LUMBOPERITONEAL SHUNT PLACEMENT USING COMPUTED TOMOGRAPHY AND FLOUROSCOPY

IN CONSCIOUS PATIENTS

abstract

• The authors have developed a minimally invasive lumboperitoneal shunt placement procedure conducted after administration of a local anaesthetic. The procedure involves placing a guide-wire and a peel-away sheath under flouroscopic and CT guidance.

Methods

• Patient population• 40 patients(21 men and 19 women; mean age

72.5 years [range 33-86 years]) underwent surgery between 06/2004-08/2006.

• After surgery, the patients underwent a 2-year follow-up. A Codman Hakim programmable valve system was used for the procedure.

Shunt placement

• This involves insertion of a catheter into the abdominal cavity using a needle tap and guide-wire (fig. 1), and the long-term outcomes are similar to those following conventional surgical and endoscopic placement.

Pain control

• Fentanyl citrate (fentanest) is used for pain control during surgery. A bispectral index monitor(fig. 2) is used to simultaneously control pain as well as monitor blood pressure and blood oxygen saturation and perform ECG during surgery.

Preoperative marking

• Using flouroscopic guidance the puncture site was designated as 2cm to the left and 2-4cm above the umbilicus.

• CT guided marking was performed to check there is no large vessels in the puncture area.

Surgical technique

• Left-sided shunt placement with the patient in the right lateral position.

• local anaesthesia is administered to the puncture site, a 14-gauge lumbar puncture needle is inserted under fluoroscopic control into the L3–4 interspace, and a lumbar catheter is positioned.

Abdominal puncture

• The abdominal puncture is carried out using a 21-gauge biopsy needle with the patient in the supine position (Fig. 4).

• the needle is inserted under CT guidance in the desired direction and at an angle (> 45°) established in advance.

Postoperative procedure

• After returning to the ward, patients did not require bed rest, and oral intake was not restricted even immediately after surgery. Patients who lived in a health care facility for the elderly were allowed to return there on the day of the operation. On the following day, rehabilitation for the gait disorder began.

Results

• The technical success rate for catheter placement was 100%. The mean operation time was 53 minutes, and 7 (17.5%) of 40 patients developed shunt dysfunction complications (Table 2).

..cont’d

• The duration of this surgery was almost equivalent to that of conventional surgeries performed after induction of general anaesthesia, but the time-related cost of this method may be lower considering the faster anaesthesia induction and recovery and the postoperative extubation.

• Moreover, this method is advantageous since it can be performed without anaesthesiologists.

conclusions

• This procedure is less invasive than conventional LP shunt placement and could be performed as an outpatient surgery for treatment of NPH in patients who reside in health care facilities for the elderly, a number expected to grow in the future. Improvement of patient’s quality of life by treating symptoms of hydrocephalus will improve his or her condition and facilitate the work of caregivers, for which the demand will increase in the future.

Thank you