Frequency, Predictors, and Outcome of Seizures in Patients With Myelomeningocele: Single-Center Retrospective Cohort Study

To determine the frequency, predictors, and outcomes of seizures in patients with myelomeningocele, we retrospectively analyzed the data from patients with myelomeningocele followed longitudinally at a single center from 1975 to 2013. We identified a total of 122 patients (61% female). The mean follow-up duration was 11.1 years (minimum-maximum = 0-34.5 years, SD = 8.8, median = 9.1 years). A total of 108 (88.5%) patients had hydrocephalus, and 98 (90.7%) of those patients required a ventriculoperitoneal shunt procedure. Twenty-four (19.7%) patients manifested with seizures, 23 of whom had hydrocephalus. The average age of seizure onset was 4.8 years (median 2 years of age). Falx dysgenesis ( P = .004), lumbar myelomeningocele ( P = .007), and cortical atrophy ( P = .028) were significantly associated with epileptic seizure development. The average seizure-free period at the last follow-up in patients with a history of myelomeningocele and seizures was 8.1 years. We conclude that myelomeningocele patients with seizures have an overall good prognosis with considerable long-term seizure freedom.

Embolization of a Superior Mesenteric Arteriovenous Fistula Identified During Consultation for a Transjugular Intrahepatic Portosystemic Shunt Procedure: A Case Report

Superior mesenteric arteriovenous fistula is a rare vascular anomaly often presenting with sequelae of portal hypertension, heart failure, or mesenteric ischemia. This report describes a 75-year-old woman with a history of extensive small bowel resection who presented with variceal bleeding. She was referred to vascular and interventional radiology for a transjugular intrahepatic portosystemic shunt procedure; however, her history was inconsistent with cirrhosis. This prompted further review of her imaging, which identified a superior mesenteric arteriovenous fistula as the probable etiology of her varices. This was subsequently embolized with a vascular plug and follow-up upper endoscopy at 1-month demonstrated complete resolution of her varices. This patient was able to avoid a procedure with potentially catastrophic consequences, highlighting the necessity of comprehensive consultations by interventional physicians. Level of Evidence: Level 4, Case Report.

607 A Close Loop Audit on Proper Documentation of Ventriculo-Peritoneal (VP) Shunt Valve Settings in Operation Note

Aim Re-audit the practice of proper documentation of shunt type and settings in VP shunt surgery in Queen's Medical Centre, Nottingham for the period of 1st November 2019 – 31st October 2020. It is very important as programmable shunt setting could get changed during MRI, causing shunt failure. Method It was a retrospective collection of data of patients admitted to Queens medical Centre, Nottingham who had undergone VP shunt procedure. Exceptions: 4 files were excluded from study as they did not undergo VP shunt procedure. Results Total number of patients: 98. 4 patients were excluded. Actual sample size 94. Total VP shunt procedure done: 107. In 96 out of 107 procedures the shunt valve type and settings were properly documented. In 11 out of 107 procedures the shunt valve type and settings were not documented. In 33 out of 107 procedures programmable shunt valves were used. All 33 procedures had proper documentations. Previous audit result Duration of data collection: 2 years (from March 2016 to February 2018). Sample size 200. Total VP shunts done 247. Proper documentation of shunt valve type and settings were done in 209 out of 247 procedures. In 38 out of 247 procedures shunt valve type and settings were not documented. In 55 out of 247 procedures programmable shunt valves were used. 3 out of these 55 procedures (programmable shunt valves) lacked proper documentation. Conclusions There is an overall improvement in the practice of documentation of VP shunt valve type and settings in operative notes after implementing the plan of actions decided on first audit.

Pediatric shunt revision analysis within the first year of shunt placement: A single center experience

Background: Hydrocephalus is a common problem in neurosurgery with shunt placement remains the mainstay of the management. However, shunt placement generally requires following surgical procedures, including shunt revision. Despite the recent developments, the incidence of shunt failure remains high, approximately 30–51% in the 1st year following the shunt placement. Methods: An observational retrospective study of pediatric neurosurgery patients whom underwent CSF shunting procedure, both primary and repeated VPS, VAS, CPS, and subdural-peritoneal shunt procedures between January 2018 and May 2019. The patients were observed for 12 months for potential complication requiring shunt revision following the shunt placement. Results: A total of 142 patients underwent shunt placement. The shunt revision within 12 months was found in 26 patients (18.3%), 25 cases were VPS (96.2%) and one case was CPS (3.8%). The mean period of time between shunt placement to shunt revision was 3.96 months. Age of under 6 months old during the shunt placement showed significantly higher risk for shunt revision (RR 2.32 CI 1.13–4.74, P = 0.018). The most common diagnosis requiring shunt revision was congenital anomaly (16 cases, 61.5%). The most common cause of revision was shunt malfunction, with 21 cases (80.8%) followed by infected shunt with 5 cases (19.2%). Conclusion: The 1st year observation showed relatively high rate for shunt revision. The patient underwent shunt procedure should be regularly followed up in long period for better evaluation of the outcome. The application of shunt registry in some countries appears to be efficient and beneficial for sustainable follow-up in patients underwent shunt placement.

Outcomes of Infants Undergoing Modified Blalock-Taussig Shunt Procedures in Oman

Objectives: A modified Blalock-Taussig (mBT) shunt procedure is a common palliative surgery used to treat infants and children with cyanotic congenital heart disease (CCHD). This study aimed to report the outcomes of infants and children undergoing mBT shunt procedures in Oman. In addition, risk factors associated with early mortality, inter-stage mortality and reintervention were assessed. Methods: This retrospective cohort study was conducted from January 2016 to December 2018 at the National Heart Centre, Muscat, Oman. All paediatric patients with CCHD undergoing mBT shunt procedures as a primary palliative procedure during this period were included. Data were retrieved from electronic hospital records. Kaplan-Meier survival curves were used to describe overall survival. Results: A total of 50 infants and children were included in the study. The in-hospital mortality and inter-stage mortality rates were 10% and 6.7%, respectively. Preoperative mechanical ventilation (odds ratio [OR]: 3.00, 95% confidence interval [CI]: 1.98–4.76; P = 0.007) and cardiopulmonary bypass (OR: 4.09, 95% CI: 2.44–6.85; P = 0.002) were significant risk factors for early mortality. In-hospital and interval surgical reintervention rates were 12% and 13.3%, respectively. Following the primary shunt procedure, the median time to second-stage surgery was 15.5 months (range: 5.0–34.0 months). Conclusion: The findings of this study support those reported in international research regarding the risks associated with mBT shunt surgeries. In particular, preoperative mechanical ventilation and cardiopulmonary bypass were significant risk factors for early mortality. Keywords: Pediatrics; Heart Diseases, congenital; Cardiovascular Surgical Procedures; Modified Blalock-Taussig Procedure; Patient Outcome Assessment; Hospital Mortality; Risk Factors; Oman.

Protrusion of ventriculoperitoneal shunt catheter tip through anus with silence abdomen

Introduction: Ventriculoperitoneal shunt (VPS) is most commonly performed surgical treatment for hydrocephalus by draining excessive cerebrospinal fluid (CSF) in ventricles to peritoneal cavity. Despite significant improvement in shunt procedure and being a relatively simple procedure, shunt complications remain common. Aim: The aim of this paper is to report a case of perforated bowel presented with silence abdomen following VPS insertion. Case study: We report a case of protrusion of distal VPS catheter through anus with silent abdomen, managed successfully with minimal intervention. Patient, 11-months-old male infant, diagnosed with congenital communicating hydrocephalus and VPS placement was done at 6 months of life, presented with tip of VPS protruding from anus after 4 months of VPS insertion. Patient was scheduled for removal of VPS, where shunt was disconnected through superficial abdominal incision, distal portion removed through anus without resistance. Postoperative patient recovers well without abdominal complication. Results and discussion: Perforation of bowel by distal peritoneal catheter is rare and only accounts for 0.1%–0.7% of complication. The exact pathogenesis for spontaneous bowel perforation is unclear. Management of bowel perforation secondary to VPS is highly individualized, mainly depending on its clinical symptoms and signs. Conclusions: Although bowel perforation following VPS insertion is rare, it carries high mortality up to 15% especially if unrecognized and delayed in treatment. Early detection and appropriate management are key in reducing VPS related morbidity and mortality.

Shunt Infection in Adults: A Retrospective Study of 1324 Cases

Background: Shunt infection (SI) is a serious major complication in the management of hydrocephalus after cerebral fluid shunts. Here we study retrospectively hydrocephalus shunting to evaluate the incidence of SI, including the risk factors and types of infection.Meterial and Methods: 1556 patients (age≥18years) who had undergone shunt surgery from January 2013 to December 2019 at our center were included(6-78 months follow-up period). 1324 cases of them were confirmed as effective cases. Infection rate and risk factors were investigated.Results: We found 79 (6.0%) cases (58 men and 21 women) with SI, of which 72 were ventriculo-peritoneal (VP) shunt and 7 were lumbo-peritoneal (LP) shunt. Risk factors include male gender (p=0.04), patients with a history of intracranial infection (p<0.001) and patients suffered an infection when shunt surgery performed (p=0.008). Surgery type (p=0.80), Glasgow Coma Score (GCS) before shunt procedure (p=0.57) and history of hypertension (p=0.16), diabetes (p=0.44) or cerebral infarction (p=0.29) were not risk factors of SI. Brain or spine surgery performed within 2 years prior to shunt procedure increased rate of SI (p=0.015, SI rate: 7.4%), but not when performed after shunt procedure (p=0.42). Idiopathic hydrocephalus and hydrocephalus caused by trauma, hemorrhage, tumor and other factors showed no significant correlation with SI. Of all SI, 48 (60.8%) and 62 (78.5%) cases were present within 1 and 2 months after shunt surgery, respectively. Only 2.5% (2/79) of SI were found after 1 year since shunt placement. Pathogens were found in 46 cases, and Gram positive cocci were accounted for 50.0% (23/46). Conclusions: Our study suggests that male, history of intracranial infection, patients’ infection status when shunt surgery performed and history of brain or spine surgery performed within 2 years are risk factors of SI. Infections are more likely to present within the first 2 months after shunt placement, only 2.5% shunt infections were found after more than 1 year form shunt operation.

First case report of acute cholangitis secondary to Cronobacter sakazakii

Introduction Cronobacter sakazakii is an opportunistic Gram-negative, rod-shaped bacterium which may be a causative agent of meningitis in premature infants and enterocolitis and bacteremia in neonates and adults. While there have been multiple cases of C. sakazakii infections, there have been no acute cholangitis cases reported in humans. Case presentation An 81-year-old male with a past medical history of basal cell carcinoma, alcoholic liver cirrhosis, transjugular intrahepatic portosystemic shunt procedure, complicated by staphylococcus bacteremia, pituitary tumor, glaucoma, and hypothyroidism presented to the emergency room with the complaint of diffuse and generalized 10/10 abdominal pain of 1 day’s duration. There was a concern for pancreatitis, acute cholangitis, and possible cholecystitis, and the patient underwent a percutaneous cholecystostomy tube placement. Blood cultures from admission and biliary fluid cultures both grew C. sakazakii. The patient was treated with a carbapenem and clinically improved. Conclusions The case study described a patient with multiple medical comorbidities that presented with C. sakazakii bacteremia and cholangitis. While this bacterium has been implicated in other infections, we believe this is the first time the bacteria is being documented to have caused acute cholangitis.

Management of penile emergencies- one year observation

Background: Penis is a very sensitive organ and even minor injury or discomfort may cause a patient to seek emergency evaluation. Penile emergencies and their management often rely on the results of imaging examinations. But most of the time the traumatic emergencies require urgent exploration to ensure a fair outcome. Objective was to present different types of penile emergencies and to determine the overall outcome of their managements.Methods: It was an observational study conducted at surgery department of Enam Medical College and Hospital, for one year. All patients with penile emergencies were included by selective sampling technique. The main outcome variables were type of penile emergencies, etiology of trauma, grading of trauma, types of surgical intervention, postoperative erectile function. Data processing and analysis were done using SPSS v (23). Statistical significance was determined by Students t test for quantitative data.Results: Total 33 patients admitted with emergencies. 18 (54.5%) belonged to traumatic category, 10 (30%) belonged to infective and one patient (3%) belonged to vascular (ischemic priapism) and others consist of 4 (12%). 40% of trauma was of grade III variety. Seven were victim of sharp cut injury. One who presented with ischemic priapism after 3 days underwent emergency distal shunt procedure with an acceptable functional penis post operatively. Timing of surgical intervention was compared with erectile function on the basis of International Index of Erectile Function (IIEF). A p value <0.05 was considered to be significant.Conclusions: Penile emergencies require prompt, accurate diagnosis. Early surgical intervention can save the organ.

Recurrent spontaneous CSF rhinorrhea: combined endo-nasal endoscopic repair with lumbo-peritoneal shunt insertion

Background Spontaneous cerebrospinal fluid (CSF) leaks are associated with high morbidity and recurrence rates. Most cases had increased intracranial pressure (ICP) on presentation. There is still controversy regarding the use of lumbo-peritoneal shunt to prevent its recurrence. Aim This study was conducted to evaluate the impact of lumbo-peritoneal CSF shunt following the initial as well as recurrent repair of spontaneous CSF leaks to avoid recurrence. Methods A retrospective cohort study reviewed patients with recurrent spontaneous CSF leaks over a 4-year period. All patients had increased ICP and were subjected to endoscopic repair and lumbo-peritoneal shunt procedure. Results Eighteen patients were included in this study. Most patients were obese (BMI = 33.6 ± 1.8 kg/m2) women (88.9%), with sleep apnea syndrome (77.8%). All patients presented with headache and visual complaints. Meningitis was recorded in two patients (11.1%). The most common sites of leakage were the cribriform (66.7%), followed by both cribriform and ethmoidal (16.7%), sphenoid (11.1%), and ethmoidal (5.6%) bones. The mean defect size was 5.1 ± 1.1 mm. About one third of cases had multiple defects. Encephalocele and meningocele were encountered in 61.1% and 66.7% of cases, respectively. The mean preoperative CSF pressure was 36.5 ± 1.7 mm H2O. Lumbo-peritoneal shunt was inserted for all our patients. The failure rate of repair was 11.1%. Conclusion Success rate is higher in patients with spontaneous CSF leaks and CSF hypertension treated by lumbo-peritoneal shunt. Future prospective studies with larger sample sizes should confirm the efficacy and safety of this management plan.