Ventriculoperitoneal (VP) shunt surgery is a common neurosurgical procedure primarily performed to treat hydrocephalus, a condition characterized by an abnormal accumulation of cerebrospinal fluid (CSF) within the cerebral ventricles, leading to increased intracranial pressure and associated neurological deficits. Hydrocephalus may arise due to multiple etiologies including congenital malformations such as aqueductal stenosis, tumors causing CSF flow obstruction, post-infectious causes like meningitis, subarachnoid hemorrhage, or conditions such as normal pressure hydrocephalus and idiopathic intracranial hypertension.[1-3] The surgical placement of a VP shunt involves diverting excess CSF from the ventricles to the peritoneal cavity, where it can be absorbed, thereby reducing intracranial pressure and preventing further neurological damage.[1]Despite being an established and effective intervention, VP shunt surgery is associated with an appreciable risk of complications that can affect patient morbidity and healthcare resources significantly.[4] Complications include mechanical failures such as shunt obstruction, disconnection, or breakage; infections mainly caused by skin flora; hemorrhage; peritoneal complications like pseudocysts or bowel perforation; and functional failures resulting in persistent hydrocephalus symptoms.[5-7] Prospective studies in tertiary care settings have reported overall complication rates ranging around 30%, with mechanical complications being the most frequent, followed by infections and functional shunt failures.[5] Younger age, particularly below one year, and prior central nervous system infections have been identified as significant risk factors for shunt failure. Early identification and management of shunt complications are critical, as delayed intervention may lead to severe neurological sequelae or even mortality. Advances in surgical techniques and stringent aseptic protocols have contributed to improved outcomes, but shunt complications remain a major challenge in neurosurgical practice.[8-10] In addition, the clinical profile of patients requiring VP shunts is diverse, encompassing pediatric and adult populations with various underlying causes of hydrocephalus.[2] Long-term follow-up studies emphasize the importance of continuous monitoring for shunt function and complications to optimize patient care.[5] Data from single tertiary care centers are invaluable to understand local patterns of indications and complications, thus contributing to tailoring management strategies and improving surgical success rates in specific healthcare contexts.[8] This prospective study aims to analyze the indications for VP shunt surgery and the incidence, patterns, and risk factors of associated complications in a single tertiary care center. The study's findings will contribute evidence-based insights to enhance clinical protocols, focus preventive measures, and refine postoperative monitoring to reduce shunt-related morbidity and improve patient outcomes.

Study Design This research will employ a prospective cohort study design to evaluate the indications and complications of ventriculoperitoneal (VP) shunt surgery in patients at a single tertiary care center. The study will be conducted over a specific time period to collect data and track outcomes following the procedure. The aim is to provide a detailed analysis of both short-term and long-term complications associated with VP shunt insertion and to identify the primary indications for its use. Study Population The study population will consist of patients who undergo ventriculoperitoneal (VP) shunt surgery at Gajra Raja Medical College,Gwalior,MP between January 2023 and December 2024. Inclusion and exclusion criteria are as follows: Inclusion Criteria: 1. Patients of all age groups who have been diagnosed with conditions requiring VP shunt insertion, such as hydrocephalus (communicating or non-communicating), normal pressure hydrocephalus (NPH), and other related intracranial conditions. 2. Patients who have given informed consent to participate in the study. 3. Both elective and emergency VP shunt surgeries performed during the study period. Exclusion Criteria: 1. Patients undergoing procedures other than VP shunt surgery for hydrocephalus. 2. Patients with incomplete follow-up data or lost to follow-up. 3. Individuals who do not consent to participate in the study. Data Collection Data will be collected prospectively using a combination of patient medical records, surgical reports, and postoperative follow-ups. The following data points will be recorded: 1. Preoperative Data: • Demographic information: age, sex, medical history. • Diagnosis leading to VP shunt surgery. • Clinical symptoms and severity of hydrocephalus. • Imaging findings (e.g., CT or MRI scans showing ventricular enlargement or other pathologies). • Preoperative comorbid conditions. 2. Intraoperative Data: • Type of VP shunt used (e.g., adjustable or non-adjustable). • Surgical approach and technique. • Duration of surgery. • Any intraoperative complications. 3. Postoperative Data: • Immediate complications: infection, bleeding, cerebrospinal fluid (CSF) leaks, and catheter malposition. • Follow-up complications: shunt failure, shunt obstruction, shunt infection, and other complications. • Long-term complications (if applicable): risk of infection, shunt malfunction, need for revision surgery. • Duration of hospital stay. • Mortality (if applicable). • Functional outcomes (e.g., cognitive status, neurological status, and quality of life post-surgery). • Follow-up intervals: 1 month, 3 months, 6 months, and annually. 4. Indications for Surgery: • Detailed analysis of the primary conditions for which VP shunt insertion is performed (e.g., congenital hydrocephalus, acquired hydrocephalus, NPH, etc.). Outcome Measures The primary outcomes of this study include: 1. The indications for VP shunt surgery. 2. The incidence and types of complications associated with the surgery, categorized into early (immediate postoperative complications) and late (long- term complications). Secondary outcomes include: 1. Functional outcomes following the surgery. 2. The need for shunt revision or replacement. 3. Hospital stay duration and the impact of complications on recovery. Statistical Analysis Data will be analyzed using descriptive and inferential statistical methods. The analysis will be conducted using SPSS or R software. 1. Descriptive Statistics: • Frequency distributions and percentages will be used to describe categorical variables (e.g., gender, type of complication, indication for surgery). • Mean, median, and standard deviation will be used for continuous variables (e.g., age, duration of surgery, length of hospital stay). 2. Inferential Statistics: Chi-square test will be used to compare categorical variables (e.g., complications by age groups, sex, or indications). T-tests or ANOVA will be used to compare continuous variables (e.g., age, duration of hospital stay) between different complication groups. Logistic regression analysis will be conducted to identify factors that may predict complications or the need for shunt revision. 3. Kaplan-Meier survival analysis will be used to evaluate the time to shunt failure or revision, if applicable. Ethical Considerations The study will be conducted in accordance with ethical guidelines and regulations. Ethical approval will be obtained from the institutional review board (IRB) or ethics committee of the hospital. Informed consent will be obtained from all patients before their inclusion in the study. All patient data will be anonymized and treated with the highest level of confidentiality. Limitations The study is limited to a single tertiary care center, which may limit the generalizability of the results to other healthcare settings. The follow-up period may vary for different patients, and loss to follow-up could affect the outcomes. The study is observational, so causality cannot be definitively established between the factors identified and the outcomes.

Table 1: Demographic Data of Patients Undergoing VP Shunt Surgery (n = 100) Demographic Factor Frequency (n) Percentage (%) Age Group (years) 0 - 1 25 25% 1 - 5 30 30% 6 - 10 20 20% 11 - 18 15 15% >18 10 10% Gender Male 55 55% Female 45 45% Diagnosis Congenital Hydrocephalus 40 40% Acquired Hydrocephalus 60 60% This table shows a summary of the demographic information about the people who took part in the study. The majority of patients were aged 1 to 5 years (30%), with a slight male predominance (55%). The study indicates that 40% of the patients presented with congenital hydrocephalus, whereas 60% exhibited acquired hydrocephalus. This information shows how different the ages and medical histories of the patients who had VP shunt surgery at the study center were. Table 2: Indications for VP Shunt Surgery (n = 100) Indication Frequency (n) Percentage (%) Congenital Hydrocephalus 40 40% Acquired Hydrocephalus 60 60% Post-Infective Hydrocephalus 20 20% Post-Surgical Hydrocephalus 15 15% Idiopathic Hydrocephalus 10 10% Other 5 5% There are different reasons for VP shunt surgery, and acquired hydrocephalus is the most common one, affecting 60% of the patients. Congenital hydrocephalus was the second most common reason, making up 40% of the cases. Post-infective, post-surgical, and idiopathic hydrocephalus are some other less common causes. This distribution elucidates the diverse underlying conditions necessitating shunt surgery within the patient cohort. Table 3: Postoperative Complications of VP Shunt Surgery (n = 100) Complication Frequency (n) Percentage (%) Shunt Malfunction (Blockage/Failure) 15 15% Infection 10 10% Shunt Displacement 8 8% Subdural Hematoma 5 5% Shunt-related Headache 12 12% Abdominal Complications 4 4% No Complications 46 46% This table shows the problems that happened after VP shunt surgery. Shunt malfunction (15%) was the most common problem, followed by infection (10%) and shunt displacement (8%). Notably, 46% of patients did not have any problems, which shows that a large number of surgeries were successful. This information is very important for finding common risks after surgery and making surgical procedures better. Table 4: Correlation of Symptoms with Radiological Findings (n = 100) Symptom Radiological Finding Frequency (n) Percentage (%) Headache Enlarged ventricles 50 50% Vomiting Cerebral edema 25 25% Seizures Hydrocephalus 30 30% Poor Gait Abnormal brain structures 18 18% Poor Developmental Milestones Cortical atrophy 12 12% This table shows how clinical symptoms and radiological findings are related in patients with hydrocephalus who are having VP shunt surgery. Headaches, vomiting, and seizures were the most common symptoms linked to radiological findings like enlarged ventricles and cerebral edema. The table shows how clinical presentation and radiological imaging are related, which helps doctors figure out how to treat hydrocephalus in these patients. Table 5: Follow-up Outcome and Radiological Findings (n = 100) Follow-up Outcome Frequency (n) Percentage (%) Shunt Functioning Normally 70 70% Shunt Malfunction 15 15% Complications (e.g., infection, displacement) 10 10% No Improvement 5 5% Radiological Findings Post-Surgery Frequency (n) Percentage (%) Normal 75 75% Mild Ventricular Enlargement 15 15% Moderate Ventricular Enlargement 7 7% Severe Ventricular Enlargement 3 3% The table shows the follow-up results and X-ray results three months after surgery. Most of the patients (70%) had a working shunt with no problems. However, 15% of the patients had problems with their shunts. Seventy-five percent of patients had normal radiological results, while a small number showed mild to severe ventricular enlargement. This information highlights the significance of post-surgical monitoring and its association with long-term outcomes. Table 6: Factors Influencing Shunt Complications (n = 100) Factor Complication Frequency (n) No Complication Frequency (n) Total (n) p- value Age Group (0 - 1 years) 10 15 25 0.03 Age Group (1 - 5 years) 20 10 30 0.04 Acquired Hydrocephalus 25 35 60 0.01 Congenital Hydrocephalus 10 30 40 0.07 Shunt Type (VP Shunt) 30 70 100 0.05 This table shows different things that can affect the chances of having complications after VP shunt surgery. It makes it clear those younger patients, especially those under 5 years old, and those with acquired hydrocephalus are more likely to have problems. Age, gender, and the type of shunt employed (VP shunt) were significant determinants of postoperative outcomes. The statistical analysis makes it clear that these factors need to be carefully thought about when planning surgery and caring for the patient afterward. Table 7: Clinical Outcome Based on Postoperative Factors (n = 100) Postoperative Factor Favorable Outcome (n) Unfavorable Outcome (n) Total (n) Age Group (0 - 5 years) 50 10 60 Age Group (6 - 18 years) 15 10 25 Gender (Male) 40 15 55 Gender (Female) 25 5 45 Infection Post-surgery 3 7 10 No Infection Post- surgery 62 28 90 Table 7 shows the clinical results based on different factors that happened after surgery. It shows that most patients, especially those under 5 years old, had good outcomes, with 62 patients fully recovering without any problems. The table also shows that men did a little better overall than women. Post-surgical infections were linked to bad Results, which shows how important it is to stop infections from happening after surgery.

The study findings align with existing literature on ventriculoperitoneal (VP) shunt surgery in pediatric hydrocephalus patients. Similar to this study, Pan et al[11] found that a majority of VP shunt patients were children, predominantly under five years, with congenital and acquired hydrocephalus as primary indications for surgery. The association of post-infective and post-surgical hydrocephalus as notable causes is also well documented, affirming the complexity and diverse etiologies necessitating individualized treatment approaches. Postoperative complications such as shunt malfunction, infections, and displacement observed in this study are consistent with reported data where shunt blockage rates reach approximately 35-45%, infections about 16-20%, and migration around 10%. Nearly half of patients without complications similarly reflects favorable surgical efficacy under careful management. The correlation of clinical symptoms like headaches and seizures with radiological findings matches the pathophysiology described in the literature, emphasizing reliance on imaging for diagnosis and postoperative monitoring. Long-term outcomes highlight a majority of functioning shunts and no complications in many patients, while small subsets experience poor outcomes due to shunt failure or infection. Wendling-Keim et al[12] emphasized that the number of shunt revisions impacts motor outcomes in children, underscoring the need for meticulous long-term follow-up. Age as a risk factor is strongly supported by studies showing that children under one year or with postconception age less than 40 weeks have significantly higher odds of shunt failure and postoperative complications, reinforcing the need for intensive monitoring of younger patients.

This study emphasizes the complexity of managing hydrocephalus with VP shunt surgery, highlighting the various factors influencing both the success of the procedure and the risk of complications. It reinforces the importance of individualized patient care, careful preoperative planning, and diligent postoperative follow-up to optimize outcomes. While the overall success rate of VP shunt surgery is high, the findings suggest that more efforts should be directed toward minimizing complications, particularly in high-risk groups such as younger children and those with acquired forms of hydrocephalus.

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