Management of Sterile Abdominal Pseudocysts in the Context of Ventriculoperitoneal Shunts: A Systematic Review of Repositioning vs. Externalization

Introduction: Ventriculoperitoneal shunts (VPS) are used to manage hydrocephalus but are known to have many complications, such as obstruction, infection, and pseudocyst formation. Abdominal pseudocysts (APC) are one of the most common abdominal complications related to VPS. Management options for APCs involve externalizing the VPS with later internalization or repositioning the distal catheter in the peritoneum. This systematic review explores whether repositioning is equally efficacious in managing sterile APCs compared to externalization.

Methods: The Pubmed/Medline and Scopus databases were searched from inception to June 2023 for cases of APC as a complication of VPS. Our search strategy combined the following terms: abdominal pseudocyst, pseudocyst, ventriculoperitoneal shunt, treatment, management, complications, and outcomes. Inclusion criteria included studies on managing sterile abdominal pseudocysts related to VPS. Studies with the following criteria were excluded: 1) non-English; 2) basic science studies; 3) animal studies; 4) review papers; 5) letters or editorials; 6) shunt conversion (i.e., VA). The primary outcome assessed was failure rates.

Results: Initial searches yielded 362 results. After the title and abstract screening, 87 articles were fully assessed for eligibility. A full-text evaluation of articles produced 47 eligible studies. Patients who underwent repositioning had a 20 out of 65 (30.8%) failure rate compared to 21 out of 71 (29.6%) who underwent externalization. Confirmed antibiotic use was demonstrated in 1 of 65 with no failure for repositioning and 44 of 71 with a failure rate of 36.4% for externalization. These revisions were mainly due to APC recurrence and some due to infection or blockage.

Conclusion : In the context of a sterile APC, the data suggests that repositioning is equally effective to externalization related to complications and outcomes. Important to note is that both methods have a high percentage of needing further revisions. However, few studies have directly compared these two methods.