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CASE REPORT
Year : 2018  |  Volume : 45  |  Issue : 2  |  Page : 90-92

Abdominal pseudocyst secondary to ventriculoperitoneal shunt along with left staghorn renal calculus management: A rare case report


1 Department of Urology, Sentini Hospital, Vijayawada, Andhra Pradesh, India
2 Department of Radiology, Sentini Hospital, Vijayawada, Andhra Pradesh, India
3 Department of Anaesthesiology, Sentini Hospital, Vijayawada, Andhra Pradesh, India

Date of Web Publication10-Dec-2018

Correspondence Address:
Ajay Kumar Guntaka
Department of Urology, Sentini Hospital, Vijayawada, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.JSS_31_18

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  Abstract 


Abdominal cerebrospinal fluid pseudocyst is an unusual and important complication in patients with ventriculoperitoneal (VP) shunt. Abdominal pseudocyst secondary to long-term (23 years) VP shunt is a rare complication, and associated staghorn calculus presentation is not yet reported in the literature. Herein, we present our management of abdominal pseudocyst with left staghorn calculus removal at the same sitting.

Keywords: Calculus, pseudocyst, ventriculoperitoneal shunt


How to cite this article:
Guntaka AK, Prasad Babu B S, Mutyala AK. Abdominal pseudocyst secondary to ventriculoperitoneal shunt along with left staghorn renal calculus management: A rare case report. J Sci Soc 2018;45:90-2

How to cite this URL:
Guntaka AK, Prasad Babu B S, Mutyala AK. Abdominal pseudocyst secondary to ventriculoperitoneal shunt along with left staghorn renal calculus management: A rare case report. J Sci Soc [serial online] 2018 [cited 2019 May 26];45:90-2. Available from: http://www.jscisociety.com/text.asp?2018/45/2/90/247152




  Introduction Top


Ventriculoperitoneal shunt (VPS) placement is a surgical procedure performed to relieve high intracranial pressure caused by hydrocephalus of diverse etiologies in children and adults.[1] Various extracranial complications of VPS may be seen, such as tube disconnection, infection, omental clogging, abdominal visceral perforation, and bowel obstruction.[1],[2],[3] Abdominal cerebrospinal fluid (CSF) pseudocyst is a rare but important complication of VPS, with its incidence ranging from <0.33% to 6.8%.[1],[2],[3],[4],[5],[6] Abdominal CSF pseudocyst formation in patients with VPS is an unusual complication and commonly presents with abdominal lump/distension in adult patients and with features of raised intracranial pressure in children. Delay in the diagnosis of this complication can lead to a progressive increase in the size of the cyst as it is not lined by epithelium. Hence, no resorption of CSF takes place leading to increased intracystic pressure and malfunctioning of VPS manifested by hydrocephalus and raised intracranial pressure. Cases have been reported in the pediatric age group and very few cases in adults. The presentation of abdominal pseudocyst helped in the identification of staghorn renal calculus, which helped us treat both the things at the same sitting. We present the rare case of a 27-year-old female with abdominal pseudocyst and left staghorn renal calculus management by an open approach which is safer, in the same sitting without any complications.


  Case Report Top


A 27-year-old female presented to our outpatient department services with a lump in the abdomen and pain in the left lumbar region. She gives a history of VPS insertion for tuberculous meningitis with hydrocephalus at 4 years of age. On investigations, ultrasound abdomen and pelvis shows abdominal pseudocyst secondary to the VPS and left staghorn renal calculus. Computed tomography scan [Figure 1] showed a 15 cm × 15 cm × 10 cm abdominal pseudocyst, with left staghorn renal calculus measuring 6 cm × 4 cm with mild hydronephrosis. Hence, the decision of simultaneous management of both pseudocyst excision with left staghorn calculus removal was taken. The patient underwent left 11th rib skin incision after positioning in right semilateral postion [Figure 2]a Pseudocyst wall excised by peritoneal approach [Figure 2]b with the drainage of the pseudocyst fluid (800 ml) [Figure 2]c and placement of the distal end of the VPS tube into the peritoneal cavity with closure of peritoneum, and then the left staghorn calculus removed by open nephrolithotomy [Figure 3]a and [Figure 3]b. Postoperative [Figure 4] X-ray KUB region showing only distal end of VP Shunt and was uneventful.
Figure 1: (a) X-ray kidney, ureter, and bladder showing radio-opaque shadow in the left renal area with the lower end of the ventriculoperitoneal shunt. (b) Computed tomography scan kidney, ureter, and bladder plain showing an abdominal pseudocyst measuring 15 cm × 15 cm × 10 cm with the lower end of the ventriculoperitoneal shunt and left staghorn renal calculus

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Figure 2: (a) Abdomen showing hump due to abdominal pseudocyst. (b) Exploration showing the cyst wall with the lower end of the ventriculoperitoneal shunt. (c) Suction jar showing 800 ml of pseudocyst fluid

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Figure 3: (a) Nephrolithotomy showing renal calculus. (b) Nephrolithotomy closure by 2–0 Vicryl suture material

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Figure 4: Postoperative X-ray kidney, ureter, and bladder showing only the lower end of the ventriculoperitoneal shunt

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  Discussion Top


The use of the peritoneal cavity for CSF absorption in VPS was first introduced in 1908 by Kausch.[7] The most common causes of shunt malfunction are catheter obstruction and infection. The most common distal VPS complications include shunt infection, recurrent ascites, peritoneal cyst, omental cyst, subphrenic or lesser sac loculation, mesenteric cyst, subcutaneous collection, incisional hernia, intestinal volvulus, and intestinal perforation.[8] Malfunction of the ventriculoperitoneal shunt after initial placement occurs in approximately 25–35% of patients at 1 year [9] and 70–80% of patients require at least one revision at some point in their lives.[10] Peritoneal CSF pseudocyst formation is an unusual complication, with reported incidence of <1.0%–4.5%.[8],[5] An abdominal CSF pseudocyst was first described by Harsh in 1954.[11] The wall of the pseudocyst is composed of fibrous tissue or an inflamed serosal surface without an epithelial lining and is filled with CSF and debris.[8] Elevated intracranial pressure and abdominal pain is the most common presentation of an abdominal CSF pseudocyst in children, whereas abdominal pain, lump, and distension predominate in adults.[8] Treatment of pseudocysts is highly variable and there is no established standard; therefore, the method of treatment should be tailored to the overall clinical picture. Treatment options include percutaneous drainage of the pseudocyst with distal repositioning of peritoneal catheter (open or laparoscopic), placement of distal catheter in an alternative location such as the contralateral abdomen, the pleural space or the right atrium, and endoscopic third ventriculostomy with the removal of shunt hardware completely.[12],[13],[14],[15]


  Conclusion Top


This report described a rare adult case of a giant abdominal pseudocyst as a long-term (23 years) complication of VPS along with staghorn renal calculus management by open approach in the same sitting without any postoperative complications. Not only neurosurgeons but also physicians should be aware of this possible complication because early diagnosis and treatment would improve the clinical outcome and reduce the patient's suffering and distress.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sena FG, Sousa RM, Meguins LC. Abdominal cerebrospinal fluid pseudocyst: A complication of ventriculoperitoneal shunt in a Brazilian amazon woman. Case report. G Chir 2010;31:371-3.  Back to cited text no. 1
    
2.
Pernas JC, Catala J. Case 72: Pseudocyst around ventriculoperitoneal shunt. Radiology 2004;232:239-43.  Back to cited text no. 2
    
3.
Leung GK. Abdominal cerebrospinal fluid (CSF) pseudocyst presented with inferior vena caval obstruction and hydronephrosis. Childs Nerv Syst 2010;26:1243-5.  Back to cited text no. 3
    
4.
Aparici-Robles F, Molina-Fabrega R. Abdominal cerebrospinal fluid pseudocyst: A complication of ventriculoperitoneal shunts in adults. J Med Imaging Radiat Oncol 2008;52:40-3.  Back to cited text no. 4
    
5.
Oh A, Wildbrett P, Golub R, Yu LM, Goodrich J, Lee T, et al. Laparoscopic repositioning of a ventriculo-peritoneal catheter tip for a sterile abdominal cerebrospinal fluid (CSF) pseudocyst. Surg Endosc 2001;15:518.  Back to cited text no. 5
    
6.
Pathi R, Sage M, Slavotinek J, Hanieh A. Abdominal cerebrospinal fluid pseudocyst. Australas Radiol 2004;48:61-3.  Back to cited text no. 6
    
7.
Kausch W. Die Behandlung des Hydrocephalus der kleinen Kinder. Arch Kiln Chir 1908;87:709-96.  Back to cited text no. 7
    
8.
Sharma AK, Pandey AK, Diyora BD, Mamidanna R, Sayal PP, Ingale HA. Abdominal CSF pseudocyst in a patient with ventriculo-peritoneal shunt. Indian J Surg 2004;66:360-3.  Back to cited text no. 8
    
9.
Vinchon M, Fichten A, Delestret I, Dhellemmes P. Shunt revision for asymptomatic failure: Surgical and clinical results. Neurosurgery 2003;52:347-53.  Back to cited text no. 9
    
10.
Blount JP, Campbell JA, Haines SJ. Complications in ventricular cerebrospinal fluid shunting. Neurosurg Clin N Am 1993;4:633-56.  Back to cited text no. 10
    
11.
Harsh GR 3rd. Peritoneal shunt for hydrocephalus, utilizing the fimbria of the fallopian tube for entrance to the peritoneal cavity. J Neurosurg 1954;11:284-94.  Back to cited text no. 11
    
12.
de Oliveira RS, Barbosa A, Vicente YA, Machado HR. An alternative approach for management of abdominal cerebrospinal fluid pseudocysts in children. Childs Nerv Syst 2007;23:85-90.  Back to cited text no. 12
    
13.
Mobley LW 3rd, Doran SE, Hellbusch LC. Abdominal pseudocyst: Predisposing factors and treatment algorithm. Pediatr Neurosurg 2005;41:77-83.  Back to cited text no. 13
    
14.
Moussa WM, Mohamed MA. Efficacy of postoperative antibiotic injection in and around ventriculoperitoneal shunt in reduction of shunt infection: A randomized controlled trial. Clin Neurol Neurosurg 2016;143:144-9.  Back to cited text no. 14
    
15.
Yuh SJ, Vassilyadi M. Management of abdominal pseudocyst in shunt-dependent hydrocephalus. Surg Neurol Int 2012;3:146.  Back to cited text no. 15
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