  PubMed  Google Scholar 

  44. Lourie H, Bajwa S (1985) Transdiaphragmatic migration of a ventriculo-peritoneal catheter. Neurosurgery 17:324–326

    Article  CAS  PubMed  Google Scholar 

  45. Martin LM, Donaldson-Hugh ME, Cameron MM (1997) Cerebrospinal fluid hydrothorax caused by transdiaphragmatic migration of a ventriculoperitoneal catheter through the foramen of Bochdalek. Childs Nerv Syst 13:282–284

    Article  CAS  PubMed  Google Scholar 

  46. Martinez-Lage JF, Poza M, Izura V (1993) Retrograde migration of the abdominal catheter as a complication of ventriculoperitoneal shunts: the fish hook sign. Childs Nerv Syst 9:425–427

    Article  CAS  PubMed  Google Scholar 

  47. Martinez-Lage JF, Torres J, Campillo H, Sanchez-del-Rincon I, Bueno F, Zambudio G, Poza M (2000) Ventriculopleural shunting with new technology valves. Childs Nerv Syst 16:867–871

    Article  CAS  PubMed  Google Scholar 

  48. Martínez-Lage JF, Girón O, López A, Martínez-Lage L, Roqués JL, Almagro MJ (2008) Acute cholecystitis complicating ventriculo-peritoneal shunting: report of a case and review of the literature. Childs Nerv Syst 24:777–779

    Article  PubMed  Google Scholar 

  49. Matsuoka H, Takegami T, Maruyama D, Hamasaki T, Kakita K, Mineura K (2008) Transanal prolapse of a ventriculoperitoneal shunt catheter. Neurol Med Chir (Tokyo) 48:526–528

    Article  Google Scholar 

  50. Matushita H, Cardeal D, Campos Pinto F, Pereira Plese JP, Santos de Miranda J (2008) The ventriculoomental bursa shunt. Childs Nerv Syst 24:949–953

    Article  PubMed  Google Scholar 

  51. Milton C, Sanders P, Steele P (2001) Late cardiopulmonary complication of ventriculo–atrial shunt. Lancet 358:1608

    Article  CAS  PubMed  Google Scholar 

  52. Mobley LW III, Doran SE, Hellbusch LC (2005) Abdominal pseudocyst: predisposing factors and treatment algorithm. Pediatr Neurosurg 41:77–83

    Article  PubMed  Google Scholar 

  53. Murthy KVR, Reddy SJ, Prasad DV (2009) Perforation of the distal end of the ventriculoperitoneal shunt into the bladder with calculus formation. Pediatr Neurosurg 45:53–55

    Article  Google Scholar 

  54. Newton HB, Rosenblum MK, Walker RW (1992) Extraneural metastases of infratentorial glioblastoma multiforme to the peritoneal cavity. Cancer 69:2149–2153

    Article  CAS  PubMed  Google Scholar 

  55. Novelli PM, Reigel DH (1997) A closer look at the ventriculo-gallbladder shunt for the treatment of hydrocephalus. Pediatr Neurosurg 26:197–199

    Article  CAS  PubMed  Google Scholar 

  56. Olavarria G, Reitman AJ, Goldman S, Tomita T (2005) Post-shunt ascites in infants with optic chiasmal hypothalamic astrocytoma: role of ventricular gallbladder shunt. Childs Nerv Syst 21:382–384

    Article  PubMed  Google Scholar 

  57. Oliveira RS, Barbosa A, Moraes Villela YA, Machado HR (2007) An alternative approach for management of abdominal cerebrospinal fluid pseudocysts in children. Childs Nerv Syst 23:85–90

    Article  PubMed  Google Scholar 

  58. Oshio T, Matsumura C, Kirino A (1991) Recurrent perforations of viscus due to ventriculoperitoneal shunt in a hydrocephalic child. J Pediatr Surg 26:1404–1405

    Article  CAS  PubMed  Google Scholar 

  59. Park CK, Wang KC, Seo JK, Cho BK (2000) Transoral protrusion of a peritoneal catheter: a case report and literature review. Childs Nerv Syst 16:184–189

    Article  CAS  PubMed  Google Scholar 

  60. Parry SW, Schuhmacher JF, Llewellyn RC (1975) Abdominal pseudocysts and ascites formation after ventriculoperitoneal shunt procedures. Report of four cases. J Neurosurg 43(4):476–480

    Article  CAS  PubMed  Google Scholar 

  61. Pathi R, Sage M, Slavotinek J, Hanieh A (2004) Abdominal cerebrospinal fluid pseudocyst. Australas Radiol 48:61–63

    Article  PubMed  Google Scholar 

  62. Picasa JA (1956) The posterior-peritoneal shunt technique for the treatment of internal hydrocephalus in infants. J Neurosurg 13:289–293

    Article  Google Scholar 

  63. Pohlman GD, Wilcox DT, Hankinson TC (2011) Erosive bladder perforation as a complication of ventriculoperitoneal shunt with extrusion from the urethral meatus: case report and literature review. Pediatr Neurosurg 47:223–226

    Article  PubMed  Google Scholar 

  64. Pollack IF, Hurtt M, Pang D, Albright AL (1994) Dissemination of low-grade intracranial astrocytomas in children. Cancer 73:2869–2878

    Article  CAS  PubMed  Google Scholar 

  65. Pudenz RH (1980) The surgical treatment of hydrocephalus—an historical review. Surg Neurol 15:15–26

    Article  Google Scholar 

  66. Rainov N, Schobess A, Heidecke V, Burkert W (1994) Abdominal CSF pseudocysts in patients with ventriculo–peritoneal shunts. Report of fourteen cases and review of the literature. Acta Neurochir 127:73–78

    Article  CAS  PubMed  Google Scholar 

  67. Rengachary SS (1997) Transdiaphragmatic ventriculoperitoneal shunting: technical case report. Neurosurgery 41:695–697

    CAS  PubMed  Google Scholar 

  68. Rickert CR (1998) Abdominal metastases of pediatric brain tumors via ventriculo-peritoneal shunts. Childs Nerv Syst 14:10–14

    Article  CAS  PubMed  Google Scholar 

  69. Roitberg BZ, Tomita T, McLone DG (1998) Abdominal cerebrospinal fluid pseudocyst: a complication of ventriculoperitoneal shunt in children. Pediatr Neurosurg 29:267–273

    Article  CAS  PubMed  Google Scholar 

  70. Ruggiero C, Spennato P, De Paulis D, Aliberti F, Cinalli G (2010) Intracardiac migration of the distal catheter of ventriculoperitoneal shunt: a case report. Childs Nerv Syst 26:957–962

    Article  PubMed  Google Scholar 

  71. Salomao JF, Leibinger RD (1999) Abdominal pseudocysts complicating CSF shunting in infants and children. Report of 18 cases. Pediatr Neurosurg 31:274–278

    Article  CAS  PubMed  Google Scholar 

  72. Sathyanarayana S, Wylen EL, Baskaya MK et al (2000) Spontaneous bowel perforation after ventriculoperitoneal shunt surgery: case report and a review of 45 cases. Surg Neurol 54:388–396

    Article  CAS  PubMed  Google Scholar 

  73. Shafiee S, Nejat F, Raouf SM, Mehdizadeh M, El Khashab M (2011) Coiling and migration of peritoneal catheter into the breast: a very rare complication of ventriculoperitoneal shunt. Childs Nerv Syst 27:1499–1501

    Article  PubMed  Google Scholar 

  74. Shibasaki T, Takeda F, Kawafuchi J, Suzuki Y, Yanagisawa S (1977) Extra- neural metastases of malignant brain tumors through ventriculo-peritoneal shunt. Report of two autopsy cases and review of the literature. Neurosurgery (Tokyo) 5:71–79

    CAS  Google Scholar 

  75. Shuper A, Horev G, Michovitz S, Korenreich L, Zaizov R, Cohen IJ (1997) Optic chiasm glioma, electrolyte abnormalities, nonobstructive hydrocephalus and ascites. Med Pediatr Oncol 29(1):33–35

    Article  CAS  PubMed  Google Scholar 

  76. Smith GW, Moretz WH, Pritchard WL (1958) Ventriculo-biliary shunt, a new treatment for hydrocephalus. Surg Forum 9:701–705

    CAS  PubMed  Google Scholar 

  77. Taub E, Lavyne MH (1994) Thoracic complications of ventriculoperitoneal shunts: case report and review of the literature. Neurosurgery 34:181–183

    Article  CAS  PubMed  Google Scholar 

  78. Vernet O, Campiche R, de Tribolet N (1993) Long-term results after ventriculoatrial shunting in children. Childs Nerv Syst 9(5):253–255

    Article  CAS  PubMed  Google Scholar 

  79. Wang GM, Fu SL, Ge PF, Fan WH, Li GM, Meng FK, Luo YN (2011) Use of a new type of trocar for the surgical treatment of hydrocephalus: a simple and effective technique. J Int Med Res 39(3):766–771

    Article  PubMed  Google Scholar 

  80. West K, Turner MK, Vane DW, Boaz J, Kalsbeck J, Grosfeld JL (1987) Ventricular gallbladder shunts: an alternative procedure in hydrocephalus. J Pediatr Surg 22:609–612

    Article  CAS  PubMed  Google Scholar 

  81. Wilson CB, Bertan V (1966) Perforation of the bowel complicating peritoneal shunt for hydrocephalus. Report of two cases. Am Surg 32:601–603

    CAS  PubMed  Google Scholar 

  82. Yousfi MM, Jackson NS, Abbas M et al (2003) Bowel perforation complicating ventriculoperitoneal shunt: case report and review. Gastrointest Endosc 58:144–148

    Article  PubMed  Google Scholar 

  83. Yukinaka M, Nomura M, Mitani T, Kondo Y, Tabata T, Nakaya Y et al (1998) Cerebrospinal ascites developed 3 years after ventriculoperitoneal shunting in a hydrocephalic patient. Intern Med 37(7):638–641

    Article  CAS  PubMed  Google Scholar 

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  1. Pediatric Neurosurgical Unit, Hospital Universitario 12 de Octubre, Madrid, 28041, Spain

    José Hinojosa MD

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  1. Pediatric Neurosurgery, Catholic University Medical School, Rome, Italy

    Concezio Di Rocco

  2. Department of Neurosurgery, Adnan Menderes University School of Medi, Aydin, Turkey

    Mehmet Turgut

  3. Division of Pediatric Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA

    George Jallo

  4. Regional Service of Neurosurgery and Unit of Pediatric Neurosurgery, Virgen de la Arrixaca University Hospital, Murcia, Spain

    Juan F. Martínez-Lage

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Hinojosa, J. (2015). Complications of Peritoneal Shunts. In: Di Rocco, C., Turgut, M., Jallo, G., Martínez-Lage, J. (eds) Complications of CSF Shunting in Hydrocephalus. Springer, Cham. https://doi.org/10.1007/978-3-319-09961-3_13

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