Expanded Polytetrafluoroethylene人工硬膜使用時の新しい髄液漏予防手技Mesh and Glue法—耐圧性を改善したMAGスプレー法とその有効性に関する基礎的検討

Mesh and Glue Technique as a New Sealing Technique for the Use of Expanded Polytetrafluoroethylene Dura Substitute : the experimental studies of its tolerance for pressure and long-term histological changes

I．はじめに

　97年春にWHOの勧告^7）を受けて，厚生省がヒト乾燥硬膜の使用の禁止を決めて以来^2），脳外科手術後の硬膜欠損に対してはexpanded polytetra-fluoroethylene（ePTFE）人工硬膜（Gore-Tex Dura Substitute^®；WL Gore ＆ Associates，Flagstaff，Arlz.，U.S.A.）を使用せざるを得なくなった．しかしながら本材料は生体組織との親和性に乏しく，縫合部からの髄液漏れが問題となるケースがある．単純な縫合部へのフィブリン糊の塗布では本問題は解決しなかったことから，われわれは吸収性のメッシュを利用した新しい縫合部のシール法としてMesh and Glue法（MAG法）を開発した^4）．

　本法は先に報告したように^4），吸収性のメッシュにあらかじめフィブリノゲン液を浸潤させ，縫合部に貼付した後にトロンビン液をかけ，メッシュの形に沿ったフィブリンを形成させるものである．われわれの施設では1997年6月に本法を臨床に応用して以来，これまでに100例以上のケースにMAG法を行い，術後の髄液漏予防法としての本法の有効性を確認するに至った．

　xpanded polytetrafluoroethylene (ePTFE) as a dural substitute is sometimes associated with leakage ofcerebrospinal fluid through the suture line. We have developed a new technique to seal the suture line withan absorbable mesh and fibrin glue. It is named as the mesh-and-glue technique. In this paper, the basicbackground of the efficacy of this technique was examined using in vitro and in vivo experimental models.

　The sealing effect was estimated on water leakage through 1cm of suture line on the ePTFE suturedwith 4 - 0 braided nylon at intervals of 2mm. The burst pressure of the non-sealed, conventional fibringlue, simple glue spray, mesh-and-glue, and mesh-and-glue combined with spray was 2.8±0.4, 4.3±1.2, 64.421.4, 142.7±22.2 and 406.1＋29.7cm H₂0 respectively. It was worth noting that mesh-and-glue combinedwith the spray method can tolerate even arterial pressure. It was also observed that mesh-and-glue can seala small dural defect.

　Long-term pathological changes of the mesh-and-glue was examined in a murine craniotomy model. Implanted mesh and fibrin glue was gradually transformed into a tight connective tissue firmly adhering tothe surrounding structure within two months.

　These experimental results well support the clinical efficacy of the mesh-and-glue technique. This technique can also be applied to seal the arachnoid membrane after spinal surgery or to seal the suture line ofarteriotomy in carotid endoarterectomy.