Letter to the Editor. Abdominal pseudocysts and ventriculoperitoneal shunts

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  • University of Florida College of Medicine, Jacksonville, FL
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TO THE EDITOR: I read with great interest the article by Erwood et al.1 published in the Journal of Neurosurgery: Pediatrics in which they address the abdominal pseudocysts and failure of peritoneal absorption in patients with ventriculoperitoneal shunts (Erwood A, Rindler RS, Motiwala M, et al. Management of sterile abdominal pseudocysts related to ventriculoperitoneal shunts. J Neurosurg Pediatr. 2020;25[1]:57–61). They propose as an algorithm ventriculoatrial shunts, ventriculopleural shunts, and/or reintroduction into the abdomen with a laparoscopic procedure.

We have previously reported on the usefulness of ventriculogallbladder shunts in the described setting.2 Our patients ranged from 4 months to 17 years of age, and there were only 2 early shunt malfunctions and a late-onset 5-year malfunction. The follow-up for ventriculogallbladder shunts ranged from 1 to 8 years. We instituted this protocol after review of the animal experiments with ventriculogallbladder shunts3 and clinical experiences reported by others. We have had very good collaboration from our pediatric general surgery colleagues once the indications were explained to them, and procedures were performed as co-surgeons.

We recommend that where pediatric surgery is available, ventriculogallbladder shunts should be considered as a good alternative over others.

Disclosures

The author reports no conflict of interest.

References

  • 1

    Erwood A, Rindler RS, Motiwala M, et al. . Management of sterile abdominal pseudocysts related to ventriculoperitoneal shunts. J Neurosurg Pediatr. 2020;25(1):5761.

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  • 2

    Aldana PR, James HE, Postlethwait RA. Ventriculogallbladder shunts in pediatric patients. J Neurosurg Pediatr. 2008;1(4):284287.

  • 3

    Smith GW, Moretz WH, Pritchard WL. Ventriculo-biliary shunt; a new treatment for hydrocephalus. Surg Forum. 1958;9:701705.

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  • Pediatric Neurosurgery Associates at Children’s Healthcare of Atlanta, GA, Emory University Hospital, Atlanta, GA

Response

We are grateful for the insightful commentary from Dr. James regarding our article.

It is certainly true that ventriculogallbladder shunts are a viable alternative for patients in whom a ventriculoperitoneal shunt is not an ideal option. Like Dr. James, we have also had successful institutional experience with gallbladder shunts, placing them in 7 patients over the last 25 years. All 7 children had a history of intraventricular hemorrhage of prematurity and developed posthemorrhagic hydrocephalus. All of them underwent ventriculogallbladder shunting due to failed ventriculoatrial shunts with poor alternative venous access (e.g., internal jugular vein, subclavian vein, femoral vein, etc.), abdominal peritoneal scarring, and/or a history of abdominal pseudocysts.

The longest lifetime of a single gallbladder shunt was 17 years, and revision to a ventriculopleural shunt was ultimately required because abdominal adhesions precluded replacement into the gallbladder after it had retracted. The shortest lifetime of a gallbladder shunt was 7 days, because it became infected with gram-negative rods. The remainder lasted for a median of 2.4 years, ranging from 3 months (still in place) to 9 years. Most failures were ultimately distal, with findings of elevated gallbladder pressures or catheter retraction from the gallbladder. Only one child had his catheter replaced in the gallbladder after retraction, but this was a long, painstaking undertaking for our pediatric surgeons due to significant peritoneal scarring.

None of the children with sterile abdominal pseudocysts in our published series underwent gallbladder shunting as a result of their pseudocyst. However, 2 patients with gallbladder shunts had interesting clinical courses. One patient, who was included in our study, had a history of a failed gallbladder shunt from a distal disconnection that was converted to a ventriculoperitoneal shunt lasting 2 years prior to pseudocyst development. The gallbladder shunt had been originally placed for history of multiple failed ventriculoatrial shunts and peritoneal scarring, but no previous history of abdominal pseudocysts. A second patient developed an abdominal pseudocyst from ventriculoperitoneal shunting and underwent immediate revision to a gallbladder shunt with simultaneous pseudocyst aspiration that was ultimately negative for infection. This patient was not included in our study because he had undergone shunt revisions within the last year.

From our small series, it is clear that a ventriculogallbladder shunt placed with the assistance of our pediatric surgeons can be a long-term solution for many patients in whom “traditional” sites are no longer available. However, dense peritoneal adhesions that are often present in patients who develop pseudocysts may or may not involve the right upper quadrant. If present, this situation would make gallbladder dissection difficult. This again highlights the importance of laparoscopic assistance in dealing with this group of patients.

Diagram from Prolo et al. (pp 179–188).

Contributor Notes

Correspondence Hector E. James: pedneurosurgery@aol.com.

INCLUDE WHEN CITING Published online April 24, 2020; DOI: 10.3171/2020.3.PEDS20136.

Disclosures The author reports no conflict of interest.

  • 1

    Erwood A, Rindler RS, Motiwala M, et al. . Management of sterile abdominal pseudocysts related to ventriculoperitoneal shunts. J Neurosurg Pediatr. 2020;25(1):5761.

    • Search Google Scholar
    • Export Citation
  • 2

    Aldana PR, James HE, Postlethwait RA. Ventriculogallbladder shunts in pediatric patients. J Neurosurg Pediatr. 2008;1(4):284287.

  • 3

    Smith GW, Moretz WH, Pritchard WL. Ventriculo-biliary shunt; a new treatment for hydrocephalus. Surg Forum. 1958;9:701705.

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