Case Report

Breast Breast Capsular Cerebrospinal Fluid Collection from Migration of a Ventriculoperitoneal Shunt Catheter William J. Knaus II, MD* Parisa Kamali, MD† Yoon Chun, MD‡ Samuel J. Lin, MD, MBA, FACS†

Summary: In this case report we have described an unusual complication of ventriculoperitoneal shunt migration into a breast implant capsule. The patient was appropriately diagnosed with computed tomographic imaging and successfully managed with shunt revision and cerebrospinal fluid aspiration. Given the high complication profile of ventriculoperitoneal shunt catheters, this case suggests an opportunity for improved perioperative communication between plastic surgeons and neurosurgeons in patients with breast implants. Coordination regarding the subcutaneous catheter tunneling may hopefully minimize the risk of this complication. (Plast Reconstr Surg Glob Open 2016;4:e640; doi: 10.1097/GOX.0000000000000590; Published online 17 March 2016.)

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reast reconstruction represents one of the most common operations performed by plastic surgeons in the United States. In 2013, nearly 100,000 breast reconstruction operations were performed with almost 80% utilizing implantbased techniques.1 As our experience with this technique continues to increase, reconstruction is being offered to progressively comorbid patients.2 With these trends, other surgical specialties have likely been increasingly exposed to patients with a history of implant-based breast reconstruction, which may impact surgical approaches. In this case report, we describe a fluid collection around a breast implant from the migration of a ventriculoperitoneal shunt From the *Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.; †Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.; and ‡Division of Plastic Surgery, Brigham and Women’s Hospital, Boston, Mass. Received for publication February 6, 2015; accepted December 2, 2015. Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. DOI: 10.1097/GOX.0000000000000590



catheter. The goal of this case report is to present an unusual case of breast swelling and improve awareness of this potential problem.

CASE REPORT

The patient is a 47-year-old woman who previously underwent an immediate, 2-stage breast implant reconstruction for low-stage breast cancer. The patient underwent a right total mastectomy with sentinel lymph node biopsy in early 2011 with placement of a subpectoral Inamed 133MV 500cm3 tissue expander (Allergan, Santa Barbara, Calif.) and AlloDerm (LifeCell Corp, Bridgewater, N.J.) placement. After successful tissue expansion, the patient underwent exchange to an Inamed style 20 600cm3, smooth, round implant several months later. Unfortunately, the patient subsequently was diagnosed with left lung adenocarcinoma with lymph node involvement. Because of worsening headaches, a work-up was initiated, which revealed metastatic lesions in the brain in April 2015. Under the care of a neurosurgeon, the patient underwent a midoccipital craniotomy with resection of the metastatic lesions, which was complicated by hemorrhage requiring reoperation and

Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.

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PRS Global Open • 2016 subsequent hydrocephalus. A ventriculoperitoneal shunt was placed to relieve her increased intracranial pressure from a right frontal craniotomy with tubing tunneled from the right neck to the subxiphoid and placed intraperitoneal in the right subcostal area. The patient was discharged to a rehabilitation facility and noted gradual swelling of her right breast 2 weeks later (Fig. 1). Because of progressing pleuritic chest pain and shortness of breath, the patient presented to the Emergency Department for evaluation. An ultrasound of the right breast demonstrated a 2.4 transverse × 0.6 anteroposterior × 3.8-cm craniocaudal collection superior to the breast implant, and a computed tomograph of the chest showed a malpositioned shunt catheter coiled around the right breast implant with the tip in the anterior chest wall (Fig.  2). This was likely because of ventriculoperitoneal shunt placement through the breast pocket into the peritoneal cavity, followed by migration of the shunt into the breast

pocket. The patient went to the operating room for revision of the ventriculoperitoneal shunt, and the existing catheter was used to aspirate the cerebrospinal fluid before removal and a new catheter was tunneled to the left of the midline and placed intraperitoneal from the left subcostal area. The patient had improvement in her symptoms and recovered uneventfully without further breast swelling or infection of the implant.

DISCUSSION

Ventriculoperitoneal shunts are a common neurosurgical procedure for the treatment of hydrocephalus but are unfortunately associated with a high complication profile. Over 30,000 shunts are placed by neurosurgeons in the United States each year.3 Commonly, these shunts are tunneled subcutaneously from the craniotomy site through the thorax and ultimately secured into the intraperitoneal cavity. Revision rates have been reported to be approximately 50%, according to retrospective reviews, with shunt malfunction cited as the most common etiology.4 Multiple case reports have described the migration of the distal shunt catheter into the bowel,5 chest,6 pulmonary artery,7 and heart.8 Samuel J. Lin, MD, MBA, FACS Division of Plastic Surgery Beth Israel Deaconess Medical Center 110 Francis Street Suite 5A Boston, MA 02215 E-mail: [email protected]

REFERENCES

Fig. 1. Clinical image of breast after implant-based reconstruction and fluid collection.

Fig. 2. Image of ventriculoperitoneal catheter within breast capsule.

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1. 2013 Plastic Surgery Statistics Report.” Available at: http:// www.plasticsurgery.org/Documents/news-resources/ statistics/2013-statistics/plastic-surgery-statistics-full-report-2013.pdf. Accessed August 30, 2015. 2. Albomoz CR, Cordeiro PG, Pusic AL, et al. Diminishing relative contraindications for immediate breast reconstruction. Plast Reconstr Surg. 2014;134:363e–369e. 3. Khan F, Rehman A, Shamim MS, et al. Factors affecting ventriculoperitoneal shunt survival in adult patients. Surg Neurol Int. 2015;6:25. 4. Reddy GK, Bollam P, Caldito G. Long-term outcomes of ventriculoperitoneal shunt surgery in patients with hydrocephalus. World Neurosurg. 2014;81:404–410. 5. Birbilis T, Zezos P, Liratzopoulos N, et al. Spontaneous bowel perforation complicating ventriculoperitoneal shunt: a case report. Cases J. 2009;2:8251. 6. Karapolat S, Onen A, Sanli A. Intrathoracic migration of ventriculoperitoneal shunt: a case report. Cases J. 2008;1:42. 7. Ryugo M, Imagawa H, Nagashima M, et al. Migration of distal ventriculoperitoneal shunt catheter into the pulmonary artery. Ann Vasc Dis. 2009;2:51–53. 8. Chong JY, Kim JM, Cho DC, et al. Upward migration of distal ventriculoperitoneal shunt catheter into the heart: case report. J Korean Neurosurg Soc. 2008;44:170–173.

Breast Capsular Cerebrospinal Fluid Collection from Migration of a Ventriculoperitoneal Shunt Catheter.

In this case report we have described an unusual complication of ventriculoperitoneal shunt migration into a breast implant capsule. The patient was a...
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