Retroperitoneal Migration And Transgluteal Extrusion of a Distal Lumboperitoneal Shunt Catheter: An Unusual Complication of Cerebrospinal Fluid Shunt
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.329540
Source of Support: None, Conflict of Interest: None
Keywords: Catheter migration, CSF shunt, rare complications, transgluteal
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., 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. Even smaller is the rate (1–3%) of complications, associated with perforation of hollow organs and protrusion through the anus, vagina, or urethra.,, 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.
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.
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.
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. 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. 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 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.
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.
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Conflicts of interest
There are no conflicts of interest.