Gastrointestinal Cancer Surgery in Patients With a Prior Ventriculoperitoneal Shunt: The Department of Veterans Affairs Experience

摘要

BACKGROUND: The estimated prevalence of hydrocephalus in all age groups is between 1% and 1.5%. Placement of a ventriculoperitoneal (VP) shunt in such patients offers them relatively normal lives. There are minimal data concerning the risk of postoperative complications in patients with shunts who undergo subsequent major visceral operations. We hypothesized that healthy adults who had VP shunts placed for acquired conditions and later underwent surgery for gastric or colon cancer would frequently have dense, shunt-related adhesions and high rates of adverse outcomes, particularly infection. METHODS: We assumed that all veterans were healthy on entry into military service. We searched national Department of Veterans Affairs databases from October 1994 through September 2003 to identify all Department of Veterans Affairs patients with shunts for acquired conditions and a curative-intent operation for stomach or colon cancer. We conducted chart reviews to determine their clinical courses. RESULTS: Five patients had codes for VP shunt, gastric cancer, and gastrectomy; 3 met our inclusion criteria. Fourteen had codes for VP shunt, colon cancer, and colectomy; 4 met our criteria. One of the evaluable gastrectomy patients had dense, shunt-related adhesions. None of the colectomy patients had notable adhesions. There were no postoperative complications in any of the seven patients. CONCLUSION: We believe this is the first report analyzing the clinical course of adults with VP shunts who later had major abdominal cancer surgery. The presence of a shunt was associated with dense adhesions in 1 (14%) of the 7 patients in this series, but not with an increased risk of postoperative complications. Hydrocephalus is a congenital or acquired condition in which cerebrospinal fluid accumulates in the ventricles and subarachnoid space around the brain. It is typically accompanied by an increase in the intracranial pressure and enlargement of the ventricles. The elevated intracranial pressure can damage brain tissue, producing headache, nausea, vomiting, gross motor disturbances, and cognitive impairment. The estimated prevalence of hydrocephalus is 1% to 1.5% in all age groups. 1 Before the 20th century, the treatment of hydrocephalus ranged from bleeding, purging, injection of astringents, head wrapping, and application of potions to the head to more sophisticated treatments, such as insertion of ventricular setons or cannulas and lumbar punctures. 2 Most of the invasive procedures resulted in disastrous outcomes, mainly due to infection. In order to decrease the risk of infection, attention then focused on surgical interventions leading to internal drainage of the cerebrospinal fluid. In 1905, Kausch introduced ventriculoperitoneal (VP) shunting as primary treatment for hydrocephalus. 3 This method, which uses the peritoneal cavity for absorption of cerebrospinal fluid, has since become standard therapy. The catheter is introduced into a lateral ventricle through a burr hole. The tubing has an adjacent subcutaneous reservoir. There is generally a unidirectional valve designed to prevent reflux of intra-abdominal fluids into the cerebrospinal fluid. 4 The tubing is tunneled subcutaneously with its distal end lying free in the peritoneal cavity. A variety of materials such as silicone, titanium, synthetic ruby, barium sulfate, stainless steel, and various plastics are used in the construction of shunts. 2 Innovations in shunt technology have revolutionized the care of patients with hydrocephalus. According to 1988 National Hospital Discharge Survey data, the number of shunts placed in the United States is 18,000/year, costing more than $100 million. There are more than 127,000 patients with cerebrospinal fluid shunts in the United States, of which most are VP shunts. 5 This statistic indicates their therapeutic value in treating hydrocephalus. Shunts have allowed patients with hydrocephalus to have near-normal life expectancies. Consequently, such patients would be expected to undergo abdominal operations for various conditions at the same rate as individuals without shunts. Operations for various abdominal cancers in adult patients with VP shunts have the potential to cause local and/or ascending infection of the shunt, with grave consequences. To date, there have been few investigations of complications occurring in patients with cerebrospinal fluid shunts after abdominal operations. Children have been the primary focus of these studies, with 0% to 31% 6 – 10 developing a VP shunt infection after augmentation cystoplasty. Infections are among the most devastating complications, as they are linked with shunt malfunction, meningitis, seizures, future shunt infection, reduced IQ, and poor school performance. 11