腰大池腹腔分流.

1、St. Marianna University School of Medicine Department of Neurosurgery Kotaro Oshio M.D. PhD.The preparation and practical surgical technique of lumboperitoneal shunts腰大池-腹腔分流術(shù)前準(zhǔn)備及臨床手術(shù)方法Topics1. Historical background of LP shunting LP分流的歷史背景2. Benefits and complications of LP shunting Experience in u

2、sing LP shunting LP 分流的優(yōu)勢及并發(fā)癥使用經(jīng)驗(yàn)3. Indication of LP shunting Diagnosis iNPH accordance with the guidelines LP分流的適應(yīng)癥自發(fā)性正常顱壓腦積水的診斷4. Video seminar The detailed procedure of LP shunt 手術(shù)視頻LP分流的具體步驟Why LP shunt was not standard?And Why LP shunt now? 為什么為什么LP分流曾經(jīng)不是標(biāo)準(zhǔn)而現(xiàn)在廣泛分流曾經(jīng)不是標(biāo)準(zhǔn)而現(xiàn)在廣泛使用？使用？ First introdu

3、ction of LP shunt was 1950s. For treatment of hydrocephalus. LP分流最早于1950年推出，以治療腦積水 Simple technique 但技術(shù)很簡單Most neurosurgeon hesitate to do LP shunt. Because “Too much complication” then.很多的神很多的神經(jīng)經(jīng)外科大夫由于外科大夫由于術(shù)術(shù)后太多的并后太多的并發(fā)發(fā)癥，而放棄癥，而放棄LP分流分流Improvement 改良改良1. Material & Equipment 材料和設(shè)備2. “Diagnosis

4、” 診斷History of LP shunt LPLP 分流的歷史分流的歷史 1950s first introduction Material : polyethylene 聚乙烯 - induce arachnoiditis and scoliosis 引起蛛網(wǎng)膜炎和脊柱側(cè)凸 1975 Selman et.al. Material : Silicone 硅樹脂 - less arachnoiditis and scoliosisComplication : LP shunt VP shunt postural overdrainage : SDFC & SDH Etc.Diagn

5、osis & Treatment difficult ! favorable indication: communicating hydrocephalus給診斷和治療帶來困難Improvement of the material材料的改進(jìn)Unfortunately, NO adjustable valve !NO CT scan, NO MRI !沒有可調(diào)壓閥門，沒有CT，沒有MRIMRICTAntisiphon deviceAdjustable ValveAccurate diagnosis & less complication in shunt surgery準(zhǔn)確診斷、

6、并發(fā)癥少準(zhǔn)確診斷、并發(fā)癥少Before making guideline of iNPH Hebb and Cusimano Neurosurgery: 49, No. 5, 2001Shunting INPH systematic review : Suggest : Criteria for iNPH is not unified (沒有統(tǒng)一的標(biāo)準(zhǔn) iNPH) significant improvement: only 29% (range 10-100%) Complications occurred in 38% (range, 5100%) Required additional s

7、urgery 22% (range, 047%) permanent neurological deficit and death: 6% (range, 035%)life-threatening intraparenchymal or subdural hematomas requiring surgical evacuation.Diagnosis Evolution診斷的發(fā)展診斷的發(fā)展 Diagnostic radiological equipment:CT, MRI Clarify of the pathophysiology: iNPH guideline放射診斷設(shè)備：CT， MR

8、I明確的病理生理： INPH方針Before 2000 iNPH “Treatable dementia”Shunt responder only 29% 在2000年之前，INPH“可治療老年癡呆癥”分流治療者只有29Disease dementia(Alzheimer type)老年癡呆癥Neurodegenerative disease神經(jīng)退行性疾病Complication 38%iNPHShunt responder80%complication 20%NowComplications of LP shunting.LP分流的并發(fā)癥分流的并發(fā)癥 Wang VY et. al. USCF

9、 group Neurosurgery. 2007 ;60 :1045-8 74 Patients (Average 47.6 y) NPH (14) 19% Communicating hydrocephalus (8) 11% Pseudotumor cerebri (26) 35% Pseudomeningocele (15) 20% CSF leak (11) 15% Complication Revision : 27 cases (36.5%) Over drainage symptoms: 11 cases (14.8%) infection : 3 cases (4%) No

10、serious complicationOnly 30%Recent report of LP shunt LP shunt equally effective as VP shuntComplication rate significant reduceno incidence of subdural hematoma hygroma & low complication Obstruction 1 (1%) Lumber catheter Migration 3 (9%) Pseudomeningocele 2 (6%) Infection 2 (6%) Overdrainage

11、2 (6%) Peritoneal catheter Migration 1 (3%) Abdominal pain 1 (3%) Lumboperitoneal shunts for the treatment of normal pressure hydrocephalusO. Bloch, M.W. McDermott / Journal of Clinical Neuroscience 19 (2012) 11071111Benefits of LP shunting “Avoid intraparenchymal hematoma with ventricular catheter

12、placement.”Benefits of LP shuntingLP分流的優(yōu)勢分流的優(yōu)勢 “Avoid intraparenchymal hematoma with ventricular catheter placement.” 避免腦室導(dǎo)管穿刺部位發(fā)生腦實(shí)質(zhì)血腫 Hebb and Cusimano Neurosurgery: 49, No. 5, 2001 Shunting INPH systematic review : Complications occurred in 38% (range, 5100%) Required additional surgery 22% (rang

13、e, 047%) permanent neurological deficit and death: 6% (range, 035%) Serious complication : VP shuntComplications of LP shunting1. Shunt over drainage:過度分流 CSF leakage subdural fluid collection subdural hematoma2. Shunt malfunction: obstruction migration of shunt catheter flipping the shunt valve3. I

14、nfection閥門壓力和腹腔壓力Diameter difference between Lumber catheter & TUHOY Needle導(dǎo)管和腰穿針之間存在直徑差Factor & counterplan原因及對策Sterile operation &Appropriate antimicrobial無菌操作和適當(dāng)?shù)目股豀ow should we set the appropriate shunt pressure?應(yīng)該如何設(shè)置相應(yīng)的分流壓力？Important surgical tips: anchoring catheterShunt valve fi

15、xation系住導(dǎo)管、固定閥門For avoiding severe complication如何避免嚴(yán)重的并發(fā)癥如何避免嚴(yán)重的并發(fā)癥1. Appropriate shunt pressure setting 設(shè)定適當(dāng)?shù)姆至鲏毫?. Avoid unintentional valve pressure change 防止閥門設(shè)定壓力意外改變3. LP shunting (no puncture brain) LP分流（無穿刺大腦）Polaris is effective. I have not experienced a unintentional pressure change.The ma

16、nner of initial Valve Pressure decision閥門壓力的調(diào)節(jié)方法閥門壓力的調(diào)節(jié)方法 Opening Pressure at Implantation植入時設(shè)定的壓力 To avoid subdural hematomas in older patients, we initially establish a high opening pressure and decrease it step by step when necessary. 初始高壓，然后根據(jù)需要逐步調(diào)低 Another Factor Obesity; choice a little lower

17、pressure 肥胖患者，可以選擇低一點(diǎn)的壓力Bergsneider M et al. Neurosurgery. 2004; 55 :851-8Even very high opening valve pressure setting (170mmH2O)resulted in a significant reduction ICPPredicted shunt under drainage did not occur even at the OPV setting of 200 mm H2O閥門壓力設(shè)定為200mmH2O也沒有發(fā)生分流不足ICP measurement at 11 NPH

18、 patients implanted programmable shunt valve without an antisiphon device . Actual CSF pressure wave form Obesity makes CSF pressure肥胖會使腦脊液壓力上升肥胖會使腦脊液壓力上升 Risk factor for intraabdominal hypertension腹內(nèi)高血壓的風(fēng)險因素腹內(nèi)高血壓的風(fēng)險因素Reintam Blaser A et.al. Acta Anaesthesiol Scand. 2011 55(5):607-14Risk factors for

19、 intra-abdominal hypertension in mechanically ventilated patients.Quick Refererence Tablefor suitable shunt pressure Concept: obesity = IAP suitable valve pressure 理念： 肥胖=IAP 適合的閥門壓力Hydrostatic pressureValve Pressure CSF flow volumeIntra-abdominal Pressure (IAP)腹內(nèi)壓Intracranial Pressure (ICP)Ref) Miy

20、ake H et.al. Neurol Med Chir (Tokyo) 48, 427432, 2008 Desirable conditionunderdrainageoverdrainageFor Avoid unintentional valve pressure change防止閥門設(shè)定壓力意外改變 Basic concept of us 基本的治療理念 uLoss of adjustability after MRI examination. MRI檢查后喪失調(diào)節(jié)能力 uAbove all, unintentional changes in pressure setting.設(shè)定好

21、的閥門壓力發(fā)生意外改變Akbar M. Loss of Adjustability of Codman-Medos Hydrocephalus Valves after Exposure to 3.0T MRI. New England. J. Med. 2005; 353 : 1413 -1414. 6 out of 12 (50%) tested Codman-Medos valves showed permanent failure of adjustability after exposure to a 3.0 T MRIIn contrast, all tested Sophy-SU

22、8 devices could still be re-ajusted after all procedures . 12枚Codman-Medos閥門中6枚在接觸3.0T MRI后，被消磁，永久喪失調(diào)節(jié)能力，而索菲SU8閥門在相同情況下，不受影響。Loss of adjustability after MRI examinationMRI檢查后喪失調(diào)節(jié)能力 Nomura S. Effect of cell phone magnetic fields on adjustable cerebrospinal fluid shunt valves. Surgical Neurology, 63(2

23、005), 467-468. 可以改變不同閥門壓力的最小磁通密度Utsuki S. Alteration of the Pressure Setting of a Codman-Hakim Programmable valve by a Television. Neurol. Med. Chir. (Tokyo) 46, 405-407, 2006. we should recognize that there are many sources of weak magnetic fields that may influence a programmable valve in everyday

24、 life. 日常生活中有許多的若磁場，可能造成可調(diào)壓閥門壓力發(fā)生意外改變 Daily life magnetic fields (1) 日常生活中的磁場（1）Zuzak T.J. Magnetic toys: forbidden for pediatric patients with certain programmable valves.? Childs Nervous Syst. 25: 161-164 (2009). Anderson R. Adjustment and malfunction of a programmable valve after exposure to toy

25、magnets. J. Neurosurg. : Pediatrics 101 : 222-225. Both Codman and Strata programmable valves revealed alterations of pressure settings after exposure to commercially available toy magnets.Surgeons should warn the families of patients with programmable valves to avoid toy magnets.It was shown that t

26、he magnetic properties of magnetic toys are of sufficient strength to alter programmable Strata and Codman valves.Daily life magnetic fields (2) 日常生活中的磁場（2）u headphones 14.0 mTu earphones (Walkman) 23.0 mTu cordless telephone 34.0 mTu cellular telephone 17.5 mTu toy magnet67 82 mTDe Schneider et al.

27、 J.Neurosurgery 96:331-334, 2002Potential sources of dysadjustment daily lifeIndication of LP shunting Communicating hydrocephalus 交通性腦積水交通性腦積水a(chǎn). idiopathic Normal Pressure Hydrocephalus (iNPH) 自發(fā)性正常顱壓腦積水b. Secondary Normal Pressure Hydrocephalus 繼發(fā)性正常顱壓腦積水 Contraindication: obstructive hydrocephalu

28、s 禁忌癥禁忌癥：梗阻性腦積水梗阻性腦積水 Exclusion! : Intracranial solid occupying lesion (+) Queckenstedt test positive It is important to diagnose in accordance with the guidelinesidiopathic Normal Pressure Hydrocephalus (iNPH) Age : 60 y.o. (Japanese iNPH GL) ref) 40 y.o. ( Relkin N et.al. Neurosurgery 2005, iNPH g

29、uideline US & Euro) Symptom (Triad) 1： gait disturbance, urinary incontinence, dementia Radiological findings: Ventricle dilatation (Evans index 0.3), CSF pressure Improvement = Probable iNPH Treatment: Shunt surgery (V-P shunt, L-P shunt)- Improvement = Definite iNPHImprovement symptom: Gait UI

30、 DementsSINPHONI (The study of iNPH on neurological improvement)iNPH specific radiological feature :VentriculomegalyTight high-convexity and medial subarachnoid spaceExpanded sylvian fissure Hashimoto M et. al. Cerebrospinal Fluid Res. 2010 7:18.Diagnosis of idiopathic normal pressure hydrocephalus

31、is supported by MRI-based scheme: a prospective cohort study. (Disproportionately Enlarged Subarachnoid-space Hydrocephalus)Shunt effective rate 80%Classification of Normal Pressure Hydrocephalus (NPH)NPHIdiopathic NPHDESHNon-DESHSecondaryNPHAcquiredetiologiesCongenital/Developmentaletiologies (Disp

32、roportionately Enlarged Subarachnoid-space Hydrocephalus) 60 y.o.(Japanese iNPH GL) 80%20%Etiology of iNPH Probable iNPH is estimated: a minimum prevalence of iNPH in our population of 21.9/100,000.Prevalence of probable idiopathic normal pressure hydrocephalus in a Norwegian population.Brean A, Eid

33、e PK. Acta Neurol Scand 2008: 118: 4853MRI feature of iNPHWhy LP shunt?before iNPH guideline (20th century) Once relinquish surgery for iNPH secondary hydrocephalus (relatively young ) hydrocephalus in children mostly adapt the VP shunt. 2004 iNPH guidelines the proportion of elderly patients LP shu

34、nt is preferred than VP shunt Avoid intraparenchymal hematoma with ventricular catheter placement. iNPH patients : Age 74.5 + 5.1 Y.O. Video seminar The detailed procedure of lumboperitoneal shunt 1. Introduction of Surgical materials & Design 手術(shù)耗材和設(shè)計介紹2. Preoperative preparation: 術(shù)前準(zhǔn)備A) shunt v

35、alve adjusting 閥門調(diào)節(jié)B) Operation room arrangement 手術(shù)室安排C) Positioning 擺體位3. Surgical procedure (video) 手術(shù)過程（視頻）Lumbo-peritoneal Catheter腰大腰大池池-腹腔導(dǎo)管腹腔導(dǎo)管 The Sophysa Lumbo-Peritoneal Catheter Set索菲薩LP分流導(dǎo)管套裝- Lumbar catheter（腰椎管）, 0.76 mm ID,1.6 mm OD, length 60 cm, multi-perforated proximal tip, radiop

36、aque, depth markings at 11, 16, 21, 26 cm from the proximal tip.- Intermediary catheter（中間管）, 1.1 mm ID, 2.5 mm OD, length 10 cm, with integrated proximal asymmetric step-down connector for attachment to lumbar catheter, radiopaque stripe.（在腰椎管和閥門中間過度連接）- Peritoneal catheter（腹腔管）,1.1 mm ID,2.5 mm OD

37、, length 70 cm, multiperforated open end, radiopaque stripe.- Tuohy needle 14 Gauge, length 9 cm.- Female Luer-Lock connector（Luer 接頭）. Adjustment for valve pressure PolarisPositionOperating Pressure (mm H2O) SPVSPV-140SPV-300 SPV-4001301050802704010015031108015023041501102203305200140300400SPVA : P

38、olaris Adjustable Valve, 30-200, AntechamberPreoperative preparation Design of LP shuntPolaris valvePeritoneal catheterLumbar catheterIntermediary catheter* Design : Shunt valve would place above iliac crest for pumping.Design of LP shuntPolaris valvePeritoneal catheterLumbar catheterIntermediary catheterOperating room arrangementAnesthesiologistSurgeonSurgeonBipolar & monopolar coagulatorsuctionApparatus & nurseArm standApparatus & nursePositioning & skin incisionLateral positi