Ventriculo-gallbladder shunt reflux: A case study and review of the literature.

BACKGROUND

Ventriculo-gallbladder (VGB) shunt represents an uncommon yet well-documented surgical intervention for the treatment of hydrocephalus through cerebrospinal fluid (CSF) diversion into the gastrointestinal tract through the gallbladder. When other ventricular shunt types have failed or are contraindicated, VGB shunts are effective. In exceptionally rare circumstances, biliary reflux can occur and cause accumulation of bile in the ventricular system. The authors report a case of bile reflux through a ventricular gallbladder shunt with eventual patient recovery after surgical intervention. Prior reports of VGB shunt complications are discussed.

CASE DESCRIPTION: The authors present the case of a 3-year-old girl with a history of craniopharyngioma causing obstructive hydrocephalus. At an outside facility, she underwent ventriculo-peritoneal (VP) shunt placement, which failed due to abdominal pseudocyst after 6 months. The patient then underwent a subtotal resection of her tumor and placement of a right VGB shunt system with a subdural and ventricular catheter connected distally to a Certas valve. Her postoperative course was complicated by the left-sided tonic-clonic seizures and hyponatremia. Three months later, the patient presented to our emergency department with persistent hyponatremia, encephalopathy, and seizure activity in the setting of COVID-19. Imaging demonstrated a right hypodense subdural fluid collection. Right frontal craniotomy demonstrated accumulation of bile in the subdural space secondary to retrograde flow from the gallbladder, which was evacuated. After externalized subdural drainage evolved from biliary fluid to normal CSF, the externalized ventricular shunt and subdural drain were replaced with a ventriculo-atrial shunt. The patient gradually improved with each follow-up visit over the course of several years.

CONCLUSION

This case demonstrates a potentially life-threatening complication of VGB shunt in the form of biliary reflux into the subdural space. Valveless VGB shunts should be avoided to prevent this rare but potentially fatal complication.