Shimogawa Takafumi, Morioka Takato, Shimogawa Takafumi, Hamamura Takeshi, Hashiguchi Kimiaki, Murakami Nobuya
Department of Neurosurgery, Kyushu Rosai Hospital.
No Shinkei Geka. 2014 May;42(5):419-28.
Vagal nerve stimulation (VNS) is a less invasive palliative treatment for intractable epilepsy and was approved for use in Japan in July 2010. Surgical complications of VNS such as vagal nerve dysfunction, cardiac arrhythmia with asystole, and vocal cord palsy as well as complications arising from fracture of the leads or generator and infections are well known in the West. The aim of the present report is to describe the surgical complications encountered in our hospital and discuss their countermeasures.
We reviewed the clinical records of 26 patients who underwent VNS therapy between March 2011 and June 2013. The cases involved 17 male and 9 female patients, including 8 children(<15 years of age).
Three patients(11.5%)experienced severe bradycardia and cardiac asystole following test stimulations of the vagal nerve with a stainless-steel surgical hook left in place, to extend the operative field. It was believed that the current spread through the hook and stimulated the cardiac branch of the vagal nerve. In an adult patient with severe intellectual disability, inappropriate dermatological therapy for a superficial purulent wound on the neck caused lead infection 10 months postoperatively. In a child with moderate intellectual disability, lead fracture was noted in association with rotation of the pulse generator at one month postoperatively. In the former case, the lead was cut off whilst the electrode and anchoring coil on the vagal nerve remained;the whole VNS system was removed in the latter case. Subfascial implantation of the generator was recommended. In an adult patient, disconnection between the leads and generator head was noted at 10 months postoperatively.
During intraoperative test stimulations of the vagal nerve, stainless-steel surgical hooks should be removed to avoid the spread of current. In intellectually disabled patients, the pulse generator should be placed in the subfascial area instead of the subcutaneous area, especially children. The connection between the leads and the generator should be performed with the aid of a microscope, after removal of the fluid and tissue.
迷走神经刺激术（VNS）是一种用于治疗顽固性癫痫的侵入性较小的姑息治疗方法，于2010年7月在日本获批使用。在西方，VNS的手术并发症如迷走神经功能障碍、伴有心搏停止的心律失常、声带麻痹以及导线或发生器骨折和感染引起的并发症已广为人知。本报告的目的是描述我院遇到的手术并发症并讨论其应对措施。
我们回顾了2011年3月至2013年6月期间接受VNS治疗的26例患者的临床记录。病例包括17例男性和9例女性患者，其中8例为儿童（<15岁）。
3例患者（11.5%）在使用留在原位的不锈钢手术钩对迷走神经进行测试刺激以扩大手术视野后出现严重心动过缓和心搏停止。据信电流通过钩子传播并刺激了迷走神经的心脏分支。在一名重度智力残疾的成年患者中，对颈部浅表化脓性伤口进行的不当皮肤科治疗导致术后10个月发生导线感染。在一名中度智力残疾的儿童中，术后1个月发现导线骨折与脉冲发生器旋转有关。在前一种情况下，导线被切断，而迷走神经上的电极和锚定线圈保留；在后一种情况下，整个VNS系统被移除。建议将发生器植入筋膜下。在一名成年患者中，术后10个月发现导线与发生器头部断开连接。
在术中对迷走神经进行测试刺激时，应移除不锈钢手术钩以避免电流传播。在智力残疾患者中，尤其是儿童，应将脉冲发生器置于筋膜下区域而非皮下区域。在清除液体和组织后，应借助显微镜进行导线与发生器之间的连接。
