Recurrent intrahepatic dislocation of ventriculoperitoneal shunt

Dislocation of ventriculoperitoneal (VP) shunt catheters is a well known complication after treatment of cerebrospinal fluid disorders; however, secondary perforation of the liver capsule by the catheter is exceptional. The literature on VP shunt complications involving the liver, their possible pathomechanisms and minimally invasive recovery strategies in reference to our own experience is reviewed.

We present a patient who suffered penetration of the liver by the peritoneal catheter of her VP shunt. Causing intermittent epigastric pain, the shunt tip was found to have progressively dislocated into the liver, as documented by CT scans. A laparoscopic approach was indicated to recover the shunt. The peritoneal catheter was found to be covered by widespread adhesions, consistent with peritoneal fibrosis. After local adhesiolysis, it was successfully recovered without shunt dysfunction, hemorrhage of the liver, or biliary fistula. After 4 months, dislocation recurred with formation of a subdiaphragmatic pseudocapsule. Early formation of fibrosis was detected during laparoscopic revision surgery. Although bacterial smears from both laparoscopic surgeries did not show any pathological findings, the patient presented with an abscess in the Douglas pouch 4 months later. Coagulase-negative staphylococci were found on ultrasound-guided insertion of a pigtail catheter. The VP shunt had to be replaced by a ventriculoatrial shunt. The infection was treated successfully with piperacillin. The subsequent 6 months follow-up period was without adverse events.

The treatment of choice in this exceptional case of intrahepatic shunt dislocation was laparoscopic recovery of the catheter. Laparoscopy allowed good visualization during adhesiolysis, immediate exclusion of hemorrhage or bile fistula at the puncture site, as well as function control and safe deposition of the shunt tip. Chronic infection as an underlying cause of peritoneal fibrosis has to be ruled out.