ABSTRACT
PURPOSE: Ventriculo-peritoneal shunt is the gold standard for non-obstructive hydrocephalus. Despite advances in material, infection prevention, and valve technologies, failure can still occur. The aim of this article is to present a comprehensive study based on the experience of a reference center in pediatric neurosurgery in Rio de Janeiro with the use of the ventriculo-gallbladder shunt as an alternative to peritoneal failure. METHODS: A retrospective study was conducted from January 2018 to December 2023 of patients diagnosed with cerebrospinal fluid shunt dysfunction due to peritoneal failure and submitted to ventriculo-gallbladder shunt as an alternative in a reference center of Rio de Janeiro. RESULTS: From 2018 to 2023, 18 peritoneal failures were diagnosed. Among them, 10 patients (55.5%) were selected for ventriculo-gallbladder shunt (VGS). Different causes were responsible for the hydrocephalus in these patients. VGS was placed at a mean age of 35.4 months. Four patients had temporary complications: 2 self-limited diarrheas in the first month and 2 shunt infections. After the resolution of the infection, a new VGS was placed successfully. The average follow-up was 18.8 months (follow-up 9-68 months) without further issues. CONCLUSION: VGS is a viable option for patients facing peritoneal failure. This paper provides valuable insights into the surgical technique and outcomes associated with this alternative.
Subject(s)
Cerebrospinal Fluid Shunts , Gallbladder , Hydrocephalus , Humans , Child, Preschool , Hydrocephalus/surgery , Retrospective Studies , Female , Male , Infant , Child , Gallbladder/surgery , Cerebrospinal Fluid Shunts/methods , Cerebrospinal Fluid Shunts/adverse effects , Ventriculoperitoneal Shunt/methods , Ventriculoperitoneal Shunt/adverse effectsABSTRACT
O tratamento das hidrocefalias corresponde a mais da metade do movimento anual de um serviço de neurocirurgia pediátrica. Ainda hoje a cirurgia para implantação das derivações ventrículoperitoneais é o tratamento de escolha, uma vez que proporciona um imediato controle da pressão intracraniana e possui técnica amplamente difundida entre os serviços de neurocirurgia. A maioria dos casos tem como origem a hidrocefalia congênita, com incidência estimada de cerca de 326 casos por 100.000 nascidos vivos na América Latina. Um grande desafio para o neurocirurgião é a falha do sistema de derivação ventriculoperitoneal, cuja incidência após os primeiros 15 anos de cirurgia pode ser superior a 80%. Dentre as causas de falha da drenagem, podemos identificar as mecânicas (obstruções, hiperdrenagem, migrações, fraturas ou desconexões dos cateteres) e as infecciosas. Pouco se conhece sobre os fatores relacionados ao sucesso cirúrgico naqueles que atingiram a adolescência livres de complicações e com um ótimo funcionamento do sistema, uma vez que um número pequeno de pacientes chega ao fim da adolescência sem a necessidade de revisões cirúrgicas. O presente estudo tem como fonte de dados de pesquisa duas grandes unidades públicas de saúde especializadas em pediatria no município do Rio de Janeiro: o Hospital Municipal Jesus e o Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira. Trata-se de um estudo de coorte retrospectivo dos adolescentes que foram submetidos à derivação ventriculoperitoneal para o tratamento de hidrocefalia congênita, sendo registradas as variáveis clínicas observadas no momento em que foram operados, os aspectos radiológicos e os relacionados à técnica cirúrgica. Os adolescentes que receberam apenas a primeira intervenção cirúrgica para colocação da derivação ventrículo peritoneal foram comparados com aqueles submetidos a pelo menos uma reintervenção para avaliar a associação entre fatores clínicos, radiológicos e da técnica cirúrgica com o tempo de permanência das derivações. O peso no momento da cirurgia e o tempo cirúrgico mostraram associação significativa com a longevidade, relacionados ao sucesso cirúrgico da derivação ventriculoperitoneal em adolescentes com diagnóstico de hidrocefalia congênita.
More than half of the annual movement of a pediatric neurosurgery service comprehend the treatment of hydrocephalus. Even today, the treatment of choice for hydrocephalus is the surgical implantation of ventriculoperitoneal shunt since it provides immediate control of intracranial pressure, and its technique is widely used among neurosurgery services. Most cases originate from congenital hydrocephalus, which has an estimated incidence of about 326 cases per 100,000 live births in Latin America. The major challenge for the neurosurgeon is the failure of the ventriculoperitoneal shunt system, which accounts for more than 80% incidence after the first 15 years of surgery. Among the causes of drainage failure, we can distinguish the mechanical ones (obstructions, hyperdrainage, migrations, fractures, or disconnections of the catheters) and the infectious ones. Little is known about the factors related to surgical success in those who reached adolescence free of complications and with an optimal functioning of the system, since a small number of patients reach the end of adolescence without the need for surgical revisions. The source of the research data for this study are two large public health pediatric hospitals in the city of Rio de Janeiro: The Hospital Municipal Jesus and the Instituto Nacional da Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira. This is a retrospective cohort study of adolescents who underwent ventriculoperitoneal shunt for the treatment of congenital hydrocephalus, in which the clinical variables observed at the time of the first surgery, the radiological aspects and those related to the surgical technique used will be registered. Adolescents who received only the first surgical intervention for placement of the peritoneal ventricle shunt were compared with those who underwent at least one reintervention, to assess the association between clinical, radiological, and surgical technique factors with the length of stay of the shunts. The weight at the time of the surgery and the length of the procedure showed a significant association with longevity, related to the surgical success the peritoneal ventricle shunt in adolescents diagnosed as congenital hydrocephalus.
Subject(s)
Humans , Adolescent , Survival Analysis , Ventriculoperitoneal Shunt/adverse effects , Hydrocephalus/surgery , Hydrocephalus/therapy , Tertiary Healthcare , Brazil , Retrospective Studies , Cohort StudiesABSTRACT
OBJECTIVE: The goal of this study was to analyze the factors that have an impact on morbidity and mortality in patients with myelomeningocele (MMC). METHODS: A retrospective cohort study was conducted to analyze factors associated with MMC that influence the morbidity and mortality of the disease. Data were collected from medical records of children who underwent the primary repair of MMC at the Fernandes Figueira Institute-Oswaldo Cruz Foundation (IFF-Fiocruz) between January 1995 and January 2015, with a minimum follow-up of 1 year. The following variables were analyzed: demographic characteristics (gestational age, sex, and birth weight); clinical features (head circumference at birth, anatomical and functional levels of MMC, hydrocephalus, symptomatic Chiari malformation type II, neurogenic bladder, and urinary tract infection [UTI]); and surgical details such as timing of repair of MMC, age at first shunt placement, shunt surgery modality (elective or emergency), concurrent surgery (correction of MMC and shunt insertion in the same surgical procedure), incidence and cause of shunt dysfunction, use of external ventricular drain, transfontanelle puncture, surgical wound complications prior to shunting, and endoscopic treatment of hydrocephalus. RESULTS: A total of 231 patients with MMC were included in the analysis. Patients were followed for periods ranging from 1 to 20 years, with a mean of 6.9 years. The frequency of shunt placement was observed mainly among patients with MMC at the highest spinal levels (p < 0.01). The main causes of morbidity and mortality in patients with MMC were shunt failures, diagnosed in 91 of 193 cases (47.2%) of hydrocephalus, and repeated UTIs, in 129 of 231 cases (55.8%) of MMC; these were the main causes of hospitalization and death. Head circumference ≥ 38 cm at birth was found to be a significant risk factor for shunt revision (p < 0.001; 95% CI 1.092-1.354). Also, the lumbar functional level of MMC was associated with less revision than upper levels (p < 0.014; 95% CI 0.143-0.805). There was a significant association between recurrent UTI and thoracic functional level. CONCLUSIONS: Macrocephaly at birth and higher levels of the defect have an impact on worse outcome and, therefore, are a challenge to the daily practice of pediatric neurosurgery.
Subject(s)
Arnold-Chiari Malformation/surgery , Hydrocephalus/surgery , Meningomyelocele/diagnosis , Meningomyelocele/surgery , Adolescent , Child , Child, Preschool , Female , Follow-Up Studies , Gestational Age , Humans , Hydrocephalus/diagnosis , Male , Neurosurgical Procedures/adverse effects , Neurosurgical Procedures/methods , Prognosis , Retrospective Studies , Ventriculoperitoneal Shunt/adverse effects , Ventriculoperitoneal Shunt/methodsABSTRACT
A 6-year-old girl was admitted to our emergency room because of a gunshot wound in the posterior craniocervical junction. On admission, she was alert, but left hemiplegia and right hemiparesis were noted. Cranial CT scanning showed a retained bullet in the cerebellomedullary cistern without bone destruction. Moreover, fourth ventricle hemorrhage was observed. There were no signs of acute hydrocephalus. The patient underwent suboccipital craniectomy and C-1 laminectomy for bullet removal. Postoperatively, the patient experienced significant neurological improvement. To the best of the authors' knowledge, this is the first documented case of a patient with a retained bullet in the cerebellomedullary cistern. The management strategies in such a unique case are discussed.