脳室心房連絡術における問題

SOME PROBLEMS IN VENTRICULO-ATRIAL SHUNT OPERATION

I．はじめに

　水頭症に対しては，非常に古くから，各種各様の治療が試みられ，すでにHippocratesの時代に，小児水頭症の治療に関する記載があるという^9）。しかしそのほとんどすべてが，悲観的結果に終つていた。最近になつて，高分子化学の進歩によつて，一定の内圧以上になると開く，一方通行弁を有する精巧な誘導管が作られ，ほぼ永久的に生体内に留置できるようになつた。このような誘導管を用いて，脳室内の髄液を，体循環の静脈系に短絡する方法が行なわれてからは，水頭症の治療成績には，画期的飛躍が見られる^{1）12）15）19）20）27）28）}。

　この方法は，現在もつとも生埋的な優れた，髄液の誘導法として広く応用され，わが国においても，国産の誘導管によつて，かなりよい結果が得られているようである^16）。しかし，われわれの教室における症例について観察して見ると，なお問題が少なくないように思われる。そこで，経験例をまとめて，若干考察を加えて見たい。

Since 1961, ventriculo-atrial shunt operations have been carried out on 92 patients of various intracra-nial diseases of 11 days to 58 years of age. Primary disease of the patients was infantile hydrocephalus in 17, hydroencephalodysplasia in 3, tumor in pineal region in 15, the other supratentorial tumor in 8, the fourth ventricle tumor in 15, the other infra-tentorial tumor in 13, meningioma of tentorium cerebelli in 1, and miscellaneous in 20. In every cases was used a silicon-rubber tube made in Japan, with a slit valve at the end of the cardiac tube.

The shunting tube was passed through the various routs: right temporal region-V. facialis dextra in 64,-V. jugularis interna dextra in 18,-V. jugularisexterna dextra in 16, right frontal region-V. facialis dextra in 4,-V. jugularis externa dextra in 7, left frontal region-V. jugularis externa sinistra in 1, left temporal region-V. facialis sinistra in 1,-V. jug-ularis externa sinistra in 4,-V. jugularis interna sinistra in 2, left occipital region-V. facialis dextra in 1,-V. jugularis externa sinistra in 1, 119 times in 92 patients in total.

Although majority of these patients were improved after ventriculo-atrial shunt operation, the following troubles were observed in a few cases : Occlusion of shunting tube was found 30 times in 20 patients. The occlusion was found at ventricular tube 8 times in 7 patients, at the cardiac end of the tube 19 times in 11 patients, and an occlusion due to kinking of the tube occured at cervical region 3 times in 2 patients. Reconstruction of shunt was attempted, 2times in 10 patients, 3 times in 3 patients, 4 times in one patient, 5 times in 2 patients. Although variously organized clot densely attached at the end of cardiac tube in the right atrium, in 3 of 15 autopsied cases, 16 days, 50 days, 1 year after op-eration respectively, the tube was not closed by the clot in all 3 cases. After shunt hemipareses was observed in 2 cases, septicemia in 2, meningitis in 1. A plain film revealed a few drips of Myosil in the shunting tube in a patient who had ventriculo-atrial shunt following myosil ventriculography 3 mounths previously. Any sign of closure of the shunt, however, did not appear more than 1 year after operation in this patients.