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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 33-37

An analysis of outcome of pediatric hydrocephalus: A 10-year study from Central India


Department of Pediatric Surgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India

Date of Submission23-Aug-2020
Date of Acceptance15-Sep-2020
Date of Web Publication06-Nov-2020

Correspondence Address:
Dr. Roshan Chanchlani
Department of Pediatric Surgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpai.jpai_9_20

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  Abstract 


Introduction: Ventriculoperitoneal (VP) shunt is an easy and inexpensive procedure done for the management of hydrocephalus all over the world. However, it is associated with several complications and morbidity. Objectives: The objective of this study was to assess the outcome of children having hydrocephalus who underwent VP shunt. Methods: In this retrospective study, records of 196 children who were operated for hydrocephalus by a single surgeon were analyzed and the spectrum of complications was noted. This 10-year study was conducted from May 2010 to April 2020, and the patients were operated in various hospitals and tertiary care centers in Bhopal city, Madhya Pradesh, India. Results: Out of the 196 patients, 120 were boys and 76 were girls. In this series, 130 (66.3%) patients were <1 year of age. The median age was 20.7 months (range 1.4 months to 9.5 years). Aqueductal stenosis (35.7%) was the most common congenital and tubercular meningitis (16.3%) was the most common acquired cause of hydrocephalus. Vomiting (18.4%) was the most common symptom and enlargement of the head (40.8%) was the most common sign. Common indications for shunt revision were shunt obstruction (10.2%) and shunt infection (6.6%). In this study, most of the shunt failures (20, 47.61%) were seen within 3 months of surgery. Mortality in this series was 12.8%.Conclusions: Of the 196 children who underwent VP shunt for hydrocephalus over a period of 10 years, 12.8% died, 10.2% had shunt obstruction, and 6.6% had shunt infection. Complications of shunt procedures adversely affect the final surgical outcome. Cerebrospinal fluid shunting features a propensity for mechanical failure, and patients with VP shunts should receive regular follow-up through the transition to adulthood.

Keywords: Head circumference, pediatric hydrocephalus, ventriculoperitoneal shunt


How to cite this article:
Chanchlani R. An analysis of outcome of pediatric hydrocephalus: A 10-year study from Central India. J Pediatr Assoc India 2020;9:33-7

How to cite this URL:
Chanchlani R. An analysis of outcome of pediatric hydrocephalus: A 10-year study from Central India. J Pediatr Assoc India [serial online] 2020 [cited 2020 Nov 25];9:33-7. Available from: http://www.indjpai.com/text.asp?2020/9/1/33/300105




  Introduction Top


With present-day high standards of care, most of the patients operated for pediatric hydrocephalus survive, but morbidity and mortality from hydrocephalus still exist.[1] Ventriculoperitoneal (VP) shunt is the most common surgery done for pediatric hydrocephalus.[2] Despite technical advances, shunt infection is yet a serious complication.[3],[4] Besides VP shunt, other shunting techniques for hydrocephalus are endoscopic third ventriculostomy, ventriculoatrial shunts, and lumbar-peritoneal shunts.[5]

Objectives

The objective of this study was to assess the outcome of children having hydrocephalus who underwent VP shunt.


  Methods Top


In this retrospective study, records of 196 patients operated for hydrocephalus in the pediatric age group were studied and the spectrum of complications was noted. This 10-year study was conducted from May 2010 to April 2020 by a single surgeon, and the patients were operated in various hospitals and tertiary care centers in Bhopal city, Madhya Pradesh, India.

Inclusion criteria

Patients 12 years of age and below, with a diagnosis of hydrocephalus, were included.

Exclusion criteria

Patients over the age of 12 years, patients with intracranial space-occupying lesions, and those not giving consent for surgery were excluded.

On admission, demographic profiles such as age, sex, weight, head circumference, and duration of symptoms and signs were noted. Thorough clinical examination was done. General condition of patients was assessed, and necessary radiological and laboratory investigations were done. Transfontanelle ultrasonography (USG), computed tomography (CT), and magnetic resonance imaging (MRI) were done to assess ventricular dilatation and parenchymal thickness.

After investigation, patients were subjected to VP shunt insertion under general anesthesia. Third-generation cephalosporins were given at the time of induction in all cases. After incision over the scalp, a small burr hole was made and dura was incised with cautery and fenestrated ventricular end was placed into the lateral ventricle. A tunnel was made in the subcutaneous plane for shunt tube placement and distal end was placed in the suprahepatic space through a small transverse right upper quadrant incision. The upper end of the shunt tube was fixed to scalp layers with absorbable suture. Postoperatively, all patients were monitored in the pediatric intensive care unit or neonatal intensive care unit. They were given intravenous (IV) fluids, antibiotics, and analgesics. The patients were discharged in 5 days if there were no complications.

The patients were followed up in the outpatient department at various intervals up to 1 year after surgery. Milestones of development, convulsions, acceptance of feed, fever, and signs of increased intracranial pressure were noted clinically on follow-up. Function of VP shunt was checked by compressing and rapid refilling of the shunt chamber. Three months after surgery, a follow-up CT scan was done.

Data were collected, analyzed, and compared with other available literature.


  Results Top


In the 10-year period, out of the 196 children operated, 120 were boys and 76 were girls, 130 (66.3%) were <1 year of age, and the median age was 20.7 months (range: 1.4 months to 9.5 years). [Table 1] shows the causative factors for hydrocephalus. Aqueductal stenosis was the most common congenital and tubercular meningitis was the common acquired cause of hydrocephalus.
Table 1: Causative factors for hydrocephalus

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The symptoms of hydrocephalus are shown in [Table 2]. Vomiting and headache were the most common symptoms.
Table 2: Symptoms of hydrocephalus

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The signs of hydrocephalus are shown in [Table 3]. Enlargement of the head was the most common sign.
Table 3: Signs of hydrocephalus

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The complications of VP shunts requiring revision are shown in [Table 4].
Table 4: Complications of ventriculoperitoneal shunts requiring revision (n=196)

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The most common indications of shunt revision were shunt obstruction comprising 20 (10.2%) cases and shunt infection comprising 13 (6.6%) cases. There were 2 cases of cerebrospinal fluid (CSF) leak from abdominal wound following VP shunting, and both were managed successfully by revision of the peritoneal part of the shunt. Two cases presented as extrusion of the peritoneal part of VP shunt catheter through the anus without features of peritonitis or meningitis [Figure 1]. This was managed by a mini-laparotomy with revision of the peritoneal part of the shunt alone.
Figure 1: Extrusion of shunt through anus

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We observed two cases of CSF pseudocysts in the peritoneal cavity following VP shunt operations [Figure 2], both presenting with progressive abdominal distention and malfunction of the peritoneal part of the shunt. Both were managed by formal exploratory laparotomy, excision of the cysts, and relocation of the peritoneal catheter.
Figure 2: Cerebrospinal fluid pseudocyst

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The complications of VP shunts which did not require revision are shown in [Table 5].
Table 5: Complications of ventriculoperitoneal shunts which did not require revision of shunt (n=196)

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There were 2 cases of inguinal hernia after VP shunts related to an accumulation of CSF in excess of the peritoneal absorption rate. Two cases of subgaleal fluid accumulation after shunt surgery were seen in this study [Figure 3].
Figure 3: Subgaleal cerebrospinal fluid collection

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I also encountered extrusion of the peritoneal part of the VP shunt catheter, one each from neck wound [Figure 4] and from the abdominal wound [Figure 5]. In both cases, disconnection of tube was done from shunt chamber under local anesthesia and distal tubing was pulled out. Re-shunting on the opposite side was done later.
Figure 4: Extrusion of shunt through neck wound

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Figure 5: Extrusion of shunt through abdominal wound

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In this study, two cases of craniosynostosis were seen [Figure 6].
Figure 6: Craniosynostosis

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Mortality in this study was 12.8% (25 out of 196).


  Discussion Top


Hydrocephalus is the pathological accumulation of intracranial CSF due to overproduction or decreased circulation to other brain compartments leading to swelling of the ventricular system and ultimately to brain damage.[6],[7] The most common causes of shunt failure in children are obstruction and infection.[8] In this study, the overall complication of VP shunt in congenital hydrocephalus was 72 (36.7%), which is in accordance with global figures of 25%–40%.[3],[9],[10] The incidence of shunt blockage has been reported in the literature to range from 5% to 47%.[11],[12] In this series, the incidence of shunt blockage was 10.2%.

In this study, infection was the second common complication following shunt surgery, with an incidence of 6.6%. In various studies, 40% of shunt infections are due to Staphylococcus epidermidis and 20% are due to Staphylococcus aureus.[13] Because these organisms form a part of the normal skin flora, endogenous spread from patients or staff is the probable route of infection.[14] Shunt infection was treated by intermittent CSF tapping and IV antibiotics based on culture and sensitivity of CSF and exteriorization of shunt. Revision of shunt was done only when CSF samples confirmed the absence of infection. Choux et al.[15] showed that better selection of indications, adequate skin preparation with disinfecting baths, and a standardized surgical technique greatly reduced the infection level. Premature neonates are at the greatest risk for shunt infection as their immune system is not fully developed.[16] Rotim et al.[17] adopting a strict protocol for shunt placement, including adequate skin preparation, perioperative antibiotics, and short operating time, reduced their rate of shunt infection from 17.9% to 8%.

In our study, two cases presented as extrusion of the peritoneal part of VP shunt catheter through the anus without features of peritonitis or meningitis. Perforation of bowel by catheter tubing is a rare complication of VP shunt placement carrying the risk of ascending infection to the brain in the form of meningitis, encephalitis, or brain abscess.[18] We observed two cases of CSF pseudocysts in the peritoneal cavity following VP shunt operations, both presenting with progressive abdominal distention and malfunction of the peritoneal part of the shunt. CSF pseudocysts in the peritoneal cavity are a known complication of VP shunt malfunction, with an incidence of <1%–4.5%.[19],[20] USG and CT scan of the abdomen and pelvis are excellent imaging modalities for the diagnosis of CSF pseudocysts. The treatment options for CSF pseudocysts in the peritoneal cavity are excision of the cysts and relocation of the shunt that can be done either through formal laparotomy or laparoscopically.[21],[22] Two cases of subgaleal fluid accumulation after shunt surgery were seen in this study. Various studies have described this complication mostly with malfunctioning shunt in the early postoperative period.[23],[24] We also encountered extrusion of the peritoneal part of the VP shunt catheter, one each from the neck wound and the abdominal wound. In this study, two cases of craniosynostosis were seen. Hydrocephalus is found in 4%–10% of cases of craniosynostosis.[25]

Although the risk in performing shunt operation is low, the complications related to shunts are many, and in this study, most of the failures (20, 47.61%) were seen within 3 months of surgery. Several reports have mentioned a similar incidence of 40%–60% of shunt infections that manifest within 3 months after shunt insertion.[26] In this study, there were 25 (12.8%) deaths, and the mortality reported in various studies was around 13.7%.[27] In modern times, endoscopic third ventriculostomy obviates the need for a ventricular shunt, thus avoiding shunt-related complications.[28] CSF shunting has a propensity for mechanical failure, and children with VP shunts should be regularly followed up through transition to adulthood.


  Conclusions Top


Complications of VP shunt procedures in children can adversely affect the final neurological outcome. Patients with VP shunts should receive regular follow-up, and it is necessary to decrease the infection rate by increasing the awareness among the operation theater and hospital staff for maintaining strict asepsis in hospital settings.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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