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The patient was a product of premature delivery of 25 week
gestation and was put in ventilator with grade IV IVH. The patient
had stricture of the small intestine with fistula in the right upper
quadrant of the abdomen, which was repaired surgically. The patient
was operated for progressing hydrocephalus 11-July-2006, which was
complicated and exposed for external drain later. The shunt was
inserted from the right side. Revision of the shunt was performed
07-August-2006 and the infection was treated with vancomycin
for 2 weeks and reinsertion of the VPS was done 10-September-2006.
The patient was brought to the clinic 30-September-2006 with
another attack of VPS malfunction. The fontanel was bulging and the
HC was 40 cm with the dimensions of the anterior fontanel 6cm X4 cm.
The patient could move all limbs and had no convulsions with normal
defecation and micturition and he was able to stand. Neurologically,
the patient showed no considerable deficits.
The patient was sent for brain and abdominal CT-scan, chest and
skull X-ray. The patient came 03-October-2006 with further
deterioration with engorged veins of the scalp.
Right ventriculo-atrial shunt was inserted. The right IJV was
hypoplastic and with difficulty the distal part was passed only for
3 cm after what it was impossible to push it further, despite the
dissection down to the retrosternal area. PS Medical 1-level
performance delta small VPS was used. Check for function was
positive. Considering that the IJV was hypoplastic and four slits in
the distal end of the shunt were not convincing for future function,
it was decided to explore the old shunt which was in the left side.
The old abdominal incision was refreshed in the left upper
quadrant and the shunt was identified and the distal wall was kept
under control. After removing the abdominal part exteriorly, the
shunt start to function properly. The distal part was put to its old
canal and it went easy, but the last 10 cm showed resistance, from
which a conclusion was achieved, that scars were present at the last
10 cm of the canal around the shunt. From the same incision, another
point of peritoneal entry lateral to the previous one was done and
inspection of the peritoneal cavity was done. The scars were mainly
in the right side of the abdominal cavity, for what the catheter was
inserted parallel to the descending colon.
Routine closure.
Comments:
1. This case is one of difficult, and challenging cases and
require special attention and hold several considerations.
2. The presence of hypoplastic IJV make the judgment for future
functioning of the recently available shunts in the market
under question. The one way flow must be reconstructed not in the
lateral wall of the distal end, but at the tip of catheter. This
needs a new concept in constructing the VAS, so that their one flow
mechanism must be devised at the tip of the catheter.
3. Hemorrhage and infection are among the most common causes of
malfunction. Strict observation and constant attention must be paid
to the reservoir to be kept clean with clear CSF during insertion,
otherwise the device will be exposed to malfunction.
4. In these circumstances, it is preferable to use low-pressure
valves or 1-level performance of delta type, to keep the flow in
higher rates. |
