Upward Migration of a Peritoneal Catheter Following Ventriculoperitoneal Shunt
An 8-month-old boy was admitted to our clinic with scalp swelling that developed 21 days after a VP shunt operation. He had no other neurological symptoms except scalp swelling. He was a preterm baby born at 24 weeks of gestational age and was only 520 g at birth. The patient had developed a massive intraventricular hemorrhage associated with hydrocephalus on brain ultrasonography. Furthermore, the QUAD test for preterm screening was positive for Down's syndrome. He had many severe preterm complications, including hematological problems such as anemia and thrombocytopenia that required transfusion; pulmonary problems such as respiratory distress syndrome treated with surfactant and a chest tube was inserted to manage pneumothorax. He also had retinopathy and many cardiac problems such as patent ductusarteriosus (PDA), ventricular septal defect, right ventricular hypertrophy, and a patent foramen ovale. We intended to wait for natural closure for most problems but PDA required ligation surgery. Endocrinological problems such as hyperglycemia, hypothyroidism, and osteopenia were managed with hormones and mineral replacement. Urological complications such as a dilated bladder and ureter and hydronephrosis developed but were mild; thus, we decided to follow-up closely without surgical intervention. He also had a small bowel perforation and bilateral inguinal hernia, which had gone through repair surgery.\nFor only 25 weeks after birth, he had 3 surgeries, brain ultrasonography was conducted and progression of the hydrocephalus and encephalomalacic changes in the right frontal lobe was found (). Spinal tapping for intracranial pressure control was held every day until shunt surgery was capable. At 30 weeks of his gestational age (14 weeks of corrected age) his body weight was 4500 g (<10 percentile) a VP shunt has been inserted using an ultra small, low pressure valve system (Strata®; PS Medical, Gola, CA, USA) and a distal catheter of about 30 cm in length was placed in the peritoneal cavity. No complications occurred except mild redness of the left clavicle area where the catheter passed. The patient was discharged without any complications 12 days after surgery.\nHe visited our outpatient office with prominent swelling of the surgical site 21 days after surgery, and a round coil like mass was palpable under the scalp, but no neurological changes were noticed. Simple chest, abdomen, and skull X-ray images were taken, and no shunt catheter on the trunk was found, but the distal catheter had migrated upward into the subgaleal space (). Brain computed tomography scans indicated decreased ventricle size compared to those taken before surgery (). Shunted cerebrospinal fluid (CSF) was thought to be absorbed in the subgaleal space and shunt function seemed to be maintained.\nThe distal catheter inserted previously for the VP shunt was found coiled freely in the subgaleal space under the primary incision during revision surgery. The shunt was otherwise functioning, but the reservoir was filled with an old hematoma, and the CSF was bloody and turbid (). We placed an extraventricular drainage (EVD) tube rather than a shunt system to wait for the CSF to clear out to prevent shunt system blockage. The VP shunt was reinserted 1 week after the EVD, and the patient was discharged. No further problems were noted during regular follow-ups at the outpatient office.