Y HOC VIET NAM SO DAC BIET — THANG 11/2010
SO SANH CAC M Q C DO DOT HUY THAN KINH GIAO CAM NGUC TREN OIEU TRj
C H Q N GRA NHIEU MO HOI TAY NGUYEN PHAT
BANG
PHAU THUATNOI SOI LONG NGLfC
Pham Vinh Quang*, Nguyin Van Nam*, Kieu Trung Thanh*
I. OAT VAN OE
Phlu thuat ndi soi ldng ngyc cat buy TKGC nguc la phuong phap cd hieu qua cao dk dieu tri chung ra nhieu md hdi tay nguyen phat (RNMHTNP). Nhung mgt sd hau qua khong mong mudn sau md nhu ra nhieu md hoi bii, tai phat, hgi chiing Homer hoac khd tay qua miic lam anh hudng den ket qua dieu trj, ty le cac hau qua nay cd lien quan den miic do can thiep vao chudi TKGC ngyc tren.
Nghien ciiu nay nham so sanh hieu qua dieu tri giiia cac mirc do ddt buy TKGC ngyc tren, de xac djnh muc do can thiep hgp ly, vira dat hieu qua dieu tri, vira ban che dugc cac hau qua khdng mmong mudn.
II. OOI TUQNG VA PHUONG PHAP NGHIEN COU 1. Boi tuffng nghien cA'u
Gom 138 benh nhan dugc chan doan la chung RNMHNP khu tru d long ban tay. Chi tien hanh phlu thuat cho cac benh nhan bi muc do nhieu (muc do Il-ban tay dam nudc) va rat nhilu (muc do Ill-ban tay gid gigt) theo phan loai cua Karasna M.J. Tat ca cac b?nh nhan diu dugc tryc tiep tham kham, phau thuat, theo ddi va danh gia ket qua tai Khoa phlu thuat ldng ngyc - Benh vien Quan y 103, trong khoang thdi gian tir 11/2005 din 9/2009.
2. Phuffng phdp nghien ciru
2.1. Tham kham lam sang: Xac dinh chan doan, loai trir chiing RNMH thii phat.
Danh gia mirc do RNMH d long ban tay...
2.2. Tham kham can lam sang.: Cac xet nghiem danh gia tinh trang KMP, cac xet nghiem loai trir RNMH thit phat.
2.3. Giai thich cho benh nhan: Giai thich ky cho tat ca cac benh nhan ve tinh trang benh, phuang phap dieu tri, ket qua cd the dat dugc va dac biet la cac hau qua khdng mong mudn cd the xay ra sau md.
2.4. Phuong phap vd cam: Gay me vdi dng ndi khi quan 2 ndng.
2.5. Dyng cu, trang thiet bi - He thdng may phlu thuat ngi soi - Bg dyng cy PTNS thdng thudng 2.6. Quy trinh ky thuat
* Dgt tu the benh nhdn: Tu the nam ngira dau cao (nita nam nira ngoi).
* Ldp ddu do nhiet do (sensor) d Idng ban tay ben chuan bi cat TKGC ngyc vao may theo ddi (Monitoring), ghi nhiet do trude va sau khi ddt buy TKGC ngyc.
* Vi tri cdc cua vdo (dgt trocar): sir dyng 2 cira vao
+ 1 d KLS 4 dudng nach giua de dua dng soi vao KMP.
+ 1 d KLS 3 dudng nach tnrdc de cho dyng cy cat huy TKGC ngyc.
* Mdc do ddt huy TKGC nguc tren vd ' Benh vi^n Qudny 103
CHUYEN DE: PHAU THUAT TIM MACH VA LONG NGUC VIET NAM
cdc nhdnh ndi them
- Ddt buy TKGC ngyc: 138 benh nhan dugc chia lam 3 nhdm ngau nhien
+ Nhdm 1: Dot buy TKGC ngyc tren XS 2 v a X S 3 .
+ Nhdm 2: Ddt buy TKGC ngyc tren XS 2, XS 3 va XS 4.
+ Nhdm 3: Dot buy TKGC ngyc tren XS 3 v a X S 4 .
Theo ddi sy thay ddi nhiet do ldng ban tay tren may Monitoring
- c i t cac nhanh TKGC ndi them tren XS2.
* Kiem tra vd ritt bd dung cii ndi soi
* Sau khi md xong mot ben, chuyen sang ben nguc ddi dien, thuc hien lgi cdc budc ky thudt tuang tu.
2.7. Theo ddi sau md: Theo doi phat hien, xu tri cac bien chung cd the xay ra.
2.8. Danh gia ket qua sau md 24 gid
* Cai thien tinh trang RNMH long ban tay.
* Danh gia miic do RNMH bu: Dya theo Karasna M.J.
+ RMH bii miic do nhe: Md hdi ra d than, ben, diii gay am udt nhung chua gay udt quan ao
+ RMH bii mirc do trung binh: Md hdi ra d cac viing tren nhung nhieu hon da lam udt quan ao.
+ RMH bii miic do nSng: Md hdi ra nhieu, cd the chay thanli ddng, d phy nil thudng ra nhieu d khe giiia 2 vii hoac dudi quang vii, cd cam giac ndng hoac lanh rit khd chiu. Tham chi mdt sd ngudi mudn quay lai trang thai nhu trude md.
2.9. Theo ddi, danh gia kit qua xa
Cac benh nhan dugc tai kham, giri thu hoac ggi dien thoai theo mgt mau cau hdi dieu tra thdng nhat, vao cac thdi dilm sau md I thang, 6 thang va 1 nam.
- Sy cai thien ra md hdi ldng ban tay.
- Cac hau qua khdng mong mudn sau ml - Ket qua chung: Theo tieu chuin cua Bryne W.J [5]
+ Tdt: Ldng ban tay khd am, benh nhan thoa man vdi ket qua dieu tri.
+ Trung binh: Tay khd hon so vdi truac md, nhung benh nhan chua hoan toan hai ldng vdi ket qua dieu tri.
+ Khdng thay ddi: RNMH mo hoi khdng thay ddi so vdi trude md.
+ Xau: Khi RNMH bu qua nhilu lam benh nhan than phien hay ngugc lai ldng ban tay khd qua miic hoac cd hgi chung Homer.
3. Nghien ciru mo hoc tuyen md lm a Idng bdn tay
Nghien cim md hgc tuyen md hdi d long ban tay d 60 tieu ban ciia 30 b?nh nhan, gom:
30 tieu ban trude md va 30 tieu ban sau mo.
Cac tieu ban cat lat va nhuom Hematoxylin Eosin va chup anh tren kinh hien vi dien tir d vat kinh 400X (do phong dai 400 lan), do DK ngoai va DK trong ciia mdt dng tuyen md hdi ldn nhat d anh c5 9x12 (cd do phdng dai la 1200 lin). Nghien ciiu DK trong va DK ngoai ciia mot dng tuyen md hdi, cd y nghia gian tiep danh gia dien tich che tiet ciia dng tuyen md hdi do.
Tdng sd 30 benh nhan chia lam 2 nhdm:
> 15 benh nhan d miic do cd ddt huy TKGC cao nhit din tren XS 2.
> 15 benh nhan d miic do cd dot huy TKGC cao nhit din tren XS 3.
So sanh giiia 2 nhdm nay, nham xac dinh hach TKGC chi phdi chinh cho tuyen md hoi d ldng ban tay. Nghien ciiu nay dugc thuc hien tai Trung tam Md phdi - Hgc vien quan y.
3.1. Xir ly sd lieu: Cac so lieu nghien cihi dugc xir ly bang chuong trinh xir ly sd li?u SPSS 13.0 for Window
Y HOC VIET NAM SO DAC BIET-THANG 11/2010
KET QUA VA BAN LUAN
3.L Mdc do can thiep vdo chudi TKGC nguc tren
Bilu do LTy le cac miic do can thiep MiFC cat
,391%^
| 0 f
W IP
34,8%
26,1%
^*TrenXS2,XS3 •TrenXS2,XS3,XS4 •TrenXS3,XS4
Chiing tdi ap dyng 3 mile do can thiep vao chuoi TKGC ngyc tren, mgt each ngau nhien theo kinh nghiem mdi phlu thuat vien trong khoa, rieng miic do cat buy TKGC ngyc tren XS 3 va XS 4 thyc hien gan day nhat sau khi tham khao cac tai lieu va cac kinh nghiem riit ra tir 2 miic do cdn lai.
- Mirc do ddt huy TKGC tren XS 2, XS 3 la 54 benh nhan (26,1%).
- Mirc do ddt huy TKGC tren XS 2, XS 3, XS 4 la 36 benh nhan (39,1%).
- Mirc do ddt hiiy TKGC tren XS 3, XS 4 la 48 benh nhan (34,8%).
Q ca 3 miic do deu tim va ddt buy cac nhanh ndi tren XS 2 trong pham vi khoang 20 cm tinh tir bd ngoai chudi TKGC ra phia ngoai
3.2. Su thay ddi nhiet do long bdn tay trude vd sau cdt huy TKGC nguc tren & mirc do cit huy TKGC ngifc tren XS 3, XS4(n= 48)
Bang L Thay ddi nhiet do Idng ban tay khi ddt TKGC tren XS 3, XS 4
^ ~ ^ ^ ~ ^ ^ ^ Nhiet do long ban tay
Vi tri ^ ^ ^ ^ ^ Tren XS 3 (n= 48)
Tren XS 4 (n= 48) Tong
Ben p So CO thay
do!
46 2 48
hai Tyle
(O/o)
95,8 4,2 100,0
Ben trai So CO thay
doi 46 2 48
Tyle
(O/o)
95,8 4,2 100,0
CHUYEN DE: PHAU THUAT TIM MACH VA LONG NGUC Vl|T NAM
Chiing tdi tiln hanh ddt buy TKGC tren XS 4, theo ddi thay ddi nhiet do ldng ban tay Uong khoang thdi gian 2-3 phut, sau dd dot buy TKGC tren XS 3 va tilp tyc theo ddi sy thay doi nhiet do ldng ban tay.
Kit qua cho thiy mdt sy khac biet ro rang, chi cd 2 benh nhan (4,2%) vdi 4 ben, sau khi cit buy TKGC tren XS 4 la cd thay ddi nhiet do tren 0,5 do C. Tit ca cac trudng hgp cdn lai 46/48 benh nhan (95,8%) diu tang tren 0,5 do C sau khi cat buy TKGC tren XS 3. Dilu nay da chimg minh bang thyc te lam sang la: Trong chudi TKGC ngyc tren thi cac sgi d miic XS 3 (giai han tren cua hach T3) chi phoi chii yeu TKGC cho ldng ban tay, hay ndi each khac la: Hach T3 Id hach chi phoi chinh cho tuyen md hdi d long bdn tay.
Ket qua nay phu hgp vdd nhan xet cua Lin va Daniel L [8], cac tac gia nay md lai cit huy hach T3 cho cac benh nhan bi RNMH tai phat sau khi cat buy duy nhat hach T2, sau ml cd ket qua tdt.
Mdt sd tac gia do sy thay ddi nhiet do ldng ban tay sau khi cat buy hach T2, da cho rang hach T2 la hach chinh chi phdi tuyln md hdi d long ban tay... Nhung chiing toi ddng y vdi tac gia Efthymiou CA [10] cho rang: Cac sgi sau hach tir cac bach T3 va T4 di qua than TKGC den hach T2, sau dd din DRTK canh tay mdi la thanh phan chinh chi phdi cho tuyen md hdi d ldng ban tay. Khi cat hiiy TKGC ngang miic XS 2 thi da cit buy tat ca cac sgi TKGC ngoai vi chi phii cho chi tren tir cac hach TKGC nguc tren, chii khdng phai hach T2 la hach chinli chi phdi TKGC cho chi tren.
3.3. Kit qud md hgc tuyen md hoi long bdn tay trude vd sau mo
Bang 2. Ket qua md hgc tuyen md hdi long ban tay trude va sau mo
DK(mm)
Nhom ^ ^ ^ " ^ ^ ^ . ^ Dot tiuy TKGC
tren XS 2 (n=15)
Dot hiiy TKGC tren XS 3 (n=15)
DK ngoai (a)
OK trong (b)
OK ngoai (c)
OK trong (d)
So sanh
Tru'dc dot huy TKGC X ± SD
26 ± 7,14
8,8 ± 3,23
24,5 ± 7,3
9,1 ± 3,46
Max
14,5
4,5
11,5
4,5
Min
35
14
35
15 Pac = 0,6127 Pbd = 0,8622
Sau dot huy TKGC X ± S D
14,8 ± 5,19
5,13 ± 1,82
14,1 ± 4,89
4,73 ± 1,51 Max
8,5
3
7,5
2,5
Min
25,5
9
24
7,5 Pac = 0,7397 Pbd = 0,5807
So sanh
p< 0,01
p< 0,01
p< 0,01
D< 0,01
Y HOC VIET NAM SO DAC BIET —THANG 11/2010
Kit qua cho thiy DK trong va DK ngoai ciia dng tuyen md hdi d ca nhdm ddt buy TKGC cao nhit tdi tren XS 2 va nhdm ddt hiiy TKGC cao nhit tdi tren XS 3, diu giam CO y nghia thdng ke khi so sanh vdi trude ddt huy vdi p < 0,01. JChi so sanh giiia 2 nhdm thi sy khac biet khdng cd y nghia thdng ke vdi p > 0,05. Nhu vay, khi ddt buy TKGC tren XS 3 cQng cd hieu qua lam giam tiet ciia
dng tuyln md hdi nhu khi ddt buy TKGC tren XS 2. Ket qua nay, mdt lan niia chiing minh ring: Hach T3 la hach TKGC chi phdi chinh cho ldng ban tay.
Trong cac tai lieu chiing tdi tham khao dugc, chua cd tac gia nao nghien ciiu ve sy thay ddi ve hinh thai, ciing nhu sy che tiet ciia tuyen md hdi Idng ban tay trude va sau ddt buy TKGC ngyc.
3.4. So sdnh ede hdu qud khong mong mudn giira 3 mite dp can thiep
Bang 3. Ty Ie cac hau qua khdng mong mudn
^~-~^^^Thdl gian
Cac hau qua ._
RNMH bii
Hoi chu'ng Horner Kho tay qua mufc RNMH tai phat
1thang (n=124) 31 (25%)
- - -
6 thang (n=124) 31 (25%)
- - -
12 thang (n=113) 28 (24,8%)
- - -
Trong cac hau qua khdng mong mudn thi hay gSp nhit la RNMH bii qua mirc, theo doi hau qua nay theo thdi gian thay RNMH bii sau 1 thang va 6 thang la 25%) va sau 12 thang la 24,8%. Nhu vay cd the thay ty le RNMH bu it thay doi theo thdi gian. Pedro M theo doi 406 benh nhan trong 12 thang, ty le RNMH bii la 55% va khdng thay ddi theo thdi gian.
Khdng gap trudng hgp nao bi RNMH long ban tay tai phat, kit qua nay chiing td vai trd quan trgng cua viec tim va cat huy cac nhanh TKGC ndi them chi phoi cho chi tren 0 tren XS 2. Mgt so tac gia khi md lai cac trudng hgp RNMH long ban tay tai phat, da tim thiy cac nhanh TK ndi them d tren XS 2, sau khi cit huy cac nhanh TK nay thi dat kit qua tdt.
Chiing tdi cung khdng gap trudng hgp nao bj hgi chimg Homner, nhung mdt sd tac
gia khi cat buy TKGC tren XS 2 vdi sd lugng benh nhan ldn da gap hdi chimg Homner sau md: Kwong K.F gap 2/202 benh nhan, va Moya L md 458 trudng hgp cd 0,32% xuat hien hgi chiing nay. Nguyen nhan cua hdi chiing nay, dugc giai thich do sy bat thudng ve vi tri cua hach sao hoac hach Tl nam tren XS 2. Do vay, gidi ban cat buy TKGC ngyc an toan la dudi XS 2
Chiing tdi cung khdng cd trudng hgp nao bi khd long ban tay qua mirc sau md d cac thdi diem theo doi. Liu Y cdng bd, khi cit hach T4 ty le khd tay qua miic la 1,4%, va cat T3 cd ty le la 12,9%. Chiing tdi thdng nhat vdi tac gia Deway T.M, khi cat huy qua nhieu chang tren chuoi TKGC ngyc tren thi cd the dan den tinh trang bi khd ldng ban tay qua miic sau md.
CHUYEN DE: PHAU THUAT TIM MACH VA LONG NGUC VIET NAM
3.5. So sdnh RNMH bit giua 3 mue dp can thiep
* Ty le RNMH bii
Bilu d6 2. So sanh ty le RNMH bu giua 3 miic do can thiep
B:4h
• 1 tlwiig
* 6 tiiang
• 12 tliaiK
Nhom 1 Nhom 2 Nlioiu ->
Ket qua cho thay: Ty le RNMH bii cao nhit la d nhdm 1 (dot huy TKGC tren XS 2, XS 3) va ty le RNMH bii thip nhit la d nhdm 3 (ddt hiiy TKGC tren XS 3, XS 4) d cac thdi diem theo ddi. Ket qua nay phii hgp vdi Reisfeld R kep cliping d miic XS 3 va XS 4 cd ty le RNMH bii it ban khi kep d mirc XS 2vaXS3.
* Miic do RNMH bu sau md 24 gid, ca 3 miic do can thiep deu chi RNMH bii miic do nhe.
Tai cac thdi diem theo doi tiep, nhdm 2 cd miic do RNMH bii nang nhit, sau 12 thang cd 6,6% RNMH bii mirc do vira, 3,3%
RNMH bii miic do nang.
Licht P.B khi so sanh ty le RNMH bii giiia cac mirc do ddt buy TKGC, thiy d miic do dot hiiy tren XS 2, XS 3, XS 4 la cd ty le
RNMH bu cao nhat la 38% va trong dd co 16% la miic do nang.
Nhdm 3 chi RNMH bii d miic do nhe 6 tat ca cac thdi diem theo doi.
3.6. Ket qud chung
* Cai thien ra md hdi Idng ban tay Ket qua nghien ciiu cho thay, 100%
benh nhan van cd ket qua long ban tay kho am tai cac thdi diem theo doi, d ca 3 miic dp can thiep, khdng cd trudng hgp nao RNMH ldng ban tay tai phat hoac khd tay qua miic.
Ket qua nay phii hgp vdi nhieu tac gia khac. Ddng thdi cho thay: Dot hdy TKGC d mite tren XS 3 vd XS 4 eiing ed kit qua cai thien RNMH d long bdn tay tot nhu d cac mire dp ed dot huy TKGC tren XS 2.
* Kit qua chung theo tieu chuin cua Bryne W.J.
Y HOC VIET NAM SO DAC B I E T - T H A N G 11/2010
Bilu do 3. Kit qua chung
100 80 60 40 20 0
95.2
4.4 0.9
4 ns-"*- -2... 0 . 4 ^ 0.8 n ' ™ * « i » 4 ^ » 4 ^ ^1 | « » Tot T. ^^ ^ - - * •
^•^"8 Kem
binh Khong ^ . ^ thay doi
1 thang "6 thang ! 12 thang
12thang 6 thang I thang
Sau md 1 thang va 6 thang theo ddi dugc 124 benh nhan, cd kit qua nhu nhau, dat kit qua tot 95,2%, trung binh 4%) va kem 0,8%. Sau md 12 thang, theo ddi dugc 113 benh nhan, ty 1? dat kit qua tot la 94,7%, trung binh la 4,4% va kem la 0,9%. Pedro M theo ddi 406 benh nhan trong 12 thang, dat ket qua tdt sau khi ra vien, 6 thang, 12 thang tuong iing la 100%, 99.3% va 97.8%.
* So sdnh ket qud giira 3 mirc do can thiep
Bieu do 4. Ket qua cua 3 miic do can thiep theo thdi gian theo ddi
9J:8 93.8 -935
100 100 100 100
8.5
24h llhane 5 thing 12 Ihang 24h I Ihang 6 Chang 12 Ihang 24h I thang 6 Ihang 12 thang
Nhdm I Nhdm 2 Nhdm 3
Nhdm 2 co kit qua thap nhat, sau md 24 - Nhdm 3 dat ket qua tdt nhat, 100%
gio dat kit qua tdt la 97,2%, 2,8 % ket qua benh nhan cd ket qua tdt d tat ca cac thdi tmng binh. Din 1 va 6 thang chi cdn 93,8% dilm theo ddi.
dat kit qua tdt, 6,3% kit qua trung binh va
3,1% kit qua kem. Din 12 thang, cd 93,3% V. KET LUAN
dat kit qua tot, 6,6% kit qua trung binh va So sanh 3 miic do can thiep vao chudi 3,2% kit qua kem. TKGC ngyc dilu tri chimg RNMHNP d long
CHUYEN DE: PHAU THUAT TIM MACH VA LONG NGUC VIET NAM
ban tay cho 138 benh nhan bi. Chiing tdi riit ra mot sd ket luan sau:
1. Kit qud chung: Sau md 24 gid, ket qua tdt la 99,3%, kit qua trung binh la 0,7%, sau 1 thang va 6 thang cd kit qua tdt la 95,2%, trung binh la 4% va kem la 0,8%, sau 12 thang dat kit qua tot la 94,7%, trung binh la 4,4% va kem la 0,9%
2. Mdc dp ddt hdy ngang TKGC nguc tren XS 3, XS 4 Id mire dp can thiep hop ly nhdt di diiu tri chung RNMHNP ff Idng bdn tay.
- Dat myc dich dieu tri la cai thien tinh trang RNMH d ldng ban tay, 100% benh nhan cd ket qua tdt d cac thdi diem theo ddi.
- An toan, khdng tdn thuong hach Tl hoac bach sao, khdng cd hgi chimg homner, ban che tdn thuang bd mach TKLS.
- Ty le RNMH bii thap, miic do nhe.
- Khdng ddt buy TKGC ngyc qua nhieu, ban che dugc hau qua khd tay qua miic.
3. Ddt huy cae nhdnh TKGC noi them den DRTK cdnh tay d tren XS 2 ngdn ngira duffc RNMH Idng bdn tay tdi phdt.
TAI LIEU THAM KHAO
1. Nguyen Ngoc Bich, Tran Hieu Hoc, Ngo Van Dang, Pham Viet Ha, Ta Thanh Tiing, Tran Vinh, Nguyen Quang Anh, Ta Dang Luan (2004). Phau thuat ndi soi ngirc di^t hach giao cam dieu trj b^nh ra nhieu md hdi ta>, nach, mat (kit qua tren 350 trudng hgp). Y hgc thuc hanh
2. Le Quang Dinh, Nguyen Hoai Nam (2010), Ket qua cat than kinh giao cam ngirc noi soi vdi gay me noi khi qv.m ) ndng frong dilu frj tang tiet mo hdi tay va nach, Y Hoc TP. Hd Chi Minh, s6 l:Trl35-138
3. Tran Ngoc Lu-cng, Tran Doan Ket, Ta Van Binh va Cs (2004). Kit qua birdc diu qua 131 trudng hop dot hach giao cam qua
ndi soi long nguc de chua chung ra mo hoi tay. Y hoc thuc hanh. Cdng trinh nghien ciru khoa hoc, Hgi nghi ngoai khoa toan qu6c. S6 49. U 360-365.
4. Van Tan, Ho Nam va Cs (2004). Kit qua phau thuat dieu trj udt ban tay do mo hoi qua noi soi Idng nguc cai tien tren 1298 benh nhan. Y hoc thuc hanh. Cdng trinh nghien cuu khoa hoc, Hgi nghj ngoai khoa toan qudc. Sd 491. 2004. 668-671.
5. Byrne W.J, Waslsh TN, Hedrman W.P (1990), Endoscopic transthoracic electrocautery of the sympathetic chain for palma and axillary hyperhldrosis, Br Surg77:
1046-1049 Consequences, Ann Thorac Surg;81:1227-33
6. Chiou.T.S. and Liao K.K (1996), Orientation landmarks of endoscopic transaxillary T-2 sympathectomy for palmar hyperhldrosis, J Neurosurg 85 (2), pp. 310- 315.
7. Chou S.H, Lee SH, Kao EL (1993).
Thoracic endoscopic T2-T3 sympathectomy in palmar hyperhldrosis: experience of 112 cases. Surg Today ;23:105-107
8. Daniel L. Miller, Seth D. Force (2007) .
Outpatient Microthoracoscopic Sympathectomy for Palmar Hyperhldrosis.
Ann Thorac Surg ;83:\850-\ 853.
9. Dewey T.M, Herbert M.A, Hill S.L, Prince S.L and Mack M.J (2006), One-year follow-up after thoracoscopic
sympathectomy for hyperhldrosis:
outcomes and consequences, Ann Thorac Surg8\ (4), pp. 1227-1233.
10. Efthymiou CA, James A.C.T.(2008), "
Compensatory hyperhldrosis: a consequence of truncal sympathectomy treated by video assisted application of botulinum toxin and reoperation", European Journal of Cardio- Thoracic Surgery Volume 33, Issue 6, Pages
1157-1158
