EP420 - “I Pooped Out a Piece of My VP Shunt”: A Case of Ventricular-Peritoneal Shunt Erosion Resulting in Ileocecectomy and Salpingo-oophorectomy

Purpose/Background: Background:

A ventriculoperitoneal (VP) shunt is a cerebral shunt that drains excess cerebrospinal fluid (CSF) from the ventricles to the peritoneal cavity, relieving pressure caused by decreased CSF absorption or outflow obstruction [1]. Shunts are primarily used to manage congenital, acquired, or normal pressure hydrocephalus, as well as other conditions, such as pseudotumor cerebri. Untreated hydrocephalus can result in chronic headaches, cognitive decline, visual disturbances, and in severe cases cerebral edema and herniation [2]. Shunt malfunction and infection are common complications, often necessitating surgical revision. Common shunt types are ventriculoperitoneal (VP), ventriculoatrial (VA), and ventriculopleural (VPL) which drain CSF into the peritoneal cavity, the atrium, or the pleural cavity respectively [1].

We present an interesting case of a VP shunt that eroded into the left ovary, fallopian tube, and small bowel, forming an enteric and adnexal fistula requiring an ileocecectomy and left salpingo-oophorectomy. This case highlights one of the rare complications that can occur with VP shunts requiring surgical exploration.

Methods/Interventions: -

Results/Outcomes:

Case Presentation:

A 31-year-old woman with congenital hydrocephalus and multiple prior shunt revisions, most recently converted from a VP to a VA shunt two months earlier, presented to the emergency department after passing a large shunt fragment in her stool [Figure 1]. On presentation, she denied abdominal pain, fevers, chills, and obstructive symptoms, although she reported new irregular bowel movements. CT of the abdomen and pelvis revealed a retained VP catheter fragment within the lumen of the distal ileum, extending through and beyond the ileocecal valve into the cecum. The remainder of the catheter was noted to be coiled in the left adnexa with associated significant inflammatory thickening. The patient underwent exploratory laparotomy with extensive lysis of adhesions. Intraoperatively, the catheter was found to have perforated the left ovary and small bowel in two locations [Figure 1]. A joint procedure with Colorectal Surgery and Gynecology was performed, including an ileocecetomy with side-to-side functional end-to-end anastomosis to adequately takedown the fistula, flexible sigmoidoscopy, hysteroscopy and left salpingo-oophorectomy. A JP drain was placed and removed on postoperative day six. The patient tolerated diet advancement and was discharged in stable condition following adequate return of bowel function.

Conclusion/Discussion:

Discussion:

This case highlights a unique presentation of asymptomatic passage of a shunt fragment per rectum following incomplete removal of a VP shunt during revision two months prior to presentation. The VP shunt eroded into the left ovary, terminal ileum and into the cecum resulting in an acquired fistula requiring surgical intervention.

Bowel perforation by VP shunts is exceedingly rare, with an estimated incidence of 0.1%-1% [3,4]. When it occurs, the colon or stomach are most frequently involved; erosion through the small bowel is very uncommon [3]. Clinical presentation varies from asymptomatic, to peritonitis, shunt malfunction, or even meningitis.

This case underscores the importance of maintaining suspicion of visceral erosion in patients with prior shunt revisions and abnormal abdominal findings. Prompt recognition and multidisciplinary surgical management are essential in preventing serious complication such as infection or sepsis.

Figure 1
VP shunt passed per rectum and brought with patient in Ziploc bag

Intraoperative finding: ileocectomy with left salpingo-oophorectomy removed en bloc