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Table of Contents    
ORIGINAL ARTICLE
Year : 2013  |  Volume : 61  |  Issue : 5  |  Page : 513-516

Comparative study of lumboperitoneal shunt versus ventriculoperitoneal shunt in post meningitis communicating hydrocephalus in children


1 Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
2 Department of Surgery, GSVM Medical College, Kanpur, Uttar Pradesh, India

Date of Submission31-Jul-2013
Date of Decision09-Aug-2013
Date of Acceptance20-Oct-2013
Date of Web Publication22-Nov-2013

Correspondence Address:
Amit Singh
Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.121932

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 » Abstract 

Background: Managing post meningitis hydrocephalus in children is a herculean task for the treating pediatric surgeon or neurosurgeon because of the morbidity associated with the disease per se and the complications of shunt surgery. By this study, the effectiveness of lumboperitoneal (LP) shunt and ventriculoperitoneal (VP) shunt in cases of post meningitis communicating hydrocephalus was assessed in children. Materials and Methods: This was a retrospective analysis of the records of children admitted in our institute between December 2005 and March 2008. Only children with post meningitis communicating hydrocephalus who underwent either LP or VP with a minimum follow-up period of 36 months were included in the study. Children with non-communicating hydrocephalus or hydrocephalus due to another etiology were excluded. Investigations were included plain brain computed tomography scan, air encephalography and X-ray skull. Medium pressure Chabbra shunt with slit valves was used in all cases of VP and LP shunt. A comparative analysis of the outcome was carried out between the two groups. Results: There were 66 males and 24 females (M: F 2.7:1. The average age at presentation was 40.3 months. LP shunt was performed in 37 while VP shunt in 53 cases Complication rate in the LP and VP shunt was 15% and 29% respectively with non-obstructed complications higher in VP group when compared to LP group. Obstructed complication rate was similar in both groups. Conclusion: Due to less morbidity and ease of placement, LP shunt can be an alternative to VP shunt in cases of communicating hydrocephalus in children, which has more non-obstructed complication rates as compared to LP shunt.


Keywords: Communicating hydrocephalus, lumboperitoneal shunt, ventriculoperitoneal shunt


How to cite this article:
Singh A, Vajpeyi I N. Comparative study of lumboperitoneal shunt versus ventriculoperitoneal shunt in post meningitis communicating hydrocephalus in children. Neurol India 2013;61:513-6

How to cite this URL:
Singh A, Vajpeyi I N. Comparative study of lumboperitoneal shunt versus ventriculoperitoneal shunt in post meningitis communicating hydrocephalus in children. Neurol India [serial online] 2013 [cited 2017 Dec 13];61:513-6. Available from: http://www.neurologyindia.com/text.asp?2013/61/5/513/121932



 » Introduction Top


Hydrocephalus in children is a surgical disease usually not amendable to medical treatment. Various types of shunt are described for cerebrospinal fluid (CSF) diversion with ventriculoperitoneal (VP) shunt gaining the acceptability over others. Lumboperitoneal (LP) shunts, which have gained wide acceptance as an alternative to VP shunt in adults, is still an unknown entity for pediatric surgeons. The most common causes of hydrocephalus in children are tubercular meningitis followed by congenital hydrocephalus. Shunt surgery in children is associated with more morbidity than in adults. This study assesses the role of LP shunt in communicating hydrocephalus along with comparison with VP shunt in term of efficacy and morbidity.


 » Materials and Methods Top


This was a retrospective analysis of case records of children admitted with a diagnosis of post meningitis communicating hydrocephalus between December 2005 and March 2008. Institute's ethical committee clearance was obtained for the study. Children below 12 years of age with post-meningitis communicating hydrocephalus who had undergone either LP or VP shunt and followed-up for a period of minimum 36 months were included in the study. Children with non-communicating hydrocephalus, hydrocephalus due to other etiology, children with follow-up period less than 36 months, incomplete data, lost to follow-up were excluded from the study. Communicating hydrocephalus was defined as the presence of panventriculomegaly with normal or widened sulci. To diagnosis Communicating hydrocephalus, we have performed air encephalogram which is the gold standard for diagnosis of communicating hydrocephalus. Air encephalogram was performed by doing lumbar puncture in aseptic conditions and injecting about 5 ml of air after withdrawing same amount of CSF from the subarachnoid space. Plain X-ray skull anterior posterior and lateral view was taken after 5 min in a sitting position. Air in the ventricles confirmed the diagnosis of communicating hydrocephalus. Indications for CSF shunting were assessed on the basis of neurological symptoms and computed tomography (CT) findings. Both the shunts were performed under general anesthesia by single experienced surgeon. Medium pressure Chabbra shunt with slit valve was used for VP as well as LP shunt.

For performing LP shunt child was placed in right lateral decubitus position and a field is prepared and draped extending from the midline of the lumbar region around the left flank to the left lower quadrant. The peritoneal cavity is opened through a muscle splitting incision. Longitudinal midline incision given in the mid lumbar region and thecal space is opened. Proximal end of the shunt is placed in the thecal sac and the distal end is tunneled to the abdominal incision. The distal end is placed in the peritoneal cavity and wounds are closed.

For VP shunt child was placed in the supine position with extension and tilting of the neck to the opposite side where the incision is to be made. Incision was given over the posterior parietal scalp just below parietal prominence. The flap is raised and a burr hole is made over one half of the line joining the internal auditory meatus to the vertex. Next an abdominal incision is made 2 cm below the costal margin along a straight line with cranial incision. Proximal end of VP shunt is placed into the frontal horn of the lateral ventricle and the distal end tunnels through the subcutaneous space up to the abdominal incision. Distal end is placed in the peritoneal cavity and wounds are closed.

Follow-up include 3 monthly visits to the hydrocephalus clinic in 1 st year followed by 6 monthly in 2 nd year and yearly thereafter. During follow-up, CT was done at 6 months and 1 year post surgery. In each follow-up visit, children were examined for signs of raised intracranial pressure and if required fundoscopy were done to document papilledema.


 » Results Top


A total of 147 hydrocephalus children were admitted between December 2005 and March 2008. Out of these children, 109 children had post-meningitis hydrocephalus. Out of the 109 children, 9 (8.2%) children were lost to follow-up while 6 (5.5%) children were aged more than 12 years. Records of 4 (3.6%) children were found to be incomplete. Only 90 children satisfying the criteria were included in the study. There were 66 males and 24 females (M:F 2.7:1). The average age at presentation was 40.3 months. VP shunt was performed in 53 (58.8%) children while 37 (41.1%) underwent LP shunt. Most common presenting symptom was increasing head size followed by fever [Table 1]. Glasgow coma scale (GCS) at the time of presentation and at the time of discharge is shown in [Table 2]. GCS categories in the two groups are statistically not significant. Improvement in GCS was seen in both groups during the follow-up [Table 2]. The complications associated with both LP and VP shunts after a mean follow-up period of 41.9 months (range: 36-54 months) are shown in [Table 3]. Among children with VP shunt, revision of the shunt was required in 12 (22.6%) children and in 5 (13.5%) children with LP shunt. Seizure disorder was seen in 3 (5.6%) children with VP Shunt while none in LP shunt group. There were 2 (3.7%) deaths in VP shunt group while none in LP shunt groups. Death of both the children was not related to surgical procedure. One of them expired because of fungal septicemia (mucormycosis) while the other child expired because of pneumonitis. Shunt obstruction rate was similar in both LP as well VP groups, while non-obstructive complication rate was higher in VP shunt group when compared to LP shunt group. In VP shunt group, follow-up CT scan done at 6 months and 1-year post surgery showed regression of hydrocephalus in 41 (41/53) patients and in LP shunt group regression of hydrocephalus was seen in 31 (31/37) patients. Overall complication rate seen in cases of VP shunt was 45.2% while 16.2% in cases of LP shunt.
Table 1: Major clinical presentation in children with hydrocephalus

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Table 2: GCS at the time of presentation and at the time of discharge

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Table 3: Complications in ventriculoperitoneal and lumboperitoneal shunt

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 » Discussion Top


Hydrocephalus has been a challenge for the treating surgeons throughout the history of medicine since Hippocrates described the disease as water on the brain in 5 th century B.C. [1] Over the years the physicians are trying to understand the hydrodynamic and pathophysiology of this complex neurological disorder. Hydrocephalus is a condition characterized by excessive accumulation of CSF in the ventricles either due to blockage of CSF outflow in the ventricles or in the subarachnoid space, or due to excessive production of CSF mainly because of malignancy, the former being more common than the latter. CSF is produced in the brain by modified ependymal cells in the choroid plexus (approx. 50-70%) and the remainder is formed around blood vessels and along ventricular walls. It circulates from the lateral ventricles to the foramina of Monro (interventricular foramina), third ventricles, and aqueduct of Sylvius (cerebral aqueduct), fourth ventricles, foramen of Magendie (median aperture) and foramina of Luschka (lateral apertures), subarachnoid space over the brain and spinal canal. The CSF contains approximately 0.3% plasma proteins, or approximately 15-40 mg/DL, depending upon sampling site and it is produced at a rate of 500 ml/day. [2] Since the subarachnoid space around the brain and spinal cord can contain only 135-150 ml, large amounts are drained primarily into the blood through the arachnoid granulations in the superior sagittal sinus. Thus the CSF turns over about 3.7 times a day. This continuous flow into the venous system dilutes the concentration of larger, lipid-insoluble molecules penetrating the brain and CSF. [3] CSF pressure, as measured by lumbar puncture, is 10-18 cm H 2 O (8-15 mm Hg or 1.1-2 kPa) with the patient lying on the side and 20-30 cm H 2 O (16-24 mm Hg or 2.1-3.2 kPa) with the patient sitting us. [4] In newborns, CSF pressure ranges from 8 to 10 cm H 2 O (4.4-7.3 mm Hg or 0.78-0.98 kPa). The CSF protects the brain and spinal cord from injury by providing a liquid cushion and is continually being produced, circulated and absorbed.

Hydrocephalus can either be classified as congenital and acquired or as communicating and non-communicating. Congenital hydrocephalus accounts for >70% of cases. The most obvious indication of hydrocephalus in children and infants is often a rapid increase in head circumference or an unusually large head size. Other symptoms may include vomiting, sleepiness, irritability, downward deviation of the eyes (also called "sunsetting"), and seizures. The most common symptoms seen in our study group were an increase in head size 35 (38.8%) followed by irritability 22 (24.4%) and vomiting 15 (16.6%). The outcome of shunt surgery has been unsatisfactory thus more than 20 shunting approaches have been suggested until now. These include VP shunt, ventriculoatrial shunt, ventriculothoracic shunt, ventriculosagital shunt, LP shunt etc., Despite having a high incidence of shunt obstruction and seizure disorder, VP shunt is extensively used for shunting in all types of hydrocephalus. [5],[6] On the other hand use of an LP shunt, which is available for last four decades does not achieve wide acceptance despite having a low complication rate. Various authors have demonstrated the effectiveness of an LP shunt in the treatment of various forms of communicating hydrocephalus. [7],[8],[9],[10],[11],[12],[13],[14] LP shunt has several advantages and disadvantages an over VP shunt as described by Aoki [5] LP shunt being a totally extra cranial shunt, chances of meningitis, subdural hematoma or ventriculitis does not exist.

In our series, infection rate found in LP shunt group was 5.4% while the shunt blockage rate was 10.8%, which is in consonance with other reported series. [15],[16],[17] Infection rate in VP shunt group was 16.9% while shunt blockage rates was 9.4%. The reported infection and obstruction rate in VP shunt varies from 0% to 13.8% [18] and 70% of infection was seen within 2 months of surgery as described by Lima et al. [19] In our study group, incidence of infection was similar across all age group a finding in contrast to what has been described by Kulkarni et al. and Dallacasa et al. [20],[21] We do not encounter any unusual complications (excessive drainage, scoliosis, arachnoiditis, cysts, abscess etc.) in LP shunt group as described by Chumas et al. [8] despite a long follow up period. In one case of VP shunt, catheter migrating into the scrotum through patent processus vaginalis was seen which required revision of shunt along with herniotomy. The infection rate in our study was higher in cases of VP shunt as compared to LP shunt though the shunt obstruction rates found to be similar in both groups. This is the highlight of our study showing that despite being operated by a single surgeon thereby eliminating all the compounding factors, complication rates are higher in cases of VP shunt when compared to LP shunt. Though our series is limited due to its retrospective nature, but it effectively highlighted the role of LP shunt in cases of communicating hydrocephalus and in cases where the ventricles are not available for shunting.

LP shunt because of less morbidity and ease of placement can be an alternative to VP shunt in cases of communicating hydrocephalus in children, which has more non-obstructed complication rates as compared to LP shunt.

 
 » References Top

1.Hippocrates: De Morbis. Cited by Whytt R: Observations on the Dropsy in the Brain. Edinburgh: Balfour; 1768. p. 4  Back to cited text no. 1
    
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5.Aoki N. Lumboperitoneal shunt: Clinical applications, complications, and comparison with ventriculoperitoneal shunt. Neurosurgery 1990;26:998-1003;1003.  Back to cited text no. 5
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13.Rosenberg ML, Corbett JJ, Smith C, Goodwin J, Sergott R, Savino P, et al. Cerebrospinal fluid diversion procedures in pseudotumor cerebri. Neurology 1993;43:1071-2.  Back to cited text no. 13
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14.Selman WR, Spetzler RF, Wilson CB, Grollmus JW. Percutaneous lumboperitoneal shunt: Review of 130 cases. Neurosurgery 1980;6:255-7.  Back to cited text no. 14
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17.Duthell R, Christophe N, Fotso MJ, Beauchesne P, Jacques B. Lumbo Peritoneal Shunting In: Schmidek, Sweet, (Ed). Operative Neurosurgical Techniques, Indications, Methods and Results. Philadelphia: WB Saunders; 2000:604-7.  Back to cited text no. 17
    
18.Epstein, FJ. Increased intracranial pressure in hydrocephalic children with functioning shunts: A complication of shunt dependency. Concepts in Pediatric Neurosurgery 1983;4:119-130.  Back to cited text no. 18
    
19.Lima MM, Pereira CU, Silva AM. Ventriculoperitoneal shunt infections in children and adolescents with hydrocephalus. Arq Neuropsiquiatr 2007;65:118-23.  Back to cited text no. 19
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20.Kulkarni AV, Drake JM, Lamberti-Pasculli M. Cerebrospinal fluid shunt infection: A prospective study of risk factors. J Neurosurg 2001;94:195-201.  Back to cited text no. 20
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21.Dallacasa P, Dappozzo A, Galassi E, Sandri F, Cocchi G, Masi M. Cerebrospinal fluid shunt infections in infants. Childs Nerv Syst 1995;11:643-8.  Back to cited text no. 21
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    Tables

  [Table 1], [Table 2], [Table 3]

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