Medical Journal of Dr. D.Y. Patil Vidyapeeth

REVIEW ARTICLE
Year
: 2022  |  Volume : 15  |  Issue : 5  |  Page : 629--659

Systematic literature review of the management of transanal extrusion of distal ventriculoperitoneal shunt catheter: 1966–2020


Rajendra K Ghritlaharey 
 Department of Pediatric Surgery, Gandhi Medical College and Associated Kamla Nehru and Hamidia Hospitals, Bhopal, Madhya Pradesh, India

Correspondence Address:
Rajendra K Ghritlaharey
Department of Pediatric Surgery, Gandhi Medical College and Associated Kamla Nehru and Hamidia Hospitals, Bhopal - 462 001, Madhya Pradesh
India

Abstract

Perforation of the colon with or without transanal extrusion of the distal ventriculoperitoneal shunt (VPS) catheter is a well-known but a serious complication after VPS insertion done for the treatment of hydrocephalus. The objectives were to review the demographics, clinical characteristics, operative procedures performed, postoperative complications, and the final outcome of the published cases, relating to the transanal extrusion of the distal VPS shunt catheter. Electronic database search was performed to retrieve the published/available literature relating to the transanal extrusion of VPS catheter. The manuscripts relating to the above-mentioned complication were retrieved from 1966 to December 2020. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines are followed for this review. This review included 210 cases comprising 142 (67.6%) males and 68 (32.3%) females. In two-third (n = 141) of the cases, the indication for the initial VPS insertion was the congenital hydrocephalus. In 60% of the cases, the initial VPS insertion was done during infancy. In 70% of the cases, the interval from VPS insertion to the diagnosis of transanal extrusion of the distal VPS catheter was within 12 months. Transanal extrusion of the distal VPS catheter was the chief complaint. In two-third of the cases, it was asymptomatic transanal extrusion of distal VPS catheter. In remaining one-third of the cases, it was symptomatic transanal extrusion of the distal VPS catheter, and they had either symptoms relating to the central nervous system or gastrointestinal tract. Three-fourth of the cases were managed by the removal of the entire or the distal VPS catheter with or without external ventricular drainage (EVD). Fifty percent of the above-mentioned complication was managed by doing percutaneous surgical procedures, and another one-third of them were managed by doing laparotomy. Complications were also evident in 16 (7.6%) of the cases during the postoperative period. This review revealed only 6 (2.8%) deaths. Transanal extrusion of the distal VPS catheter occurred across all the age groups. Eighty percent of the complications occurred in children below the age of 10 years. Three-fourth of the cases were managed by the removal of the entire or distal VPS catheter with or without EVD. In three-fourth of the cases, repair of the perforated bowel/colon was not done and that healed spontaneously after the removal of the extruded VPS catheter.



How to cite this article:
Ghritlaharey RK. Systematic literature review of the management of transanal extrusion of distal ventriculoperitoneal shunt catheter: 1966–2020.Med J DY Patil Vidyapeeth 2022;15:629-659


How to cite this URL:
Ghritlaharey RK. Systematic literature review of the management of transanal extrusion of distal ventriculoperitoneal shunt catheter: 1966–2020. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 Dec 7 ];15:629-659
Available from: https://www.mjdrdypv.org/text.asp?2022/15/5/629/339382


Full Text



 Introduction



Ventriculoperitoneal shunt (VPS) insertion is a well-accepted and the most frequently performed surgical procedure for the management of hydrocephalus across all age groups.[1],[2],[3],[4] VPS insertion is though a simple procedure associated with wide varieties of complications, and many of the complications require shunt revision.[2],[3],[4],[5] Perforation of the hollow viscera by the VPS catheter, followed by the extrusion of the distal VPS catheter through the natural orifices, is a known but serious complication after the VPS insertion.[5],[6],[7] Perforation and migration of the distal VPS catheter into the urinary bladder with or without perurethral extrusion of the distal VPS catheter have been reported in n = 41 isolated case reports to date.[7],[8] Transoral extrusion of the distal VPS catheter has also been reported in n = 27 isolated cases to date.[6],[9] Perforation of the colon, followed by the transanal extrusion of the distal VPS catheter, is more frequent and reported in 0.1%–2.5% of the cases.[5],[10],[11] This manuscript is a systematic review of the literature to highlight the demographics, clinical characteristics, surgical management, postoperative complications, and the final outcome of the cases of the transanal extrusion of the distal VPS catheter.[5],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60],[61],[62],[63],[64],[65],[66],[67],[68],[69],[70],[71],[72],[73],[74],[75],[76],[77],[78],[79],[80],[81],[82],[83],[84],[85],[86],[87],[88],[89],[90],[91],[92],[93],[94],[95],[96],[97],[98],[99],[100],[101],[102],[103],[104],[105],[106],[107],[108],[109],[110],[111],[112],[113],[114],[115],[116],[117],[118],[119],[120],[121],[122],[123],[124],[125],[126],[127],[128],[129],[130],[131],[132],[133],[134],[135],[136],[137],[138],[139],[140],[141],[142],[143],[144],[145],[146],[147],[148],[149],[150],[151],[152],[153],[154],[155],[156],[157],[158],[159],[160],[161],[162],[163],[164],[165],[166]

 Materials and Methods



Present manuscript is a systematic review of the published literature on the management of trans-anal extrusion of the distal VPS catheter. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines are followed for this systematic review. PubMed, Medline, PubMed Central, Goggle Scholar, Google Images, and ResearchGate electronic database, online search was performed to retrieve the published/available literature relating to the transanal extrusion of the distal VPS catheter. The keywords employed during online database search were “trans-anal extrusion of ventriculoperitoneal shunt catheter,” trans-rectal extrusion of ventriculoperitoneal shunt catheter,” “anal/rectal protrusion of ventriculoperitoneal shunt catheter,” “extrusion/protrusion of peritoneal shunt catheter,” “colon perforation by ventriculoperitoneal shunt catheter,” “visceral perforation by ventriculoperitoneal shunt catheter,” “distal migration of ventriculoperitoneal shunt catheter,” and “rare/unusual complication of ventriculoperitoneal shunt catheter.” Literature/manuscripts relating to the above-mentioned complication were retrieved from 1966 to December 2020. Manuscripts' selection for present review was done by assessing the titles, abstracts, and full text of the manuscripts. Selection of the manuscripts and extraction of the desired information from the manuscripts were done independently by the author alone. Literature/case reports retrieved in language other than English were also included for the present review and were translated to the English language using “Google translator” and the desired details were extracted. Case reports/literature relating to the perforation of the colon and migration of the distal VPS catheter within the colon but without transanal extrusion were excluded from the review. Cases/literature with incomplete desired details, conference proceedings, and unpublished data retrieved during the online search relating to the above complications were also excluded from the review. Published case reports/case series on the management of transanal extrusion of the distal VPS catheter were reviewed for their demographics, indication for the initial VPS insertion, interval from the initial VPS insertion/last VPS revision to the diagnosis of transanal extrusion of the distal VPS, clinical characteristics, diagnostic modalities used, surgical procedures performed, postoperative complications, and the final outcome of the above cases. For the cases that required VPS revision(s) in the past, the interval was calculated from the last VPS revision to the time of diagnosis of transanal extrusion of the distal VPS catheter. Present manuscript is a review of the already published manuscripts, and institutional ethical committee approval is not required.

 Results



Wilson and Bertan first time in 1966 published two cases of perforation of the bowel with passage of the peritoneal catheter as a complication of peritoneal shunt used for the treatment of hydrocephalus.[12] They reported two infants; both of them presented with a history of the passage of the peritoneal catheter during the bowel movement. In one of the infant, transanal passage of the peritoneal catheter was associated with intestinal obstruction and peritonitis, required laparotomy for the management, and he died during the postoperative period. Another child, transanal passage of the peritoneal catheter was not associated with symptoms or signs of peritonitis, intestinal obstruction, or meningitis, and she required only an observation and she survived. The shunt implanted in both of the cases was “lumber subarachnoid-peritoneal shunt” (lumber-peritoneal shunt/spinal-peritoneal shunt), and the transanal passage of the peritoneal catheter was of above shunt and not peritoneal catheter of the VPS, and therefore, both of the above cases were neither listed in [Table 1] nor included for the review.[12] Published literature/manuscripts of the 260 cases relating to the management of transanal extrusion of the distal VPS catheter were retrieved during the electronic database search from 1966 to December 2020 and the details are provided in [Figure 1]. Eighty percent (n = 210) of the cases were reported/published during the last two decades from 2001 to 2020. Fifty-six percent (n = 146) of the cases were published during the last 10 years from 2011 to 2020. Results of the electronic database search for the manuscripts relating to the management of the transanal extrusion of the distal VPS catheter are provided as PRISMA flow diagram and detailed in [Figure 2]. Among 260 cases, 210 were selected for the present review and remaining 50 were excluded due to the incomplete details. The desired details for the above 210 cases were retrieved from the 156 manuscripts.[10],[11],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60],[61],[62],[63],[64],[65],[66],[67],[68],[69],[70],[71],[72],[73],[74],[75],[76],[77],[78],[79],[80],[81],[82],[83],[84],[85],[86],[87],[88],[89],[90],[91],[92],[93],[94],[95],[96],[97],[98],[99],[100],[101],[102],[103],[104],[105],[106],[107],[108],[109],[110],[111],[112],[113],[114],[115],[116],[117],[118],[119],[120],[121],[122],[123],[124],[125],[126],[127],[128],[129],[130],[131],[132],[133],[134],[135],[136],[137],[138],[139],[140],[141],[142],[143],[144],[145],[146],[147],[148],[149],[150],[151],[152],[153],[154],[155],[156],[157],[158],[159],[160],[161],[162],[163],[164],[165],[166] Desired details for the 196 cases were extracted from the 144 full-text manuscripts.[10],[11],[13],[14],[18],[20],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[41],[43],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60],[61],[62],[63],[65],[66],[67],[68],[69],[70],[71],[72],[73],[74],[75],[76],[77],[78],[79],[80],[81],[82],[83],[84],[85],[86],[87],[88],[89],[90],[91],[92],[93],[94],[95],[96],[97],[98],[99],[100],[101],[103],[104],[105],[106],[107],[108],[109],[110],[111],[112],[113],[114],[115],[116],[117],[118],[120],[121],[122],[123],[124],[125],[126],[127],[128],[129],[130],[131],[132],[133],[134],[135],[136],[137],[138],[139],[140],[141],[142],[143],[144],[145],[146],[147],[148],[149],[150],[151],[152],[153],[154],[155],[156],[157],[158],[159],[160],[161],[162],[163],[164],[165],[166] Desired details for the 14 of the cases were also extracted from the 12 abstracts.[15],[16],[17],[19],[21],[40],[42],[44],[64],[102],[119] This review also included one similar case managed by the author in 2020. To date, she is doing well, and the same is also included in [Table 1] (Case No. 210/present case).{Table 1}{Figure 1}{Figure 2}

The total number of manuscripts included/reviewed for systematic review is n = 156.[10],[11],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60],[61],[62],[63],[64],[65],[66],[67],[68],[69],[70],[71],[72],[73],[74],[75],[76],[77],[78],[79],[80],[81],[82],[83],[84],[85],[86],[87],[88],[89],[90],[91],[92],[93],[94],[95],[96],[97],[98],[99],[100],[101],[102],[103],[104],[105],[106],[107],[108],[109],[110],[111],[112],[113],[114],[115],[116],[117],[118],[119],[120],[121],[122],[123],[124],[125],[126],[127],[128],[129],[130],[131],[132],[133],[134],[135],[136],[137],[138],[139],[140],[141],[142],[143],[144],[145],[146],[147],[148],[149],[150],[151],[152],[153],[154],[155],[156],[157],[158],[159],[160],[161],[162],[163],[164],[165],[166] Manuscripts published in the English language are n = 137.[10],[11],[13],[14],[15],[16],[17],[19],[20],[21],[22],[23],[24],[25],[26],[27],[29],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[43],[44],[45],[49],[50],[51],[52],[53],[54],[55],[56],[58],[59],[60],[61],[62],[63],[64],[65],[66],[67],[69],[70],[72],[73],[74],[75],[76],[77],[78],[79],[80],[81],[82],[83],[84],[86],[87],[89],[90],[91],[92],[93],[94],[95],[96],[97],[98],[99],[100],[101],[102],[104],[105],[107],[108],[109],[110],[111],[112],[113],[114],[115],[116],[117],[119],[120],[121],[122],[123],[124],[125],[126],[127],[128],[129],[130],[131],[132],[133],[134],[135],[136],[137],[138],[139],[140],[141],[142],[143],[144],[145],[146],[148],[149],[150],[152],[153],[154],[155],[157],[158],[159],[160],[161],[162],[163],[164],[165],[166] Manuscripts published in languages other than the English are n = 19.[18],[28],[30],[42],[46],[47],[48],[57],[68],[71],[81],[85],[88],[103],[106],[118],[147],[151],[156] Among 156 manuscripts selected for the retrieval of the desired details, 124 of the manuscripts detailed the isolated case.[13],[15],[17],[18],[19],[20],[22],[23],[26],[27],[28],[29],[30],[32],[33],[35],[36],[38],[39],[40],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[59],[60],[61],[62],[64],[65],[66],[67],[69],[71],[72],[73],[74],[75],[76],[77],[78],[79],[80],[81],[82],[83],[85],[86],[87],[89],[90],[91],[92],[93],[94],[96],[97],[98],[99],[100],[101],[102],[104],[105],[106],[107],[108],[109],[110],[111],[112],[115],[116],[117],[118],[119],[120],[121],[122],[123],[124],[125],[126],[127],[128],[129],[130],[132],[133],[134],[136],[137],[138],[140],[141],[142],[143],[145],[146],[147],[149],[150],[151],[152],[153],[154],[155],[157],[158],[160],[161],[162],[163],[164] Twenty of the manuscripts described/included two cases.[14],[21],[25],[31],[34],[41],[57],[58],[68],[70],[84],[95],[103],[113],[135],[139],[148],[156],[159],[165] Nine of the manuscripts included 3–5 cases.[16],[24],[37],[63],[88],[114],[131],[144],[166]

Two of the manuscripts included 6–10 cases on the management of transanal extrusion of the distal VPS catheter.[10],[11] Transanal extrusion of the distal part of the dural-peritoneal shunt/subdural-peritoneal shunt (DPS) and cysto-peritoneal shunt (CPS) has also been reported. This review also included n = 6 cases of transanal extrusion of the distal catheter of DPS, and n = 3 cases of transanal extrusion of the distal catheter of CPS for the present review.[31],[42],[52],[71],[81],[86],[89],[141],[146]

Demographics and clinical details of 210 cases included for the review and were published on the management of transanal extrusion of the distal VPS catheter are detailed in [Table 1]. In [Table 1], cases are presented in descending order, i.e., in the order of publication. This review included a total of 210 cases comprising 142 (67.6%) males and 68 (32.3%) females with a male-to-female ratio of 2.08:1. Indications for the initial VPS insertion for the entire cases are provided in [Figure 3]. Distribution of the age of the cases at the initial VPS insertion is detailed in [Figure 4]. Distribution of the age at the time of diagnosis of the transanal extrusion of the distal VPS catheter is detailed in [Figure 5]. The interval from the initial VPS insertion/last shunt revision to the diagnosis of the transanal extrusion of the distal VPS catheter for entire cases is detailed in [Figure 6].{Figure 3}{Figure 4}{Figure 5}{Figure 6}

Transanal extrusion of the distal VPS catheter was the chief complaint and clinical finding. In two-third (n = 142) of the cases, it was asymptomatic transanal extrusion of distal VPS catheter, and there were neither features of meningitis nor peritonitis.[10],[11],[13],[14],[15],[20],[21],[24],[25],[26],[30],[31],[32],[35],[36],[37],[40],[41],[42],[44],[45],[47],[48],[50],[53],[54],[56],[57],[58],[59],[60],[62],[63],[65],[69],[70],[71],[72],[73],[74],[75],[76],[77],[78],[79],[82],[84],[85],[86],[87],[88],[89],[90],[92],[93],[94],[95],[96],[98],[100],[101],[103],[104],[105],[106],[107],[108],[110],[112],[115],[117],[119],[121],[122],[124],[123],[124],[125],[126],[127],[129],[131],[132],[133],[134],[135],[136],[137],[138],[139],[142],[143],[144],[145],[146],[147],[148],[151],[152],[155],[157],[159],[160],[161],[163],[165],[166] Remaining one-third (n = 68) of the cases were symptomatic transanal extrusion of the distal VPS catheter, and they had either symptoms relating to central nervous system (CNS) or gastrointestinal tract (GIT). Among 68 symptomatic cases, 35 (16.66%) of them had symptoms related to the CNS along with transanal extrusion of distal VPS catheter.[16],[17],[18],[19],[22],[23],[27],[28],[31],[33],[34],[37],[39],[43],[49],[58],[61],[66],[67],[68],[70],[81],[88],[95],[97],[102],[103],[118],[120],[130],[141],[150],[162],[164],[166] Another 33 (15.71%) symptomatic cases presented with transanal extrusion of distal VPS catheter with additional symptoms related to the GIT.[11],[16],[24],[29],[38],[46],[51],[52],[55],[58],[64],[80],[83],[91],[99],[109],[111],[116],[120],[123],[128],[140],[153],[154],[156],[158] During the clinical examination, transanal extrusion of the distal VPS catheter was evident in 180 (85.71%) of the cases.[10],[11],[15],[16],[17],[18],[19],[20],[21],[22],[24],[25],[26],[27],[28],[29],[31],[33],[34],[35],[37],[40],[41],[42],[43],[44],[46],[47],[48],[49],[50],[54],[55],[56],[57],[58],[60],[62],[63],[64],[65],[66],[67],[68],[70],[73],[74],[75],[77],[78],[79],[80],[81],[82],[83],[84],[85],[86],[87],[88],[91],[92],[93],[94],[95],[96],[97],[98],[99],[100],[101],[102],[103],[104],[106],[107],[109],[110],[111],[112],[113],[114],[115],[116],[117],[118],[119],[120],[121],[122],[123],[124],[125],[126],[127],[129],[131],[132],[133],[134],[135],[136],[137],[138],[139],[140],[141],[142],[143],[144],[145],[146],[147],[148],[149],[150],[151],[152],[153],[155],[156],[157],[158],[159],[160],[161],[162],[163],[164],[165],[166] In 18 (8.57%) of the cases, the transanal extrusion of the distal VPS catheter was not evident, neither during the clinical examination nor on per-rectal digital examination, and it was retracted back into the colon.[23],[30],[31],[39],[45],[52],[53],[59],[69],[76],[83],[90],[105],[120],[128],[130],[154],[161] In another 10 (4.76%) of the cases, the distal VPS catheter had already passed per-rectum and not evident during the clinical examination.[13],[14],[32],[36],[38],[51],[61],[71],[162] At two of the occasion, the distal transanal protruded part of the VPS catheter was cut out by the parents and also not evident during the clinical examination.[89],[108] Clinical features were evident for the meningitis in 22 (10.47%) of the cases.[16],[18],[19],[27],[28],[34],[37],[43],[58],[61],[63],[67],[68],[69],[70],[81],[88],[95],[102],[103],[130],[166] In another 29 (13.8%) of the cases, their cerebrospinal fluid (CSF) was positive for bacterial infection, but none of the above cases had features of meningitis.[17],[18],[19],[23],[31],[33],[39],[57],[63],[68],[69],[72],[76],[77],[78],[83],[101],[103],[118],[120],[130],[136],[150],[152],[154],[164] Clinical features of peritonitis were evident only in 8 (3.8%) of the cases.[16],[29],[58],[83],[140] Associated neural tube defects (NTDs) were also documented in n = 34 (16.19%) of the cases, and they were myelomeningocele, encephalocele, and other spinal deformities.[10],[13],[14],[24],[26],[37],[41],[48],[61],[68],[73],[74],[75],[77],[88],[90],[101],[109],[112],[114],[118],[124],[131],[138],[157],[159] In one-fifth (n = 44) of the cases, their VPS catheters were also revised in the past for various complications related to the VPS.[13],[15],[16],[22],[24],[31],[36],[44],[46],[48],[50],[53],[55],[59],[68],[69],[71],[77],[86],[87],[88],[90],[93],[96],[103],[108],[109],[110],[113],[116],[125],[126],[127],[131],[133],[138],[139],[142],[149],[159],[166]

Clinical diagnosis of transanal extrusion of the distal VPS catheter in most of the cases was obvious due to the classical history and presence of the distal VPS catheter protruding out of the anus. Plain skiagram of the abdomen and chest including head (shunt series) and the ultrasonography (USG) of the abdomen were the most common radiological investigations ordered for the confirmation of the VPS catheter continuity and abdominal fluid collection or gas under the diaphragm. Other radiological investigations ordered by the authors were computed tomography (CT) scan of the head and abdomen. CT scan of the head was ordered during the course of investigation for one-fifth (n = 43) of the cases.[20],[22],[27],[49],[57],[62],[63],[65],[66],[76],[77],[79],[81],[91],[92],[94],[95],[97],[98],[103],[104],[105],[117],[120],[122],[124],[125],[128],[131],[132],[137],[141],[145],[150],[151],[152],[155],[156],[157],[160],[164] CT scan of the abdomen was also ordered for 25 (11.9%) of the cases.[45],[47],[55],[76],[77],[83],[86],[87],[89],[90],[96],[97],[107],[108],[109],[111],[116],[126],[130],[138],[151],[153],[154],[162],[163]

Operative procedures executed for management of transanal extrusion of the distal VPS catheter are detailed in [Table 1] and [Figure 7]. Fifty percent (n = 106) of the cases were managed by using percutaneous incision(s). Skin incision was preferably given at the scalp over the cranial site of the shunt with or without another abdominal skin incision. The VPS catheter was divided into two parts. The distal transanal protruded part was gently pulled distally and removed while the ventricular catheter/proximal catheter either removed or kept as an EVD.[10],[13],[14],[16],[17],[18],[19],[21],[22],[27],[28],[31],[32],[34],[37],[41],[42],[43],[45],[49],[57],[58],[61],[62],[63],[66],[67],[70],[74],[75],[81],[82],[84],[85],[88],[90],[91],[94],[95],[98],[100],[102],[103],[104],[112],[113],[114],[121],[123],[124],[125],[126],[127],[129],[130],[131],[132],[134],[135],[137],[139],[141],[142],[143],[144],[145],[147],[150],[152],[153],[154],[155],[158],[159],[160],[163],[165],[166, present case] One-third (n = 69) cases of transanal extrusion of the distal VPS catheter were managed by doing laparotomies. Formal laparotomies were performed for the management of n = 59 cases, while mini-laparotomies were done for 10 of the cases. During the formal abdominal exploration, most of the authors revealed that there were fibrous tissues around the VPS catheter.[10],[11],[15],[16],[20],[21],[23],[25],[26],[29],[30],[33],[35],[44],[46],[48],[52],[54],[58],[59],[60],[64],[68],[69],[72],[73],[77],[78],[80],[87],[92],[93],[96],[97],[99],[107],[108],[110],[111],[118],[119],[120],[122],[128],[133],[138],[146],[148],[149],[156],[157],[161],[164] Endoscopic procedures (colonoscopic) were done for the management of above complication in 15 (7.14%) of the cases.[40],[47],[53],[55],[56],[65],[76],[79],[83],[84],[89],[105],[117],[136] In 6 (2.85%) of the cases, their distal VPS catheters were retrieved by per-rectal maneuver.[24],[50],[86],[115] Laparoscopic procedures were done in six of the cases for the management of above-mentioned complication.[101],[106],[109],[116],[131],[151] Operative procedures not required in five of the cases, as their distal VPS catheter had already passed per-rectally.[36],[38],[51],[71],[162] In two of the cases, operative procedures could not be done as parents of the child refused for further surgical interventions.[95],[140] In one of the cases, the operative details were not available.[39] Two of the cases had perforation of the appendix by the VPS catheter and trans-anal extrusion of distal VPS catheter.[122],[153] One of cases had ileal perforation and transanal extrusion of the distal VPS catheter.[29]{Figure 7}

Postoperative complications were also documented in 16 (7.6%) of the cases and were, meningitis (n = 4), brain abscesses (n = 4), abdominal abscess (n = 2), peritonitis (n = 1), intestinal obstruction (n = 1), transanal extrusion of distal VPS catheter (n = 1), CSF leak from old abdominal wound site (n = 1), CSF abdominal pseudocyst (n = 1), and pleural effusion (n = 1).[13],[27],[33],[44],[49],[54],[57],[63],[67],[70],[77],[106],[138],[141],[149],[164] Above cases required additional surgical procedures for the management of their complications. Two of the child's parents refused further surgical procedure and their complication could not be treated further.[49],[95] This review also documented 6 (2.85%) deaths.[13],[17],[54],[63],[67],[106]

 Discussion



Sells et al. in 1973 reported a 3-year-old girl with a history of passage of the distal VPS catheter twice in four months. Each time, she was asymptomatic and not required laparotomy and her complication was managed with VPS revisions. Initially, she was treated with myelomeningocele excision and ventriculoatrial (VA) shunt for the hydrocephalus. Her VPS was inserted following the four unsuccessful VA shunt procedures. She further required four VPS revisions during the next 30 months for the VPS-related complications. She was well for the next 8 months, after that, she was diagnosed with subhepatic abscess and VPS catheter obstruction and was treated with removal of her VPS catheter, drainage of peritoneal abscess, and ventriculostomy, but she died 3 weeks later due to the above complication. Her postmortem examination revealed multiple intraperitoneal abscesses and acute peritonitis but not evident bowel perforation.[13]

Perforation of the colon by the distal VPS catheter is reported to occur in 0.1%–2.5% of the cases. Many of the cases of bowel perforation by the distal VPS catheter presented with the transanal extrusion of the distal VPS catheter.[5],[10],[11] Grosfeld et al. reviewed 185 infants and children with VPS insertion done for the treatment of hydrocephalus during the period 1969–1973. They found that VPS catheter had perforated the colon in five of the children. In 2 (1.08%) of the cases, the distal VPS catheter had passed per-rectally.[14] Vinchon et al. in a retrospective review of the cases of bowel perforation by the peritoneal catheter of the VPS in a series of 1956 with a mean follow-up period of 10 years. They found that 3 (0.15%) of the cases reported with the per-rectal extrusion of the distal VPS catheter.[63] Ghritlaharey et al. in a review of 398 cases of VPS insertion done in children for the treatment of hydrocephalus and documented that 10 (2.51%) of them presented with the transanal extrusion of the distal VPS catheter.[10] Ahmed et al., in a retrospective analysis of 50 children with VPS insertion done for the management hydrocephalus, evident that 3 (6%) of them presented with transrectal extrusion of the distal VPS catheter.[167] Ghritlaharey et al. in another study included 236 cases of VPS insertions done in children under the age of 12 years during the period 2006–2010. They found that 5 (2.1%) of them presented with transanal extrusion of the distal VPS catheter.[5] Thiong'o et al. observed that 2 (1.01%) of their cases presented with transanal extrusion of the distal VPS catheter among 197 VPS insertion done in children during January 2011 to April 2014.[113] Biluts et al. in a prospective cohort study observed that 1 (0.9%) of their case presented with the extrusion of the distal VPS catheter through the anus among 141 VPS insertions done in 114 children ≤12 years.[168] Sekhar et al., in a retrospective study of approximately 750 VPS implantation done during the period from May 2000 to April 2015, documented that 3 (0.4%) of the children presented with transanal protrusion of the distal VPS catheter.[169] Ezzat et al. revealed that 6 (0.5%) of their cases presented with the transanal extrusion of the distal VPS catheter among the 1092 VPS insertions done in children below the age of 12 years.[11] Pan, in a retrospective study of 137 children with VPS implantation done for the hydrocephalus, found that 2 (1.4%) of them presented with transanal extrusion of the distal VPS catheter in the follow-up period.[170] Hamdan in a retrospective study documented that 2 (0.9%) of their cases presented with transanal extrusion of the distal VPS catheter among 205 VPS insertions done over a period of 5 years.[171]

Present review documented that the transanal extrusion of the distal VPS catheter occurred more in male, n = 142 (67.6%). This finding is probably due to the fact that VPS insertions are done more in male, especially in children. Some of the studies also reported that VPS insertions were dome more in males than in females. Grosfeld et al. reported that 54% of the VPS insertions done in children were boys.[14] Ahmed et al. in a prospective analysis reported that 56% of the VPS insertion was done in boys.[167] Ghritlaharey et al. in a retrospective review of 236 cases of VPS insertion done in children and revealed that 65% of the cases were boys.[5] Hamdan, in a retrospective study of VPS insertion done, documented that more than 73% of the cases were male.[171] Pan, in a retrospective study of children with VPS implantation done for the treatment hydrocephalus, also documented that 56.9% of the cases were male.[170]

The age of the cases at the time of initial VPS catheter insertion ranged from 1 day to 85 years.

This review revealed that 60% (n = 126) of the cases were infants at the time of initial VPS insertion.[10],[11],[13],[15],[17],[18],[21],[22],[24],[25],[26],[27],[28],[30],[31],[32],[34],[35],[36],[37],[39],[41],[44],[46],[48],[49],[53],[54],[55],[57],[58],[60],[62],[63],[68],[71],[73],[74],[75],[77],[78],[82],[83],[84],[88],[90],[92],[94],[96],[98],[99],[100],[101],[102],[103],[104],[106],[107],[108],[109],[110],[112],[113],[114],[115],[116],[117],[118],[119],[121],[122],[123],[125],[126],[127],[129],[131],[132],[133],[135],[138],[140],[141],[143],[144],[146],[147],[148],[150],[152],[154],[155],[157],[159],[160],[164],[166, present case] One-fifth (n = 41) of the cases were 2–5 years of the age at the time of initial VPS insertion.[10],[11],[16],[23],[29],[34],[37],[38],[43],[52],[61],[65],[70],[72],[81],[84],[85],[89],[91],[95],[103],[105],[120],[124],[139],[142],[145],[149],[161],[165],[166] Fifteen (7.14%) of the cases were 31–60 years of the age at the time of VPS insertion.[42],[45],[51],[56],[66],[69],[76],[80],[136],[151],[153],[156],[158],[163] The findings of a greater number of transanal extrusion of the distal VPS catheter during infancy is probably due to the fact that VPS insertions are done more frequently during the infancy. Ahmed et al., in a retrospective outcome analysis of children who had received VPS for the treatment of hydrocephalus, documented that 76% of the VPS insertions were done during infancy.[167] Ghritlaharey et al., in a retrospective study of 236 children under the age of 12 years, revealed that 61% of the VPS insertions were done in infants.[5] Biluts et al., in a prospective cohort study of outcome for VPS insertions done in children ≤12 years, evident that 71% of the VPS insertions were done in infants.[168] Pan in a study in children also documented that three-fourth of the VPS insertions were done during infancy.[170]

Congenital hydrocephalus was the most common indication for the placement of VPS catheter, and it was documented in two-third (n = 141) of the cases included for the present review.[10],[11],[13],[14],[15],[16],[17],[18],[20],[21],[22],[23],[24],[25],[26],[27],[28],[30],[31],[34],[35],[36],[37],[41],[43],[44],[46],[48],[50],[52],[55],[57],[58],[60],[61],[62],[63],[64],[68],[70],[73],[74],[75],[77],[81],[82],[84],[85],[88],[90],[91],[92],[94],[96],[97],[98],[99],[100],[101],[102],[103],[104],[107],[108],[109],[110],[112],[113],[114],[115],[117,[118],[119],[121],[122],[123],[124],[125],[126],[128],[129],[131],[133],[134],[135],[138],[139],[140],[142],[143],[144],[147],[148],[149],[150],[155],[157],[159],[160],[161],[165],[166,present case] Other causes of hydrocephalus that required VPS insertion in order of frequency were hydrocephalus due to brain tumor (n = 16), meningitis/infection (n = 14), head trauma (n = 12), tubercular meningitis (n = 11), ventricular hemorrhage in children (n = 6), and others. In the present review, the finding of a greater number of the initial VPS insertions was done for the congenital hydrocephalus, and it may be due to the fact that in children, the most common indication for VPS insertion is hydrocephalus relating to the congenital pathology, and similar findings were also reported by various authors. Grosfeld et al. reviewed 185 infants and children with VPS insertion and documented that 50% of the cases of hydrocephalus were due to congenital nature and associated with NTD as well.[14] Ghritlaharey et al. in a retrospective review of 398 cases and documented that more than 65% of the VPS implantations were done for the hydrocephalus of the congenital origin.[10] Ahmed et al., in a retrospective analysis of 50 children, documented that more than 70% of the VPS insertions were done for congenital hydrocephalus.[167] Ghritlaharey et al., in retrospective study of 236 cases of VPS insertions done in children, documented that more than 60% of the VPS insertions were done for the cases of hydrocephalus with congenital pathology.[5] Biluts et al., in a cohort study of outcome for 141 VPS insertions done in 114 children ≤12 years, documented that 70% of the VPS insertions were done for the hydrocephalus due to congenital pathology.[168]

Age of the cases at the time of diagnosis of transanal extrusion of the distal VPS catheter ranged from 1 month to 93 years. In 73% (n = 153) of the cases, the complication occurred in children below 5 years of the age. Sixty-six (31.4%) of the cases were infants.[10],[11],[15],[18],[21],[22],[25],[26],[28],[30],[31],[35],[39],[48],[49],[54],[58],[62],[63],[68],[74],[75],[78],[84],[88],[92],[94],[99],[100],[101],[103],[104],[107],[112],[113],[114],[115],[122],[123],[125],[127],[129],[131],[132],[134],[140],[144],[147],[150],[152],[159],[160],[164, present case] Eighty-seven (41.4%) of the cases were children of 2–5 years of the age at the time of occurrence of above complication.[10],[11],[13],[14],[16],[17],[20],[21],[23],[24],[27],[32],[34],[36],[37],[41],[43],[46],[52],[53],[57],[58],[60],[65],[68],[70],[71],[72],[77],[81],[82],[83],[84],[85],[88],[89],[91],[95],[96],[98],[103],[105],[106],[110],[113],[116],[117],[118],[119],[120],[121],[124],[128],[131],[133],[135],[139],[141],[143],[146],[148],[149],[154],[157],[165],[166]

Eleven of the cases were 11–20 years of age at the time of diagnosis of complication.[16],[25],[38],[40],[44],[67],[90],[102],[109],[114],[137] Although no age was bar for the occurrence of transanal extrusion of the distal VPS catheter but infrequently reported after the age of 60 years and only six of the cases were evident.[47],[51],[86],[93],[111],[162]

For the cases included for review, the interval from the initial VPS insertion or the last VPS revision to the diagnosis of transanal extrusion of the distal VPS catheter ranged from 3 days to 12 years. The most important fact evident on the present review is that in 70% (n = 147) of the cases, it occurred within 12 months after the VPS insertions. In 55 (26.16%) of the cases, the interval was 0–3 months.[10],[11],[15],[16],[22],[25],[31],[39],[46],[48],[58],[59],[62],[68],[74],[75],[78],[85],[88],[90],[93],[99],[101],[103],[104],[107],[108],[110],[111],[113],[115],[123],[125],[126],[130],[132],[133],[138],[141],[144],[147],[149],[152],[160],[164],[166] In 45 (21.42%) of the cases, the interval was 4–6 months.[10],[11],[13],[18],[21],[26],[28],[32],[33],[35],[36],[37],[43],[45],[56],[57],[58],[63],[64],[70],[71],[79],[81],[91],[92],[103],[112],[114],[121],[122],[127],[129],[139],[140],[142],[144],[155],[159],[166, present case] In 47 (26.16%) of the cases, it was 7–12 months.[10],[14],[16],[17],[19],[23],[24],[30],[34],[37],[41],[49],[52],[54],[57],[63],[65],[67],[73],[80],[84],[88],[94],[95],[100],[114],[117],[119],[120],[124],[143],[144],[146],[150],[151],[158],[161],[163],[165] In another 27 (22.38%) of the cases, it was 13–24 months.[10],[21],[24],[27],[34],[40],[42],[47],[51],[66],[72],[76],[87],[89],[95],[96],[98],[105],[106],[109],[116],[135],[136],[137],[154],[156] In 19 (9.04%) of the cases, it was 3–5 years.[25],[29],[31],[44],[55],[60],[61],[70],[77],[82],[83],[86],[118],[135],[145],[148],[156],[157] Among 210 cases included for review, only five of the cases presented with the said complication 5 years after the VPS insertion/shunt revision.[38],[97],[114],[153],[159] Ghritlaharey et al., in a review of 10 asymptomatic cases of transanal extrusion of distal VPS catheter in children, reported that the mean interval was 6.1 months and ranged from 2 to 20 months.[10] Ezzat et al., in a review of the management of 15 cases of the VPS complications, including 6 cases of per-rectal extrusion of the distal VPS catheter, found that the interval was 6 months or less for 6 of their cases.[11]

Radiological investigations ordered by the various authors were in the following order of frequency (1) plain X-rays of the abdomen, chest including head and neck (shunt series), (2) USG of the abdomen, (3) CT scan of the head, and (4) CT scan of the abdomen. Plain roentgenogram of the abdomen, chest, and head and neck were most commonly done for the entire cases. Plain roentgenograms were needed to confirm the continuity of the VPS catheter and location of the ventricular catheter and to document the course of peritoneal catheter within the peritoneal cavity. It also helped in assessing the presence or absence of free gas under the diaphragm. USG of the abdomen was the second most common radiological investigation ordered by the authors. USG of the abdomen helped in the detection of peritoneal fluid collection if any and the free gas under the diaphragm, especially in the cases presented with peritonitis. CT scan of the head was required during the course of investigation for understanding the ventricular dilatation (hydrocephalus), for the confirmation of the position of the ventricular catheter within the ventricle, and for the assessment of the brain parenchyma. CT scan of the head was ordered for the management of above-mentioned complication for one-fifth (n = 43) of their cases.[20],[22],[27],[49],[57],[62],[63],[65],[66],[76],[77],[79],[81],[91],[92],[94],[95],[97],[98],[103],[104],[105],[117],[120],[122],[124],[125],[128],[131],[132],[137],[141],[145],[150],[151],[152],[155],[156],[157],[160],[164] Most important facts delineated on the abdominal CT scan were the site of the bowel perforation and the course of the distal VPS catheter within the peritoneal cavity and the bowel. CT scan of the abdomen was ordered only for 25 (11.9%) of the cases.[45],[47],[55],[76],[77],[83],[86],[87],[89],[90],[96],[97],[107],[108],[109],[111],[116],[126],[130],[138],[151],[153],[154],[162],[163]

The objectives for managing the cases of transanal extrusion of the distal VPS catheter were three-fold (1) removal of the entire or distal VPS catheter, (2) repair or not to repair the perforated colon, and (3) immediate or delayed VPS revision or re-VPS insertion. The preferred surgical procedures were removal of the entire or the distal VPS catheter with or without EVD and were opted by the authors for the management of three-fourth (n = 160) of the cases. Fifty-four percent (n = 114) of the cases were managed by the removal of the entire VPS catheter with or without EVD.[10],[15],[16],[17],[18],[19],[21],[27],[29],[30],[31],[34],[35],[37],[39],[40],[42],[43],[44],[45],[46],[48],[49],[53],[54],[57],[58],[59],[60],[62],[63],[64],[65],[67],[68],[70],[74],[76],[77],[81],[82],[85],[86],[87],[88],[89],[91],[92],[93],[94],[95],[96],[98],[100],[103],[105],[107],[109],[110],[111],[112],[113],[114],[116],[118],[120],[121],[122],[123],[124],[125],[127],[128],[129],[131],[132],[133],[134],[135],[137],[138],[142],[144],[146],[150],[152],[154],[155],[158],[159],[160],[161],[163],[164, present case] Twenty-two percent (n = 46) of the cases were managed by the removal of the distal VPS catheter and keeping the ventricular/proximal VPS catheter as EVD.[11],[21],[22],[23],[28],[31],[47],[63],[66],[69],[72],[75],[78],[79],[80],[84],[88],[90],[101],[102],[104],[106],[126],[130],[139],[141],[143],[145],[147],[148],[149],[153],[156],[165],[166] Removal of the distal VPS catheter/part of distal catheter and immediate relocation or shunt revision were opted for 29 (13.8%) of the cases.[10],[16],[20],[25],[26],[33],[41],[52],[70],[73],[83],[97],[99],[108],[115],[117],[119],[151],[157],[162] Removal of the distal VPS catheter with or without other procedures were opted for 9 (4.2%) of the cases.[24],[37],[50],[55],[56],[136] Ventricular/proximal VPS catheter required removal in 6 (2.8%) of the cases.[13],[14],[16],[32],[61] In 4 of the cases, their distal catheters already passed per-rectum, and they were asymptomatic and not required any surgical therapy.[36],[38],[51],[71] In two of the cases, the surgical procedures could not be done, as their parents refused further surgical procedures.[95],[140] Endoscopic/colonoscopic removal of the distal VPS catheter is a best tool for the cases where transanal extruded VPS catheter retracted back into the colon. This technique has an added advantage of that it also delineates the site of bowel perforation by the distal VPS catheter. Endoscopic technique was opted for the management of 15 (7.14%) of the cases.[40],[47],[53],[55],[56],[65],[76],[79],[83],[84],[89],[105],[117],[136] In five of the cases, the distal VPS catheter had retracted back into the colon, while in 10 of the cases, it was evident during the clinical examination. It was also possible to repair the perforated colon by above method in some of the cases.[40],[47],[53],[55],[56],[65],[76],[79],[83],[84],[89],[105],[117],[136] In another six of the cases, endoscopic procedures were also done along with laparotomy or laparoscopic procedures for management of the cases.[44],[59],[68],[80],[111],[151]

During various surgical procedures performed for the management of transanal extrusion of the distal VPS catheter, the perforated bowel/colon was repaired only in one-fourth (n = 54) of the cases. Colon perforation was repaired during laparotomy in n = 47 of the cases during laparoscopic procedure in n = 5 of the cases, and during endoscopic procedures in n = 2 of the cases.[11],[20],[21],[29],[33],[35],[46],[48],[52],[58],[59],[60],[64],[68],[69],[72],[73],[77],[78],[80],[83],[87],[96],[97],[99],[101],[105],[106],[107],[108],[109],[110],[111],[116],[118],[119],[120],[122],[128],[133],[138],[146],[148],[149],[151],[157],[161] The colon perforation healed spontaneously after the removal of the extruded VPS catheter in remaining three-fourth of the cases.

Shunt revision was also an important aspect of the management for the cases of trans-anal extrusion of the distal VPS catheter. Delayed VPS revision/delayed re-VPS insertion was preferred as compared to the immediate VPS revision or immediate re-VPS insertion by the authors. Present review retrieved details of 125 shunt revisions done during the course of management. Delayed VPS revision and delayed re-VPS insertion were preferred by the authors for the management of 89 of the cases. By delaying the shunt revisions/re-VPS insertions for 2–4 weeks, a sufficient time was provided for the treatment of meningitis, if present. Another important aspect was that it was also possible to evaluate the cases for the requirement of shunt revision.[10],[11],[13],[18],[21],[22],[28],[31],[37],[39],[43],[53],[57],[58],[62],[63],[66],[68],[70],[74],[75],[77],[78],[80],[81],[82],[84],[88],[90],[91],[94],[96],[100],[101],[102],[103],[104],[113],[114],[118],[120],[121],[124],[125],[127],[131],[134],[139],[143],[144],[145],[147],[148],[150],[159],[160],[163],[164],[165],[166, present case]

Ghritlaharey, and some others authors managed their cases of transanal extrusion of distal VPS catheter by removal of the distal/entire VPS catheter and revising either the distal or the entire VPS catheter, immediately during the same operative procedure. Immediate VPS revisions and immediate re-VPS insertions were preferred by the authors for 25 of the cases.[10],[15],[20],[25],[26],[30],[41],[54],[58],[60],[70],[83],[92],[111],[117],[122],[137] Conversion of VPS to the VA shunt or other shunt was also opted during shunt revisions. For 11 of the cases, their VPS were converted to either VA shunt (n = 9) or ventriculopleural shunt (n = 2). Eight of the above procedures were done as delayed procedures, and 3 of them were performed as immediate procedures.[16],[23],[33],[52],[76],[119],[126],[149],[153],[156] Twenty-two of the cases not required re-VPS insertion, neither during immediate postoperative period nor during the follow-up period.[29],[31],[32],[34],[34],[45],[61],[63],[65],[69],[79],[85],[97],[105],[107],[128],[130],[136],[142],[146],[158],[161]

Postoperative complications were also documented in 16 (7.6%) of the cases.[13],[27],[33],[44],[49],[54],[57],[63],[67],[70],[77],[106],[138],[141],[149],[164] Among 210 cases reviewed on the management of the transanal extrusion of the distal VPS catheter, 6 (2.85%) of them died during the postoperative period. Five of them were children below the age of 3 years, and another one was 18 years old. The causes of death were meningitis for 5 cases and peritonitis/abdominal abscess for another one of the cases.[13],[17],[54],[63],[67],[106] Sathyanarayana et al., in a review of 45 cases of bowel perforation by the shunt catheter, found that the deaths also occurred in the cases who had presented without the transanal extrusion of the shunt catheter.[45] Park et al., in an analysis of 50 cases of bowel perforation by the shunt catheter, also evident deaths of the cases presented without the transanal extrusion of the shunt catheter.[172]

Major limitation of the present review is that n = 50 (19.23%) of the cases relating to transanal extrusions of the distal VPS catheter were excluded from review. The reasons for exclusion were either unavailability of the full-text of the manuscripts or the details for such cases were not available/not provided in the manuscripts. A total of 22 manuscripts were excluded from the review. In fourteen of the manuscripts, full text is available that also included 41 cases of transanal extrusion of the distal VPS catheter, but the desired details are not included in the texts and were excluded from the review. Eight manuscripts included 9 cases were also excluded, as I failed to obtain full texts using different resources. Other things are that authors managed their cases using different modalities and surgical techniques, probably depending on their expertise, experience, and availability of local resources. Based on the findings of the present review, a management plan is proposed for transanal extrusion of the distal VPS catheter and detailed as a flowchart in [Figure 8].{Figure 8}

Transanal extrusion of the distal VPS catheter occurred across all age groups. Eighty percent of the complication occurred in children below the age of 10 years. In 70% of the cases, the interval from the initial VPS insertion/last shunt revision to the diagnosis of transanal extrusion of the distal VPS catheter was within 12 months. Two-third of the cases, it was asymptomatic transanal extrusion of the distal VPS catheter. Ascending infection was also evident in approximately one-fourth of the cases, either as apparent meningitis or positive bacterial growth on their cerebrospinal fluids. Although there were bowel perforations, peritonitis was rare findings and documented only in 8 of 210 cases reviewed. Three-fourth of the cases were managed by removal of the entire or the distal VPS catheter with or without external ventricular drainage. In three-fourth of the cases, repair of the perforated bowel/colon was not done and that healed spontaneously after the removal of the extruded VPS catheter. Fifty percent of the cases were treated by using percutaneous techniques, and only one-third of the cases were managed by doing laparotomies. For the cases required shunt revision, delayed re-VPS insertion was preferred over the immediate re-VPS insertion or immediate revision of the distal VPS catheter.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Frassanito P, Tamburrini G, Di Rocco C. Surgical treatment of hydrocephalus based on CSF shunt devices. In: Di Rocco C, Pang D, Rutka J, editors. Textbook of Pediatric Neurosurgery. Cham, Switzerland: Springer; 2020. p. 567-75.
2Stone JJ, Walker CT, Jacobson M, Phillips V, Silberstein HJ. Revision rate of pediatric ventriculoperitoneal shunts after 15 years. J Neurosurg Pediatr 2013;11:15-9.
3Naftel RP, Argo JL, Shannon CN, Taylor TH, Tubbs RS, Clements RH, et al. Laparoscopic versus open insertion of the peritoneal catheter in ventriculoperitoneal shunt placement: Review of 810 consecutive cases. J Neurosurg 2011;115:151-8.
4Reddy GK, Bollam P, Caldito G. Long-term outcomes of ventriculoperitoneal shunt surgery in patients with hydrocephalus. World Neurosurg 2014;81:404-10.
5Ghritlaharey RK, Budhwani KS, Shrivastava DK, Srivastava J. Ventriculoperitoneal shunt complications needing shunt revision in children: A review of 5 years of experience with 48 revisions. Afr J Paediatr Surg 2012;9:32-9.
6Ghritlaharey RK. Review of the management of peroral extrusion of ventriculoperitoneal shunt catheter. J Clin Diagn Res 2016;10:E01-6.
7Miranda ME, de Sousa MB, Tatsuo ES, Quites LV, Giannetti AV. Bladder perforation by ventriculoperitoneal shunt. Childs Nerv Syst 2016;32:2321-6.
8Yang X, Liang R, Zhang Y. An unusual complication of ventriculoperitoneal shunt with bladder perforation and extrusion through the urethra orifice in an adult male patient. Int J Neurosci 2019;129:101-2.
9Feeney V, Ansar N, Donaldson-Hugh B, Alalade AF. Transoral Protrusion of a ventriculoperitoneal catheter caused by jejunal perforation in an adult: Rare case report and review of the literature. World Neurosurg 2020;137:200-5.
10Ghritlaharey RK, Budhwani KS, Shrivastava DK, Gupta G, Kushwaha AS, Chanchlani R, et al. Trans-anal protrusion of ventriculo-peritoneal shunt catheter with silent bowel perforation: Report of ten cases in children. Pediatr Surg Int 2007;23:575-80.
11Ezzat AA, Soliman MA, Hasanain AA, Thabit MA, Elshitany H, Kandel H, et al. Migration of the distal catheter of ventriculoperitoneal shunts in pediatric age group: Case series. World Neurosurg 2018;119:e131-7.
12Wilson CB, Bertan V. Perforation of the bowel complicating peritoneal shunt for hydrocephalus. Report of two cases. Am Surg 1966;32:601-3.
13Sells CJ, Loeser JD. Peritonitis following perforation of the bowel: A rare complication of a ventriculoperitoneal shunt. J Pediatr 1973;83:823-4.
14Grosfeld JL, Cooney DR, Smith J, Campbell RL. Intra-abdominal complications following ventriculoperitoneal shunt procedures. Pediatrics 1974;54:791-6.
15Giuffrè R, Di Lorenzo N. Two unusual complications of ventriculo-peritoneal shunt in the same infant. Surg Neurol 1975;3:23-4.
16Schulhof LA, Worth RM, Kalsbeck JE. Bowel perforation due to peritoneal shunt. A report of seven cases and a review of the literature. Surg Neurol 1975;3:265-9.
17Pascual Castroviejo I, Mulas F, Casas C, Martínez Bermejo A, Otero B. Anal extrusion: A complication of ventriculo-peritoneal shunt for hydrocephalus (author's transl). An Esp Pediatr 1975;8:685-8.
18Yamasaki S, Osaka K, Hirayama A, Asada M, Ebara K, Matsumoto S, et al. Intra-abdominal complications following ventriculoperitoneal shunt. J Jap Soc Pediatr Surg 1976;12:619-24.
19Takagi S, Yamashita Y, Nakayama K. Complications resulting from ventriculo-peritoneal shunt: An anticipatory comment-case report (author's transl). No Shinkei Geka 1976;4:993-6.
20Murtagh FR, Quencer RM, Poole CA. Extracranial complications of cerebrospinal fluid shunt function in childhood hydrocephalus. AJR Am J Roentgenol 1980;135:763-6.
21Abu-Dalu K, Pode D, Hadani M, Sahar A. Colonic complications of ventriculoperitoneal shunts. Neurosurgery 1983;13:167-9.
22Miserocchi G, Sironi VA, Ravagnati L. Anal protrusion as a complication of ventriculo-peritoneal shunt. Case report and review of the literature. J Neurosurg Sci 1984;28:43-6.
23Aricó M, Beluffi G, Fiori P, Chiari G, Pezzotta S, Podesta AF, et al. Rectal extrusion of the catheter and air ventriculography following bowel perforation in ventriculo-peritoneal shunt. Pediatr Radiol 1985;15:53-5.
24Prabhu S, Cochran W, Azmy AF. Wandering distal ends of ventriculo-peritoneal shunts. Z Kinderchir 1985;40:80-1.
25Gelabert González M. Extrusion of peritoneal catheter through the anus. Childs Nerv Syst 1987;3:183-4.
26Ali J, Cheah FK. Per rectal extrusion of a ventriculo peritoneal shunt catheter. A case report. Med J Malaysia 1987;42:201-3.
27Sharma BS, Kak VK. Multiple subdural abscesses following colonic perforation—A rare complication of a ventriculoperitoneal shunt. Pediatr Radiol 1988;18:407-8.
28Takahashi J, Makita Y, Nabeshima S, Tei T, Keyaki A, Miyamoto Y. Spontaneous extrusion of peritoneal tubes after ventriculoperitoneal shunting. Report of two cases. Neurol Med Chir (Tokyo) 1988;28:808-11.
29Fernandes MA. Extrusion of ventriculoperitoneal shunt through the anus. Indian Pediatr 1989;26:86-7.
30Aranda G, Pretto R, Velarde C. Asymptomatic rectosigmoid perforation and peranal extrusion of a catheter of ventriculoperitoneal derivation. Rev Med Panama 1989;14:108-11.
31Hornig GW, Shillito J Jr. Intestinal perforation by peritoneal shunt tubing: Report of two cases. Surg Neurol 1990;33:288-90.
32Mertol T, Atabay H, Güner M, Aktuğ T. Intra abdominal complications of V-P shunts. Turk Neurosurg 1994;4:123-6.
33Janjua KJ, Ashraf AN, Sendi A. Colonic perforation: Rare complication of CSF shunt. Br J Clin Pract 1995;49:44-5.
34Gupta VK, Sharma BS, Gupta SK, Kak VK. Extrusion of ventriculoperitoneal shunt per anum. Neurol India 1995;43:175-6.
35Basklar C, Baykaner K, Turkyilmaz Z, Sonmez K, Kale N. Rectal extrusion of ventriculoperitoneal shunt without abdominal signs: Case report and review of the literature. Gazi Med J 1995;6:199-202.
36Ashpole R, Boulton R, Holmes AE. A case of asymptomatic passage per-rectum of a fractured redundant peritoneal catheter from a ventriculo-peritoneal shunt. Eur J Pediatr Surg 1995;5:280-1.
37Sami A, Ait Ben Ali S, Choukry M, Achouri M, Naja A, Ouboukhlik A, et al. Anal migration of ventriculo-peritoneal shunt catheter. Apropos of 3 cases. Neurochirurgie 1995;41:315-8.
38Swann IL. Expulsion of ventriculoperitoneal shunt tubing. Arch Dis Child 1996;74:184.
39Latcham F. Expulsion of ventriculoperitoneal shunt tubing. Arch Dis Child 1996;75:89-90.
40Brown SR, Gourlay R, Battersby RD. Sigmoidoscopic neurosurgery? Treatment of an unusual complication of ventriculoperitoneal shunting. Br J Neurosurg 1996;10:419-20.
41Adeloye A. Protrusion of ventriculo peritoneal shunt through the anus: Report of two cases. East Afr Med J 1997;74:337-9.
42Yamamura K, Kodama O, Kajikawa H, Kawanishi M, Sugie A, Kajikawa M, et al. Rare intra-abdominal complications of a ventriculoperitoneal shunt: Report of three cases. No Shinkei Geka 1998;26:1007-11.
43Digray NC, Thappa DR, Arora M, Mengi Y, Goswamy HL. Silent bowel perforation and transanal prolapse of a ventriculoperitoneal shunt. Pediatr Surg Int 2000;16:94-5.
44Chen HS. Rectal penetration by a disconnected ventriculoperitoneal shunt tube: An unusual complication. Chang Gung Med J 2000;23:180-4.
45Sathyanarayana S, Wylen EL, Baskaya MK, Nanda A. Spontaneous bowel perforation after ventriculoperitoneal shunt surgery: Case report and a review of 45 cases. Surg Neurol 2000;54:388-96.
46Erol F, Kazez A, Kaplan M, Özveren F. Protrusion of ventriculo-peritoneal shunt through the anus: Case report. Turk J Neurosurg 2001;11:68-71.
47Shinkawa H, Inoue T, Fujita T, Nojiri T, Furuya Y, Kuroda T, et al. Unusual complication due to ventriculo-peritoneal shunt which peritoneal end perforated the rectum and protruded out of the anus: Report of a case. Jpn J Gatroenterol Surg 2001;34:59-63.
48Sencan A, Dağlar Z, Küçükoğlu T, Umur AS, Selcuki M, Mir E. Ventriculo-peritoneal shunt protruding from the anus: A rare complication. Pediatrik Cerrahi Dergisi 2002;16:38-40.
49Bharti P, Kumar T, Bharti S. Rare shunt complication: Letter to editor. Neurol India 2002;50:108-9.
50O'Donoghue GT, Kumar R, Taleb F, Phillips J. Per-anal extrusion of a disconnected ventriculoperitoneal catheter—An unusual complication. Ir Med J 2002;95:88-9.
51Sturdee SW, Timothy J, Tyagi A. Total extrusion of a cranial peritoneal shunt per rectum. J Clin Neurosci 2002;9:199-200.
52Surchev J, Georgiev K, Enchev Y, Avramov R. Extremely rare complications in cerebrospinal fluid shunt operations. J Neurosurg Sci 2002;46:100-2.
53Sharma A, Pandey AK, Radhakrishnan M, Kumbhani D, Das HS, Desai N. Endoscopic management of anal protrusion of ventriculo-peritoneal shunt. Indian J Gastroenterol 2003;22:29-30.
54Caksen H, Kiymaz N, Odabaş D, Tuncer O, Ataş B. Anal protrusion of ventriculo-peritoneal shunt catheter in an infant. Brain Dev 2003;25:146-7.
55Yousfi MM, Jackson NS, Abbas M, Zimmerman RS, Fleischer DE. Bowel perforation complicating ventriculoperitoneal shunt: Case report and review. Gastrointest Endosc 2003;58:144-8.
56Pikoulis E, Psallidas N, Daskalakis P, Kouzelis K, Leppäniemi A, Tsatsoulis P. A rare complication of a ventriculoperitoneal shunt resolved by colonoscopy. Endoscopy 2003;35:463.
57Yüceer N, Senoğlu M, Arda MN. Late ventriculoperitoneal shunt complication: Prolapse of the peritoneal catheter through the anus in two cases. Turk Neurosurg J 2004;14:133-6.
58Yilmaz N, Krymaz N, Yilmaz C, Caksen H, Yuca SA. Anal protrusion of ventriculo-peritoneal shunt catheter: Report of two infants. J Pediatr Neurol 2004;2:241-4.
59Ali A, Michael C, Margarita L, Ryan M, Afonso R. Endoscopic and clinical management of colonic perforation by ventriculoperitoneal shunt. Am J Gastroenterol 2004;99:S160.
60Ferreira PR, Bizzi JJ, Amantéa SL. Protrusion of ventriculoperitoneal shunt catheter through the anal orifice. A rare abdominal complication. J Pediatr Surg 2005;40:1509-10.
61Ansari S, Nejat F, Dadmehr M. Extrusion of ventriculoperitoneal shunt catheter through the rectum and retrograde meningitis. Pediatr Infect Dis J 2005;24:1027.
62Gupta SK, Jaiswal AK, Kumar S. Ventriculoperitoneal shunt catheter masquerading as ascariasis. J Clin Neurosci 2005;12:966-7.
63Vinchon M, Baroncini M, Laurent T, Patrick D. Bowel perforation caused by peritoneal shunt catheters: Diagnosis and treatment. Neurosurgery 2006;58:S76-82.
64Akcora B, Serarslan Y, Sangun O. Bowel perforation and transanal protrusion of a ventriculoperitoneal shunt catheter. Pediatr Neurosurg 2006;42:129-31.
65Sharma A, Pandey AK, Diyora B, Shah S, Sayal P. Management of ventriculo-peritoneal shunt protruding through anus. Indian J Surg 2006;68:172-3.
66Doglietto F, Sabatino G, Albanese A, Mangiola A, Anile C, Maira G. Late perforation of the bowel in patients with a ventriculoperitoneal shunt. Eur J Neurol 2006;13:e5.
67de Aquino HB, Carelli EF, Borges Neto AG, Pereira CU. Nonfunctional abdominal complications of the distal catheter on the treatment of hydrocephalus: An inflammatory hypothesis? Experience with six cases. Childs Nerv Syst 2006;22:1225-30.
68Ceran C, Karadağ Ö, Gürünlüoğlu K, Önal Ç. Colon perforation and transanal protrusion of ventriculo-peritoneal shunt: Two cases. J İnönü Univ Fac Med 2006;13:271-3.
69Martinez Hernández-Magro P, Barrera Román C, Villanueva Sáenz E, Zavala MJ. Colonic perforation as a complication of ventriculoperitoneal shunt: A case report. Tech Coloproctol 2006;10:353-5.
70Handa R, Kale R, Harjai MM. Unusual complication of ventriculoperitoneal shunt: Anal extrusion. Med J Armed Forces India 2007;63:82-4.
71Baeza-Herrera C, Atzín-Fuentes JL, Velasco-Soria L, García-Cabello LM, Godoy-Esquivel AH. Spontaneous disconnection and expulsion per rectum of a subarachnoid-peritoneal shunt catheter. Bol Med Hosp Infant Mex 2007;64:107-11.
72Jang HD, Kim MS, Lin NH, Kim SH. Anal extrusion of distal V-P shunt catheter after double perforation of large intestine. J Korean Neurosurg Soci 2007;42:232-4.
73Zhou F, Chen G, Zhang J. Bowel perforation secondary to ventriculoperitoneal shunt: Case report and clinical analysis. J Int Med Res 2007;35:926-9.
74Kanojia R, Sinha SK, Rawat J, Wakhlu A, Kureel S, Tandon R. Unusual ventriculoperitoneal shunt extrusion: Experience with 5 cases and review of the literature. Pediatr Neurosurg 2008;44:49-51.
75Sengul G, Akar A. Transanal prolapse of a ventriculoperitoneal shunt. Neurosciences (Riyadh) 2008;13:174-5.
76Li HN, Tan TC, Cheung FC. Transanal protrusion of ventriculoperitoneal shunt. Surgical Practice 2008;12:93-6.
77Matsuoka H, Takegami T, Maruyama D, Hamasaki T, Kakita K, Mineura K. Transanal prolapse of a ventriculoperitoneal shunt catheter—Case report. Neurol Med Chir (Tokyo) 2008;48:526-8.
78Mohta A, Jagdish S. Spontaneous anal extrusion of ventriculoperitoneal shunt. Afr J Paediatr Surg 2009;6:71-2.
79Vuyyuru S, Ravuri SR, Tandra VR, Panigrahi MK. Anal extrusion of a ventriculo peritoneal shunt tube: Endoscopic removal. J Pediatr Neurosci 2009;4:124-6.
80Birbilis T, Zezos P, Liratzopoulos N, Oikonomou A, Karanikas M, Kontogianidis K, et al. Spontaneous bowel perforation complicating ventriculoperitoneal shunt: A case report. Cases J 2009;2:8251.
81Urfalı B, Akçora B, Akdemir G, Çavuş G, Eriş Ö, Serarslan Y. An arachnoidal cystoperitoneal shunt catheter which protruded via anus and caused subdural empyema after colonic perforation: A rare complication. Erciyes Med J 2009;31:364-8.
82Kumar B, Sharma SB, Singh DK. Extrusion of ventriculo-peritoneal shunt catheter. Indian J Pediatr 2010;77:336.
83Chiang LL, Kuo MF, Fan PC, Hsu WM. Transanal repair of colonic perforation due to ventriculoperitoneal shunt — Case report and review of the literature. J Formos Med Assoc 2010;109:472-5.
84Hai A, Rab AZ, Ghani I, Huda MF, Quadir AQ. Perforation into gut by ventriculoperitoneal shunts: A report of two cases and review of the literature. J Indian Assoc Pediatr Surg 2011;16:31-3.
85Dağtekin A, Karabağ H, Avcı E, Naycı A, Bağdatoğlu C. A rare complication with ventriculoperitoneal shunt in pediatric cases. Ege Tıp Dergisi/Ege J Med 2011;50:65-8.
86Huang HM, Lee WY, Chen DC. Disconnected subduroperitoneal shunt catheter induces silent bowel perforation: An unusual complication. Int J Surg Case Rep 2011;2:76-8.
87Hayama T, Ishihara S, Yamazaki N, Akahane T, Shimada R, Horiuchi A, et al. Severance of a ventriculoperitoneal shunt catheter implanted between the cerebral ventricle and peritoneal cavity, resulting in protrusion from the anus. Int Surg 2011;96:148-52.
88Seyithanoğlu MH, Doğan K, Gündağ M, Kitiş S, Öztürk Ş, Dündar T, et al. Late complication of ventriculoperitoneal shunt: Protrusion of peritoneal catheter through the anus in four cases. Turk Neurosurg J 2011;21:269-73.
89Oliveira SB, Monteiro IM. Endoscopic management of transanal protrusion of subdural peritoneal shunt in a child. J Pediatr Gastroenterol Nutr 2011;53:465-7.
90Glatstein M, Constantini S, Scolnik D, Shimoni N, Roth J. Ventriculoperitoneal shunt catheter protrusion through the anus: Case report of an uncommon complication and literature review. Childs Nerv Syst 2011;27:2011-4.
91Gupta M, Digra NC, Sharma N, Goyal S, Agrawala A. Anal extrusion of a ventriculoperitoneal shunt catheter. J Pak Med Soc 2012;2:15-7.
92Mihajlović M, Tasić G, Raicević M, Mrdak M, Petrović B, Radlović V. Asymptomatic perforation of large bowel and urinary bladder as a complication of ventriculoperitoneal shunt: Report of two cases. Srp Arh Celok Lek 2012;140:211-5.
93Chang PK, Wu CC, Lee CC, Lee TY, Jao SW, Hsiao CW. Tube found in anus during defecation: Sigmoid colon perforation after ventriculoperitoneal shunt surgery in an elderly patient. J Med Sci 2012;6:135-7.
94Kundal VK, Gajdhar M, Sharma C, Agrawal D, Kundal R. Wandering distal end of ventriculo-peritoneal shunt: Our experience with five cases and review of literature. J Nepal Paediatr Soc 2012;32:266-9.
95Teegala R, Kota LP. Unusual complications of ventriculo peritoneal shunt surgery. J Neurosci Rural Pract 2012;3:361-4.
96Ozturk H, Is M, Ozturk H, Kucuk A, Dosoglu M. Transanal protrusion of a ventriculoperitoneal shunt catheter. J Coll Physicians Surg Pak 2012;22:733-4.
97Filho PMM, D'Agostini D, Silva R dos S, Azambuja Junior ND, Winkelmann L, Zambonin D. Bowel perforation and extrusion of a ventriculo-peritoneal shunt through the anus. J Bras Neurocirug 2013;24:69-74.
98Sharifian A, Abdollahi A, Maddah G, Anaraki F, Alvandipour M, Abbasi Sahebi M, et al. Spontaneous transanal protrusion of ventriculoperitoneal catheter: A case report. Acta Med Iran 2013;51:135-8.
99Elizabeth KE, Devakumar VK, Famesh A. Unusual migration of VP shunt. Indian Pediatr 2013;50:435.
100Phani K. Trananal protrusion of ventriculo-peritoneal shunt catheter. J NTR Univ Health Sci 2013;2:115-7.
101Lawther S, Patel R, Gabra H. Laparoscopic management of silent colonic perforation with trans-anal protrusion of ventriculo-peritoneal shunt catheter. J Ped Surg Case Rep 2013;1:106-7.
102Mattei TA, Salma A, Lin JJ. Spontaneous bowel perforation from distal catheter leading to meningitis: A rare but frequently overlooked complication of ventriculoperitoneal shunts. Pediatr Neurol 2013;48:477-8.
103Gedik AH, Uzuner S, Cindemir E, Bayraktar S, Torun E, Seyithanoglu H, et al. Trans-anal protrusion of ventriculo-peritoneal shunt related to colon perforation: Two case reports. Turk Arch Ped 2013;48:255-8.
104Upadhyay PK, Geeta T. Prolapse of ventricular shunt tube from rectum in a child with congenital hydrocephalus. Med Sci 2013;1:60-2.
105Wang R, Wang Y, Zhang R, Huang L, Luo Y. Migration of the distal catheter of a ventriculoperitoneal shunt into the colon: Case report and clinical analysis. J Pediatr Case Rep 2014;2:1-3.
106Ishii T, Morita K, Tsugawa J, Sato S. A case of sigmoid colon perforation with ventriculoperitoneal shunt tube. J Jap Soc Pediatr Surg 2014;50:230-4.
107Grewal SS, Jhawar SS, Gupta B, Bedi NK. Silent bowel perforation with per anal protrusion of ventriculoperitoneal shunt. CHRISMED J Health Res 2014;1:113-5.
108Plummer NR, Tokala A, Date RS. Transanal protrusion of ventriculoperitoneal shunt reflecting asymptomatic perforation of the large bowel. BMJ Case Rep 2014;2014:bcr2014-204842.
109AkmanT, Güven M, Aras AB, Çıkman Ö, Safak O, Karaaslan O, et al. Patients with Chiari malformation type 2 in VP shunt rare complication. J Clin Anal Med 2014;5:540-3.
110Singh AP, Mathur V, Goyal RB, Pardeshi RJ, Jangid M. A rare case of bowel perforation secondary to ventriculo peritoneal shunt. J Evol Med Dent Sci 2014;3:12362-5.
111Chang HK, Tsai SH, Chen YL, Hsu YP. Silent bowel perforation cause by migration of ventriculoperitoneal shunt masquerading as acute enteritis. J Med Sci 2014;34:277-9.
112Bansal H, Gupta G, Gupta M, Kaushal R. Unusual ventriculoperitoneal (VP) Shunt tube extrusion through anus in a child with Dandy Walker malformation: A rare case report. J Clin Diagn Res 2015;9:D25-6.
113Thiong'o GM, Luzzio C, Albright AL. Ventriculoperitoneal shunt perforations of the gastrointestinal tract. J Neurosurg Pediatr 2015;16:36-41.
114Dheer Y, Pandey A, Archika, Kureel SN. Transanal prolapse of ventriculo-peritoneal shunt in patients of lumbosacral meningomyelocele with hydrocephalous - A case series. Int J Adv Case Rep 2015;2:1363-5.
115Farazi MM, Salam MA, Azim MA. Transanal extrusion of the ventriculoperitoneal shunt tube. Med Today 2015;27:44-5.
116Lee CH, Tseng SH, Chen Y. Ileal perforation and transanal protrusion of the peritoneal tube in a boy with a ventriculoperitoneal shunt and literature review. Formos J Surg 2015;48:209-13.
117Hegde A, Nair RP, Ganapathy S, Kongwad LI. Shunt malfunction in patients with hydrocephalus: Complications revisited. BMJ Case Rep 2016;2016:bcr2015-213619.
118Sosuncu E, Gülşen I, Kıymaz N, Ağengin K. Şimşek M, Melek M. Anal protrusion caused by a ventriculoperitoneal shunt. Van Tip Derg 2016;23:95-7.
119Fariborz G, Ehsan M. The spontaneous extrusion of the ventriculoperitoneal shunt through the anus: A case report and review of the literature. Ir J Neurosurg 2016;2(SUP3):88.
120Moghul D, Rahim MT. Protrusion of VP shunt through anus a rare complication after shunt insertion at French Medical Institute for Children (FMIC), Kabul, Afghanistan (Case report). Int J Gastroenterol Hepatol Transp Nutr 2016;1:70-2.
121Raghavendra H, Pendyala S, Punit T, Panigraghi MK. Spontaneous transanal externalization of ventriculoperitoneal shunt. J Med Sci Res 2016;4:8-10.
122Bodeliwala S, Agrawal A, Mittal A, Singh D, Vageesh BG, Singh H. Transanal protrusion of ventriculoperitoneal shunt via appendicular perforation: A rare case report. J Pediatr Neurosci 2016;11:274-6.
123Kumar TR, Kishore MS. En-masse protrusion of ventriculo-peritoneal shunt tube through the anus. Indian Pediatr 2016;53:747-8.
124Sarkari A, Borkar SA, Mahapatra AK. Anal extrusion of migrated ventriculo-peritoneal shunt catheter: An unusual complication and review of literature. Asian J Neurosurg 2016;11:459.
125Bhingare P, Sawant N. Rare complication of ventriculoperitoneal shunt: Anal extrusion. JMSCR 2016;4:14622-6.
126Bales J, Morton RP, Airhart N, Flum D, Avellino AM. Transanal presentation of a distal ventriculoperitoneal shunt catheter: Management of bowel perforation without laparotomy. Surg Neurol Int 2016;7:S1150-3.
127Gupta VK, Sandhu MR, Pannu PR, Seth A. Spontaneous perforation of gut by ventriculoperitoneal shunt: A rare complication. J Med Coll Chandigarh 2017;7:39-41.
128Sahoo SK, Srivastava C, Tomar A. Shunt tip perforating large bowel through vermiform appendix. Med J DY Patil Univ 2017;10:216-7.
129Indra Gunawan P, Gunadi Ranuh IR, Fardah Atthiyah A. Anal extrusion of the ventriculoperitoneal shunt catheter. Acta Med Acad 2017;46:65-6.
130Liu Y, Li C, Tian Y. Ventriculo-peritoneal shunt trans-anal protrusion causing Escherichia coli ventriculitis in child: Case report and review of the literature. Chinese Neurosurg J 2017;3:9.
131Al Hinai Q, Salhotra N, Al Zabin M, Ali A, Al Abri S, Hashim M, et al. Series of 3 cases of silent colonic perforation by ventriculoperitonal shunt catheter prolapsing through anus, an infrequent complication: A case report. Am J Med Case Rep 2017;5:59-61.
132Sodhi D, Sodhi NA, Kawatra A. Per anal protrusion of ventriculo-peritoneal shunt. Ind J Basic Appl Med Res 2017;6:369-71.
133Amouei A, Babaei-Zarch M, Ehsani F, Tabataei SM, Babai M, Asadi MJ. Penetration of ventriculoperitoneal shunt into the transverse colon and anal extrusion in a child: A rare case report. Case Rep Clin Pract 2017;2:29-32.
134Ajaj S, Taleb FS. Anal extrusion of a ventriculoperitoneal shunt: A new case. Ibnosina J Med BS 2017;9:81-3.
135Rattan KN, Hooda R. Per anal extrusion of ventriculoperitoneal shunt - Report of two cases. Indian J Res 2017;6:63-4.
136Alexander B, Savvas M, Aristeidis R. Rare complications of CSF shunts-A single center experience. Encephalos 2017;54:83-93.
137Alkhaffaf MT, Abdulhameed AL. Anal exposure of ventriculoperitoneal shunt an unusual complication-Case report. WJPPS 2017;6:52-7.
138Osman B, Roushias S, Hargest R, Narahari K. Migration of ventriculoperitoneal shunt to urethral and rectal orifices. BMJ Case Rep 2017;2017:220187.
139Hasan A, Sharma S, Chopra S, Purohit DK. Anal extrusion of ventriculoperitoneal shunt: A report of two cases and review of literature. J Pediatr Neurosci 2018;13:8-12.
140Nair RP, Kongwad LI. Abandoning dislodged shunt catheters-unraveling Pandora's box. Childs Nerv Syst 2018;34:381-3.
141Chung BSR, Lee HJ. Delayed brain abscess after bowel perforation by a subdural-peritoneal shunt. J Radiol Med Imaging 2018;1:2003.
142Guthe SP, Pravin S, Darade P, Velho V. Silent migration of ventriculoperitoneal shunt per anus in a child: Management and review of literature. Asian J Neurosurg 2018;13:446-8.
143Sharma A, Shukla A, Iyenger SN. Rectal migration of ventriculo-peritoneal shunt: A rare case report. Romanian Neurosurgery 2018;32:303-5.
144Chugh A, Gotecha S, Amle G, Patil A, Punia P, Kotecha M. Abnormal migration and extrusion of abdominal end of ventriculoperitoneal shunt: An experience of eight cases. J Pediatr Neurosci 2018;13:317-21.
145Manish, Gupta A, Sharma R. Trananal migration of ventriculoperitoneal shunt. RUSH J Health Sci 2018;3:170-3.
146Sujka J, Sola R Jr., Juang D. Transanal protrusion of subdural peritoneal shunt in the setting of appendicitis. J Ped Surg Case Rep 2018;34:35-6.
147Noskiewicz J, Kopaczewski B, Rzanny-Owczarzak M, Jarmusz K, Kocąb B, Mańkowski P. Intestinal perforation caused by ventriculoperitoneal shunt. Nowa Med 2018;25:108-11.
148Burhan B, Serdar KB, Abdurrahman A, Edip AM, Ebuzer D. Abdominal complications of ventriculoperitoneal shunt in pediatric patients: Experiences of a pediatric surgery clinic. World Neurosurg 2018;118:e129-36.
149Asghar MU, Um-e-Salima, Ahmad M. An assessment of a rarely occurring complication: Ventriculoperitoneal (VP) anal extrusion. IAJPS 2019;6:6209-11.
150Turkis OF, Karadag A, Middlebrooks EH, Senoglu M. Anal extrusion of a ventriculoperitoneal shunt. J Coll Physicians Surg Pak 2019;29:478-80.
151Pérez OL, Leafat BM, Rodríguez RE, Benítez EM. Resolution for minimum access in anal extrusion of peritoneal ventricle shunt catheter. Rev Ciencias Médicas 2019;23:562-7.
152Marino M, Phillips C. Methicillin-resistant Staphylococcus aureus meningitis from transanal migration of a ventriculoperitoneal shunt. J Emerg Med 2019;57:e81-4.
153Meza G, D'Addino J, Olano P. Spontaneous anal extrusion of a distal ventriculoperitoneal catheter in an adult: Case report. IJSR 2019;8:27-8.
154Zain M, Ibrahim A, Khalil AM, Kotb M, Khairi A. Silent colonic perforation complicating a ventriculoperitoneal shunt with trans-anal protrusion. MOJ Clin Med Case Rep 2019;9:124-6.
155Chakkarwar A, Ansari I, Kotecha N, Shinde S. Trans anal migration of ventriculo-peritoneal shunt: A rare case. Int J Curr Med Appl Sci 2019;24:23-5.
156Sandoval BM, Granados LR, Sandoval OL, Pena JL, Franco JA. Ventricular peritoneal shunt complication: Bowel perforation, catheter migration through the rectum, report of three cases. Acta Med 2019;17:409-12.
157Al-Ani AH, Alhosani ME, Aljabberi KM. Asymptomatic migration of ventriculoperitoneal shunt tube through the anus. J Univ Surg 2019;7:1-4.
158Al Fauzi A, Parenrengi MA, Wahyuhadi J, Subagio EA, Turchan A. Ventriculoperitoneal shunt catheter migration and transanal extrusion in persistent vegetative state adult patient. Fol Med Indones 2019;55:322-5.
159Koko AM, Ismail NJ, Lasseini A, Saddiku SM. Uncommon complications of ventriculoperitoneal shunt surgery: Review of four cases and literature review. Egypt J Neurosurg 2020;35:1-5.
160Bakshi S. Spontaneous trans-anal extrusion of caudally migrated ventriculo-peritoneal shunt tip in a child: A case report. Surg Case Rep 2020;6:50.
161Alhassan BA, Agyen-Mensah K, Rahman GA, Makafui CS. Ventriculoperitoneal shunt migration through the anus in a child: Case report and management algorithm. J Adv Med Med Res 2020;32:53-7.
162Kim D, Kim HY, Jin SC, Lee S. Disappearance of a distal shunt catheter: A case report of an unusual cause of shunt malfunction. Korean J Neurotrauma 2020;16:79-84.
163Khay K, Maoufid F. Trnasanal protrusion of ventriculoperitoneal shunt. J Clin Med Images 2020;4:1-11.
164Cardinale JP, Carrillo CO, Colón J. Perioperative management for rectal migration of a ventriculoperitoneal shunt. Ochsner J 2020;20:239-41.
165Kuldeep M, Gandhi A, Jain S, Garg DK, Rai A. Anal extrusion of ventriculoperitoneal shunt: A report of two cases and review of literature. Int J Sci Res 2020;9:21-2.
166Sinha VD, Bhardwaj S, Purohit D, Chopra S. Unusual extrusion of distal end of ventriculoperitoneal shunt: - Case series with literature review. Interdiscip Neurosurg 2021;24:101026.
167Ahmed A, Sandlas G, Kothari P, Sarda D, Gupta A, Karkera P, et al. Outcome analysis of shunt surgery in hydrocephalus. J Indian Assoc Pediatr Surg 2009;14:98-101.
168Biluts H. Admasu AK. Outcome of ventriculoperitoneal shunt insertion at Myungsung Christian Medical Centre in Ethiopia. East Cent Afr J Surg 2015;20:39-48.
169Sekhar Vijya MV, Rao Giri DK, Babji K. Unusual complications of ventriculo-peritoneal shunt: 15 years experience. IAIM 2015;2:77-81.
170Pan P. Outcome analysis of ventriculoperitoneal shunt surgery in pediatric hydrocephalus. J Pediatr Neurosci 2018;13:176-81.
171Hamdan AR. Ventriculoperitoneal shunt complications: A local study at Qena University Hospital: A retrospective study. Egypt J Neurosurg 2018;33:8.
172Park CK, Wang KC, Seo JK, Cho BK. Transoral protrusion of a peritoneal catheter: A case report and literature review. Childs Nerv Syst 2000;16:184-9.