Y HOC VIET NAM THANG 2 - SO 2/2012
KET QUA SOfM CUA PHAU THUAT DOT CHON LOC T3
DIEU TR| CHUNG BENH RA MO HOI TAY
B A N GDUNG CU SIEU NHO
Tran Ngoc LUdng*
T O M T A T
Nghien cii'u thi/c hien 6 51 benh nhan du'dc mo trong thdi gian 2 thang (tir 6 thang 6 den 9 thang 8 nam 2011) vdi 28 nam, 23 nCr co tuoi trung binh 19,9 tuoi (11- 42). Co 17 benh nhan (33,3%) mo hoi nhieu d tay chan, 33 benh nhan (64,7%) d ca tay chan nach.
Gay me bang ong npi l<hi quan 1 nong, tiT the ngira dau cao, 2 tay dang, bp dung cu sieu nho 3mm. Ky thuat dot: diet hach d 13 bang dao dien, de tranh tai phat ddt 1 doan giiJa 2 dau 1,5 cm. Ket qua: thdi gian mo trung binh 10,5 phiit (10- 25). Khong can dan lu'u.
Khong co bat cir 1 bien" chu'ng nao nhu' tran khf, tran mau mang phoi hay hpi chu'ng Horner. 100% I<h6 ban tay trong do kho tay mirc dp binh thu'dng d 91,2%, kho hdn binh thu'dng d 5 benh nhan (9,8%). Co 21 tru'dng tidp (41,1%) khoi hoac giam mo hoi nach, 42 tru'dng hdp (82,4%) khoi hoac giam mo hdi chan. Mo hoi ra bu d IUng d 38 tru'dng hdp (78%), ra bu d ngi/c bung 41 (80,4%). Tat ca benh nhan deu hai Idng vdi cupc mo, khong ngu'di nao muon quay trd lai tinh trang ban dau.
Nhu" vay: phau thuat dot hach chpn Ipc T3 bang dung cu sieu nhd cd the la phau thuat chpn li/a cho dieu tri chu'ng ra mo hoi tay vdi thdi gian mo nhanh, ty le khoi cao, ty le tay qua kho thap va ra bu mo hoi d nhu'ng cho khac trong gidi han chap nhan du'dc.
SUMMARY
The eariy results of selective T3 sympathectomy to treat the palmar hyperhidrosis by needle scope
There were 51 patients (28 male, 23 female) underwent the endoscopic thoracic sympathectomy for palmar hyperhidrosis with mean age of 19.9 years (11- 42). Palmar, plantar and palmar, axillar, plantar sweating was in 17 (33,.3%) and 33 (64.7%) respectively. Under general anesthesia with single lumen tracheal intubation, semi- fowler position, the arms was extended slightly upward. The instruments is of needle scope. The technique: selective T3 sympathectomy of 1.5cm distance by electrocautery.
Results: mean operative time was 10.5 minutes(10- 25). No need of drainage. There was not any complication like pneumothorax, Horner's syndrome.
Dry hands were in 51 (100%) including 46 (91.2%) of normal hand, 5 (9.8%) of over dryness. Axillar sweating was cured or decreased in 21 cases (41.1%) and plantar sweating in 42 cases (82.4%). The compensatory sweating of the back and of the breast, abdomen area are in 38 cases (74.5%) and 41 cases
* Benfi vien Npi tiet Trung u'dng
Plian bien Idioa tipc:GS.TS. Ha Van Quyet
(80.4%) respectively. All of patients are satisfied.
Conclusion: Selective T3 sympathectomy by needle scope may be a procedure of choice for treatment of hyperhidrosis with 100% dryhand, very low overdryness rate and the compensatory sweating is in acceptable limit.
I.
OAT VAN OEChirng benh ra md hdi tay cd the gap tdi 10% trong quan the dan cU. Benh khdng nguy hiem den tinh mang nhu'ng gay nhieu phien toai cho hpc tap, lao ddng. Oieu trj ndi khoa chi cd tac dung cho nhu'ng tru'dng hpp nhe. Cat hach giao cam ngi/c qua ndi soi da du'pc ap dung rdng rai nhu la mdt phu'dng phap an toan va hieu qua de dieu tri md hdi tay vdi ty le thanh cdng rat cao. Tuy nhien tac dung phu ma anh hu'dng cung nhieu den chat lu'dng cuoc sdng la hien tu'dng ra md hdi bii. TrUdc nam 2005, phan Idn cac tac gia ddt hach d T2 hay T2-3 hoac T2-3-4 de chO'a ra mo hdi tay. Hien nay, mot sd tac gia dot chon Ipc tren tiTng hach d T2 hoac T3 hoac d T4. Vdi tu' the nira ngdi va gay me bang dng ndi khi quan 1 ndng chiing tdi li/a chpn ddt hach d ngang miTc T3.
Muc dich ciia de tai: Danh gia kha nang thut hien ky thuat va ket qua cua phu'dng phap md.
II. 0 6 l TUONG VA PHUONG P H A P NGHIEN CUU Benh nhan den kham, dieu tri vdi chu'ng ra md hdi tay.
Tieu chuan loai triT: nhu'ng benh nhan bj cu'dng giao cam do cu'dng nang tuyen giap va nhu'ng benh ndi khoa khac
Thdi gian: tir ngay 6 thang 06 nam 2011 den ngay 9 thang 8 nam 2012.
2 . 1 . Phu'dng phap nghien cu'u: tien ciTu, Kham lam sang va can lam sang:
-I- Xac djnh tudi, gidi, thdi gian bi benh, viing bj benh.
-f- Xet nghiem ndng do FTA, TSH trong mau de danh gia chirc nang tuyen giap.
-I- Chup phoi thang, ghi dien tam dd va cac xet nghiem thu'dng quy de md
Y HOC VIET NAM T H A N G 2 - SO 2/2012 2.2. Ky thuat mo
+ Gay me: toan than.dat ndi khi quan. Sir dung toan bd dng ndi khi quan 1 ndng, lam xep phoi tirng ben.
+ Tu' the benh nhan: nam ngii'a dau cao (Semi- Fowler position) va quay nghieng ve phia ddi dien, hai tay dang
+ Chpc kim bdm hdi vao khoang lien su'dn 5 du'dng nach giu'a, bdm khoang 10 ml dung dich mudi dang tru'dng cd pha Xylocain.
+ Bdm khi CO^ ap li/c lOmmHg, lu'u lu'dng 3,51/phut.
-I- 1 troca 3mm khoang lien su'dn 4 hoac 5 du'dng nach giu'a cho dng kfnh soi, 1 trdca 3mm khoang lien su'dn 3 du'dng nach tru'dc che dung cu ddt. Trong tru'dng hdp neu thay dinh mang phoi nhieu thi cd the dat them 1 trdca thd 3 d du'dl trdca chd dng kinh soi.
+ Trong tru'dng hdp phdi khdng dfnh: Xac dinh xu'dng su'dn 3 sau khi du'a dng kfnh soi vao, tim du'dng di ciia day than kinh giao cam, ddt hach tren du'dng di ciia day d moi dau xu'dng su'dn. Dot bang each cat dirt day bang dung cu ddt dien. Ocng thdi neu thay cd day KUNT thi cung dot ludn. Kiem tra si/ chay mau, neu khdng cd thi lam nd phci va riit trdca, khdng can dan lu'u, khdng khau vet rach da.
Oe tranh tai phat: sau khi cat ddi day diing dung cu ddt tiep tuc ddt ve phfa 2 dau ciia day, lam sao cho khoang each giCTa 2 dau day khoang 1,5 cm, du'dc do bang khoang each giO'a 2 dau ciia 2 ham dung cu ddt.
+ Trdng tru'dng hdp dfnh phoi: Dfnh theo kieu mang nhen: du'a dung cu ddt vao thu'dng la dau ddt hinh L qua trocar nam d phfa tren. ViTa
dot, vira eat di v'e phfa trong ciia dfnh phoi ndi vi trf eiia dau xu'dng su'dn. Odt hach d che vj trf ciia dau xu'dng xu'dn 3. Thdng thu'dng khdng can phai dSt dan lu'u mang phdi kfn.
Thed ddi trong md: dat dien cy'c vac long ban tay, thed ddi va ghi lai SLT thay dd'i nhiet do tru'dc va sau ddt bang may Monitor.
Ghi lai dien tim tru'dc va sau khi ddt cung bang may Monitor.
Thed ddi ngay sau md: bud'i chieu ngay mo hay ngay sau mo chup phdi thang mpt each thu'dng qui, ghi lai dien tim,
Oanh gia sau md bang phdng van qua dien thoai theo mdt mau thdng nhat
III. KET QUA
Tud'i: nhd nhat 11 tudi, Idn nhat 42 tuoi, trung binh 19,9± 6,1 tudi
Gidi: nam 28 ngu'di (54,9%), nu'23 (45,1%).
Ndi ra md hdi: tay chan d 17 tru'dng hdp (33,33%), tay chan nach 33 benh nhan (64,7%), tay chan nach mat ngi/e chi d 1 benh niian (1,96%).
Mirc dp ra md hdi: chu yeu dam nu'dc va nhd gidt 50 benh nhan (97,97%)
Oinh phdi: 2 tru'dng hdp d 1 ben, dfnh theo kieu mang nhen: tach va ddt de dang
Thdi gian phau thuat: nhanh nhat 10 phiit, lau nhat 25 phiit, trung binh 10,5± 2,5 phiit.
Khdng cd tru'dng hdp nao dat dan liTu, khdng cd benh nhan bi hdi chu'ng Horner, khong ed tran djch hay tran khf mang phdi
Ket qua ngay sau mo va sau 6 thang;
100% khd tay.
Bang 1 - Tin Sd benh nhan
Ty le %
h trang md hdi nach sau mo Khoi
7 13,7
Giam 14 27,4
Khong thay doi 25 49,1
Tang 5 9,8
Tong 51 100 Bang 2- Tinh trang md hdi chan sau mo
So benh nhan Ty le %
Khoi 7 13,7
Giam 35 68,7
Khong thay dd'i 7
13,7
Tang 2 3,9
long 51 100 Ban tay binh thu'dng 46 benh nhan (90,2%), khd qua 5 benh nhan (9,8%)
Bang 3- Md hdi ra bii d lu'ng
So benh nhan Ty le %
Binh thu'dng nhU tru'dc
13 25,5
Nhieu htfn mirc do vira phai
22 43,1
Nhieu hdn nhfeu 16
35,4
Tong 51 100
Y HOC VIET NAM THANG 2 - SO 2/2012 Bang 4 - Md hd
So benh nhan Ty le %
i ra bii d ngu'c-i- bunc Binh thu'dng nhU
tru'dc 10 19,6
Nhieu hdn mu'c do vCra phai
23 51,0
Nhieu hdn nhfeu 18
3,9
Tong 51 100 Tat ea benh nhan deu hai Idng, khdng cd benh nhan nao mong mudn trd lai nhu' ban dau tru'dc mo.
IV. BAN LUAN
4 . 1 - Dac diem chung
Chu'ng ra md hdi tay thu'dng xuat hien tir tud'i nhd va tiep dien trong sudt eude ddi. SiT lo lang va hdi hop cd the lam nang len tinh trang benh. Ngu'di bi chu'ng ra nhieu md hdi thu'dng bi md hdi nhieu d tay, nach, chan, hay than ngu'di.
Nhieu ngu'di cd the ket hdp giii'a eae yeu tc tren.
Ty le nam va nCi' tu'dng du'dng nhau. Trong nghien ciTu ciia chiing tdi, sd lu'dng nam nu" cung khdng khac nhau vdi ty le lan Iddt la 28 (54,8%) va 23 (45,1%). Tud'i trung binh la 19,9 tuoi vdi nhd nhat la 11 tudi va Idn nhat la 42 tud'i. Tud'i trung binh trong nghien ciTu ciia Dominique Gossot d 530 benh nhan la 28,2 tud'i (15-56), eiia Yu- Tang Chang d 234 benh nhan la 22,9 tudi.
Benh nhan nhd tud'i nhat eiia ehiing tdi la 11 tuoi. Mae dii tud'i benh nhan cdn it nhu'ng ehiing tdi van md vi md hdi tay chau ra nhd giot khdng the viet du'dc.
Ve Sl/ phan bd eiia ra nhieu md hdi, ehii yeu xuat hien d tay chan hoae tay chan nach vdi ty le theo thir tir la 17 (33,33%) benh nhan va 33 (64,7%) benh nhan, cdn d tay chan nach mat chi cd d 1 benh nhan. Theo nghien ciTu ciia Dominique Gosset va cdng siT thi d tay chan cung chiem 30%, nhu'ng tay chan nach la 51,2%, tay chan mat 6%, tay nach chan mat d 4,8%, va d mat ddn thuan la 8%. Tat ca so benh nhan eiia chiing tdi den dieu tri vdi ly do dau tien la ra md hdi tay, mong mudn du'dc khd tay. Mue dich dieu trj dau tien ciia chung tdi cung la chu'a khdi ra mo hdi tay, cdn md hdi d nhu'ng ndi khac khdng dat van de quan trong. Bdi vi chiing tdi nghi rang: neu chu'a du'dc ra md hdi nach ma mo hdi d lu'ng va ngi/c ra nhieu hdn thi tinh trang cung khdng phai la tdt hdn. Nhu'ng ket qua cho thay ty le khdi va giam md hdi nach cung d 21 (41,1%), d Chan la 42 (82,4%) benh nhan.
4.2- Ky thuat, ket qua
Dot hach giao cam de dieu trj chiTng ra mo hdi tay nhu'ng trong mdt sd tru'dng hdp tac dung phu nhu' ra mo hdi bii nhieu hay ban tay qua khd lai tao cho benh nhan nhu'ng phien toai mdi. Oa
ed nhii'ng phu'dng phap khac nhau de khac phue nhij'ng hau qua nay. Ky thuat eat hach giao cam da thay dd'i tir lay doan hach day giao cam den diet hach, eat ngang, kep elip hay tham chf la cat nhanh. Phau thuat eat nhanh giti' lai than chinh du'dc md ta va thu'c hien dau tien bdi Wittmcser.
Ky thuat nay lam giam ty le ra mo hdi bii nhu'ng lai lam tang ty le tai phat hdn la eae ky thuat tru'dc. Cd khdang 5.0- 23% sd benh nhan mo hdi tay cdn nhu' tru'dc md d 1 hoae ca 2 ban tay. Vi vay viec cat ngang hach nhu'ng khdng lay doan la mdt phu'dng phap du'dc chap nhan rdng rai nhat hien nay.
Qua cac nghien eiru eho thay: hach T2 chi phdi ehii yeu den ban tay, eat hach T2 lam ban tay khd vinh vien va cung eat ludn than kinh giao cam ehi phdi mat. Va khd dau, khd mat la nhu'ng nguyen nhan chfnh tao ra md hdi bii nhieu d than. Ngoai ra T2 rat gan vdi hach sao, neu ddt T2 thi de gay ra hdi chiTng Horner. Trong 467 benh nhan eiia Gossot va edng SLT cd 4 ca bi hpi chiTng Horner sau mo vdi ty le 0,4%. Yoon SH.
diet hach T2-3 d 24 benh nhan thi ed tdi 4 benh nhan bi hdi chiTng nay sau md. Nghien eiiu giai phau eho thay eae sdi tru'dc hach bat ngucn ehii yeu tir doan tiiy sdng T3 den T6 va doan T3, T4 la doan du'dc cci la ehii yeu nhat. Ocan can cat tdt nhat de dieu trj ehiing ra md hdi tay van cdn dang dMc ban cai. Cat hach T3 hcae T4 da du'dc thu'c hien vdi nhu'ng ket qua kha quan trong nhu'ng nam qua nhu'ng ty le ra md hdi bii cung thay dd'i theo eae thdng bao.
Trong nghien ciTu nay chiing tdi ehi ddt hach T3, ngay tren dau xu'dng su'dn, ddt va diet hach tren mdt khoang each la 1,5 cm de tranh tai phat. Chiing tdi gay me bang dng ndi khi quan 1 ndng cho nen chiing tdi li/a chon ddt hach T3 de thi/c hien de hdn vi neu ddt T4 thi viee lam xep phdi de nhin T4 khd khan hdn. Trdng khi md' chung tdi thed ddi thay nhiet dd ban tay deu tang len va sau md 100% ban tay deu khd sd vdi tru'dc mc. Trdng dd ban tay khd nhu' ban tay binh thu'dng, da mem mai d 46 benh nhan (90,2%), ban tay khd hdn binh thu'dng d 5 ea (9,8%). Khdng ed benh nhan nao da tay qua
Y HOC VIET NAM T H A N G 2 - SO 2/2012 khd. Yanuo Lin ed 68 benh nhan ddt hach T3 thi
ty le ban tay qua khd la 12,9%. Nhu'ng neu chf ddt T2 nhu' ket qua d 64 benh nhan eiia Dod Yun Lee thi ty le nay len tdi 79,7%.
Cina CS va edng s i / , d 30 benh nhan, ddt va tach day giad earn tir T2 den T3 cho nhu'ng benh nhan nhieu md hdi d tay, tiT T2 den T4 cho nhii'ng benh nhan nhieu mo hdi d nach.
Dcminique Gdsset ddt va lay day giao cam d hau het benh nhan td T2 den T5 phu thudc vac cd md hdi nach hay khdng? Ty le ra md hdi bu trcng nhdm nay la 72,2% va cd 2 benh nhan ra qua nhieu khdng the chju di/ng du'dc mudn quay lai tinh trang nhu' tru'dc md. Md hdi ra bii miTc dp vuci d trdng sd benh nhan eiia ehiing tdi chiem 43,1% d luTig, 5 1 % d ngiTc bung nhuTig khdng cd bat ciT iDenh nhan nao mong mudn quay lai trang thai ban dau, 100% deu hai Idng vdi ket qua mo.
Sau khi chpc kim Verres, ehiing tci siT dung 10 ml dung dich Xylocain va nu'dc mudi dang tru'dng de bdm vao khoang mang phdi, viTa bdm vira an kim sau vad khdang de tranh lam thiing phoi vi nu'dc ed tac dung day td chiTc phci ra.
Mat khac sau khi ddt hach xong , den thi lam nd phdi khi bdp bdng neu ed dich trad ra ngoai chiTng td phoi da nd hoan toan ed the riit trdca.
Day la mpt diem cai tien ciia ehiing tdi, ma trong nghien ciTu eiia minh chiing tdi khdng gap tru'dng hdp nao cd tran khi mang phdi. Gosset gap 12 tru'dng hdp (1,27%), Cd 2 benh nhan dinh mang phdi theo kieu mang nhen deu du'dc tach dfnh va ddt de dang. Khdng ed benh nhan nao can dat dan lu'u, ke ca 2 tru'dng hdp tach dfnh.
Ve thdi gian md thu'dng mdi ben ehi mat 5 phiit vi chung tdi sir dung dung cu loai sieu nhd chd nen viee chpc trdca rat de dang ke ea d tre nhd, sau md' khdng can phai khau. Ngoai ra chf cd ddt doan d ehc T3 nen thao tac cung nhanh hdn so vdi ddt tir
T2 den T4. 2 tru'dng hdp dfnh phd'i thdi gian cung chf mat hdn 20 phut ehc mdl benh nhan.
V. KET LUAN
Phau thuat ddt hach giao cam chpn Ipc tai T3 bang dung eu sieu nhd cd the la phau thuat du'dc chpn lya de dieu trj chiTng ra mc hdi tay.
Thdi gian phau thuat nhanh, an toan, hieu qua.
Tat ca deu tay khd sau mo va ehii yeu tay kho d miTc do nhu' tay binh thu'dng. Benh nhan deu hai Idng vdi cupc phau thuat, khdng ed tru'dng hdp nao mudn quay trd lai tinh trang ban dau.
T A I LIEU THAM K H A O
1. Dominique Gossot et al. Thoracoscopic sympatliectomy for upper lim iiyperhidrosis:
looking for the right operation.kr\x\ Thorac Surg 1997; 64: 975- 978
2. Dominique Gossot et a\.Early complications of thoracis endoscopic sympathectomy: a prospective study of 940 procedures. Ann Thorac Surg2001;71: 1116- 1119
3. Dominique Gossot et al.Long- term results of endoscopic thoraic sympathectomy for upper lim hyperhidrosis. Ann Thorac Surg 2003; 75: 1075-1079 4. Doo yun Lee et zA.Selective division of T3 rami
communicates(t3 ramicotomy) in the treatment of palmar hypertiidmsis Ann Thorac Surg 2004; 78:
1052-1055
5. Cina CS et a\. Endoscopic thoracic sympathectomy for hyperhiodrosis: technique and results. Min Access Surg 2007;3: 132- 40
6. Yanguo Liu et a\.Surgical treatment of primary palmar hyperhidrosis: a prosspective randomized study comparing T3 and T4 sympathicotomy.
European Journal of cardiothoracic Surgery 2009.
35(3): 398- 402
7. Yu- Tang Chang et a\. Treatment of palmar hyperhidrosis T~l level compared with TS and T2.
Ann Surg 2007; 246(2): 330- 336.
NGHIEN Cl)U LAM SANG VA DIEN SINH LY THAN KINH
CUA HOI CHI/NG ONG CO TAY 0 NGOOl SUY THAN MAN TJNH GIAI DOAN CUOI
Nguyen Trong Hu'ng*
Hoi chu'ng dng co tay (OCT) la benh ddn day than kinh hay gap d ngu'di suy than man tfnh dang dieu trj Ipc mau bang than nhan tao chu ky (TNT).
Chan doan du'a vao cac trieu chu'ng lam sang gdi y va chii yeu vao tham do dien sinh ly day than kinh giu'a
* Bp mon Than kinh - Dai hoc Y Ha Npi
Phan bien khoa A7pc;PGS.TS. Nguyen Cong Hoan
tai vung ong OCT. I^uc tieu. Nghien ciTu lam sang ya dien sinh ly hoi chu'ng ong cd tay d ngu'di suy than man tinh dang Ipc mau bang TNT chu ky. Ddi tu'dng
& pliUOng pliap: 97 ngu'di binh thu'dng va 95 b?nh nhan dang dieu trj TNT chu ky du'dc kham lam sang
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