本文選題：經(jīng)自然腔道內(nèi)鏡手術(shù) + 胸交感神經(jīng)切斷術(shù)　； 參考：《福建醫(yī)科大學(xué)》2013年博士論文

【摘要】：目的 通過動物實(shí)驗(yàn)研究初步探討分別經(jīng)食道、陰道和臍實(shí)施胸交感神經(jīng)切斷術(shù)和心包開窗術(shù)的可行性和安全性。在積累動物實(shí)驗(yàn)經(jīng)驗(yàn)的基礎(chǔ)上，將經(jīng)臍胸交感神經(jīng)切斷術(shù)初步應(yīng)用于臨床，探討其可行性、安全性和有效性，為胸部NOTES手術(shù)的開展積累經(jīng)驗(yàn)。 方法 動物實(shí)驗(yàn)部分以豬為實(shí)驗(yàn)動物，分別開展經(jīng)食道、陰道-膈肌、臍-膈肌實(shí)施胸交感神經(jīng)切斷術(shù)和心包開窗術(shù)。每組各進(jìn)行10例實(shí)驗(yàn)，其中急性實(shí)驗(yàn)3例，存活實(shí)驗(yàn)7例。急性實(shí)驗(yàn)術(shù)后立即處死尸檢，存活實(shí)驗(yàn)4周后尸檢。臨床經(jīng)臍胸交感神經(jīng)切斷術(shù)在全麻雙腔氣管插管下完成，記錄術(shù)中情況，并對手術(shù)結(jié)果進(jìn)行跟蹤隨訪。 結(jié)果 共進(jìn)行動物實(shí)驗(yàn)30例次，經(jīng)食道組術(shù)中死亡2例，其余28例均成功完成目標(biāo)手術(shù)。急性實(shí)驗(yàn)尸檢發(fā)現(xiàn)經(jīng)食道組發(fā)生胸主動脈損傷1例，左奇靜脈損傷1例；經(jīng)陰道組發(fā)生胸壁損傷2例，直腸損傷1例。各組胸交感神經(jīng)切斷準(zhǔn)確徹底，心包開窗術(shù)完成良好。存活實(shí)驗(yàn)尸檢發(fā)現(xiàn)食管造口愈合良好，食管外膜層和肺組織發(fā)生粘連3例；經(jīng)陰道組陰道和膈肌切口均愈合良好，膈肌切口與肺組織粘連4例；經(jīng)臍組膈肌切口與肺組織粘連3例。各組未見明顯胸、腹腔感染跡象。臨床共實(shí)施36例經(jīng)臍胸交感神經(jīng)切斷術(shù)，均順利完成。平均手術(shù)時(shí)間54min，均于術(shù)后第一天出院。術(shù)后隨訪6~12個(gè)月，手汗和腋汗的治愈率分別為100%和76%。共發(fā)生代償性出汗13例（36.1%），所有患者手汗無復(fù)發(fā)，無膈疝、臍疝及霍納氏綜合征等嚴(yán)重并發(fā)癥發(fā)生。 結(jié)論 1、經(jīng)食道入路雖然具有操作路徑短的優(yōu)勢，但是該入路難度較大，就目前的技術(shù)而言在消毒、切口的選擇和閉合上仍無法確保安全。 2、陰道入路的切開和縫合均可在直視下完成，，安全性高，但實(shí)施胸腔內(nèi)手術(shù)路徑太長，器械的可控性差。 3、經(jīng)臍入路具有較高的可行性和安全性，就胸交感神經(jīng)切斷術(shù)治療手汗癥而言可以獲得等同于胸腔鏡手術(shù)的有效率，而且美容效果顯著，但手術(shù)時(shí)間較長，其潛在的風(fēng)險(xiǎn)和優(yōu)勢有待于進(jìn)一步評估。
[Abstract]:Purpose To explore the feasibility and safety of thoracic sympathetic neurotomy and pericardial fenestration through esophagus vagina and umbilical cord respectively. Based on the accumulation of animal experimental experience, we applied transumbilical thoracic sympathetic neurotomy to clinical practice, and discussed its feasibility, safety and effectiveness, and accumulated experience for the development of thoracic NOTES operation. Method In the animal experiment, pigs were used as experimental animals. Thoracic sympathetic neurotomy and pericardial fenestration were performed through esophagus, vagina, diaphragm and umbilical diaphragm respectively. There were 10 cases in each group, including 3 cases of acute experiment and 7 cases of survival test. Autopsy was performed immediately after acute experiment and 4 weeks after survival test. Clinical transumbilical thoracic sympathetic neurotomy was performed under general anesthesia with double lumen endotracheal intubation to record the intraoperative situation and follow up the results of the operation. Result 30 animal experiments were carried out, 2 cases died in the transesophageal group, and the other 28 cases successfully completed the target operation. Acute autopsy showed that thoracic aorta injury occurred in 1 case, left azygos vein injury in 1 case, thoracic wall injury in 2 cases and rectal injury in 1 case in transesophageal group. Thoracic sympathetic nerve transection in each group was accurate and complete, pericardial fenestration was completed well. In the survival experiment, the esophagostomy healed well, the esophagus outer layer and lung tissue were conglutinated in 3 cases, the vagina and diaphragm incision healed well in the transvaginal group, and 4 cases were conglutinated between the diaphragm incision and the lung tissue. Adhesion between diaphragm incision and lung tissue was found in 3 cases in the transumbilical group. There were no obvious signs of chest and abdominal cavity infection in each group. A total of 36 cases of umbilical thoracic sympathectomy were performed successfully. The average operative time was 54 minutes and all patients were discharged on the first day after operation. The cure rates of hand sweat and axillary sweat were 100% and 76% respectively. There were 13 cases of compensatory sweating. No recurrence of hand sweat, no diaphragmatic hernia, umbilical hernia, Horner's syndrome and other serious complications occurred in all patients. Conclusion 1. Although the transesophageal approach has the advantage of short operating path, it is difficult to access the route. In terms of current technology, the selection and closure of incision are still not safe. 2. The incision and suture of vagina approach can be completed under the direct vision, the safety is high, but the intrathoracic operation path is too long, and the controllability of the instrument is poor. 3. The transumbilical approach has high feasibility and safety. In the treatment of palmar hyperhidrosis, thoracic sympathetic neurotomy can obtain the same effective rate as thoracoscopic surgery, and the cosmetic effect is significant, but the operation time is longer. Its potential risks and advantages need to be further evaluated.
【學(xué)位授予單位】：福建醫(yī)科大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2013
【分類號】：R655

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