Ventriculoperitoneal shunt with a rare twist: small-bowel ischemia and necrosis secondary to knotting of peritoneal catheter

Case report

Lee A. Tan Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois

Search for other papers by Lee A. Tan in
jns
Google Scholar
PubMed
Close
 M.D.
,
Manish K. Kasliwal Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois

Search for other papers by Manish K. Kasliwal in
jns
Google Scholar
PubMed
Close
 M.D., M.Ch.
,
Roham Moftakhar Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois

Search for other papers by Roham Moftakhar in
jns
Google Scholar
PubMed
Close
 M.D.
, and
Lorenzo F. Munoz Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois

Search for other papers by Lorenzo F. Munoz in
jns
Google Scholar
PubMed
Close
 M.D.
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $536.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $636.00
USD  $45.00
USD  $536.00
USD  $636.00
Print or Print + Online Sign in

Small-bowel ischemia and necrosis due to knotting of the peritoneal catheter is an extremely rare complication related to a ventriculoperitoneal shunt (VPS). A 3-month-old girl, with a history of Chiari II malformation and myelomeningocele (MM) after undergoing right occipital VPS insertion and MM repair at birth, presented to the emergency department with a high-grade fever. Examination of a CSF sample obtained via shunt tap raised suspicion for the presence of infection. Antibiotic therapy was initiated, and subsequently the VPS was removed and an external ventricular drain was placed. Intraoperatively, as attempts at pulling the distal catheter from the scalp incision were met with resistance, the distal catheter was cut and left in the abdomen while the remainder of the shunt system was successfully removed. While the patient was awaiting definitive shunt revision surgery to replace the VPS, she developed abdominal distension due to small-bowel obstruction. An emergency exploratory laparotomy revealed a knot in the distal catheter looping around and strangulating the distal ileum, causing small-bowel ischemia and necrosis in addition to the obstruction. A small-bowel resection with ileostomy was performed, with subsequent placement of ventriculoatrial shunt for treatment of hydrocephalus. The authors report this exceedingly rare clinical scenario to highlight the fact that any retained distal catheter must be carefully managed with immediate abdominal exploration to remove the distal catheter to avoid bowel necrosis as pulling of a knotted peritoneal catheter may strangulate the bowel and cause ischemia, with significant clinical morbidity and possible mortality.

Abbreviations used in this paper:

KUB = kidney/ureter/bladder; MM = myelomeningocele; VPS = ventriculoperitoneal shunt.
  • Collapse
  • Expand
  • 1

    Al-Tamimi YZ, , Sinha P, , Chumas PD, , Crimmins D, , Drake J, & Kestle J, et al.: Ventriculoperitoneal shunt 30-day failure rate: a retrospective international cohort study. Neurosurgery 74:2934, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Bakas P, , Papadakis E, , Hassiakos D, & Liapis A: Second-trimester miscarriage and umbilical cord knot. Case report and review of the literature. Clin Exp Obstet Gynecol 40:448451, 2013

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Blickstein I, , Shoham-Schwartz Z, & Lancet M: Predisposing factors in the formation of true knots of the umbilical cord—analysis of morphometric and perinatal data. Int J Gynaecol Obstet 25:395398, 1987

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Borcek AO, , Civi S, , Golen M, , Emmez H, & Baykaner MK: An unusual ventriculoperitoneal shunt complication: spontaneous knot formation. Turk Neurosurg 22:261264, 2012

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Chong JY, , Kim JM, , Cho DC, & Kim CH: Upward migration of distal ventriculoperitoneal shunt catheter into the heart: case report. J Korean Neurosurg Soc 44:170173, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Chopra I, , Gnanalingham K, , Pal D, & Peterson D: A knot in the catheter—an unusual cause of ventriculo-peritoneal shunt blockage. Acta Neurochir (Wien) 146:10551057, 2004

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Chung JJ, , Yu JS, , Kim JH, , Nam SJ, & Kim MJ: Intraabdominal complications secondary to ventriculoperitoneal shunts: CT findings and review of the literature. AJR Am J Roentgenol 193:13111317, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Cochrane DD, & Kestle J: Ventricular shunting for hydrocephalus in children: patients, procedures, surgeons and institutions in English Canada, 1989–2001. Eur J Pediatr Surg 12:Suppl 1 S6S11, 2002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Eftekhar B, & Hunn A: Ventriculoperitoneal shunt blockage due to spontaneous knot formation in the peritoneal catheter. Case report. J Neurosurg Pediatr 1:142143, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Fekete G, , Nagy A, , Pataki I, , Bognar L, & Novák L: Shunt insufficiency due to knot formation in the peritoneal catheter. Ideggyogy Sz 66:277279, 2013

  • 11

    Fewel ME, & Garton HJL: Migration of distal ventriculoperitoneal shunt catheter into the heart. Case report and review of the literature. J Neurosurg 100:2 Suppl Pediatrics 206211, 2004

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Kestle J, , Drake J, , Milner R, , Sainte-Rose C, , Cinalli G, & Boop F, et al.: Long-term follow-up data from the Shunt Design Trial. Pediatr Neurosurg 33:230236, 2000

  • 13

    Lo WB, , Ramirez R, , Rodrigues D, & Solanki GA: Ventriculoperitoneal shunt disconnection associated with spontaneous knot formation in the peritoneal catheter. BMJ Case Reports 2013. (http://casereports.bmj.com/content/2013/bcr-2013-009590.long) [Accessed June 8, 2014]

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Mohammed W, , Wiig U, & Caird J: Spontaneous knot; a rare cause of ventriculoperitoneal shunt blockage. Br J Neurosurg 25:113114, 2011

  • 15

    Mohindra S, & Sharma M: Spontaneous knotting of peritoneal catheter: a report of an asymptomatic patient. J Pediatr Neurosci 7:151153, 2012

  • 16

    Murtagh FR, , Quencer RM, & Poole CA: Extracranial complications of cerebrospinal fluid shunt function in childhood hydrocephalus. AJR Am J Roentgenol 135:763766, 1980

  • 17

    Raymer DM, & Smith DE: Spontaneous knotting of an agitated string. Proc Natl Acad Sci U S A 104:1643216437, 2007

  • 18

    Starreveld Y, , Poenaru D, & Ellis P: Ventriculoperitoneal shunt knot: a rare cause of bowel obstruction and ischemia. Can J Surg 41:239240, 1998

  • 19

    Sturdee SW, , Timothy J, & Tyagi A: Total extrusion of a cranial peritoneal shunt per rectum. J Clin Neurosci 9:199200, 2002

  • 20

    Toshifumi K, , Nobuhiro S, & Tatsuro I: [Intesitinal obstruction caused by ventriculoperitoneal shunt knot. A case report.]. J Iwate Med Assoc 53:4346, 2001. (Jpn)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Ul-Haq A, , Al-Otaibi F, , Alshanafey S, , Sabbagh MD, & Al Shail E: Ventriculoperitoneal shunt peritoneal catheter knot formation. Case Rep Neurol Med 2013:628493, 2013

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Woerdeman PA, & Hanlo PW: Ventriculoperitoneal shunt occlusion due to spontaneous intraabdominal knot formation in the catheter. Case report. J Neurosurg 105:3 Suppl 231232, 2006

    • PubMed
    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 977 268 35
Full Text Views 504 22 3
PDF Downloads 266 28 4
EPUB Downloads 0 0 0