Keywords
ventriculoperitoneal shunt - catheter displacement - shunt complication
Palavras-chave
derivação ventriculoperitoneal - migração de cateter - complicação da derivação
Introduction
The ventriculoperitoneal shunt method is commonly used in neurosurgical practice for the treatment of comorbidities related to the production or drainage of cerebrospinal fluid, being recognized since the appearance of the first valves removed for this purpose in 1950 by Holtes and Spitz.[1] It is commonly used for the treatment of idiopathic intracranial hypertension.[2] However, despite their considerable effectiveness, these devices are often plagued by mechanical and functional failures.
These complications, which commonly occur in the shunt distal catheter, are caused by mechanical failures, bacterial infections, and displacements with extrusion of the peritoneal connection to the subcutaneous tissue.[3]
In the present report, we present a recent case of an obese patient with migration of the tip of the distal catheter to the abdominal subcutaneous adipose tissue, requiring two sequential surgical reviews. After using and failing conventional practices of sutural repositioning and anchoring, we used the experimental technical application of coupling and extension of the distal catheter from the connector to a second catheter. The technique apparently proved to be efficient in the search for reducing the complications related to it is displacement without compromising the possibility of subsequent surgical revision of different needs.
Methodology for Literature Review
Methodology for Literature Review
The information and references contained in the review of the present article were obtained through research on a search platform, using the SciELO, PubMed, and Up to Date databases looking for more recent data on the topic.
The keywords and search strategies, used to review the topic Pseudotumor cerebri and looking for historical precedents similar to the case presented, were: pseudotumor AND cerebri, ventriculoperitoneal AND shunt AND obese. It was also used to collect updated information a time limit for works produced in the past 5 years.
Case Report
Female patient, 52 years old, body mass index (BMI) = 45.88 (1.52 cm and 106 kg). Initially admitted with a clinical condition of holocranial headache, presenting the upper limit on the numerical rating scale (NRS), claiming to be the worst pain of her life, persistent, without symptomatic relief with the use of analgesics and progressive for 7 days, along with nausea and emesis. On clinical examination, the patient presented papilledema. In imaging studies, it did not show any significant radiological alterations or something that justified the current clinical alterations. For diagnostic confirmation, a tap test was performed with the use of a digital spinal manometer with an opening pressure of 15 mmHg and with symptomatic relief after removal of 30 ml of cerebrospinal fluid, leading to the diagnostic confirmation of idiopathic intracranial hypertension (IIH).
First, the patient follows the clinical management with acetazolamide, a carbonic anhydrase inhibitor commonly used in the treatment of IIH; however, after using the drug in the ideal dose, the patient did not show any clinical improvement; therefore, surgical intervention was chosen.
Ventriculoperitoneal shunt (VPS) was performed using the stereotaxic method, without complications of the surgical procedure, just with the presence of only ∼ 11 cm of the distal catheter in the intraperitoneal region. Along with the clinical improvement of the previous symptoms of the patient, it was observed relief in the immediate postoperative period, and she was discharged 2 days after the surgery.
Seven days after the surgery, the patient returned to medical care with abdominal pain. For the investigation, an ultrasound of the abdomen was performed, in which a liquid collection was found in the subcutaneous tissue with extrusion of the distal catheter from the intraperitoneal region – with its displacement to the subcutaneous region, causing dissection of the abdominal subcutaneous mesh and, therefore, pain.
The distal catheter was repositioned using anchoring techniques. However, after 5 days, the patient returned to medical care, presenting with recurrence of abdominal pain similar to the previous one.
Due to the persistence of the case, it was decided to order a second distal catheter from the VPS along with an appropriate connector for catheters. As operative technique, the connection of two distal catheters connected from the connector was chosen in order to obtain a greater length of the catheter in the intraperitoneal region. No changes were made to the proximal catheter.
Today, 8 months after the last surgery, the patient presents complete improvement of the signs and symptoms of both cephalic issues and abdominal pain.
Discussion
Peritoneal complications of VPS are previously known and widely exposed, being described in the literature with the need for surgical revision of the distal tip of the peritoneal catheter due to displacement in ∼ 50% of cases.[4] Obesity is considered an independent risk factor for migration of the distal catheter (odds ratio = 6.38, 95% confidence interval [CI] = 1.16–35.21; p = 0.033).[5]
However, this correlation is not yet fully physiopathologically elucidated, but it is believed that the increase of intra-abdominal pressure is one of the causes responsible for the susceptibility to displacement. It is important to highlight the direct linear relationship between the increase in BMI and the increase in intra-abdominal pressure (r = 0.52; p = 0.018) with a deviation of 0.31 (p = 0.001).[6] The sum of these relationships is notable when the epidemiological correlation between this complication and the incidence in obese patients is noticeable.[7] The interaction of the hydrophilic characteristics of the catheter, which, on one hand, helps to reduce scar fibrosis, but makes it more susceptible to uncoupling, is also significant.[8]
The results obtained with the process of extending the distal catheter through a connected connector are favorable to the belief that this technique is opportune in preventing migration of the tip of the peritoneal catheter in the case of obese patients, with great thickness of the subcutaneous adipose panicle and increased intra-abdominal pressure.
The technique is interesting because it does not require changes in the size of the standard incision, and it does not compromise the opportunity for subsequent surgical revision, a difficulty found in the subcutaneous anchoring techniques. However, despite the success achieved by the team, it is important to note that, the technique does not change the difficulties generated by the low coefficient of friction between the catheter and the adipose tissue, requiring more case studies to confirm its widespread efficacy.
In our research, we found two case reports also describing alternative techniques for the resolution of recurrence of displacement of the peritoneal catheter. However, none of the narrated techniques fully resembles the one used in the present case. Morrison et al reported a method performed on three patients using synthetic mesh for hernias to increase the friction of the catheter and prevent its retropulsion.[1] In 2017, Carnevale et al. detailed the procedure performed, successfully, with modification using the T connector[8]
Conclusions
The present study supports the use of the distal catheter extension technique with the use of a connector and complement of two continuous tubes aiming to prophylactically reduce the incidence of extrusion of the peritoneal tip for patients with high BMI. The results of the study support the need for further investigation seeking knowledge of the effectiveness and safety of the technique employed.
Fig. 1 FLAIR-weighted nuclear magnetic resonance imaging showing unaltered ventricular system and brain parenchyma evidencing the absence of hydrocephalus and indicating idiopathic intracranial hypertension.
Fig. 2 T-connector used to set and extend the distal tip of the ventricle peritoneal shunt system catheter to prevent displacement: (A) receives the first catheter from the shunt. (B) This end of the connector remains closed. (C) The tip that receives the peritoneal catheter.
