Mechanical shunt failure in hydrocephalus: a common but remediable complication with technical nuances

IF 0.7 Q4 CLINICAL NEUROLOGY Egyptian journal of neurosurgery Pub Date : 2024-03-11 DOI:10.1186/s41984-024-00273-w
Mohsin Fayaz, Azhar Khalid, Abrar Ahad Wani, Sajad Hussain Arif
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Abstract

A ventriculoperitoneal (VP) shunt is a cerebral shunt that diverts excess cerebrospinal fluid (CSF).Obstruction in the normal outflow or decreased absorption of the fluid is the usual cause. Hydrocephalus is treated by cerebral shunts.In paediatric patients, untreated hydrocephalus can be lethal and leads to many adverse effects including increase irritabilities, chronic headaches, learning difficulties, visual disturbances, and, in more advanced cases, severe mental retardation. Malfunction of the shunt with excess CSF accumulated can increase the intracranial pressure resulting in cerebral oedema and ultimately herniation. To study and evaluate the mechanical causes of shunt failure and their surgical remedies and reduce the preventable morbidity, cost and mortality associated with shunt failure. We conducted a prospective observational study including 70 patients who developed pure mechanical shunt failure for the first time from 2017 to 2020 in the Department of Neurosurgery Sher-i-kashmir Institute of Medical Sciences. Patients with previous shunt surgeries which include VP shunting and shunt revision or failure and shunt infections were excluded. Identity of all the patients has been kept anonymus. Written informed consent was obtained from all patients or their guardians in case of minors. Shunt malfunction was in the form of catheter misplacement, kinking, displacement from the ventricle or peritoneal cavity, disconnection, migration,inadvertent suturing of the catheter, air in shunt bulb. We found kinking at the proximal end in 25 (35%) patients as the most common cause of shunt failure. It was mostly as a result of inadequate and less spacious tunnelling made for the reservoir. Inadvertant suturing of shunt while closing abdomen in 7 (10%), shunt disconnection in 6 (8.5%), air in shunt bulb in 2 (2.8%), wrong placement at ventricular end in 10 (14.2%), shunt migration into the brain parenchyma in 5 (7.1%), shunt migration through the anal canal in 1(1.4%), pseudomeningocele around catheter valve in 3 (4.2%), placement of lower end into the preperitoneal space in 4 (5.7%) patients. Shunt surgery is seemingly a straightforward operation for neurosurgeons. But considering the incidence of shunt failure and its associated morbidity and mortality, it should always be done with trepidation and extreme caution. Exclusive mechanical shunt malfunction is a major concern and leads to great deal of morbidity in the shunt operations. However, there are trivial remedies and technical nuances which needs to be followed during surgery to avoid these complications.
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脑积水机械分流失效:一种常见但可补救的并发症,技术上存在细微差别
脑室腹腔分流术(VP)是一种脑分流术,用于分流多余的脑脊液(CSF)。在儿科患者中,未经治疗的脑积水可能是致命的,并会导致许多不良后果,包括烦躁不安、慢性头痛、学习困难、视力障碍,在晚期病例中还会导致严重的智力迟钝。分流器功能失常,积聚过多的 CSF 会增加颅内压,导致脑水肿,最终导致脑疝。为了研究和评估分流失效的机械原因及其手术治疗方法,降低与分流失效相关的可预防的发病率、费用和死亡率。我们开展了一项前瞻性观察研究,其中包括 2017 年至 2020 年在舍-伊-克什米尔医学科学研究所神经外科首次出现纯机械分流失效的 70 名患者。既往接受过分流手术(包括 VP 分流和分流修正或失败以及分流感染)的患者被排除在外。所有患者的身份均匿名。所有患者或未成年人的监护人都已获得书面知情同意。分流管故障的形式包括导管错位、扭结、从心室或腹腔移位、断开、移位、导管缝合不慎、分流管球内有空气。我们发现,25 名患者(35%)的分流管近端扭结是分流管失效的最常见原因。这主要是由于蓄水池的通道不够宽敞造成的。7例(10%)患者在关闭腹部时不慎缝合了分流管,6例(8.5%)患者分流管断开,2例(2.8%)患者分流管球内有空气,10例(14.2%)患者在心室末端错误放置分流管,5例(7.1%)患者分流管移入脑实质内,5例(7.1%)患者分流管移入脑实质内。1%)、分流管移入肛管 1 例(1.4%)、导管瓣膜周围假性门脉畸形 3 例(4.2%)、下端置入腹膜前间隙 4 例(5.7%)。对于神经外科医生来说,分流手术似乎是一项简单易行的操作。但考虑到分流失效的发生率及其相关的发病率和死亡率,在进行手术时应始终战战兢兢,极为谨慎。在分流手术中,独家机械分流失灵是一个主要问题,会导致大量的发病率。然而,在手术过程中需要遵循一些琐碎的补救措施和技术上的细微差别,以避免这些并发症的发生。
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