CVv46V431S12015014.pdf

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Y HOC VIET NAM THANG 6 - SO 1/2015

TAI UEU T H A M KHAO

1. An Executive Summary for The Lancefs Series (2011). Stillbirths, The Lancet, 2. Auger N. and G. Denis (2012). Late pregnancy

abortions: an analysis of Quebec stillbirtli data, 1981-2006. Int. J. Public Health, 57(2), 443-6.

3. Arnold Christianson, Christopher P. Howson, Bemadette Modell (2006). Global Report on Birth Defects. March of Dimes, pp. 2-3,14-16.

4. Tru'tfng Quang Dat, Tran Bite Phan, Ngo Van Toan (2013). Ty le say thai va mpt so yeu to lien quan den say thai d huyen Phu Cat - Binh Djnh. Tap chi nghien cutj y hpc, 3(83), 144 -150.

V i'

International Clearinghouse for Birth Defects Surveillance and Rearch (2011).

Annual Report 2011 with Data for 2009, The International Centre on Birth Defects - ICBDSR Centre, Via Carlo Mirabeiio 14, Roma Italia, 5.

Ngo A. D. et al ( 2 0 0 6 ) . Assodabon between Agent Orange and birth defects: systematic review and meta-analysis. Int. J. Epidemiol.

35(5), 1220-1230.

Simon Cousens et al (2011). National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis. The Lancet, volume 377, issue 9774, pp.

1319-1330

KET QUA PHAU THUAT NOI SOI LONG NGITC DIEU TRI TRAN KHI MANG PHOI TAI BENH VIEN PHAM NGOC THACH (01/2007-06/2013)

Nguyen The Vu*, Le Ngoc Thanh**, Pham Vinh Quang***, Nguyen Tru'dng Giang***

T 6 M TAT

M^c t l i u nghien cihi: Muc dfch ciia nghien cu'u nay la de danh gia ket qua phau thuat npi soi lam xu'dc mang phoi cTieu tri tran khf mang phoi tu" phat nguyen phat (TKMPTP nguyen phat).

Phu'dng phap va ket qua: Tff 01/2007 den 06/2013, 118 benh nhan da du'dc phau thuat npi soi long ngu'c dieu trj TKMPTP nguyen phat. Tuoi trung binh la '28.2 ± 10.2 (tff 16 den 55), co 102 nam (86.4%). Tat ca cac benh nhan deu du'dc dieu tn bang phlu thuat npi soi. Chi dinh phau thuat chung nhat la tran khf mang phoi tai phat gom 83 benh nhan.

Stapler npi soi cat bong kiii du'dc su' dung nhieu nhat cho 71 benh nhan. Lam dinh mang phoi bang phu'dng phap boc la thanh vung dinh cho 39 benh nhan va bSng phu'dng phap lam xu'dc mang phoi cho 79 benh nhan, R6 khi keo dai sau mo gap trong 5 benh nhan (4.2%) benh nhan. Khong cd benh nhan tu" vong. Thdi gian dan lull taing binh sau phau thuat la 3.1 ± 2.8 ngay

Ket luan: Phau thuat npi soi long ngi/c la phu'dng phap an toan trong dieu tri TKMPTP nguyen phat. Lam xu'dc la thanh mang phoi gay dfnh ia ky

* Benh vien Pham Ngoc Thach

** Benh vien E

*** Hoc vien Quan y

Chiu trach nhiem chinh: Nguyen The Vu Email: [email protected] Ot; 0989018789 Ngay nhan bai: 1/4/2015

Ngay phan bien khoa hoc: 14/4/2015 Ngay duyet bai: 16/4/201

thuat an toan va hieu qua hdn so vdi boc la thanh mang phoi vung dinh.

Tu" khoa: tran khf mang phoi t i / phat nguyen phat - lam xu'dc ta thanh mang phoi - boc la thanh mang phoi vung dinh - npi soi long ngu'c.

S U M M A R Y

THE RESULTS OF THORACOSCOPIC SURGERY FOR P R I M A R Y SPONTANEOUS PNEUMOTHORAX I N PHAM NGOC THACH

HOSPITAL ( 0 1 / 2 0 0 7 - 0 6 / 2 0 1 3 ) Objective; To review our experience of video- assisted thoracoscopic surgery for the treatment of primary spontaneous pneumothorax.

Patients and intervention: One hundred and eighthteen consecutive pabents undergoing thoracoscopy for primary spontaneous pneumothorax from January 2007 to July 2013.

Results: The mean age of the patients was 28.2 years (range, 16 to 55 years), and 102 were men (86.4%). All patients were successfully treated using video-assisted thoracoscopic technique. Recurrent pneumothorax was the most frequent indication for surgery, occurring in 83 patients. The most common method of management was stapling of an identified bleb, which was done in 71 cases. Pleurodesis was achieved by gauze abrasion (n = 79) and apical pleurectomy (n = 39). Postoperative prolonged air leak occurred in five patients (4.2%). There were no deaths attributable to the procedure. The mean (± SD) postoperative pleural drainage was 3.1 ± 2.8 days.

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Conclusions: Video-assisted thoracoscopic surgery is a safe procedure in the treatment of primary spontaneous pneumothorax. Pleurodesis was achieved by abrasion is a more safe and effective way of producing apical pleurectomy.

Keywords: Pnmary spontaneous pneumothorax

— pleural abrasion — apical pleurectomy — thoracoscopy

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Vdi nhihig u'u diem cita minh, phau thuat noi soi da trd thanh phu'dng phap chu yeu de dieu tri TKMPTP thay the cho phiTdng phap md ngu'c truyen thong. Tai Viet nam, ngay tir nam 1995, phau thuat npi sol dieu trj tran klii mang phoi da du'dc tien hanh tai mot so benh vien nhu' benh vien Chd Ray, benh vien Phoi Trung u'dng.... Tai benh vien Pham Ngpc Thach, khoa Ngoai Long ngi/c da tien hanh phau thuat noi soi de dieu trj TKMPTP ti!r nam 2005 va da su' dung ky thuat boc la thanh mang phoi dinh, lam xu'dc la thanh mang phoi lam dinh mang phoi nham chong tai phat.

Muc tieu cua nghien culi nay nham danh gia ket qua dieu tn tran khi mang phoi td phat nguyen phat bang phau thuat noi soi tai benh vien Ngoai Long ngu'c trong thdi gian td ^\{'2S::i^l den 06/2013.

II. 06l TUOWG VA PHirCNG PHAP N G H I I N CLTU 2.1. Doi tu'dng nghien cu'u

Bao gom l i s benh nhan TKMPTP nguyen phat du'dc phau thuat noi soi dieu trj tran khi mang phoi tai khoa Ngoai Benh vien Pham Ngpc Thach trong thdi gian t^* 01/01/2007 den 30/06/2013.

Cd 39 benh nhan phau thuat td 01/2007 den 09/2010 du'dc xir tri lam dinh bang phu'dng phap bdc la thanh mang phoi.

79 benh nhan du'dc phau thuat tir 10/2010 den thang 8/2010 du^dc Y.d tri lam dinh bang phu'dng phap lam xu'dc la thanh mang phoi,

Bing J/Chi djnh phau thuat

2.2. Chi djnh phau thuat: Cac tran khf mang phoi tu" phat nguyen phat cd:

- Tran khf mang phoi tai phat

- Tran khf mang phoi cd ro khi keo dai tren 5 ngay.

2.3. Ky thuat th u'c hien

- Dot cac bong khi neu bong khf nhd hdn 2cm - Cat bdng khi bang stapler hay cat khau bang dung c\i neu bong khf Idn hdn 2cm

- Lam dfnh mang phoi bang each lam xu'dc la thanh mang phoi vung dinh hay bdc la thanh mang phoi viing dinh..

- Do 50ml dung dich lodopovidone vao khoang mang phoi

- Dat ong dan lu'u khoang mang phoi 2.4. Cham soc hau phau

Benh nhan sau phau thuat du'dc hut dan \d\x vdj ap lyc hilt tir -15cm H2O den -iocmH^O - Ong dan lu'u du'dc rut 24 gid sau khi tren phim XQ phoi thay phoi nd hoan toan khong con dau hieu tran khi va lu'dng dich dan lu'u 24 gid ft hdn 2d0ml.

2.5. Oanh gia

Tuoi, gidi, thdi gian phau thuat, tien sir, each thu'c xd ly bdng khi, bien chirng trong mo va sau mo, thdi gian dan lull, thdi gian ro khi, mire dp dau sau mo.

III. KET QUA 3.1. Oac diem chung

- Co 13,6% benh nhan nff va 86,4% benh nhan nam vdi ty le nam/nff la 6,4/1.

- Tuoi trung binh ciia mau nghien ciru la 28,2

±10.2_tuol. Tuoi thap nhat la 16 tuoi, cao nhat la 55 tuoi. Nhdm tuoi gap nhieu nhat la tir 20 - 39 tuoi gom 77 benh nhan chiem ty le 65,3%.

3.2. Phau thuat - Chi djnh phau thuat

Chi dinh Tran khi keo dai tren 5 nqay

Tran khj tai phat Tong

Tyle

- Cac phu'dng phap Y.d ly bdng khi

Bing 2: Cac phu'dng phap xd ly bdng khi trong phau thuat Phu'dng phap

Stapler noi soi Dot bong khi Kep cat va khau tay

Tong

Sobn Tyle

61,2°

30,2°

8,6 % 100 %

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3.3. Ket qua phau thuat -Thdi gian phau thuat

Bing 3:Th6\ gian phau thuat trung binh Phiftfng phap xi^ tri mang phoi

Boc la thanh (phut) Lam xu'dc la thanh (phut)

n 39 79

Ngan nhat 45 25

Dai nhat 190 110

A ±SD 78,1 ± 31 53,1 ± 16,5 - Lu'tfng mau mat

Bang 4: Lu'dng m.au mat trung binh Phu'dng phap phau thuat Boc la thanh manq phoi (ml) Xu'dc la thanh manq phoi (ml)

n 38 37

97,4%

%

46,8%

i t nhat 30 20

Nhieu nhat 2300

400

A ±SD 152,1 ± 362,6

78,9 ± 76,4

^3.4. Ket qua sau ^hau thuat - Dan lu'u sau phau thuat

Bang 5: Phan loai thdi gian ro khi' Thdi Qian ro l<hi

Khonq ro khf Ro khf du'di 5 nqay Ro khi tren 5 nqay

Tong

Sobn 98 16 4 118

Tyle 83,1%

13.6%

3,4%

100°/o

Ty Ie cong don 83,1%

96.6%

100%

100%

Bing 5/Thdi qian dan lu'u trunq binh theo pht/dnq phap xi^ tn la thanh Phu'dng phap phau thuat

Boc ia thanh manq phoi (nqay) Lam xu'dc la thanh manq phoi (nqay)

n 39 79

I t nhat 1 1

Nhieu nhat 22 17

—

_{A ' ± S D}

3,2 ± 3,3 3,0 ± 2,7 - Bien chirng

a 7: Bien chutiq hau phau Bien chu'ng sau mo Khonq cd blen chiTnq Mau tu manq phdi Rd khi keo dai tren 5 nqay

Tong

Boc la thanh Sobn

35 3 1 39

89,7%

%

7,7%

2,6%

100%

Lam xu'dc la thanh Sobn

74 1 4 79

n 93,7%

1,3%

5,0%

100%

Phu'dng phap xu' ly la thanh Lam xu'dc la thanh

Bdc la thanh Tong

Ro khi Iceo dai n 4 1 5

80

%

20 100

Mau tu manq phoi n

1 3 4

25

%

75 100

Tong 5 4 9 IV. BAN LUAN

4.1. Oac diem chung

Bp tuoi trung binh cua nhdm benh nhan nghien cii'u la 28.2 ± 10.2 tuoi (tir 16 va cao nhat la 55 tuoi). Trong nghien ctTu ciia Bernward Paslick (1998) [3], trong 65 benh nhan TKMP nguyen phat cd do tuoi trung binh la 28 tuoi (tir 17 den 53 tuoi).

Nhdm tuoi mac benh cao nhat ca nam va nu' la tir 20 den 39 tuoi vdi ty le 65.4% doi vdi nam va 65.7% doi vcfi nii'. Trong bao cao ciia Primmose, cd den 90% benh nhan TKMPTP nguyen phat du'di 40 tuoi [7]. Nhu' vay dp tuoi hay gap nhat ciia TKMPTP nguyen phat la d trong dp tuoi lao dpng cd cu'dng dp cao nhat

Ve gidi tinh, trong nghien ciru ciia chiing toi, ty le benh nhan nam/nu' la 5.9/1. Ty le nay tiTdng du'dng vdi ty le ciia cac tac gia khac nhu' Baumann MH cd ty le tir 3-6 lan (2004) [2].

4.2. Phau thuat 4,2.1. Chi dinh phau thuat

Trong nghien ciru cua chiing toi, chi djnh phau thuat cho benh nhan tran khf mang phoi chi gom: TKMPTP nguyen phat tai phat tir lan thir hai va TKMPTP co ro khi keo dai. Benh nhan TKMPTP nguyen phat tai phat trong nghien ciiu cd ty le 70.3%, 29,7% benh nhan cd rd khf keo dai. Ayed KA (2000) cung cd ty le benh nhan TKMP tai phat tu'dng ttr (68.1%) [ i ] . Chiing toi khong chi djnh phau thuat doi vcfi nhii'ng benh

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nhan tran khi mang phoi lan dau nhu'ng tim thay bdng khf tren phim cat Idp vl tfnh ngoai trir tru'dng hdp cd rd khf keo dai.

4.2.1. Ky thuat XU-ly bong khi Ng CHS, Lee TW, Wan S (2006) cho rang: ve ket qua lau dai ciia 2 ky thuat cat khau bong khf bang tay va bang may tu'dng du'dng nhau, khau bdng khf bang chi phau thuat qua npi soi tiet kiem du'dc chi phi phau thuat, nhu'ng dieu nay ddi hdi phai du'dc thu'c hien bdi phau thuat vien CO kinh nghiem [3]. Tuy nhien ddi vdi nhdng benh nhan khdng tim thay bdng khi, Ayed KA cung chii tru'dng cat vung dinh vi cho rang cd the bd sot bong khf nam du'di mang phoi [1].

Trong nghien ciru ciia chung toi, cd 2 benh nhan khong tim thay bdng khi trong phau thuat. Ky thuat cat bdng khi bang may khau td dpng du'dc sir dung trong 61.2% benh nhan tim thay bdng khf, 49.3% trong so do cd bdng khf Idn hdn 2 cm. Chiing toi chi sir dung cat bdng khi va khau tay cho 8.5% benh nhan. Chung toi khong sir dung ky thuat cot bdng khf bang nd chi vi lo ngai se tut nd khi bdm phoi nd.

4.3. Ket qua phau thuat 4.3.1. Thdi gian phiu thuit Ket qua nghien cu'u ciia chiing toi cho thay;

thdi gian phau thuat trung binh la 61.4% ± 25.2 phut, thdi gian phau thuat trung binh doi vdi bdc la thanh mang phoi vung dinh la 78.1 ± 31 phiit, ciia nhdm lam xu'dc la thanh mang phoi la 53.1

± 16.5 phut. O. Rena va cpng sir (2008) cung 6a bao cao thdi gian phau thuat trung binh ciia nhdm bdc la thanh mang phoi dai hdn so vdi nhdm lam xu'dc la thanh mang phoi (55 ±18 phut ciia nhdm bdc la thanh so vdi 38 ± 16 phiit ciia nhdm lam xu'dc la thanh mang phoi) [6].

Ayed KA (2000) cung cd ket qua tu'dng tir: 50.7

± 10.2 phut va 61.8 ± 9.2 phut [1]. Ntiu' vay, phau thuat npi sol dieu tri TKMPTP nguyen phat sir dung ky thuat bdc la thanh mang phoi vung dinh gay dinh mang phoi lam cho cuoc mo se keo dai hdn so vdi sir dung ky thuat lam xu'dc la thanh mang phoi vung dinh

4.3.2. Lu'dng miu mat

Trong cac bao cao cua cac tac gia khac, khong de cap den lu'dng mau mat trong phau thuat. Trong nghien cdu ciia chiing toi, cd 1 tru'dng hdp bdc la thanh mang phoi vung dinh phai truyen mau trong phau thuat. Chiing toi nhan thay, co sir khac nhau ve mau mat trong phau thuat giiJa nhdm bdc la thanh mang phoi viing dinli va nhdm lam xu'dc la thanh mang

phoi. Chf cd 46.8% benh nhan trong nhdm lam xu'dc la thanh mang phoi cd mat mau, trong khi dd cd tdi 97.4% benh nhan ciia nhdm bdc la thanh mang phoi vung dfnh cd mift mau. Sir khac biet tren cd y nghTa thdng ke vdi p<0.01.

Doi vdi lu'dng mau mat trung binh trong phau thuat cung cd SLT khac biet. Doi vdi nhdm bdc la thanh mang phoi vung dinh, lu'dng mau mat trung binh la 152.1 ± 362 ml. Lu'dng mau mat nhieu nhat cua nhdm bdc la thanh la 2300 ml do rach dpng mach lien su'dn. O nhdm lam xu'dc ia thanh mang phd'i vung dinh, lu'dng mau mat trung binh chi la 78.9 ±^'76.4 ml. Nhu' vay, bdc la thanh mang phoi de gay chay mau hdn so vdi lam xu'dc la thanh mang phoi. Theo chiing toi, nguyen nhan cd the do bdc la thanh mang phoi de lam ton thu'dng cac to chirc cd lien su'dn hay lam ton thu'dng dpng mach lien su'dn.

4.4. Ket qua sau phau thuat 4.4.1. Thdi gian dan IuV

Sau phau thuat, thdi gian dan lu\i trung binh trong nghien ciru ciia chiing toi la 3.1 ± 2.7 ngay (tir 1 den 22 ngay). Neu tinh rieng theo tilrng ky thuat xd tri la thanh mang phoi thi thdi gian dan lu'u trung binh doi vdi nhdm bdc la thanh mang phoi vung dinh la 3.2 ± 3.3 ngay (tir 1 den 22) va doi vdi nhdm lam xu'dc la thanh mang phoi vung dinh la 3.0 ± 2.7 ngay (tiT 1 den 17. Ket qua nghien ciru ciia chiing toi cd diem khac so vdi cac tac gia khac. Ayed AK (2000) bao cao sd khac nhau ve thdi gian dan lu'u trung binh q\da hai nhdm bdc la thanh va lam xu'dc la thanh [10]. Theo Ayed AK, nhdm bdc la thanh cd thdi gian dan lu^i trung binh sau phau thuat ngan hdn so vdi nhdm lam xu'dc la thanh, 3 ± 1 ngay so vdi 3.5 ± 2 ngay [1].

4.4.2. Rd khi sau phiu thuat Trong nghien ciru ciia chung toi, ty l§ benh nhan rd khf sau phau thuat la 16.9%. Tuy nhien chi cd 3.4% benh nhan cd rd khi tren 5 ngay.

Theo Ayed AD, nguyen nhan hay gap ciia ro khi keo dai la bd sot ton thu'dng trong phau thuat, cd nhUng bdng khf nam du'di mang phoi khong phat hien du'dc qua quan sat du'di ong kfnh camera [1].

4.4.3. Biin chu'ng sau phau thuat Cac nghien ciru ciia cac tac gia tren the gidi deu cho thay, neu nhu' ro khf keo dai la bien chirng hay gap trong nhdm benh nhan lam xu'dc la thanh mang phoi thi chay mau sau phau thuat lai la blen chirng hay gap ciia nhdm benh nhan

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bdc la thanh mang phoi. Kocatuk a (2012) da bao cao ty le chay mau sau mo phai phau thuat lai d nhdm boc la thanh la 3.3% so vdi 1 . 1 % t>enh nhan d nhdm benh nhan lam xu'dc la thanh mang phoi [ 5 ] . Trong nghien ciTu cua Kocatuk a , ca 3 benh nhan cd rd khi keo dai phai phau thuat lai dau trong nhdm lam xu'dc la thanh mang phoi. Ket qua nghien ciAi ciia chiing tdi cung phii hdp vdi cac tac gia khac. Chiing tdi cd 9 benh nhan cd bien chu'ng sau mo, trong dd cd 5 benh nhan cd rd khi keo dai va 4 benh nhan cd tu mau sau phau thuat. Doi vdi 5 benh nhan ro khi keo dai cd 4 benh nhan trong nhdm lam xu'dc la thanh.. Trong so 4 benh nhan cd tu mau cd 3 benh nhan phau thuat lai deu nam trong nhdm benh nhan boc la thanh mang phoi vung dinh.

V. K^T LUAN

Phiu thu^t npi soi long ngi/c la phu'dng phap an toan trong dieu trj TKMPTP nguyen phat. Lam xu'dc la thanh mang phoi gay dinh la ky thuat an toan va hieu qua hdn so vdi bdc la thanh mang phoi vung dinh,

TAI L l i U THAIVI KHAO

1. Ayed AK, Chandrasekaran C, Sukumar M (2000), "The Results of Thoracoscopic Surgery for Primary Spontaneous Pneumothorax", Chest 2000, pp 118:235-238.

2. Baumann MH, Noppen M (2004),

"Pneumothorax", Respirology_,9, pp. 157-164.

3. Bernward Passliclg Christine Born, Karl Ha'ussinger andOlafThetter(1998),"Efficiency of Video-Assisted Thoracic Surgery for Primary and Secondary Spontaneous Pneumothorax" Ann Thorac Surg, 65, pp. 324-327.

4. C S H Ng, T W Lee, S Wan and A P C Yim.

Video assisted thoracic surgery in the management of spontaneous pneumothorax: the cun-ent status. Postgrad. Med. J. 2006;82; 179-185 5. Kocaturk Ct, Mehmet Zeki Gunliioglu,

Ibrahim Seyyit Dinger, Mehmet Ali Bedlrhan. (2012), "Pleural abrasion versus pleurectomy in primary spontaneous pneumothorax surgery" Turk Go^us Kalp Damar Cerrahisi Dergisi,20(3), pp.558-562.

6. O. Rena, F. Massera, E. Papalla, C. Delia Pona, M. Robustellini and C. Casadlo.

(2008)/ "Surgical pleurodesis for Vanderschueren's stage I I I primary spontaneous pneumothorax" Eur Respir J, 31, pp. 837-841 7. Primrose WR. ( 1 9 8 4 ) , "Spontaneous

pneumothorax: a retrospective review of aetiology, pathogenesis and management" Scott MedJ, 29, pp.15-20.

DANH GIA KET QUA DIEU TRI HOI NACH BANG PHAU THUAT CAT TUYEN MO HOI NACH TAI CHO

T 6 M TAT

M^c tieu: TSng tiet mo hoi nach chiem 1-3% d nhiTng nu'de c6 khi hau nSng nong, anh hu'dng khong nho d^n ddi song sinh hoat ciia benh nhan. Co nhieu phu'dng phap dieu trj t3ng tiet mo hoi nach nhutig hi^u qua con han che. Hi?n nay, dieu trj tSng tiet mo hoi nach van con nhieu thach thu'c. Trong nghien cuXi nay, chung toi danh gia ket qua phlu thuat cat tuyen mo hoi nach mo hoi nach tai cho dieu trj tang tiet mo hoi nach tai khoa Phau thuat Tao hinh Tham my Benh vien Chd Ray.

Phu'dng phSp: Nghien CUXJ mo ta tien cdu tren 40 benh nhan tSng tiet mo hoi nach nhap khoa Tao

*Khoa T^o hinh Tham my, B$nh vien Chd Ray Chju trach nhi^m chfnh: Do Quang Hiing Email: [email protected] Dt: 0903718442 Ngay nh?n bai: 08/3/2015

Ngay phan bien khoa hoc: 01/4/2015 Ngay duyet bai: 05/4/2015

Do Quang Himg'^

hinh Tham my Benh vien Chd Ray du'(?c phau thuat c3t tuyen mo hoi nach tai cho td 01/2013 den 01/2015. Danh gia ket qua du^ vao miit do cai thien tren diem lam sang va miTc dp hai long ciia benh nhan.

K€t qua: Ti le hai long sau phau thuat 1, 3 va 6 thang lan lupt la 80%, 85% va 90%. Cd 01 ca abcess nach 1 ben va 1 tru'dng hdp cho khau da khong lanh.

Ket luan: Phu'dng phap cat tuyen tuyen mo hoi nach tai cho dieu tri tang tiet mo hoi nach cho ket qua t6t, ti le tai phat it va tu'dng doi de thi/c hien

Tu' khoa: tang tiet mo hoi nach, dieu tri phau thuat, tl le tai phat

S U M M A R Y

EVALUATION OF SURGICAL LOCAL E X C I S I O N OF AXILLARY SWEAT GLANDS

TO TREAT AXILLARY H Y P E R H I D R O S I S Objectives: Axillary hyperhidrosis accounts for 1 to 3 % in tropical countries, which significantiy affects

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