Original Article

Abdominal Complications of Ventriculoperitoneal Shunt in Pediatric Patients:

Experiences of a Pediatric Surgery Clinic
Beger Burhan1, Kizilyildiz Baran Serdar3, Aycan Abdurrahman2, Akyol Mehmet Edip2, Duz Ebuzer1

- OBJECTIVE: To relate the experiences of a pediatric INTRODUCTION

surgery clinic in diagnosis
complications related to
(VPSs) in pediatric patients
treat hydrocephalus.
and treatment of abdominal
ventriculoperitoneal shunts
who had VPSs implanted to
- METHODS: Patients admitted to the Pediatric Surgery
Department of Van Yuzunciyil University Faculty of Medi-
cine between April 2013 and December 2017 who had VPSs
implanted and subsequently developed abdominal compli-
cations were reviewed retrospectively. Demographic in-
formation, surgery dates, time intervals between surgery
and development of abdominal complication, complication
types and applied treatments, and follow-up durations
were recorded.
- RESULTS: There were 16 patients (6 girls, 10 boys) with a
mean age of 3 years (range, 1 month to 8 years) reviewed.
Complications following VPS implantation included
abdominal pseudocyst, anal protrusion, volvulus, perito-
nitis, abdominal distention, and herniation. Complications
were treated successfully with contemporary surgical
methods. No issues during long-term postoperative follow-
up were identified.
- CONCLUSIONS: VPS implantation can result in abdom-
inal complications with a wide range of clinical pre-
sentations. Predicting which abdominal complications
might occur in children with VPSs can be lifesaving with
early diagnosis and treatment.
T he contemporary gold standard surgical method in hy-
drocephalus treatment is drainage via ventriculoperitoneal
shunt (VPS).1 Although VPS implantation is a commonly
performed technique, it has high complication rates. Therefore,
follow-up after implantation and treatment of complications
should be well-mastered skills of pediatric surgeons and neuro-
surgeons. The incidence of abdominal complications related to
VPSs is 5%e47%.2 Abdominal complications can occur as a result
of increasing intra-abdominal pressure, inefficacy of the shunt, or
surgical error. Early diagnosis and treatment can significantly
reduce morbidity and mortality. In this study, abdominal com-
plications that occurred related to VPS and treatment methods in
our clinic are reviewed in accordance with the literature.
MATERIALS AND METHODS
A retrospective review was performed of 16 patients who had
abdominal complications after VPS implantation at the Pediatric
Surgery Clinic of Yuzuncu Yil University Faculty of Medicine be-
tween April 2013 and December 2017. Demographic information
(age and sex), surgery dates, time intervals between surgery and
development of complication, complication types and treatment
methods, and follow-up durations of the patients were recorded in
hard copy forms and archived. All patients were evaluated for
abdominal pathology at the time of admission and the relation-
ship of pathology to VPS. Evaluation included abdominal x-ray and
ultrasound in addition to routine blood tests. If necessary, brain
tomography was performed in the event of shunt dysfunction.
Ceftriaxone (100 mg/kg) was administered for catheter infection
prophylaxis. Paracetamol (10 mg/kg) was given as an analgesic.
Patients who were given intravenous saline owing to dehydration

Key words From the 1Pediatric Surgery and 2Neurosurgery Department, Van Yuzunciyil University Faculty
- Complication of Medicine; and 3Pediatrics Department, Van Lokman Hekim Hospital, Van, Turkey
- Hydrocephalus To whom correspondence should be addressed: Beger Burhan, M.D.
- Pediatrics [E-mail: burhanbeger@hotmail.com]
- Ventriculoperitoneal shunt Citation: World Neurosurg. (2018).
https://doi.org/10.1016/j.wneu.2018.06.140
Abbreviations and Acronyms
Journal homepage: www.WORLDNEUROSURGERY.org
APC: Abdominal pseudocyst
CSF: Cerebrospinal fluid Available online: www.sciencedirect.com
HPC: Hepatic pseudocyst 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
VPS: Ventriculoperitoneal shunt

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 ORIGINAL ARTICLE
BEGER BURHAN ET AL. ABDOMINAL COMPLICATIONS OF VPS IN PEDIATRIC PATIENTS

Table 1. Age, Sex, Primary Pathology, Type, and Management of Complications

Patient Age/Sex Cause of VPS Implantation Abdominal Complication Result

1 2 years/F Congenital hydrocephalus Umblical hernia Primary repair at age 2

2 1 year/M Congenital hydrocephalus Bilateral inguinal hernia and hydrocele Bilateral hernia repair
3 2 years/M Congenital hydrocephalus Right inguinal hernia, hydrocele, and scrotal Bilateral hernia repair and replacement of
migration of catheter catheter in abdomen
4 2 years/M Congenital hydrocephalus Right inguinal hernia and hydrocele Bilateral hernia repair
5 3 years/M Congenital hydrocephalus Left inguinal hernia and hydrocele (Figures 1 Bilateral hernia repair, relapse after 14 months
and 2) and reoperation
6 3 years/F Congenital hydrocephalus Anal protrusion Laparotomy and VPS revision
7 3 years/M Congenital hydrocephalus Anal protrusion (Figure 3) Laparotomy and VPS revision
8 1 year/M Congenital hydrocephalus APC (Figures 4 and 5) Preoperative cyst aspiration and excision of
cyst; replacement of catheter into abdomen
9 9 months/F Congenital hydrocephalus Volvulus VPS was taken to external; ileostomy was
and meningomyelocele performed; patient died on postoperative day 7
10 6 years/M Congenital hydrocephalus Peritonitis and adhesion VPS was taken to external; bridectomy was
and meningomyelocele performed and ventriculoatrial shunt was
implanted
11 5 years/F Congenital hydrocephalus Peritonitis and adhesion Conservative treatment
and meningomyelocele
12 3 months/F Congenital hydrocephalus Abdominal distention owing to shunt Aspiration of ascites
and meningomyelocele dysfunction
13 8 years/M Congenital hydrocephalus Skin necrosis on catheter tunnel and leakage Change of VPS position to contralateral side
and meningomyelocele of CSF (Figure 6)
14 4 years/F Posterior fossa tumor Knotting of catheter in omentum (Figure 7) VPS revision
15 3 years/M Congenital hydrocephalus Catheter was knotted under skin (Figures 8 VPS revision
and 9)
16 4 years/M Congenital hydrocephalus Free catheter in peritoneal cavity (Figure 10) VPS revision

VPS, ventriculoperitoneal shunt; F, female; M, male; APC, abdominal pseudocyst; CSF, cerebrospinal fluid.

were scheduled for laparoscopy or laparotomy in relation to
pathology.
RESULTS
There were 16 patients included in the study (Table 1). Of patients,
10 were boys and 6 were girls. Patient age ranged from 1 month to
8 years with a mean age of 3 years. The follow-up period ranged
from 3 to 12 months with a mean follow-up period of 8 months.
Various brands and models of shunts were implanted. All shunts
implanted were medium pressure. In 8 of 16 patients, VPSs were
implanted to treat congenital hydrocephalus; 5 of these patients
had accompanying meningomyelocele. The VPS was implanted
after posterior fossa tumor surgery in 1 case.
For 1 case with umbilical hernia, as shunt dysfunction did not
occur, primary repair was performed at age 2 years. Umbilical
hernia was diagnosed 21 days after VPS implantation. In 4 cases
with inguinal hernia, 1 was bilateral, 2 were right-sided, and 1 was
left-sided (Figure 1). In 1 case, as the VPS catheter had migrated to
the scrotum (Figure 2), hernia repair was achieved by placing the
catheter back inside the abdomen. Even when 1 side was not
symptomatic, 2-sided hernia repair was carried out in all
patients. Average time to realization of inguinal distention in cases
with hernia after VPS implantation was 38 days. After diagnosis of
inguinal hernia relapse in 1 case, the patient was operated on
again after 14 months.
Laparotomy was performed in 2 cases with anal protrusion
(Figure 3). Excising the fistula tract, colonic perforation was
primarily repaired. The VPS was located to an external position,
and after 2 weeks, VPS revision was performed. In both cases,
anal protrusion developed 3 years after VPS implantation.
Abdominal pseudocyst (APC) was diagnosed in 1 case (Figures 4
and 5) 6 months after VPS implementation, and preoperative
aspiration was performed. Seeing no growth in the extracted
liquid culture, intraoperative cyst removal was performed, and
the intra-abdominal location of the VPS was changed. No
relapse occurred during 1 year of follow-up. Volvulus was identi-
fied 1 month after 1 VPS implantation. A shunt catheter was placed
externally, and ileostomy was performed; however, the patient
died on postoperative day 7.

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BEGER BURHAN ET AL. ABDOMINAL COMPLICATIONS OF VPS IN PEDIATRIC PATIENTS

In 2 cases, adhesion developed approximately 1 year after VPS

implantation. In 1 of these cases, conservative methods reduced
the symptoms; in the other case, an external shunt catheter was
implanted and bridectomy was performed; VPS revision was done
2 weeks later. In 1 case, following distention in the abdomen
resulting from excessive discharge of cerebrospinal fluid (CSF),
abdominal fluid was aspirated with drainage. In another case, at
20 days after VPS implantation, skin necrosis resulting from the
catheter and CSF leakage (Figure 6) were diagnosed. In this case,
VPS revision was done by placing the shunt on the other side of
the patient. In 1 case, the VPS catheter rotated inside the
omentum (Figure 7) in the first postoperative month and was
corrected with revision. In a 3-year-old patient, the catheter was
knotted under the skin (Figures 8 and 9), and revision was done.
In a 4-year-old boy, the whole catheter, which had ruptured from
the central part, was found free in the peritoneal cavity (Figure 10).
The catheter was removed via laparoscopy, and VPS revision was
done.

DISCUSSION
Hydrocephalus is usually defined as obstructed flow, excess pro-
duction, or defective absorption of CSF, and it is the most
frequently encountered central nervous system anomaly in chil-
dren.3-5 VPS implantation is the most effective method to drain

Figure 2. Scrotal migration of ventriculoperitoneal shunt catheter.

CSF in patients with hydrocephalus.1 A VPS was first implanted by

Kaush in 1908, but the procedure became commonly performed
after the 1960s.3 The VPS is a standard tool employed in
hydrocephalus treatment that consists of a proximal catheter
placed in the cerebral ventricle, a valve, and a distal catheter
placed in the peritoneum.1
It is estimated that hydrocephalus is diagnosed in 750,000 pa-
tients and 160,000 new VPSs are implanted each year.6 Incidence of
abdominal complications related to VPS is reported to be 5%e47%,
or approximately 8000e80,000 abdominal complications each
year.2 VPS operations are most often performed in the first 6
months of life.5 In our cases, average time interval between VPS
implementation and development of abdominal complication was
Figure 1. Inguinal hernia after ventriculoperitoneal shunt implantation.
8.1 months. Perioperative mortality of first VPS implantation is
0e8.2%; however, it is reported to be 15% after VPS revision.5

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BEGER BURHAN ET AL. ABDOMINAL COMPLICATIONS OF VPS IN PEDIATRIC PATIENTS

Figure 5. Ventriculoperitoneal shunt catheter in huge abdominal

pseudocyst.

Although complications occur more often with rigid catheters, they

Figure 3. Anal protrusion of ventriculoperitoneal shunt catheter.
Figure 4. Abdominal distention owing to abdominal pseudocyst.
are encountered with all catheter types.1
After VPS procedures, 12%e36% of cases require revision for
different causes, and 18% require >1 revision. The most frequent
reason for revision is VPS obstruction (14%).5 The most frequent
complications are shunt infections and obstructions induced by
the shunt tool.7 Abdominal complications related to VPS are
rare and include volvulus, peritonitis, ascites, and intestinal
perforation. Additionally, the shunt catheter can migrate to the
anus, scrotum, urethra, umbilicus, and other organs.7 Although
the physiopathology of scrotal hydrocele after VPS is not
completely understood, its 2 major causes are considered to be
open processus vaginalis and increased intra-abdominal pres-
sure.8 In cases with communicating hydrocephalus, increased
intra-abdominal pressure would prevent the closure of the proc-
essus vaginalis; in such cases, early surgical intervention might
prevent the shunt catheter from entering into the scrotal pouch
and becoming dysfunctional. The treatment should be performed
bilaterally even if 1 side is asymptomatic. After repair operation
relaps of hernia is more common in patients with VPS.
It is not clearly determined if occurrence of inguinal hernia is
due to the presence of CSF drainage into the peritoneal cavity or
resultant increased intra-abdominal pressure. The rate of bilateral
symptomatic hernia is reported to be 20%. Also, in patients who
underwent unilateral symptomatic inguinal hernia surgery, her-
niation is detected in 5% on the asymptomatic side as well.8,9 CSF
drainage and pressure over the absorption capacity of peritoneum,
combined with the presence of a patent processus vaginalis, would
be a potential cause of the clinical hernia. This relationship might
explain the high incidence of bilateral hernia. Average time of
hernia occurrence related to VPS is 5.3 months (range, 20 days to
48 months).9 In our series, the time interval between VPS
implantation and identification of inguinal hernia or hydrocele
was approximately 38 days. In VPS implantation cases, especially

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BEGER BURHAN ET AL. ABDOMINAL COMPLICATIONS OF VPS IN PEDIATRIC PATIENTS

Figure 7. Knotting of ventriculoperitoneal shunt catheter inside of

omentum.

Spontaneous intestinal perforation after VPS operation is quite

rare (0.01%e0.07%) and was first reported in 2 cases by Wilson and
Bertan in 1996.13 Clinicians should be aware of this condition, as it
might have an asymptomatic course and result in serious
complications and high mortality.14 The most frequent perforation
in the gastrointestinal system is reported to be in the colon, but it
might occur at any location. In 44% of patients with perforation,
the catheter is observed to protrude from the anus.15 Perforation
generally has an asymptomatic course and is diagnosed when the
catheter protrudes from the anus or the mouth. Mortality after
perforation is 15%e18% and increases if a central nervous system
infection or intra-abdominal infection is present.1 Fibrous tissue
around the perforation restricts intestinal contents from escaping
into the peritoneal cavity.16 Thus, intestinal perforation might
develop without any abdominal findings and with a clinically
asymptomatic course. Therefore, if the patient has ventriculitis or
Figure 6. Skin necrosis owing to ventriculoperitoneal shunt catheter.

if the patient is in the neonatal period, scrotal hydrocele occurring

in the early postoperative period is considered to be a shunt
complication.10 Hernia repair with laparoscopy provides the
opportunity to repair the contralateral hernia without an extra
incision and is useful to localize the catheter to the required
position in atypical migrations of the catheter.11 It is appropriate
to perform a hernia repair simultaneously in cases in which
inguinal hernia is diagnosed with careful physical examination
before VPS implantation. Umbilical hernia defect is reported to
become distinguishable by the naked eye as a consequence of
increased intra-abdominal pressure after shunt implantation.12
The patient can be operated on in optimal conditions because
occurrence of spontaneous umbilical hernia regression owing to Figure 8. Knotting of ventriculoperitoneal shunt catheter inside of skin
tunnel.
decreasing intra-abdominal pressure is possible.

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BEGER BURHAN ET AL.
Figure 9. Knotting of ventriculoperitoneal shunt catheter inside of skin
tunnel.
meningitis caused by enteric microorganisms, intestinal perforation
should be considered. Escherichia coli is the most frequently detected
organism in CSF cultures of such cases.16
It is not clear exactly how VPS causes perforations of hollow
organs. Theoretically, it is considered to be linked to chronic
Figure 10. Free catheter in peritoneal cavity.
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ORIGINAL ARTICLE
ABDOMINAL COMPLICATIONS OF VPS IN PEDIATRIC PATIENTS
irritation, catheter pressure, and allergic reactions related to the
catheter.17 Lengthiness of the catheter, a stiff or a sharp catheter
edge, development of allergic reactions to the catheter (silicon
allergy), localized infection, poor nutrition or poor general
medical condition of the patient stemming from primary disease,
and abdominal adhesions owing to surgical interventions are also
risk factors.15
The distal part of the catheter should be removed along with
antibiotic prophylaxis, and the proximal part should be placed to
external drainage. The perforated intestinal region should be
resected and anastomosed.17 In cases without peritonitis, the
distal end is reported to be removed through the anus with
colonoscopy.17 Even so, excision of the fistula tract occurring
around the catheter invading the perforation region by
laparotomy or laparoscopy is more appropriate, as leaving the
fistula tract might cause internal hernia and volvulus later
on.5,15,18
CSF distribution to the other regions in the abdomen may be
blocked by mesentery wrapping around the distal end of the shunt.
Accumulation of CSF can cause APC or hepatic pseudocyst (HPC).19
APC was first identified by Hars in 1954 and is reported to have an
incidence of 4.5%. HPC is a much rarer complication.20-22 In many
cases, APC develops at an average of 16 months after the last
abdominal surgery.23 Patients might present to the clinic with an
acute abdomen as well as less significant symptoms, such as
constipation, fever, lethargy, and headache.23 The etiopathogenesis
is not definitely determined; repetitive surgeries, shunt revisions,
protein increase in CSF, silicon allergy, intracranial tumor history,
and chronic irritation at the liver side (for HPC) caused by the
distal end of the catheter are considered to be responsible. In cases
where inflammation is the primary factor, infections related to
Staphylococcus epidermidis, Staphylococcus aureus, and Propionibacterium
acnes are considered.2,21,22 Larger APCs are generally sterile, but
multilobular ones are generally infected, and the most frequently
isolated organisms from the CSF are S. epidermidis and S. aureus.22,24
The most frequently employed radiologic diagnostic method is
ultrasonography.24 Treatment is based on external drainage and
antibiotics, and the most current treatment for APC is laparoscopic
cyst excision and movement of the catheter to a different
localization.21,25 For HPC, it is sufficient to locate the peritoneal
part in another region in the abdomen; there is no need for excision
or aspiration.21
Among VPS complications, intestinal obstruction is one of the
rarest.26 Repetitive shunt revisions related to injury as the result of
chronic pressure of the distal catheter adhesions might occur. In
addition, internal hernias and volvulus might occur also
owing to fibrotic tract development because of the catheter
presence.7,27 Regardless of the reason, in obstruction cases, con-
servative treatment includes intravenous liquid and electrolyte
balancing treatment and nasogastric intubation to decrease gastric
pressure. In cases of complete obstruction, urgent surgery may be
necessary.26
Dislocation of any of the shunt system elements from their
normal anatomic position is a rare complication.28 Weakening of
the dermal layer owing to surgical technique during the opening
of the subcutaneous tunnel for the VPS, potential spread of the
infection to the dermal follicles owing to the weak immunity of
the patient, and skin necrosis could induce skin rupture.29
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BEGER BURHAN ET AL. ABDOMINAL COMPLICATIONS OF VPS IN PEDIATRIC PATIENTS

Potential migration of the shunt catheter into the mouth, small
intestines, stomach, gallbladder, bladder, urethra, vagina,
pleural cavity, mediastinum, or heart and great vessels has been
reported, and the treatment includes repair of the wounded
organ, antibiotic prophylaxis, and shunt revision.3
Strangulation of the distal end of the VPS is a rare complication.
Too lengthy catheter, too small diameter, and too much elasticity
are considered to be the predisposing factors. Treatment requires
unwinding of the knot or VPS revision.30 Occasionally,
strangulation inside the subcutaneous tunnel might be
encountered. In the literature, irritable peritoneum cases with
abdominal pain episodes are reported, and visceral irritation
caused by the catheter is reported, with the pain reduced after
repositioning of the VPS catheter.31
These high complication rates of VPS implantation have
directed surgeons to search for alternative methods. Endoscopic
third ventriculostomy, which is performed by opening the third
ventricle to interpeduncular and prepontine cisterns, has been the
first-choice treatment method to avoid shunt complications in the
treatment of obstructive hydrocephalus. Long-term complication
rates and clinical outcomes are reported to be better.32 The
probable time of these complications is especially between 3
months and 1 year. To avoid such complications, we
recommend that postoperative follow-up examinations be sched-
uled with regular intervals. Patients should be examined carefully
especially in the first postoperative week and the first month.
CONCLUSIONS
VPS implantation can give result in abdominal complications with
a wide range of clinical presentations. Predicting which abdominal
complications might occur in children with VPSs can be lifesaving
with early diagnosis and treatment.

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ABDOMINAL COMPLICATIONS OF VPS IN PEDIATRIC PATIENTS
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