Original Article
Comparative study of lumboperitoneal shunt versus ventriculoperitoneal shunt in post meningitis communicating hydrocephalus in children Amit Singh, I. N. Vajpeyi1 Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, 1Department of Surgery, GSVM Medical College, Kanpur, Uttar Pradesh, India
Abstract
Address for correspondence: Dr. Amit Singh, Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi ‑ 110 029, India. E‑mail: [email protected] Received : 31‑07‑2013 Review completed : 09‑08‑2013 Accepted : 20‑10‑2013
Background: Managing post meningitis hydrocephalus in children is a herculean task for the treating pediatric surgeon or neurosurgeon because of the morbidity associated with the disease per se and the complications of shunt surgery. By this study, the effectiveness of lumboperitoneal (LP) shunt and ventriculoperitoneal (VP) shunt in cases of post meningitis communicating hydrocephalus was assessed in children. Materials and Methods: This was a retrospective analysis of the records of children admitted in our institute between December 2005 and March 2008. Only children with post meningitis communicating hydrocephalus who underwent either LP or VP with a minimum follow‑up period of 36 months were included in the study. Children with non‑communicating hydrocephalus or hydrocephalus due to another etiology were excluded. Investigations were included plain brain computed tomography scan, air encephalography and X‑ray skull. Medium pressure Chabbra shunt with slit valves was used in all cases of VP and LP shunt. A comparative analysis of the outcome was carried out between the two groups. Results: There were 66 males and 24 females (M: F 2.7:1. The average age at presentation was 40.3 months. LP shunt was performed in 37 while VP shunt in 53 cases Complication rate in the LP and VP shunt was 15% and 29% respectively with non‑obstructed complications higher in VP group when compared to LP group. Obstructed complication rate was similar in both groups. Conclusion: Due to less morbidity and ease of placement, LP shunt can be an alternative to VP shunt in cases of communicating hydrocephalus in children, which has more non‑obstructed complication rates as compared to LP shunt. Key words: Communicating hydrocephalus, lumboperitoneal shunt, ventriculoperitoneal
shunt
Introduction Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.121932
Neurology India | Sep-Oct 2013 | Vol 61 | Issue 5
Hydrocephalus in children is a surgical disease usually not amendable to medical treatment. Various types of shunt are described for cerebrospinal fluid (CSF) diversion with ventriculoperitoneal (VP) shunt gaining the acceptability over others. Lumboperitoneal (LP) shunts, which have gained wide acceptance as an alternative to VP shunt in adults, is still an unknown entity for pediatric surgeons. The most common causes 513
Singha and Vajpeyi: Lumboperitoneal versus ventriculoperitoneal shunt in communicating hydrocephalus
of hydrocephalus in children are tubercular meningitis followed by congenital hydrocephalus. Shunt surgery in children is associated with more morbidity than in adults. This study assesses the role of LP shunt in communicating hydrocephalus along with comparison with VP shunt in term of efficacy and morbidity.
Materials and Methods This was a retrospective analysis of case records of children admitted with a diagnosis of post meningitis communicating hydrocephalus between December 2005 and March 2008. Institute’s ethical committee clearance was obtained for the study. Children below 12 years of age with post‑meningitis communicating hydrocephalus who had undergone either LP or VP shunt and followed‑up for a period of minimum 36 months were included in the study. Children with non‑communicating hydrocephalus, hydrocephalus due to other etiology, children with follow‑up period less than 36 months, incomplete data, lost to follow‑up were excluded from the study. Communicating hydrocephalus was defined as the presence of panventriculomegaly with normal or widened sulci. To diagnosis Communicating hydrocephalus, we have performed air encephalogram which is the gold standard for diagnosis of communicating hydrocephalus. Air encephalogram was performed by doing lumbar puncture in aseptic conditions and injecting about 5 ml of air after withdrawing same amount of CSF from the subarachnoid space. Plain X‑ray skull anterior posterior and lateral view was taken after 5 min in a sitting position. Air in the ventricles confirmed the diagnosis of communicating hydrocephalus. Indications for CSF shunting were assessed on the basis of neurological symptoms and computed tomography (CT) findings. Both the shunts were performed under general anesthesia by single experienced surgeon. Medium pressure Chabbra shunt with slit valve was used for VP as well as LP shunt. For performing LP shunt child was placed in right lateral decubitus position and a field is prepared and draped extending from the midline of the lumbar region around the left flank to the left lower quadrant. The peritoneal cavity is opened through a muscle splitting incision. Longitudinal midline incision given in the mid lumbar region and thecal space is opened. Proximal end of the shunt is placed in the thecal sac and the distal end is tunneled to the abdominal incision. The distal end is placed in the peritoneal cavity and wounds are closed. For VP shunt child was placed in the supine position with extension and tilting of the neck to the opposite side where the incision is to be made. Incision was given over the posterior parietal scalp just below parietal prominence. The flap is raised and a burr hole is made 514
over one half of the line joining the internal auditory meatus to the vertex. Next an abdominal incision is made 2 cm below the costal margin along a straight line with cranial incision. Proximal end of VP shunt is placed into the frontal horn of the lateral ventricle and the distal end tunnels through the subcutaneous space up to the abdominal incision. Distal end is placed in the peritoneal cavity and wounds are closed. Follow‑up include 3 monthly visits to the hydrocephalus clinic in 1st year followed by 6 monthly in 2nd year and yearly thereafter. During follow‑up, CT was done at 6 months and 1 year post surgery. In each follow‑up visit, children were examined for signs of raised intracranial pressure and if required fundoscopy were done to document papilledema.
Results A total of 147 hydrocephalus children were admitted between December 2005 and March 2008. Out of these children, 109 children had post‑meningitis hydrocephalus. Out of the 109 children, 9 (8.2%) children were lost to follow‑up while 6 (5.5%) children were aged more than 12 years. Records of 4 (3.6%) children were found to be incomplete. Only 90 children satisfying the criteria were included in the study. There were 66 males and 24 females (M:F 2.7:1). The average age at presentation was 40.3 months. VP shunt was performed in 53 (58.8%) children while 37 (41.1%) underwent LP shunt. Most common presenting symptom was increasing head size followed by fever [Table 1]. Glasgow coma scale (GCS) at the time of presentation and at the time of discharge is shown in [Table 2]. GCS categories in the two groups are statistically not significant. Improvement in GCS was seen in both groups during the follow‑up [Table 2]. The complications associated with both LP and VP shunts after a mean follow‑up period of 41.9 months (range: 36-54 months) are shown in Table 3. Among children with VP shunt, revision of the shunt was required in 12 (22.6%) children and in 5 (13.5%) children with LP shunt. Seizure disorder was seen in 3 (5.6%) children with VP Shunt while none in LP shunt group. There were 2 (3.7%) deaths in VP shunt group while none in LP shunt groups. Death of both the children was not related to surgical procedure. One of them expired Table 1: Major clinical presentation in children with hydrocephalus
Clinical features
Number of cases (%)
Enlarging head size Fever Irritability Generalized seizure Vomiting Intolerance to feed
57 (63.3) 11 (12.2) 9 (10) 6 (6.6) 4 (4.4) 3 (3.3) Neurology India | Sep-Oct 2013 | Vol 61 | Issue 5
Singha and Vajpeyi: Lumboperitoneal versus ventriculoperitoneal shunt in communicating hydrocephalus
Table 2: GCS at the time of presentation and at the time of discharge
GCS
VP (n=53) LP (n=37) P value
GCS At presentation At discharge 13‑15 9‑12
Comparative study of lumboperitoneal shunt versus ventriculoperitoneal shunt in post meningitis communicating hydrocephalus in children Amit Singh, I. N. Vajpeyi1 Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, 1Department of Surgery, GSVM Medical College, Kanpur, Uttar Pradesh, India
Abstract
Address for correspondence: Dr. Amit Singh, Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi ‑ 110 029, India. E‑mail: [email protected] Received : 31‑07‑2013 Review completed : 09‑08‑2013 Accepted : 20‑10‑2013
Background: Managing post meningitis hydrocephalus in children is a herculean task for the treating pediatric surgeon or neurosurgeon because of the morbidity associated with the disease per se and the complications of shunt surgery. By this study, the effectiveness of lumboperitoneal (LP) shunt and ventriculoperitoneal (VP) shunt in cases of post meningitis communicating hydrocephalus was assessed in children. Materials and Methods: This was a retrospective analysis of the records of children admitted in our institute between December 2005 and March 2008. Only children with post meningitis communicating hydrocephalus who underwent either LP or VP with a minimum follow‑up period of 36 months were included in the study. Children with non‑communicating hydrocephalus or hydrocephalus due to another etiology were excluded. Investigations were included plain brain computed tomography scan, air encephalography and X‑ray skull. Medium pressure Chabbra shunt with slit valves was used in all cases of VP and LP shunt. A comparative analysis of the outcome was carried out between the two groups. Results: There were 66 males and 24 females (M: F 2.7:1. The average age at presentation was 40.3 months. LP shunt was performed in 37 while VP shunt in 53 cases Complication rate in the LP and VP shunt was 15% and 29% respectively with non‑obstructed complications higher in VP group when compared to LP group. Obstructed complication rate was similar in both groups. Conclusion: Due to less morbidity and ease of placement, LP shunt can be an alternative to VP shunt in cases of communicating hydrocephalus in children, which has more non‑obstructed complication rates as compared to LP shunt. Key words: Communicating hydrocephalus, lumboperitoneal shunt, ventriculoperitoneal
shunt
Introduction Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.121932
Neurology India | Sep-Oct 2013 | Vol 61 | Issue 5
Hydrocephalus in children is a surgical disease usually not amendable to medical treatment. Various types of shunt are described for cerebrospinal fluid (CSF) diversion with ventriculoperitoneal (VP) shunt gaining the acceptability over others. Lumboperitoneal (LP) shunts, which have gained wide acceptance as an alternative to VP shunt in adults, is still an unknown entity for pediatric surgeons. The most common causes 513
Singha and Vajpeyi: Lumboperitoneal versus ventriculoperitoneal shunt in communicating hydrocephalus
of hydrocephalus in children are tubercular meningitis followed by congenital hydrocephalus. Shunt surgery in children is associated with more morbidity than in adults. This study assesses the role of LP shunt in communicating hydrocephalus along with comparison with VP shunt in term of efficacy and morbidity.
Materials and Methods This was a retrospective analysis of case records of children admitted with a diagnosis of post meningitis communicating hydrocephalus between December 2005 and March 2008. Institute’s ethical committee clearance was obtained for the study. Children below 12 years of age with post‑meningitis communicating hydrocephalus who had undergone either LP or VP shunt and followed‑up for a period of minimum 36 months were included in the study. Children with non‑communicating hydrocephalus, hydrocephalus due to other etiology, children with follow‑up period less than 36 months, incomplete data, lost to follow‑up were excluded from the study. Communicating hydrocephalus was defined as the presence of panventriculomegaly with normal or widened sulci. To diagnosis Communicating hydrocephalus, we have performed air encephalogram which is the gold standard for diagnosis of communicating hydrocephalus. Air encephalogram was performed by doing lumbar puncture in aseptic conditions and injecting about 5 ml of air after withdrawing same amount of CSF from the subarachnoid space. Plain X‑ray skull anterior posterior and lateral view was taken after 5 min in a sitting position. Air in the ventricles confirmed the diagnosis of communicating hydrocephalus. Indications for CSF shunting were assessed on the basis of neurological symptoms and computed tomography (CT) findings. Both the shunts were performed under general anesthesia by single experienced surgeon. Medium pressure Chabbra shunt with slit valve was used for VP as well as LP shunt. For performing LP shunt child was placed in right lateral decubitus position and a field is prepared and draped extending from the midline of the lumbar region around the left flank to the left lower quadrant. The peritoneal cavity is opened through a muscle splitting incision. Longitudinal midline incision given in the mid lumbar region and thecal space is opened. Proximal end of the shunt is placed in the thecal sac and the distal end is tunneled to the abdominal incision. The distal end is placed in the peritoneal cavity and wounds are closed. For VP shunt child was placed in the supine position with extension and tilting of the neck to the opposite side where the incision is to be made. Incision was given over the posterior parietal scalp just below parietal prominence. The flap is raised and a burr hole is made 514
over one half of the line joining the internal auditory meatus to the vertex. Next an abdominal incision is made 2 cm below the costal margin along a straight line with cranial incision. Proximal end of VP shunt is placed into the frontal horn of the lateral ventricle and the distal end tunnels through the subcutaneous space up to the abdominal incision. Distal end is placed in the peritoneal cavity and wounds are closed. Follow‑up include 3 monthly visits to the hydrocephalus clinic in 1st year followed by 6 monthly in 2nd year and yearly thereafter. During follow‑up, CT was done at 6 months and 1 year post surgery. In each follow‑up visit, children were examined for signs of raised intracranial pressure and if required fundoscopy were done to document papilledema.
Results A total of 147 hydrocephalus children were admitted between December 2005 and March 2008. Out of these children, 109 children had post‑meningitis hydrocephalus. Out of the 109 children, 9 (8.2%) children were lost to follow‑up while 6 (5.5%) children were aged more than 12 years. Records of 4 (3.6%) children were found to be incomplete. Only 90 children satisfying the criteria were included in the study. There were 66 males and 24 females (M:F 2.7:1). The average age at presentation was 40.3 months. VP shunt was performed in 53 (58.8%) children while 37 (41.1%) underwent LP shunt. Most common presenting symptom was increasing head size followed by fever [Table 1]. Glasgow coma scale (GCS) at the time of presentation and at the time of discharge is shown in [Table 2]. GCS categories in the two groups are statistically not significant. Improvement in GCS was seen in both groups during the follow‑up [Table 2]. The complications associated with both LP and VP shunts after a mean follow‑up period of 41.9 months (range: 36-54 months) are shown in Table 3. Among children with VP shunt, revision of the shunt was required in 12 (22.6%) children and in 5 (13.5%) children with LP shunt. Seizure disorder was seen in 3 (5.6%) children with VP Shunt while none in LP shunt group. There were 2 (3.7%) deaths in VP shunt group while none in LP shunt groups. Death of both the children was not related to surgical procedure. One of them expired Table 1: Major clinical presentation in children with hydrocephalus
Clinical features
Number of cases (%)
Enlarging head size Fever Irritability Generalized seizure Vomiting Intolerance to feed
57 (63.3) 11 (12.2) 9 (10) 6 (6.6) 4 (4.4) 3 (3.3) Neurology India | Sep-Oct 2013 | Vol 61 | Issue 5
Singha and Vajpeyi: Lumboperitoneal versus ventriculoperitoneal shunt in communicating hydrocephalus
Table 2: GCS at the time of presentation and at the time of discharge
GCS
VP (n=53) LP (n=37) P value
GCS At presentation At discharge 13‑15 9‑12
