Utility of ventriculogallbladder shunts in complex cases of hydrocephalus related to extreme prematurity

View More View Less
  • 1 Departments of Pediatrics,
  • 2 Neurosurgery, and
  • 3 Surgery, Emory University School of Medicine, Atlanta; and
  • 4 Departments of Neurosurgery and
  • 5 Neuropsychology, Children’s Healthcare of Atlanta, Georgia
Restricted access

Purchase Now

USD  $45.00

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

USD  $505.00

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

USD  $600.00
Print or Print + Online

OBJECTIVE

The management of hydrocephalus resulting from intraventricular hemorrhage related to extreme prematurity remains demanding. Given the complexities of controlling hydrocephalus in this population, less commonly used procedures may be required. The authors examined the utility of ventriculogallbladder (VGB) shunts in a series of such children.

METHODS

The authors retrospectively reviewed the medical records of all children who underwent surgery for hydrocephalus in the period from 2011 through 2019 at Children’s Healthcare of Atlanta. Six patients who underwent VGB shunt placement were identified among a larger cohort of 609 patients who had either a new shunt or a newly changed distal terminus site. The authors present an analysis of this series, including a case of laparoscopy-assisted distal VGB shunt revision.

RESULTS

The mean age at initial shunt placement was 5.1 months (range 3.0–9.4 months), with patients undergoing a mean of 11.8 shunt procedures (range 5–17) prior to the initial VGB shunt placement at a mean age of 5.3 years (range 7.9 months–12.8 years). All 6 patients with VGB shunt placement had hydrocephalus related to extreme prematurity (gestational age < 28 weeks). At the time of VGB shunt placement, all had complex medical and surgical histories, including poor venous access due to congenital or iatrogenic thrombosis or thrombophlebitis and a peritoneum hostile to distal shunt placement related to severe necrotizing enterocolitis. VGB complications included 1 case of shunt infection, identified at postoperative day 6, and 2 cases of distal shunt failure due to retraction of the distal end of the VGB shunt. In all, there were 3 conversions back to ventriculoperitoneal or ventriculoatrial shunts due to the 2 previously mentioned complications, plus 1 patient who outgrew their initial VGB shunt. Three of 6 patients remain with a VGB shunt, including 1 who underwent laparoscopy-assisted distal shunt revision 110.5 months after initial VGB shunt insertion.

CONCLUSIONS

Placement of VGB shunts should be considered in the armamentarium of procedures that may be used in the particularly difficult cohort of children with hydrocephalus related to extreme prematurity. VGB shunts show utility as both a definitive treatment and as a “bridge” procedure until the patient is larger and comorbid abdominal and/or vascular issues have resolved sufficiently to allow conversion back to ventriculoperitoneal or ventriculoatrial shunts, if needed.

ABBREVIATIONS ETV = endoscopic third ventriculostomy; EVD = external ventricular drain; NEC = necrotizing enterocolitis; VA = ventriculoatrial; VGB = ventriculogallbladder; VP = ventriculoperitoneal; VPl = ventriculopleural.

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

USD  $505.00

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

USD  $600.00

Contributor Notes

Correspondence Andrew Reisner: Emory University School of Medicine, Children’s Healthcare of Atlanta, GA. andrew.reisner@choa.org.

INCLUDE WHEN CITING Published online February 26, 2021; DOI: 10.3171/2020.9.PEDS20522.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    World Health Organization . ICD-10: International Statistical Classification of Diseases and Related Health Problems. 10th revision . 2nd ed. World Health Organization ; 2004 .

    • Search Google Scholar
    • Export Citation
  • 2

    World Health Organization . Born Too Soon: The Global Action Report on Preterm Birth . World Health Organization ; 2012 .

  • 3

    Stoll BJ , Hansen NI , Bell EF , Trends in care practices, morbidity, and mortality of extremely preterm neonates, 1993-2012 . JAMA . 2015 ;314 (10 ):1039 1051 .

    • Search Google Scholar
    • Export Citation
  • 4

    Patel RM , Rysavy MA , Bell EF , Tyson JE . Survival of infants born at periviable gestational ages . Clin Perinatol . 2017 ;44 (2 ):287 303 .

    • Search Google Scholar
    • Export Citation
  • 5

    Jarjour IT . Neurodevelopmental outcome after extreme prematurity: a review of the literature . Pediatr Neurol . 2015 ;52 (2 ):143 152 .

    • Search Google Scholar
    • Export Citation
  • 6

    Koschnitzky JE , Keep RF , Limbrick DD Jr , Opportunities in posthemorrhagic hydrocephalus research: outcomes of the Hydrocephalus Association Posthemorrhagic Hydrocephalus Workshop . Fluids Barriers CNS . 2018 ;15 (1 ):11 .

    • Search Google Scholar
    • Export Citation
  • 7

    Gholampour S , Bahmani M , Shariati A . Comparing the efficiency of two treatment methods of hydrocephalus: shunt implantation and endoscopic third ventriculostomy . Basic Clin Neurosci . 2019 ;10 (3 ):185 198 .

    • Search Google Scholar
    • Export Citation
  • 8

    Guerra M , Blázquez JL , Rodríguez EM . Blood-brain barrier and foetal-onset hydrocephalus, with a view on potential novel treatments beyond managing CSF flow . Fluids Barriers CNS . 2017 ;14 (1 ):19 .

    • Search Google Scholar
    • Export Citation
  • 9

    Etus V , Kahilogullari G , Karabagli H , Unlu A . Early endoscopic ventricular irrigation for the treatment of neonatal posthemorrhagic hydrocephalus: a feasible treatment option or not? a multicenter study . Turk Neurosurg . 2018 ;28 (1 ):137 141 .

    • Search Google Scholar
    • Export Citation
  • 10

    Del Bigio MR , Di Curzio DL . Nonsurgical therapy for hydrocephalus: a comprehensive and critical review . Fluids Barriers CNS . 2016 ;13 :3 .

    • Search Google Scholar
    • Export Citation
  • 11

    Paulsen AH , Due-Tønnessen BJ , Lundar T , Lindegaard KF . Cerebrospinal fluid (CSF) shunting and ventriculocisternostomy (ETV) in 400 pediatric patients. Shifts in understanding, diagnostics, case-mix, and surgical management during half a century . Childs Nerv Syst . 2017 ;33 (2 ):259 268 .

    • Search Google Scholar
    • Export Citation
  • 12

    Limbrick DD Jr , Baird LC , Klimo P Jr , Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 4: Cerebrospinal fluid shunt or endoscopic third ventriculostomy for the treatment of hydrocephalus in children . J Neurosurg Pediatr . 2014 ;14 (suppl 1 ):30 34 .

    • Search Google Scholar
    • Export Citation
  • 13

    Deopujari CE , Karmarkar VS , Shaikh ST . Endoscopic third ventriculostomy: success and failure . J Korean Neurosurg Soc . 2017 ;60 (3 ):306 314 .

    • Search Google Scholar
    • Export Citation
  • 14

    West KW , Turner MK , Vane DW , Ventricular gallbladder shunts: an alternative procedure in hydrocephalus . J Pediatr Surg . 1987 ;22 (7 ):609 612 .

    • Search Google Scholar
    • Export Citation
  • 15

    Girotti ME , Singh RR , Rodgers BM . The ventriculo-gallbladder shunt in the treatment of refractory hydrocephalus: a review of the current literature . Am Surg . 2009 ;75 (8 ):734 737 .

    • Search Google Scholar
    • Export Citation
  • 16

    Hanak BW , Bonow RH , Harris CA , Browd SR . Cerebrospinal fluid shunting complications in children . Pediatr Neurosurg . 2017 ;52 (6 ):381 400 .

    • Search Google Scholar
    • Export Citation
  • 17

    Tomei KL . The evolution of cerebrospinal fluid shunts: advances in technology and technique . Pediatr Neurosurg . 2017 ;52 (6 ):369 380 .

    • Search Google Scholar
    • Export Citation
  • 18

    Paff M , Alexandru-Abrams D , Muhonen M , Loudon W . Ventriculoperitoneal shunt complications: a review . Interdiscip Neurosurg . 2018 ;13 :66 70 .

    • Search Google Scholar
    • Export Citation
  • 19

    McGirt MJ , Leveque JC , Wellons JC III , Cerebrospinal fluid shunt survival and etiology of failures: a seven-year institutional experience . Pediatr Neurosurg . 2002 ;36 (5 ):248 255 .

    • Search Google Scholar
    • Export Citation
  • 20

    Reddy GK , Bollam P , Caldito G . Long-term outcomes of ventriculoperitoneal shunt surgery in patients with hydrocephalus . World Neurosurg . 2014 ;81 (2 ):404 410 .

    • Search Google Scholar
    • Export Citation
  • 21

    Bock HC , Feldmann J , Ludwig HC . Early surgical management and long-term surgical outcome for intraventricular hemorrhage-related posthemorrhagic hydrocephalus in shunt-treated premature infants . J Neurosurg Pediatr . 2018 ;22 (1 ):61 67 .

    • Search Google Scholar
    • Export Citation
  • 22

    Vongbhavit K , Underwood MA . Intestinal perforation in the premature infant . J Neonatal Perinatal Med . 2017 ;10 (3 ):281 289 .

    • Search Google Scholar
    • Export Citation
  • 23

    Ozkiraz S , Gokmen Z , Anuk Ince D , Peripherally inserted central venous catheters in critically ill premature neonates . J Vasc Access . 2013 ;14 (4 ):320 324 .

    • Search Google Scholar
    • Export Citation
  • 24

    Maiguy-Foinard A , Décaudin B , Tourneux P , Effect of multi-lumen perfusion line on catheter-related bacteremia in premature infants: study protocol for a cluster-randomized crossover trial . Trials . 2019 ;20 (1 ):115 .

    • Search Google Scholar
    • Export Citation
  • 25

    Martherus T , Oberthuer A , Dekker J , Supporting breathing of preterm infants at birth: a narrative review . Arch Dis Child Fetal Neonatal Ed . 2019 ;104 (1 ):F102 F107 .

    • Search Google Scholar
    • Export Citation
  • 26

    Ketoff JA , Klein RL , Maukkassa KF . Ventricular cholecystic shunts in children . J Pediatr Surg . 1997 ;32 (2 ):181 183 .

  • 27

    Henderson D , Budu A , Horridge M , The ventriculo-cholecystic shunt: does CSF volume matter? Childs Nerv Syst . 2019 ;35 (9 ):1557 1560 .

    • Search Google Scholar
    • Export Citation
  • 28

    Smith GW , Moretz WH , Pritchard WL . Ventriculo-biliary shunt; a new treatment for hydrocephalus . Surg Forum . 1958 ;9 :701 705 .

    • Search Google Scholar
    • Export Citation
  • 29

    Olavarria G , Reitman AJ , Goldman S , Tomita T . Post-shunt ascites in infants with optic chiasmal hypothalamic astrocytoma: role of ventricular gallbladder shunt . Childs Nerv Syst . 2005 ;21 (5 ):382 384 .

    • Search Google Scholar
    • Export Citation
  • 30

    Novelli PM , Reigel DH . A closer look at the ventriculo-gallbladder shunt for the treatment of hydrocephalus . Pediatr Neurosurg . 1997 ;26 (4 ):197 199 .

    • Search Google Scholar
    • Export Citation
  • 31

    Demetriades AK , Haq IZ , Jarosz J , The ventriculocholecystic shunt: two case reports and a review of the literature . Br J Neurosurg . 2013 ;27 (4 ):505 508 .

    • Search Google Scholar
    • Export Citation
  • 32

    Lyngdoh BT , Islam MS . Ventriculocholecysto shunt: a solution to recurrent shunt complications in comorbid post-tubercular hydrocephalus with tubercular adhesive peritonitis . Acta Neurochir (Wien) . 2012 ;154 (12 ):2267 2270 .

    • Search Google Scholar
    • Export Citation
  • 33

    Tully HM , Dobyns WB . Infantile hydrocephalus: a review of epidemiology, classification and causes . Eur J Med Genet . 2014 ;57 (8 ):359 368 .

    • Search Google Scholar
    • Export Citation
  • 34

    Keucher TR , Mealy J . Long-term results after ventriculoperitoneal shunting for infantile hydrocephalus . J Neurosurg . 1979 ;50 (2 ):179 186 .

    • Search Google Scholar
    • Export Citation
  • 35

    Stringel G , Turner M , Crase T . Ventriculo-gallbladder shunts in children . Childs Nerv Syst . 1993 ;9 (6 ):331 333 .

  • 36

    Paulsen AH , Lundar T , Lindegaard KF . Twenty-year outcome in young adults with childhood hydrocephalus: assessment of surgical outcome, work participation, and health-related quality of life . J Neurosurg Pediatr . 2010 ;6 (6 ):527 535 .

    • Search Google Scholar
    • Export Citation
  • 37

    Ignacio RC Jr , Schermerhorn SMV , Marrotte AJ , Prieto JM . Laparoscopic ventricular-cholecystic shunt . J Pediatr Surg Case Rep . 47 :101233 .

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 11 11 11
Full Text Views 3 3 3
PDF Downloads 1 1 1
EPUB Downloads 0 0 0