Inflammation and obstruction of distal catheter slits in ventriculoperitoneal shunts: likely role of graphite

2020 ◽  
Vol 133 (5) ◽  
pp. 1495-1502
Author(s):  
Marc R. Del Bigio ◽  
Ravinder K. Sidhu ◽  
Colin J. Kazina ◽  
Demitre Serletis
Keyword(s):  
Controlled Trial ◽  
Tissue Response ◽  
Negative Consequences ◽  
Electron Microscopic ◽  
Distal Catheter ◽  
Ventriculoperitoneal Shunts ◽  
Ventriculoperitoneal Shunting ◽  
Organ Systems ◽  
Catheter Obstruction ◽  
Tissue Reactions

OBJECTIVETissue reactions that contribute to obstruction of peritoneal catheters in ventriculoperitoneal shunt systems are not well characterized. Several recent rapid obstructions in children prompted a retrospective quality assurance review.METHODSThe authors conducted a detailed investigation of 22 surgically explanted peritoneal shunt catheters and 8 autopsy cases with documented distal shunt obstruction. Patients’ medical histories were reviewed, and the catheters and/or tissues were subjected to conventional histological and immunohistochemical evaluations. In addition, 3 cases were subjected to electron microscopic examination including elemental analysis.RESULTSThe majority of symptomatic obstructions were associated with distal slit catheters (17 slit, 3 open-end, and 2 unknown type). Among the autopsy cases, deaths were attributed to shunt failure in 2 cases of slit catheter obstruction, 1 case of open-end catheter obstruction, and 1 case of catheter withdrawal from the peritoneal cavity. The early tissue response consisted of a predominantly T lymphocyte accumulation with phagocytosis of graphite particles by macrophages. This is associated with proliferation of fibroblasts, mesothelial cells, and blood vessels, which can grow through the slits and occlude the catheter lumen. As the inflammation subsides after approximately 1 year, the tissue plug becomes collagenized and calcified.CONCLUSIONSThis study, supported by experimental literature in other organ systems, indicates that graphite used to coat the slit openings of distal catheters from ventriculoperitoneal shunts likely predisposes to obstruction. Neurosurgeons and manufacturers should consider the potential negative consequences of this shunt design. The authors concur with previous recommendations that slit-valve distal catheters should not be used for ventriculoperitoneal shunting unless they can be proven safe and efficacious in a controlled trial.

scholarly journals Fetal surgery for spina bifida aperta

2018 ◽  
Vol 103 (6) ◽  
pp. F589-F595 ◽  
Author(s):  
Luc Joyeux ◽  
Enrico Danzer ◽  
Alan W Flake ◽  
Jan Deprest
Keyword(s):  
Spina Bifida ◽  
Prolonged Exposure ◽  
Controlled Trial ◽  
Fetal Surgery ◽  
Neurological Deficits ◽  
Cerebrospinal Fluid Leakage ◽  
Essential Information ◽  
Ventriculoperitoneal Shunting ◽  
Spina Bifida Aperta ◽  
Randomised Controlled

Spina bifida aperta (SBA) is one of the most common congenital malformations. It can cause severe lifelong physical and neurodevelopmental disabilities. Experimental and clinical studies have shown that the neurological deficits associated with SBA are not simply caused by incomplete neurulation at the level of the lesion. Additional damage is caused by prolonged exposure of the spinal cord and nerves to the intrauterine environment and a suction gradient due to cerebrospinal fluid leakage, leading to progressive downward displacement of the hindbrain. This natural history can be reversed by prenatal repair. A randomised controlled trial demonstrated that mid-gestational maternal-fetal surgery for SBA decreases the need for ventriculoperitoneal shunting and hindbrain herniation at 12 months and improves neurological motor function at 30 months of age. This came at the price of maternal and fetal risks, the most relevant ones being increased prematurity and a persistent uterine corporeal scar. Recently minimally invasive fetal approaches have been introduced clinically yet they lack extensive experimental or clinical trials. We aim to provide clinicians with the essential information necessary to counsel SBA parents as the basis for considering referral of selected patients to expert fetal surgery centres. We review the reported clinical outcomes and discuss recent developments of potentially less invasive fetal SBA approaches.

scholarly journals Survival and failure trends of cerebrospinal fluid shunts with distal slit valves: comparative study and literature review

2020 ◽  
Vol 25 (3) ◽  
pp. 209-216
Author(s):  
Jeremy S. Wetzel ◽  
Alex D. Waldman ◽  
Pavlos Texakalidis ◽  
Bryan Buster ◽  
Sheila R. Eshraghi ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Failure Rate ◽  
Csf Shunt ◽  
Time To Failure ◽  
Survival Curves ◽  
Mean Time To Failure ◽  
Distal Catheter ◽  
Catheter Obstruction ◽  
Shunt Survival ◽  
Mean Time

OBJECTIVEThe malfunction rates of and trends in various cerebrospinal fluid (CSF) shunt designs have been widely studied, but one area that has received little attention is the comparison of the peritoneal distal slit valve (DSV) shunt to other conventional valve (CV) type shunts. The literature that does exist comes from older case series that provide only indirect comparisons, and the conclusions are mixed. Here, the authors provide a direct comparison of the overall survival and failure trends of DSV shunts to those of other valve type shunts.METHODSThree hundred seventy-two new CSF shunts were placed in pediatric patients at the authors’ institution between January 2011 and December 2015. Only ventriculoperitoneal (VP) shunts were eligible for study inclusion. Ventriculoatrial, lumboperitoneal, cystoperitoneal, subdural-peritoneal, and spinal shunts were all excluded. Rates and patterns of shunt malfunction were compared, and survival curves were generated. Patterns of failure were categorized as proximal failure, distal failure, simultaneous proximal and distal (proximal+distal) failure, removal for infection, externalization for abdominal pseudocyst, and addition of a ventricular catheter for loculated hydrocephalus.RESULTSA total of 232 VP shunts were included in the final analysis, 115 DSV shunts and 117 CV shunts. There was no difference in the overall failure rate or time to failure between the two groups, and the follow-up period was statistically similar between the groups. The DSV group had a failure rate of 54% and a mean time to failure of 17.8 months. The CV group had a failure rate of 50% (p = 0.50) and a mean time to failure of 18.5 months (p = 0.56). The overall shunt survival curves for these two groups were similar; however, the location of failure was significantly different between the two groups. Shunts with DSVs had proportionately more distal failures than the CV group (34% vs 14%, respectively, p = 0.009). DSV shunts were also found to have proximal+distal catheter occlusions more frequently than CV shunts (23% vs 5%, respectively, p = 0.005). CV shunts were found to have significantly more proximal failures than the DSV shunts (53% vs 27%, p = 0.028). However, the only failure type that carried a statistically significant adjusted hazard ratio in a multivariate analysis was proximal+distal catheter obstruction (CV vs DSV shunt: HR 0.21, 95% CI 0.05–0.81).CONCLUSIONSThere appears to be a difference in the location of catheter obstruction leading to the malfunction of shunts with DSVs compared to shunts with CVs; however, overall shunt survival is similar between the two. These failure types are also affected by other factors such etiology of hydrocephalus and endoscope use. The implications of these findings are unclear, and this topic warrants further investigation.

scholarly journals LO76: Effect of task interruptions training on the quality of simulated ALS

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S35-S35
Author(s):  
J. Truchot ◽  
D. Michelet ◽  
D. Drummond ◽  
Y. Freund ◽  
P. Plaisance
Keyword(s):  
Life Support ◽  
Controlled Trial ◽  
Training Session ◽  
Flow Time ◽  
Mean Difference ◽  
University Hospital ◽  
Negative Consequences ◽  
Emergency Team ◽  
Phone Calls

Introduction: Task interruptions are reportedly frequent disturbances for emergency physicians performing advanced life support (ALS). The aim of this study was to evaluate the benefit of adding task interruptions in ALS simulated training session. Methods: We conducted a multi centered randomized controlled trial in four emergency departments of a university hospital in Paris, France. Each emergency team included one resident, one nurse and one emergency physician. The teams were randomized for the nature of their training session: control (without interruption) or realistic (with interruptions). The interruption consisted of an interfering family member speaking a foreign language, and of repetitive phone calls during ALS. After the first training session, teams were evaluated on a second realistic session with task interruptions. The primary outcome was non-technical skills assessed with the TEAM score during this evaluation session. We also measured the no flow time, and the Cardiff score, which reflects the quality of ALS: including chest compression depth and rate, no flow time. Results: On a total of 23 included teams, 12 had a control training session and 11 with task interruptions. Baseline characteristics and TEAM score were similar between the two groups (Mean difference: 3,3 [-2,2; 8,9]; p = 0,26). During the evaluation session, the TEAM score was lower for “realistic” teams (mean difference -8 [95% confidence interval -13; -3]). We also report a higher no flow time and similar overall Cardiff score. Conclusion: In this simulated ALS study, the presence of disturbances during simulation seemed to worsen the quality of training. This study highlights the negative consequences of task interruptions in emergency medicine.

Tissue Adaptation to Physical Stress: A Proposed “Physical Stress Theory” to Guide Physical Therapist Practice, Education, and Research

2002 ◽  
Vol 82 (4) ◽  
pp. 383-403 ◽  
Author(s):  
Michael J Mueller ◽  
Katrina S Maluf
Keyword(s):  
Stress Tolerance ◽  
Physical Therapist ◽  
Physical Stress ◽  
Tissue Response ◽  
Practice Research ◽  
Relative Level ◽  
Basic Premise ◽  
Stress Theory ◽  
Organ Systems ◽  
Practice Education

AbstractThe purpose of this perspective is to present a general theory—the Physical Stress Theory (PST). The basic premise of the PST is that changes in the relative level of physical stress cause a predictable adaptive response in all biological tissue. Specific thresholds define the upper and lower stress levels for each characteristic tissue response. Qualitatively, the 5 tissue responses to physical stress are decreased stress tolerance (eg, atrophy), maintenance, increased stress tolerance (eg, hypertrophy), injury, and death. Fundamental principles of tissue adaptation to physical stress are described that, in the authors' opinion, can be used to help guide physical therapy practice, education, and research. The description of fundamental principles is followed by a review of selected literature describing adaptation to physical stress for each of the 4 main organ systems described in the Guide to Physical Therapist Practice (ie, cardiovascular/pulmonary, integumentary, musculoskeletal, neuromuscular). Limitations and implications of the PST for practice, research, and education are presented.

Minimal-access technique for distal catheter insertion during ventricular peritoneal shunt procedures: a review of 100 cases

2009 ◽  
Vol 111 (3) ◽  
pp. 623-627 ◽  
Author(s):  
Pawel G. Ochalski ◽  
Michael B. Horowitz ◽  
Arlan H. Mintz ◽  
Steven J. Hughes ◽  
David O. Okonkwo ◽  
...  
Keyword(s):  
Catheter Placement ◽  
Minimal Access ◽  
Infection Rates ◽  
Distal Catheter ◽  
Shunt Catheter ◽  
Ventriculoperitoneal Shunting ◽  
Insertion Method ◽  
Laparoscopic Assistance ◽  
Access Technique ◽  
Mini Laparotomy

The authors report the safety and efficacy of using a percutaneous minimal-access insertion technique for distal shunt catheter placement in 100 cases. From June 2007 to March 2008, they attempted 100 minimal-access insertions of distal shunt catheters in 91 patients who required ventriculoperitoneal shunting. Using the minimal-access approach, they avoided utilizing laparoscopic assistance or a mini-laparotomy in 91% of the cases. There were no bowel injuries or misplaced distal catheters. Additional outcomes in terms of operative times, cases that required conversion to open or laparoscopically assisted implantation, and infection rates are presented. They conclude that intraperitoneal shunt catheter placement can be safely and effectively accomplished using a simplified percutaneous minimal-access insertion method that does not require direct laparoscopic visualization.

Management of Adult Hydrocephalus With Ventriculoperitoneal Shunts: Long-term Single-Institution Experience

Neurosurgery ◽  
2011 ◽  
Vol 69 (4) ◽  
pp. 774-781 ◽  
Author(s):  
G Kesava Reddy ◽  
Papireddy Bollam ◽  
Runhua Shi ◽  
Bharat Guthikonda ◽  
Anil Nanda
Keyword(s):  
Median Time ◽  
Adult Patients ◽  
Shunt Revision ◽  
Shunt Failure ◽  
Single Institution ◽  
Ventriculoperitoneal Shunts ◽  
Shunt Placement ◽  
Ventriculoperitoneal Shunting

Abstract BACKGROUND: Ventriculoperitoneal shunting is the most widely used neurosurgical procedure for the management of hydrocephalus. OBJECTIVE: To evaluate our long-term single-institution experience in the management of adult hydrocephalus patients with ventriculoperitoneal shunts. METHODS: Adult patients who underwent ventriculoperitoneal shunt placement for hydrocephalus from October 1990 to October 2009 were included. Medical charts, operative reports, imaging studies, and clinical follow-up evaluations were reviewed and analyzed retrospectively for clinical outcome in adult hydrocephalus patients. RESULTS: A total of 683 adult patients were included in the study. The most common etiologies of hydrocephalus include idiopathic (29%), tumors and cysts (20%), postcraniotomy (13%), and subarachnoid hemorrhage (13%). The overall shunt failure rate was 32%, and the majority (74%) of shunt revisions occurred within the first 6 months. The median time to first shunt revision was 9.31 months. Etiology of hydrocephalus showed a significant impact on the incidence of shunt revision/failure and on the median time to shunt revision. Similarly, the type of hydrocephalus had a significant effect on the incidence of shunt failure and the median time to shunt revision. CONCLUSION: A large proportion of patients (32%) experience shunt failure after shunt placement for hydrocephalus. Although the overall incidence of shunt revision was comparable to previously reported studies, the fact that a large proportion of adult populations with shunt placement experience shunt failure is a concern.

Implantable insulin pumps: diagnosis and management of decreased flow rates using radionuclide investigation

1996 ◽  
Vol 19 (12) ◽  
pp. 723-729
Author(s):  
H. Boulahdour ◽  
A. Behar ◽  
M.-J. Haardt ◽  
J-L. Selam
Keyword(s):  
Insulin Pumps ◽  
Distal Catheter ◽  
Non Invasive ◽  
Step Procedure ◽  
Catheter Obstruction ◽  
Catheter Malfunction ◽  
Invasive Method ◽  
One Step ◽  
Isotonic Sodium Chloride

The aim of this study was to develop a diagnostic procedure for pumping unit malfunction by radionuclide imaging (RI) and to validate the method by comparing the results with those obtained using more conventional methods. Fifteen radionuclide investigations were performed in 11 patients with intraperitoneal implantable insulin pumps. One mCi of 99 mTc in 1 ml isotonic sodium chloride was injected into the reservoir. The results based on catheter visualization and peritoneal accumulation were compared blindly to the efficacy of alkaline rinses and laparoscopic findings. In all RI stoppage cases except one alkaline rinses failed to restore flow. Where laparoscopy was performed, comparisons were concordant i.e. no outflow from the tip of the catheter. The RI images obtained were reproduced in vitro using a pump under normal flow conditions and complete proximal and distal catheter obstruction. RI is a safe, quick non invasive method which allows the location of the site of pump/catheter malfunction within a one step procedure and the prediction of the efficacy of sodium hydroxide rinses.

The Physical Environment as a Determinant of the Health Status of Older Populations

1999 ◽  
Vol 18 (3) ◽  
pp. 313-327 ◽  
Author(s):  
Kathy M. Shipp ◽  
Laurence G. Branch
Keyword(s):  
Physical Activity ◽  
Health Status ◽  
Physical Environment ◽  
The Elderly ◽  
Living Environment ◽  
Activity Level ◽  
Retirement Communities ◽  
Negative Consequences ◽  
Environmental Press ◽  
Organ Systems

ABSTRACTAlthough the physical environment as a co-determinant of health could be approached in many ways, we chose to focus on an understudied area: how the immediate living environment can act as a persuasive force affecting physical activity level in older people, with physical activity in turn affecting health status. To explore this topic, the methods and findings of a literature search are described, the theoretical underpinnings of our thesis are presented, and an example is given of how a planned environment, which upon first glance seems supportive, may have unexpected and negative consequences on the activity level, and ultimately the health status, of the residents. Theory related to changes with aging in homeostatic capacity and reserve capacity of organ systems as well as Lawton's environmental press-competence model are applied to environmental characteristics (e.g., staircases) of continuing care retirement communities. We argue that physically challenging aspects of the environment, such as stairs, should be included in the design of living spaces for the elderly with the goal of encouraging greater daily physical activity and improved health status.

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