Preventing Distal Catheter Obstruction in Laparoscopic Ventriculoperitoneal Shunt Placement in Adults: The "Falciform Technique".

BACKGROUND: Distal obstruction of ventriculoperitoneal (VP) shunts is a major problem in the treatment of hydrocephalus. To avoid this complication, we describe a simple method using the falciform ligament to place and hold the distal catheter in the right subdiaphragmatic space, preventing catheter migration and distal obstruction. MATERIALS AND METHODS: We retrospectively collected data of all VP shunt insertion and revision for adults with idiopathic normal-pressure hydrocephalus between November 2011 and September 2013. All of these were done using the "falciform technique," with the distal catheter portion performed laparoscopically. No exclusion criteria were applied. A neurosurgeon and a laparoscopic surgeon were involved in each case. The falciform ligament was used to tether the distal catheter above the liver, with the distal tip of the catheter reaching the hepatic flexure to allow for drainage directly into the right paracolic gutter. Baseline, operative, and postoperative data were collected and analyzed. RESULTS: In total, 58 patients underwent a shunt procedure during the period of study. The majority (74%) underwent new VP shunt placement, and 26% underwent revision and replacement for catheter obstruction. The female to male ratio was 1.14:1. Mean age was 67.3±17.5 years. Revisions due to distal catheter obstruction were subsequent to previous surgery placement. Median follow-up was 329 days. Three patients (5%) had proximal catheter obstruction requiring shunt revision. None of the patients (0%) was found to have distal obstruction at the end of the study period at the most recent follow-up. CONCLUSIONS: The faparoscopic falciform technique significantly reduces the rate of distal VP shunt obstruction in adults with idiopathic normal-pressure hydrocephalus. Continued follow-up is needed to confirm long-term patency of the catheter.

Factors related to hydrocephalus after aneurysmal subarachnoid hemorrhage.

OBJECTIVE: The purpose of this study was to identify factors predictive of shunt-dependent hydrocephalus among patients with aneurysmal subarachnoid hemorrhage. The data can be used to predict which patients in this group have a high probability of requiring permanent cerebrospinal fluid diversion. METHODS: Seven hundred eighteen patients with aneurysmal subarachnoid hemorrhage who were treated between 1990 and 1999 were retrospectively studied, to identify factors contributing to shunt-dependent hydrocephalus. With these data, a stepwise logistic regression procedure was used to determine the effect of each variable on the development of hydrocephalus and to create a scoring system. RESULTS: Overall, 152 of the 718 patients (21.2%) underwent shunting procedures for treatment of hydrocephalus. Four hundred seventy-nine of the patients (66.7%) were female. Of the factors investigated, the following were associated with shunt-dependent hydrocephalus, as determined with a variety of statistical methods: 1) increasing age (P < 0.001), 2) female sex (P = 0.015), 3) poor admission Hunt and Hess grade (P < 0.001), 4) thick subarachnoid hemorrhage on admission computed tomographic scans (P < 0.001), 5) intraventricular hemorrhage (P < 0.001), 6) radiological hydrocephalus at the time of admission (P < 0.001), 7) distal posterior circulation location of the ruptured aneurysm (P = 0.046), 8) clinical vasospasm (P < 0.001), and 9) endovascular treatment (P = 0.013). The presence of intracerebral hematomas, giant aneurysms, or multiple aneurysms did not influence the development of shunt-dependent hydrocephalus. CONCLUSION: The results of this study can help identify patients with a high risk of developing shunt-dependent hydrocephalus. This may help neurosurgeons expedite treatment, may decrease the cost and length of hospital stays, and may result in improved outcomes.

Titanium cage reconstruction after cervical corpectomy.

OBJECT: The authors evaluated the efficacy of titanium cage- and anterior cervical plate (ACP)-augmented fusion for reconstruction following decompressive cervical corpectomy in nontraumatic disease. METHODS: Forty-five patients ranging from 37 to 77 years of age underwent anterior cervical corpectomy followed by titanium cage-assisted reconstruction in which the cages were filled with autologous bone obtained from the resected vertebral bodies (VBs). Plates were placed in all patients. Follow-up radiographic evaluation included computerized tomography scanning and plain flexion-extension radiography. Fusion was demonstrated in all but one patient without reconstruction-related complications. The single complication involved an endplate VB fracture with pistoning of the cage into the VB. The mean follow-up period was 12.9 months. CONCLUSIONS: Autologous corpectomy bone-filled titanium cages supplemented with ACPs are an effective means of reconstruction after compressive cervical corpectomy. This technique provides a reasonable alternative to procedures involving long solid strut grafts obtained from the bone bank or from the patient.

Immediate morbidity and mortality associated with transcallosal resection of tumors of the third ventricle.

Resection of tumors of the third ventricle via the anterior interhemispheric transcallosal approach represents a surgical challenge. It carries a risk of postoperative complications, due to the role of surrounding structures in control of eloquent functions. We reviewed the immediate morbidity and mortality associated with this approach. Between June 1993 and July 2007, 38 patients underwent resection of tumors of the third ventricle via the anterior interhemispheric transcallosal approach at The University of Texas M. D. Anderson Cancer Center. Their 30-day postoperative morbidity and mortality rates were retrospectively analyzed relative to clinical variables possibly affecting these rates. Complications were categorized as neurological, regional, and systemic and were subclassified as major or minor. The overall complication rate was 50%. Major complications occurred in 37% of patients; 34% suffered neurological complications (16% being major complications). Surgical mortality was 8%. Univariate analysis demonstrated that tumor hemorrhage (p=0.04), preoperative Karnofsky Performance Scale (KPS) score (p=0.04), tumor status (recurrent versus [vs.] new or residual; p=0.01), and cauterization of any of the bridging veins (p=0.04) were associated with the incidence of postoperative complications. Multivariate analysis showed that increased age at surgery (p=0.04), tumor status (p=0.03), preoperative KPS score (p=0.02), and the extent of tumor resection (p=0.05) correlated significantly with the incidence of postoperative complications. Resection of tumors of the third ventricle via the interhemispheric transcallosal approach is associated with significant postoperative morbidity. Preserving the venous structures is of paramount importance in minimizing major neurological complications. Our results have practical risk-predictive value and can serve as the foundation for subsequent outcome studies.