Perioperative management of ventriculoperitoneal shunts during abdominal surgery

Background: Patients with ventriculoperitoneal shunts (VPSs) inserted for a variety of disorders may subsequently undergo gastrointestinal or urologic operations, and surgeons must determine the appropriate perioperative management to minimize the risk for shunt malfunction or infection. There is currently no established set of guidelines for this scenario. The objective of this study was to determine the risks and standard of practice for patients with VPSs undergoing abdominal surgery. Methods: A retrospective review of the charts of patients with VPSs who underwent abdominal or urologic surgery at the Stanford University Medical Center between 1995 and 2003 was performed. Data regarding type of abdominal surgery, level of contamination, choice of antibiotic therapy, perioperative management of the VPS, and outcomes were obtained. Results: Twenty-six patient charts were reviewed, for a total of 39 operations (5 urologic, 23 upper gastrointestinal, and 11 lower gastrointestinal). Of these, 3 were clean, 34 were clean-contaminated, and 2 were dirty operations. Seven cases were laparoscopic, whereas 32 were open. Thirty-four cases required opening the bowel or urologic system. No patient had preoperative shunt externalization. All except one patient received pre- and postoperative antibiotics, but the duration and type of antibiotics were widely variable. The remaining patient had an inguinal hernia repair and received only one preoperative dose of cephalexin. Purulent fluid was found in 2 cases. One VPS found lying in purulent material next to an anastomotic leak was externalized and subsequently revised. However, in another patient, a VPS found lying next to a purulent jejunal tear was not externalized. This patient returned 2 months later with a VPS malfunction. In the remaining 35 cases, no VPS infection or malfunction was noted over 2 to 10 years of follow-up. Conclusions: The data suggest that there is minimal risk for VPS malfunction or infection among patients undergoing routine clean and clean-contaminated abdominal and urologic surgeries. Patients with VPSs undergoing these operations do not need externalization of their shunt. None of the patients in this study had a contaminated procedure. For dirty procedures, surgeons should opt to externalize the shunt. Future studies will aim to better standardize the perioperative management of VPSs during abdominal surgery. (C) 2008 Elsevier Inc. All tights reserved.