16-05-14.ETS交感神經切除術患者大部份都會反射性出汗

STS: Sympathectomy's success variable


Compensatory sweating affects most patients who undergo cutting of sympathetic ganglia (交感神經切除手術大部份的病患都會產生反射性出汗)


By Heather Ennis


TAMPA, FLA. – A common procedure to bring relief to patients who suffer from excess sweating became the subject of heated debate here as two contradictory papers reported varying degrees of postoperative symptoms and arrived at conflicting conclusions on how and when the surgery should be performed.


Sympathectomy is often the last resort for patients who experience excessive sweating on their palms, face, scalp and underarms. The procedure involves interrupting the nerve signal that causes sweating in the affected area by selectively cutting, clipping or excising part of the sympathetic ganglia. Several methods are commonly performed, and each has drawn mixed results in the literature.


交感神經切除術通常是有手掌、臉、頭皮及上肢過度出汗者的最後一個選擇的治療方式。這手術就是把受影響部位的神經用切斷、鋏子或切除部分交感神經節的方法來達成治療目的，這幾種方法都有人在做，其效果在文獻記載上可說眾說紛紜。


A study involving 121 patients reported here by surgeons from Dallas showed the success of the surgery after one year was dependent on the type of sympathectomy performed. Researchers follow a protocol that involves excising a small part of the T2 ganglia for facial sweating or blushing, the T3 ganglia for hand sweating and T4 ganglia for armpit sweating. In patients with mixed symptoms, multiple excisions were performed.(美國達拉斯外科醫師 調查121位 交感神經切除手術病患)


一項由Dallas醫師所提出，涵蓋121位接受交感神經切除術患者的研究指出，手術成功與否（一年後評估）與交感神經切除術的手術方式有密切關係。研究顯示對於臉多汗及臉紅者切除T2交感神經節，手汗者切除T4交感神經節，T4交感神經節切除則針對腋下多汗。對於綜合性症狀者，就必須作多處的切除。


Palm sweating treatable


"The patients who were most satisfied were those whose sympathectomies were performed for isolated palmar sweating," said Dr. Todd Dewey of the Medical City Dallas Hospital. "Our most dissatisfied patients were those who had sympathectomy for isolated face sweating, face and axillary sweating, and face, palms and axillary sweating."


Medical City Dallas Hospital的Todd Dewey醫師說，最滿意的患者是只有手多汗症接受交感神經切除術的患者，而最不滿意的患者是單獨臉汗、臉加腋下多汗以及臉、手掌及腋下同時多汗的患者。


The most common postoperative symptom following sympathectomy is increased sweating on other parts of the body, most often the back, legs, groin and abdomen. This compensatory sweating can be mild or severe, and occurred in 82% of the Dallas patients.


手術後最常見的症狀是在身體其他部位呈現反射性出汗。大部份在背、小腿、鼠蹊以及腹部，這種反射性出汗可以是輕微或嚴重的，Dallas醫師的患者，有82%會發生術後反射性出汗。


Dissatisfied patients seemed to have something in common, said Dr. Dewey, who noted people who underwent surgery involving the T2 ganglia were more likely to experience disabling compensatory sweating after the procedure.


“不滿意交感神經切除術的患者，似乎有一共同點”。Dewey醫師說，切除T12交感神經節患者比較會感覺術後出現致殘性的反射性出汗。


"We would recommend limiting the level of resection to one level if possible or detailed patient counselling for all multi-level or T2 resections regarding the possibility of severe compensatory symptoms," he said.


＂我們會建議，儘可能手術只切除一個部位，或仔細的向患者說明，多重或T2切除，可能帶來嚴重的代償性症狀。＂


Fully 83% of patients who underwent T2 sympathectomy reported severe compensatory sweating one year after surgery and the majority of those reported they regretted the decision to have the surgery.


83%作過第二節交感神經切除手術的患者表示一年後，產生嚴重的反射性出汗，並且大部份的病患表示後悔開刀的決定


"Patients with T2 resections strongly report they would not have the surgery again except if T3 was part of the excision," said Dr. Dewey. "This is probably because palmar symptoms are more socially stigmatizing and that overrode their severe compensatory sweating."


Dewey醫師說，做過T2切除的患者強烈反應“寧願不作手術＂，除非是做T3部份切除術，這可能是因為手汗比代償性出汗讓社交活動更困窘。


In contrast, a second research team from Denmark reported a series of 100 patients who underwent surgery for underarm sweating.


與前述研究報告比較，丹麥也做了100位腋下多汗手術的調查研究報告。


Surgeons there routinely cut the T2 ganglia, and the study compared two groups who had either T2-T4 or T2-T3 resections. Approximately 90% of patients reported compensatory sweating, half of whom were forced to change their clothes during the day because of it.


外科醫師常規性的切除T2交感神經節，這研究也做了T2-T4及T2-T3交感神經節切除的比較。接近90%的患者都有反射性出汗，其中一半人每天都不得不因大量反射性出汗而換衣服。


There was no difference between the two groups, leading investigators to conclude compensatory sweating is determined by the original site of sweating rather than the extent or site of the surgery.（兩組研究報告的結論都沒有差別）


訪問者無法對代償性流汗做結論，不管是原來的流汗部位或是手術之後的流汗部位。


"We speculate that the risk of side-effects following sympathectomy in general depends more on the primary location of hyperhidrosis rather than the extent of sympathectomy," said Dr. Peter Licht of Aarhus University Hospital. "It's been claimed to relate to the extent of sympathectomy, but our results fail to confirm this."


Aarhus大學醫院的Peter Licht醫師說，“我們推測伴隨交感神經切除術的副作用跟多汗症的發原部位有關，而不是與交感神經切除術的程度（深度）有關。＂他也說，“以前人們都認為反射性出汗的副作用與交感神經切除術的程度有關，但我們的研究報告卻無法確認這種說法”。


譯者（王群光醫師）按：這也就是說，只要是動到交感神經（切除），不管切除幾節，其反射性出汗都是一樣的。不管切哪一節，單節或多節，都會帶來85-90%的反射性出汗副作用。


The frequency of compensatory sweating in the Danish study is more likely associated with their decision to cut the T2 ganglia in all patients, according to a Canadian surgeon who has performed more than 640 sympathectomies and has abandoned the T2 procedure because of unacceptable side-effects.


根據Danish研究系列顯示，反射性出汗發生的頻率跟所有T2神經節切除之患者都有關聯。根據一位曾開過超過640次交感神經切除術的加拿大醫師表示，＂由於令人無法接受的副作用＂他從此不再做T2交感神經節切除術。


"I had to do a number of reversals in that group," said Dr. Ernie Spratt of St. Joseph's Health Centre in Toronto. "I'm highly selective about who I will do now, and I won't do any type of cutting or cautery procedure."


加拿大多倫多Joseph's Health Centre的Ernie Spratt醫師說，＂我必須為那些（640人）病患做交感神經重建手術，我現在對於我將做的事情將深思熟慮，同時我將不再做任何的交感神經切斷或燒灼手術。＂


Dr. Spratt uses a clipping technique that can be reversed within six months of the procedure if severe compensatory sweating develops. He operates on only 35% of the patients referred to his office—most often on people with isolated hand, or hand and underarm sweating. The results in that patient group have been excellent, he said, and the key to his success is careful patient selection. For isolated underarm sweating he recommends sweat gland removal, but admits there are no good options for people with facial or scalp sweating.


Spratt醫生使用一種金屬鋏技術來取代交感神經直接切除術。如果在6個月內生嚴重的反射性出汗，金屬鋏可被移除，此為可逆性的（譯者註：有許多做過金屬鋏患者對於＂可逆＂的說法深度存疑，表示反射出汗並不會因為把金屬鋏拿掉，反射性出汗就消失）。他對於來求診的患者，開刀率只有35%，大部分都是針對只有手多汗及腋下多汗的患者，對這些患者來說，效果都非常好。Spratt醫生說，效果好的主要關鍵原因是小心嚴格挑選患者，對於單獨的腋下多汗，他建議用手術直接移除汗腺，而不是做交感神經切除術。他承認對於臉多汗及頭皮多汗並無良好的解決方法可供選擇。


"All I can say at this point is I don't think sympathectomy is the answer for that," he said. "They're very depressed when I see them, and I tell them I cannot recommend this procedure.“我只能說交感神經切除手術不是解決問題的方法 這些病人都非常沮喪 我告訴他們，我不建議作這個手術”


Other complicating factors may include the type of procedure performed—cutting, excising or clipping—and the heterogeneity of the patient population. Little is known about the relationship between preoperative sweating and the success of sympathectomy. Both presenters in Tampa stressed the need for a large randomized clinical trial to determine best practices in sympathectomy for excessive sweating.


其他複雜的因素，包刮手術執行的方式，到底是切斷、切除或是鋏，以及患者族群的異質性（基因體質不同）。


對於手術前多汗及手術成功程度之間的關係，我們知道的非常有限。此文中強調，需要做大規模的隨機取樣臨床試驗來決定，對於多汗症來說，什麼方式的交感神經手術才是最好的方法。


譯者（王群光醫師）說：台灣已做過ETS手術患者超過20萬人，高居世界第一，受害者不計其數，很多人生不如死，如墜入地獄中的心情，非常人所能理解。本人誓言將以餘生採取實際法律行動來促動禁絕此令人致殘（把交感神經主脈切斷，等同切斷任督二脈）之手術。並推動做過ETS手術者可領殘障手冊及獲國家補償，歡迎有志一同者共襄盛舉。(e-mail：bkk567@gmail.com)


（2010年12月15日）