Thoracoscopic/Laparoscopic placement of a (Denver) Shunt for refractory ascites/chylothorax in children.

Ashwin Pimpalwar, MD, FRCS, Pediatric, Surgery, Sheena A Pimpalwar, MD

1Division of Pediatric Surgery, Michael E DeBakey Department of Surgery, 2Department of Radiology Baylor College of Medicine and Texas children’s Hospital, Houston, Texas

Denver shunts are used for palliation of refractory ascites /chylothorax in children. We report our technique using laparoscopic/ thoracoscopic guidance for placement of these shunts in children.

Material Methods:
Patient 1:
A 9 year old male presented with a large right lobe hepatocellular carcinoma extending into the inferior vena cava and right atrium unresectable at exploration. Post-operatively, he developed severe symptomatic refractory ascites, liver failure and severe coagulopathy. A Denver shunt was requested to help transfer the patient to hospice care.
He underwent a laparoscopy guided placement of a Denver shunt (peritoneo-venous shunt) with a 5-mm trocar placed at the umbilicus to inspect the peritoneal contents and allow direct visualization of the catheter into the peritoneal cavity. The venous end of the catheter was placed percutaneously using ultrasound and fluoroscopic guidance. There were no intra-operative or post-operative complications.
Patient 2:
A 13 year old girl with mediastinal and left lower lobe lymphangiectasia, multiple left lower lobe AVM’s and refractory chylopericardium and chylothorax occluded her chest tube and developed pancreatitis on TPN and Sirolimus.
A 5mm thoracoscopic port was placed in the midaxillary line. The plueral end of the shunt was placed in the posterior costo-pherenic sulcus under thoracoscopic guidance. The shunt chamber was placed within a subcutaneous pocket in the anterior axillary line and was fixed in place. The venous end of the Denver shunt was advanced through a subcutaneous tunnel and placed in the left internal jugular vein using ultrasound and fluoroscopic guidance.

There were no intra-operative or post-operative complications. The first patient’s follow up at 12 months revealed a flat abdomen with a well-functioning shunt. The second patient has a well-functioning shunt at 1.5 months and is on a low fat oral diet at home.

Laparoscopic / Thoracoscopic guidance for placement of a Denver shunt allows proper location of the shunt tip under magnified visualization and is a safe and effective strategy for treatment of malignant/chylous refractory peritoneal and pleural collections in children.

Session: Poster Presentation

Program Number: P570

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