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LETTERS TO EDITOR
Year : 2019  |  Volume : 67  |  Issue : 3  |  Page : 903-905

Pleuro-peritoneal (PLP) shunt in paediatric hydrocephalus: A report


Department of Neurosurgery, Medica Superspecialty Hospital, Kolkata, West Bengal, India

Date of Web Publication23-Jul-2019

Correspondence Address:
Dr. Indrajit Rana
Medica Superspecialty Hospital, 127 Eastern Metropolitan Bypass, Mukundapur, Kolkata - 700 099, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.263192

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How to cite this article:
Tripathy LN, Rana I. Pleuro-peritoneal (PLP) shunt in paediatric hydrocephalus: A report. Neurol India 2019;67:903-5

How to cite this URL:
Tripathy LN, Rana I. Pleuro-peritoneal (PLP) shunt in paediatric hydrocephalus: A report. Neurol India [serial online] 2019 [cited 2019 Nov 21];67:903-5. Available from: http://www.neurologyindia.com/text.asp?2019/67/3/903/263192




Sir,

Post-meningitic multiloculated hydrocephalus is a difficult entity to treat, requiring repeated and multiple drainage procedures. In spite of endoscopic fenestration, septostomy and endoscopic third ventriculostomy, external diversions are frequently necessary. Ventriculo-peritoneal (VP) shunts are commonly done for such cases of hydrocephalus, but with peritoneal complications at times, conversion to ventriculo-atrial (VA) or ventriculo-pleural (VPL) shunt may be required.

We report a case of a 3-year old boy who developed post-meningitic neonatal hydrocephalus with multiple compartments and sequestrated ventricles. The initial right VP shunt got infected, requiring its removal and left frontal Ommaya reservoir insertion for aspiration as well as administration of intraventricular drugs. Intravenous antibiotics were also administered. After control of infection, a fresh left VP shunt was placed and later endoscopic septostomy was done [Figure 1]. The child developed perforation of the small intestine and peritonitis, requiring shunt exteriorization and re-insertion after control of infection. The VP shunt malfunctioned for which a VPL shunt was performed, which worked satisfactorily for some time, but subsequently, the child developed recurrent excessive pleural effusion [Figure 2] requiring frequent aspirations. A pleuro-peritoneal (PLP) shunt was performed to tackle the excessive cerebrospinal fluid (CSF) collection in the pleural cavity. The child remained asymptomatic and the chest X-ray remained satisfactory [Figure 3].
Figure 1: Non-contrast computed tomographic scan of the brain showing the post-endoscopic septostomy status. The left VP shunt is draining both the ventricles

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Figure 2: Chest X-ray: Left sided massive pleural effusion

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Figure 3: X-ray showing good resolution of the left-sided pleural effusion

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VPL shunting for the management of hydrocephalus was first reported by Ransohoff in 1954. The commonest reason for insertion of the VPL shunt is a pre-existing infected VP shunt.[1] In children, VPL shunts may dysfunction due to poor absorption, resulting in excessive pleural collection. Large hydrothorax due to excess CSF accumulation in the pleural cavity has been reported, although rarely.[2] Although timely pleural taps sometimes help in the process, there will be a proportion of children, who would need additional CSF diversion.[3]

PLP shunt as an alternative therapy for pleural effusions in adult was first reported by Alex G, et al., in 1988.[4] The PLP shunt in the management of persistent chylothorax [5] and malignancy [6] in paediatric patients has been reported earlier. The placement of a PLP shunt in persistent hydrothorax of a patient who has already undergone a VPL has never been reported in the literature.

For absorption of fluid from a cavity (e.g., pleural and peritoneal), a functional serosal surface is required.[7] A larger serosal surface has better absorptive capacity. In our case, the child had bowel perforation and peritonitis for which the VP shunt had been converted to the VPL shunt earlier. When he presented with recurrent pleural effusion, the absorption capacity of solely the peritoneal/pleural cavity was in doubt. The PLP shunt increased the absorption capacity by conecting the serosal surface of both pleural and peritoneal cavity [Figure 4]. The PLP shunt is a simple procedure. It should be considered as an alternative method of CSF diversion in patients undergoing a VPL shunt who develop a persistent symptomatic pleural effusion.
Figure 4: Pleuro-peritoneal shunt

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To conclude, the PLP shunt, commonly done for recurrent primary pleural effusion, can be considered in the patients with shunt malfunction due to inadequate absorption of CSF in the pleural cavity and in the patients with symptomatic hydrothorax.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hoffman HJ, Hendrick EB, Humphreys RP. Experience with ventriculo-pleural shunts. Childs Brain 1983;10:404-13.  Back to cited text no. 1
    
2.
Küpeli E, Yilmaz C, Akçay S. Pleural effusion following ventriculopleural shunt: Case reports and review of the literature. Ann Thorac Med 2010;5:166-70.  Back to cited text no. 2
    
3.
Shahzad A, Nagaraju M. Severe respiratory failure following ventriculopleural shunt. Indian J Crit Care Med 2015;19:690-2.  Back to cited text no. 3
    
4.
Little AG, Kadowaki MH, Ferguson KM, Staszek VM, Skinner DB. Pleuro-peritoneal shunting. Alternative therapy for pleural effusions. Ann Surg 1988;208:443-50.  Back to cited text no. 4
    
5.
Engum SA, Rescorla FJ, West KW, Scherer LR, Grosfeld JL. The use of pleuroperitoneal shunts in the management of persistent chylothorax in infants. J Pediatr Surg 1999;34:286-90.  Back to cited text no. 5
    
6.
Ponn RB, Blancaflor J, D'Agostino RS, Kiernan ME, Toole AL, Stern H. Pleuroperitoneal shunting for intractable pleural effusions. Ann Thorac Surg 1991;51:605-9.  Back to cited text no. 6
    
7.
Harischandra LS, Sharma A, Chatterjee S. Shunt migration in ventriculoperitoneal shunting: A comprehensive review of literature. Neurol India 2019;67:85-99.  Back to cited text no. 7
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