Discussion
Using shunts and diversion of cerebrospinal fluid through them has long
been used in hydrocephalus, either congenital, acquired or post
traumatic hydrocephalus. Ventriculoperitonal shunts, was first proposed
by kausch and has been used since as an effective treatment approach (1,
10).
Like any other procedure, there are different complications to this
surgery. Abdominal complications, including peritoneal pseudocysts,
intestinal volvulus, protruding in hernial sac or extrusion through
vagina, scrotum, umbilicus or gastrointestinal tract, are rare but
according to previous studies can happen in 5-47 % of cases (3-5).
Bowel perforation Is a rare complication and can happen in 0.01 to
0.07% fo patients. 75 percent of patients with bowel perforation don’t
experience the classic clinical symptoms of peritonitis or bowel
perforation and may be asymptomatic. This particular complication should
not be overlooked since it can cause a high mortality rate of 15% and
although rare, may cause severe consequences (4, 5, 7).
VP shunt anal protrusion is an extremely rare complication which have
been reported less than a hundred times in literature. Most of the cases
reported with this complication, suffered this condition in months after
surgery and most of them happened in children and were asymptomatic
(8-11)
In these cases, different aspects should be considered carefully. One of
the most important parts of the management aside from the removal of the
case, is a complete work-up on CSF (Cerebrospinal fluid) contamination,
meningitis, ventriculitis, sepsis, perforative peritonints and
peritoneal abscess formations. Each of these occurrences may have an
important impact on the course of treatment and may increase the
mortality rate up to 15 % (8).
In cases of intestinal perforation without any other complications,
different approaches have been suggested. It’s been recommended that in
the acute cases of perforation with gastrointestinal symptoms, or signs
of peritonitis, an emergency laparotomy should be done in order to
remove the shunt, repair the perforation and in additional to that, a
peritoneal lavage may be indicated (8, 9, 12). Removing the distal end
of shunt, either manual through anus or during and laparotomy, should be
done with extreme cautious in order to minimize the probable
contamination of peritoneal cavity and CSF. In the previous literature,
laparoscopic management of this situation and removal of the shunt has
also been suggested (8, 13).
The patient should receive broad-spectrum antibiotics for at least 3
weeks and In order to do a full work-up on CSF, multiple CSF cultures
must be sent and after negative results are verified, the patient can be
observed and prepped for another shunt placement surgery, either on the
other side of the brain or on the same side (9).
Here we presented a case of trans-anal protrusion of VP shunt in a
36-year-old case of post traumatic hydrocephalus, 1 year after the shunt
placement. The patient underwent surgery and the shunt was successfully
removed manually through anus. Like many other cases, there were no
peritoneal or gastrointestinal symptoms in our patients and fortunately,
the shunt had no connection to ventricle when this complication happened
and therefore chances of CSF contamination were minimal. The patient was
monitored for 3 days, receiving broad-spectrum antibiotics and was then
referred to neurosurgeons for subsequent measures.