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LETTERS TO EDITOR
Year : 2018  |  Volume : 66  |  Issue : 6  |  Page : 1831-1833

Umbilical cerebrospinal fluid fistula: Report and a review


1 Department of Neurosurgery, RIMS, Ranchi, Jharkhand, India
2 Department of Neurosurgery, Narayan Medical College, Sasaram, Bihar, India

Date of Web Publication28-Nov-2018

Correspondence Address:
Dr. Anand Kumar Jha
Department of Neurosurgery, Rajendra Institute of Medical Sciences (RIMS), Ranchi, Jharkhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.246239

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How to cite this article:
Jha AK, Kumar S, Kumar J, Sahay C B, Kumar A. Umbilical cerebrospinal fluid fistula: Report and a review. Neurol India 2018;66:1831-3

How to cite this URL:
Jha AK, Kumar S, Kumar J, Sahay C B, Kumar A. Umbilical cerebrospinal fluid fistula: Report and a review. Neurol India [serial online] 2018 [cited 2018 Dec 11];66:1831-3. Available from: http://www.neurologyindia.com/text.asp?2018/66/6/1831/246239




Sir,

A ventriculoperitoneal (VP) shunt is a commonly performed surgical procedure for hydrocephalus of different etiologies. Various complications of VP shunt are well-described in the literature.[1],[2] We report a rare complication of this common procedure, which involved the formation of an umbilical cerebrospinal fluid (CSF) fistula that was demonstrated on imaging of the abdomen.

A 6-year old girl was admitted to our department with a history of clear fluid leaking through the umbilicus for the past 7 days. This was associated with fever. The clinical history revealed insertion of a VP shunt 6 months ago for obstructive hydrocephalus. There was no history of a congenital or acquired abnormality or discharge related to the umbilicus. On examination of the abdominal end of the shunt, egress of clear fluid through the umbilicus was evident [Figure 1]a, although the shunt catheter could neither be seen nor palpated per abdomen. The umbilicus itself appeared normal. Computed tomography (CT) scan of the brain showed hydrocephalus. X-ray of the abdomen [Figure 1] was done that revealed the shunt track. Ultrasound of the abdomen did not reveal any intra-abdominal fluid collection. Analysis of the leaking fluid confirmed it to be CSF with evidence of infection. Antibiotics based on culture and sensitivity reports were administered for the next 7 days. As the infection subsided, as evident by three repeated normal CSF examinations and normal culture reports, the patient was operated for the displaced distal tip of the shunt, wherein adhesions were released, and the peritoneal end of the shunt was placed into the right sub-hepatic area of the abdomen. The patient was discharged on the 10th postoperative day and the follow-up showed absence of any leak. There was subsidence of hydrocephalus.
Figure 1: X-ray of the abdomen clearly revealed the shunt tract

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Complications of VP shunt are well-described. There are only a few case reports in the literature of an umbilical CSF fistula developing following the performance of a VP shunt.[3],[4] The mechanical pressure of a VP shunt and irritation of the anterior abdomen wall structures by the peritoneal end of the VP shunt may be the causative factors resulting in the adhesion of the distal end to the omphalomesentric tract, leading to CSF leak through the umbilicus.[3],[4],[5] Some authors have emphasized on infection being the cause for the umbilical fistula in the cases undergoing a VP shunt,[6],[7] while others have stressed on congenital and anatomical defects.[8],[9]

It is difficult to speculate on the likely cause of the fistulous communication between the peritoneal end of the shunt and umbilicus in the present case as the patient neither had any evidence of infection nor of shunt obstruction before the unique presentation of fluid discharge through the umbilicus.

Infection may probably have been a causative factor resulting in the adhesion of the shunt tube to the urachal remnant, later resulting in a fistula, possibly due to distal CSF flow obstruction (secondary to the underlying infection). X-ray of the abdomen clearly revealed the shunt tract [Figure 1], while clear fluid discharge from the umbilicus is seen in [Figure 2].
Figure 2: On examination for the abdominal end of the shunt, egress of CSF through the umbilicus was evident. The shunt catheter could neither be seen nor palpated per abdomen

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As far as management of such cases is considered, a persistent omphalomesentric tract, when identified, should be operated upon and closed to prevent late complications.[10] The principles of management of such rare fistulae are similar to that being carried out in the other commoner types of shunt malfunctions, consisting mainly of proximal diversion of the leaking fluid, as was done in this case, which results in the healing and closure of the fistula [Figure 3]. Therefore, it is important for clinicians to be aware of this complication. An early detection of these umbilical discharges after a VP shunt will enable the initiaiton of an early management.
Figure 3: Proximal diversion of the ventriculoperitoneal shunt led to the healing and closure of the fistula

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gupta A, Ahmad FU, Kumar A, Gaikwad S, Vaishya S. Umbilical CSF fistula: A rare complication of ventriculoperitoneal shunt. Acta Neurochir (Wien) 2006;148:1205-7.  Back to cited text no. 1
    
2.
Chatterjee S, Harischandra L. Cerebrospinal fluid shunts – How they work: The basics. Neurol India 2018;66:24-35.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Antunes AC, Ribeirio TR. Spontaneous CSF fistula from ventriculoperitoneal shunt drainage. Report of two cases. J Neurosurg 1975;43:481-2.  Back to cited text no. 3
    
4.
Das PC, Radhakrishna K, Rao PL. Spontaneous CSF fistula: A rare complication of ventriculoperitoneal shunt. J Pediatr Surg 1993;28:630-1.  Back to cited text no. 4
    
5.
Pomplili A, Cianfriglia F. Umblical fistula as a complication of ventriculo-peritoneal shunt. Surg Neurol 1979;12:129-30.  Back to cited text no. 5
    
6.
Woon K, Yap Y, Cartmill M. Spontaneous umbilical CSF fistula in an adult as a complication of a ventriculoperitoneal shunt. Br J Neurosurg 2006;20:244-6.  Back to cited text no. 6
    
7.
Eser O, Dogru O, Aslan A, Kundak AA. Umbilical perforation: An unusual complication of a ventriculoperitoneal shunt. Childs Nerv Syst 2006;22:1509-10.  Back to cited text no. 7
    
8.
Mohindra S, Singla N, Gupta R, Gupta SK. CSF fistula through the umbilicus following a shunt surgery: A case report and literature review. Pediatr Neurosurg 2007;43:396-8.  Back to cited text no. 8
    
9.
Ardalan M, Rafati AH, Nejat F, Khashab ME. Umbilical hernia and ventriculoperitoneal shunt complications. Iran J Pediatr 2011;20:127-8.  Back to cited text no. 9
    
10.
Wani AA, Ramzan A, Wani MA Protrusion of a peritoneal catheter through the umblicus: An unusual complication of a ventriculoperitoneal shunt. Pediatr Surg Int 2002;18:171-2.  Back to cited text no. 10
    


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