（推薦精選）腰大池腹腔分流

1、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1 TopicsHistorical background of LP shunting LP分流的歷史背景Benefits and complications of LP shunting Experience in using LP shunting LP 分流的優(yōu)勢(shì)及并發(fā)癥使用經(jīng)驗(yàn)Indication of LP shunting Diagnosis iNPH accordance with the gu

2、idelines LP分流的適應(yīng)癥自發(fā)性正常顱壓腦積水的診斷Video seminar The detailed procedure of LP shunt 手術(shù)視頻LP分流的具體步驟2 Why LP shunt was not standard?And Why LP shunt now? 為什么LP分流曾經(jīng)不是標(biāo)準(zhǔn)而現(xiàn)在廣泛使用？First introduction 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(jiǎn)單Most neurosurgeo

3、n hesitate to do LP shunt. Because “Too much complication” then.很多的神經(jīng)外科大夫由于術(shù)后太多的并發(fā)癥，而放棄LP分流3 Improvement 改良Material & Equipment 材料和設(shè)備“Diagnosis” 診斷4 History of LP shunt LPLP 分流的歷史1950s first introduction Material : polyethylene 聚乙烯- X induce arachnoiditis and scoliosis 引起蛛網(wǎng)膜炎和脊柱側(cè)凸1975 Selman et.al.

4、Material : Silicone 硅樹脂- O less arachnoiditis and scoliosisComplication :LP shunt VP shunt postural overdrainage : SDFC & SDH Etc.Diagnosis & Treatment difficult ! favorable indication: communicating hydrocephalus給診斷和治療帶來(lái)困難Improvement of the material材料的改進(jìn)Unfortunately, NO adjustable valve !NO CT sca

5、n, NO MRI !沒(méi)有可調(diào)壓閥門，沒(méi)有CT，沒(méi)有MRIMRICTAccurate diagnosis & less complication in shunt surgery準(zhǔn)確診斷、并發(fā)癥少5 Before making guideline of iNPHHebb and Cusimano Neurosurgery: 49, No. 5, 2001Shunting INPH systematic review : Suggest : Criteria for iNPH is not unified (沒(méi)有統(tǒng)一的標(biāo)準(zhǔn) iNPH)significant improvement: only 2

6、9% (range 10-100%) Complications occurred in 38% (range, 5100%) Required additional surgery 22% (range, 047%) permanent neurological deficit and death: 6% (range, 035%)life-threatening intraparenchymal or subdural hematomas requiring surgical evacuation.This paper is Foundation of guideline6 Diagnos

7、is Evolution診斷的發(fā)展Diagnostic radiological equipment:CT, MRIClarify of the pathophysiology: iNPH guideline放射診斷設(shè)備：CT， MRI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Comp

8、lication 38%iNPHShunt responder80%complication 20%Now7 Complications of LP shunting.LP分流的并發(fā)癥 Wang VY et. al. USCF group Neurosurgery. 2007 ;60 :1045-874 Patients (Average 47.6 y)NPH (14) 19% Communicating hydrocephalus (8) 11%Pseudotumor cerebri (26) 35%Pseudomeningocele (15) 20%CSF leak (11) 15%Com

9、plicationRevision : 27 cases (36.5%)Over drainage symptoms: 11 cases (14.8%)infection : 3 cases (4%) No serious complicationOnly 30%8 Recent report of LP shunt LP shunt equally effective as VP shuntComplication rate significant reduceno incidence of subdural hematoma hygroma & low complicationObstru

10、ction 1 (1%)Lumber catheter Migration 3 (9%)Pseudomeningocele 2 (6%)Infection 2 (6%)Overdrainage 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 (20

11、12) 11071111Benefits of LP shunting “Avoid intraparenchymal hematoma with ventricular catheter placement.”9 Benefits of LP shuntingLP分流的優(yōu)勢(shì)“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, 2001Shunting INPH systematic re

12、view : Complications occurred in 38% (range, 5100%) Required additional surgery 22% (range, 047%) permanent neurological deficit and death: 6% (range, 035%) Serious complication : life-threatening intraparenchymal or subdural hematomas VP shunt10 Complications of LP shuntingShunt over drainage:過(guò)度分流

13、CSF leakagesubdural fluid collectionsubdural hematoma Shunt malfunction: obstructionmigration of shunt catheterflipping the shunt valveInfectionFactor:Shunt valve pressurePeritoneal pressure閥門壓力和腹腔壓力 - What is best ? Diameter difference between Lumber catheter & TUHOY Needle導(dǎo)管和腰穿針之間存在直徑差Factor & cou

14、nterplan原因及對(duì)策Sterile operation &Appropriate antimicrobial無(wú)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 fixation系住導(dǎo)管、固定閥門11 For avoiding severe complication如何避免嚴(yán)重的并發(fā)癥PointAppropriate shunt pressure setting 設(shè)定適當(dāng)?shù)姆至鲏毫vo

15、id unintentional valve pressure change 防止閥門設(shè)定壓力意外改變LP shunting (no puncture brain) LP分流（無(wú)穿刺大腦）Polaris is effective. I have not experienced a unintentional pressure change.12 The manner of initial Valve Pressure decision閥門壓力的調(diào)節(jié)方法Opening Pressure at Implantation植入時(shí)設(shè)定的壓力To avoid subdural hematomas in o

16、lder 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 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)re

17、sulted in a significant reduction ICP13 Predicted 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(méi)有發(fā)生分流不足ICP measurement at 11 NPH patients implanted programmable shunt valve without an antisiphon device . Actual CSF pressure wave form 14 Obesity makes CSF pr

18、essure肥胖會(huì)使腦脊液壓力上升 15 Risk factor for intraabdominal hypertension腹內(nèi)高血壓的風(fēng)險(xiǎn)因素Reintam Blaser A et.al. Acta Anaesthesiol Scand. 2011 55(5):607-14Risk factors for intra-abdominal hypertension in mechanically ventilated patients.16 Quick Refererence Tablefor suitable shunt pressure Concept: obesity = IAP s

19、uitable 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) Miyake H et.al. Neurol Med Chir (Tokyo) 48, 427432, 2008 Desirable conditionunderdrainageoverdrainage17 For Avoid unintentional valve pressure c

20、hange防止閥門設(shè)定壓力意外改變Basic concept of us 基本的治療理念 Loss of adjustability after MRI examination. MRI檢查后喪失調(diào)節(jié)能力 Above all, unintentional changes in pressure setting.設(shè)定好的閥門壓力發(fā)生意外改變18 Akbar M. Loss of Adjustability of Codman-Medos Hydrocephalus Valves after Exposure to 3.0T MRI. New England. J. Med. 2005; 353

21、: 1413 -1414. 6 out of 12 (50%) tested Codman-Medos valves showed permanent failure of adjustability after exposure to a 3.0 T MRI In contrast, all tested Sophy-SU8 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 adjus

22、tability after MRI examinationMRI檢查后喪失調(diào)節(jié)能力 19 Nomura S. Effect of cell phone magnetic fields on adjustable cerebrospinal fluid shunt valves. Surgical Neurology, 63(2005), 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. Neur

23、ol. 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 life. 日常生活中有許多的若磁場(chǎng)，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(chǎng)（1）20 Zuzak T.J. Magnetic toys: forbidden for pediatric pa

24、tients with certain programmable valves.? Childs Nervous Syst. 25: 161-164 (2009). Anderson R. Adjustment and malfunction of a programmable valve after exposure to toy magnets. J. Neurosurg. : Pediatrics 101 : 222-225. Both Codman and Strata programmable valves revealed alterations of pressure setti

25、ngs 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 the magnetic properties of magnetic toys are of sufficient strength to alter programmable Strata and Codman valves.Daily life magneti

26、c fields (2) 日常生活中的磁場(chǎng)（2）21 headphones 14.0 mT earphones (Walkman) 23.0 mT cordless telephone 34.0 mT cellular telephone 17.5 mT toy magnet67 82 mTDe Schneider et al. J.Neurosurgery 96:331-334, 2002Potential sources of dysadjustment daily life22 Indication of LP shunting Communicating hydrocephalus 交

27、通性腦積水idiopathic Normal Pressure Hydrocephalus (iNPH) 自發(fā)性正常顱壓腦積水Secondary Normal Pressure Hydrocephalus 繼發(fā)性正常顱壓腦積水 Contraindication: obstructive hydrocephalus 禁忌癥：梗阻性腦積水 Exclusion! : Intracranial solid occupying lesion (+) Queckenstedt test positive It is important to diagnose in accordance with the

28、guidelines23 idiopathic Normal Pressure Hydrocephalus (iNPH)Age : 60 y.o. (Japanese iNPH GL) ref) 40 y.o. ( Relkin N et.al. Neurosurgery 2005, iNPH guideline US & Euro)Symptom (Triad) 1：gait disturbance, urinary incontinence, dementiaRadiological findings:Ventricle dilatation (Evans index 0.3), CSF

29、pressure Improvement = Probable iNPHTreatment:Shunt surgery (V-P shunt, L-P shunt)- Improvement = Definite iNPHImprovement symptom: Gait UI Dements24 SINPHONI (The study of iNPH on neurological improvement)iNPH specific radiological feature :VentriculomegalyTight high-convexity and medial subarachno

30、id spaceExpanded sylvian fissure Hashimoto M et. al. Cerebrospinal Fluid Res. 2010 7:18.Diagnosis of idiopathic normal pressure hydrocephalus is supported by MRI-based scheme: a prospective cohort study.Different with brain atrophyDESH (Disproportionately Enlarged Subarachnoid-space Hydrocephalus)Sh

31、unt effective rate 80%25 Classification of Normal Pressure Hydrocephalus (NPH)NPHIdiopathic NPHDESHNon-DESHSecondaryNPHAcquiredetiologiesCongenital/DevelopmentaletiologiesDESH (Disproportionately Enlarged Subarachnoid-space Hydrocephalus) 60 y.o.(Japanese iNPH GL) 80%20%26 Etiology of iNPHProbable i

32、NPH 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, Eide PK. Acta Neurol Scand 2008: 118: 485327 MRI feature of iNPH28 Why LP shunt?before iNPH guideline (20th century)Once

33、 relinquish surgery for iNPHsecondary hydrocephalus (relatively young )hydrocephalus in children mostly adapt the VP shunt. 2004 iNPH guidelines the proportion of elderly patientsLP shunt is preferred than VP shuntAvoid intraparenchymal hematoma with ventricular catheter placement. iNPH patients : A

34、ge 74.5 + 5.1 Y.O.29 Video seminar The detailed procedure of lumboperitoneal shunt Introduction of Surgical materials & Design 手術(shù)耗材和設(shè)計(jì)介紹Preoperative preparation: 術(shù)前準(zhǔn)備shunt valve adjusting 閥門調(diào)節(jié)Operation room arrangement 手術(shù)室安排Positioning 擺體位Surgical procedure (video) 手術(shù)過(guò)程（視頻）30 Lumbo-peritoneal Cathet

35、er腰大池-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, radiopaque, 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 integ

36、rated proximal asymmetric step-down connector for attachment to lumbar catheter, radiopaque stripe.（在腰椎管和閥門中間過(guò)度連接）- Peritoneal catheter（腹腔管）,1.1 mm ID,2.5 mm OD, length 70 cm, multiperforated open end, radiopaque stripe.- Tuohy needle 14 Gauge, length 9 cm.- Female Luer-Lock connector（Luer 接頭）. 31 A

37、djustment for valve pressure PolarisPositionOperating Pressure (mm H2O)SPVSPV-140SPV-300SPV-4001301050802704010015031108015023041501102203305200140300400SPVA : Polaris Adjustable Valve, 30-200, AntechamberPreoperative preparation 32 Design of LP shuntPolaris valvePeritoneal catheterLumbar catheterIn

38、termediary catheter* Design : Shunt valve would place above iliac crest for pumping.33 Design of LP shuntPolaris valvePeritoneal catheterLumbar catheterIntermediary catheter34 Operating room arrangementAnesthesiologistSurgeonSurgeonBipolar & monopolar coagulatorsuctionApparatus & nurseArm standApparatus & nurse35 Positioning & skin incisionLateral position Arm standFi