Spontaneous extrusion of ventriculoperitoneal catheter through anterolateral chest wall: a case report and review of literature
Ondari J1 MBCh.B, MCS (ECSA), Oduor Peter2, MBCh.B, MMed(Surg). 1. Surgery resident, University of Nairobi. 2. Department of Surgery, Egerton University
Correspondence to Ondari N.J P.O Box 15564-20100 Nakuru, E-mail:firstname.lastname@example.org
Ventriculo-peritoneal shunting is the commonest surgery for management of hydrocephalus. However, about 80% develop complications in their lifetime. These include common ones like shunt blockage and infection, to rare ones like shunt migration, extrusion and perforation of viscus. The authors present a rare case of shunt extrusion through the chest wall of an 8 year old male. The shunt was inserted 3years earlier for post-meningitic hydrocephalus. Clinical Examination revealed extrusion of the peritoneal end of the shunt at the level of the 6th rib with cloudy CSF dripping from the tube. A chest radiograph done outlined the shunt. This is an unusual extrusion of a peritoneal shunt and literature search did not reveal any papers with a similar case in the region. We hope clinicians will always be wary of these rare complications for early recognition to improve outcome.
Hydrocephalus is a common disease in the pediatric neurosurgical population whose prevalence has been estimated as 0.48 to 0.81 per 1000 live and still births1. Moreover, this prevalence has been reported to be high-er in the developing world partly due to higher birth rates and consequently higher occurrence of congenital anomalies, as well as higher rates of neonatal infections (2). Ventriculoperitoneal (VP) shunting is the common-est surgery performed for the management of hydro-cephalus as it is not a technically demanding neurosur-gical procedure (3). Despite its significant complication rate, VP shunt in-sertion remains the mainstay treatment for the man-agement of hydrocephalus. The reported worldwide complication rates range widely from 1% to 40%3. These include infection with reported rates varying from 10%–15% (4,5), shunt blockage and shunt migration (6). Rare forms of shunt complications are shunt migra-tion into the scrotum, liver, thoracic cavity, heart and cranium. In addition, there have been reports in litera-ture of shunt extrusion into anal canal, oral cavity and peritoneal catheter perforation of hollow viscera such as the intestine, urinary bladder, and stomach (7, 8). Hy-drocele, hydrothorax, ascitis, and pseudo cyst in the abdomen have also been reported.
Most reports of thoracic migration are into the pleural cavity, lung parenchyma, heart where they may cause pleural effusion, bronchial perforation, pneumotho-rax, and pneumonia (9, 10). Shunt extrusion trough the chest wall is an extremely rare complication. In our lit-erature search we found only one reported case of shunt extrusion through the anterior chest wall. In the present report we describe a case of an 8 year old boy who pre-sented with shunt extrusion through the posterolateral chest wall.
An 8 year old male child (F.M) was admitted on the 25th May 2008 to the Nakuru Provincial General Hospital with a one day history of leakage of clear fluid from the lateral chest wall (figure 1). This was followed by extru-sion of a white tube through the same site (figure 2). A week prior to admission the child had complained of pain and itchiness on the right lateral chest wall. How-ever, there was no report of cough, fever or convulsions. He had a history of ventriculoperitoneal shunt insertion in March 2005 at age 5years for postmeningitic hydro-cephalus. At that time the child was already blind, had weakness in the lower limbs and ataxia. He had been treated for meningitis two months prior to admission in March 2008.
At admission the patient had normal vital signs. Ex-amination of the central nervous system revealed a soft neck with an equivocal Kerning’s sign. The lower limbs were hypertonic. The main findings were in the right posterolateral chest wall where there was extrusion of the peritoneal end of the shunt at the level of the 6th rib. There was cloudy CSF dropping from the end of the tube. There were excoriation marks around the site. Pres-sure on the shunt reservoir resulted in release of drops of fluid from the site.
An antero-posterior chest radiograph outlined the course of the shunt (figure 3). Counseling of the parents was done, consent for surgery obtained and the patient started on anti-meningitic treatment. The patient was prepared for surgery which was performed on 16th June 2008. He underwent a VP shunt removal during which a right postauricular incision was made; the catheter iden-tified and gently pulled out. The course of the shunt was entirely subcutaneous. Reversal from anaesthesia was successful and uneventful. Post operatively the patient was started on acetazolamide once daily and antibiotics.
Ventriculoperitoneal shunting is the commonest surgery performed for the management of hydrocephalus. This is still true despite the major advances being made in endoscopic procedures including endoscopic third ven-triculostomy (ETV). Limited resources, as well paucity of endoscopic units and trained neurosurgical person-nel make this form of intervention unavailable to the majority of patients in the developing world. As such great strides have been made in shunt technology but these do not obviate the complications associated with the procedure.
The global reported incidence rate of complications fol-lowing VP shunting ranges from 1% to 40% (3). With-in the East African region, Kinasha et al (6) reported that VP shunt blockage was the commonest complica-tion (32.3%) followed by shunt infection. However, Mwan’gombe and Omulo (5) reported an infection rate of 24.6% among children operated for non-tumor hy-drocephalus in Nairobi. A review of literature revealed cases of extrusion of distal shunt catheter through the umbilicus, healed abdominal incision, rectum/anus, lumbar region, oral cavity neck incision and through a thoracic skin fistula (7,8).
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Spontaneous extrusion of the distal peritoneal catheter through the chest wall is very rare. The reports that were found in literature of thoracic migration are into the pleural cavity, lung parenchyma and heart through dia-phragmatic erosion (9,10). The exact etiology is not known. Akyuz et al (8) hypoth-esized that the extrusion may be due to the catheter tip adhering to the visceral wall; a local inflammatory process weakens the bowel wall or skin and the tip then erodes over a period of time. This favors the tip migra-tion through the abnormal site. Other reported causes of early extrusion of shunt may include focal wound dehiscence and infection. Delayed presentation may be due to many factors including ischemic necrosis of over-lying dermis, immunosuppression and poor surgical technique. Superficial shunt catheter placement during subcutaneous tunneling can also predispose to infection from overlying dermal folliculitis to spread to the subcu-taneous space causing dehiscence of overlying skin and extrusion of shunt catheter. The type of catheter or the length of the abdominal part of the catheter may also be implicated in the perforation and shunt migration and finally silicon allergy may result in a foreign body-like reaction (11).
In our patient it was difficult to establish the exact eti-ology of shunt extrusion. However, with the observed local hyperemia we inferred that a local inflammatory response may have had a contributory role in the patho-genesis.
Extrusion of VP catheter through the chest wall is a rare complication of VP shunts. This case highlights rare complications that should be anticipated for timely in-tervention. Removal of the shunt, prompt institution of antibiotics and placement of another VP shunt when ap-propriate offers a good treatment option.
We recommend meticulous surgical technique during VP shunt placement to avoid such complications.
To Dr. Peter Kitunguu for his assistance and input.
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