Intrathoracic migration of ventriculoperitoneal shunt: a case report
© Karapolat et al; licensee BioMed Central Ltd. 2008
Received: 09 July 2008
Accepted: 17 July 2008
Published: 17 July 2008
Intrathoracic migration of ventriculoperitoneal shunt can be transdiaphragmatic or supradiaphragmatic. This complication causes important respiratory symptoms.
A 7 year-old Caucasian female, hospitalized with the prediagnosis of pneumonia, was determined to have ventriculoperitoneal shunt migration at left hemithorax. A left thoracotomy was performed and the shunt was successfully removed transdiaphragmatically.
The patients with intrathoracic migration of ventriculoperitoneal shunt must be treated surgically as soon as possible. Transdiaphragmatic surgical approach would be more suitable from the point of surgical easiness.
Complications of ventriculoperitoneal shunts may occur anywhere along their course, from the cerebral ventricle to the peritoneal cavity . Among these potentials, intrathoracic migration of shunts is unusual and potentially serious . The purpose of this paper is to report a case of intrathoracic migration of ventriculoperitoneal shunts because of its rarity.
Inadequate catheter length and not fixing the shunt firmly enough to peripheral tissues are the main causes of shunt migration . Mechanism of shunt migration is various. The catheter and located adjacent to diaphragm may slowly draw back into the thorax due to negative inspiratory pressure. Besides, the intraperitoneal fibrosis resulting from shunt may apply a continuous pressure to the upper part of the shunt adhered to the diaphragm and thus may cause a diaphragmatic perforation. The ventriculoperitoneal shunt can migrate through the diaphragm into the chest on its own or after an abdominal inflammatory process occurs. In addition, shunt may pass to the thorax by means of hiatus or congenital fenestrations in diaphragm. In our case, migration of ventriculoperitoneal shunt into chest was transdiaphragmatic. There was an open communication between the peritoneal and pleural cavities. We think that the local inflammation taking place around the shunt and subdiaphragmatic area as an occurrence mechanism may cause diaphragmatic erosion and perforation and the shunt prolapsed into the pleural cavity from this defect.
Intrathoracic migration of shunt may lead respiratory complications such as pleural effusion, pneumothorax, bronchial fistula, hydrothorax, empyema and pneumonia . Our case showed a pneumonic situation.
Removal of the shunt surgically should be the main method for the treatment of this complication. After opening the diaphragm wide enough, the relationship among the abdominal cavity organs and especially the relationship of omentum with ventriculoperitoneal shunt should be examined carefully, and the adherences must be separated precisely and the shunt should not be pulled extensively and not stretched during these procedures. If shunt is pulled out without being free enough, the breaking possibility of it is high. In such a case, it will be difficult to remove the broken piece transdiaphragmatically from the abdomen. In our case, omentum surrounded the shunt from some separate parts and adhered firmly. Shunt could be removed only after separating thoroughly from omentum by a careful dissection.
In order to avoid such a complication, it should be paid attention not to keep the intraperitoneal part of the shunt very long. The more flexible material of shunt used is, the less the diaphragmatic perforation possibility will be. Besides, dysfunctional and unnecessary shunts should be taken out thoroughly. The shunts which are asymptomatic and need major surgery to be removed, and thus left in their places should be followed-up from the point of intrathoracic migration by means of radiographical examination at reasonable intervals .
The treatment of this complication is to remove the shunt surgically as soon as diagnosed promptly. Thoracotomy should be made from a lower part than the classical incision place since it will be easier to reach the diaphragm. The removal of the shunt transdiaphragmatically would be more suitable from the point of patient's comfort and surgical easiness. However, as preventive actions, not keeping the shunt very long in the first application, and removing the dysfunctional shunts totally under elective conditions will prevent the occurrence of intrathoracic migration, and thus the unnecessary morbidity and mortality.
Written informed consent was obtained from the patient's parents for the publication of this case report and for the use of images. A copy of the written consent is available for the Editor-in-Chief of this journal.
Migration of ventriculoperitoneal shunt. Karapolat et al.
Thanks to Erhan Gecikli, for English editing.
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