PEDIATRIC SURGERY UPDATE ©

VOLUME 52 NO 01 JANUARY 2019

Ventriculo-Pleural Shunts

Shunting of cerebrospinal fluid (CSF) into extracranial sites usually include the use of the peritoneum (ventriculo-peritoneal shunt) and atrium (ventriculo-atrial shunt) for palliation of symptoms associated with hydrocephalus. Another alternative includes the use of the pleura for absorption of the CSF using a ventriculo-pleural shunt in selected patient when conventional sites  not suitable either due to adhesions, infection, thrombosis or obliteration. Ventriculo-pleural shunts are an acceptable alternative for CSF decompression in children as well among adults patients. It is estimated that up to 50% of children will experience a failure of any shunt within the first year. Clinical manifestations of early shunt failure include nausea, vomiting, irritability, altered consciousness, bulging fontanelle among infants. Depress level of consciousness and loss of milestone are the main indication of late shunt failure. CSF shunts complications are either mechanical, functional or infectious in nature. Mechanical complications include obstruction of the shunt, fracture or disconnection of the device and migration. In-growth of portions of the choroid plexus or ependymal surface of the ventricles into the inlet holes of the proximal catheter accounts for the most common cause of obstruction. CSF malabsorption leads to abnormal accumulation of the fluid resulting in functional failure of the shunt. The most common complication of ventriculo-pleural shunts (VPLS) is pleural effusion. Only 20% of the pleural effusions are symptomatic requiring revision and most of these patients are infants. Anti-siphon devices seem to reduce the incidence of pleural effusion. The hydrothorax associated with VPLS is due to impaired pleural absorption and excessive drainage of CSF into the pleural space. The fluid is clear transudate with some mononuclear cells. In most cases of pleural effusion the fluid resolves spontaneously. Pleural CSF effusion might result in respiratory distress needing thoracentesis. Administration of acetazolamide reduces CSF production and reduces respiratory symptoms. With recurrent or worsening of symptom shunt replacement must be undertaken.

References:
1- Khan TA, Khalil-Marzouk JF: Fibrothorax in adulthood caused by a cerebrospinal fluid shunt in the treatment of hydrocephalus.  J Neurosurg. 109(3):478-9, 2008
2- Irani F, Elkambergy H, Okoli K, Abou DS: Recurrent symptomatic pleural effusion due to a ventriculopleural shunt. Respir Care. 54(8):1112-4, 2009
3- Kupeli E, Yilmaz C, Akcay S: Pleural effusion following ventriculopleural shunt: Case reports and review of the literature. Ann Thorac Med 5(3): 166-170, 2010
4- Richardson MD, Handler MH: Minimally invasive technique for insertion of ventriculopleural shunt catheters. J Neurosurg Pediatr. 12(5):501-4, 2013
5- Alam S, Manjunath NM: Severe respiratory failure following ventriculopleural shunt. Indian J Crit Care Med. 19(11): 690-692, 2015
6- Hanak BW, Bonow RH, Harris CA, Browd SR: Cerebrospinal Fluid Shunting Complications in Children. Pediatr Neurosurg. 52(6):381-400, 2017

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*Edited by: Humberto Lugo-Vicente, MD, FACS, FAAP
P.O. Box 10426, Caparra Heights Station, San Juan, Puerto Rico 00922-0426
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Pediatric Surgery Update ISSN 1089-7739
Last updated: February 2019