British Journal of Neurosurgery, April 2007; 21(2): 235 – 236
NEUROSURGICAL IMAGE
Jejunal perforation and peroral extrusion of a peritoneal shunt catheter
T. O. ODEBODE Division of Neurosurgery, Department of Surgery, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
Clinical details The incidence of intestinal perforation following a ventriculo-peritoneal shunt (VPS) insertion ranges between 0.1 and 0.7% of all abdominal complications of this procedure.1 Perforation of the colon constitutes the majority, while those of the stomach and small bowel are rare events. A case of transoral protrusion of a peritoneal shunt catheter that had spontaneously perforated the jejunal wall is described. The patient was a 15-month-old female infant who presented with oral protrusion of a distal catheter of a Chhabra-slit-in-spring silicone shunt system inserted for hydrocephalus 6 months earlier (Fig. 1). Two weeks before current presentation she developed skin necrosis and infection along the shunt tract behind the right ear, and this exposed the shunt. At presentation, she was a well-nourished infant without clinical evidence of meningitis or peritonitis. A plain abdominal radiograph demonstrated an opaque tube along the course of the oesophagus (Fig. 2). After commencement of intravenous broad spectrum antibiotic she was subjected to a laparotomy, which revealed an encasing fibrosis round the tube blending with the wall of the perforated middle jejunum, but without evidence of peritonitis. After ligating the tube flush with the jejunum, the distal tube was removed from the mouth, while the proximal portion was extracted through the postauricular wound. A new shunt was implanted 3 weeks later and the child has remained asymptomatic. Discussion In the case reported, the 6-month interval between shunt insertion and oral extrusion of the peritoneal shunt catheter indicates spontaneous late gut perforation. This type of perforation has been related to age, male gender, malnutrition, poor general
condition, length and type of catheter, previous abdominal operation or infection1,2 and, recently, evidence of silicone allergy from foreign body reaction.3 Of these factors, age stands out as the main risk factor for bowel perforation,1 and this has been attributed to weaker intestinal musculature and stronger intestinal peristaltic activity in children.1 Though the exact pathophysiology of late perforation in this and other reported cases is difficult to establish, the predisposing factors probably produce perforation through a chronic irritative process in which the catheter adheres to the serosal surface of the bowel by way of foreign body reaction,1,2 related to silicone allergy3 and subjects a fixed point to repeated pressure, which slowly produces an ulcer and eventually a perforation.1,2 A characteristic encasing fibrosis has been found round the tube at surgery,1 as in the current case. Furthermore, in several occurrences, skin inflammation or breakdown over the catheter, was present long before the diagnosis of bowel perforation was made,3 as in this case, suggesting that the shunt was infected before perforating the bowel. In this perspective, bowel perforation can be likened to a mechanism of rejection of an infected foreign body. Other predisposing factors described in association with extruded peritoneal catheter include the type of catheter used.1 A stiff, hard tipped, sharp or springcoiled peritoneal catheter, such as the Ramondi and Hakim – Codman catheter is more likely to cause bowel perforation than a soft one. For over a decade, the soft tipped Chhabra-slit-in-spring silicone shunt catheter (G. Surgiwear, Limited, India) has been the most commonly used shunt system for treating hydrocephalus at the few Neurosurgical centres available in Nigeria and, to date, there has been no report of bowel perforation by this catheter. This report therefore constitutes the first bowel perforation by the Chhabra shunt catheter from Nigeria.
Correspondence: Dr T. O. Odebode, Box 5173, GPO Ilorin 24001, Kwara State, Nigeria. Tel: 234-803-3858033. E-mail:
[email protected] Received for publication 17 January 2007. Accepted 6 February 2007. ISSN 0268-8697 print/ISSN 1360-046X online ª The Neurosurgical Foundation DOI: 10.1080/02688690701264346
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FIG. 1. Clinical photograph showing the distal end of the ventriculo-peritoneal shunt catheter protruding from the mouth.
FIG. 2. Abdominal radiograph showing upward migration of shunt catheter along the oesophagus.
An earlier report of bowel perforation emanating from Nigeria2 involved the use of the Holter type of shunt catheter. A diagnosis of bowel perforation is easily made if a shunt catheter protrudes from the anal or oral orifice, but bowel perforation without extrusion of its distal end is most likely under-diagnosed, being detected usually at shunt revision for shunt obstruction or at autopsy. The passage of clear fluid per anus or clinically evident meningitis in the absence of abdominal symptoms in a patient harbouring a VPS, should raise the suspicion of distal gut perforation. Abdominal radiograph or computed tomography may indicate a tube along the course of a particular bowel, but the latter is not indicated when there is a protrusion.
A review of the literature showed that at least 119 cases of catheter-induced gut perforations, including the current case, have been reported over the last seven decades (1936 – 2006). Children aged 10 years or less constitute 70.1% of the patients and males outnumber females by a ratio of 3:2. The reason for greater male predisposition to a gut perforation by a VPS catheter is unknown. The more stationary colon is the commonest (70%) site of perforation, followed by the stomach (16%) and the most mobile small bowel (14%), raising the suspicion that bowel perforation might be influenced by gut mobility. The review also revealed that at all levels of perforation, the catheter was more likely to extrude through the anus (61.9%) or not at all (31.4%). Oral route extrusion including the current infant occurred sparingly (four cases; 5.7%), and is commoner after perforation of the stomach (three cases) than small bowel (current case) wall. Following small bowel perforation in 11 reported cases, four patients extruded their catheters through the anus and five did not extrude, while the current case alone, uniquely extruded her distal catheter through the mouth. Opinions differ widely about the management of this complication. As carried out in this case, it is probably safest to close the bowel opening primarily after shunt retrieval, and consider the wound and distal shunt contaminated especially in cases presenting with a wound sepsis and shunt exposure like the current case. However, many authors consider laparatomy unnecessary, because the opening into the bowel lumen is often small and self-sealing, especially in late onset perforations. In retrospect, judging from the fact that the anticipated peritoneal findings were absent, the tube should have been divided well above the abdomen and externalised, while an assistant pulled the tube out of the abdomen from the mouth where it presented. This method would have saved the patient cost and length of hospital stay. In all cases after a period of observation, while the patient is on broad-spectrum antibiotics, a new shunt can be re-internalised. Although gut perforation following a VPS insertion is infrequent; it can be fatal with mortality rate as high as 15% if it goes unrecognised, especially in patients without catheter extrusion who are at a high risk of developing meningitis or ventriculitis. A high level of suspicion for bowel perforation in shunted individuals is therefore required to minimise fatality rate from bowel perforation by a distal shunt catheter.
References 1 Park CK, Wang KC, Seo JK, Cho BK. Transoral protrusion of a peritoneal catheter: a case report and literature review. Child’s Nerv Syst 2000;16:184 – 9. 2 Adeloye A. Protrusion of ventriculoperitoneal shunt through the anus: Report of two cases. East Afri Med J 1997;74(5):337 – 9. 3 Brownlee JD, Brodkey JS, Schaefer IK. Colonic perforation by ventriculoperitoneal shunt tubing: A case of suspected silicone allergy. Surg Neurol 1998;49:21 – 4.
