Role of ventriculoperitoneal shunting in patients with neoplasms of the central nervous system: An analysis of 59 cases

Abstract

Abstract. Approximately 1-5% of patients with cerebral metastasis and ~40% of patients with primary brain tumors suffer from hydrocephalus. These patients often exhibit a poor prognosis. The aim of the present study was to reassess the validity of ventriculoperitoneal shunting (VPS) with the assistance of the general surgeon in oncological patients. A total of 59 patients underwent first-time VPS at the Beth Israel Deaconess Medical Center (Boston, USA) between 2004 and 2012; 40 patients had hydrocephalus from brain metastasis and 19 from primary tumors. The analyzed independent variables included demographics, body mass index, past medical history, clinical presentation, indication for surgery, Karnofsky performance status (KPS) score and surgical technique; the dependent variables were postoperative symptoms and occurrence, cause and time of shunt failure. The outcomes were analyzed with the t-test and Kaplan-Meier estimates for shunt survival. The mean age of the patients was 57.2 years and the mean operative time was 50.4 min. Symptomatic palliation was achieved in 93% of the cases; patients with severe symptoms, such as debilitating headaches, nausea and vomiting, benefited significantly from VPS. The mean follow-up time was 6.3 months; complications occurred in only 7 patients (11.8%) during follow-up: 2 in the proximal shunt (1 infection and 1 obstruction), both requiring revision, 1 infection in the distal catheter requiring shunt removal, 2 cases of intracerebral bleeding that were monitored with computed tomography scans, 1 wound infection treated with antibiotics and 1 valve complication that required temporary revision. The initial and 3-month KPS scores were 65±16.4 and 75±16.0, respectively. The mean overall shunt survival was 6.4 months (range, 1.0 day-76.0 months) from the placement of the VP shunt. At 3 months after VPS, 93.5% of the patients remained alive with functioning shunts and at 1 year 87% of the shunts were still functioning. In conclusion, VPS remains a valid option for cancer patients with low KPS, as it improves the quality of life in such patients, even in the setting of previous infection, hemorrhage, or leptomeningeal disease, since shunt patency outlasts the overall survival of nearly all patients.

Management of hydrocephalus in patients with leptomeningeal metastases: an ethical approach to decision-making

“…VPS involves placement of a catheter in the lateral ventricle, connected into the peritoneal cavity [ 8 ]. VPS allows for rapid normalization of elevated intracranial pressure (ICP) and is thus commonly employed to relieve symptoms of hydrocephalus [ 5 , 8 , 9 ]. Table 1 depicts studies that have previously reported symptoms and outcomes for patients with leptomeningeal disease-associated HC who have undergone shunting.…”

“…Table 1 depicts studies that have previously reported symptoms and outcomes for patients with leptomeningeal disease-associated HC who have undergone shunting. Overall, these retrospective series have demonstrated significant improvement in hydrocephalus-associated symptoms following VPS placement, with rates of symptom improvement ranging from 75 to > 90% (Table 1 ) [ 4 , 5 , 9 – 11 ]. Shunting has also led to marked patient improvements in performance status, with post-surgical Karnofsky Performance Status (KPS) increases of 10–20 points [ 4 , 11 ].…”

“…Shunting has also led to marked patient improvements in performance status, with post-surgical Karnofsky Performance Status (KPS) increases of 10–20 points [ 4 , 11 ]. While it has not been standard-of-care to intervene on patients with low performance scores, the minimal published data suggests that VPS may improve quality-of-life even in patients with low KPS [ 9 , 10 ].…”

“…Despite the symptomatic relief following VPS experienced by many patients, there are gradations of benefit based upon various patient factors. For example, it appears that while headache and nausea are most likely to improve following VPS, results are variable with respect to cognitive dysfunction, urinary incontinence, and gait dysfunction [ 9 , 11 ]. Moreover, per the results of Murakami et al, only patients with a presenting KPS ≥ 30 benefited from VPS.…”

Unlike Diamonds, Defibrillators Aren’t Forever: Why It Is Sometimes Ethical to Deactivate Cardiac Implantable Electrical Devices

“…Some examples include vasectomy reversal, 17,18,19 the removal of hernia mesh, 20,21 removal or deactivation of deep brain stimulation, 22,23,24,25 and the removal of a ventriculoperitoneal (VP) shunt. 26,27 Some of these, like the VP shunt or (arguably) a deep brain stimulator, are lifesustaining. Does Huddle want to suggest they cannot be removed even if they function imperfectly?…”