Surgical Management of the Bystanding Ventriculoperitoneal Shunt During Peritonitis: A Systematic Review and Individual Level Meta-analysis

Introduction: Patients with a ventriculoperitoneal shunt (VPS) are at risk for shunt contamination during primary abdominal infections. VPS externalization or replacement has been performed to limit the risk of ascending infection. In this study, the effect of prophylactic VPS externalization (PE) on patient outcomes is explored.

Methods: Pubmed, Embase, Medline, and Cochrane databases were searched for reports of patients with VPS presenting with peritonitis and without shunt infection, which were systematically reviewed. Adverse outcomes were examined via pooled estimates (weighted by sample size) and meta-analysis of available individual-level data. Adverse outcomes were defined as any revision, shunt infection, or mortality. The odds of an adverse outcome were estimated using binomial regression.

Results: 4,604 studies were screened, and 10 were included for final analysis, representing 128 patients. Three studies reported adult patients, 4 reported pediatric patients, and 4 reported both. Infection and revision rates in situ were 2.9% (N=34) and 17.4% (N=23), respectively. Respective rates for PE were 8.3% (N=12) and 25% (N=12). Mortality rate was 0% in both groups. In meta-analysis of individual-level data describing 26 patients from 4 studies, 38.5% underwent PE. Adverse events were reported in 26.7% of the in situ group and 40.0% of the PE group. PE was associated with greater odds of adverse outcomes (OR 7.6, 95%CI 2.3-28.2 p=0.001). There was substantial heterogeneity in reporting of possible confounders such as shunt management, interventions for the primary pathology, adjunctive treatments, and antibiotic use.

Conclusion : High rates of adverse outcomes were demonstrated in reported cases of PE compared to in situ management of VPS in the setting of peritonitis. Meta-analysis was severely limited by study heterogeneity, suggesting opportunity for improved reporting. Given an insufficient evidence base, neurosurgeons must exercise individual judgment when deciding between PE or in situ VPS management in the setting of peritonitis.