ENDOSCOPIC MANAGEMENT OF VENTRICULOPERITONEAL SHUNT EROSION INTO THE DUODENUM

Seyed A Arshad, MD, Andrew Christensen, MD, Edward Auyang, MD, MS, FACS, Jason Mckee, MD, FACS. University of New Mexcio

Ventriculoperitoneal (VP) shunt placement is a common procedure performed for the management of hydrocephalus. Of the complications associated with this procedure, bowel perforation constitutes around 0.1%. [1] Colonic and gastric perforation is the most common, with small bowel perforation being exceedingly rare. [2,3] Standard management of hollow viscus perforation includes exploratory surgery. Described is the case of a rare duodenal perforation, managed only by upper endoscopy.

A 16-year-old female with past medical history significant for hydrocephalus, multiple previous VP shunt placements and manipulations, and multiple previous abdominal and pelvic surgeries presented to the emergency department with a two day history of generalized abdominal pain, however, no overt signs of peritonitis. A CT showed a previously abandoned VP shunt perforating the duodenum. Retrospective review of a CT scan performed one year prior also showed this shunt eroding into the duodenum.

Given that the erosion of the shunt into the duodenum had been longstanding, it was presumed that there likely was a well formed tract around the catheter. With the patient’s history of multiple previous abdominal and pelvic operations, an attempt was made at endoscopic removal of the shunt.

Under general anesthesia, an upper endoscopy was preformed showing the catheter entering the third portion of the duodenum and extending distally. The catheter was able to be removed with use of an endoscopic grasper. Examination of the shunt ex-vivo showed a cracked end, likely from prior attempts at shunt removal. Post-operative x-ray showed removal of the suspect shunt in its entirety.

Post-operatively, the patient was kept NPO with nasogastric tube decompression for a period of 5 days. At that time, an upper gastrointestinal contrast study was performed which showed no extravasation from the duodenum. The patient’s diet was able to be advanced and the patient was subsequently discharged with no further sequela.

Although exceedingly rare, small bowel perforation by ventriculoperitoneal shunts is a possible complication of placement. Traditionally managed by exploratory surgery, endoscopic management of this complication is possible and should be considered as an adjunct to surgical intervention. Granted the use of endoscopy has been described for management of gastric and colonic perforation, and for verification of small bowel perforation, we believe this is the first case describing the use of endoscopic-only management of VP shunts eroded into the small bowel. [4]