Failure of peritoneal and gallbladder shunts in a child with craniopharyngioma
A 1-year-old girl presented with a 7-day history of irritability and acute visual deterioration. Imaging revealed a calcified cystic suprasellar mass []. She underwent emergent endoscopic fenestration of the cyst with insertion of an ommaya reservoir to decompress the visual apparatus and ventricular system. Endoscopic biopsy of the lesion was undertaken at the same time, and a grade I adamantinomatous craniopharyngioma was diagnosed.\nPostoperatively, she developed a persistent CSF leak through her wound requiring insertion of an external ventricular drain (EVD). It was necessary to drain 40-50 mL/h of CSF to prevent symptoms and allow wound healing. CSF was sterile after 48 h culture with a white cell count of 8 cells per microliter and a red cell count of 550 cells per microliter. Endoscopic third ventriculostomy was not feasible so she underwent ventriculoperitoneal (VP) shunt insertion and debulking of the craniopharyngioma [].\nAfter multidisciplinary team discussion she travelled to the USA for proton beam therapy to the residual tumour. She had been experiencing intermittent abdominal pain and distension and while in the USA she developed symptomatic CSF ascites with CSF demonstrated in all four quadrants of the abdomen on ultrasound scanning. The unit she attended in the USA preferred to use ventriculogallbladder shunts when the peritoneum could not be used,[] and the VP shunt was revised to a ventriculogallbladder shunt with resolution of her ascites.\nAt nearly 2 years old, she developed a new craniopharyngioma cyst and underwent repeat endoscopic fenestration with Ommaya reservoir insertion. Postoperatively, she again developed a persistent CSF wound leak. This was associated with a distended, tender abdomen. Abdominal computed tomography showed a markedly dilated gallbladder []. It was clear that the accumulation of CSF within the gallbladder was preventing the shunt from functioning at its maximum capacity. At this time, she had no ascites so the distal shunt catheter was revised to a peritoneal catheter. The VP shunt allowed wound healing but within a month the CSF ascites had recurred [], and the peritoneal catheter was revised to an atrial catheter. Six months after insertion of the ventriculoatrial shunt, she remains asymptomatic.