腰大池腹腔分流

St.MariannaUniversitySchoolofMedicineDepartmentofNeurosurgeryKotaroOshioM.D.PhD.Thepreparationandpracticalsurgicaltechniqueoflumboperitonealshunts腰大池-腹腔分流术前准备及临床手术方法Topics1.HistoricalbackgroundofLPshuntingLP分流的历史背景2.BenefitsandcomplicationsofLPshunting–ExperienceinusingLPshuntingLP分流的优势及并发症——使用经验3.IndicationofLPshunting–DiagnosisiNPHaccordancewiththeguidelinesLP分流的适应症——自发性正常颅压脑积水的诊断4.VideoseminarThedetailedprocedureofLPshunt手术视频——LP分流的具体步骤WhyLPshuntwasnotstandard?AndWhyLPshuntnow?为什么LP分流曾经不是标准而现在广泛使用？•FirstintroductionofLPshuntwas1950’s.–Fortreatmentofhydrocephalus.LP分流最早于1950年推出，以治疗脑积水•Simpletechnique但技术很简单MostneurosurgeonhesitatetodoLPshunt.Because“Toomuchcomplication”then.很多的神经外科大夫由于术后太多的并发症，而放弃LP分流Improvement改良1.Material&Equipment材料和设备2.“Diagnosis”诊断HistoryofLPshuntLPLP分流的历史•1950’sfirstintroduction–Material:polyethylene聚乙烯•-Xinducearachnoiditisandscoliosis引起蛛网膜炎和脊柱侧凸•1975Selmanet.al.–Material:Silicone硅树脂•-OlessarachnoiditisandscoliosisComplication:LPshunt＞VPshunt–posturaloverdrainage:SDFC&SDHEtc.Diagnosis&Treatmentdifficult!favorableindication:communicatinghydrocephalus给诊断和治疗带来困难Improvementofthematerial材料的改进Unfortunately,NOadjustablevalve!NOCTscan,NOMRI!没有可调压阀门，没有CT，没有MRIMRICTAntisiphondeviceAdjustableValveAccuratediagnosis&lesscomplicationinshuntsurgery准确诊断、并发症少BeforemakingguidelineofiNPH•HebbandCusimanoNeurosurgery:49,No.5,2001ShuntingINPHsystematicreview:•Suggest:CriteriaforiNPHisnotunified(没有统一的标准iNPH)•significantimprovement:only29%(range10-100%)•Complicationsoccurredin38%(range,5–100%)–Requiredadditionalsurgery22%(range,0–47%)–permanentneurologicaldeficitanddeath:6%(range,0–35%)life-threateningintraparenchymalorsubduralhematomasrequiringsurgicalevacuation.⇒ThispaperisFoundationofguidelineDiagnosisEvolution诊断的发展•Diagnosticradiologicalequipment:CT,MRI•Clarifyofthepathophysiology:iNPHguideline放射诊断设备：CT，MRI明确的病理生理：INPH方针Before2000iNPH“Treatabledementia”Shuntresponderonly29%在2000年之前，INPH“可治疗老年痴呆症”分流治疗者只有29％Diseasedementia(Alzheimertype)老年痴呆症Neurodegenerativedisease神经退行性疾病Complication38%iNPHShuntresponder80%complication20%NowComplicationsofLPshunting.LP分流的并发症•WangVYet.al.USCFgroupNeurosurgery.2007;60:1045-8•74Patients(Average47.6y)–NPH(14)19%–Communicatinghydrocephalus(8)11%–Pseudotumorcerebri(26)35%–Pseudomeningocele(15)20%–CSFleak(11)15%•Complication–Revision:27cases(36.5%)–Overdrainagesymptoms:11cases(14.8%)–infection:3cases(4%)–NoseriouscomplicationOnly30%RecentreportofLPshunt•LPshuntequallyeffectiveasVPshunt•Complicationratesignificantreducenoincidenceofsubduralhematomahygroma&lowcomplication–Obstruction1(1%)–LumbercatheterMigration3(9%)–Pseudomeningocele2(6%)–Infection2(6%)–Overdrainage2(6%)–PeritonealcatheterMigration1(3%)–Abdominalpain1(3%)LumboperitonealshuntsforthetreatmentofnormalpressurehydrocephalusO.Bloch,M.W.McDermott/JournalofClinicalNeuroscience19(2012)1107–1111•BenefitsofLPshunting“Avoidintraparenchymalhematomawithventricularcatheterplacement.”BenefitsofLPshuntingLP分流的优势•“Avoidintraparenchymalhematomawithventricularcatheterplacement.”避免脑室导管穿刺部位发生脑实质血肿•HebbandCusimanoNeurosurgery:49,No.5,2001–ShuntingINPHsystematicreview:•Complicationsoccurredin38%(range,5–100%)–Requiredadditionalsurgery22%(range,0–47%)–permanentneurologicaldeficitanddeath:6%(range,0–35%)Seriouscomplication:life-threateningintraparenchymalorsubduralhematomasVPshuntComplicationsofLPshunting1.Shuntoverdrainage:过度分流•CSFleakage•subduralfluidcollection•subduralhematoma2.Shuntmalfunction:•obstruction•migrationofshuntcatheter•flippingtheshuntvalve3.Infection阀门压力和腹腔压力DiameterdifferencebetweenLumbercatheter&TUHOYNeedle导管和腰穿针之间存在直径差Factor&counterplan原因及对策Sterileoperation&Appropriateantimicrobial无菌操作和适当的抗生素Howshouldwesettheappropriateshuntpressure?应该如何设置相应的分流压力？Importantsurgicaltips:anchoringcatheterShuntvalvefixation系住导管、固定阀门Foravoidingseverecomplication如何避免严重的并发症Point1.Appropriateshuntpressuresetting设定适当的分流压力2.Avoidunintentionalvalvepressurechange防止阀门设定压力意外改变3.LPshunting(nopuncturebrain)LP分流（无穿刺大脑）Polarisiseffective.Ihavenotexperiencedaunintentionalpressurechange.ThemannerofinitialValvePressuredecision阀门压力的调节方法•OpeningPressureatImplantation植入时设定的压力–Toavoidsubduralhematomasinolderpatients,weinitiallyestablishahighopeningpressureanddecreaseitstepbystepwhennecessary.初始高压，然后根据需要逐步调低•AnotherFactor–Obesity;choicealittlelowerpressure肥胖患者，可以选择低一点的压力BergsneiderMetal.Neurosurgery.2004;55:851-8Evenveryhighopeningvalvepressuresetting(≧170mmH2O)resultedinasignificantreductionICPPredictedshuntunderdrainagedidnotoccurevenattheOPVsettingof200mmH2O阀门压力设定为200mmH2O也没有发生分流不足•ICPmeasurementat11NPHpatientsimplantedprogrammableshuntvalvewithoutanantisiphondevice.ActualCSFpressurewaveformQuickRefererenceTableforsuitableshuntpressureConcept:obesity=IAPsuitablevalvepressure理念：肥胖=IAP适合的阀门压力HydrostaticpressureValvePressure＝CSFflowvolumeIntra-abdominalPressure(IAP)腹内压IntracranialPressure(ICP)Ref)MiyakeHet.al.NeurolMedChir(Tokyo)48,427~432,2008DesirableconditionunderdrainageoverdrainageForAvoidunintentionalvalvepressurechange防止阀门设定压力意外改变•Basicconceptofus基本的