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Length of peritoneal end of shunt catheters in

hydrocephalus in children and rate of
complications
ARTICLE JANUARY 2012
DOI: 10.4103/2278-9588.102468

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5 AUTHORS, INCLUDING:
Amit Agrawal
Narayana Medical College & Hospital
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Original Article

Length of peritoneal end of shunt catheters

in hydrocephalus in children and rate of
complications
Mahesh Gupta, Naseeb C. Digra1, Narendra Sharma2, Subhash Goyal, Amit Agrawal
Department of Surgery, M.M. Institute of Medical Sciences and Research, Mullana, Ambala, Haryana,
1
Departments of Surgery, 2Radiodiagnosis, Government Medical College, Jammu, India

ABSTRACT
Objectives: In the present study, we reviewed our experience with full-length low-and medium-pressure
peritoneal shunts and recorded any additional complications/benefits caused by using these shunts.
Materials and Methods: This study was conducted from May 2005 to December 2006 in the Department of
Surgery, Government Medical College Hospital, Jammu. Over the study period, all the children who underwent
ventriculoperitoneal shunt for hydrocephalus were included. Ventriculoperitoneal shunt was placed in all the
cases by using the Chhabra Slit n spring hydrocephalus shunt system. In all the cases, the shunt was placed on
the right side with a common technique of insertion. In the present study, the full length of the distal catheter
was placed in the peritoneal cavity in all the cases. Before placing the peritoneal catheter into the abdomen, the
length of the inserted peritoneal tube was measured. All patients were followed up on a fortnightly basis for the
first three months and thereafter on a three-monthly basis.
Results: Atotal of 30 children underwent right ventriculoperitoneal shunt for congenital hydrocephalus during
the study period. Mean age of the patients was 11.1months (range: 136months, SD: 11.0963, median: 7months).
There were 16male and 14female patients and 75% children were less than 17months of age. In the present
study, the full length of the distal catheter was placed into the peritoneal cavity and it was observed that the
minimum length of the distal catheter placed inside was 44cm and the maximum length was 52cm. Twenty-five
children (83.3%) had normal shunt functioning with no clinical or radiological evidence of shunt complications
at a follow-up at one year. Five children (16.6%) had features of shunt malfunction and were evaluated further.
Conclusion: In accordance with the literature, we find that the length of the peritoneal catheter of the shunt
tube does not increase the distal complication rate; however, the use of adequate length of the peritoneal catheter
does eliminate the need to lengthen the peritoneal catheter as the child grows.
Keywords: Abdominal fat pad shift, hydrocephalus, shunt complication, subcutaneous migration,
ventriculoperitoneal shunt
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DOI:
10.4103/2278-9588.102468

INTRODUCTION
Since the attempt of the first peritoneal shunting
procedures for diversion of cerebrospinal fluid (CSF)
in children with hydrocephalus,[1,2] a large variety of
diversion procedures has been attempted.[2-7] With
the widespread use of the silastic catheters, the

Correspondence to:
Dr.Mahesh Gupta, Department of Surgery, M. M. Institute of Medical Sciences and Research, Mullana, Ambala, Haryana 133203, India.
E-mail: gm982003@yahoo.co.in

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Gupta, etal.: Shunt catheters in hydrocephalus

ventriculoperitoneal route has become a preferred

procedure of CSF diversion with overall low rates
of complication and revision.[2-7] In the present
study, we reviewed our experience with full-length
low-and medium-pressure peritoneal shunts and
recorded any additional complications/benefits
caused by using these shunts.

MATERIALS AND METHODS

This study was conducted from May 2005
to December 2006 in the Department of
Surgery, Government Medical College Hospital,
Jammu. Over the study period, all the children
who underwent ventriculoperitoneal shunt for
hydrocephalus were included. Adetailed history of
illness was recorded at the time of admission for all
the children suffering from hydrocephalus as per the
predesigned pro forma. The history was taken from
the mother or from the responsible member of the
family attending the child. The details noted were
age at birth, change in head size, either gradual
or rapid enlargement, history of nausea, vomiting,
convulsions, and abnormal limb movements,
details of birth history including perinatal events,
and details of relevant family history, especially for
significant complaints in other offspring. Adetailed
physical and neurological examination was
conducted including size of the head, condition of
the anterior fontanelle, whether open or closed, lax
or tense, suture lines whether fused or separated,
presence of setting-sun sign, and motor and
sensory examinations. Relevant investigations
including
hemogram,
serum
electrolytes,
ultrasound head, or computed tomography (CT)
scan to confirm the diagnosis of hydrocephalus,
extent of ventricular dilatation, cortical thickness,
and ventricle-to-hemispheric ratio were performed.
Ventriculoperitoneal shunt was placed in all the
cases using Chhabra Slit n spring hydrocephalus
shunt system. In all the cases, the shunt was placed
on the right side with a common technique of
insertion. In the present study, the full length of the
distal catheter was placed intheperitoneal cavity in
all the cases. Before placing the peritoneal catheter
into the abdomen, the length of inserted peritoneal
tube was measured. All patients were followed up
on a fortnightly basis for the first three months and
thereafter on a three-monthly basis.

RESULTS
A total of 30 children underwent right
ventriculoperitoneal
shunt
for
congenital
hydrocephalus during the study period. Mean
age of the patients was 11.1months (range:
136months, SD: 11.0963, median: 7months).
There were 16male and 14female patients, and
75% children were less than 17months of age. All
patients had congenital hydrocephalus (imaging
finding suggestive of aqueduct stenosis); in
addition, nine children had associated lumbosacral
mengingomyelocele. Of the 30cases, 24 were
admitted with symptoms of increased size of head,
nine cases had signs of raised intracranial pressure
(headache, vomiting, papilloedema), and seven
cases had neurological signs including setting-sun
sign, abducens nerve palsy, and respiratory distress.
The features of raised intracranial pressure were
mostly seen in patients of the older age group. Of
the 30cases, 50% were operated upon with lowpressure shunts and 50% with medium-pressure
shunts. Patency and functioning of the shunt was
confirmed by free CSF flow intraoperatively before
placement into the peritoneal cavity. CSF pressure
was high in the older children. CSF examination
was normal in all the cases. In the present study, the
entire length of the distal catheter was placed into
the peritoneal cavity and it was observed that the
minimum length of the distal catheter placed inside
was 44cm and the maximum length was 52cm
[Table1]. Twenty-five children (83.3%) had normal
shunt functioning with no clinical or radiological
evidence of shunt complications at a follow-up at
one year. Five children (16.6%) had features of shunt
malfunction and were evaluated further [Table2].

DISCUSSION
Since the time Ames discussed his clinical
experience and found that the peritoneal cavity
was suitable for CSF shunting, ventriculoperitoneal
shunts have become the method of choice for
Table1: Length of the distal catheter in peritoneal cavity
Age (years)
<1month
1 month-1year
>1year

Cases (n=30)

Length of peritoneal
catheter (cm)

4(13.3%)
17(56.6%)
9(30%)

5052
4750
4448

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Gupta, etal.: Shunt catheters in hydrocephalus

Table2 : Details of shunt malfunctions at follow-up

Case

Age at Presentation Hydrocephalus Type of Length of Complications Time of

Treatment
the time
shunt
peritoneal
complication
of shunt
catheter
after shunt
(months)
(in cm)
insertion

Case 1

Increase in
head size

Without MMC

Medium

46

Block

Within first
2months

Case 2

24

Headache and
vomiting

With MMC

Low

49

Block

Within first
2months

Case 3

24

Extrusion of
peritoneal
shunt from
anus

Without MMC

Medium

46

Extrusion
from anus

4months

Case 4

Low

48

Subacute
intestinal
obstruction

6months

Case 5

Abdominal
Without MMC
distension,
X-ray subacute
intestinal
obstruction
Abdominal
With MMC
distension,
USG abdomen
confirmed the
diagnosis

Medium

47

CSF ascites

6months

Revision with
mediumpressure shunt
Revision with
low-pressure
shunt
Shunt removal
followed by
revision with
mediumpressure shunt
Improved with
conservative
management
Placed inside
the right atria
(ventriculoatrial
shunt)

MMC - Myelo-menigocoele, CSF - Cerebrospinal fluid, USG - Ultrasonography

CSF diversion in infancy.[8] Although various

CSF diversionary procedures have reduced
the associated neurological deficit and death
significantly[7] and despite continual development
of new valve designs, shunt placement for the
treatment of hydrocephalus has not met all the
expectations.[9] Ventriculoperitoneal shunt is widely
preferred because of its well-known advantages,
such as: Apotential infection of the shunting system
has a lower systemic life-threatening risk compared
to shunts into the venous system, in children, a large
amount of tubing can be placed intraperitoneally,
minimizing the need for elective lengthening with
growth, and the operation is safe, easy to perform,
and is not time consuming.[10] As in the present
series, the most common complication is blockage
of the system at the peritoneal end by the omentum
or development of a fibrous scar over the end of the
catheter tip;[1,2,5] other less common complications
are shunt infection and intestinal obstruction,[1,6,11,12]
colonic perforation,[13,14] CSF pseudocyst of the lesser
sac, subphrenic CSF loculation, bowel perforation
with formation of CSF enteric fistula, intrathoracic
migration of the tip of shunt, and CSF ascites,[15]
14

and, rarely, migration of the shunt tip through a

patent processus vaginalis into the scrotum.[16] A
common cause of shunt failure is shunt infection,
with a reported incidence of 515%,[17-20] but there
were no cases of shunt infection in the present
series.[21,22] The intestinal obstruction is reported
due to the adhesive band in the region of tubing[6]
rather than the length of the peritoneal catheter.
A few articles in the literature discuss the issue of
the length of peritoneal catheter and complications
related to it.[5,8,21-23] As the child grows, the peritoneal
catheter may get blocked, as it becomes relatively
short and out of the peritoneal cavity. By using fulllength peritoneal, the problem of blockage and
revision of shunting due to growth of the child is
decreased.[21] The use of a long shunt tube has been
shown to be effective in prevention, dislocation, or
disconnection of a tube.[21-24] In unusual situations,
proximal migration of the peritoneal catheter may
result in movement of the catheter into the subgaleal
tissue.[25] Various factors may contribute to the
proximal migration of the peritoneal catheter,[26-28]
and it has been recommended that in careful

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Gupta, etal.: Shunt catheters in hydrocephalus

placement of the subcutaneous catheter between

the subcutaneous fat pad and the abdominal muscle
wall, no purse-string suture is necessary, but the
peritoneum should be tightly closed and the usual
length of the intraperitoneal part of the catheter
may be sufficient to prevent this complication.[29]

CONCLUSION
It hold true that to prevent malfunction of the
shunt, optimal placement of ventricular catheters
inside the lateral ventricle, prevention of infection,
avoidance of contamination by cotton fibers, hair,
or talc, and improvement in the biocompatibility of
the implanted materials[23] are important factors. In
accordance with the literature, we found that the
length of the peritoneal catheter of the shunt tube
does not increase the distal complication rate;
however, the use of adequate length of peritoneal
catheter does eliminate the need to lengthen the
peritoneal catheter as the child grows.[21] However,
since the number of cases and the follow-up period
in our study are small, we suggest that a larger study
over an extended period of follow-up be conducted
to assess any specific complications related to the
use of the full length of distal catheters.

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Gupta, etal.: Shunt catheters in hydrocephalus

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How to cite this article: Gupta M, Digra NC, Sharma N, Goyal S, Agrawal A.
Length of peritoneal end of shunt catheters in hydrocephalus in children and
rate of complications. J Cranio Max Dis 2012;1:12-6.
Source of Support: Nil. Conflict of Interest: None declared.
Submission: May 16, 2012, Acceptance: July 28, 2012

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