Abdominal Complications Related to Ventriculoperitoneal Shunt Placement: A Comprehensive Review of Literature

Abstract

Ever since the shunt device became the gold standard treatment for hydrocephalus, complications due to infections and mechanical problems have increased while lives have been saved. In addition, abdominal complications have become an important issue as the peritoneum is now the main place to insert the distal catheter. The most common complications were abdominal pseudocyst, distal catheter migration, inguinal hernia, catheter disconnection, and intestinal obstruction. The pediatric population is more prone to develop most of these complications due to their rapidly growing body, weaker abdominal musculature, and increased intraabdominal pressure. The goal of this review was to study the main aspects associated with abdominal complications after ventriculoperitoneal shunt (VPS) insertion, including the pathophysiology, epidemiological aspects, as well as the rationale for management and prevention according to the current "state-of-the-art." It is paramount to recognize the risk factors associated with various types of complications to manage them properly.

Keywords: abdominal pseudocyst; ascite; catheters; hernia; hydrocephalus; risk factors; shunt infections; shunt migrations.

Figure 1. The ventriculoperitoneal shunt placement protocol.

During surgical procedure, the neurosurgeon (N) and resident (R) are in front of each other, and the table with instruments (T) is positioned at the head of operating bed (P) (left). The distal catheter is introduced to peritoneum cavity avoiding touching the hardware and, instead, use delicate forceps (right).

Figure 2. Abdominal pseudocyst.

Computed tomography scan of abdomen shows a localized collection of fluid in left peritoneal cavity (*) (left). Intraoperative view of abdominal pseudocyst is shown with dilation of peritoneal cavity, and the distal catheter tip (white arrow) is seen (right).

Figure 3. Conversion of VPS into EVD.

Patient with abdominal pseudocyst underwent an externalization of distal VPS catheter at the level of the clavicular region (*) (left). CSF depicting clear aspect (right). VPS: ventriculoperitoneal shunt; EVD: external ventricle drainage; CSF: cerebrospinal fluid.

Figure 4. Ascite as an abdominal complication related to VPS.

(A) Abdominal X-ray shows its increased size and the distal VPS catheter; (B) coronal view of computed tomography scan of the abdomen shows a homogeneous distribution of peritoneal fluid (*); (C) axial view of computed tomography scan of abdomen depicted the tip of distal catheter (white arrow). VPS: ventriculoperitoneal shunt.

Figure 5. Migration of distal VPS catheter.

The image shows a patient with abdominal wall perforation by a distal ventriculoperitoneal catheter. An anomalous scar formation was observed in the surgical incision. VPS: ventriculoperitoneal shunt.

Figure 6. Migration of distal VPS catheter to scrotum.

Abdominal X-ray shows the migration of distal catheter of VPS (white arrow) to the left scrotum (left). During the physical exam, a transillumination of the left scrotum allows to perceive the entanglement of distal catheter inside of this region (right). VPS: ventriculoperitoneal shunt.

Figure 7. Shunt disconnection.

The cervical X-ray displayed a shunt disconnection at the level of left retromastoid region (thin black arrow) in both projections anteroposterior (A) and lateral(B). The abdominal X-ray shows a complete migration of the distal catheter (thick black arrow) (C). The shunt mineralization as well of distal catheter was shown in this other patient (blue arrows) (D).