Hydrocephalus refers to the abnormal accumulation of cerebrospinal fluid (CSF) within the brain’s ventricular system [1]. Although it can affect individuals of all ages, hydrocephalus is often observed in newborns and infants due to congenital causes or events related to premature birth [2]. Untreated chronic hydrocephalus can lead to significant cognitive and neurological morbidity, while acute obstructive hydrocephalus may result in seizures, headaches, altered consciousness, coma, and even death [3]. The primary treatment for hydrocephalus involves the placement of a Ventriculoperitoneal (VP) shunt or, in some cases of obstructive etiologies, endoscopic third ventriculostomy (ETV) to drain the excess CSF [3]. However, despite the effectiveness and increased use of the former option, VP shunts are linked to considerable complications and are susceptible to failure, putting patients at risk for repeated surgical interventions [3], [4]. This situation is not uncommon and can greatly impact patients’ quality of life.

Common causes of VP shunt failure include shunt infection, malfunction, and obstruction. Among these, infection is a particularly prevalent complication that poses a substantial risk for patients with shunts [5]. It may lead to prolonged hospital stays, multiple surgeries, and increased healthcare costs. Staphylococcus species are the most frequently isolated pathogens in cases of shunt infection, typically introduced during the surgical procedure or through subsequent contamination [6]. Other pathogens, including unusual organisms, can also be involved, especially in the era of widespread use of broad-spectrum antibiotics [7]. The use of antibiotic-impregnated shunt systems and the implementation of infection-control protocols within high-income healthcare facilities have effectively decreased infection rates, though these measures are often underutilized in low-resource areas [8].

Another significant complication is shunt malfunction due to catheter obstruction at either the proximal or distal ends, or from valve failure. These complications may arise from tissue ingrowth, catheter migration, pseudocyst formation, or mechanical wear over time [9]. Previous studies indicate that up to 40% of pediatric patients who underwent VP shunt placement required revision surgery within two years of insertion, underscoring the susceptibility of these devices to failure [10]. Recurrent revision surgeries resulting from shunt failures place additional pressure on already limited healthcare systems in low-resource countries and conflict-affected regions, where access to specialized neurosurgical care is often constrained. Revisions may also at times require four-hands surgery, which can be challenging to schedule in low-resource environments [11].

The Gaza Strip is one of the most intense conflict zones in the world. It has been occupied for over five decades and has faced a continuous blockade for nearly two decades, leaving significant portions of the population vulnerable and healthcare services chronically on the brink of collapse [12], [13], [14]. This low-resource region encounters considerable challenges in neurosurgery, including VP shunt surgeries, due to ongoing shortages of medical supplies, limited access to advanced surgical instruments, limited critical care capacity, and disrupted patient follow-up stemming from the region’s geopolitical instability [12], [13], [14]. Before the war in 2023, only four board-certified senior neurosurgeons practiced in the Gaza Strip, two trained in Jordan, and two in Qatar, none of whom had specialized higher training in pediatric neurosurgery (resulting in a ratio of approximately one board-certified neurosurgeon per 550,000 residents). The Gaza Strip had two neurosurgical departments located within Shifa Medical Complex and European Gaza Hospitals, which also hosted the local neurosurgery board training program. In addition to the four senior neurosurgeons, these departments employed five other neurosurgeons with master’s degrees and nine residents at various stages of training. VP shunt surgeries in the Strip were performed in either of these two departments.

The logistical and expertise limitations mentioned may lead to a higher rate of shunt failures and complications compared to those observed in resource-rich areas. According to Anele et al. (2021), inadequate access to surgical revisions and infection prevention resources is a critical factor contributing to poor hydrocephalus outcomes in low-income countries [15], which accurately reflects the healthcare challenges faced in Gaza.

That being said, this is the first study from the Gaza Strip to evaluate the outcomes of VP shunt procedures at a tertiary center (Shifa Medical Complex). Reporting these outcomes informs decision-makers and policymakers. It also enables the surgeon to communicate with patients based on locally generated data, which is essential for moderating patient expectations prior to consenting to the procedure.