Journal ArticleThe placement of a ventriculoperitoneal (VP) shunt is the current treatment of choice for diversion of cerebrospinal  fluid associated with hydrocephalus. Although there are a host of reported potential abdominal complications related to the procedure, they are notably uncommon. The authors report their experience with the primary insertion of an extended length open-ended peritoneal tubing (120 cm) undertaken expressly to avoid the need for a lengthening procedure because of growth of the patient. In a review of new insertions of VP shunts using the extended length tubing over a 14-year period at Childrens Hospital of Los Angeles, a total of 998 shunts were placed in 952 patients, with a mean follow-up period of 6.7 years. The patients experienced a total of 52 distal shunt revisions for a variety of malfunction  etiologies. In patients ranging in age from premature neonate to 20 years, there was no increase in the distal  complication rate, and specifically no complications were experienced that were directly related to the use of the  extended length tubing. The authors conclude that the use of an extended length peritoneal shunt catheter is not associated with an increase in complications and eliminates the need to lengthen the peritoneal catheter for growth of the patient

Couldwell, William T.

LeMay, Daniel R.

English

The University of Utah: J. Willard Marriott Digital Library

ENTRICULOPERITONEAL (VP) shunting has becomethe standard method for cerebrospinal fluid (CSF)diversion in the management of hydrocephalus.Since the introduction of relatively inert silicone elasto-meres for the distal catheter, many of the initial reac-tive fibrotic problems of early peritoneal catheters havebeen alleviated.10,11 A litany of additional potential prob-lems associated with placement of a peritoneal catheterhave been well documented in the literature and theseinclude catheter obstruction, various manifestation of in-fection,13,24,27,28 pseudocyst formation,4,7,18 bowel and blad-der perforation,1,17 volvulus,25 abdominal wall penetra-tion,6 diaphragm transmigration,15 scrotal extrusion,20,21umbilical fistula,3 and increased incidence of inguinalhernia.16 For 20 years at the Childrens Hospital of LosAngeles an extended length of peritoneal tubing has beenused during the insertion of VP shunts in children of allages including premature neonates. We report our experi-ence with the use of this extended tubing over a 14-yearperiod at the Childrens Hospital.Clinical Material and MethodsA retrospective review was performed of patients whounderwent insertion of a new, complete VP shunt at ourinstitution in the 14-year period between January 1979and February 1993. All patients treated during this time,regardless of age, were equipped with a standard Holter–Hausner ventricular catheter reservoir, with or withoutan accompanying valve, and a one-piece extended (120cm) length of open-ended peritoneal tubing. All patientsreceived intraoperative antibiotic drugs (15 mg/kg vanco-mycin to a maximum of 500 mg intravenously and 4mg genamicin intrathecally) at the time of shunt inser-tion. Additionally, three postoperative doses of van-comycin were administered intravenously. Only those pa-tients receiving follow-up care over time at our institution,where subsequent shunt revisions were recorded and per-formed, were included in the present analysis.ResultsOver the 14-year inclusive period from January 1979 toFebruary 1993, 952 patients underwent a total of 998 newcomplete shunt insertions. The number of shunts exceed-ed the total number of patients because 20 patients under-went two and two patients underwent three separatenew shunt insertions resulting in simultaneous indwellingshunts. The series was comprised of 531 male and 421female patients with a mean age of 3.4 years (range pre-mature neonate to 20 years). The mean follow-up durationfor the series was 6.7 years. There were 92 infections in 81patients.There were a total of 888 proximal shunt revisions per-formed in 350 patients (mean 0.89 revisions/shunt inser-tion, range one–28 revisions) for failure of the proximalJ. Neurosurg. / Volume 85 / September, 1996J Neurosurg 85:425–427, 1996Experience with use of extended length peritonealshunt cathetersWILLIAM T. COULDWELL, M.D., PH.D., DANIEL R. LEMAY, M.D., PH.D.,AND J. GORDON MCCOMB, M.D.The Division of Neurological Surgery, Childrens Hospital of Los Angeles, University of SouthernCalifornia School of Medicine, Los Angeles, CaliforniaU The placement of a ventriculoperitoneal (VP) shunt is the current treatment of choice for diversion of cerebrospinalfluid associated with hydrocephalus. Although there are a host of reported potential abdominal complications relatedto the procedure, they are notably uncommon. The authors report their experience with the primary insertion of anextended length open-ended peritoneal tubing (120 cm) undertaken expressly to avoid the need for a lengthening pro-cedure because of growth of the patient. In a review of new insertions of VP shunts using the extended length tubingover a 14-year period at Childrens Hospital of Los Angeles, a total of 998 shunts were placed in 952 patients, with amean follow-up period of 6.7 years. The patients experienced a total of 52 distal shunt revisions for a variety of mal-function etiologies. In patients ranging in age from premature neonate to 20 years, there was no increase in the distalcomplication rate, and specifically no complications were experienced that were directly related to the use of theextended length tubing. The authors conclude that the use of an extended length peritoneal shunt catheter is not asso-ciated with an increase in complications and eliminates the need to lengthen the peritoneal catheter for growth of thepatient.KEY WORDS • ventriculoperitoneal shunt • obstruction • distal revision •extended length tubing • shunt malfunctionV425shunt system. Failure was defined as obstruction of theventricular catheter, proximal valve failure, or disconnec-tion at these sites.In comparison, 52 distal revisions were performed in 44patients (mean 0.052 revisions/insertion, range one–fourrevisions) for reasons of obstruction, fracture, infection ofthe distal tubing, or associated diverse peritoneal patholo-gy and comprised the focus for this review (Table 1). DiscussionSince the early 1970s, the use of the VP shunt has elim-inated cardiovascular, pulmonary, and renal complicationsassociated with ventriculoatrial shunt devices,9 and thisprocedure has been established as the method of choicefor CSF diversion in infancy.2,14 Mechanical malfunctionand infection are the most significant problems associatedwith shunting devices.22,26 Although there are fewerreports on the pathogenesis of peritoneal catheter failureas compared to proximal malfunction,5,12 nonetheless sev-eral well-recognized complications associated with thedistal peritoneal tube have been described.Low-grade shunt infection is an important determinantof shunt malfunction and may occur without evidenceof clinical sepsis.8 Peritoneal obstruction may also occurwith low-grade infection, and pathological studies havedemonstrated granulomatous inflammation of foreignbodies in this location.26 In addition, embolization ofchoroid plexus and leptomeninges may precipitate peri-toneal obstruction. Cellular invasion of the lumen or athin veil of tissue may also produce obstruction. Perfor-ation of the bowel is a well-recognized complication ofVP shunting.23,29 Most of the cases reported in the litera-ture are secondary to the use of a Raimondi peritonealcatheter, especially with fracture leading to exposure of afree wire end.19 Aberrant catheter migration into a varietyof abdominal viscera, the abdominal wall, or diaphragmmay occur.Extended length tubing inserted in young children orpremature neonates appears to be extremely well tolerat-ed. Patients undergoing follow-up evaluation throughouttheir major growth period have noted no problems withthe tubing, which gradually uncoils as length is required.The primary insertion has offered little difficulty withplacement of the additional tubing in the peritoneum; thetube is coiled in large loops (Fig. 1 left). The 120 cm ofperitoneal tubing inserted in the patients in the presentseries is more than ample length for the adult, therebyavoiding the need for a subsequent lengthening proceduredue to patient growth (Fig. 1 right). Moreover, a connec-tor is eliminated, obviating a site for disconnection whileallowing the tubing to slide freely between the peritonealcavity and the attachment to the proximally located valveas the patient grows. The redundant tubing within the ab-dominal cavity enables migration within the peritonealcavity and theoretically decreases the possibility for locu-lation and pseudocyst formation.Calcification and breakdown of the silicone elastomereswith age potentiates fragility of the catheter and thusbreakage and may prevent advancement of the tubingalong the tract as the child grows. However, tube fracturesbefell only three patients in the present series, occurringin the neck (presumably due to increased motion) afterextended periods in place (. 6 years). This complicationmay be alleviated in the future pending development ofmore durable elastomeres.Special mention should be made of the three patientsexperiencing strangulated/incarcerated viscera. Thesethree patients developed this complication only after at-tempted removal via the cephalad incision of the peri-toneal tube using traction on the catheter. This attemptresulted in fracture of the tubing, leaving an intraab-dominal segment that had become knotted around a loopof bowel or the omentum. In our experience, immediateperitoneal exploration is mandatory under these circum-stances. One child experienced protrusion of the shuntcatheter through the abdominal wall, but this was sec-ondary to an abcess that had formed at the abdominalincision.In this study there were no patients who requiredlengthening procedures of the peritoneal catheter forgrowth of the child. The above experience suggeststhat there is no increased incidence of distal shunt mal-functions specifically attributable to the extended tubinglength. The use of the open-ended peritoneal tube hasresulted in a low rate of distal obstruction (3.5% per inser-tion) and a paucity of distally related complications inW. T. Couldwell, D. R. LeMay, and J. G. McComb426 J. Neurosurg. / Volume 85 / September, 1996TABLE 1Etiologies of distal malfunctions leading to ventriculoperitonealshunt revisions in 44 childrenEtiology No. of Revisionsobstruction 35pseudocyst 6 fractured tubing 3incarcerated bowel 3disconnection 2cerebrospinal fluid ascites 2abdominal wall protrusion 1total 52  FIG. 1. Left: Abdominal radiograph demonstrating the pres-ence of an extended length catheter with the redundant shunt tub-ing coiled in the peritoneal cavity. Right: Abdominal radiographin the same patient 9 years later showing that much of the tub-ing has spontaneously migrated out of the peritoneal cavity withgrowth of the child.general. Primary placement of such tubes is a useful tech-nique in VP shunt insertion.References1. Alonso-Vanegas M, Alvarez JL, Delgado L, et al: Gastric per-foration due to ventriculo-peritoneal shunt. Pediatr Neurosurg21:192–194, 19942. Ames RH: Ventriculo-peritoneal shunts in the management ofhydrocephalus. J Neurosurg 27:525–529, 19673. Antunes ACM, Ribeiro TR: Spontaneous umbilical fistula fromventriculoperitoneal shunt drainage. Report of two cases. JNeurosurg 43:481–482, 19754. Bryant MS, Bremer AM, Tepas JJ II, et al: Abdominal compli-cations of ventriculoperitoneal shunts. Case reports and reviewof the literature. Am Surg 54:50–55, 1988 5. Davidson RI: Peritoneal bypass in the treatment of hydro-cephalus: historical review and abdominal complications. JNeurol Neurosurg Psychiatry 39:640–646, 19766. DeSousa AL, Worth RM: Extrusion of peritoneal catheterthrough abdominal incision: report of a rare complication ofventriculoperitoneal shunt. Neurosurgery 5:504–505, 19797. Fischer EG, Shillito J Jr: Large abdominal cysts: a complicationof peritoneal shunts. Report of three cases. J Neurosurg 31:441–444, 19698. Fokes EC Jr: Occult infections of ventriculoatrial shunts. JNeurosurg 33:517–523, 19709. Hammon WM: Evaluation and use of the ventriculo-peritonealshunt in hydrocephalus. J Neurosurg 34:792–795, 197110. Ingraham FD, Alexander E Jr, Matson DD: Polyethylene, a newsynthetic plastic for use in surgery. Experimental applicationsin neurosurgery. JAMA 135:82–87, 194711. Jackson IJ, Snodgrass SR: Peritoneal shunts in the treatment ofhydrocephalus and increased intracranial pressure. A 4-yearsurvey of 62 patients. J Neurosurg 12:216–222, 195512. Kast J, Duong D, Nowzari F, et al: Time-related patterns of ven-tricular shunt failure. Childs Nerv Syst 10:524–528, 199413. Keen PE, Weitzner S: Inflammatory pseudotumor of mesen-tery: a complication of ventriculoperitoneal shunt. Case report.J Neurosurg 38:371–373, 197314. Little JR, Rhoton AL Jr, Mellinger JF: Comparison of ventricu-loperitoneal and ventriculoatrial shunts for hydrocephalus inchildren. Mayo Clin Proc 47:396–401, 197215. Lourie H, Bajwa S: Transdiaphragmatic migration of a ven-triculoperitoneal catheter. Neurosurgery 17:324–326, 198516. Moazam F, Glenn JD, Kaplan BJ, et al: Inguinal hernias af-ter ventriculoperitoneal shunt procedures in pediatric patients.Surg Gynecol Obstet 159:570–572, 198417. Oi S, Shose Y, Asano N, et al: Intragastric migration of a ven-triculoperitoneal shunt catheter. Neurosurgery 21:255–257,1987 18. Parry SW, Schuhmacher JF, Llewellyn RC: Abdominal pseudo-cysts and ascites formation after ventriculoperitoneal shunt pro-cedures. Report of four cases. J Neurosurg 43:476–480, 197519. Pierce KR, Loeser JD: Perforation of the intestine by a Raimon-di peritoneal catheter. Case report. J Neurosurg 43:112–113,197520. Ram Z, Findler G, Guttman I, et al: Ventriculoperitoneal shuntmalfunction due to migration of the abdominal catheter into thescrotum. J Pediatr Surg 22:1045–1046, 198721. Ramani PS: Extrusion of abdominal catheter of ventriculoperi-toneal shunt into the scrotum. Case report. J Neurosurg 40:772–773, 197422. Robertson JS, Maraqa MI, Jennett B: Ventriculo-peritonealshunting for hydrocephalus. Br Med J 2:289–292, 197323. Rubin RC, Ghatak NR, Visudhipan P: Asymptomatic perforat-ed viscus and gram-negative ventriculitis as a complicationof valve-regulated ventriculoperitoneal shunts. Report of twocases. J Neurosurg 37:616–618, 197224. Rush DS, Walsh JW, Belin RP, et al: Ventricular sepsis and ab-dominally related complications in children with cerebrospinalfluid shunts. Surgery 97:420–427, 198525. Sakoda TH, Maxwell JA, Brackett CE Jr: Intestinal volvulussecondary to a ventriculoperitoneal shunt. Case report. J Neu-rosurg 35:95–96, 197126. Sekhar LN, Moossy J, Guthkelch AN: Malfunctioning ven-triculoperitoneal shunts. Clinical and pathological features. JNeurosurg 56:411–416, 198227. Sells CJ, Loeser JD: Peritonitis following perforation of thebowel: a rare complication of a ventriculoperitoneal shunt. JPediatr 83:823–824, 197328. Tchirkow G, Verhagen AD: Bacterial peritonitis in patientswith ventriculoperitoneal shunt. J Pediatr Surg 14:182–184,197929. Visudhipan P, Ghatak NR: Complications of ventriculo-atrialand peritoneal shunts. Report of a case with pulmonary em-bolisms and intestinal perforation. J Med Assoc Thai 54:361–367, 1971Manuscript received November 3, 1995.Accepted in final form April 15, 1996.Address reprint requests to: J. Gordon McComb, M.D., Univer-sity of Southern California, Childrens Hospital of Los Angeles,1300 North Vermont Avenue, Suite 906, Los Angeles, California90027.J. Neurosurg. / Volume 85 / September, 1996                                                                                                   Extended length peritoneal catheter427

Experience with use of extended length peritoneal shunt catheters

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Experience with use of extended length peritoneal shunt catheters

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