9 USE OF THE VENTRICULO-CHOLECYSTIC SHUNT IN THE MANAGEMENT OF COMPLEX PATIENTS- WHAT DO PAEDIATRIC SURGEONS NEED TO KNOW ABOUT THIS?
Duncan Henderson, Michelle Horridge, Ross Fisher
Sheffield Children's Hospital, Sheffield, United Kingdom

Abstract
Aim of the Study 
The preferential placement of distal CSF shunt tubing is into the peritoneum, followed by the right atrium. However, when the peritoneum and right atrium are compromised it is unclear how best to proceed. The pleural cavity is often utilized, which has associated morbidities. We present our experience using the gall bladder as a safe and effective alternative. 

Methods 
We performed a retrospective review of 2 patients who underwent VC shunt insertion by a single paediatric surgeon and neurosurgical team in a tertiary paediatric surgical centre. 

Main Results 
Male born at 28+4 weeks (1019g) with grade IV Intraventricular haemorrhage and necorotising enterocolitis and subsequently laparotomy. He had a ventriculo-peritoneal (VP) shunt insertion and revision due to adhesions blocking the distal tubing. He had insertion of a left ventriculo-atrial (VA) shunt, followed by a right VA shunt and 2 revisions of this. He then had a VC shunt inserted which has remained operational for 16 months, his longest duration without need for revision.

Two year old male with hydrocephalus secondary to a posterior fossa tumour, underwent multiple distal shunt revisions. It was concluded the peritoneum was non-absorptive. The right atrium was unsuitable due to infected portacath tubing, with aureus positive cultures. Long term central access was required to receive regular chemotherapy. Therefore, a VC shunt was inserted and at four months post operatively there have been no further shunt revisions.  

Conclusion 
In our experience, the gall bladder is a viable option for distal CSF shunt catheter placement. When the peritoneum and right atrium are compromised, the gall bladder is a safe and effective alternative. These cases demonstrate the need for consideration of alternative CSF diversion sites in complex cases and highlight the importance of early multidisciplinary working to ensure the best outcome for these patients.

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