Ventriculoperitoneal shunt complications needing shunt revision in children: a review of 5 years of experience with 48 revisions.

BACKGROUND: The aim of this study was to review the management of ventriculoperitoneal (VP) shunt complications in children. PATIENTS AND METHODS: During the last 5 years (January 1, 2006 to December 31, 2010), 236 VP shunt operations were performed in children under 12 years of age; of these, 40 (16.94%) developed shunt complications and those who underwent VP shunt revisions were studied. RESULTS: This prospective study included 40 (28 boys and 12 girls) children and required 48 shunt revisions. Complications following VP shunts that required shunt revisions were peritoneal catheter/peritoneal end malfunction (18), shunt/shunt tract infections (7), extrusion of peritoneal catheter through anus (5), ventricular catheter malfunction (4), cerebrospinal fluid (CSF) leak from abdominal wound (4), shunt system failure (2), ventricular end/shunt displacement (2), CSF pseudocysts peritoneal cavity (2), extrusion of peritoneal catheter from neck, chest, abdominal scar and through umbilicus, one each. Four-fifth of these shunt complications occurred within 6 months of previous surgery. Surgical procedures done during shunt revisions in order of frequency were revision of peritoneal part of shunt (27, 56.25%), revision of entire shunt system (6, 12.5%), extra ventricular drainage and delayed re-shunt (5, 10.41%), shunt removal and delayed re-shunt (5, 10.41%), opposite side shunting (2, 4.16%), cysts excision and revision of peritoneal catheter (2, 4.16%) and revision of ventricular catheter (1, 2.08%). The mortalities following VP shunt operations were 44 (18.64%) and following shunt revisions were 4 (10%). CONCLUSIONS: VP shunt done for hydrocephalus in children is not only prone for complications and need for revision surgery but also associated with considerable mortality.

Tube thoracostomy: primary management option for empyema thoracis in children.

AIM: The aim of this study was to review our experience with tube thoracostomy in the management of empyema thoracis in children. PATIENTS AND METHODS: This retrospective study included 46 children (26 boys and 20 girls) who were admitted and managed for empyema thoracis, between January 1, 2010 and December 31, 2010 at the author's department of paediatric surgery. RESULTS: During the last 12 months, 46 children aged below 12 years were treated for empyema thoracis: Five (10.86%) were infants, 22 (47.82%) were 1 to 5 years and 19 (41.30%) were 6 to 12 years of age. All the patients presented with complaints of cough, fever and breathlessness of variable durations. Twenty three (50%) children had history of pneumonia and treatment prior to development of empyema. Thirty five (76.08%) children had right-sided and 11 (23.91%) had left-sided empyema. Thirty nine (84.78%) children were successfully treated with tube thoracostomy, systemic antibiotics and other supportive measures. Seven (15.21%) children failed to respond with above and needed decortications. Most commonly isolated bacteria were Pseudomonas (n = 12) and Staphylococcus aureus (n = 7). The average length of hospital stay in patients with tube thoracostomy was 15.35 days, and in patients who needed decortications was 16.28 days following thoracotomy. There was no mortality amongst above treated children. CONCLUSIONS: Majority of children with empyema thoracis are manageable with tube thoracostomy, antibiotics, physiotherapy and other supportive treatment. Few of them who fail to above measures need more aggressive management.

Exploratory laparotomy for acute intestinal conditions in children: a review of 10 years of experience with 334 cases.

AIM: The aim of this study was to review 10 years of experience in the management of children with acute intestinal conditions requiring exploratory laparotomy. PATIENTS AND METHODS: This retrospective study included 334 children (244 boys and 90 girls) who underwent laparotomy for acute intestinal conditions between Jan 1, 2000 to Dec 31, 2009. Patients were grouped into two categories: group A (n = 44) included patients who needed laparotomy with terminal ileostomy and group B (n = 290) included patients who needed laparotomy without terminal ileostomy. We excluded neonates and patients with jejunoileal and colonic atresias, anorectal malformations, congenital pouch colon, neonatal necrotising enterocolitis, Hirschsprung's disease, appendicitis, abdominal trauma and gastrointestinal tumours. RESULTS: During the last 10 years, 334 laparotomies were performed in children under 12 years: 59.88% for intestinal obstruction and 40.11% for perforation peritonitis. Causes in order of frequency were: ileal perforations 34.13%; intussusceptions 26.34%; Meckel's obstruction 10.17%; congenital bands and malrotation 6.88%; postoperative adhesions 5.98%; miscellaneous peritonitis 5.68%; miscellaneous intestinal obstructions 4.79%; abdominal tuberculosis 4.19% and roundworm intestinal obstruction 1.79%. Ileostomy closures (n = 39) was tolerated well by all except one. The mortalities were 28 (8.38%) in group B and 6 (1.79%) in group A. CONCLUSIONS: The need for re-exploration not only increases the morbidity but also increases mortality as well. Diverting temporary ileostomy adds little cumulative morbidity to the primary operation and is a safe option for diversion in selected cases. The best way to further reduce the mortality is to create ileostomy at first operation.

Trans-anal protrusion of ventriculo-peritoneal shunt catheter with silent bowel perforation: report of ten cases in children.

Ventriculo-peritoneal (VP) shunting used in the treatment for hydrocephalus is associated with several complications. Mechanical failure of shunt is the commonest complication of all. Visceral/bowel perforation is an unusual but serious complication of VP shunting. This article reports our experience in the management of ten children who had VP Shunt catheter protrusion from anus. This is a retrospective study of ten patients who had VP shunt catheter protrusion from anus, admitted in the department of paediatric surgery between Jan 1996 and Dec 2005. The records of above ten cases were reviewed for their clinical presentation and management, etc. We had performed 398 VP shunt operations in the last 10 years. Two hundred and seventy one (68.09%) VP Shunts were done for congenital hydrocephalus of which 164 were done in infancy/neonatal period and 107 VP shunts were done in the age group of >1-12 years. One hundred and twenty-seven (31.90%) VP shunt operations were done for patients who had hydrocephalus as a complication following tubercular meningitis (TBM). Out of 398 VP shunts, ten patients (2.51%) had protrusion of the distal end of peritoneal catheter from anus without causing/leading to peritonitis. We observed a 08.29% mortality of all VP shunt operations. Protrusion of VP shunt catheter per rectum can occur without producing peritonitis. Formal exploration and localization of entry of VP shunt catheter in bowel is not mandatory. Mini laparotomy and revision of peritoneal part of shunt can be done if there is no shunt infection.