EP318 - Hyperthermic Intraperitoneal Chemotherapy with a Ventriculoperitoneal Shunt: Is it Safe? A Case Report

Purpose/Background: Ventriculoperitoneal (VP) shunts for the management of hydrocephalus are designed to successfully shunt excess cerebrospinal fluid into the peritoneum. Though these shunts contain one-way valves, there is concern that an intrabdominal process, including infection, may result in translocation to the neurologic system. In patients with peritonitis, the shunt will often be externalized until the infection resolves. Hyperthermic intraperitoneal chemotherapy (HIPEC) results in improved survival outcomes in patients with appendiceal mucinous adenocarcinoma. In patients with VP shunts and mucinous carcinoma, the potential neurologic side effects of intraperitoneal chemotherapy are not well documented in the literature. We present an interesting case of HIPEC use in the setting of a VP shunt.

Methods/Interventions: The patient is a 62-year-old male with history of hydrocephalus managed by a VP shunt who presented to the hospital with abdominal pain and unintentional weight loss. CT scan at this time was concerning for a right lower quadrant mass with adjacent lesions in omentum and mesentery (Figure 1). He underwent CT guided biopsy with findings compatible with low grade peritoneal mucinous carcinoma, thought to be appendiceal in origin. Colonoscopy was completed and revealed an additional mass in the transverse colon with biopsies consistent with adenocarcinoma.

Results/Outcomes: He completed neoadjuvant chemotherapy and underwent repeat colonoscopy and staging imaging. A multidisciplinary decision was made to proceed with cytoreduction and HIPEC. Neurosurgery was consulted and recommended simply clamping the VP shunt during the chemotherapy installation as these shunts have valves to prevent retrograde flow. He underwent an uneventful subtotal colectomy with cytoreduction including multiple small bowel resections and HIPEC. He was noted to have extensive disease with peritoneal carcinomatosis index of 15. The VP shunt was occluded during the mitomycin C infusions using a rubber shod clamp (Figure 2). The patient was awakened from anesthesia without any neurologic symptoms. Unfortunately, the patient’s later postoperative course was complicated by deep venous thrombosis, pulmonary embolism, small bowel anastomotic leak and septic shock requiring ICU admission and multiple returns to the operating room. The pathology returned as mucinous adenocarcinoma.

Conclusion/Discussion: There is existing literature discussing VP shunt exteriorization in the setting of intraabdominal infections and peritonitis. However, the effects of hyperthermic intraperitoneal chemotherapy in patients with VP shunts are not well reported. This case, to our knowledge, represents a unique presentation of mucinous cancer in a patient with a VP shunt and raises significant management questions. Our patient had a successful outcome, with no neurologic adverse events; however, additional research is needed. Avenues for further research should focus on the short- and long-term effects of intraperitoneal driven therapies as well as patient prohibitive factors.

Figure 1 - Preoperative Computed Tomography Scan
CT demonstrating large complex fluid vs mass (11.7 x 6.2 cm) in the right lower quadrant ileocolic mesentery

Figure 2 - Intraoperative Management of VP Shunt
Intraoperative depiction of VP shunt occlusion using a rubber shod clamp.