Intraperitoneal knotting of a ventriculoperitoneal shunt causing small bowel obstruction in an adult

Abstract

Hydrocephalus is generally not reversible thus the insertion of ventriculoperitoneal (VP) shunts remains a cornerstone for the longterm management of this condition. 1 A review of practice over 1 year in the United States found that 8300 new VP shunts were inserted and that the median age of patients undergoing shunt insertion and revision procedures was 31 years old. 1 Small bowel obstruction (SBO) is an uncommon complication of VP shunts. We report the case of a young adult female who developed this complication as a consequence of her VP shunt forming a knot around the small bowel and its mesentery. We believe this is the first reported case of a VP shunt inserted in a paediatric patient where knot formation presented in adulthood with SBO.A 32-year-old woman with global developmental disability from a high-level care facility presented to the emergency department with a 2-day history of obstipation and bilious vomiting for 24 h. The patient had a history of recurrent SBO with five admissions for non-operative management in the previous 2 years. The past medical history was significant for hydrocephalus secondary to complications of neonatal bacterial meningitis with the insertion of a VP shunt in infancy. Multiple revisions of the shunt were required in early childhood, but none since the age of 8 years. On examination, the abdomen was soft but distended and mildly tender. Plain abdominal X-ray confirmed SBO and the shunt was coiled in the mid-abdomen, unchanged from previous imaging. She was managed initially with bowel rest and intravenous fluids but resisted attempts to place a nasogastric tube (NGT). Computed tomography of the abdomen was performed and this demonstrated a SBO associated with the VP shunt (Fig. 1). After neurosurgical consultation, it was decided to proceed with operative treatment. At laparotomy, the VP shunt was encased in a dense fibrous tract and tightly knotted around the mesentery of a large portion of the ileum (Fig. 2). The involved loops were thickened and markedly dilated with dense fibrotic adhesions consistent with chronic obstruction. The shunt was dissected out and shortened by 25 cm. Extensive adhesiolysis was performed. The patient was kept intubated post-operatively to facilitate the use of a NGT in the anticipation that an ileus would develop. Her post-operative course was complicated by aspiration pneumonia after extubation and she was discharged from hospital on a normal diet 2 weeks after her surgery.The placement of shunts into the peritoneal cavity is the most common method of shunting cerebrospinal fluid in hydrocephalus. Complication rates are approximately 30% in the first year and continue at a rate of 4-5% per year thereafter. 2 Complications are more common temporally close to the insertion and among children. 3 Intra-abdominal complications of VP shunts are uncommon, with the exception of infection and shunt obstruction, 2 although a large range of complications have been described including bowel obstruction, pseudocyst formation, inguinal hernia and hydroco...

Closed-Loop Bowel Obstruction Induced by Ventriculoperitoneal Shunt Catheter Coiling at the Sigmoid Colon: A Case Report

“…Before shunt revision surgeries, reviewing pre-operative shunt series can help identify any existing loops or knots of the peritoneal catheter [ 15 ]. Only one case described a VP shunt inserted in a pediatric patient, with multiple shunt revisions for recurrent hydrocephalus, where a knot formation manifested in adulthood with small intestinal obstruction [ 16 ]. Another case reported bowel obstruction caused by knotting of the VP shunt in an adult patient who had the shunt placement during infancy with no subsequent manipulation [ 17 ].…”

“…Before shunt revision surgeries, reviewing preoperative shunt series can help identify any existing loops or knots of the peritoneal catheter [15]. Only one case described a VP shunt inserted in a pediatric patient, with multiple shunt revisions for recurrent hydrocephalus, where a knot formation manifested in adulthood with small intestinal obstruction [16].…”

Ventriculoperitoneal shunt knotting causing bowel obstruction and necrosis in an adult patient

“…Sometimes, the knot is formed around the omentum without necrosis 2. Very rarely, a spontaneous knotting of the peritoneal catheter around a segment of the bowel is noted, but not causing necrosis 7 16–21. Even rarer is the knotting of the peritoneal catheter around a bowel segment, causing bowel obstruction and necrosis.…”

A rare case of ventriculoperitoneal shunt knot causing intestinal obstruction in an adult

“…7 Only one study in the available literature report a case of VP shunt inserted in a paediatric patient where knot formation presented in adult age with small bowel obstruction. 1 That too had multiple shunt revisions for recurrent hydrocephalus. So, authors believe this to be the first case of intestinal obstruction by a VPS knot in an adult with no history of manipulation after primary surgery which happened in infancy period.…”

“…Ventriculoperitoneal shunt (VPS) insertion is the most commonly done neurosurgical procedure worldwide and remains a cornerstone for management of hydrocephalus. 1 Each year, about 36,000 shunt related surgeries are performed in United States. Meticulous operative technique and improved shunt design have prevented much of the morbidity of the procedure in recent years.…”