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CASE REPORT
Year : 2008  |  Volume : 3  |  Issue : 2  |  Page : 166-168
 

Transoral migration of peritoneal end of ventriculoperitoneal shunt: A case report of a rare complication and review of literature


1 Department of Neurosurgery, Sri Ramakrishna Hospital, Tamilnadu, India
2 Department of Neurosurgery, GKNM Hospital, Coimbatore, Tamil Nadu, India

Correspondence Address:
R Murali
6, Chaturvedi Nagar, Sanganoor Road, Ganapathy, Coimbatore, Tamil Nadu-641 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1817-1745.43651

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   Abstract 

A rare complication of ventriculoperitoneal (VP) shunt is presented. A 6-year-old boy presented with a tube coming out of the mouth. He had a VP shunt done earlier. Clinical features and imaging studies showed that the peritoneal end had perforated the stomach and then migrated to and excited from the mouth. The shunt was removed and he made an uneventful recovery. Though migration of the peritoneal end of the shunt tube into various organs is known, only five cases have been reported in the English literature of a shunt tube coming out of the mouth and this is the sixth. The management of this very rare problem is discussed and the literature reviewed.


Keywords: Migration, peritoneal end, transoral, ventriculoperitoneal shunt


How to cite this article:
Murali R, Ravikumar V. Transoral migration of peritoneal end of ventriculoperitoneal shunt: A case report of a rare complication and review of literature. J Pediatr Neurosci 2008;3:166-8

How to cite this URL:
Murali R, Ravikumar V. Transoral migration of peritoneal end of ventriculoperitoneal shunt: A case report of a rare complication and review of literature. J Pediatr Neurosci [serial online] 2008 [cited 2019 Aug 19];3:166-8. Available from: http://www.pediatricneurosciences.com/text.asp?2008/3/2/166/43651



   Introduction Top


Ventriculoperitoneal shunt (VP) is one of the most common neurosurgical procedures done. Unfortunately, it also has a high-complication rate which varies widely. Out of this, abdominal complications account for about 25%. Perforation of the bowel occurs not infrequently followed by distal migration of the catheter. However, we report here a very rare case of proximal migration of the peritoneal catheter, after perforating the stomach, and coming out of the mouth. To our knowledge, only five such cases have been reported in the English literature and this is the sixth. Management also differs here from other cases. Relevant literature is reviewed.


   Case Report Top


A 6-year-old boy had VP shunt done for congenital hydrocephalus 5 years before. He presented with history of a tube coming out his mouth a few hours prior to admission. He felt a nauseous sensation and then a tube came out of the mouth. There was no headache, vomiting, fever, or loose motion. On examination, he was a moderately nourished boy who was afebrile. He was not anemic or jaundiced. Abdomen was soft with a midline epigastric scar. There was no tenderness and bowel sounds were heard. The peritoneal end of the tube was found to be coming out of his mouth and it was still attached to the main tube [Figure 1] . On compressing the reservoir, cerebrospinal fluid (CSF) drained, indicating that the shunt was still functioning. There was no evidence of meningitis or peritonitis.

Investigations

Computed tomography (CT) scan of the brain showed the ventricular end in position and normally draining ventricles [Figure 2].

X-rays of the skull, chest, and abdomen were taken which showed that the tube was a single entity and in continuity. The tube was seen to be coming out of the skull and reaching the peritoneum subcutaneously in a normal manner. However, it then entered the stomach and looped into the oesophagus and was seen coming out of the mouth [Figure 3] and [Figure 4].

X-ray of the abdomen did not show any air under the diaphragm.

CSF studies did not reveal any infection.

Course in hospital

The patient was taken up for surgery under general anesthesia (GA) and an incision was made in the chest wall just above the shunt tube and it was isolated and was cut, and two parts were created (ventricular and peritoneal). The peritoneal end was removed by gently pulling on the tube coming out of the mouth and it came out in one piece. The ventricular end was connected to a closed system of drainage in an aseptic manner. He was kept nil orally for 48 hours and since the abdomen was soft, he was started on oral feeds. An attempt was made to see whether he was shunt dependent by closing the tube. He remained asymptomatic for 4 days and so was taken up for shunt removal. Under GA, the scalp flap was opened and the ventricular end was gently tugged upon. It would not budge and rather than risk a ventricular bleed it was decided to leave it in situ . The tube was cut at the level of the mastoid and anchored to the periosteum and the distal end was removed. He made an uneventful recovery and was able to take normal food. He remained asymptomatic at the time of discharge 1 week later and till date (2 years later).


   Discussion Top


A VP shunt is the commonest pediatric neurosurgical procedure done. Complications are common and migration of the peritoneal end into virtually every abdominal organ has been reported. There are reports of migration of the peritoneal catheter of VP [1] and lumbar shunts. [2] with intestinal perforation. [1],[3] Vaginal, uterine, [3] urinary bladder [3] and gallbladder perforation [4] have been reported. Pneumothorax, [4] intestinal obstruction, or volvulus [5] is also seen. Extrusion through the anus, [4] umbilicus, [6] abdominal incision [7] and into the scrotum, chest, heart, and pulmonary artery have been reported. Upward migration of VP shunts [8] has also been reported. Very few cases have been reported in the literature about this very rare complication. [9],[10],[11] Ventriculitis [12] and peritonitis [3] complicating migration of the tube have been well recognized.

Normally, peristalsis would have pushed the shunt tube distally and out of the anus. Here, the tube has passed the gastro-oesophageal junction proximally and up the oesophagus to emerge out of the mouth. Surprisingly, the shunt still worked and there was no infection - peritonitis or meningitis. This absence of infection was also seen in the case of Park et al , while the case of Kothari et al, [12] had infection with  Escherichia More Details coli . Probably, the tube coming out of the mouth was so dramatic that immediate medical attention was sought. Institution of antibiotics and early removal of the shunt precluded the setting in of infection. Park et al , did laparoscopic exploration for the tube removal while no such procedure was necessary in our case. Kothari et al , [11] pulled out the shunt by an incision behind the ear. This would entail pulling the extruded shunt tube through the peritoneal cavity again entailing possibility of infection. It is better to cut the tube and pull out the tube through the mouth as in our case.

Removal of the shunt presented no problem and early feeding can be instituted if there is no clinical evidence of peritonitis.

An extremely rare complication of VP shunt is presented, viz . transoral migration of the peritoneal end of VP shunt. The shunt tube was removed uneventfully and without any abdominal intervention.

 
   References Top

1.Sells CJ, Loeser JD. Peritonitis following perforation of the bowel: A rare complication of a ventriculo-peritoneal shunt. J Pediatr 1973;83:823-4.  Back to cited text no. 1  [PUBMED]  
2.Eisenberg HM, Davidson RI, Shillito J Jr. Lumboperitoneal shunts: Review of 34 cases. J Neurosurg 1971;35:427-31.  Back to cited text no. 2  [PUBMED]  
3.Schulhof LA, Worth RM, Kalsbeck JE. Bowel perforation due to peritoneal shunt: A report of seven cases and a review of the literature. Surg Neurol 1975;3:265-9.   Back to cited text no. 3  [PUBMED]  
4.Portnoy HD, Croissant PD. Two unusual complications of a ventriculoperitoneal shunt: Case report. J Neurosurg 1974;39:775-6.   Back to cited text no. 4    
5.Sakoda TH, Maxwell JA, Brackett CE. Intestinal volvulus secondary to a ventriculo-peritoneal shunt: Case report. J Neurosurg 1971;35:95-6.   Back to cited text no. 5    
6.Adeloye A. Spontaneous extrusion of the abdominal tube through the umbilicus complicating peritoneal shunt for hydrocephalus. J Neurosurg 1973;38:758-60.  Back to cited text no. 6  [PUBMED]  
7.De Sousa AL, Worth RM. Extrusion of peritoneal catheter through abdominal incision: Report of a rare complication of ventriculoperitoneal shunt. Neurosurgery 1979;5:504-6.  Back to cited text no. 7    
8.Mori K, Yamashita J, Handa H. "Missing tube" of peritoneal shunt: Migration of the whole system into the ventricle. Surg Neurol 1975;4:57-9.   Back to cited text no. 8  [PUBMED]  
9.Park CK, Wang KC, Seo JK, Cho BK. Transoral protrusion of a peritoneal catheter: A case report and literature review. Childs Nerv Syst 2000;16:184-9.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.Griffith JA, DeFeo. Peroral extrusion of ventriculoperitoneal catheter. Neurosurgery 1987;2:259-61.  Back to cited text no. 10    
11.Kothari PR, Shankar G, Kulkarni B. Extruded ventriculo-peritoneal shunt: An unusual complication. J Indian Assoc Pediatr Surg 2006;4:255-6.  Back to cited text no. 11    
12.Rubin RC, Ghatak NR, Visudhiphan P. Asymptomatic perforated viscus and gram-negative ventriculitis as a complication of valve-regulated ventriculoperitoneal shunts: Report of two cases. J Neurosurg 1972;37:616-8.  Back to cited text no. 12    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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