Dear Editor,
We thank the authors for their comments on the paper, ‘Unusual complication of Ventriculoperitoneal shunt: Anal extrusion'.
We are in full agreement with the observation that irrespective of clinical manifestation of meningitis or whether the CSF is clear and negative on microscopic examination, under no circumstances should a fresh shunt be placed at the time of initial presentation.
Why we failed to apply the same algorithm in Case 2 ? The algorithm was made after our experience with Case 2. The very purpose of this manuscript was to highlight our failure to adhere to established management principles in Case 2 and bring to the notice of the medical fraternity the host of problems that we faced as a result of it, along with the attendant morbidity that the patient was subjected to. The message is very clear. Wait out a period of observation to let even low grade infection manifest itself, in which case it is not important whether the shunt is pulled out in a retrograde manner from the neck or from the subcostal region of the abdomen where the shunt tube dips into the peritoneal cavity.
However, we feel that the retrograde pulling for the removal of an anal extrusion of a shunt will not cause contamination of the peritoneal cavity since the fibrosed shunt tube track is supposed to be fused to the serosa of the intestine.
We have no answer as to how the anal extrusion of the shunt recurred within forty eight hours. We have documented what happened in this patient. However, it is just not possible that there was an inadvertent intra-luminal positioning of the shunt catheter since while placing a VP shunt, the peritoneal cavity is opened by an incision in the subcostal region and the peritoneal end of the shunt tubing is placed in the peritoneal cavity in the suprahepatic compartment.