腰大池腹腔分流优秀课件

St.MariannaUniversitySchoolofMedicineDepartmentofNeurosurgeryKotaroOshioM.D.PhD.Thepreparationandpracticalsurgicaltechniqueoflumboperitonealshunts腰大池-腹腔分流术前准备及临床手术方法1TopicsHistoricalbackgroundofLPshuntingLP分流的历史背景BenefitsandcomplicationsofLPshuntingExperienceinusingLPshuntingLP分流的优势及并发症——使用经验IndicationofLPshuntingDiagnosisiNPHaccordancewiththeguidelinesLP分流的适应症——自发性正常颅压脑积水的诊断VideoseminarThedetailedprocedureofLPshunt手术视频——LP分流的具体步骤2WhyLPshuntwasnotstandard?AndWhyLPshuntnow?为什么LP分流曾经不是 标准 excel标准偏差excel标准偏差函数exl标准差函数国标检验抽样标准表免费下载红头文件格式标准下载 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3Improvement改良Material&Equipment材料和设备“Diagnosis”诊断4HistoryofLPshuntLPLP分流的历史1950’sfirstintroductionMaterial: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MRIAccuratediagnosis&lesscomplicationinshuntsurgery准确诊断、并发症少5BeforemakingguidelineofiNPHHebbandCusimanoNeurosurgery: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.⇒　ThispaperisFoundationofguideline6DiagnosisEvolution诊断的发展Diagnosticradiologicalequipment:　CT,MRIClarifyofthepathophysiology:iNPHguideline放射诊断设备：CT，MRI明确的病理生理：INPH方针7ComplicationsofLPshunting.LP分流的并发症WangVYet.al.USCFgroupNeurosurgery.2007;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%8RecentreportofLPshuntLPshuntequallyeffectiveasVPshuntComplicationratesignificantreducenoincidenceofsubduralhematomahygroma&lowcomplicationObstruction1(1%)LumbercatheterMigration3(9%)Pseudomeningocele2(6%)Infection2(6%)Overdrainage2(6%)PeritonealcatheterMigration1(3%)Abdominalpain1(3%)LumboperitonealshuntsforthetreatmentofnormalpressurehydrocephalusO.Bloch,M.W.McDermott/JournalofClinicalNeuroscience19(2012)1107–1111BenefitsofLPshunting“Avoidintraparenchymalhematomawithventricularcatheterplacement.”9BenefitsofLPshuntingLP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.5,2001ShuntingINPHsystematicreview:Complicationsoccurredin38%(range,5–100%)Requiredadditionalsurgery22%(range,0–47%)permanentneurologicaldeficitanddeath:6%(range,0–35%)Seriouscomplication:life-threateningintraparenchymalorsubduralhematomasVPshunt10ComplicationsofLPshuntingShuntoverdrainage:过度分流CSFleakagesubduralfluidcollectionsubduralhematomaShuntmalfunction:obstructionmigrationofshuntcatheterflippingtheshuntvalveInfectionFactor&counterplan原因及对策Howshouldwesettheappropriateshuntpressure?应该如何设置相应的分流压力？11Foravoidingseverecomplication如何避免严重的并发症PointAppropriateshuntpressuresetting设定适当的分流压力Avoidunintentionalvalvepressurechange防止阀门设定压力意外改变LPshunting(nopuncturebrain)LP分流（无穿刺大脑）Polarisiseffective.Ihavenotexperiencedaunintentionalpressurechange.12ThemannerofinitialValvePressuredecision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AnotherFactorObesity;choicealittlelowerpressure肥胖患者，可以选择低一点的压力BergsneiderMetal.Neurosurgery.2004;55:851-8Evenveryhighopeningvalvepressuresetting(≧170mmH2O)　resultedinasignificantreductionICP13PredictedshuntunderdrainagedidnotoccurevenattheOPVsettingof200mmH2O阀门压力设定为200mmH2O也没有发生分流不足ICPmeasurementat11NPHpatientsimplantedprogrammableshuntvalvewithoutanantisiphondevice.14ObesitymakesCSFpressure肥胖会使脑脊液压力上升15Riskfactorforintraabdominalhypertension腹内高血压的风险因素ReintamBlaserAet.al.ActaAnaesthesiolScand.201155(5):607-14Riskfactorsforintra-abdominalhypertensioninmechanicallyventilatedpatients.16QuickRefererenceTableforsuitableshuntpressureConcept: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)48,427~432,2008Desirableconditionunderdrainageoverdrainage17ForAvoidunintentionalvalvepressurechange防止阀门设定压力意外改变Basicconceptofus基本的治疗理念LossofadjustabilityafterMRIexamination.MRI检查后丧失调节能力Aboveall,unintentionalchangesinpressuresetting.设定好的阀门压力发生意外改变18AkbarM.LossofAdjustabilityofCodman-MedosHydrocephalusValvesafterExposureto3.0TMRI.NewEngland.J.Med.2005;353:1413-1414.« 6outof12(50%)testedCodman-Medosvalvesshowedpermanentfailureofadjustabilityafterexposuretoa3.0TMRI…Incontrast,alltestedSophy-SU8devicescouldstillbere-ajustedafterallprocedures ».12枚Codman-Medos阀门中6枚在接触3.0TMRI后，被消磁，永久丧失调节能力，而索菲SU8阀门在相同情况下，不受影响。LossofadjustabilityafterMRIexaminationMRI检查后丧失调节能力19NomuraS.Effectofcellphonemagneticfieldsonadjustablecerebrospinalfluidshuntvalves.SurgicalNeurology,63(2005),467-468.可以改变不同阀门压力的最小磁通密度UtsukiS.AlterationofthePressureSettingofaCodman-HakimProgrammablevalvebyaTelevision.Neurol.Med.Chir.(Tokyo)46,405-407,2006..« …weshouldrecognizethattherearemanysourcesofweakmagneticfieldsthatmayinfluenceaprogrammablevalveineverydaylife ».日常生活中有许多的若磁场，可能造成可调压阀门压力发生意外改变Dailylifemagneticfields(1)日常生活中的磁场（1）20ZuzakT.J.Magnetictoys:forbiddenforpediatricpatientswithcertainprogrammablevalves.?Child’sNervousSyst.25:161-164(2009).AndersonR.Adjustmentandmalfunctionofaprogrammablevalveafterexposuretotoymagnets.J.Neurosurg.:Pediatrics101:222-225.« BothCodmanandStrataprogrammablevalvesrevealedalterationsofpressuresettingsafterexposuretocommerciallyavailabletoymagnets. »Surgeonsshouldwarnthefamiliesofpatientswithprogrammablevalvestoavoidtoymagnets.»« ItwasshownthatthemagneticpropertiesofmagnetictoysareofsufficientstrengthtoalterprogrammableStrataandCodmanvalves. »Dailylifemagneticfields(2)日常生活中的磁场（2）21headphones14.0mTearphones(Walkman)23.0mTcordlesstelephone34.0mTcellulartelephone17.5mTtoymagnet67à82mTDeSchneideretal.J.Neurosurgery96:331-334,2002Potentialsourcesofdysadjustment–dailylife22IndicationofLPshuntingCommunicatinghydrocephalus交通性脑积水idiopathicNormalPressureHydrocephalus(iNPH)自发性正常颅压脑积水SecondaryNormalPressureHydrocephalus继发性正常颅压脑积水Contraindication:obstructivehydrocephalus禁忌症：梗阻性脑积水Exclusion!:Intracranialsolidoccupyinglesion(+)QueckenstedttestpositiveItisimportanttodiagnoseinaccordancewiththeguidelines23idiopathicNormalPressureHydrocephalus(iNPH)Age:≧60y.o.(JapaneseiNPHGL)ref)≧40y.o.(RelkinNet.al.Neurosurgery2005,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>Dements24SINPHONI(ThestudyofiNPHonneurologicalimprovement)iNPHspecificradiologicalfeature:VentriculomegalyTighthigh-convexityandmedialsubarachnoidspaceExpandedsylvianfissureHashimotoMet.al.CerebrospinalFluidRes.20107:18.DiagnosisofidiopathicnormalpressurehydrocephalusissupportedbyMRI-basedscheme:aprospectivecohortstudy.DifferentwithbrainatrophyDESH(DisproportionatelyEnlargedSubarachnoid-spaceHydrocephalus)Shunteffectiverate≧80%25ClassificationofNormalPressureHydrocephalus(NPH)DESH(DisproportionatelyEnlargedSubarachnoid-spaceHydrocephalus)≧60y.o.(JapaneseiNPHGL)80%20%26EtiologyofiNPHProbableiNPHisestimated:aminimumprevalenceofiNPHinourpopulationof21.9/100,000.PrevalenceofprobableidiopathicnormalpressurehydrocephalusinaNorwegianpopulation.BreanA,EidePK.ActaNeurolScand2008:118:48–5327MRIfeatureofiNPH28WhyLPshunt?beforeiNPHguideline(20thcentury)OncerelinquishsurgeryforiNPHsecondaryhydrocephalus(relativelyyoung)hydrocephalusinchildrenmostlyadapttheVPshunt.2004iNPHguidelinestheproportionofelderlypatientsLPshuntispreferredthanVPshuntAvoidintraparenchymalhematomawithventricularcatheterplacement.iNPHpatients:Age74.5+5.1Y.O.29VideoseminarThedetailedprocedureoflumboperitonealshuntIntroductionofSurgicalmaterials&Design手术耗材和设计介绍Preoperativepreparation:术前准备shuntvalveadjusting阀门调节Operationroomarrangement手术室安排Positioning摆体位Surgicalprocedure(video)手术过程（视频）30Lumbo-peritonealCatheter腰大池-腹腔导管    TheSophysaLumbo-PeritonealCatheterSet索菲萨LP分流导管套装-Lumbarcatheter（腰椎管）,0.76mmID,1.6mmOD,length60cm,multi-perforatedproximaltip,radiopaque,depthmarkingsat11,16,21,26cmfromtheproximaltip.-Intermediarycatheter（中间管）,1.1mmID,2.5mmOD,length10cm,withintegratedproximalasymmetricstep-downconnectorforattachmenttolumbarcatheter,radiopaquestripe.（在腰椎管和阀门中间过度连接）-Peritonealcatheter（腹腔管）,1.1mmID,2.5mmOD,length70cm,multiperforatedopenend,radiopaquestripe.-Tuohyneedle14Gauge,length9cm.-FemaleLuer-Lockconnector（Luer接头）.31Adjustmentforvalvepressure[Polaris]SPVA:Polaris®AdjustableValve,30-200,AntechamberPreoperativepreparation32DesignofLPshuntPolaris®valvePeritonealcatheterLumbarcatheterIntermediarycatheter*Design:Shuntvalvewouldplaceaboveiliaccrestforpumping.33DesignofLPshunt34OperatingroomarrangementApparatus&nurse35Positioning&skinincisionLateralpositionArmstandFixation@Sternum&PubisFixation@Thoracicspine&SacrumForlumberpunctureOpentheoperativefield36LPshuntingissimple!Lumbarpuncture,insertlumbarcatheterOpentheabdomenplacetheshuntvalveabovetheiliacbone(髂骨).connectthecathetereachparts&implantandclosing.Themainstepsoftheprocedure37LPshuntsimple4steps38Videotime!39Postoperativefollowup术后随访observationpoint观察点OverdrainagesymptomsUnderdrainagesymptoms⇒　checkCTscan&adjustvalvepressure检查CT并调节阀门压力Mostlyinacoupleofmonth!(alsoreportedinacoupleofyear)Headache,nausea头痛，恶心40Thankyouforyourattention.Ihopeyoulearnedsomethingtoday.感谢您的关注。我希望你今天学到了一些东西。Don’thesitatetodoLPshunt!41Lumbo-PeritonealCatheterSet(Sophysa)42ThetipsoflumbarpunctureDirectionforTuohyNeedleHeight:L3/4–L4/543PlacementoflumbarcatheterLumbarcatheterlength:onceinsertuntil3rdmarker　（=27cm）removeTUOHYneedlecarefullyremove5-6cmfrom3rdmarker44