Migration of Abdominal Catheter of Ventriculoperitoneal Shunt Into
The Scrotum: A Case Report
Çetin Refik KAYAOĞLU, Göksin ŞENGÜL, Aykut SEZER, Murat SİLİ, Mustafa ÇOBAN, İsmail Hakkı AYDIN
Department of Neurosurgery, Medical School, Atatürk University, Erzurum
✔ A case of migration of abdominal catheter of ventriculoperitoneal shunt into Scrotum is presen- ted. To explain this complication, different mechanism have been suggested. Several authors pointed out that the dissection of the catheter was due to tight ligature at the connector site or to bowel contractions and repeated tractions of the peritoneal catheter.
Key words: Hydrocephalus, scrotum, migration, ventriculoperitoneal catheter J Nervous Sys Surgery 2008; 1(3):181-184
Ventriküloperitoneal Şantın Abdominal Kateterinin Skrotuma Migrasyonu:
Bir Olgu Sunumu
✔ Ventriküloperitoneal şantın abdominal kateterinin skrotuma migrasyonu nadirdir. Bu kompli- kasyonu açıklamak için farklı mekanizmalar ileri sürülmüştür. Birkaç yazar kateterin ayrılmasının konnektörün çok sıkı bağlanmasına veya barsak kontraksiyonuna ve peritoneal kateterin tekrarla- yan gerilmelerine bağlı olduğunu gösterdiler.
Anahtar kelimeler: Hidrosefali, skrotum, ventriküloperitoneal katater, migrasyon J Nervous Sys Surgery 2008; 1(3):181-184
V
en tri cu lo pe ri to ne al shunts are com- monly emp lo yed in the ma na ge ment of hydro cep ha lus and nu me ro us shunt mal func ti ons. Va rio us comp li ca ti ons such as dis sec ti ons as well as mig ra ti ons ha ve be en re por ted in the li te ra tu re. The se inc lu de mig ra ti- on in to the la te ral ven tri cu le (1), me di as ti num(5), chest (4), gas tro in tes ti nal tract (18), ab do mi- nal wall (19), blad der (9), va gi na (12), and scro- tum (2,6,14,16).
We pre sent a ca se of mig ra ti on of the pe ri to ne al cat he ter in to the scro tum and the cau sal mec ha- nisms are dis cus sed with a re vi ew of the li te ra- tu re.
CASE REPORT
A fi ve-month old ma le in fant, ope ra ted on be cau- se of a na sal en cep ha lo cel when he was two -days old, de ve lo ped hydro cep ha lus a we ek af ter the ope ra ti on. A ven tri cu lo pe ri to ne al shunt was in ser- ted. He was disc har ged wit ho ut prob lems ten days af ter the ven tri cu lo pe ri to ne al shunt in ser ti on, but was re add mit ted at 5 months be cau se of an en lar- ged right scro tum. On physi ci al exa mi na ti on an en lar ged right scro tum and the dis tal part of pe ri- to ne al cat he ter in this re gi on was de ter mi ned.
Ra di og rap hic exa mi na ti on sho wed the shunt tip wit hin the en lar ged right scro tum. At sur gery, the pre vio us in ci si on scar was re in ci sed. The dis tal Sinir Sistemi Cerrahisi / Cilt 1 / Sayı 3, 2008 181
Sinir Sistemi Cerrahisi Derg 1(3):181-184, 2008
cat he ter tip was fo und, shor te ned and re po si tio ned in to the ab do mi nal ca vity. Af ter the sur gery the scro tal swel ling di sap pe rad and the pa ti ent was disc har ge wit ho ut any prob lem.
DISCUSSION
Hydro ce le as so cia ted with slip pa ge of the shunt tip in to the scro tum ha ve bee en men tio ned in the li te ra tu re. In ad di ti on to the fre qu ent ab do mi nal comp li ca ti ons such as pe ri to ni tis, in fec ti ons, vis ce ral per fo ra ti ons, cyst for ma ti on, etc, the re are al so comp li ca ti ons such as up ward or down- ward mig ra ti on of the cat he ter (6).
Gros feld and Coo ney (8) fo und that the ave ra ge in ter val from pla ce ment of the ven tri cu lo pe ri to- ne al shunt to the de ve lo pe ment of her ni a or hydro ce le was 6.8 months, whi le this in ter val was abo ut 5 months in our pa ti ent. In the ir se ri es of fo ur ca ses, ho we ver, the ran ge that Ok tem et al. (14) fo und was 24 ho urs-6 months.
To exp la in this comp li ca ti on, dif fe rent mec ha- nisms ha ve be en sug ges ted. Fu wa et al. (6) po in- ted out that the dis sec ti on of the cat he ter was du e to eit her to o tight li ga tu re at the con nec tor or the bo wel con trac ti ons and re pea ted trac ti ons of the pe ri to ne al cat he ter.
Mur tag and Leh man (13) re por ted that pe ris tal tic in tes ti nal and omen tal ac ti vity pus hed any fo re- ign body pre sent in the pe ri to ne al ca vity to wards the umb li cus or in gui nal ca nal. Sin ce the cat he- ter is a fo re ing body, both omen tal and in tes ti nal ac ti vity con tri bu tes to the mig ra ti on of the cat- he ter.
Gros feld and Coo ney (8) fo und that chil dren with ven tri cu lo at ri al shunts had a much lo wer in ci den ce of in gui nal her ni a than tho se with ven tri cu lo pe ri to ne al shunts. The se re sults sug- gest that the ic rea sed fre qu ency of in gui nal her- ni as and hydro ce les in chil dren with ven tri cu lo- pe ri to ne al shunts may se em to be re la ted to
in crea sed in tra ab do mi nal pres su re and /or flu id cau sed by the pre sen ce of ex cess flu id in the pe ri to ne al ca vity, at a ti me when the re is pa tency of the pro ces sus va gi na lis. The hig her in ci den ce of in gui nal her ni a in con di ti ons of in crea sed in tra ab do mi nal pres su re du e to the va rio us obs- truc ti ve le si ons sup port this mec ha nism (17).
In crea sed in tra ab do mi nal pres su re may cau se hydro ce le, wit ho ut or with in gui nal her ni as, in two ways. The pre sen ce of rai sed in tra ab do mi- nal pres su re and/or flu id may eit her pre vent na tu ral clo su re of the pro ces sus va gi na lis or con vert a po tent pro ces sus va gi na lis to a cli ni cal pro ces sus va gi na lis.The lat ter se ems to be much less li kely to hap pen. Ro we et al (17) al so fo und that pa ti ents with evi dent bi la te ral in gui nal her- ni as had hig her in ci den ce of rai sed in tra ab do mi- nal pres su re than tho se with uni la tea ral evi dent in gui nal her ni as and a pa tent pro ces sus va gi na- lis on the con tra la te ral si de, but the in ci den ce of the rai sed in tra ab do mi nal pres su re in chil dren with uni la te ral in gui nal her ni as was the sa me as tho se with or wit ho ut the pa tent pro ces sus va gi- na lis on the con tra la te ral si de. The se re sults sug- gest that rai sed in tra ab do mi nal pres su re may cau se the in crea sed de ve lop ment of bi la te ral in gui nal her ni as, but not con ti nu ed pa tency of the pro ces sus va gi na lis.
As for the pe ri od of ti me of na tu ral clo su re of the pro ces sus va gi na lis, the re is no com mon ag ree ment among aut hors. The re are two types of stu di es that can pro vi de in for ma ti on abo ut the na tu ral clo su re his tory of the pro ces sus va gi na- lis. Alt ho ugh the first gro up of the stu di es are ba sed on au top si es, the ot her gro up of the stu di- es are ba sed on the pa tency of the con tra la te ral pro ces sus va gi na lis in in gui nal her ni al re pa ir. In one study ba sed on au top si es, the pro ces sus va gi na lis was fo und to be partly or comp le tely open in 80 % of ca ses at birth (11). The re sults fo und in anot her study al so sug gest that the re may be so me deg re e of pa tency of at le ast one pro ces sus va gi na lis in over 50 % of ca ses thro-
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Ç. R. Kayaoğlu, G. Şengül, A. Sezer, M. Sili, M. Çoban, İ. H. Aydın
ug ho ut in fancy (15). Se ve ral stu di es ba sed on the in ci den ce of pa tency of con tra la te ral pro ces sus va gi na lis at va rio us age, du ring bi la te ral in gui- nal esp lo ra ti on in ca ses of cli ni cally uni la te ral her ni as, sug gest that the pa tency ra te of pro ces- sus va gi na lis is abo ut 70 % to 80 % at birth, gra du ally dec rea sing to abo ut 30 % to 40 % by 3 to 4 ye ars of age (7,17). In one study that was un der ta ken in 430 chil dren bet we en 1985 and 1995, Clar nett et al (3) pro po sed that the de ve- lop ment of an in gui nal her ni a or hydro ce le af ter the in ser ti on of a ven tri cu lo pe ri to ne al shunt co uld be used as an in di rect mar ker of pa tency of the pro ces sus va gi na lis at the ti me of in ser ti- on of the ven tri cu lo pe ri to ne al shunt. In ad di ti on, they cla im that the pro ces sus va gi na lis re ma ins pa tent in at le ast 30 % of chil dren in the first few months of li fe, af ter which ti me the pa tency ra te ap pe ars to fall off qui te sharply. This study also de mons tra tes that the in ci den ce of sub se qu ent de ve lop ment of hyd ro ce le, with or wit ho ut in gui nal her ni a, is clo sely re la ted to the age of
in ser ti on of the ven tri cu lo pe ri to na el shunt.
In conc lu si on, we believe that the fac tors men- tio ned abo ve con tri bute con co mi tantly to the de ve lop ment of hydro ce le. In a hydro cep ha lic in fant, who se pro ces sus va gi na li ses are open, pe ris tal tic in tes ti nal and omen tal mo ve ments may dri ve the cat he ter in to the in gui nal ca nal and sub se qu ently in to the scro tum. If, in in fants with a re la ti vely small ab do mi nal ca vity, the in tra ab do mi nal pres su re is to o much rai sed du e to lar ge vo lu me of ce reb ros pi nal flu id which ex ce eds the abi lity of the pe ri to ne al li ning to ab sor be, this the ory may be es pe ci ally tru e.
If an in fant with a ven tri cu lo pe ri to ne al shunt de ve lops hydro ce le, this comp li ca ti on sho uld be im me dia tely re cog ni sed and re pai red sur gi cally.
Using a shunt inc lu ding a high pres su re val ve and a shor ter cat he ter may per haps dec rea se the in ci den ce of this comp li ca ti on.
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