本文選題：手汗癥 + 胸腔鏡手術(shù)　； 參考：《福建醫(yī)科大學(xué)》2013年博士論文

【摘要】：目的：進(jìn)一步研究胸交感神經(jīng)支配手掌皮膚汗腺的神經(jīng)通路，探討胸交感神經(jīng)切斷術(shù)治療的解剖依據(jù)。分析胸交感神經(jīng)切斷術(shù)術(shù)后長期隨訪結(jié)果，，探討手汗個(gè)體化治療術(shù)式選擇。 方法：（1）15只大鼠前肢足墊皮膚辣根過氧化物酶逆行示蹤交感節(jié)后神經(jīng)元定位。（2）胸腔鏡下50例100側(cè)手汗癥患者、60例60側(cè)正常對(duì)照上胸段交感神經(jīng)鏈結(jié)構(gòu)鏡下結(jié)構(gòu)觀察及對(duì)照，I型20段，II型18段，III型14段Kuntz神經(jīng)纖維核固紅－固綠髓鞘染色研究其有髓與無髓神經(jīng)纖維比例。I型9段，II型8段， III型5段kuntz神經(jīng)纖維透射電鏡超微結(jié)構(gòu)觀察。（3）996例胸腔鏡胸交感神經(jīng)切斷術(shù)術(shù)后3年以上手汗癥患者長期隨訪調(diào)查，到訪的809例中分為：R2組：R2-4交感神經(jīng)干切斷162例；R3組：R3交感神經(jīng)干及R3旁路神經(jīng)切斷374例、R3-4組：R3-4交感神經(jīng)干及R3-4旁路纖維切斷138例，R4組：R4交感神經(jīng)干及R4旁路纖維切斷135例，比較各組術(shù)中手溫監(jiān)測(cè)特點(diǎn)，術(shù)后手汗及伴發(fā)的頭、腋窩、腳部多汗治療效果。 結(jié)果：(1)15例大鼠支配前肢足墊皮膚的交感節(jié)后神經(jīng)元主要位于頸中神經(jīng)節(jié)（23.5%）、頸胸神經(jīng)節(jié)（72.9%）、T3神經(jīng)節(jié)（2.8%）。(2)每側(cè)胸腔T2-T4肋骨表面出現(xiàn)至少一種類型kuntz神經(jīng)的概率：手汗癥為81%（81/100），正常對(duì)照為35%（21/60），兩者對(duì)比差別具統(tǒng)計(jì)學(xué)意義。核固紅－固綠髓鞘染色顯示kuntz神經(jīng)纖維中有髓神經(jīng)比例：I型78.2%，II型93.7%，III型92.6%。透視電鏡超微結(jié)構(gòu)觀察顯示I型kuntz神經(jīng)以有髓神經(jīng)纖維為主，II型及III型kuntz神經(jīng)以無髓神經(jīng)纖維為主。（3）996例胸腔鏡胸交感神經(jīng)切斷術(shù)術(shù)后3年以上手汗癥患者到訪809例，手汗100%有效，長期隨訪有1.48%復(fù)發(fā)，頭汗、腋汗、腳汗有效率分別為63.2%、68.7%、32.9%。中、重度代償性多汗是引起術(shù)后病人不滿意甚至后悔的主要原因， R2、R3、R3-4、R4組中-重度代償性多汗分別為19.7%，9.8%，13.1%，4.2%，四組之間及各組之間兩兩比較差異有統(tǒng)計(jì)學(xué)意義（P0.05）。R2組病人術(shù)后滿意度最低。 結(jié)論：（1）手部皮膚的交感節(jié)后神經(jīng)元主要位于頸胸和頸中神經(jīng)節(jié)，胸交感神經(jīng)手術(shù)治療手汗癥切除神經(jīng)節(jié)沒有必要。（2）治療手汗癥不需要完全阻斷手的交感神經(jīng)支配，低位切斷有利于降低術(shù)后代償性多汗的發(fā)生率，但R4切斷應(yīng)該慎重，應(yīng)該根據(jù)術(shù)前病人對(duì)手干燥的要求，結(jié)合術(shù)中手溫變化和解剖特點(diǎn)綜合考慮。
[Abstract]:Objective: to study the nerve pathway of thoracic sympathetic nerve innervating the sweat gland of palmar skin and to explore the anatomical basis of thoracic sympathetic neurotomy. To analyze the results of long-term follow-up of thoracic sympathetic neurotomy and discuss the choice of individualized treatment for hand sweat. Methods horseradish peroxidase retrograde tracing of postganglionic neuronal localization in the skin of forelimb foot pad of 15 rats was performed in 15 rats. Under thoracoscope, 50 cases (100 sides of hand hyperhidrosis) and 60 cases (60 sides of normal control) with sympathetic nerve chain structure of upper thoracic segment were observed under thoracoscope. Study on the ultrastructure of medullary and unmyelinated nerve fibers in type I, type 9, type II, and III type 5 kuntz nerve fibers, ultrastructure of transmission electron microscopy in 14 segments of Kuntz nerve fiber nuclei of type I, II, II, and III, and of 14 segments of Kuntz nerve fiber, type I, type I and type I, type I, type I and type I To observe the long-term follow-up of 996 patients with palmar hyperhidrosis after thoracoscopic thoracic sympathetic neurotomy for more than 3 years. The 809 cases were divided into two groups: 1 / R2 group: R2-4 sympathetic trunk transection 162 cases: R3 group: R3 sympathetic trunk and R3 bypass nerve transection 374 cases R3-4 group: R3-4 sympathetic trunk and R3-4 bypass fiber transection 138 cases: R4 group R: 4 sympathetic trunk and R4 bypass fiber transection 135 cases. The monitoring characteristics of hand temperature during operation and the therapeutic effect of hand sweating and accompanied head, axillary and foot hyperhidrosis were compared in each group. Results in 15 rats, the sympathetic postganglionic neurons innervating the skin of forelimb and foot pad were mainly located in the middle cervical ganglion, 72.9% T 3 ganglion and 2.8% T 3 ganglion.) the probability of at least one type of kuntz nerve on the surface of each side of the thoracic T2-T4 rib was as follows: palmar hyperhidrosis was the same as that of palmar hyperhidrosis. 81 / 100 and 35 / 21 / 60 in normal control, the difference was statistically significant. The myelin staining of nucleus fixed red and solid green showed that the proportion of myelinated nerve in kuntz nerve fibers was 78.2% in type I and 93.7% in type II, and 92.6% in type III. The ultrastructural observation of electron microscopy showed that the type I kuntz nerves were mainly myelinated nerve fibers and the III type kuntz nerves were mainly unmyelinated nerve fibers. 996 patients with palmar hyperhidrosis more than 3 years after thoracoscopic thoracic sympathetic neurotomy visited 809 cases. The effective rate of hand sweat was 100%, and the recurrence rate was 1.48%. The effective rates of head sweat, axillary sweat and foot sweat were 63.2% and 68.7% respectively. Moderate and severe compensatory hyperhidrosis was the main cause of dissatisfaction and even regret. The moderate to severe compensatory hyperhidrosis in R2R3R3R3-4 group was 19.7and 9.80.13.1and 4.2.The difference between the four groups and between the four groups was the lowest (P0.05.R2 group). Conclusion the sympathetic postganglionic neurons in the skin of the hand are mainly located in the cervical thoracic and middle cervical ganglion. There is no need for thoracic sympathetic nerve operation in the treatment of palmar hyperhidrosis with excision of ganglion. 2) the sympathetic nerve innervation of the hand should not be completely blocked in the treatment of hand hyperhidrosis. Lower transection is helpful to reduce the incidence of compensatory hyperhidrosis after operation, but R4 transection should be considered carefully, according to the requirement of dry hands before operation, combined with the changes of hand temperature and anatomical characteristics during operation.
【學(xué)位授予單位】：福建醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2013
【分類號(hào)】：R655

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