Recurrent Perforations of Viscus Due to Ventriculoperitoneal in a Hydrocephalic Child By T. Oshio,
C. Matsumura,
A. Kirino, M. Go, Y. Bando, Kagawa, Japan
l In this report, we describe the first case of recurrent perforations of viscus due to ventriculoperitoneal shunt for the treatment of hydrocephalus. Based on our own experience and a survey of literature, we suggest that perforation of the gastrointestinal tract should be suspected in patients with ventriculoperitoneal shunt, particularly when abdominal symptoms or ventriculitis are presented. To manage this complication, at the first perforation in the present case, a fibrin sealant was effective for closure of the perforated stomach wall. At the second perforation, when laparotomy was performed, we could not find any abnormality in the abdominal cavity except for a sheath and slight omental adhesions near it. Copyright o 1991 by W.B. Saunders Company INDEX WORDS: Hydrocephalus; ventriculitis; peritonitis.
ventriculoperitoneal
shunt;
ECURRENT perforations of the gastrointestinal tract due to ventriculoperitoneal (VP) shunt have not been reported in the literature. This article describes a patient with perforation in the stomach at 3 years of age and in the jejunum at 5, following VP shunt.
R
CASE REPORT A S-year l-month-old boy, who had a VP shunt (unishunt with Raimondi catheter) for the treatment of posttraumatic hydrocephalus when he was 1 year old, was admitted to the pediatric unit complaining of fever, abdominal pain, and vomiting. On admission, a white blood cell (WBC) count was 17,lOOimm’. His abdomen was distended with slight peritoneal irritation at the left upper quadrant. A plain abdominal x-ray film showed distension of the jejunum. He was treated successfully with nasogastric suction, intravenous fluid transfusion, and chemotherapy. Two months later, he was admitted to the neurosurgical unit with symptoms of malfunction of the VP shunt. A WBC count was 12,lOOimm’. A brain computed tomography (CT) scan showed dilatation of ventricle and subcutaneous swelling beside the catheter in his head. Staphylococcus epidennidis was cultured from blood and tap sample of the subcutaneous swelling in his head. On the plain abdominal x-ray film, the tip of the catheter was seen on the left upper abdomen, which was the same position as 2 months before. He was diagnosed as having a sepsis and ventriculitis caused by ascending infection from the tip of the catheter, which was thought to be a perforation of viscus from 2 months before. The catheter of the abdominal wall was exposed and cut. Radiographs of the abdomen, following injection into the catheter with contrast medium, showed opacification of a fibrous tract and lumen of stomach (Fig 1). Fibrin sealant was injected through the catheter From the Departments of Surgery and Neurosurgery, National Kagawa Children’s Hospital, Kagawa, Japan. Address reprint requests to T. Oshio, MD, Department of Surgery, National Kagawa Children’s Hospital, Zentsuji City, Kagawa 765, Japan. Copyright o 1991 by W.B. Saunders Company 0022-3468191/2612-0016$03.00l0 1404
Y. Manabe,
Shunt
and Y. Nakagawa
for a closure of the perforated stomach wall nonoperatively. Six days later, reinjection with contrast medium into the catheter was performed. There was no opacification of the stomach. When injection with higher pressure was done, contrast medium ejected out from the skin edge of the catheter through the fibrous sheath around the catheter. The abdominal catheter was removed and oral feeding was started. Two weeks later, a silastic abdominal catheter, which was softer than the Raimondi tube, was successfully replaced on the same side. At the age of 5 years 9 months, he was admitted to the pediatric surgical unit because of abdominal pain, fever, and vomiting. On admission, a WBC count was 14,00O/mm’. A slight distension of the abdomen and signs of peritoneal irritation were noted. A plain abdominal x-ray film showed dilatation of the small bowel. A perforation of viscus due to the VP shunt tube was strongly suspected. Shortly after admission he improved without complication; therefore, he was followed conservatively. Twenty-six days later, he was admitted to the neurosurgical unit because of severe headache that was suspected to be caused by blockage of the VP shunt system. On admission, there were no signs of peritoneal irritation. A brain CT scan showed severe dilatation of the ventricles. On plain abdominal x-ray film, the tip of the VP shunt was seen at the left side of abdominal cavity, which was the same as the position of the last admission. There was no appearance of dilatation at the small bowel. The catheter near the level of its insertion into the abdomen was exposed. When the distal catheter was pulled out several centimeters for examination, perforation of viscus due to VP shunt was suspected because the catheter was grossly contaminated with yellowish bowel contents. The perforation of small bowel was confirmed by radiograph, following injection into the catheter with contrast medium (Fig 2). Laparotomy was performed for the purpose of making clear, if possible, the cause of the recurrent perforations of viscus occurring in the VP shunt. The intraperitoneal part of the catheter was enveloped by fibrous tissue, which was only 1 cm in length from the peritoneal wall to the intestine. Despite multiple revisions of the VP shunt and recurrent perforations of viscera, there were no signs of peritonitis, scars, or remnant of the sheath of the last perforation, except for a slight omental adhesion near the sheath. The catheter was placed 15 cm normoperistalitically in the lumen of the jejunum. The part of the jejunum involving the sheath and catheter was resected and was closed in two layers. Cerebrospinal fluid from the proximal catheter was sterile, but tap samples near the catheter were cultured of Enterobacter. Twenty-one days later, revision of the VP shunt was performed. DISCUSSION
Although various types of shunting procedures have been devised for cerebrospinal fluid diversion in hydrocephalus, the VP shunt has become popular since the introduction of a peritoneal catheter with a slit-valve at its tip’ and with the development of suitable substances such as polyethylene and silicon.* The VP shunt has a lower morbidity than the ventriculoatrial shunt. But, as more patients with treated hydrocephalus survive longer, more complications, especially in the abdomen, are being encountered. JournalofPediatricSurgery,
Vol26,No12(December),1991:pp1404-1405
PERFORATIONS
OF VISCUS
Fig 1. The radiograph and lumen of stomach contrast medium.
DUE TO VP SHUNT
shows the opacification following injection into
of a fibrous the catheter
tract with
Gastrointestinal perforation due to a VP shunt is rare; 7.5 cases, including the present case, have been reported in the literature. The case of recurrent perforations of viscus has not been found except for this case. Thirty-eight patients were alive after perforation, 11 patients, including 5 cases diagnosed at autopsy,3-h had died, and the status of 26 patients was unknown. The location of the gastrointestinal perforation was noted in 29 cases. Perforation of t,he stomach has been reported in two instances. One is reported herein and the other was an adult case.3 Perforation of the duodenum was reported in one patient who was diagnosed at autopsy.’ Perforation of the small bowel was noted in five cases. Two cases, including this case, occurred at the jejunum,4 one was at the ileum,” and hvo were unknown. Perforation was found at the large bowel in 20 cases and at the rectum’ in one. The cause of perforation of viscus due to the VP shunt is uncertain, but it was thought to be as follows*: the abdominal VP shunt catheter adheres to the serosal surface of the viscus as a result of a foreign body reaction and, later, decubitus ulceration of the viscus wall occurs. The final outcome is that part of
Fig 2. The radiograph shows the opacification of the small bowel after the injection into the abdominal catheter with contrast medium.
the catheter enters the lumen of the bowel. The catheter is already encased by a fibrous tissue “sheath,” thus preventing free perforation of the bowel and no clinical signs of intraabdominal catastrophe are found on examination. In view of the high mortality rate associated with this complication, early diagnosis of bowel perforation is essential.’ Radiographs of injection of a contrast medium to the shunt system with or without fluoroscopic guidance can be readily used to diagnose viscus perforation. If the catheter would be placed inside of gastrointestinal lumen for long times, severe ventriculitis and, finally, sepsis might develop due to ascending infection from the gastrointestinal flora through the catheter and its sheath. The management of this complication, basically, should remove of the catheter from the lumen of the gastrointestinal tract. Transitory external drainage and complete replacement after a period of vigorous antibiotics administration are needed for the treatment of infection of the VP shunt system. In this case in which stomach perforation occurred, using a fibrin sealant for closure of the perforated stomach wall and continuous suction of nasogastric tube for decreasing pressure of the stomach were effective.
REFERENCES 1. Ames RH: Ventriculo-peritoneal shunts in the management of hydrocephalus. J Neurosurg 27:525-529,1967 2. Raimondi AJ, Robinson JS, Kuwamura K: Complications of ventriculo-peritoneal shunting and a clinical comparison of the three-piece and one-piece system. Child Brain 3:321-342, 1977 3. Nishijima M, Endoh S, Ohyama H, et al: Gastric perforation by a ventriculo-peritoneal shunt. Neurosurgery 10:754-756,1982 4. Rubin RC, Ghatak NR, Visudhipan P: Asymptomatic perforated viscus and gram-negative ventricuhtis as a complication of valve-regulated venticuloperitoneal shunt. Report of two cases. J Neurosurg 37:616-618, 1972 5. Sakamoto K, Kobayashi N, Sato N, et al: Rare complications
after cerebrospinal fluid peritoneal shunts. J Jpn Sot Pediatr Surg 12:137, 1976 (abstr) 6. Nitta M, Kato T, Asai A, et al: Complications after ventriculoperitoneal shunt. J Jpn Red Cross Hosp 30:83-84, 1978 7. Shitatake K, Makita Y, Kondo A, et al: A case of bowel perforation after ventriculo-peritoneal shunt. J Jpn Surg Sot 78:95, 1977 (abstr) 8. Abu-Dalu K, Pode D, Hadani M, et al: Colonic complications of ventriculo-peritoneal shunts. Neurosurgery 13:167-169, 1983 9. Azimi F, Dinn WM, Naumann RA: Intestinal perforation, an infrequent complication ofventriculo-peritoneal shunts. Radiology 121:701-702,
1976
C. Matsumura,
A. Kirino, M. Go, Y. Bando, Kagawa, Japan
l In this report, we describe the first case of recurrent perforations of viscus due to ventriculoperitoneal shunt for the treatment of hydrocephalus. Based on our own experience and a survey of literature, we suggest that perforation of the gastrointestinal tract should be suspected in patients with ventriculoperitoneal shunt, particularly when abdominal symptoms or ventriculitis are presented. To manage this complication, at the first perforation in the present case, a fibrin sealant was effective for closure of the perforated stomach wall. At the second perforation, when laparotomy was performed, we could not find any abnormality in the abdominal cavity except for a sheath and slight omental adhesions near it. Copyright o 1991 by W.B. Saunders Company INDEX WORDS: Hydrocephalus; ventriculitis; peritonitis.
ventriculoperitoneal
shunt;
ECURRENT perforations of the gastrointestinal tract due to ventriculoperitoneal (VP) shunt have not been reported in the literature. This article describes a patient with perforation in the stomach at 3 years of age and in the jejunum at 5, following VP shunt.
R
CASE REPORT A S-year l-month-old boy, who had a VP shunt (unishunt with Raimondi catheter) for the treatment of posttraumatic hydrocephalus when he was 1 year old, was admitted to the pediatric unit complaining of fever, abdominal pain, and vomiting. On admission, a white blood cell (WBC) count was 17,lOOimm’. His abdomen was distended with slight peritoneal irritation at the left upper quadrant. A plain abdominal x-ray film showed distension of the jejunum. He was treated successfully with nasogastric suction, intravenous fluid transfusion, and chemotherapy. Two months later, he was admitted to the neurosurgical unit with symptoms of malfunction of the VP shunt. A WBC count was 12,lOOimm’. A brain computed tomography (CT) scan showed dilatation of ventricle and subcutaneous swelling beside the catheter in his head. Staphylococcus epidennidis was cultured from blood and tap sample of the subcutaneous swelling in his head. On the plain abdominal x-ray film, the tip of the catheter was seen on the left upper abdomen, which was the same position as 2 months before. He was diagnosed as having a sepsis and ventriculitis caused by ascending infection from the tip of the catheter, which was thought to be a perforation of viscus from 2 months before. The catheter of the abdominal wall was exposed and cut. Radiographs of the abdomen, following injection into the catheter with contrast medium, showed opacification of a fibrous tract and lumen of stomach (Fig 1). Fibrin sealant was injected through the catheter From the Departments of Surgery and Neurosurgery, National Kagawa Children’s Hospital, Kagawa, Japan. Address reprint requests to T. Oshio, MD, Department of Surgery, National Kagawa Children’s Hospital, Zentsuji City, Kagawa 765, Japan. Copyright o 1991 by W.B. Saunders Company 0022-3468191/2612-0016$03.00l0 1404
Y. Manabe,
Shunt
and Y. Nakagawa
for a closure of the perforated stomach wall nonoperatively. Six days later, reinjection with contrast medium into the catheter was performed. There was no opacification of the stomach. When injection with higher pressure was done, contrast medium ejected out from the skin edge of the catheter through the fibrous sheath around the catheter. The abdominal catheter was removed and oral feeding was started. Two weeks later, a silastic abdominal catheter, which was softer than the Raimondi tube, was successfully replaced on the same side. At the age of 5 years 9 months, he was admitted to the pediatric surgical unit because of abdominal pain, fever, and vomiting. On admission, a WBC count was 14,00O/mm’. A slight distension of the abdomen and signs of peritoneal irritation were noted. A plain abdominal x-ray film showed dilatation of the small bowel. A perforation of viscus due to the VP shunt tube was strongly suspected. Shortly after admission he improved without complication; therefore, he was followed conservatively. Twenty-six days later, he was admitted to the neurosurgical unit because of severe headache that was suspected to be caused by blockage of the VP shunt system. On admission, there were no signs of peritoneal irritation. A brain CT scan showed severe dilatation of the ventricles. On plain abdominal x-ray film, the tip of the VP shunt was seen at the left side of abdominal cavity, which was the same as the position of the last admission. There was no appearance of dilatation at the small bowel. The catheter near the level of its insertion into the abdomen was exposed. When the distal catheter was pulled out several centimeters for examination, perforation of viscus due to VP shunt was suspected because the catheter was grossly contaminated with yellowish bowel contents. The perforation of small bowel was confirmed by radiograph, following injection into the catheter with contrast medium (Fig 2). Laparotomy was performed for the purpose of making clear, if possible, the cause of the recurrent perforations of viscus occurring in the VP shunt. The intraperitoneal part of the catheter was enveloped by fibrous tissue, which was only 1 cm in length from the peritoneal wall to the intestine. Despite multiple revisions of the VP shunt and recurrent perforations of viscera, there were no signs of peritonitis, scars, or remnant of the sheath of the last perforation, except for a slight omental adhesion near the sheath. The catheter was placed 15 cm normoperistalitically in the lumen of the jejunum. The part of the jejunum involving the sheath and catheter was resected and was closed in two layers. Cerebrospinal fluid from the proximal catheter was sterile, but tap samples near the catheter were cultured of Enterobacter. Twenty-one days later, revision of the VP shunt was performed. DISCUSSION
Although various types of shunting procedures have been devised for cerebrospinal fluid diversion in hydrocephalus, the VP shunt has become popular since the introduction of a peritoneal catheter with a slit-valve at its tip’ and with the development of suitable substances such as polyethylene and silicon.* The VP shunt has a lower morbidity than the ventriculoatrial shunt. But, as more patients with treated hydrocephalus survive longer, more complications, especially in the abdomen, are being encountered. JournalofPediatricSurgery,
Vol26,No12(December),1991:pp1404-1405
PERFORATIONS
OF VISCUS
Fig 1. The radiograph and lumen of stomach contrast medium.
DUE TO VP SHUNT
shows the opacification following injection into
of a fibrous the catheter
tract with
Gastrointestinal perforation due to a VP shunt is rare; 7.5 cases, including the present case, have been reported in the literature. The case of recurrent perforations of viscus has not been found except for this case. Thirty-eight patients were alive after perforation, 11 patients, including 5 cases diagnosed at autopsy,3-h had died, and the status of 26 patients was unknown. The location of the gastrointestinal perforation was noted in 29 cases. Perforation of t,he stomach has been reported in two instances. One is reported herein and the other was an adult case.3 Perforation of the duodenum was reported in one patient who was diagnosed at autopsy.’ Perforation of the small bowel was noted in five cases. Two cases, including this case, occurred at the jejunum,4 one was at the ileum,” and hvo were unknown. Perforation was found at the large bowel in 20 cases and at the rectum’ in one. The cause of perforation of viscus due to the VP shunt is uncertain, but it was thought to be as follows*: the abdominal VP shunt catheter adheres to the serosal surface of the viscus as a result of a foreign body reaction and, later, decubitus ulceration of the viscus wall occurs. The final outcome is that part of
Fig 2. The radiograph shows the opacification of the small bowel after the injection into the abdominal catheter with contrast medium.
the catheter enters the lumen of the bowel. The catheter is already encased by a fibrous tissue “sheath,” thus preventing free perforation of the bowel and no clinical signs of intraabdominal catastrophe are found on examination. In view of the high mortality rate associated with this complication, early diagnosis of bowel perforation is essential.’ Radiographs of injection of a contrast medium to the shunt system with or without fluoroscopic guidance can be readily used to diagnose viscus perforation. If the catheter would be placed inside of gastrointestinal lumen for long times, severe ventriculitis and, finally, sepsis might develop due to ascending infection from the gastrointestinal flora through the catheter and its sheath. The management of this complication, basically, should remove of the catheter from the lumen of the gastrointestinal tract. Transitory external drainage and complete replacement after a period of vigorous antibiotics administration are needed for the treatment of infection of the VP shunt system. In this case in which stomach perforation occurred, using a fibrin sealant for closure of the perforated stomach wall and continuous suction of nasogastric tube for decreasing pressure of the stomach were effective.
REFERENCES 1. Ames RH: Ventriculo-peritoneal shunts in the management of hydrocephalus. J Neurosurg 27:525-529,1967 2. Raimondi AJ, Robinson JS, Kuwamura K: Complications of ventriculo-peritoneal shunting and a clinical comparison of the three-piece and one-piece system. Child Brain 3:321-342, 1977 3. Nishijima M, Endoh S, Ohyama H, et al: Gastric perforation by a ventriculo-peritoneal shunt. Neurosurgery 10:754-756,1982 4. Rubin RC, Ghatak NR, Visudhipan P: Asymptomatic perforated viscus and gram-negative ventricuhtis as a complication of valve-regulated venticuloperitoneal shunt. Report of two cases. J Neurosurg 37:616-618, 1972 5. Sakamoto K, Kobayashi N, Sato N, et al: Rare complications
after cerebrospinal fluid peritoneal shunts. J Jpn Sot Pediatr Surg 12:137, 1976 (abstr) 6. Nitta M, Kato T, Asai A, et al: Complications after ventriculoperitoneal shunt. J Jpn Red Cross Hosp 30:83-84, 1978 7. Shitatake K, Makita Y, Kondo A, et al: A case of bowel perforation after ventriculo-peritoneal shunt. J Jpn Surg Sot 78:95, 1977 (abstr) 8. Abu-Dalu K, Pode D, Hadani M, et al: Colonic complications of ventriculo-peritoneal shunts. Neurosurgery 13:167-169, 1983 9. Azimi F, Dinn WM, Naumann RA: Intestinal perforation, an infrequent complication ofventriculo-peritoneal shunts. Radiology 121:701-702,
1976
