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1、Thepreparationandpracticalsurgicaltechniqueoflumboperitonealshunts腰大池-腹腔分流术前准备及临床手术方法1Topics1.HistoricalbackgroundofLPshuntingLP分流的历史背景2.BenefitsandcomplicationsofLPshuntingExperienceinusingLPshuntingLP分流的优势及并发症使用经验3.IndicationofLPshuntingDiagnosisiNPHaccordancewiththeguidelinesLP分流的适应症自发性正常颅压脑积水的诊断
2、4.VideoseminarThedetailedprocedureofLPshunt手术视频LP分流的具体步骤2WhyLPshuntwasnotstandard?AndWhyLPshuntnow?为什么什么LP分流曾分流曾经不是不是标准而准而现在广泛使用？在广泛使用？FirstintroductionofLPshuntwas1950s.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“Toomuchcomplicat
3、ion”then.很多的神很多的神经经外科大夫由于外科大夫由于术术后太多的并后太多的并发发症，而放弃症，而放弃LP分流分流3Improvement改良改良1.Material&Equipment材料和设备2.“Diagnosis”诊断4HistoryofLPshuntLPLP分流的分流的历史史1950sfirstintroductionMaterial:polyethylene聚乙烯-XXinducearachnoiditisandscoliosis引起蛛网膜炎和脊柱侧凸1975Selmanet.al.Material:Silicone硅树脂-O Olessarachnoiditisandsc
4、oliosisComplication: LPshuntVPshuntposturaloverdrainage: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MRIMRICTAccurate diagnosis & less complication in shunt
5、surgery准确诊断、并发症少准确诊断、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,5100%)Requiredadditionalsurgery22%(range,047%)perman
6、entneurologicaldeficitanddeath:6%(range,035%)life-threateningintraparenchymalorsubduralhematomasrequiringsurgicalevacuation. ThispaperisFoundationofguidelineThispaperisFoundationofguideline6DiagnosisEvolution诊断的断的发展展Diagnosticradiologicalequipment:CT,MRIClarifyofthepathophysiology:iNPHguideline放射诊断设
7、备：CT，MRI明确的病理生理：INPH方针Before2000iNPH“Treatabledementia”Shunt responder only29% 在2000年之前，INPH“可治疗老年痴呆症”分流治疗者只有29Diseasedementia(Alzheimertype)老年痴呆症Neurodegenerativedisease神经退行性疾病Complication38%iNPHShunt responder80%complication 20%Now7ComplicationsofLPshunting.LP分流的并分流的并发症症WangVYet.al.USCFgroupNeuros
8、urgery.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%8RecentreportofLPshuntLPshuntequ
9、allyeffectiveasVPshuntComplicationratesignificantreducenoincidenceofsubduralhematomahygroma&lowcomplicationObstruction1(1%)LumbercatheterMigration3(9%)Pseudomeningocele2(6%)Infection2(6%)Overdrainage2(6%)PeritonealcatheterMigration1(3%)Abdominalpain1(3%)Lumboperitonealshuntsforthetreatmentofnormalpr
10、essurehydrocephalusO.Bloch,M.W.McDermott/JournalofClinicalNeuroscience19(2012)11071111BenefitsofLPshunting“Avoidintraparenchymalhematomawithventricularcatheterplacement.”9BenefitsofLPshuntingLP分流的分流的优势“Avoidintraparenchymalhematomawithventricularcatheterplacement.”避免脑室导管穿刺部位发生脑实质血肿HebbandCusimanoNeu
11、rosurgery: 49,No.5,2001ShuntingINPHsystematicreview:Complicationsoccurredin38%(range,5100%)Requiredadditionalsurgery22%(range,047%)permanentneurologicaldeficitanddeath:6%(range,035%)Seriouscomplication:life-threateningintraparenchymalorsubduralhematomaslife-threateningintraparenchymalorsubduralhemat
12、omasVPshunt10ComplicationsofLPshunting1.Shuntoverdrainage:过度分流CSFleakagesubduralfluidcollectionsubduralhematoma2.Shuntmalfunction:obstructionmigrationofshuntcatheterflippingtheshuntvalve3.InfectionFactor:Factor:ShuntvalvepressureShuntvalvepressurePeritonealpressurePeritonealpressure阀门压力和腹腔压力-Whatisb
13、est?-Whatisbest?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11Foravoidingseverecomp
14、lication如何避免如何避免严重的并重的并发症症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.12ThemannerofinitialValvePressuredecision阀门压力的力的调节方法方法OpeningPressure
15、atImplantation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(1
16、70mmH2O)resultedinasignificantreductionICP13PredictedshuntunderdrainagedidnotoccurevenattheOPVsettingof200mmH2O阀门压力设定为200mmH2O也没有发生分流不足ICPmeasurementat11NPHpatientsimplantedprogrammableshuntvalvewithoutanantisiphondevice.ActualCSFpressurewaveform14QuickRefererenceTableforsuitableshuntpressureConcept
17、:obesity=IAPsuitablevalvepressure理念： 肥胖=IAP适合的阀门压力HydrostaticpressureValvePressureCSFflowvolumeIntra-abdominalPressure(IAP)腹内压IntracranialPressure(ICP)Ref)MiyakeHet.al.NeurolMedChir(Tokyo)48,427432,2008Desirableconditionunderdrainageoverdrainage17ForAvoidunintentionalvalvepressurechange防止阀门设定压力意外改变B
18、asicconceptofus 基本的治疗理念 uLossofadjustabilityafterMRIexamination.MRI检查后丧失调节能力uAboveall,unintentionalchangesinpressuresetting.设定好的阀门压力发生意外改变18Akbar M. Loss of Adjustability of Codman-Medos Hydrocephalus Valves after Exposure to 3.0T MRI. New England. J. Med. 2005; 353 : 1413 -1414.6outof12(50%)testedC
19、odman-Medosvalvesshowedpermanentfailureofadjustabilityafterexposuretoa3.0TMRIIncontrast,alltestedSophy-SU8devicescouldstillbere-ajustedafterallprocedures.12枚Codman-Medos阀门中6枚在接触3.0T MRI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19Nomura S. Effect of cell pho
20、ne magnetic fields on adjustable cerebrospinal fluid shunt valves. Surgical Neurology, 63(2005), 467-468. 可以改变不同阀门压力的最小磁通密度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 a
21、re many sources of weak magneticfieldsthatmayinfluenceaprogrammablevalveineverydaylife.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）20Zuzak T.J. Magnetic toys: forbidden for pediatric patients with certain programmable valves.? Childs Nervous Syst. 25: 161-164 (2009). Anderson
22、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 revealedalterationsofpressuresettingsafterexposuretocommerciallyavailabletoymagnets.Surgeons should warn the families of patients
23、withprogrammablevalvestoavoidtoymagnets.It was shown that the magnetic properties of magnetic toys are ofsufficientstrengthtoalterprogrammableStrataandCodmanvalves.Dailylifemagneticfields(2)日常生活中的磁场（2）21uheadphones14.0mTuearphones(Walkman)23.0mTucordlesstelephone34.0mTucellulartelephone17.5mTutoymag
24、net6782mTDeSchneideretal.J.Neurosurgery96:331-334,2002Potentialsourcesofdysadjustmentdailylife22IndicationofLPshuntingCommunicatinghydrocephalus交通性交通性脑积脑积水水a.idiopathicNormalPressureHydrocephalus(iNPH)自发性正常颅压脑积水b.SecondaryNormalPressureHydrocephalus继发性正常颅压脑积水Contraindication:obstructivehydrocephalus
25、禁忌症：梗阻性禁忌症：梗阻性脑积脑积水水Exclusion!:Intracranialsolidoccupyinglesion(+)QueckenstedttestpositiveItisimportanttodiagnoseinaccordancewiththeguidelines23idiopathic Normal Pressure Hydrocephalus (iNPH)Age:60y.o.(JapaneseiNPHGL)ref)40y.o.(RelkinNet.al.Neurosurgery2005,iNPHguidelineUS&Euro)Symptom(Triad)1：gaitd
26、isturbance,urinaryincontinence,dementiaRadiologicalfindings:Ventricledilatation(Evansindex0.3),CSFpressureImprovement=ProbableiNPHTreatment:Shuntsurgery(V-Pshunt,L-Pshunt)-Improvement=DefiniteiNPHImprovementsymptom:GaitUIDements24SINPHONI (The study of iNPH on neurological improvement)iNPHspecificra
27、diologicalfeature:VentriculomegalyTighthigh-convexityandmedialsubarachnoidspaceExpandedsylvianfissureHashimotoMet.al.CerebrospinalFluidRes.20107:18.DiagnosisofidiopathicnormalpressurehydrocephalusissupportedbyMRI-basedscheme:aprospectivecohortstudy.DifferentDifferentDifferentDifferentwithbrainwithbr
28、ainwithbrainwithbrainatrophyatrophyatrophyatrophyDESHDESH(DisproportionatelyEnlargedSubarachnoid-spaceHydrocephalus)Shunt effective rate 80%25ClassificationofNormalPressureHydrocephalus(NPH)NPHIdiopathicNPHDESHNon-DESHSecondaryNPHAcquiredetiologiesCongenital/DevelopmentaletiologiesDESHDESH(Dispropor
29、tionatelyEnlargedSubarachnoid-spaceHydrocephalus)60y.o.(JapaneseiNPHGL)80%20%26EtiologyofiNPHProbableiNPHisestimated:aminimumprevalenceofiNPHinourpopulationof21.9/100,000.PrevalenceofprobableidiopathicnormalpressurehydrocephalusinaNorwegianpopulation.BreanA,EidePK.ActaNeurolScand2008:118:485327Video
30、seminarThedetailedprocedureoflumboperitonealshunt1.IntroductionofSurgicalmaterials&Design手术耗材和设计介绍2.Preoperativepreparation:术前准备A)shuntvalveadjusting阀门调节B)Operationroomarrangement手术室安排C)Positioning摆体位3.Surgicalprocedure(video)手术过程（视频）30Lumbo-peritonealCatheter腰大池腰大池-腹腔腹腔导管管TheSophysaLumbo-Peritoneal
31、CatheterSet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,radiopaqu
32、estripe.（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）.31AdjustmentforvalvepressurePolarisPositionOperatingPressure(mmH2O)SPVSPV-140SPV-300SPV-400130105080270401001503110801502
33、3041501102203305200140300400SPVA:PolarisAdjustableValve,30-200,AntechamberPreoperative preparation 32DesignofLPshuntPolarisvalvePeritonealcatheterLumbarcatheterIntermediarycatheter*Design:Shuntvalvewouldplaceaboveiliaccrestforpumping.33DesignofLPshuntPolarisvalvePeritonealcatheterLumbarcatheterInter
34、mediarycatheter34OperatingroomarrangementAnesthesiologistSurgeonSurgeonBipolar&monopolarcoagulatorsuctionApparatus&nurseArmstandApparatus&nurse35Positioning&skinincisionLateralpositionArmstandFixationSternum&PubisFixationThoracicspine&SacrumForlumberpunctureOpentheoperativefield36LPshuntingissimple!
35、1.Lumbarpuncture,insertlumbarcatheter2.Opentheabdomen3.placetheshuntvalveabovetheiliacbone(髂骨).4.connectthecathetereachparts&implantandclosing.Themainstepsoftheprocedure37LPshuntsimple4stepsIntermediarycatheterLumbarcatheterPeritonealcatheterValveimplant:RelaypointValvefixationbysutureRelaypointskin
36、incision38Videotime!39Postoperativefollowup术后随后随访observationpoint观察点察点OverdrainagesymptomsUnderdrainagesymptomscheckCTscan&adjustvalvepressure检查CT并并调节阀门压力力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。DonthesitatetodoLPshunt!DonthesitatetodoLPshunt!41
