腹腔镜下脑室-腹腔分流术治疗小儿脑积水的疗效观察

目的探讨腹腔镜下脑室-腹腔分流术治疗小儿脑积水的临床效果。方法回顾性分析我院神经外科2012-03-2013-04收治的68例脑积水患儿的临床资料，根据手术方式分为实验组（37例）和对照组（31例），实验组行腹腔镜下脑室-腹腔分流术，对照组采用传统脑室-腹腔分流术。观察2组患者手术情况及术后随访情况。结果对照组手术时间、术后排气时间均明显长于实验组（P＜0.05）；2组手术前后双侧脑室额角差值差异无统计学意义（P＞0.05）；术后3个月2组总有效率差异无统计学意义（P＞0.05）；2组Kamofsky评分同期比较差异无统计学意义（P＞0.05），2组术后Kamofsky评分较术前显著升高（ P＜0.05）；术后对照组分流管梗阻（22.58％）、腹腔感染（19.36％）发生率均显著高于实验组（5.14％、2.70％，P＜0.05）。结论腹腔镜下脑室-腹腔分流术治疗小儿脑积水具有手术过程短、患者恢复快、术后并发症少等优点，且疗效可靠，值得临床推广。     

腹腔镜下脑室-腹腔分流术治疗脑积水的疗效观察

目的 观察腹腔镜下脑室-腹腔分流术治疗脑积水的临床疗效。方法 回顾性分析2009-06-2012-06我科收治的68例脑积水患者的临床资料,按手术方式分为腹腔镜下脑室-腹腔分流术治疗组（观察组）34例,常规手术组（对照组）34例,对比2组临床疗效和术后并发症情况。结果 2组患者随访12～24个月,观察组和对照组治疗有效率分别为91.2%（31/34）、61.8%（21/34）,差异有统计学意义（P＜0.05）;观察组分流管腹腔端梗阻率和腹部感染率均明显低于对照组,差异均有统计学意义（P＜0.05）。结论 腹腔镜辅助下脑室腹腔分流术治疗脑积水安全、有效,术后分流管阻塞及感染发生率低。     

脑积水腹腔镜下"套管式"侧脑室-肝膈间隙分流术(附46例报道)

目的探讨腹腔镜下“套管式”(自行研制的多孔式套管)侧脑室-肝膈间隙分流术治疗脑积水的方法与效果。方法对46例脑积水病人在腹腔镜下行“套管式”侧脑室-肝膈间隙分流术。分流管末端的固定方式分别采用腹腔镜缝合打结固定法、腹腔镜钛夹固定法和腹腔镜穿刺皮下固定法。结果统计学分析发现手术前后的颅内压、脑室体部宽度指数均有显著性差异,P <0.05。随访发现1例并发肝膈间隙脓肿,6例分流管脑室端梗阻,2例腹腔端梗阻。结论电视腹腔镜下“套管式”侧脑室-肝膈间隙分流术方法先进,省时、省力,创伤微小,效果满意,术后并发症发病率低,是一种值得推广的分流方法。     

应用腹腔镜治疗脑积水的技术改进

脑室-腹腔分流术是治疗脑积水的一种常用方法,腹腔镜下脑室-肝膈间隙分流术治疗脑积水并发症少,是一种安全有效的治疗方法,但腹腔端分流管的固定均需丝线、钛夹等异物固定[1].我院2008年6月至2009年8月采用新的方法完成10例腹腔镜下侧脑室-肝膈间隙分流术,不需任何固定物,手术操作简捷、固定可靠、分流有效.     

新型腹腔穿刺针与单孔腹腔镜联合在脑室-腹腔分流术治疗脑积水的应用

目的探讨新型腹腔穿刺针联合单孔腹腔镜在治疗脑积水手术时脑室腹腔分流管腹腔端放置中的应用价值。方法回顾性分析84例采用新型腹腔穿刺针（腹穿组）联合单孔腹腔镜行脑室腹腔分流术治疗脑积水病人的临床资料。结果腹穿组手术时间及腹部切口长度明显低于传统手术组,而传统手术组的感染及分流管堵塞的并发症远远高于腹穿组。结论应用新型腹腔穿刺针联合腹腔镜进行脑室腹腔分流术腹腔端置入,具有较多优势,如创伤小、手术视野开阔、减少并发症的发生等,特别是在肥胖、既往有腹部手术史或分流调整术的病人。     

腹腔穿刺置管系统在脑室-腹腔分流术中的应用

目的探讨腹腔穿刺置管系统在脑室-腹腔分流术中的可操作性及安全性。方法 12例脑积水病人采用腹腔穿刺置管系统,以"脐周四点提起法"提起腹壁经脐缘穿刺置入脑室-腹腔分流管腹腔端。3例腹腔镜手术志愿者按上述方法及部位模拟穿刺置入脑室-腹腔分流管,并借助腹腔镜观察穿刺置管全过程。计算穿刺置管时间、观察腹腔穿刺置管成功率及安全性。结果置管成功率为100%,平均穿刺置管时间4min,均未出现腹腔内出血及腹腔内脏器损伤。结论腹腔穿刺置管系统应用于脑室-腹腔分流术具有操作简单、安全、微创、成功率高、不遗留手术瘢痕等优点。     

微创脑室-腹腔分流术的基础与临床应用

目的 探索脑积水脑室-腹腔(V-P)分流术的改进方法,以提高疗效、降低并发症.方法 解剖研究尸体大网膜成人16例、儿童12例,普外腹腔镜手术中观测大网膜下缘位置.95例脑积水患者脑室端CT定位确定穿刺点和深度,在腹腔镜和特制微创腹腔穿刺置管器协助下行左下腹穿刺将分流管腹腔端置于盆腔无大网膜区.结果 成人尸体大网膜上腹型和中腹型占81.3%;儿童无下腹型.临床病例随访3-45个月,Salmon's分级,有效率95.7%,并发症9例(9.5%):感染3例、梗阻5例、不明原因气颅1例.结论 微创V-P分流术治疗脑积水临床疗效满意度高,实用性强.     

微创脑室-腹腔分流术的基础与临床应用

目的 探索脑积水脑室-腹腔(V-P)分流术的改进方法,以提高疗效、降低并发症.方法 解剖研究尸体大网膜成人16例、儿童12例,普外腹腔镜手术中观测大网膜下缘位置.95例脑积水患者脑室端CT定位确定穿刺点和深度,在腹腔镜和特制微创腹腔穿刺置管器协助下行左下腹穿刺将分流管腹腔端置于盆腔无大网膜区.结果 成人尸体大网膜上腹型和中腹型占81.3%;儿童无下腹型.临床病例随访3-45个月,Salmon's分级,有效率95.7%,并发症9例(9.5%):感染3例、梗阻5例、不明原因气颅1例.结论 微创V-P分流术治疗脑积水临床疗效满意度高,实用性强.     

经肋间肝膈下间隙置管脑室-腹腔分流术治疗脑积水的体会

目的探讨经肋间肝膈下间隙脑室-腹腔分流术治疗脑积水的疗效。方法1996到2006年我科采用经右腋前线8-9肋间作切口直接将分流管置于肝膈下间隙，行脑室-腹腔分流术治疗脑积水53例。结果整个手术仅1h左右，无分流管腹腔端堵塞及血、气胸发生。术后B超随访31例，肝膈下间隙均无异常。结论该方法操作简单，避免了对肠道的干扰，能有效地避免分流管腹腔端堵塞，在脑积水的治疗中不失为一种安全可靠的方法。     

腰大池-腹腔分流术和脑室-腹腔分流术治疗交通性脑积水的对比分析

目的 比较腰大池-腹腔分流术（LPS）和脑室-腹腔分流术（VPS）治疗交通性脑积水的临床效果。方法 回顾性分析2013年1月至2017年12月收治的108例交通性脑积水的临床资料，其中50例行VPS（VPS组），58例行LPS（LPS组）。术后随访3个月~5年，同一病人一种或几种临床症状好转或脑室缩小即为改善。结果 术后3个月，VPS组改善率（84.0%，42/50）与LPS组（87.9%，51/58）无统计学差异（P>0.05）。VPS组堵管发生率（18.00%，9/50）和感染发生率（14.00%，7/50）均明显高于LPS组[分别为3.44%（2/58）、1.72%（1/58）；P<0.05]。结论 对于交通性脑积水，与VPS相比，LPS疗效可靠、并发症少     

颅脑损伤去骨瓣减压术后脑积水危险因素分析及分流时机

目的 探讨颅脑损伤病人去骨瓣减压术后发生脑积水的危险因素及分流术时机。方法 回顾性分析2017年1月~2019年12月去骨瓣减压术治疗的128例颅脑损伤的临床资料。多因素logistic回归分析检验脑积水危险因素。结果 128例中，术后发生脑积水28例，发生率为21.9%。多因素Logistic回归分析结果表明，蛛网膜下腔出血、脑室出血、骨窗面积≥7 cm2是颅脑损伤去骨瓣减压术后继发脑积水的独立危险因素（P<0.05）。28例脑积水中，22例行脑室-腹腔分流术，按照分流中位时间的3.5 d分为早期分流组和晚期分流组，各11例；早期分流组术后颅内压改善效果更好（P<0.05），颅内压恢复时间明显缩短（P<0.05）；但是两组脑脊液指标和并发症发生率均无统计学差异（P>0.05）。结论 脑积水是颅脑损伤去骨瓣减压术后常见并发症，手术治疗前应充分评估脑积水发生的因素，一旦发生脑积水应查明原因并早期进行分流手术治疗     

外伤性脑积水脑室-腹腔分流的临床观察

目的评价脑室-腹腔(V-P)分流对创伤性脑损伤后不同程度的脑积水的治疗效果。方法根据CT影像显示脑室大小,将创伤性脑损伤后脑积水患者50例分为轻度(19例),中度(17例),重度(14例)三组,行V-P分流手术治疗,比较手术前后脑室径与双顶径的比值(V/BP),室周水肿带直径及GOS评分。结果分流三个月后轻中度脑积水组三项指标均显著优于术前(P<0.05),重度脑积水组与术前相比,差异无显著性意义(P>0.05)。结论轻中度外伤性脑积水V-P分流效果较好,重度脑积水患者分流手术后恢复欠佳,临床上对外伤性脑积水患者应尽早发现、及时治疗。     

微创脑室-腹腔分流术的基础与临床应用

目的 探索脑积水脑室-腹腔(V-P)分流术的改进方法,以提高疗效、降低并发症.方法 解剖研究尸体大网膜成人16例、儿童12例,普外腹腔镜手术中观测大网膜下缘位置.95例脑积水患者脑室端CT定位确定穿刺点和深度,在腹腔镜和特制微创腹腔穿刺置管器协助下行左下腹穿刺将分流管腹腔端置于盆腔无大网膜区.结果 成人尸体大网膜上腹型和中腹型占81.3%;儿童无下腹型.临床病例随访3-45个月,Salmon's分级,有效率95.7%,并发症9例(9.5%):感染3例、梗阻5例、不明原因气颅1例.结论 微创V-P分流术治疗脑积水临床疗效满意度高,实用性强.

Abstract：

Objective To explore a new approach for improving therapeutic effects and minimizing complications of ventriculoperitoneal shunt(VPS). Methods The length of and lower edge of the greater omentum were measured and analyzed in 28 autopsies ( 16 adults and 12 children) and laparoscopic surgeries. 95 cases of hydrocephalus treated by MIVPS( minimally invasive ventriculoperitoneal shunt) were retrospectively reviewed. The depth and positions of puncture into ventricles were confirmed by CT scanning. And then distal ventriculoperitoneal shunt was navigated into left pelvic area by the assistance of laparoscopy and the special abdominal puncture device. Results The findings of autopsies demonstrated that the percentage of upper and middle abdominal types of greater omentum position was 81. 3% in adults. There was no lower abdominal type in children. These cases were followed up from 3 to 45months. The Salmon' s classification rate was 95.7% . Complications were found in 9 cases ( 9. 5% ):infection in 3 cases (3.2%), obstruction in 5 cases ( 5.3% ), and 1 case of unknown pneumocephalus (1.0%). Conclusions MIVPS is better than previous VPS. It is helpful to reduce complications and should be considered for advanced clinical application.     

颅脑损伤继发正常压力脑积水的临床治疗分析

目的 探讨颅脑损伤继发正常压力脑积水的治疗方法及疗效。方法 回顾性分析2017年1月至2019年9月收治的69例颅脑损伤继发正常压力脑积水的临床资料。采用腰大池-腹腔分流术（LPS）治疗31例（LPS组），采用脑室-腹腔分流术（VPS）治疗23例（VPS组），保守治疗15例（保守组）。所有病例均随访3个月以上，对比分析各组围手术期并发症、术后3个月头颅CT平扫、CT灌注成像参数[脑血容量（CBV）、脑血流量（CBF）、平均通过时间（MTT）、达峰时间（TTP）]、GOS评分、日常生活能力量表（ADL）评分。结果 LPS组和VPS组均手术成功，无手术死亡病例。保守组死亡1例。术后3个月，LPS组和VPS组Evan’s指数、戴帽征高度、CBV、CBF等指标均明显优于保守组（P<0.05），但是LPS组和VPS组之间均无统计学差异（P>0.05）。LPS组并发症总发生率（12.90%，4/31）和VPS组（39.13%，9/23）明显高于保守组（0%；P<0.05），但是LPS组明显低于VPS组（P<0.05）。术后3个月，LPS组和VPS组GOS评分及ADL评分均显著高于保守组（P<0.05），但是LPS组和VPS组之间无统计学差异（P>0.05）。结论 对于颅脑损伤继发正常压力脑积水，建议积极手术治疗，VPS和LPS均是有效的方法，而LPS并发症相对更少。     

神经内镜下和传统分流术治疗脑积水的疗效评价

目的 评价神经内镜下第三脑室底造瘘术(ETV)或联合神经内镜引导下脑室腹腔分流术(EVPS)与传统分流术治疗脑积水的临床效果和并发症.方法 深圳大学第一附属医院神经外科自2002年6月至2009年6月共手术治疗299例脑积水患者,其中神经内镜组(98例)患者行神经内镜下ETV或联合EVPS(20例梗阻性脑积水患者仅行ETV,78例行ETV联合EVPS),传统分流组(201例)患者行传统分流术(196例行脑室腹腔分流术,5例行脑室心房分流术),分析2组患者的临床资料并比较其临床疗效和并发症的发生率.结果 与传统分流组比较,神经内镜组远期疗效好、堵管发生率低、置管位置准确率高、置管次数少,差异均有统计学意义(P<0.05).结论 应用神经内镜治疗不同原因脑积水是有益的手术方法,具有远期疗效好、堵管发生率低、置管位置准确等优势.     

Ventriculoperitoneal shunt surgery and the incidence of shunt revision in adult patients with hemorrhage-related hydrocephalus

Objective

Ventriculoperitoneal shunt surgery remains the most widely accepted neurosurgical procedure for the management of hydrocephalus. However, shunt failure and complications are common and may require multiple surgical procedures during a patient's lifetime. The purpose of this study is to evaluate the ventriculoperitoneal shunt surgery and the incidence of shunt revision in adult patients with hemorrhage-related hydrocephalus.

Methods

Adult patients who underwent ventriculoperitoneal shunt placement for hemorrhage-related hydrocephalus from October 1990 to October 2009 were included in this study. Medical charts, operative reports, imaging studies, and clinical follow-up evaluations were reviewed and analyzed retrospectively.

Results

A total of 133 adult patients with the median age of 54.5 years were included. Among patients, 41% were males, and 62% Caucasians. The overall shunt revision rate was 51.9%. The shunt revision rate within the first 6 months after the initial placement of ventriculoperitoneal shunts was 45.1%. The median time to first shunt revision was 0.50 (95% CI, 0.24–9.2) months. No significant association was observed between perioperative variables (gender, ethnicity, hydrocephalus type, or hemorrhage type) and the shunt revision rate in these patients. Major causes of shunt revision include infection (3.6%), overdrainage (7.6%), obstruction (4.8%), proximal shunt complication (7.6%), distal shunt complication (3.6%), old shunt dysfunction (6.8%), valve malfunction (10.0%), externalization (3.6%), shunt complication (12.0%), shunt adjustment/replacement (24.0%) and other (16.4%).

Conclusion

Although ventriculoperitoneal shunting remains to be the treatment of choice for adult patients with post hemorrhage-related hydrocephalus, a thorough understanding of predisposing factors related to the shunt failure is necessary to improve treatment outcomes.     

Non-shaved ventriculoperitoneal shunt in Thailand.

The objective of this study was to determine whether non-shaved patients undergoing ventriculoperitoneal shunt operations would experience a significantly increased shunt infection rate as compared to shaved patients. Clinical trials of non-shaved scalp preparation were performed in ventriculoperitoneal shunt procedures at Songklanagarind Hospital from January 1994 to December 1999. Exclusion criteria were poor scalp condition, previous shunt procedures and immunocompromised hosts. Statistical analysis using univariate, multivariate and logistic regression was used. One hundred and nineteen patients were included in the study. Thirty-six cases were in the non-shaved group. Thirty-eight of 119 cases were less than one year of age and congenital hydrocephalus was the most common problem. The only notable risk factor for shunt infection was an operation lasting more than 59 min. The shunt infection rate in the non-shaved and shaved groups was 6.25% and 14.94%, respectively (p>0.05). In conclusion, leaving the hair intact for ventriculoperitoneal shunt surgery is safe and not associated with increased risk of shunt infection. The non-shaved method may encourage quicker restoration of the patients' self-image and facilitate their early return to normal life.