OPERATIVE TECHNIQUE
A Novel Technique for Distal Shunt Revision: Retrospective Analysis of Guidewire-Assisted Distal Catheter Replacement BACKGROUND: Ventriculoperitoneal shunt revision is a common procedure. Disconnection and fracture of the distal catheter remain a common cause of ventriculoperitoneal shunt malfunction. OBJECTIVE: To describe a novel procedure for peritoneal replacement of the distal catheter by using a guidewire and a modified Seldinger technique (guidewire-assisted distal catheter replacement) and retrospectively evaluate the results of the surgical procedure. METHODS: Between September 2005 and December 2013, 68 patients were treated by a single surgeon (DMW) with distal catheter replacement using our technique. In brief, the previously placed distal catheter was exposed at its entry site into the abdomen. A soft guidewire with hydrophilic coating was inserted down the distal catheter into the peritoneum. The distal catheter was then removed over the guidewire, leaving the guidewire in place. A peel-away sheath and dilator were then inserted over the guidewire, and the dilator and guidewire were removed. The new distal catheter was then passed from the valve to the abdomen and was then fed through the peel-away sheath into the peritoneum. Charts were retrospectively reviewed for preoperative presentation, operative technique, and postoperative outcome. Records were specifically examined for any early or late complications. RESULTS: The mean patient age at surgery was 13 years. No immediate acute complications were noted. Of the 68 total patients, 45 patients had more than 6 months of follow-up. Of the 68 patients, 7 patients required another distal revision after guidewireassisted distal catheter replacement. CONCLUSION: Distal shunt malfunction due to a mechanical failure is a common reason for shunt revision. We describe a technique for guidewire-assisted distal catheter replacement.
Eric A. Sribnick, MD, PhD*‡ Frederick H. Sklar, MD§ David M. Wrubel, MD*‡ *Department of Neurosurgery, Emory University, Atlanta, Georgia; ‡Children’s Healthcare of Atlanta, Atlanta, Georgia; §University of Texas Southwestern Medical Center, Dallas, Texas Correspondence: David M. Wrubel, MD, 5455 Meridian Mark Dr, Ste 540, Atlanta, GA 30342. E-mail: [email protected] Received, November 26, 2014. Accepted, March 20, 2015. Published Online, May 1, 2015. Copyright © 2015 by the Congress of Neurological Surgeons.
KEY WORDS: Guidewire, Modified Seldinger technique, Shunt revision, Ventriculoperitoneal shunt Operative Neurosurgery 11:367–370, 2015
P
lacement and revision of ventricular shunts remains one of the most common neurosurgical procedures. A review of the Nationwide Inpatient Sample found that shunt revisions occurred almost as frequently as shunt placements in 2000 because of shunt malfunctions and infections.1 In the United States, shunt placement, removal, or revision ranked 10th among procedures with the highest readmission rates.2 Distal ventriculoperitoneal shunt (VPS) complications are the cause of failure in approximately ABBREVIATION: VPS, ventriculoperitoneal shunt
OPERATIVE NEUROSURGERY
DOI: 10.1227/NEU.0000000000000793
5% to 20% of shunt failures.3,4 The mechanical causes for distal malfunction can include catheter fracture, obstruction, migration, or misplacement.5 In this article, we describe a novel technique for distal VPS revision that, in appropriate patients, allows the surgeon to replace the distal catheter by using the original tract through the abdominal wall. The previously placed distal catheter is exposed at its abdominal insertion point and replaced by using a guidewire and a modified Seldinger technique. In addition to explaining this technique in detail, we present the outcomes from 68 retrospectively analyzed patients who underwent the procedure.
VOLUME 11 | NUMBER 3 | SEPTEMBER 2015 | 367
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
SRIBNICK ET AL
METHODS Patient Selection This retrospective study was reviewed and approved by the Institutional Review Board of Children’s Healthcare of Atlanta. Between September 2005 and December 2013, 68 patients were treated by a single surgeon (DMW) with distal catheter replacement using our technique. We retrospectively examined patient records for preoperative presentation, operative technique, and postoperative outcome. Records were specifically examined for any early or late complications.
Surgical Technique Patients were selected for this technique if the tip of the distal catheter was thought to be in the peritoneum and there was a strong suspicion that shunt failure was due to a distal mechanical failure, such as a fractured distal catheter. Surgery began with incision for exposure of the shunt valve. The proximal catheter, distal catheter, and shunt valve were all assessed for function intraoperatively by the standard technique of manometry. Before distal catheter revision was performed, malfunction of the distal catheter was confirmed at the time of surgery. Next, the patient’s prior abdominal incision for peritoneal placement of the distal catheter was reopened, and the failed distal catheter was identified and pulled down from the chest wall to remove as much of the old catheter as possible (Figure A). Next, a soft 0.035-in diameter guidewire with hydrophilic coating (Terumo, Radiofocus Glidewire, Urologic wire, Straight) was inserted into the exposed end of the distal catheter and passed into the peritoneal space (Figure B). The distal catheter was then removed by passing it from the peritoneal space over the guidewire (Figure C), leaving the guidewire in place (Figure D). A 13F peel-away introducer sheath and dilator (Cook
Medical, Bloomington, Indiana) were then inserted over the guidewire (Figure E). Once the introducer sheath was in the peritoneal space, the guidewire and dilator were removed (Figure F). A new distal catheter was then connected to the valve and passed from the valve down to the abdominal incision. The abdominal portion of the distal catheter was then passed into the peritoneum through the peel-away sheath introducer (Figure G), and the peel-away sheath was removed (Figure H).
RESULTS The mean age of patients in this series was 13 years (range, 2-22 years), and the patients included 24 girls and 44 boys. Preoperative evaluation of these patients revealed the following symptoms (Table): 37 patients were noted to have headache, 21 were asymptomatic, and 17 had nausea or emesis. Of the 68 total patients, 63 underwent head computed tomography, which showed evidence of ventricular enlargement in 40 patients. A total of 62 patients received a radiographic shunt series, and a fracture of the catheter was seen in 50 patients. In 1 patient, the radiographic shunt series revealed a shortened distal catheter. Shunt valve aspiration (shunt tap) was performed in 10 patients, showing poor proximal flow in 4 patients and poor distal flow in 8 patients. The mean time for surgery was 41 minutes (range, 2270 minutes). All 68 patients underwent a distal revision with the use of the techniques noted above. Fifteen patients also required a proximal VPS revision. There were no noted intraoperative complications or immediate postoperative complications. Of
FIGURE. Steps of the procedure. A, the failed distal catheter is identified at the abdominal incision and is cut. B, a soft 0.035-in diameter guidewire with hydrophilic coating is inserted into the exposed end of the distal catheter and then the guidewire is passed into the peritoneal space. C, the failed distal catheter is then removed by passing it from the peritoneal space, over the guidewire. D, the guidewire remains in the peritoneum. E, a 13F peel-away introducer sheath and dilator are then inserted over the guidewire. F, once the introducer sheath is in the peritoneal space, the guidewire and dilator are removed. G, a new distal catheter is then passed into the peritoneum through the peel-away sheath introducer. H, the peel-away sheath is removed.
368 | VOLUME 11 | NUMBER 3 | SEPTEMBER 2015
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Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
GUIDEWIRE-ASSISTED DISTAL SHUNT REVISION
TABLE. Characteristics of Patients Noted on Preoperative Workupa Preoperative symptoms exhibited, n (%) HA Asymptomatic Nausea and/or emesis Neurological changes Decreased LOC Seizure Neck pain Head CT Total Ventricular enlargement No prior CT for comparison No interval change Shunt series Total Showed fracture Shortened catheter Appeared intact Shunt aspiration Total Poor proximal flow Poor distal flow a
37 (54) 21 (31) 17 (25) 15 (22) 8 (12) 7 (10) 4 (6) 63 40 5 18 62 50 1 11 10 4 8
CT, computed tomography; HA, headache; LOC, level of consciousness.
the 68 total patients, 45 patients had follow-up of 6 months or longer. The charts of patients in whom guidewire-assisted distal catheter replacement was performed were reviewed for any postoperative complications, particularly the need for any further distal VPS revisions. Distal VPS revisions were noted in 7 patients: 4 patients underwent revision within 1 month of surgery, 2 patients had revision within 2 years of surgery, and 1 patient had revision approximately 4 years after the original surgery. For the patients requiring distal revision within 1 month of surgery, 1 patient required distal revision to convert from a pressure-regulated diaphragm valve (Delta valve, Medtronic, Minneapolis, Minnesota) to a distal slit valve (Uni-Shunt, Codman, Raynham, Massachusetts). A second patient required revision of the proximal catheter and valve secondary to blood in the catheter and valve, and the abdominal portion of the VPS was exposed but was reimplanted after exploration. A third patient required revision of the entire VPS owing to several blockages noted at exploration. The fourth patient required VPS revision because of cranial wound dehiscence. To the best of our knowledge, the patient with wound dehiscence was the only patient to have a wound infection following revision.
DISCUSSION We report a novel method of guidewire-assisted distal catheter replacement. This technique utilizes a hydrophilic-coated
OPERATIVE NEUROSURGERY
guidewire and is a variation of the widely used modified Seldinger technique. A similar technique for gaining peritoneal access for lavage has been described previously in the general surgery literature,6 and others have described using a laparoscope to place a peritoneal catheter with the Seldinger technique.7 One potential benefit of our method is that it is less invasive than standard techniques for distal revision, because the existing entry point through the abdominal wall is utilized and need not be excessively manipulated or enlarged. This could potentially lead to less postoperative pain. In addition, because creating a new access site for the peritoneum is unnecessary, this method may reduce operative time, and prior research has shown a trend toward longer operative times correlating with increased risk for VPS infection.8 By using the Seldinger technique without a laparoscope, one may be able to reduce cost and avoid the need for a general surgeon’s assistance. As with any surgical technique, there are favorable and unfavorable conditions for its use. We believe that this technique is best utilized in cases where (1) the distal catheter is confirmed to be not functioning, or in danger of not functioning, and (2) there is a clear mechanical cause (eg, a fractured distal catheter or a distal catheter that requires lengthening). This technique should be avoided when there is suspicion that the peritoneal placement is to blame for the distal malfunction (eg, a pseudocyst is suspected, abdominal adhesions are suspected, or there is possible distal catheter misplacement). Indeed, in the 4 patients who required distal revision within 1 month of a guidewire-assisted catheter exchange, 3 showed no signs of a mechanical cause of distal catheter malfunction (ie, they had no abnormalities noted on preoperative radiographic shunt series). Finally, this technique requires that the peritoneal catheter to be revised have an open end so that the guidewire can pass beyond the distal tip. For peritoneal catheters with a closed end (eg, catheters with a distal slit valve), this technique would not be useful. There are limitations to the presented research. This is retrospective research; the children in this series were not chosen in a standardized fashion, so there could be selection bias; and approximately one-third of the patients were considered lost to follow-up (less than 1 year of follow-up without a distal shunt revision). Future studies examining this technique could be improved by having specific inclusion criteria and examining patients in a prospective fashion.
CONCLUSION This article described a novel surgical technique for guidewireassisted distal catheter replacement that may be a useful adjunct in selected patients. We presented a review of patients in whom we used this technique. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
VOLUME 11 | NUMBER 3 | SEPTEMBER 2015 | 369
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
SRIBNICK ET AL
REFERENCES 1. Patwardhan RV, Nanda A. Implanted ventricular shunts in the United States: the billion-dollar-a-year cost of hydrocephalus treatment. Neurosurgery. 2005;56(1): 139-144. 2. Weiss AJ, Elixhauser A, Steiner C. Readmissions to U.S. Hospitals by Procedure, 2010: Statistical Brief #154. Published April 2013. National Center for Biotechnology Information, U.S. National Library of Medicine. Available at: http://www.ncbi.nlm. nih.gov/books/NBK154387/. Accessed August 26, 2014. 3. Wu Y, Green NL, Wrensch MR, Zhao S, Gupta N. Ventriculoperitoneal shunt complications in California: 1990 to 2000. Neurosurgery. 2007;61(3): 557-562. 4. Borgbjerg BM, Gjerris F, Albeck MJ, Hauerberg J, Børgesen SE. Frequency and causes of shunt revisions in different cerebrospinal fluid shunt types. Acta Neurochir (Wien). 1995;136(3-4):189-194. 5. Browd SR, Ragel BT, Gottfried ON, Kestle JR. Failure of cerebrospinal fluid shunts: part I: obstruction and mechanical failure. Pediatr Neurol. 2006;34(2): 83-92. 6. Ochsner MG, Herr D, Drucker W, Champion HR. A modified Seldinger technique for peritoneal lavage in trauma patients who are obese. Surg Gynecol Obstet. 1991;173(2):158-160. 7. Tepetes K, Tzovaras G, Paterakis K, Spyridakis M, Xautouras N, Hatzitheofilou C. One trocar laparoscopic placement of peritoneal shunt for hydrocephalus: a simplified technique. Clin Neurol Neurosurg. 2006;108(6):580-582. 8. Kontny U, Höfling B, Gutjahr P, Voth D, Schwarz M, Schmitt HJ. CSF shunt infections in children. Infection. 1993;21(2):89-92.
370 | VOLUME 11 | NUMBER 3 | SEPTEMBER 2015
COMMENT
T
his article reports the results of a retrospective analysis of a series of 68 hydrocephalus cases with malfunction of the distal shunt catheter. The authors applied a modified Seldinger technique using an urologic guide-ire system and an introducer sheath and dilator to facilitate the replacement of the abdominal catheter. As suggested by the authors, the proposed technique may be less invasive than standard techniques for distal revision because the existing entry point through the abdominal wall is used and does not have to be excessively manipulated or enlarged. This could potentially lead to less postoperative pain. In addition, this method may reduce both operative time and postoperative complications. Unfortunately, this study suffers from the drawbacks of a retrospective chart review, ie, incomplete study data sets, and lack of a control group, eg, a patient cohort with conventional peritoneal revision with open access or new access to the peritoneum. Therefore, before accepting the conclusions of the authors, this report requires confirmation by controlled clinical trials. Petra M. Klinge Providence, Rhode Island
www.operativeneurosurgery-online.com
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
A Novel Technique for Distal Shunt Revision: Retrospective Analysis of Guidewire-Assisted Distal Catheter Replacement BACKGROUND: Ventriculoperitoneal shunt revision is a common procedure. Disconnection and fracture of the distal catheter remain a common cause of ventriculoperitoneal shunt malfunction. OBJECTIVE: To describe a novel procedure for peritoneal replacement of the distal catheter by using a guidewire and a modified Seldinger technique (guidewire-assisted distal catheter replacement) and retrospectively evaluate the results of the surgical procedure. METHODS: Between September 2005 and December 2013, 68 patients were treated by a single surgeon (DMW) with distal catheter replacement using our technique. In brief, the previously placed distal catheter was exposed at its entry site into the abdomen. A soft guidewire with hydrophilic coating was inserted down the distal catheter into the peritoneum. The distal catheter was then removed over the guidewire, leaving the guidewire in place. A peel-away sheath and dilator were then inserted over the guidewire, and the dilator and guidewire were removed. The new distal catheter was then passed from the valve to the abdomen and was then fed through the peel-away sheath into the peritoneum. Charts were retrospectively reviewed for preoperative presentation, operative technique, and postoperative outcome. Records were specifically examined for any early or late complications. RESULTS: The mean patient age at surgery was 13 years. No immediate acute complications were noted. Of the 68 total patients, 45 patients had more than 6 months of follow-up. Of the 68 patients, 7 patients required another distal revision after guidewireassisted distal catheter replacement. CONCLUSION: Distal shunt malfunction due to a mechanical failure is a common reason for shunt revision. We describe a technique for guidewire-assisted distal catheter replacement.
Eric A. Sribnick, MD, PhD*‡ Frederick H. Sklar, MD§ David M. Wrubel, MD*‡ *Department of Neurosurgery, Emory University, Atlanta, Georgia; ‡Children’s Healthcare of Atlanta, Atlanta, Georgia; §University of Texas Southwestern Medical Center, Dallas, Texas Correspondence: David M. Wrubel, MD, 5455 Meridian Mark Dr, Ste 540, Atlanta, GA 30342. E-mail: [email protected] Received, November 26, 2014. Accepted, March 20, 2015. Published Online, May 1, 2015. Copyright © 2015 by the Congress of Neurological Surgeons.
KEY WORDS: Guidewire, Modified Seldinger technique, Shunt revision, Ventriculoperitoneal shunt Operative Neurosurgery 11:367–370, 2015
P
lacement and revision of ventricular shunts remains one of the most common neurosurgical procedures. A review of the Nationwide Inpatient Sample found that shunt revisions occurred almost as frequently as shunt placements in 2000 because of shunt malfunctions and infections.1 In the United States, shunt placement, removal, or revision ranked 10th among procedures with the highest readmission rates.2 Distal ventriculoperitoneal shunt (VPS) complications are the cause of failure in approximately ABBREVIATION: VPS, ventriculoperitoneal shunt
OPERATIVE NEUROSURGERY
DOI: 10.1227/NEU.0000000000000793
5% to 20% of shunt failures.3,4 The mechanical causes for distal malfunction can include catheter fracture, obstruction, migration, or misplacement.5 In this article, we describe a novel technique for distal VPS revision that, in appropriate patients, allows the surgeon to replace the distal catheter by using the original tract through the abdominal wall. The previously placed distal catheter is exposed at its abdominal insertion point and replaced by using a guidewire and a modified Seldinger technique. In addition to explaining this technique in detail, we present the outcomes from 68 retrospectively analyzed patients who underwent the procedure.
VOLUME 11 | NUMBER 3 | SEPTEMBER 2015 | 367
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
SRIBNICK ET AL
METHODS Patient Selection This retrospective study was reviewed and approved by the Institutional Review Board of Children’s Healthcare of Atlanta. Between September 2005 and December 2013, 68 patients were treated by a single surgeon (DMW) with distal catheter replacement using our technique. We retrospectively examined patient records for preoperative presentation, operative technique, and postoperative outcome. Records were specifically examined for any early or late complications.
Surgical Technique Patients were selected for this technique if the tip of the distal catheter was thought to be in the peritoneum and there was a strong suspicion that shunt failure was due to a distal mechanical failure, such as a fractured distal catheter. Surgery began with incision for exposure of the shunt valve. The proximal catheter, distal catheter, and shunt valve were all assessed for function intraoperatively by the standard technique of manometry. Before distal catheter revision was performed, malfunction of the distal catheter was confirmed at the time of surgery. Next, the patient’s prior abdominal incision for peritoneal placement of the distal catheter was reopened, and the failed distal catheter was identified and pulled down from the chest wall to remove as much of the old catheter as possible (Figure A). Next, a soft 0.035-in diameter guidewire with hydrophilic coating (Terumo, Radiofocus Glidewire, Urologic wire, Straight) was inserted into the exposed end of the distal catheter and passed into the peritoneal space (Figure B). The distal catheter was then removed by passing it from the peritoneal space over the guidewire (Figure C), leaving the guidewire in place (Figure D). A 13F peel-away introducer sheath and dilator (Cook
Medical, Bloomington, Indiana) were then inserted over the guidewire (Figure E). Once the introducer sheath was in the peritoneal space, the guidewire and dilator were removed (Figure F). A new distal catheter was then connected to the valve and passed from the valve down to the abdominal incision. The abdominal portion of the distal catheter was then passed into the peritoneum through the peel-away sheath introducer (Figure G), and the peel-away sheath was removed (Figure H).
RESULTS The mean age of patients in this series was 13 years (range, 2-22 years), and the patients included 24 girls and 44 boys. Preoperative evaluation of these patients revealed the following symptoms (Table): 37 patients were noted to have headache, 21 were asymptomatic, and 17 had nausea or emesis. Of the 68 total patients, 63 underwent head computed tomography, which showed evidence of ventricular enlargement in 40 patients. A total of 62 patients received a radiographic shunt series, and a fracture of the catheter was seen in 50 patients. In 1 patient, the radiographic shunt series revealed a shortened distal catheter. Shunt valve aspiration (shunt tap) was performed in 10 patients, showing poor proximal flow in 4 patients and poor distal flow in 8 patients. The mean time for surgery was 41 minutes (range, 2270 minutes). All 68 patients underwent a distal revision with the use of the techniques noted above. Fifteen patients also required a proximal VPS revision. There were no noted intraoperative complications or immediate postoperative complications. Of
FIGURE. Steps of the procedure. A, the failed distal catheter is identified at the abdominal incision and is cut. B, a soft 0.035-in diameter guidewire with hydrophilic coating is inserted into the exposed end of the distal catheter and then the guidewire is passed into the peritoneal space. C, the failed distal catheter is then removed by passing it from the peritoneal space, over the guidewire. D, the guidewire remains in the peritoneum. E, a 13F peel-away introducer sheath and dilator are then inserted over the guidewire. F, once the introducer sheath is in the peritoneal space, the guidewire and dilator are removed. G, a new distal catheter is then passed into the peritoneum through the peel-away sheath introducer. H, the peel-away sheath is removed.
368 | VOLUME 11 | NUMBER 3 | SEPTEMBER 2015
www.operativeneurosurgery-online.com
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
GUIDEWIRE-ASSISTED DISTAL SHUNT REVISION
TABLE. Characteristics of Patients Noted on Preoperative Workupa Preoperative symptoms exhibited, n (%) HA Asymptomatic Nausea and/or emesis Neurological changes Decreased LOC Seizure Neck pain Head CT Total Ventricular enlargement No prior CT for comparison No interval change Shunt series Total Showed fracture Shortened catheter Appeared intact Shunt aspiration Total Poor proximal flow Poor distal flow a
37 (54) 21 (31) 17 (25) 15 (22) 8 (12) 7 (10) 4 (6) 63 40 5 18 62 50 1 11 10 4 8
CT, computed tomography; HA, headache; LOC, level of consciousness.
the 68 total patients, 45 patients had follow-up of 6 months or longer. The charts of patients in whom guidewire-assisted distal catheter replacement was performed were reviewed for any postoperative complications, particularly the need for any further distal VPS revisions. Distal VPS revisions were noted in 7 patients: 4 patients underwent revision within 1 month of surgery, 2 patients had revision within 2 years of surgery, and 1 patient had revision approximately 4 years after the original surgery. For the patients requiring distal revision within 1 month of surgery, 1 patient required distal revision to convert from a pressure-regulated diaphragm valve (Delta valve, Medtronic, Minneapolis, Minnesota) to a distal slit valve (Uni-Shunt, Codman, Raynham, Massachusetts). A second patient required revision of the proximal catheter and valve secondary to blood in the catheter and valve, and the abdominal portion of the VPS was exposed but was reimplanted after exploration. A third patient required revision of the entire VPS owing to several blockages noted at exploration. The fourth patient required VPS revision because of cranial wound dehiscence. To the best of our knowledge, the patient with wound dehiscence was the only patient to have a wound infection following revision.
DISCUSSION We report a novel method of guidewire-assisted distal catheter replacement. This technique utilizes a hydrophilic-coated
OPERATIVE NEUROSURGERY
guidewire and is a variation of the widely used modified Seldinger technique. A similar technique for gaining peritoneal access for lavage has been described previously in the general surgery literature,6 and others have described using a laparoscope to place a peritoneal catheter with the Seldinger technique.7 One potential benefit of our method is that it is less invasive than standard techniques for distal revision, because the existing entry point through the abdominal wall is utilized and need not be excessively manipulated or enlarged. This could potentially lead to less postoperative pain. In addition, because creating a new access site for the peritoneum is unnecessary, this method may reduce operative time, and prior research has shown a trend toward longer operative times correlating with increased risk for VPS infection.8 By using the Seldinger technique without a laparoscope, one may be able to reduce cost and avoid the need for a general surgeon’s assistance. As with any surgical technique, there are favorable and unfavorable conditions for its use. We believe that this technique is best utilized in cases where (1) the distal catheter is confirmed to be not functioning, or in danger of not functioning, and (2) there is a clear mechanical cause (eg, a fractured distal catheter or a distal catheter that requires lengthening). This technique should be avoided when there is suspicion that the peritoneal placement is to blame for the distal malfunction (eg, a pseudocyst is suspected, abdominal adhesions are suspected, or there is possible distal catheter misplacement). Indeed, in the 4 patients who required distal revision within 1 month of a guidewire-assisted catheter exchange, 3 showed no signs of a mechanical cause of distal catheter malfunction (ie, they had no abnormalities noted on preoperative radiographic shunt series). Finally, this technique requires that the peritoneal catheter to be revised have an open end so that the guidewire can pass beyond the distal tip. For peritoneal catheters with a closed end (eg, catheters with a distal slit valve), this technique would not be useful. There are limitations to the presented research. This is retrospective research; the children in this series were not chosen in a standardized fashion, so there could be selection bias; and approximately one-third of the patients were considered lost to follow-up (less than 1 year of follow-up without a distal shunt revision). Future studies examining this technique could be improved by having specific inclusion criteria and examining patients in a prospective fashion.
CONCLUSION This article described a novel surgical technique for guidewireassisted distal catheter replacement that may be a useful adjunct in selected patients. We presented a review of patients in whom we used this technique. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
VOLUME 11 | NUMBER 3 | SEPTEMBER 2015 | 369
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
SRIBNICK ET AL
REFERENCES 1. Patwardhan RV, Nanda A. Implanted ventricular shunts in the United States: the billion-dollar-a-year cost of hydrocephalus treatment. Neurosurgery. 2005;56(1): 139-144. 2. Weiss AJ, Elixhauser A, Steiner C. Readmissions to U.S. Hospitals by Procedure, 2010: Statistical Brief #154. Published April 2013. National Center for Biotechnology Information, U.S. National Library of Medicine. Available at: http://www.ncbi.nlm. nih.gov/books/NBK154387/. Accessed August 26, 2014. 3. Wu Y, Green NL, Wrensch MR, Zhao S, Gupta N. Ventriculoperitoneal shunt complications in California: 1990 to 2000. Neurosurgery. 2007;61(3): 557-562. 4. Borgbjerg BM, Gjerris F, Albeck MJ, Hauerberg J, Børgesen SE. Frequency and causes of shunt revisions in different cerebrospinal fluid shunt types. Acta Neurochir (Wien). 1995;136(3-4):189-194. 5. Browd SR, Ragel BT, Gottfried ON, Kestle JR. Failure of cerebrospinal fluid shunts: part I: obstruction and mechanical failure. Pediatr Neurol. 2006;34(2): 83-92. 6. Ochsner MG, Herr D, Drucker W, Champion HR. A modified Seldinger technique for peritoneal lavage in trauma patients who are obese. Surg Gynecol Obstet. 1991;173(2):158-160. 7. Tepetes K, Tzovaras G, Paterakis K, Spyridakis M, Xautouras N, Hatzitheofilou C. One trocar laparoscopic placement of peritoneal shunt for hydrocephalus: a simplified technique. Clin Neurol Neurosurg. 2006;108(6):580-582. 8. Kontny U, Höfling B, Gutjahr P, Voth D, Schwarz M, Schmitt HJ. CSF shunt infections in children. Infection. 1993;21(2):89-92.
370 | VOLUME 11 | NUMBER 3 | SEPTEMBER 2015
COMMENT
T
his article reports the results of a retrospective analysis of a series of 68 hydrocephalus cases with malfunction of the distal shunt catheter. The authors applied a modified Seldinger technique using an urologic guide-ire system and an introducer sheath and dilator to facilitate the replacement of the abdominal catheter. As suggested by the authors, the proposed technique may be less invasive than standard techniques for distal revision because the existing entry point through the abdominal wall is used and does not have to be excessively manipulated or enlarged. This could potentially lead to less postoperative pain. In addition, this method may reduce both operative time and postoperative complications. Unfortunately, this study suffers from the drawbacks of a retrospective chart review, ie, incomplete study data sets, and lack of a control group, eg, a patient cohort with conventional peritoneal revision with open access or new access to the peritoneum. Therefore, before accepting the conclusions of the authors, this report requires confirmation by controlled clinical trials. Petra M. Klinge Providence, Rhode Island
www.operativeneurosurgery-online.com
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
