【作者】 王一青；

【导师】 胡坚；

【作者基本信息】 浙江大学 ， 外科学（专业学位）， 2015， 硕士

【摘要】 目的手汗症在我国各地人群中均有着一定的发生率。手汗症会不同程度地甚至严重影响到人们的工作、学习和社交生活,对学生、军人等特定职业尤为明显。胸腔镜下胸交感神经链切断术(ETS)是应用最为广泛并最有效的治疗技术,随着胸腔镜技术的日益成熟和发展,微创治疗手汗症技术手段也日臻完善。本中心自1998年开展ETS以来,随着微创治疗理念的不断更新和发展,在手术方式(包括体位、切口、流程等)、工具器械、麻醉插管方式、手术范围等进行了一系列临床研究和技术改良,逐渐确立了目前治疗手汗症的规范、完善、有效的个性化治疗策略,并创新性地开展了纯单侧单孔可弯曲胸腔镜经前纵隔行双侧胸交感神经链切断术的手术治疗和经自然腔道(食管隧道)胸交感神经切断术的动物实验两项工作,为手汗症的微创治疗发展作出了不懈努力。本研究回顾性分析本中心自1998年以来收治的167例手汗症患者,根据不同的历史阶段的手术方法分组,本文就该组病例的手术方式(体位、切口、流程等)进行分析研究,比较各种手术治疗方式的术中流程,术后恢复,有效率和并发症的发生率等,论证微创技术及理念的逐步发展在手汗症治疗上的体现以及患者的获益,为今后手汗症微创治疗的创新和发展提供实践和理论依据。方法回顾性分析1998年至2015年本中心收治的所有手汗症患者,根据治疗方式不同分为手术治疗组和CT引导下无水酒精注射组,手术治疗组根据不同历史阶段的手术方式不同分为侧卧位术中翻身双侧三(两)孔法、平卧位双侧三(两)孔法、平卧位双侧单孔法、单孔可弯曲胸腔镜经纵隔法。收集整理所有病例的手术资料(包括手术体位、切口数量和位置、切除／阻滞神经节段范围、麻醉插管方式、手术时间、出血量),术后恢复资料(包括术后住院时间、住院期间并发症),随访资料(包括症状改善情况,是否出现代偿性多汗、手干症、霍纳综合征等),分组比较组间差异。结果1998年至今,于我院就诊的手汗症患者共167例,男性75例,女性92例,平均年龄22.0±5.5岁(最大43岁,最小12岁)。其中9例行CT引导下无水酒精注射,其余158例均行手术治疗。手术治疗的患者中采取侧卧位翻身双侧三(两)孔法69例,平卧位双侧三(两)孔法24例,平卧位双侧单孔法49例,单孔可弯曲胸腔镜经纵隔法16例,组间年龄、性别组成无明显统计学差异。结果表明,手术治疗相比CT引导下无水酒精注射,治疗有效率显著增高,术后并发症(特别是代偿性多汗)发生率并未明显增多。在微创技术逐步改进的过程中,在手术体位方面,我们把手术体位从早期的侧卧位、术中需翻身重新消毒铺巾再行对侧手术改进为平卧位术中无需改变体位后,数据表明,手术时间、出血量、术后住院时间都显著缩短,手术有效性及术后并发症发生率未见明显差异；在手术切口方面,我们从最早的双侧三孔改进到双侧两孔、双侧单孔甚至单侧单孔行双侧手术,数据表明在同一体位下,切口减少并未增加手术时间、出血量,术后住院时间、治疗有效性及术后并发症发生率无明显差异,减少切口数量可显著减少患者局部疼痛,改善外观,增加患者满意度,促进术后恢复；在手术范围方面,我们从早期切断T2-4,改进为单纯切断T3或T4,切断方式从早期完整切除神经改进为仅电凝烧灼神经及kuntz束,数据表明,各组治疗有效性无差异,而仅切断T3或T4显著降低代偿性多汗的发生率,且改进后的方法创伤更小。另外,单孔可弯曲胸腔镜经纵隔法治疗手汗症和其他术式一样有效,手术时间、出血量、术后住院时间以及术后并发症发生率方面与同期其他手术方式相比无显著差异,但可明显减少切口数量和长度,对术后美容及患者满意度优势明显,适合特定需求的患者。动物实验证明：经食道行胸交感神经切断具有可操作性,术后并发症(如食道瘘)在可控范围内。结论1.胸腔镜下胸交感神经链切断术仍是目前治疗手汗症最有效的方法,CT引导下无水酒精注射法治疗手汗症尚处于初级探索阶段,临床应用应慎重,其有效性还有待进一步验证。2.从本中心逐步发展改进ETS技术的历程,我们可以看到微创技术及理念在胸外科领域的发展,通过改进手术方式范围和麻醉插管方式等,逐步规范了手术流程,降低了手术时间、出血量,加快了术后恢复,降低并发症发生率,体现了微创技术理念从原始的理念性的微创,到成熟的技术性的微创,再到微微创甚至将来无痕手术的趋势。3.随着社会经济水平以及人们对生活质量要求的进一步提高,在确保手术安全和有效的前体下,越来越多患者对手术切口美观有了需求,为此国内各大中心作出了许多努力,比如单孔技术,使用隐蔽位置的切口,以及本中心创新的单侧单孔可弯曲胸腔镜经纵膈手术法,以这些微痕手术技术作为基础,将来必将最后过渡到无痕手术的阶段,本中心的动物实验已经证实了经食管行交感神经切断术的可行性,有待进一步临床研究后应用。更多还原

【Abstract】 ObjectivePalmar hyperhidrosis has a certain morbidity in various regions of China. Palmar hyperhidrosis affects people’s work, study and social communication, especially for students and soldiers. Endoscopic thoracic sympathectomy (ETS) is currently the most widely used and the most effective treatment technology, and with the development of thoracoscopic technology, ETS has become more and more mature. Since our centre started ETS in1998, we made several efforts to develop the surgical procedures(position, incision, process, et al), instrument, anesthesia intubation and surgical range, gradually establish a normative and effective treatment strategies for ETS, we also innovativlly to do ETS via a single unilateral incision approach by the pleura videoscope and research to develop the natural orifice translumenal endoscopic surgery(NOTES) on ETS (through the esophagus). This study retrospective analysis167cases of palmar hyperhidrosis in our center from1998to2015, according to the grouping operation mode in different stages and analyse several preoperative, in operation and postoperative parameters, the efficiency of operation and the occurrence rate of complications, to demonstrate the patient profit from the development of minimally invasive techniques and concepts and provide practical and theoretical basis for the innovation and development for the minimally invasive treatment of palmar hyperhidrosis in the future.MethodRetrospectively analyse all the palmar hyperhidrosis cases in our centre from1998to2015, divide to five groups according the treatment methods:CT guided percutaneous ethanol injection group, lateral position turning in the operation and bilateral three or two hole group(lateral position-3or2hole group), supine position and bilateral three or two hole group(supine position-3or2hole group), supine position and bilateral single hole group(supine position-single hole group) and unilateral unique hole pleura videoscope group. Collect the operation data(surgical range, anesthesia intubation way, operation time and amount of bleeding), hospitalization data(hospitalization days after operation and in hospital complications), follow up data(efficiency of treatment and if compensatory hyperhidrosis, hands dry and horner syndrome happened) of all cases and analyse the difference between groups.ResultFrom1998to2015, there were167patients of palmar hyperhidrosis came to our centre,75males and92females, the average age is22.0±5.5years old(12～43), among the167cases,9accepted CT guided percutaneous ethanol injection treatment, other158accepted surgical treatment. Among the surgical groups, there were69cases in the lateral position-3or2hole group,24cases in the supine position-3or2hole group,49cases in the supine position-single hole group and16in the unilateral unique hole pleura videoscope group, the age and gender composition has no significant statistical difference between groups. The results show that surgical treatment had obvious high efficiency than CT guided percutaneous ethanol injection treatment, and the occurrence rate of complications had no significant statistical difference. In the process of technology improvement, we first changed the operation position from lateral position to supine position to save the step of turning position in the operation, the data showed the operation time, amount of bleeding and hospitalization days after operation obviously reduced, the treatment efficiency and complications incidence had no statistical difference; on the side of incisions, we made3incisions on two sides at the start, and then bilateral2incisions, and bilateral1incisions now, the data showed incision reducing did not lead to the operation time, amount of bleeding and hospitalization days after operation increasing and also the treatment efficiency and complications incidence had no statistical difference, incision reducing could obviously depress the pain of patients after operation, improve the appearance and increase the patients’ satisfaction degree; on the side of operation range, we change the range from T2-T4to just cut off T3or T4ganglion, change the cut off method from complete resection to electric coagulation, the results showed the efficiency has no difference and just cut off T3or T4ganglion obviously reducing the incidence of compensatory hyperhidrosis. In addition, the surgical method of unilateral unique hole pleura videoscope group also had the same operation parameter with others in the same time, and this technology could go a step further to reduce incision and fit the patients with specific needs of the postoperative appearance. The animal experiment suggested that NOTES by esophagus to do ETS is operative and the postoperative complications such as esophageal fistula is in the controllable range.Conclusion1. ETS is still the most effective method of all the treatment for palmar hyperhidrosis, CT guided percutaneous ethanol injection is still in the initial stage of exploration, the clinical application should be cautious;2. In the process of ETS technology improvements, we could see the development of minimally invasive techniques and concepts in the thoracic surgery, the improvements of all the details of operation gradually accelerate the postoperative recovery and reduce the incidence of complications, demonstrates the practicality of minimally invasive techniques and concepts;3. Along with the development of social economic level and the need for life quality of patients, patients has more and more needs of the postoperative appearance, we made lots of efforts on this purpose, such as single hole techniques of thoracoscope, using hidden location of incision and the technique of unique hole pleura videoscope sympathectomy develop by our centre. The animal experiments in our centre has confirmed the feasibility of NOTES on ETS by esophagus and should to be raised by more further research and then clinical application.更多还原