scholarly journals Reviewing the prognostic factors in myelomeningocele

2019 ◽  
Vol 47 (4) ◽  
pp. E2 ◽  
Author(s):  
Tatiana Protzenko ◽  
Antônio Bellas ◽  
Marcelo Sampaio Pousa ◽  
Michelle Protzenko ◽  
Juliana Marin Fontes ◽  
...  
Keyword(s):  
Head Circumference ◽  
Primary Repair ◽  
External Ventricular Drain ◽  
Significant Risk ◽  
Morbidity And Mortality ◽  
Shunt Revision ◽  
Wound Complications ◽  
Functional Level ◽  
Shunt Insertion ◽  
Shunt Placement

OBJECTIVEThe goal of this study was to analyze the factors that have an impact on morbidity and mortality in patients with myelomeningocele (MMC).METHODSA retrospective cohort study was conducted to analyze factors associated with MMC that influence the morbidity and mortality of the disease. Data were collected from medical records of children who underwent the primary repair of MMC at the Fernandes Figueira Institute–Oswaldo Cruz Foundation (IFF-Fiocruz) between January 1995 and January 2015, with a minimum follow-up of 1 year. The following variables were analyzed: demographic characteristics (gestational age, sex, and birth weight); clinical features (head circumference at birth, anatomical and functional levels of MMC, hydrocephalus, symptomatic Chiari malformation type II, neurogenic bladder, and urinary tract infection [UTI]); and surgical details such as timing of repair of MMC, age at first shunt placement, shunt surgery modality (elective or emergency), concurrent surgery (correction of MMC and shunt insertion in the same surgical procedure), incidence and cause of shunt dysfunction, use of external ventricular drain, transfontanelle puncture, surgical wound complications prior to shunting, and endoscopic treatment of hydrocephalus.RESULTSA total of 231 patients with MMC were included in the analysis. Patients were followed for periods ranging from 1 to 20 years, with a mean of 6.9 years. The frequency of shunt placement was observed mainly among patients with MMC at the highest spinal levels (p < 0.01). The main causes of morbidity and mortality in patients with MMC were shunt failures, diagnosed in 91 of 193 cases (47.2%) of hydrocephalus, and repeated UTIs, in 129 of 231 cases (55.8%) of MMC; these were the main causes of hospitalization and death. Head circumference ≥ 38 cm at birth was found to be a significant risk factor for shunt revision (p < 0.001; 95% CI 1.092–1.354). Also, the lumbar functional level of MMC was associated with less revision than upper levels (p < 0.014; 95% CI 0.143–0.805). There was a significant association between recurrent UTI and thoracic functional level.CONCLUSIONSMacrocephaly at birth and higher levels of the defect have an impact on worse outcome and, therefore, are a challenge to the daily practice of pediatric neurosurgery.

Transesophageal Echocardiography-Guided Ventriculoatrial Shunt Insertion

2019 ◽  
Vol 19 (1) ◽  
pp. 25-31
Author(s):  
Albert McAnsah Isaacs ◽  
Danae Krahn ◽  
Andrew M Walker ◽  
Heather Hurdle ◽  
Mark G Hamilton
Keyword(s):  
Transesophageal Echocardiography ◽  
Perioperative Complications ◽  
Superior Vena ◽  
Vena Cava ◽  
Shunt Revision ◽  
Shunt Valve ◽  
Shunt Insertion ◽  
Distal Catheter ◽  
Shunt Placement ◽  
Time Required

Abstract BACKGROUND Determining an optimal location within the right atrium (RA) for placement of the distal ventriculoatrial (VA) shunt catheter offer several operative challenges that place patients at risk for perioperative complications and downstream VA shunt failure. Utilizing transesophageal echocardiography (TEE) guidance to place distal VA shunt catheters may help to circumvent these risks. OBJECTIVE To review our current practice of VA shunt insertion using TEE guidance. METHODS A retrospective review of all consecutive patients who underwent VA shunt procedures between December 19, 2016 and January 22, 2019, during which time intraoperative TEE was used for shunt placement was performed. Data on the time required for shunt placement and total procedure time, baseline echocardiography findings, and short- and long-term complications of shunt placement were assessed. RESULTS A total of 33 patients underwent VA shunt procedures, with a median follow-up time of 250 (88-412) d. The only immediate complication related to shunt placement or TEE use was transient ectopy in 1 patient. The mean time for atrial catheter insertion was 12.6 ± 4.8 min. Right-heart catheters were inserted between the RA-superior vena cava junction and 22 mm within the RA in all but 3 procedures. A total of 7/33 patients (21%) underwent shunt revision. Indications for revisions included distal clots, proximal obstruction, positive blood culture, and shunt valve revision. No other complications of VA shunt insertion were reported. CONCLUSION VA shunt insertion using TEE allows for precise distal catheter placement. Early patient experience confirms this technique has a low complication rate.

Utility of ventriculogallbladder shunts in complex cases of hydrocephalus related to extreme prematurity

2021 ◽  
pp. 1-7
Author(s):  
Andrew Reisner ◽  
Alexis D. Smith ◽  
David M. Wrubel ◽  
Bryan E. Buster ◽  
Michael S. Sawvel ◽  
...  
Keyword(s):  
Medical Records ◽  
Intraventricular Hemorrhage ◽  
Venous Access ◽  
Shunt Infection ◽  
Definitive Treatment ◽  
Shunt Revision ◽  
Extreme Prematurity ◽  
Shunt Insertion ◽  
Shunt Placement ◽  
The Mean

OBJECTIVEThe management of hydrocephalus resulting from intraventricular hemorrhage related to extreme prematurity remains demanding. Given the complexities of controlling hydrocephalus in this population, less commonly used procedures may be required. The authors examined the utility of ventriculogallbladder (VGB) shunts in a series of such children.METHODSThe authors retrospectively reviewed the medical records of all children who underwent surgery for hydrocephalus in the period from 2011 through 2019 at Children’s Healthcare of Atlanta. Six patients who underwent VGB shunt placement were identified among a larger cohort of 609 patients who had either a new shunt or a newly changed distal terminus site. The authors present an analysis of this series, including a case of laparoscopy-assisted distal VGB shunt revision.RESULTSThe mean age at initial shunt placement was 5.1 months (range 3.0–9.4 months), with patients undergoing a mean of 11.8 shunt procedures (range 5–17) prior to the initial VGB shunt placement at a mean age of 5.3 years (range 7.9 months–12.8 years). All 6 patients with VGB shunt placement had hydrocephalus related to extreme prematurity (gestational age < 28 weeks). At the time of VGB shunt placement, all had complex medical and surgical histories, including poor venous access due to congenital or iatrogenic thrombosis or thrombophlebitis and a peritoneum hostile to distal shunt placement related to severe necrotizing enterocolitis. VGB complications included 1 case of shunt infection, identified at postoperative day 6, and 2 cases of distal shunt failure due to retraction of the distal end of the VGB shunt. In all, there were 3 conversions back to ventriculoperitoneal or ventriculoatrial shunts due to the 2 previously mentioned complications, plus 1 patient who outgrew their initial VGB shunt. Three of 6 patients remain with a VGB shunt, including 1 who underwent laparoscopy-assisted distal shunt revision 110.5 months after initial VGB shunt insertion.CONCLUSIONSPlacement of VGB shunts should be considered in the armamentarium of procedures that may be used in the particularly difficult cohort of children with hydrocephalus related to extreme prematurity. VGB shunts show utility as both a definitive treatment and as a “bridge” procedure until the patient is larger and comorbid abdominal and/or vascular issues have resolved sufficiently to allow conversion back to ventriculoperitoneal or ventriculoatrial shunts, if needed.

Analysis of Factors associated with Revision of Ventriculoperitoneal shunt at National Institute of Neurological and Allied Science, Nepal

2019 ◽  
Vol 4 (2) ◽  
pp. 10-19
Author(s):  
Nikunja Yogi ◽  
Suraj Thulung ◽  
Mayush Bahadur Munakarmi ◽  
Rachana Nakarmi ◽  
Dinesh Nath Gongal
Keyword(s):  
External Ventricular Drain ◽  
Shunt Revision ◽  
Categorical Variables ◽  
Shunt Surgery ◽  
Shunt Insertion ◽  
Vp Shunt ◽  
Factors Associated ◽  
Duration Of Surgery ◽  
Drain Placement ◽  
One Year

Introduction: Ventriculoperitoneal (VP) shunt is the commonest procedure for hydrocephalus. The cases requiring shunt revision is a major obstacle in its management. Various factors have been implicated for failure or revision of shunt like patient’s age, sex, cause of hydrocephalus, duration of surgery. This study aims to analyze the rate of VP shunt revision and various factors associated with it. Methods: In this study, we analyzed 237 cases aged three months to 75 years, of VP shunt from January 2010-December 2014 with at least one year follow up at National Institute of Neurological and Allied Sciences. We evaluated the rate of VP shunt revision and various factors associated with it. The categorical variables were evaluated by chi-square test. Odds ratio was calculated for each factors at 95% CI. Results: There were 54 (22.78%) cases having at least one revision within one year of shunt insertion. The odds of revision of shunt was 6.58 times higher when inserted through frontal approach than occipital approach. The external ventricular drain placement prior to shunt surgery had statistically significant association with shunt revision (p=0.02). There was no difference in patients requiring/not requiring shunt revision when compared in terms of age group, gender, various etiologies and side of shunt insertions. Conclusions: The rate of shunt revision in our study was 22.78% which is comparable to other studies. Frontal approach in VP shunt insertion was associated with increased rate of shunt failure thus requiring revision. Likewise, external ventricular drain placement prior to shunt surgery was associated with increased incidence of revision surgery.

Is Acute Appendicitis a Surgical Emergency?

2007 ◽  
Vol 73 (6) ◽  
pp. 626-629 ◽  
Author(s):  
Kurt Stahlfeld ◽  
John Hower ◽  
Sarah Homitsky ◽  
Jeffrey Madden
Keyword(s):  
Length Of Stay ◽  
Acute Appendicitis ◽  
Negative Impact ◽  
Significant Risk ◽  
Antibiotic Use ◽  
Hospital Length ◽  
Morbidity And Mortality ◽  
Hospital Length Of Stay ◽  
Wound Complications ◽  
Group A

Urgent appendectomy has become the basis of management for acute appendicitis because of the disparity in morbidity and mortality rates between perforated and nonperforated appendicitis. Immediate surgery results in the confirmation of diagnosis and the control of sepsis without the risk of recurrent appendicitis. However, when notified by the emergency room of the diagnosis, many surgeons are opting to begin antibiotics and intravenous fluids and to schedule the appendectomy at their convenience. We hypothesize that using intravenous antibiotics and hydration to delay appendectomy until “normal business hours” has a negative impact on patient morbidity and mortality. During a 23-month period, the medical records of 81 patients at a single institution who underwent appendectomy were reviewed. All patients had preoperative CT scans and all operations were performed by one of two surgeons. Group A included those patients who underwent appendectomy within 10 hours of CT diagnosis and group B included those appendectomies performed greater than 10 hours after diagnosis. Wound complications, antibiotic use, total analgesic requirements, length of operation, and hospital length of stay were used for comparison. The average time to operation (3.18 vs 15.85 hours), operative time (54.1 vs 55.7 minutes), length of stay (2.65 vs 2.09 days), wound infections (4 vs 0), and antibiotic use at discharge (19 vs 3) for group A and B were not statistically different. This data suggests that delaying operative intervention for acute appendicitis to accommodate a surgeon's preference or to maximize a hospital's efficiency does not pose a significant risk to the patient.

scholarly journals Relationship between external ventricular drain clamp trials and ventriculoperitoneal shunt insertion following nontraumatic subarachnoid hemorrhage: a single-center study

2019 ◽  
Vol 130 (3) ◽  
pp. 956-962 ◽  
Author(s):  
Luis C. Ascanio ◽  
Raghav Gupta ◽  
Nimer Adeeb ◽  
Justin M. Moore ◽  
Christoph J. Griessenauer ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
External Ventricular Drain ◽  
Median Number ◽  
Study Patient ◽  
Shunt Insertion ◽  
Female Ratio ◽  
Posthemorrhagic Hydrocephalus ◽  
Vp Shunt ◽  
Shunt Placement ◽  
Lengths Of Stay

OBJECTIVECurrently, there is no established standard regarding the ideal number of external ventricular drain (EVD) clamp trials performed before ventriculoperitoneal (VP) shunt insertion following nontraumatic subarachnoid hemorrhage (SAH). In this study, the authors aimed to evaluate this relationship.METHODSA retrospective review of all patients presenting with SAH between July 2007 and December 2016 was performed. Patients with SAH who had received an EVD within the first 24 hours of hospital admission and had undergone at least 1 clamp trial prior to EVD removal were eligible for inclusion in the study. Patient demographics, clinical presentations, SAH etiologies and grades, clamp trial data, hospital lengths of stay, and functional outcomes were recorded.RESULTSOne hundred fourteen patients with nontraumatic SAH complicated by posthemorrhagic hydrocephalus were included in the study. The median patient age was 57 years (range 28–90 years), with a male/female ratio of 1:1.7. A ruptured aneurysm was the underlying etiology of SAH in 79.8% of patients. A majority of patients (69.4%) had a Hunt and Hess grade III–V on admission. The median number of clamp trials performed was 2 (range 1–6). A VP shunt was required in 40.4% of patients. In those who underwent 2 and 3 clamp trials, 60% and 38.9%, respectively, did not require subsequent VP shunt placement.CONCLUSIONSSurgical placement of a VP shunt is associated with complications. Clamp trials are routinely performed before making the decision to insert a shunt. In the present study, the authors found that a significant percentage of patients passed their second and third clamp trials without requiring subsequent shunt insertion. These data support performing multiple clamp trials prior to shunt placement.

scholarly journals Post-haemorrhagic hydrocephalus is associated with poorer surgical and neurodevelopmental sequelae than other causes of infant hydrocephalus

2021 ◽  
Author(s):  
Malak Mohamed ◽  
Saniya Mediratta ◽  
Aswin Chari ◽  
Cristine Sortica da Costa ◽  
Greg James ◽  
...  
Keyword(s):  
Gestational Age ◽  
Cox Regression ◽  
Severe Disabilities ◽  
Median Number ◽  
Shunt Revision ◽  
Endocrine Dysfunction ◽  
Neurodevelopmental Outcomes ◽  
Shunt Insertion ◽  
Street Hospital ◽  
Shunt Survival

Abstract Purpose This retrospective cohort study aimed to investigate the surgical and neurodevelopmental outcomes (NDO) of infant hydrocephalus. We also sought to determine whether these outcomes are disproportionately poorer in post-haemorrhagic hydrocephalus (PHH) compared to other causes of infant hydrocephalus. Methods A review of all infants with hydrocephalus who had ventriculoperitoneal (VP) shunts inserted at Great Ormond Street Hospital (GOSH) from 2008 to 2018 was performed. Demographic, surgical, neurodevelopmental, and other clinical data extracted from electronic patient notes were analysed by aetiology. Shunt survival, NDO, cerebral palsy (CP), epilepsy, speech delay, education, behavioural disorders, endocrine dysfunction, and mortality were evaluated. Results A total of 323 infants with median gestational age of 37.0 (23.29–42.14) weeks and birthweight of 2640 g (525–4684 g) were evaluated. PHH was the most common aetiology (31.9%) and was associated with significantly higher 5-year shunt revision rates, revisions beyond a year, and median number of revisions than congenital or “other” hydrocephalus (all p < 0.02). Cox regression demonstrated poorest shunt survival in PHH, related to gestational age at birth and corrected age at shunt insertion. PHH also had the highest rate of severe disabilities, increasing with age to 65.0% at 10 years, as well as the highest CP rate; only genetic hydrocephalus had significantly higher endocrine dysfunction (p = 0.01) and mortality rates (p = 0.04). Conclusions Infants with PHH have poorer surgical and NDO compared to all other aetiologies, except genetic hydrocephalus. Research into measures of reducing neurodisability following PHH is urgently required. Long-term follow-up is essential to optimise support and outcomes.

scholarly journals Effect of electromagnetic-navigated shunt placement on failure rates: a prospective multicenter study

2010 ◽  
Vol 113 (6) ◽  
pp. 1273-1278 ◽  
Author(s):  
Caroline Hayhurst ◽  
Tjemme Beems ◽  
Michael D. Jenkinson ◽  
Patricia Byrne ◽  
Simon Clark ◽  
...  
Keyword(s):  
Revision Rate ◽  
Shunt Revision ◽  
Standard Group ◽  
Fisher Exact Test ◽  
Anatomical Landmarks ◽  
Failure Rates ◽  
Shunt Failure ◽  
Catheter Position ◽  
Optimal Position ◽  
Shunt Placement

Object As many as 40% of shunts fail in the first year, mainly due to proximal obstruction. The role of catheter position on failure rates has not been clearly demonstrated. The authors conducted a prospective cohort study of navigated shunt placement compared with standard blind shunt placement at 3 European centers to assess the effect on shunt failure rates. Methods All adult and pediatric patients undergoing de novo ventriculoperitoneal shunt placement were included (patients with slit ventricles were excluded). The first cohort underwent standard shunt placement using anatomical landmarks. All centers subsequently adopted electromagnetic (EM) navigation for routine shunt placements, forming the second cohort. Catheter position was graded on postoperative CT in both groups using a 3-point scale developed for this study: (1) optimal position free-floating in CSF; (2) touching choroid or ventricular wall; or (3) intraparenchymal. Episodes and type of shunt revision were recorded. Early shunt failure was defined as that occurring within 30 days of surgery. Patients with shunts were followed-up for 12 months in the standard group, for a median of 6 months in the EM-navigated group, or until shunt failure. Results A total of 75 patients were included in the study, 41 with standard shunts and 34 with EM-navigated shunts. Seventy-four percent of navigated shunts were Grade 1 compared with 37% of the standard shunts (p = 0.001, chi-square test). There were no Grade 3 placements in the navigated group, but 8 in the standard group, and 75% of these failed. Early shunt failure occurred in 9 patients in the standard group and in 2 in the navigated group, reducing the early revision rate from 22 to 5.9% (p = 0.048, Fisher exact test). Early shunt failures were due to proximal obstruction in 78% of standard shunts (7 of 9) and in 50% of EM-navigated shunts (1 of 2). Conclusions Noninvasive EM image guidance in shunt surgery reduces poor shunt placement, resulting in a significant decrease in the early shunt revision rate.

External Ventricular Drain Infection

2007 ◽  
Vol 107 (1) ◽  
pp. 248 ◽  
Author(s):  
George K. C. Wong ◽  
Wayne W. S. Poon
Keyword(s):  
Major Trauma ◽  
Independent Predictor ◽  
External Ventricular Drain ◽  
Significant Risk ◽  
Significant Risk Factor ◽  
External Ventricular Drainage ◽  
Infection Rates ◽  
The Mean ◽  
The Relationship ◽  
Shed Light

Object The authors explored the relationship among the duration of external ventricular drainage, revision of external ventricular drains (EVDs), and cerebrospinal fluid (CSF) infection to shed light on the practice of electively revising these drains. Methods In a retrospective study of 199 patients with 269 EVDs in the intensive care unit at a major trauma center in Australasia, the authors found 21 CSF infections. Acinetobacter accounted for 10 (48%) of these infections. Whereas the duration of drainage was not an independent predictor of infection, multiple insertions of EVDs was a significant risk factor. Second and third EVDs in previously uninfected patients were more likely to become infected than first EVDs. An EVD infection was initially identified a mean of 5.5 ±0.7 days postinsertion (standard error of the mean); these data—that is, the number of days—were normally distributed. Conclusions This pattern of infection is best explained by EVD-associated CSF infections being acquired by the introduction of bacteria on insertion of the drain rather than by subsequent retrograde colonization. Elective EVD revision would be expected to increase infection rates in light of these results, and thus the practice has been abandoned by the authors' institution.

scholarly journals Outcomes of Craniofacial Open Surgery in Octogenarians

2018 ◽  
Vol 79 (06) ◽  
pp. 515-521
Author(s):  
Barak Ringel ◽  
Narin Carmel-Neiderman ◽  
Daniel Ben-Ner ◽  
Aviyah Pery ◽  
Ahmad Safadi ◽  
...  
Keyword(s):  
Skull Base ◽  
Skull Base Surgery ◽  
Medical Center ◽  
Morbidity And Mortality ◽  
Wound Complications ◽  
Steady Increase ◽  
Systemic Complications ◽  
Female Ratio ◽  
Younger Patients ◽  
Surgery In Octogenarians

Introduction The steady increase in average life expectancy has led to a rise in the number of referrals of elderly patients for major operations. It is not clear whether age itself is a risk factor for morbidity and mortality after skull base operations. We investigated a possible link among a cohort of patients older than 80 years of age who underwent those surgeries in our department. Methods We conducted a retrospective analysis of all patients who underwent skull base surgery at the TASMC (Tel Aviv Sourasky Medical Center) between 2000 and 2016. Results A total of 369 patients underwent open skull base surgeries in our institution, and 13 were patients older than 80 years. The median age of the octogenarians was 83.4 (range 80–89), and the male-to-female ratio was 7:6. Twelve patients had major systemic comorbidities. Four patients had major complications associated with surgery: three had early wound complications, and one each had early central nervous system complications, early and late systemic complications, and late orbital complications. This complication rate is comparable to that of our younger group of 356 patients. The overall survival rate was measured for 30 days, 1 year, and 3 years, and it was not significantly different between the octogenarians and that of the younger patients. Further comparison of the elderly group with 13 matched younger patients revealed no difference of morbidity and mortality between the two groups. Conclusions Despite their systemic comorbidities, the morbidity and mortality rates associated with skull base surgery in octogenarians appear to be comparable to that of younger patients undergoing the same procedures.

Prospective surveillance of complications in a pediatric neurosurgery unit

2010 ◽  
Vol 5 (6) ◽  
pp. 544-548 ◽  
Author(s):  
James M. Drake ◽  
Jay Riva-Cambrin ◽  
Andrew Jea ◽  
Kurtis Auguste ◽  
Mandeep Tamber ◽  
...  
Keyword(s):  
External Ventricular Drain ◽  
Pediatric Neurosurgery ◽  
Shunt Infection ◽  
Shunt Revision ◽  
Third Ventriculostomy ◽  
Neurosurgical Procedures ◽  
Csf Leakage ◽  
Second Procedure ◽  
Shunt Infections ◽  
Csf Leaks

Object Complications of specific pediatric neurosurgical procedures are well recognized. However, focused surveillance on a specific neurosurgical unit, for all procedures, may lead to better understanding of the most important complications, and allow targeted strategies for quality improvement. Methods The authors prospectively recorded the morbidity and mortality events at a large pediatric neurosurgical unit over a 2-year period. Morbidity was defined as any significant adverse outcome or death (for obstructive shunt failure, within 30 days). Multiple and unrelated complications in the same patient were recorded as separate events. Results There were 1082 surgical procedures performed during the evaluation period. One hundred seventy-seven complications (16.4%) occurred in 147 patients. By procedure, the most common complications occurred in vascular surgery (41.7%) and brain tumor surgery (27.9%). The most common complications were CSF leakage (31 cases), a new neurological deficit (27 cases), early shunt or endoscopic third ventriculostomy obstruction (27 cases), and shunt infection (24 cases). Meningitis occurred in 19 cases: in 58% of shunt infections, 13% of CSF leaks, and 10% of wound infections. Sixty-four percent of adverse events required a second procedure, most commonly an external ventricular drain placement or shunt revision. Conclusions Complications in pediatric neurosurgical procedures are common, result in significant morbidity, and more than half the time require a repeat surgical procedure. Targeted strategies to prevent common complications, such as shunt infections or CSF leaks, might significantly reduce this burden.

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