Relieve of Abdominal Discomfort, Nausea and Vomiting

Without Peritonitis Sign After Removal of Fractured Shunt

Catheter in Peritoneal Cavity (a case report)

Asadullah Asadullah1, Muhammad Arifin Parenrengi2,&

1
Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga,
Surabaya, East Java, Indonesia
2
Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga /
Dr. Soetomo Academic Hospital, Surabaya, East Java, Indonesia.

&
Corresponding author
Muhammad Arifin Parenrengi
Department of Neurosurgery, Faculty of Medicine; Universitas Airlangga /
Dr Soetomo General Academic Hospital, Surabaya, East Java, Indonesia.
St. Mayjen. Prof. Dr. Moestopo 47, Surabaya, East Java, Indonesia-60131
Phone: (+62) 81333888007
Fax: ((+62 031) 5022472
Email: muhammad.arifin@fk.unair.ac.id

1
Abstract
Ventriculoperitoneal (VP) shunt failure is very common, and shunt fracture is the
most common cause of advanced shunt failure. Peritoneal catheters are
occasionally dislodged in the abdominal cavity and their management is
controversial. This case report describes a case of unspecified abdominal
discomfort following a shunt fracture with removal of a peritoneal catheter in the
abdomen. A 7-year-old woman presents with unspecified abdominal discomfort,
nausea, and vomiting. The patient had a history of shunt fracture and underwent
shunt revision, the dislodged peritoneal catheter was left in the abdominal cavity.
There are no signs of shunt failure and peritonitis, the patient has also been
treated with drugs but there is no improvement in symptoms. Laparotomy was
performed to remove the peritoneal catheter, the patient's symptoms disappeared
immediately after the procedure. Migration of a severed shunt catheter into the
abdominal cavity can sometimes lead to subsequent complications such as
unspecified abdominal discomfort, nausea, and vomiting. Laparoscopic removal to
remove a severed shunt catheter is a safe procedure and should be considered to
prevent complications.
Keywords: Shunt Termination, Shunt Fracture, Shunt Complications, Child
Health, Case Report

2
Introduction
Ventriculoperitoneal (VP) shunt surgery is the most commonly performed
neurosurgical procedure[1, 2]. Despite improvements in surgical materials,
devices, and techniques, many problems and complications are still encountered in
shunt surgery[3, 4]. Complications of VP shunting include obstruction, infection,
severance, fracture, or migration of the shunt, as well as abdominal pseudocyst,
skin necrosis, open shunt, and ileus[5–7]. Discontinuity (break or fracture) of the
VP shunt can be found and reported in 4% and 15% in the literature[8, 9]
Peripheral drainage fractures where the loose ends are usually detached
somewhere in the peritoneal cavity.
In contrast to mandatory intravascular or cardiac catheter removal due to reported
high morbidity, peritoneal catheter removal is less important. Because
complications such as bowel perforation are rare and their incidence is only 0.1-
0.7%, for asymptomatic patients some authors prefer to leave the catheter in the
peritoneal cavity[10]. Today in the modern era, laparoscopic removal of a
migrating shunt catheter can be safely performed, either as an emergency or an
elective process and therefore many other surgeons tend to evacuate the catheter
to prevent the risk of complications[9, 11]. Until now, the management of a
dislodge shunt in the peritoneal cavity is still controversial. Presented here is a
case of relieving abdominal discomfort, nausea and vomiting without signs of
peritonitis after removal of a severed shunt catheter in the peritoneal cavity.

Patient and observation

Patient Information: A 7-year-old woman came to our emergency department

(ED) with her parents due to progressive loss of consciousness since 3 days before
admission. Prior to this he had a history of headache, vomiting and non-specific
abdominal discomfort for 6 days. Five years earlier, the child had a VP shunt, due
to communicating hydrocephalus with tuberculous meningoencephalitis. The
patient received an anti-tuberculosis regimen and completed treatment after 1
year. The patient has routinely checked in our outpatient clinical service line
without any previous clinical complaints.

Clinical Findings: On examination his Glasgow coma scale (GCS) was 8, he had a
lump in the right neck along the shunt pathway, the patient also had a funduscopy
in our ER and we found bilateral papilledema (Figure 1). We did a plain X-ray of the
cervical and we found a discontinuity of the shunt catheter in the cervical region
(Figure 2).

To evaluate the cause of the loss of consciousness in this patient we performed a

computed tomography (CT) of the head. We found dilatation of the lateral and third
ventricles as a sign of hydrocephalus. We diagnosed this patient with shunt
malfunction due to a shunt fracture (Figure 3).

3
We then decided to place another shunt at the contralateral point of the previous
shunt, removed the previous shunt and since there was no sign of peritonitis we
removed the peritoneal catheter.

Three weeks after the shunt revision, the patient returned to our ED complaining of
abdominal discomfort, poor intake, nausea, and vomiting. After a brief discussion
with the pediatric surgeon, we decided to remove the dislodge shunt in the
peritoneal cavity with a laparoscopic approach.

Timeline of current episode: A 7-year-old woman came to our emergency

department (ED) with her parents due to progressive loss of consciousness since 3
days before admission. The patient received an anti-tuberculosis regimen and
completed treatment after 1 year. After the installation of the second VP shunt, the
patient's condition improved with GCS 15 one day after surgery, the patient went
home three days after surgery. A few days after evacuation of the catheter, the
patient's symptoms improved, oral intake was good and the patient was discharged
after 5 days postoperatively (Figure 4).

Diagnosis assesment: Three weeks after shunt revision, the patient returned to
our ED complaining of abdominal discomfort, poor intake, nausea, and vomiting.
After a brief discussion with the pediatric surgeon, we decided to remove the shunt
dislodge in the peritoneal cavity with a laparoscopic approach

Therapeutic interventions: Laparoscopy was performed by a pediatric surgeon

with CO2 insufflation of 8-10 mmHg in one hour. Then we removed about 80 cm
from the peritoneal catheter, we found no adhesion between the peritoneal
catheter and abdominal organs during the operation.

Follow-up and outcome of interventions: A few days after catheter

evacuation, the patient's symptoms improved, oral intake was good and the
patient was discharged after 5 days postoperatively.

Patient Perspective: the condition experienced by a 7 year old woman after

surgery is that her condition is getting better and there are no more disturbances
in the patient's oral intake

Informed Consent: informed consent was obtained from the patient for this
publication

Discussion
Fracture and shunt disconnection are the most common late shunt
complications[12]. Most VP shunt fractures occur in the neck and repetitive motion
is considered the most important factor in these fractures[13, 14]. Here we
present our patient with a shunt fracture in the neck after 5 years of VP shunt
placement.
4
The management of shunt fractures is still controversial until now, some surgeons
suggest that shunt revision can be delayed if there are no signs of increased
intracranial pressure[15]. In our case, the patient presented with decreased
consciousness and hydrocephalus caused by shunt failure. The patient's condition
improved after the shunt revision was performed.
Management of a dislodge shunt in the peritoneal cavity has been reported with
low complications and some cases have reported that it appears to be left in the
peritoneal cavity without causing problems[5]. Shunt surgery is associated with
some rare abdominal complications that may occur years afterward. These include
intestinal volvulus, pseudocysts, and extrusion of the catheter through the
scrotum, umbilicus, vagina, or gastrointestinal tract[6–8]. Factors that may cause
this problem are the small bowel wall on the part of children, sharp and rigid tip of
the VP shunt, use of trocar by surgeon, prolonged irritation by the shunt, previous
surgery, infection and silicone allergy[16].
Our patient presented with non-specific symptoms such as abdominal discomfort,
nausea and vomiting. We could not find any such symptoms caused by peritoneal
catheters reported in previous literature so we tried to evaluate other possible
factors such as shunt failure and peritonitis, we also tried to administer medication
to the patient but the symptoms did not decrease. After a brief discussion with the
pediatrician and pediatric surgeon we suggested that it might be caused by a
ventricular catheter in the peritoneal cavity.
The presence of a VP shunt does not appear to have a significant risk in patients
undergoing a laparoscopic procedure. Reported as long as the insufflation
pressure at any time is less than 16 mm Hg and the operating time does not
exceed 3 hours has been shown to be safe[17]. Laparoscopy in this patient was
performed with CO2 insufflation of 8-10 mmHg in 1 hour duration. No
complications occurred and we found no signs of peritonitis, adhesions, or
perforation of hollow organs. The patient's symptoms diminished after evacuation
of the peritoneal catheter.

Conclusion
Migration of a severed shunt catheter into the abdominal cavity can sometimes
lead to further complications. Leaving a severed catheter in place carries the risk
of potential complications in the future; therefore, early laparoscopic or minimally
invasive techniques to remove a severed shunt catheter should be considered.

Competing interests
The authors declare no competing interests.

Authors’ contributions

5
AA and MAP contributed to study selection, data abstraction, data analysis, data
interpretation, drafting of the manuscript, revising the article critically for
important intellectual content. AA: Contributed to designing the search strategy,
data abstraction, data interpretation, revising the article critically for important
intellectual content. AA: Contributed to designing the search strategy, revising the
article critically for important intellectual content. MAP: Contributed to screening
titles, abstracts, and full texts, revising the article critically for important
intellectual content. All the authors have read and approved the final version of
this manuscript.

Tables and figures

Figure 1: Patient with decrease of consciousness (A). lump in the right neck (B)
Figure 2: Cervical x-ray, white arrow shown shunt catheter discontinuity in
cervical region (A). Babygram x-ray, white arrow shown shunt catheter dislodge in
abdominal cavity (B)
Figure 3: Head CT scan in 2015 shown hydrocephalus with leptomeningeal
enhancement (A and B). Head CT scan in 2020 shown dilatation of ventricle as
sign of hydrocephalus(C)
Figure 4: Intra operative image

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[3] Gu M. Since January 2020 Elsevier has created a COVID-19 resource centre
with free information in English and Mandarin on the novel coronavirus
COVID- 19 . The COVID-19 resource centre is hosted on Elsevier Connect ,
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Pediatr 2016; 18: 325–328.

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[7] Bal F, W DW, N TA, et al. Ekstrusi Anal Ventriculoperitoneal Shunt : Laporan
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[12] Lee L, Low. S, Low D, et al. Late pediatric ventriculoperitoneal shunt
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[13] Lee YH, Park EK, Kim DS, et al. What should we do with a discontinued
shunt? Child’s Nerv Syst 2010; 26: 791–796.
[14] Kaplan M, Cakin H, Ozdemir N, et al. Is the elapsed time following the
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SCARE 2020 Checklist

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4
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