|Year : 2013 | Volume
| Issue : 2 | Page : 115-117
Transanal protrusion of ventriculo-peritoneal shunt catheter
Department of Neurosurgery, GSL Medical College, Rajahmundry, Andhra Pradesh, India
|Date of Web Publication||21-May-2013|
M.Ch 80-26-10, A-3, Heritage Residency, A.V. Apparao Road, Rajahmundry - 533103, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Ventriculo-peritoneal (VP) shunting used in the treatment for hydrocephalus is associated with several complications. Bowel perforation is an unusual, but serious complication of VP shunting. We report the case of a 9-month-old girl who presented with transanal protrusion of VP shunt catheter. The shunt catheter was removed and a fresh VP shunt was inserted on the opposite side. Presently, the child is doing well on follow-up.
Keywords: Anal protrusion, bowel perforation, hydrocephalus, ventriculo-peritoneal shunt
|How to cite this article:|
Phani K. Transanal protrusion of ventriculo-peritoneal shunt catheter. J NTR Univ Health Sci 2013;2:115-7
| Introduction|| |
Ventriculo-peritoneal (VP) shunting used in the treatment for hydrocephalus is associated with several complications with a reported incidence of 5-47% of cases.  Bowel perforation with protrusion of VP shunt catheter from anus is reported to occur in <0.1-0.7% of cases.  Perforation occurs mostly without peritonitis. Here, we report a case of transanal protrusion of VP shunt catheter with a review of pertinent literature.
| Case Reports|| |
A 9-month-old female child had undergone a left-sided VP shunt (Chhabra-slit-in-spring silicone shunt) procedure 7 months back for congenital hydrocephalus. She presented to us with complaints of protrusion of a white tube per anus on defecation for past 2 days with clear fluid dripping from it [Figure 1]. On examination, the child was afebrile, alert, and had no neck rigidity, and the abdomen was soft. On rectal examination, there was a white tube coming from beyond the reach of finger. Total leukocyte count was 9200/mm 3 . X-ray of the abdomen showed the course of the shunt tube toward the rectum and anal opening and did not reveal any evidence of gas under diaphragm [Figure 2]. The child was operated and the cranial end was removed through a small incision behind the ear. The distal tube was extracted per rectum. The proximal tube was cultured and was found to be sterile. A revision shunt was done on the right side within 7 days. The child was asymptomatic at 2 months follow-up.
|Figure 2: X-ray of abdomen, erect view showing outline of shunt catheter in the rectal and anal regions|
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| Discussion|| |
VP shunting is among the most frequently performed operations in the management of hydrocephalus, but with a good share of its complications. On an average, each patient operated is likely to have 2-3 operations throughout their childhood for shunt revision. About 80% of the shunts develop complication at some stage. One-third of these complications occur with in the first year of shunt placement.  Migration of distal end of the tube, fibrous encasement of the distal end, kinking, or blockade of the distal end, protrusion of part of shunt through the surgical wound, failure of peritoneal absorption of diverted cerebrospinal fluid (CSF) with resultant ascites and infection are some of the common forms of complications encountered. Visceral perforation is an unusual but serious complication of VP shunting with a reported mortality of upto 15%. Non-enteric viscus perforation has been sporadically reported in literature and includes urinary bladder, vagina, gallbladder, stomach, scrotum, liver, uterus, and urethra. ,,, The bowel, however, is the most commonly involved site for perforation and is reported to occur in <0.1-0.7% of cases.  A search of the literature revealed a total of 94 patients who had bowel perforation with >49 cases reported in the age group 0-10 years.  The above stated count of cases excludes our reported case. Sigmoid and transverse colon followed by stomach are the most frequent sites of gastrointestinal perforations by VP shunts. Of these 94 patients who had bowel perforation, the shunt catheter protruded through the anus in only 55. The interval between shunt insertion to protrusion of catheter from anus ranges from 2 to 20 months with an average of 6.1 months. Peritonitis was found in 7.45%, meningitis in 12.8%, and both the entities together in 3.2% following perforation.  Our patient did not have any peritonitis or meningitis.
The possible factors responsible for perforation are thin bowel wall in children, sharp and stiff end of the VP shunt, , use of trocar by operating surgeons,  chronic irritation by the shunt,  previous surgery, infection, and silicone allergy.  The perforation of the bowel lumen occurs when the shunt tip gets adherent to the serosa of the bowel wall and the continuous water hammer effect of the CSF pulsations sets in a slow drilling mechanism into play. Once the tip of the shunt catheter perforates and makes its entry into the bowel lumen, the peristaltic waves carry forward the long leftover tube in the peritoneal cavity through the entire length of the bowel distally, eventually extruding it through the anal opening. Spillage of the bowel contents into the peritoneal cavity with resulting peritonitis following the removal of the shunt tubing is usually not seen due to the fibrous tract around the catheter, which is attached to the bowel wall.
The management of these patients depends on the clinical presentation. Asymptomatic cases that predominate will need a simple removal of the complete shunt tubing, followed by a fresh surgery at an appropriate time as was done in our case. Presence of meningitis will necessitate the exteriorization of the proximal end with removal of the distal end. Presence of peritonitis will mandate the exteriorization of the proximal end along with an exploratory laparotomy for treating the bowel perforation. 
| Conclusion|| |
Anal protrusion of ventriculo-peritoneal shunt is an uncommon, but well-documented entity. The presentation may be without any symptoms or may be with meningitis and peritonitis. In a patient with simple bowel perforation and no other complications, a formal laparotomy is not required, while presence of peritonitis will necessitate an urgent laparotomy. If detected on time and managed properly, the results are good.
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[Figure 1], [Figure 2]