Elsevier

Neurologia i Neurochirurgia Polska

Volume 51, Issue 4, July–August 2017, Pages 290-298
Neurologia i Neurochirurgia Polska

Original research article
Our initial experience with ventriculo-epiplooic shunt in treatment of hydrocephalus in two centers

https://doi.org/10.1016/j.pjnns.2017.04.007Get rights and content

Abstract

Introduction

Hydrocephalus represents impairment in cerebrospinal fluid (CSF) dynamics. If the treatment of hydrocephalus is considered difficult, the repeated revisions of ventriculo-peritoneal (VP) shunts are even more challenging.

Objective

The aim of this article is to evaluate the efficiency of ventriculo-epiplooic (VEp) shunt as a feasible alternative in hydrocephalic patients.

Material and methods

A technical modification regarding the insertion of peritoneal catheter was imagined: midline laparotomy 8–10 cm long was performed in order to open the peritoneal cavity; the great omentum was dissected between its two layers; we placed the distal end of the catheter between the two epiplooic layers; a fenestration of 4 cm in diameter into the visceral layer was also performed.

A retrospective study of medical records of 15 consecutive patients with hydrocephalus treated with VEp shunt is also presented.

Results

Between 2008 and 2014 we performed VEp shunt in 15 patients: 5 with congenital hydrocephalus, 8 with secondary hydrocephalus and 2 with normal pressure hydrocephalus. There were 7 men and 8 women. VEp shunt was performed in 13 patients with multiple distal shunt failures and in 2 patients, with history of abdominal surgery, as de novo extracranial drainage procedure. The outcome was favorable in all cases, with no significant postoperative complications.

Conclusions

VEp shunt is a new, safe and efficient surgical technique for the treatment of hydrocephalus. VEp shunt is indicated in patients with history of recurrent distal shunt failures, and in patients with history of open abdominal surgery and high risk for developing abdominal complications.

Introduction

The real incidence of hydrocephalus in the general population is as of yet uncertain, the prevalence being estimated at 1–1.5% [1], [2], [3], while gender distribution is considered equal. Age distribution has two peaks: the first during infancy, predominantly congenital hydrocephalus, whereas the second peak is found in adults, where normal pressure hydrocephalus is encountered [2].

If not properly treated, hydrocephalus signifies high morbidity and mortality, causing severe and permanent neurological consequences. The cumulative costs implied for the diagnosis and treatment of these patients are often insurmountable [4].

Management of hydrocephalus is a challenging endeavor, numerous therapies having been devised across history. To this day, surgery remains the treatment of choice for hydrocephalus, no medical remedy being effective. Several surgical techniques have been described, grouped as internal, external or extracranial drainages. Third ventriculostomy, first reported by Dandy and later improved by Stookey and Scarff [5], belongs to the internal drainage techniques. External ventricular drainage (EVD) can only be utilized for a limited amount of time. Extracranial ventricular drainages are among the most frequently used in the treatment of hydrocephalus. They are represented by VP shunt, ventriculoatrial shunt, lumboperitoneal shunt and ventriculopleural shunt. From a historical perspective, other drainages have been reported that are currently abandoned or rarely used, such as the ventriculosubgaleal shunt, ventriculocholecystic shunt, ventriculoureteral shunt, lumboureteral shunt, ventriculomastoid drainage, ventriculosternal shunt, drainage into the thoracic duct, salivary gland, spinal epidural space, bone stomach, ileum and fallopian tube [2], [6], [7], [8], [9], [10], [11], [12]. Ventriculosinusal shunts, such as ventriculosagittal [13] or ventriculotransverse shunts [14], being considered anatomically and physiologically the most appropriate treatment of this disease, have also been attempted. We previously reported the ventriculo-epiplooic (VEp) shunting in animal models [15].

The objective of this study is to report our initial experience with the VEp shunt in human patients, and review the surgical technique. We also aim to establish the indications, emphasize the advantages compared with the standard VP shunt, and evaluate its efficiency and safety by analyzing immediate and long-term results.

Section snippets

Material and methods

We retrospectively reviewed medical records of consecutive patients with positive diagnosis of hydrocephalus, in which we had performed VEp shunts between February 2008 and July 2014, in two centers. In order to perform VEp shunt, we used a basic shunt tray and a cerebrospinal fluid (CSF) drainage system: ventricular catheter, peritoneal catheter, and valve (high, medium, low or programmable) or connector.

The surgical technique is standard for the cranial step (lateral ventricle

Results

Between February 2008 and July 2014 we performed VEp shunts in 15 patients with hydrocephalus. We performed VEp shunt 13 patients with prior VP shunt and multiple distal shunt failures with shunt revisions, varying in number from 1 to 38. In two cases with nonfunctional third ventriculostomy, we practiced VEp shunt as a first extracranial drainage procedure, without attempting a VP shunt beforehand (Table 1).

We performed it in all types of hydrocephalus, thus 5 patients had congenital

Discussions

Nowadays, VP shunt is the most common surgical procedure for the treatment of hydrocephalus. The abdominal step of VP shunt is represented by the placement of the distal end of the peritoneal catheter into the peritoneal cavity, either by open surgery, or by using the trocar. In both techniques, the distal end of the catheter is introduced through a small peritoneal breach, located lateral and superior to the umbilicus on the right midclaviculary line, and then a sufficiently long portion of

Conclusions

Ventriculo-epiplooic (VEp) shunt is a new, safe and efficient surgical technique for the treatment of hydrocephalus. In this procedure, the distal tip of the peritoneal catheter is introduced between the two omental layers. The distal tip is isolated from abdominal viscera; therefore complications specific to VP shunts can be prevented. VEp shunting is indicated and may represent a saving option in patients with previous VP shunts and multiple distal failures due to repetitive abdominal

Patient consent

The patients or patients’ families were informed, and they approved and signed an informed consent form.

Conflicts of interest

None declared.

Acknowledgement and financial support

None declared.

Ethics

The work described in this article has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans; Uniform Requirements for manuscripts submitted to Biomedical journals.

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