St.MariannaUniversitySchoolofMedicineDepartmentofNeurosurgeryKotaroOshioM.D.PhD.Thepreparationandpracticalsurgicaltechniqueoflumboperitonealshunts

腰大池-腹腔分流術(shù)前準(zhǔn)備及臨床手術(shù)方法腰大池腹腔分流1/44TopicsHistoricalbackgroundofLPshuntingLP分流歷史背景BenefitsandcomplicationsofLPshuntingExperienceinusingLPshuntingLP分流優(yōu)勢(shì)及并發(fā)癥——使用經(jīng)驗(yàn)IndicationofLPshuntingDiagnosisiNPH

accordancewiththeguidelinesLP分流適應(yīng)癥——自發(fā)性正常顱壓腦積水診療VideoseminarThedetailedprocedureofLPshunt

手術(shù)視頻——LP分流詳細(xì)步驟腰大池腹腔分流2/44

WhyLPshuntwasnotstandard?

AndWhyLPshuntnow?為何LP分流曾經(jīng)不是標(biāo)準(zhǔn)而現(xiàn)在廣泛使用？

FirstintroductionofLPshuntwas1950’s.Fortreatmentofhydrocephalus.LP分流最早于1950年推出，以治療腦積水Simpletechnique但技術(shù)很簡(jiǎn)單MostneurosurgeonhesitatetodoLPshunt.Because“Toomuchcomplication”then.很多神經(jīng)外科大夫因?yàn)樾g(shù)后太多并發(fā)癥，而放棄LP分流腰大池腹腔分流3/44Improvement改良Material&Equipment材料和設(shè)備“Diagnosis”

診療腰大池腹腔分流4/44HistoryofLPshuntLP

LP分流歷史1950’sfirstintroductionMaterial:polyethylene聚乙烯->Xinducearachnoiditisandscoliosis

引發(fā)蛛網(wǎng)膜炎和脊柱側(cè)凸1975Selmanet.al.Material:Silicone硅樹(shù)脂->OlessarachnoiditisandscoliosisComplication:

LPshunt＞VPshunt

posturaloverdrainage:SDFC&SDHEtc.

Diagnosis&Treatmentdifficult!

favorableindication:communicatinghydrocephalus給診療和治療帶來(lái)困難Improvementofthematerial材料改進(jìn)Unfortunately,

NOadjustablevalve! NOCTscan,NOMRI!沒(méi)有可調(diào)壓閥門(mén)，沒(méi)有CT，沒(méi)有MRIMRICTAntisiphondeviceAdjustableValveAccuratediagnosis&lesscomplicationinshuntsurgery準(zhǔn)確診療、并發(fā)癥少腰大池腹腔分流5/44BeforemakingguidelineofiNPHHebbandCusimanoNeurosurgery:49,No.5,ShuntingINPH

systematicreview:Suggest:CriteriaforiNPHisnotunified

(沒(méi)有統(tǒng)一標(biāo)準(zhǔn)

iNPH)significantimprovement:only29%(range10-100%)Complications

occurredin38%(range,5–100%)Requiredadditionalsurgery22%(range,0–47%)permanentneurologicaldeficitanddeath:6%(range,0–35%)

life-threateningintraparenchymalorsubdural hematomasrequiringsurgicalevacuation.?ThispaperisFoundationofguideline腰大池腹腔分流6/44DiagnosisEvolution

診療發(fā)展Diagnosticradiologicalequipment:

CT,MRIClarifyofthepathophysiology:iNPHguideline放射診療設(shè)備：CT，MRI

明確病理生理：INPH方針Before

iNPH“Treatabledementia”Shuntresponderonly29%

在年之前，INPH“可治療老年癡呆癥”分流治療者只有29％Diseasedementia(Alzheimertype)老年癡呆癥Neurodegenerativedisease神經(jīng)退行性疾病Complication38%iNPHShuntresponder80%complication20%Now腰大池腹腔分流7/44ComplicationsofLPshunting.

LP分流并發(fā)癥

WangVYet.al.USCFgroupNeurosurgery.

;60:1045-874Patients(Average47.6y)NPH(14)19%Communicatinghydrocephalus(8)11%Pseudotumorcerebri(26)35%Pseudomeningocele(15)20%CSFleak(11)15%ComplicationRevision:27cases(36.5%)Overdrainagesymptoms:11cases(14.8%)infection:3cases(4%)NoseriouscomplicationOnly30%腰大池腹腔分流8/44RecentreportofLPshunt

LPshuntequallyeffectiveasVPshuntComplicationratesignificantreduce

noincidenceofsubduralhematoma

hygroma&lowcomplicationObstruction1(1%)LumbercatheterMigration3(9%)Pseudomeningocele2(6%)Infection2(6%)Overdrainage2(6%)PeritonealcatheterMigration1(3%)Abdominalpain1(3%)

Lumboperitonealshuntsforthetreatmentofnormalpressurehydrocephalus

O.Bloch,M.W.McDermott/JournalofClinicalNeuroscience19()1107–1111BenefitsofLPshunting“Avoidintraparenchymalhematoma

withventricularcatheterplacement.”腰大池腹腔分流9/44BenefitsofLPshunting

LP分流優(yōu)勢(shì)“Avoidintraparenchymalhematomawithventricularcatheterplacement.”防止腦室導(dǎo)管穿刺部位發(fā)生腦實(shí)質(zhì)血腫HebbandCusimanoNeurosurgery:49,No.5,ShuntingINPHsystematicreview:Complicationsoccurredin38%(range,5–100%)Requiredadditionalsurgery22%(range,0–47%)permanentneurologicaldeficitanddeath:6%(range,0–35%)

Seriouscomplication:

life-threateningintraparenchymalorsubduralhematomasVPshunt腰大池腹腔分流10/44ComplicationsofLPshuntingShuntoverdrainage:過(guò)分分流

CSFleakagesubduralfluidcollectionsubduralhematomaShuntmalfunction:obstructionmigrationofshuntcatheterflippingtheshuntvalveInfectionFactor:ShuntvalvepressurePeritonealpressure閥門(mén)壓力和腹腔壓力->Whatisbest?DiameterdifferencebetweenLumbercatheter&TUHOYNeedle導(dǎo)管和腰穿針之間存在直徑差Factor&counterplan原因及對(duì)策Sterileoperation&Appropriateantimicrobial無(wú)菌操作和適當(dāng)抗生素Howshouldwesettheappropriateshuntpressure?應(yīng)該怎樣設(shè)置對(duì)應(yīng)分流壓力？Importantsurgicaltips:

anchoringcatheter

Shuntvalvefixation系住導(dǎo)管、固定閥門(mén)腰大池腹腔分流11/44Foravoidingseverecomplication

怎樣防止嚴(yán)重并發(fā)癥PointAppropriateshuntpressuresetting設(shè)定適當(dāng)分流壓力Avoidunintentionalvalvepressurechange預(yù)防閥門(mén)設(shè)定壓力意外改變LPshunting(nopuncturebrain)

LP分流（無(wú)穿刺大腦）Polarisiseffective.Ihavenotexperiencedaunintentionalpressurechange.腰大池腹腔分流12/44ThemannerofinitialValvePressuredecision

閥門(mén)壓力調(diào)整方法OpeningPressureatImplantation植入時(shí)設(shè)定壓力Toavoidsubduralhematomasinolderpatients,weinitiallyestablishahighopeningpressureanddecreaseitstepbystepwhennecessary.

初始高壓，然后依據(jù)需要逐步調(diào)低AnotherFactorObesity;choicealittlelowerpressure肥胖患者，能夠選擇低一點(diǎn)壓力BergsneiderMetal.Neurosurgery.

;55:851-8Evenveryhighopeningvalvepressuresetting(≧170mmH2O)

resultedinasignificantreductionICP腰大池腹腔分流13/44PredictedshuntunderdrainagedidnotoccurevenattheOPVsettingof200mmH2O

閥門(mén)壓力設(shè)定為200mmH2O也沒(méi)有發(fā)生分流不足ICPmeasurementat11NPHpatientsimplantedprogrammableshuntvalvewithoutanantisiphondevice.ActualCSFpressurewaveform腰大池腹腔分流14/44ObesitymakesCSFpressure肥胖會(huì)使腦脊液壓力上升

腰大池腹腔分流15/44Riskfactorforintraabdominalhypertension

腹內(nèi)高血壓風(fēng)險(xiǎn)原因ReintamBlaserAet.al.

ActaAnaesthesiolScand.55(5):607-14Riskfactorsforintra-abdominalhypertensioninmechanicallyventilatedpatients.腰大池腹腔分流16/44QuickRefererenceTable

forsuitableshuntpressureConcept:obesity=IAPsuitablevalvepressure

理念：肥胖=IAP適合閥門(mén)壓力HydrostaticpressureValvePressure＝CSFflowvolumeIntra-abdominalPressure(IAP)腹內(nèi)壓IntracranialPressure(ICP)Ref)MiyakeHet.al.NeurolMedChir(Tokyo)48,427~432,Desirableconditionunderdrainageoverdrainage腰大池腹腔分流17/44ForAvoidunintentionalvalvepressurechange

預(yù)防閥門(mén)設(shè)定壓力意外改變

Basicconceptofus基本治療理念LossofadjustabilityafterMRIexamination.MRI檢驗(yàn)后喪失調(diào)整能力

Aboveall,unintentionalchangesinpressuresetting.設(shè)定好閥門(mén)壓力發(fā)生意外改變腰大池腹腔分流18/44AkbarM.LossofAdjustabilityofCodman-MedosHydrocephalusValvesafterExposureto3.0TMRI.NewEngland.J.Med.;353:1413-1414.?

6outof12(50%)testedCodman-Medosvalvesshowedpermanentfailureofadjustabilityafterexposuretoa3.0TMRI…Incontrast,alltestedSophy-SU8devicescouldstillbere-ajustedafterallprocedures

?.12枚Codman-Medos閥門(mén)中6枚在接觸3.0TMRI后，被消磁，永久喪失調(diào)整能力，而索菲SU8閥門(mén)在相同情況下，不受影響。LossofadjustabilityafterMRIexaminationMRI檢驗(yàn)后喪失調(diào)整能力

腰大池腹腔分流19/44NomuraS.Effectofcellphonemagneticfieldsonadjustablecerebrospinalfluidshuntvalves.SurgicalNeurology,63(),467-468.能夠改變不一樣閥門(mén)壓力最小磁通密度UtsukiS.AlterationofthePressureSettingofaCodman-HakimProgrammablevalvebyaTelevision.Neurol.Med.Chir.(Tokyo)46,405-407,..?

…weshouldrecognizethattherearemanysourcesofweakmagneticfieldsthatmayinfluenceaprogrammablevalveineverydaylife

?.日常生活中有許多若磁場(chǎng)，可能造成可調(diào)壓閥門(mén)壓力發(fā)生意外改變

Dailylifemagneticfields(1)日常生活中磁場(chǎng)（1）腰大池腹腔分流20/44ZuzakT.J.Magnetictoys:forbiddenforpediatricpatientswithcertainprogrammablevalves.?Child’sNervousSyst.25:161-164().AndersonR.Adjustmentandmalfunctionofaprogrammablevalveafterexposuretotoymagnets.J.Neurosurg.:Pediatrics101:222-225.?

BothCodmanandStrataprogrammablevalvesrevealedalterationsofpressuresettingsafterexposuretocommerciallyavailabletoymagnets.

?Surgeonsshouldwarnthefamiliesofpatientswithprogrammablevalvestoavoidtoymagnets.??

ItwasshownthatthemagneticpropertiesofmagnetictoysareofsufficientstrengthtoalterprogrammableStrataandCodmanvalves.

?Dailylifemagneticfields(2)日常生活中磁場(chǎng)（2）腰大池腹腔分流21/44headphones 14.0mTearphones(Walkman) 23.0mTcordlesstelephone 34.0mTcellulartelephone 17.5mTtoymagnet 67à82mTDeSchneideretal.J.Neurosurgery96:331-334,Potentialsourcesofdysadjustment–dailylife腰大池腹腔分流22/44IndicationofLPshuntingCommunicatinghydrocephalus交通性腦積水idiopathicNormalPressureHydrocephalus(iNPH)自發(fā)性正常顱壓腦積水SecondaryNormalPressureHydrocephalus繼發(fā)性正常顱壓腦積水

Contraindication:obstructivehydrocephalus禁忌癥：梗阻性腦積水Exclusion!:Intracranialsolidoccupyinglesion(+)Queckenstedttestpositive

Itisimportanttodiagnoseinaccordancewiththeguidelines腰大池腹腔分流23/44idiopathicNormalPressureHydrocephalus(iNPH)Age:≧

60y.o.(JapaneseiNPHGL)

ref)≧40y.o.(RelkinNet.al.Neurosurgery,iNPHguidelineUS&Euro)Symptom(Triad)≧

1：gaitdisturbance,urinaryincontinence,dementiaRadiologicalfindings:Ventricledilatation(Evansindex>0.3),CSFpressure<200mmH2ODiagnosis:CSFdrainagetest(US&Euro),CSFtaptest(≧30ml)(J)->Improvement=ProbableiNPHTreatment:Shuntsurgery(V-Pshunt,L-Pshunt)

->Improvement=DefiniteiNPHImprovementsymptom:Gait>UI>Dements腰大池腹腔分流24/44SINPHONI

(ThestudyofiNPHonneurologicalimprovement)iNPH

specificradiologicalfeature:

Ventriculomegaly Tighthigh-convexity

andmedialsubarachnoidspace ExpandedsylvianfissureHashimotoMet.al.CerebrospinalFluidRes.7:18.DiagnosisofidiopathicnormalpressurehydrocephalusissupportedbyMRI-basedscheme:aprospectivecohortstudy.DifferentwithbrainatrophyDESH(DisproportionatelyEnlargedSubarachnoid-spaceHydrocephalus)Shunteffectiverate≧80%腰大池腹腔分流25/44ClassificationofNormalPressureHydrocephalus(NPH)NPHIdiopathicNPHDESHNon-DESHSecondaryNPHAcquiredetiologiesCongenital/DevelopmentaletiologiesDESH(DisproportionatelyEnlargedSubarachnoid-spaceHydrocephalus)≧

60y.o.(JapaneseiNPHGL)80%20%腰大池腹腔分流26/44EtiologyofiNPHProbableiNPHisestimated:aminimumprevalenceofiNPHinourpopulationof21.9/100,000.PrevalenceofprobableidiopathicnormalpressurehydrocephalusinaNorwegianpopulation.BreanA,EidePK.ActaNeurolScand:118:48–53腰大池腹腔分流27/44MRIfeatureofiNPH腰大池腹腔分流28/44WhyLPshunt?beforeiNPHguideline(20thcentury)OncerelinquishsurgeryforiNPHsecondary

hydrocephalus(relativelyyoung)hydrocephalusinchildren

mostlyadapttheVPshunt.

iNPHguidelinestheproportionofelderlypatientsLPshuntispreferredthanVPshuntAvoidintraparenchymalhematomawithventricularcatheterplacement.<SINPHONI>iNPHpatients:Age74.5+5.1Y.O.腰大池腹腔分流29/44

Videoseminar

ThedetailedprocedureoflumboperitonealshuntIntroductionofSurgicalmaterials&Design手術(shù)耗材和設(shè)計(jì)介紹Preoperativepreparation:術(shù)前準(zhǔn)備shuntvalveadjusting閥門(mén)調(diào)整Operationroomarrangement手術(shù)室安排Positioning擺體位Surgicalprocedure(video)手術(shù)過(guò)程（視頻）腰大池腹腔分流30/44Lumbo-peritonealCatheter

腰大池-腹腔導(dǎo)管

TheSophysaLumbo-PeritonealCatheterSet

索菲薩LP分流導(dǎo)管套裝-Lumbarcatheter（腰椎管）,0.76mmID,1.6mmOD,length60cm,multi-perforatedproximaltip,radiopaque,depthmarkingsat11,16,21,26cmfromtheproximaltip.

-Intermediarycatheter（中間管）,1.1mmID,2.5mmOD,length10cm,withintegratedproximalasymmetricstep-downconnectorforattachmenttolumbarcatheter,radiopaquestripe.（在腰椎管和閥門(mén)中間過(guò)分連接）

-Peritonealcatheter（腹腔管）,1.1mmID,2.5mmOD,length70cm,multiperforatedopenend,radiopaquestripe.

-Tuohyneedle14Gauge,length9cm.

-FemaleLuer-Lockconnector（Luer接頭）.腰大池腹腔分流31/44Adjustmentforvalvepressure[Polaris]PositionOperatingPressure(mmH2O)

SPVSPV-140SPV-300SPV-4001301050802704010015031108015023041501102203305200140300400SPVA:Polaris?AdjustableValve,30-200,AntechamberPreoperativepreparation腰大池腹腔分流32/44<A-Pview>DesignofLPshuntPolaris?

valvePeritonealcatheterLumbarcatheterIntermediarycatheter*Design:Shuntvalvewouldplaceaboveiliaccrestforpumping.腰大池腹腔分流33/44DesignofLPshuntPolaris?

valvePeritonealcatheterLumbarcatheterIntermediarycatheter<Lateralview>腰大池腹腔分流34/44OperatingroomarrangementAnesthesiologistSurgeonSurgeonBipolar&monopolarcoagulatorsuctionApparatus&nurseArmstandApparatus&nurse腰大池腹腔分流35/44Positioning&skinincision

LateralpositionArmstandFixation@ Sternum&Pubis<Ventral><Dorsal>F