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In children with a ventriculoperitoneal (VP) shunt in situ, is shunt externalisation of the abdominal portion mandatory in acute appendicitis?
A boy aged 8 years with a long-term VP shunt presented to the emergency department with right iliac fossa pain, nausea and vomiting. Abdominal ultrasound showed likely appendicitis. We wondered whether, in a child with a VP shunt in situ with appendicitis, the shunt should always be removed and what antibiotic regimen should be used?
PubMed: ‘ventriculoperitoneal’ AND ‘shunt’ AND ‘appendicitis’ OR ‘peritonitis’
Returned 89 results—of these 6 were relevant to our question. Other articles were excluded as they focused on bowel pathologies other than appendicitis, only included patients with primary VP shunt problems and were evaluating different surgical techniques.
This systematic review demonstrates there are only a limited number of cases reported in the literature of children and adults with VP shunts being managed for appendicitis (box 1). The details of each report are very heterogenous making it difficult to draw clear conclusions (Table 1). Each of the studies has limitations. The rarity of these cases results in reports spanning decades during which time many clinical factors are almost certain to have substantially differed. Barina et al1 only included adult cases with no paediatric data. Häussler et al2 include the largest number of cases but give few details on the exact nature of each case or the complications which occurred. A number of the studies did not provide any long-term follow-up. In addition, there is little or no discussion of microbiology results and the consequent antibiotic choices.
The cumulative figures for acute postoperative complications for the included studies
Shunt left in situ
Twelve patients with perforated appendicitis:
Three requiring externalisation.
Two requiring conversion to ventriculoatrial (VA) shunt.
One had shunt ‘discontinued’.
Sixteen patients with non-perforated appendicitis:
One requiring externalisation.
One requiring conversion to VA shunt.
One collection in pouch of Douglas, treated successfully with antibiotics and shunt left in situ.
Shunt pre-emptively removed
Five patients with perforated appendicitis:
One patient pre-emptively switched to VA shunt.
One patient died from Escherichia coli septicaemia and probable ventriculitis.
One patient with non-perforated appendicitis—no complications.
These data suggest the risk of ascending shunt infection is low in non-perforated appendicitis. In cases of perforated appendicitis, the picture is more complicated. Here, the risk of shunt infection and other complications appears higher, although this is predominantly based on the findings of the study by Häussler et al.2 In addition, trying to draw conclusions about the exact cause of complications such as CSF pseudocysts with so many variables not accounted for is exceedingly difficult. In these cases of perforated appendicitis, the risk of developing a shunt infection secondary to peritonitis must also be balanced against the risk of revising the shunt. One meta-analysis by Ramanan et al3 demonstrated an incidence rate of CSF infections for externalised ventricular devices of 11.4 per 1000 catheter days.
The limited data in these studies suggest shunt removal should not be mandatory in patients with appendicitis, particularly if the appendix is not perforated, but needs careful consideration based on the clinical and microbiological findings. There is insufficient data to suggest an empiric antibiotic regimen and thus this should be made on a case-by-case basis in accordance with local protocols and in conjunction with a microbiology or infectious diseases expert.
Clinical bottom line
If the appendix is not perforated the risk of shunt infection is low, therefore, consideration should be given to leaving the original shunt in situ. (Grade C)
While a perforated appendix is not an absolute indication for externalisation of the shunt, clinicians should have a low threshold for externalisation based on the clinical status of the child and the intraoperative findings. (Grade C)
Choice of antibiotics will depend on the results of blood, peritoneal and cerebrospinal fluid (CSF) cultures and should include those with adequate CSF penetration. (Grade D)
Patient consent for publication Not required.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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