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.
CASE REPORT: 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.
CONCLUSION: 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.