Short summary

Revision rates are high regarding ventriculo-peritoneal shunts. We aim to conduct a retrospective 10-year study (2006-2017) on ventriculo-peritoneal shunt (VP shunt) treatment, cause of readmission and revision. In this study, we wish to assess complications regarding VP shunt insertion (in relation to the surgery and after) e.g. infection, hardware malfunction and over-/undershunting, and especially what type of hardware was implanted in the patient. 

Rationale

Purpose

With this study, we aim to create a large database based on patient medical records, where we focus on ventriculo-peritoneal shunt treatment and shunt revisions. We wish to examine the etiology of and complications associated to the insertion and revision, and in addition if there is a correlation with any specific type of hardware implanted in the patients and complications.

Background

The ventriculo-peritoneal shunt redirects cerebrospinal fluid from the lateral horns of the ventricle system. Indications for treatment with a VP-shunt includes increased intracranial pressure, which could be caused either by malabsorption or obstruction of the CSF system. In addition, dilated ventricular system (hydrocephalus) due to congenital anomaly, intracranial hemorrhage (especially subarachnoid hemorrhage), infection, and tumor/pseudotumor cerebri or normal pressure hydrocephalus. Hydrocephalus can develop at any age, from prematurity to the very old - the latter group as normal pressure hydrocephalus (NPH). Even though, a VP shunt is the main treatment modality for hydrocephalus, there can exist very different surgical environments, including patient age, etiologies, shunt materials used, and surgeon's experiences.

A VP shunt complication is a major obstacle in the management of hydrocephalus. Furthermore, it is conceivable that the features of VP shunt complication can differ according to a patient's age and the etiology of the hydrocephalus. The incidence of complications following VP shunt insertion is reported to be around 20 to 40%. Risks associated with shunt insertion include 4% intraparenchymal or intraventricular hemorrhage, seizures, malposition and infection. Problems in patients with established CSF shunt include under-shunting, obstruction (10%/year), breakage or hardware malfunction, infection (1-40% often associated with obstruction and IQ decrease post infectiously). Infection also covers distal catheter problems such as peritonitis), over-shunting (which presents itself radiologically with slit ventricle syndrome, subdural hematomas and spinal headaches), seizures and skin breakdown over hardware.

Even though patient deaths are greater in adults with shunt insertions, shunts in adults fail more slowly and tend to survive longer than those in children. The incidence of shunt failure is higher in the first six months following the VP shunt and the cause is different regarding shunt malfunction.

Description of the cohort

We include all patients who are identified via specific treatment code (SKS-codes) in the electronic patient record system, Cosmic: KAAF05 (primary VP-shunt insertion) and KAAF20 (shunt revision) between 2007-2016 and admitted to the department of neurosurgery, Odense University Hospital. 

Data and biological material

All data is collected without direct involvement of patients.

• Demographics: Ethnicity, age, gender, BMI, previous operations, co-morbidities, previous medical conditions and actual medical conditions, expositions and dispositions.
• Blood samples: Red blood cell count (hemoglobin, thrombocytes, reticulocytes etc.), acute phase reactants (e.g. C-reactive protein), white blood cell count and differential analysis, blood cultures.
• Bacterial swap and culturing from the incision.
• Operation notes: Type of shunt and chamber combinations, complications associated with the procedure, length of operation, ASA score/performance status.
• Immediate post-operative complications (within the same admission) e.g. signs of infections, CSF leakage, rupture of sutures.
• Use of external drainage or not and how long. 

Collaborating researchers and departments

Department of neurosurgery, Odense University Hospital

• Medical Student Mikkel Christian Schou Andersen, BSc
• Associate professor and consultant Christian Bonde Pedersen PhD, MD
• Professor and consultant Frantz Rom Poulsen PhD, MD