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.