Pathophysiology and Management of Abdominal Complications of Ventriculo-peritoneal Shunts

  • Matthieu VinchonEmail author
Living reference work entry


The peritoneal cavity has gained a wide acceptance as the most desirable site for distal catheter implantation, especially in children. However, abdominal complications are far from rare when considering the lifespan of a pediatric patient. From a practical point of view, these complications can be classified as septic, like bowel perforation and peritoneal wound infection; likely aseptic like ascites, hernias, and lost peritoneal catheters; and dubious, like peritoneal pseudocyst, appendicitis, and CSF oozing. The pathophysiology, diagnosis, and management of these complications are detailed in the present section, ending with a list of tips proposed for complication avoidance. Related topics like surgery and pregnancy in the shunted patient will also be considered.

These complications, inherent to the implantation of an inert catheter in a living and growing organism, should be known, anticipated, and part of the information given to the patient and his caretakers. The bright side is that in some fortunate cases, the outcome can be shunt independence, through shunt weaning or endoscopic procedure.

In the end, in spite of its failures, the peritoneum generally remains the most desirable site for distal catheter re-implantation. At the time of primary insertion either, these potential complications do not undermine the status of the peritoneum as the preferred site, and atrial shunts are relegated to plan B. Nevertheless, the best shunt is clearly no shunt, and endoscopic management should be proposed first whenever possible. If atrial shunt is plan B and peritoneal shunt is plan A, endoscopy is plan 0.


Ventriculo-peritoneal shunt Complications Pseudocysts Appendicitis Bowel perforation 


  1. Addiss DG, Shaffer N, Fowler BS, Tauxe RV (1990) The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 132:910–925CrossRefGoogle Scholar
  2. Allam E, Patel A, Lewis G, Mushi E, Audisio RA, Virgo KS, Johnson FE (2011) Cholecystectomy in patients with prior ventriculoperitoneal shunts. Am J Surg 201:503–507CrossRefGoogle Scholar
  3. Besson R, Hladky JP, Dhellemmes P, Debeugny P (1995) Peritoneal pseudocyst: peritoneal shunt complications. Eur J Surg 5:195–197CrossRefGoogle Scholar
  4. Britz GW, Kim K, Loeser JD (1996) Hydrocephalus secondary to diffuse villous hyperplasia of the choroid plexus. J Neurosurg 85:689–691CrossRefGoogle Scholar
  5. Byard RW (1996) Mechanisms of sudden death and autopsy findings in patients with Arnold–Chiari malformation and ventriculoatrial catheters. Am J Forensic Med Pathol 17:260–263CrossRefGoogle Scholar
  6. Cairns A, Geraghty J, Al-Rifai A, Babbs C (2009) Percutaneous endoscopic gastrostomy and ventriculoperitoneal shunts: a dangerous combination? Dig Endosc 21:228–231CrossRefGoogle Scholar
  7. Charalambides C, Sgouros S (2012) Spontaneous knot formation in the peritoneal catheter: a rare cause of ventriculoperitoneal shunt malfunction. Pediatr Neurosurg 48:310–312CrossRefGoogle Scholar
  8. Chong JY, Kim JM, Cho DC, Kim CH (2008) Upward migration of distal ventriculoperitoneal shunt catheter into the heart: case report. J Korean Neurosurg Soc 44:170–173CrossRefGoogle Scholar
  9. Clarnette TD, Lam SK, Hutson JM (1998) Ventriculo-peritoneal shunts in children reveal the natural history of closure of the processus vaginalis. Pediatr Surg 33:413–416CrossRefGoogle Scholar
  10. Clyde BL, Albright AL (1995) Evidence of a patent fibrous tract in fractured, outgrown, or disconnected ventriculoperitoneal shunts. Pediatr Neurosurg 23:20–25CrossRefGoogle Scholar
  11. Cornips E, Van Calenbergh F, Plets C, Devlieger H, Casaer P (1997) Use of external drainage for posthemorrhagic hydrocephalus in very low birth weight premature infants. Childs Nerv Syst 13:369–374CrossRefGoogle Scholar
  12. Cusimano MD, Meffe FM, Gentili F, Sermer M (1991) Management of pregnant women with cerebrospinal fluid shunts. Pediatr Neurosurg 17:10–13CrossRefGoogle Scholar
  13. Danismend N, Kuday C (1988) Unusual complication of ventriculoperitoneal shunt. Neurosurgery 22:798CrossRefGoogle Scholar
  14. Dean DF, Keller IB (1972) Cerebrospinal fluid ascites: a complication of a ventriculoperitoneal shunt. J Neurol Neurosurg Psychiatry 35:474–476CrossRefGoogle Scholar
  15. Di Rocco C (1987) The treatment of infantile hydrocephalus. CRC Press, Boca RatonGoogle Scholar
  16. Egelhoff J, Babcock DS, McLaurin R (1985) Cerebrospinal fluid pseudocysts: sonographic appearance and clinical management. Pediatr Neurosci 12:80–86CrossRefGoogle Scholar
  17. Faillace WJ, Garrison RD (1998) Hydrothorax after ventriculoperitoneal shunt placement in a premature infant: an iatrogenic postoperative complication. J Neurosurg 88:594–597CrossRefGoogle Scholar
  18. Gaskill SJ, Cossman RM, Hiskman MS, Marlin AE (1998) Laparoscopic surgery in a patient with a ventriculoperitoneal shunt: a new technique. Pediatr Neurosurg 28:106–107CrossRefGoogle Scholar
  19. Gonzalez MG (1987) Extrusion of peritoneal catheter through the anus. Childs Nerv Syst 3:183–184CrossRefGoogle Scholar
  20. Griffith JA, De Feo D (1987) Peroral extrusion of a ventriculoperitoneal shunt catheter. Neurosurgery 21:259–261CrossRefGoogle Scholar
  21. Hadani M, Findler G, Muggia-Sullam M, Sahar A (1982) Acute appendicitis in children with a ventriculoperitoneal shunt. Surg Neurol 18:69–71CrossRefGoogle Scholar
  22. Heggers JP, Kossovsky N, Parsons RW, Robson MC, Pelley RP (1983) Biocompatibility of silicone implants. Ann Plast Surg 11:38–45CrossRefGoogle Scholar
  23. Kestle JR, Riva-Cambrin J, Wellons JC III et al (2011) A standardized protocol to reduce cerebrospinal fluid shunt infection: the Hydrocephalus Clinical Research Network Quality Improvement Initiative. J Neurosurg Pediatr 8:22–29CrossRefGoogle Scholar
  24. Klimo P Jr, Van Poppel M, Thompson CJ et al (2014) Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 6: preoperative antibiotics for shunt surgery in children with hydrocephalus: a systematic review and meta-analysis. J Neurosurg Pediatr 14(Suppl 1):44–52CrossRefGoogle Scholar
  25. Körner H, Söndenaa K, Söreide JA, Andersen E, Nysted A, Lende TH, Kjellevold KH (1997) Incidence of acute nonperforated and perforated appendicitis: age-specific and sex-specific analysis. World J Surg 21:313–317CrossRefGoogle Scholar
  26. Kwok CK, Yue CP, Wen HL (1989) Bilateral scrotal migration of abdominal catheters: a rare complication of ventriculoperitoneal shunts. Surg Neurol 31:330–331CrossRefGoogle Scholar
  27. Langmoen IA, Lundar T, Vatne K, Hovind KH (1992) Occurrence and management of fractured peripheral catheters in CSF shunts. Childs Nerv Syst 8:222–225CrossRefGoogle Scholar
  28. Leibrock L, Baker R, Uematsu S (1975) Simulated acute appendicitis secondary to ventriculoperitoneal shunt. Surg Neurol 4:481–482PubMedGoogle Scholar
  29. Lejeune JP, Sion P, Combelles G, Dhellemmes P, Torrealba JG (1983) Peritoneal CSF pseudocysts. Rare complication of ventriculo-peritoneal shunts. Neurochirurgie 30:235–223Google Scholar
  30. Magee JF, Barker NE, Blair GK, Steinbok P (1996) Inguinal herniation with glial implants: possible complication of ventriculoperitoneal shunting. Pediatr Pathol Lab Med 16:591–596CrossRefGoogle Scholar
  31. May P, Sgouros S (2010) Treatment of hydrocephalus in the modern era (1950s–current date). In: Mallucci C, Sgouros S (eds) Cerebrospinal fluid disorders. Informa Healthcare Publisher, New York, 63–66Google Scholar
  32. Mazza C, Pasqualin A, Da Pian R (1980) Results of treatment with ventriculoatrial and ventriculoperitoneal shunt in infantile nontumoral hydrocephalus. Childs Brain 7:1–14PubMedGoogle Scholar
  33. Moss SD, Pattisapu JV, Walker ML (1988) Use of the peritoneal trocar in pediatric shunt procedures. Concepts Pediatr Neurosurg 8:23–28Google Scholar
  34. Nakagaki H, Matsunaga M, Maeyama R, Mizoguchi R (1979) Intraperitoneal pseudocyst after ventriculoperitoneal shunt. Surg Neurol 11:447–450PubMedGoogle Scholar
  35. Oatridge A, Holdcroft A, Saeed N, Hajnal JV, Puri BK, Fusi L, Bydder GM (2002) Change in brain size during and after pregnancy: study in healthy women and women with preeclampsia. Am J Neuroradiol 23:19–26PubMedGoogle Scholar
  36. Oi S, Shose Y, Oshio T, Matsumoto S (1987) Intragastric migration of a ventriculoperitoneal shunt catheter. Neurosurgery 21:255–257CrossRefGoogle Scholar
  37. Parry SW, Schuhmacher JF, Llewellyn RC (1975) Abdominal pseudocysts and ascites formation after ventriculoperitoneal shunt procedures: report of four cases. J Neurosurg 43:476–480CrossRefGoogle Scholar
  38. Patel CD, Matloub H (1973) Vaginal perforation as a complication of ventriculoperitoneal shunts. J Neurosurg 38:761–762CrossRefGoogle Scholar
  39. Piatt JH (1995) Cerebrospinal fluid shunt failure: late is different from early. Pediatr Neurosurg 23:133–139CrossRefGoogle Scholar
  40. Pieper R, Kager L (1982) The incidence of acute appendicitis and appendectomy. An epidemiological study of 971 cases. Acta Chir Scand 148:45–49PubMedGoogle Scholar
  41. Pomeranz S, Rapapport HZ, Umansky F, Shalit MN (1988) Technical note: the removal of free peritoneal catheters in the revision of ventriculoperitoneal shunts. Neurosurgery 22:436–438CrossRefGoogle Scholar
  42. Pompili A, Cianfriglia F (1979) Umbilical fistula as a complication of ventriculoperitoneal shunt. Surg Neurol 12:129–130PubMedGoogle Scholar
  43. Pumberger W, Löbl M, Geissler W (1998) Appendicitis in children with a ventriculoperitoneal shunt. Pediatr Neurosurg 28:21–26CrossRefGoogle Scholar
  44. Raskin J, Guillaume DJ, Ragel BT (2010) Laparoscopic-induced pneumocephalus in a patient with a ventriculoperitoneal shunt. Pediatr Neurosurg 46:390–391CrossRefGoogle Scholar
  45. Rekate HL, Yonas H, White RJ, Nulsen FE (1979) The acute abdomen in patients with ventriculoperitoneal shunts. Surg Neurol 11:442–445PubMedGoogle Scholar
  46. Rickert CH (1998) Abdominal metastases of pediatric brain tumors via ventriculo-peritoneal shunts. Childs Nerv Syst 14:10–14CrossRefGoogle Scholar
  47. Roitberg BZ, Tomita T, McLone DG (1998) Abdominal cerebrospinal fluid pseudocysts: a complication of ventriculoperitoneal shunt in children. Pediatr Neurosurg 29:267–273CrossRefGoogle Scholar
  48. Rubin RC, Ghatak NR, Visudhipan P (1972) Asymptomatic perforated viscus and Gram-negative ventriculitis as a complication of valve-regulated ventriculoperitoneal shunts. J Neurosurg 37:616–618CrossRefGoogle Scholar
  49. Rush DS, Walsh JW (1982) Abdominal complications of CSF-peritoneal shunts. Monogr Neural Sci 8:52–54Google Scholar
  50. Ryken TC (1996) Idiopathic intracranial hypertension (pseudotumor cerebri), hydrocephalus, and ventriculoperitoneal shunts in pregnancy. In: Loftus CM (ed) Neurosurgical aspects of pregnancy. AANS Publisher, Park Ridge, pp 165–176Google Scholar
  51. Schulman AS, Sawyer RG (2005) The safety of percutaneous endoscopic gastrostomy tube placement in patients with existing ventriculoperitoneal shunts. J Parenter Enter Nutr 29:442–444CrossRefGoogle Scholar
  52. Tan LA, Kasliwal MK, Moftakhar R, Munoz LF (2014) Ventriculoperitoneal shunt with a rare twist: small-bowel ischemia and necrosis secondary to knotting of peritoneal catheter. J Neurosurg Pediatr 14:234–237CrossRefGoogle Scholar
  53. Touho H, Nakauchi M, Tasawa T, Nakagawa J, Karasawa J (1987) Intrahepatic migration of a peritoneal catheter: case report. Neurosurgery 21:258–259CrossRefGoogle Scholar
  54. Tulipan N, Cleves MA (2006) Effect of an intraoperative double-gloving strategy on the incidence of cerebrospinal fluid shunt infection. J Neurosurg 104(1 Suppl):5–8PubMedGoogle Scholar
  55. Vinchon M, Dhellemmes P (2004) Abdominal complications of peritoneal shunts. In: Cinalli G, Maixner W, Sainte-Rose C (eds) Pediatric hydrocephalus, 1st edn. Springer, Milano pp. 315–328CrossRefGoogle Scholar
  56. Vinchon M, Baroncini M, Laurent T, Dhellemmes P (2006) Bowel perforation caused by peritoneal shunt catheters: diagnosis and treatment. Neurosurgery 58(1 Suppl):76–82CrossRefGoogle Scholar
  57. Vinchon M, Baroncini M, Delestret I (2012) Adult outcome of pediatric hydrocephalus. Childs Nerv Syst 28:847–854CrossRefGoogle Scholar
  58. West GA, Berger MS, Geyer J (1994) Childhood optic pathway tumors associated with ascites following ventriculoperitoneal shunt placement. Pediatr Neurosurg 21:254–259CrossRefGoogle Scholar
  59. Williams NMA, Everson NW, Jackson D, Johnstone JM (1998) Is the incidence of acute appendicitis really falling? Ann R Coll Surg Engl 80:122–124PubMedPubMedCentralGoogle Scholar
  60. Wisoff JH, Kratzert KJ, Hanwerker SM, Young BK, Epstein F (1991) Pregnancy in patients with cerebrospinal fluid shunts: report of a series and review of the literature. Neurosurgery 29:827–831CrossRefGoogle Scholar
  61. Yoshida Y, Nakajima Y, Tokuda K, Kidani R (2016) Recurrent hiccups caused by malposition of the peritoneal catheter of a lumboperitoneal shunt: a case report. No Shinkei Geka 44:129–133PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2019

Authors and Affiliations

  1. 1.Department of Pediatric NeurosurgeryLille University Hospital, CHRU de LilleLille CedexFrance

Section editors and affiliations

  • Wirginia Maixner
    • 1
  1. 1.Department of Pediatric NeurosurgeryRoyal Children’s HospitalMelbourneAustralia

Personalised recommendations