S.K. Akshulakov, M.P. Rabandiyarov
Almatisnky State Institute of Postgraduate Education, Almaty, Republic of Kazakhstan
Surgical treatment of hydrocephalus is one of the most urgent problems of modern neurosurgery. Liquoroshunting operations with bringning excessive CSF into the abdominal cavity are considered to be the most spread and effective method of surgical treatment of decompensated hydrocephalus. Use of such interventions allows to control hydrocephalus in 82.6-95.2% of cases (Simernitsky B.P., 1989; Khachatryan V.A., 1991; Kim Von Gi, 1996; etc.).
Ventriculoperitoneal shunting is characterized by some serious disadvantages, consisting in frequent development of postoperative complications. They include secondary displacement of a drainage system and peritoneal pseudocyst. These complications lead to shunt dysfunction and repeated development of hydrocephalic-hypertensive syndrome. Improvement of results depends on elaborating available and effective methods of early diagnosis and correction of complications of liquoroshunting operations in general, and peritoneal pseudocyst and secondary displacement of drainage system components in particular.
The study goal was to improve diagnosis and treatment of distal complications of liquorushunting operations.
Materials and Methods. There were 349 patients with hydrocephalus, who underwent ventriculoperitoneal shunting. All of them were treated in the 7th Municipal Clinical Hospital of Almaty. Their age varied from 1 up to 61 years.
The patients were subject to complex examination, including clinical-and-neurologic, psychologic, ophthalmologic, rentgenologic, liquorologic and liquorodynamic studies.
Results and Discussion. Complications of liquoroshunting operations were diagnosed on the basis of general estimation of results, obtained during clinical, rentgenologic, liquorologic, liquorodynamic and laboratory examinations.
Peritoneal pseudocyst was diagnosed in 14 (4.0%) of cases on the basis of accumulation of a great volume of CSF in the abdominal cavity and appearance of clinical manifestations of hydrocephalic-hypertensive syndrome. Revealing the relationship between this complication and liquorushunting operation was considered to be important.
Clinical manifestations of peritoneal pseudocyst are various. Thus, examination should be aimed at proving existence of interrelation between these manifestations and CSF accumulation. A degree and persistence of abdominal distention, presence of impaired diaphragmatic respiration and dyspeptic disorders (intestine atonia, local pain, frequent urination) are estimated. The time of onset and dynamics of these signs are ascertained. A volume and localization of accumulated CSF within the abdominal cavity are determined with the help of percussion (a dull sound due to fluid presence, a tympanic sound above a place of fluid localization), sonography, MRI and CT. X-rays of the abdominal cavity can be used for revealing CSF accumulation in the abdominal cavity. Subcutaneous CSF accumulation along a catheter path is often an indirect sign of peritoneal pseudocyst.
As for our study, results of brain imaging in peritoneal pseudocyst were indicative of more marked hydrocephalus, periventricular edema and narrowing of subarachnoid fissures.
Thus, it should be noted, that diagnosis of peritoneal pseudocyst is limited to estimating dynamics of local manifestation of CSF accumulation in the abdominal cavity, signs of hypertension syndrome. Sonography, CT and MRI of the abdominal cavity confirm diagnosis and allow to exclude presence of other pathologic states.
The analysis showed high probability of peritoneal pseudocyst development in pleocytosis, CSF hyperproteinorachea, erythrorachea, a complicated postoperative period. Draining excessive CSF into the right subcostal area was characterized by a high risk as well.
According to our data, the most effective method of treatment of peritoneal pseudocyst was removal of a peritoneal catheter and implantation of a distal catheter into the venous system. Reimplantation of a peritoneal catheter into the abdominal cavity with the purpose of treatment of peritoneal pseudocyst was effective in some rare patients. However, it happened only in case of technical errors, made during catheter insertion, and its atypical localization.
Diagnosis of secondary displacement of drainage system components was based on complex estimation of results of clinical manifestations and imaging findings. It was revealed in 80 cases (23.0%). Signs of decompensated hydrocephalus (headache, vomiting, hypokinesia, choked disks, separation of cranial sutures, protrusion of the frontal fontanel, etc.) and their marked augmentation were watched after stabilization of a patient's state in a postoperative period. Rentgenologic examination demonstrated atypical localization of drainage system components in comparison with postoperative X-rays. MRI-examination was indicative of more marked hydrocephalus. CT findings showed more marked ventriculomegaly, narrowing of subarachnoid fissures, periventricular edema and atypical localization of drainage system components, watched in some sections.
Shuntography made it possible to reveal presence or absence of ruptured drainage system components and to visualize localization of the system more precisely.
Thus, secondary displacement of a shunt can be diagnosed only by data of dynamic estimation of clinical-and-ophthalmologic manifestations. Use of CT, MRI and sonography increases diagnosis efficacy. Final diagnosis is made with the help of shuntography.
The analysis showed, that risk factors of secondary displacement included insufficient fixing of drainage system components, a length of a catheter's intraperitoneal part of less than 15 cm, an effect of trauma on a shunting system in additional fixing of a peritoneal catheter. Probability of secondary displacement of drainage system components is very high in children of less than 5 years old.
Removal of a peritoneal catheter and its reimplantation, joining of drainage system components were performed. According to our data, the most effective method of eliminating secondary displacement was reimplantation of a shunting system as a whole.