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Table of Contents    
CASE REPORT
Year : 2021  |  Volume : 69  |  Issue : 5  |  Page : 1394-1396

Retroperitoneal Migration And Transgluteal Extrusion of a Distal Lumboperitoneal Shunt Catheter: An Unusual Complication of Cerebrospinal Fluid Shunt


Department of Neurosurgery, University Hospital, St. Ivan Rilski, Medical University, Sofia, Bulgaria

Date of Submission13-Dec-2017
Date of Decision17-Jul-2019
Date of Acceptance07-Oct-2019
Date of Web Publication30-Oct-2021

Correspondence Address:
Surchev K Jivko
Department of Neurosurgery, University Hospital, St. Ivan Rilski, 15, Akad. Ivan Geshov Str., Sofia - 1431
Bulgaria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.329540

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 » Abstract 


Cerebrospinal fluid shunts provide many and different complications. Only 1–3% of them are rare, related to migration, and perforation of hollow organs. Even more unusual are the complications associated with the distal catheter leaving the peritoneal cavity and the tip migrating through some of the anatomical foramens to the muscle layers on the back. We present a rare complication, migration of the distal lumboperitoneal shunt catheter through the retroperitoneum and the gluteal muscles to the hypoderma. The peritoneal catheter entered the retroperitoneal area, passed through the greater sciatic foramen below the piriformis, and through the gluteal muscles, before it reached the hypodermal area. Despite the continuous improvement of the material of flexible silicone catheters, injuries of hollow organs with subsequent migration to unusual areas still occur. Our case is the only one that has been reported, in which the catheter made its way through the retroperitoneum and the gluteal muscles.


Keywords: Catheter migration, CSF shunt, rare complications, transgluteal
Key Message: I present a very rare CSF shunt complication.


How to cite this article:
Jivko SK. Retroperitoneal Migration And Transgluteal Extrusion of a Distal Lumboperitoneal Shunt Catheter: An Unusual Complication of Cerebrospinal Fluid Shunt. Neurol India 2021;69:1394-6

How to cite this URL:
Jivko SK. Retroperitoneal Migration And Transgluteal Extrusion of a Distal Lumboperitoneal Shunt Catheter: An Unusual Complication of Cerebrospinal Fluid Shunt. Neurol India [serial online] 2021 [cited 2021 Nov 30];69:1394-6. Available from: https://www.neurologyindia.com/text.asp?2021/69/5/1394/329540




One of the most frequent surgeries in children's neurosurgery is the implantation of cerebrospinal fluid (CSF) shunt. Although it is not a complicated technique, or perhaps because of that, 20–70% of implanted shunts are being revised.[1],[2] The more frequent and common complications are malfunctions due to obstruction of the proximal or distal catheter or the valve mechanism. On rare occasions [1–10%] there is migration or disconnection of the shunt or parts of it.[3] Even smaller is the rate (1–3%) of complications, associated with perforation of hollow organs and protrusion through the anus, vagina, or urethra.[4],[5],[6] In more than a half of the cases with perforation, the patients are asymptomatic or with protrusion of the distal catheter through the anus, urethra, or mouth.

In extremely rare instances, the complications are associated with the distal catheter leaving the peritoneal cavity through some of the anatomical openings (foramens) of the anterior wall of the abdominal cavity or to the muscle layers of the back. In literature, there is only one case of breakthrough through the muscles to the undercoat on the back.


 » Case History Top


We present a rare complication of migration of the distal shunt catheter from the abdominal cavity through the retroperitoneum to the hypoderm in the area of the gluteal muscles. Before publishing this case, we obtained informed consent from the mother of the patient.

A female child (aged 4 years and 3 months) underwent a shunt procedure at the age of 20 months with a Codman–Hakim lumboperitoneal shunt, because of internal and external hydrocephalus. Five months later, due to shunt malfunction data (increased intracranial pressure, tensed craniotomy after ventriculostomy), an additional third ventriculostomy was made. Thirty months after the shunt implantation a swelling in the left gluteus occurred, 4 cm left lateral to the midline of coccygeal projection level. The general surgeon suspected a hypodermal abscess (no ultrasonography was done). He made an incision and found the tip of the distal catheter. No fluid was flowing through it. The child was afebrile and without any complaints except the finding, so only an incision and no drainage were made. The patient was sent to a specialized children's neurosurgery clinic. [Figure 1]a represents a photograph from the physical examination on which can be seen the actual position of the migrated peritoneal catheter tip.
Figure 1: (a) Image from physical view which shows the exact location of peritoneal catheter's top migration; (b) conventional radiography of abdomen; (c) 3D CT (subsequent noncontrast CT 3D imaging)

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The overview conventional radiography of the abdomen [Figure 1]b shows the correct position of the spinal catheter and the valve mechanism. The peritoneal catheter passes from the peritoneal area in the retroperitoneum and between the muscle fibers of the gluteal muscles before reaching the subcutaneous area. The results of a three dimensional (3D) computed tomography study [subsequent noncontrast computed tomography (CT) 3D imaging], led to the conclusion that in unexpected circumstances the catheter tip had passed through the greater sciatic foramen below the piriformis [Figure 1]c. It was a matter of chance that after entering the retroperitoneal space the catheter passed between the muscle fibers of a whole group of muscles to reach the subcutis 4 cm left lateral to the midline of coccygeal projection level.

We performed a surgical revision, during which we disconnected the peritoneal catheter from the valve. We removed the proximal catheter and the valve mechanism. After suturing the incision and dressing the wound, we extirpated the peritoneal catheter by pulling it out of the gluteal area.

Postoperatively, the child had no complaints and was afebrile, without any evidence of peritonitis or intracranial hypertension. The lack of intracranial hypertension was most likely due to the additional third ventriculostomy.


 » Discussion Top


We present this case because of the lack of similar cases described in the literature. There is only one reported migration of a catheter tip which cut through the muscles of the back to the hypoderm at the level of the lower thoracic vertebrae paraspinal.[7] Unlike this case, the one we describe is with a malfunctioning shunt. The fact that these two cases are rare is probably due to the thicker muscles of the back, compared to those of the anterior abdominal wall.

In the literature, there is still no unanimous opinion on the cause and mechanism for drilling hollow abdominal organs or for the catheter migrating from the abdominal cavity through anatomical openings. Perforation may occur at the time of implantation or later (even years after the intervention).

It is assumed that perforations are a result of chronic inflammatory processes and not of operative trauma.[8] A freely moving catheter may lead to the serosa of a hollow organ and as a result of CSF pulsations can penetrate the organ wall. This is the mechanism in which the tip of the catheter is fixed in the excavation of the peritoneum, covering the natural opening of the peritoneum. Some authors accept that increased intraabdominal pressure occurring when the distal end of the peritoneal catheter is fixed can lead to erosion and perforation of the wall.

Most often, these complications are due to the fixed contact of the tip of the distal catheter with a visceral organ[9] or with the peritoneum “cushioning” a natural opening. If the catheter is hard, perforation is more likely. With the introduction of soft and flexible catheters at the end of last century, we observe a reduction in the frequency of these rare complications.[10]


 » Conclusion Top


For the distal shunt catheter to exit the abdominal cavity is a very rare and unpredictable complication. Migration after a breakthrough of a hollow visceral organ or through a natural anatomical opening requires the removal of the extruded shunt, control of a potential infection and, if necessary, CSF diversion.

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.



 
 » References Top

1.
Wang JY, Jackson EM, Jallo GI, Ahn ES. Shunt revision requirements after posthemorrhagic hydrocephalus of prematurity: Insight into the time course of shunt dependency. Childs Nerv Syst 2015;31:2123-30.  Back to cited text no. 1
    
2.
Kaestner S, Poetschke M, Roth C, Deinsberger W. Different origins of hydrocephalus lead to different shunt revision rates. Neurol Neurochir Pol 2017;51:72-6.  Back to cited text no. 2
    
3.
Weprin BE, Swift DM. Complications of ventricular shunts. Tech Neurosurg 2002;7:224-42.  Back to cited text no. 3
    
4.
Ezzat AA, Soliman MA, Hasanain AA, Thabit MA, Elshitany H, Kandel H, et al. Migration of the distal catheter of ventriculoperitoneal shunts in pediatric age group: Case series. World Neurosurg 2018;119:e131-7.  Back to cited text no. 4
    
5.
Harischandra LS, Sharma A, Chatterjee S. Shunt migration in ventriculoperitoneal shunting: A comprehensive review of literature. Neurol India 2019;67:85.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Chugh A, Gotecha S, Amle G, Patil A, Punia P, Kotecha M. Abnormal migration and extrusion of abdominal end of ventriculoperitoneal shunt: An experience of eight cases. J Pediatr Neurosci 2018;13:317.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Greene J, Valerie C. Retroperitoneal, paraspinal migration of distal ventriculoperitoneal shunt catheter: A peculiar complication of cerebrospinal fluid shunt. Pediatr Neurosurg 2013;49:86-8.  Back to cited text no. 7
    
8.
Teegala R, Kota LP. Unusual complications of ventriculo peritoneal shunt surgery. J Neurosci Rural Pract 2012;3:361-4.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Surchev J, Georgiev K, Enchev Y, Avramov R, Di Rocco C. Extremely rare complications in cerebrospinal fluid shunt operations. J Neurosurg Sci 2002;46:100-3.  Back to cited text no. 9
    
10.
Borkar SA, Mahapatra AK. Ventriculoperitoneal shunt catheter protrusion through the anus. Childs Nerv Syst 2012;28:341-2.  Back to cited text no. 10
    


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